Surgery News - December 2007 - (Page 14)

TRAUMA SURGERY NEWS • D E C E M B E R 2 0 0 7 Comorbidities May Play Role Mortality • from page 1 our ICU we have managed our patients study is higher than typically seen in traudifferently, using lung-protective ventila- ma surgical ICU patients with ARDS. It’s closer to the mortality seen tion strategies, infection conwith ARDS in the medical ICU. trol measures, early extuba“I would not be surprised if tion protocols, and judicious most of these nontrauma suruse of IV fluids, which may gical patients with ARDS have have improved the incidence underlying chronic medical coof ARDS,” Dr. Towfigh said. morbidities, like those patients Patients who developed in the medical ICU—but they ARDS were an average of 3.6 have surgical disease as well,” years older than those who said Dr. Cocanour an ACS Feldidn’t. They were also sicker low with the University of Calupon ICU admission, as reDevelopment of ifornia, Davis. flected in a mean APACHE-2 ARDS was Dr. Towfigh replied that she score of 23.8, compared with associated with a just 5.3 in nontrauma surgical 6.9-fold increased and her coworkers plan to reanalyze their data to examine patients without ARDS, and rate of mortality diabetes and other medical cothey had roughly a 50% within the ICU. morbidities as potential risk facgreater prevalence of obesity. DR. TOWFIGH tors for ARDS among nontrauIn a multivariate logistic regression analysis, risk factors for ARDS ma surgical ICU patients. Dr. Cocanour noted that the high inciwere obesity and evidence of sepsis, including tachycardia and use of pressors on dence of ARDS among acute care surgery patients in this study underscores the need admission. Development of ARDS was associated to include surgical critical care as part of with a 6.9-fold increased rate of mortali- the training for acute care surgery. ■ ty within the ICU, as well as with other major adverse outcomes. Other indepenAcute Respiratory dent predictors of ICU mortality included Distress Syndrome Affects the use of pressors, which conferred a 2.9fold increased risk, and a positive fluid bal30-Day Mortality ance, with a 2.3-fold greater risk. Nontrauma patients were admitted to 42.4% the ICU from virtually all general surgery divisions. Patients from two divisions had a disproportionate incidence of ARDS: Those admitted from acute care surgery represented 23% of all nontrauma surgical ICU patients but accounted for 46% of those who developed ARDS; and colorectal surgery patients made up 8% of the to4.0% tal ICU population but 11% of those with ARDS. With ARDS Without ARDS Discussant Dr. Christine S. Cocanour Note: Based on data for 2,046 nontrauma commented that the mortality rate assosurgical intensive care unit patients. ciated with development of ARDS in nonSource: Dr. Towfigh trauma surgical patients in the ICU in this Repeat CT Scan at 48 Hours Advised After Splenic Injury B Y J E F F E VA N S Else vier Global Medical Ne ws repeat CT scan at 48 hours after hospital admission for blunt splenic injury may help to reduce the rate of failure due to pseudoaneurysms, and thereby increase the percentage of nonoperatively managed patients, according to a retrospective study of management protocols. Nonoperative management (NOM) of blunt splenic injuries has become more common in the past 2 decades because many patients will not go on to have a delayed rupture, said Dr. Daryl Gray, who presented the study at the annual meeting of the American Association for the Surgery of Trauma. Dr. Gray, director of the trauma program at the London (Ontario) Health Sciences Centre, and his trauma team followed a protocol for blunt splenic injury in the 1990s that involved NOM for stable patients with a CT-proven splenic injury of any grade. These patients were on bed rest for about 7 days, when a repeat CT scan was performed. Patients could usually go home if the scan was normal and the splenic injury was low grade. During 1995-2000, the center managed 82 (52%) of 159 blunt splenic injuries nonoperatively with a failure rate of 6%. The failures occurred at a mean of 4.8 days after hospital admission, according to Dr. Gray, who is an ACS Fellow. Why these failures developed was unclear until the investigators learned that many probably were caused by the rupture of splenic pseudoaneurysms. The medical literature suggested that pseudoaneurysms developed at or before 48 hours. Because it appeared that the trauma team was missing the window in which splenic failures were occurring, Dr. Gray and his associates changed their protocol in 2000 to perform a repeat CT scan at 48 hours. “If they’re failing on day 4, then something is going to be happening on day 2,” he said in an interview. And then “lo and behold, one of the first patients that we scanned early had a pseudoaneurysm.” For patients with low-grade splenic injuries (grades 1-3), “if we do a CT scan at 48 hours and it shows no extravasation [of contrast agent] or no splenic pseudoaneurysm, we discharge the patient the next day,” he said. During 2000-2007, Dr. Gray and his colleagues treated 259 (70%) of 368 patients with blunt splenic injuries nonoperatively. The rate of NOM of blunt splenic injuries at different centers has been reported to range from about 50% to 70%, he said. Another 34 patients (9%) underwent splenic arterial embolization, compared with none in the early cohort, and 75 (20%) received operative management. The results of the study showed there were no failed cases of NOM in the later cohort. NOM was used at a significantly higher rate in the later cohort than in the early cohort, even though the 2000-2007 group had a significantly higher mean splenic injury grade (3 vs. 1). The process of developing algorithms for the management of splenic injury, and an understanding of the role of latent pseudoaneurysms in NOM failure, also have helped to reduce the length of hospital stay for blunt splenic injury patients. The length of stay in Dr. Gray’s study declined significantly from a median of 8 days in the early cohort to 6 days in the later cohort. ■ Protocol Cuts Trauma-Related Mortality, Blood Product Usage B Y J E F F E VA N S ELSEVIER GLOBAL MEDICAL NEWS Else vier Global Medical Ne ws of a trauma exsanguination protocol at a The development reducedlevel I trauma center significantly 30-day mortality while simultaneously cutting blood product usage, reported Dr. Bryan A. Cotton and his associates at Vanderbilt University, Nashville, Tenn. Hemorrhage accounts for a majority of deaths after trauma, and delivery of blood products to the OR on an “as-needed” basis often fails to control trauma-related coagulopathy. Dr. Cotton and a multidisciplinary group of his colleagues established a trauma exsanguination protocol that aims to have blood product packages ready soon after a trauma patient has arrived and been assessed. It also eliminates the waiting time associated with thawing and the need to base requests for blood products on laboratory measurements. Dr. Cotton and his coinvestigators studied the effect of their protocol in a prospective comparison of 94 patients who initially received blood products through the protocol in the first 18 months of its implementation, and in 117 patients who received care in the 18 months prior to the use of the protocol. The comparison group included patients who were admitted directly to the trauma service, went immediately to the OR, were initially operated on by the trauma team, and received at least 10 U of packed red blood cells during the initial 24 hours, Dr. Cotton said in an interview. He presented the study at the annual meeting of the American Association for the Surgery of Trauma. Only about one out of every four patients who are taken directly to the OR requires activation of the protocol. But it is better to activate the protocol and then later not need it than to fail to start it and later need it, said Dr. Cotton, director of surgical critical care at the Nashville Veterans Affairs Medical Center. In Vanderbilt’s protocol, the attending trauma surgeon decides whether the patient will need a blood bank response beyond what is routine. If so, the blood bank delivers a box with 10 U of nonirradiated, uncrossed, packed red blood cells; 4 U of AB-negative plasma; and 2 U of singledonor platelets. Calls between the trauma team and the blood bank confirm the need for a second box—containing 6 U of nonirradiated packed red blood cells, 4 U of thawed plasma, and 2 U of single-donor platelets—and so on until the attending surgeon tells the blood bank to stop. Mortality at 30 days was significantly lower among protocol-treated patients than among patients in the comparator group (51% vs. 66%). Compared with patients who were treated before the protocol was implemented, the protocol-treated group contained a significantly greater percentage of unexpected survivors (22% vs. 5%) and a significantly lower percentage of unexpected deaths (9% vs. 22%), according to predictions calculated using the Trauma-Related Injury Severity Score (TRISS). Patients in each group had a mean age of 36-39 years. Use of the protocol was an independent predictor of 30-day mortality after adjustment for age, gender, mechanism of injury, TRISS value, and 24-hour transfusion of blood products. Trauma patients who received treatment under the protocol were 74% less likely to die than were those who did not. Protocol-treated patients received significantly more intraoperative units of red blood cells, fresh frozen plasma, and platelets than did those in the earlier cohort, but significantly lower amounts of intraoperative crystalloids (4.9 L vs. 6.7 L). Despite the greater use of blood products in protocol-treated patients during the operation, the average total amount of blood products of all types used in the initial 24 hours post injury was significantly in favor of protocol-treated patients (32 U vs. 39 U). Use of the protocol was also a significant predictor of reductions in the total amou

Table of Contents Feed for the Digital Edition of Surgery News - December 2007

Surgery News - December 2007 Contents Breast Radiation Boost Cuts Cancer Recurrence Mortality Soars in Some Patients With Respiratory Distress New Codes Promote Alcohol Screening New Ideas News From the College: Quality Standards General Surgery: Helping Hand Trauma: Spleen Protocol

Surgery News - December 2007

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