TBD Meeting (4490-18)

LAKE BUENA VISTA, FLA. – Blunt splenic injury patients undergoing splenic artery embolization are at higher risk of infectious complications and readmissions in the long term, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

As nonoperative treatments are becoming more common for managing blunt splenic injury (BSI), it is important to understand the risks associated with splenic artery embolization (SAE) and how this treatment may be impacting a larger trend of posttrauma readmissions, according to presenter Rishi Rattan, MD, an acute care surgeon at the University of Miami.

©monkeybusinessimages/Thinkstock

[email protected]

LAKE BUENA VISTA, FLA. – Blunt splenic injury patients undergoing splenic artery embolization are at higher risk of infectious complications and readmissions in the long term, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

As nonoperative treatments are becoming more common for managing blunt splenic injury (BSI), it is important to understand the risks associated with splenic artery embolization (SAE) and how this treatment may be impacting a larger trend of posttrauma readmissions, according to presenter Rishi Rattan, MD, an acute care surgeon at the University of Miami.

©monkeybusinessimages/Thinkstock

[email protected]

LAKE BUENA VISTA, FLA. – Blunt splenic injury patients undergoing splenic artery embolization are at higher risk of infectious complications and readmissions in the long term, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

As nonoperative treatments are becoming more common for managing blunt splenic injury (BSI), it is important to understand the risks associated with splenic artery embolization (SAE) and how this treatment may be impacting a larger trend of posttrauma readmissions, according to presenter Rishi Rattan, MD, an acute care surgeon at the University of Miami.

©monkeybusinessimages/Thinkstock

[email protected]

LAKE BUENA VISTA, FLA. – Every year brings new studies, updates, and trials, and it can be a challenge to keep up.

Christian Jones, MD, FACS, a general surgeon in the division of acute care surgery at Johns Hopkins University, Baltimore, ranked some of the more notable trauma studies published in the past year and presented his perspective on them at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Day 2 is the “sweet spot” for cholecystectomy

When it comes to cholecystectomy, acute cholecystitis (AC) patients appear to fare the best when operations are conducted on day 2 after admission, according to a study of patients registered in the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).

The retrospective study of 15,760 AC patients found that the rate of 30-day mortality of AC patients was significantly higher for patients who underwent a cholecystectomy on day of (odds ratio = .42) 3 days after (OR = .34), and 4 days after admission (OR = 1.0), compared with those who were operated on between 1 day after (OR = .23), and 2 days after (OR = .29) admission.

Lead author My Blohm, MD, of the department of clinical sciences, intervention, and technology at the Karolinska Institutet, Stockholm, and fellow investigators hypothesized that waiting allows patients to be medically optimized for surgery (J Gastrointest Surg. 2017;21[1]: 33-40).

With 90-day mortality rates showing nearly identical results for day 1 and day 2, holding off on surgery may be the best move for the patient, even if it is not the ideal situation for a provider.

“Sure, as we all know by now, delayed cholecystectomy is seldom necessary, later surgery is more difficult, and more likely to be associated with complications at least with an equal conversion to an open procedure, but even more surprising is the higher mortality on the admissions day,” said Dr. Jones.

Antibiotics for abscess drainage patients

For patients requiring abscess drainage, antibiotics may be the best bet to keep infection at bay, according to a study published in the New England Journal of Medicine in June 2017.

The prospective, randomized, placebo-controlled, double-blind, study of 786 simple skin abscess drainage patients found clindamycin and Bactrim (sulfamethoxazole and trimethoprim) outperformed a placebo in an evaluation of symptoms of true ongoing infection in patients even 30 days after the procedure (N Engl J Med. 2017 Jun 29;376[26]:2545-55).

Patients studied had Staphylococcus aureus (527) or methicillin-resistant S. aureus (388).

After 10 days of therapy, cure rate of infection for the clindamycin and Bactrim groups were 83% and 82% respectively, compared with 70% in the placebo group, according to Robert S. Daum, MD, principal investigator at the MRSA Research Center, University of Chicago. After 30 days, cure rate for both antibiotic groups remained superior to that of the placebo group.

While these treatments were successful, concern of drug resistance is notable and should be taken into consideration when deciding on treatment options.

“This does get to our typical concern with increased antibiotic usage, and that’s the concern of the health of the community versus the health of the individual patient,” said Dr. Jones. “Is the increased rate of [antibiotic] resistance important enough to have a lower cure rate of simple abscess drainage? We don’t know the answer to that.”

Loop ileostomies look good for C. diff patients

This minimally invasive procedure has been the subject of some well-received studies with findings that indicate it is a promising choice for patients with a Clostridium difficile–associated disease (CDAD) over total colectomy, Dr. Jones said.

In a study published in the Journal of Trauma and Acute Care Surgery, a study group of patients with CDAD who had loop ileostomy had no statistical difference in almost any recorded characteristic compared with those who underwent a total colectomy, except mortality rate. The retrospective, multicenter study of 98 CDAD patients found the mortality rate of the loop ileostomy group to be 17.2%, compared with 39.7% in the total colectomy group (J Trauma Acute Care Surg. 2017 Jul;83[1]:36-40).

“The outcomes all favored loop ileostomy in a statistically significant fashion,” said Dr. Jones. “Unsurprisingly, estimated blood loss and need for transfusions were all significantly less in the loop ileostomy patients, and the adjusted overall mortality, even if requiring a reoperation, still favored doing the loop ileostomy first.”

The one difference between LI and colectomy patients was a longer time from initial diagnosis to operation among LI patients, with about 12 hours from diagnosis for the colectomy versus 24 hours for LI patients, according to lead author Paula Ferrada, MD, FACS, director of the surgical and trauma intensive care unit at Virginia Commonwealth University, Richmond, and her fellow investigators,

Contrary to previous findings, the study found that LI can be performed on sick patients as well, according to the researchers, and failure of the procedure is not associated with increased mortality.

While these findings are encouraging, “there are things that the individual patient may reveal to you on your examination that tell you they are not a candidate and that you should go to total colectomy,” said Dr. Jones. “Keep in mind that perhaps we can be a bit more aggressive in this less invasive procedure.”
 

The skin vac actually works

A study published in Annals of Surgery found prophylactic negative-pressure dressings are associated with a decreased rate of surgical site infections in laparotomy wounds.

“The biggest surprise to me out of all of these studies is that a new piece of technology actually seems to work,” said Dr. Jones.

The randomized study included 50 laparotomy patients with a stapled wound, half of whom received a skin vac over their incision while the other half had a standard OpSite occlusive dressing (Ann Surg. 2017 Jun;265[6]:1082-6).

Patients in both arms had the same type of wound and had their dressings on for 4 days before being switched.

Rate of surgical site infections for the skin vac group was 8.3% over 30 days from operation, compared with 32% in the OpSite group. Average length of stay for patients with the pressure dressing was 6.1 days, while patients with an OpSite dressing had a length of 14.7 days, more than double, according to lead author Donal Peter O’Leary, MD, surgeon at Cork University Hospital, Ireland.

The difference in length of stay does become insignificant if six OpSite patients who stayed longer than 20 days are discounted, only two of whom were delayed because of wound complications as opposed to placement issues or unassociated infections.

“But a surgical site infection difference of 50% or more using a skin vac instead of a standard dressing, whether you’re talking about clean, clean-contaminated, or contaminated cases with a skin closure, seems to be worthy of notice,” explained Dr. Jones.

[email protected]

LAKE BUENA VISTA, FLA. – Every year brings new studies, updates, and trials, and it can be a challenge to keep up.

Christian Jones, MD, FACS, a general surgeon in the division of acute care surgery at Johns Hopkins University, Baltimore, ranked some of the more notable trauma studies published in the past year and presented his perspective on them at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Day 2 is the “sweet spot” for cholecystectomy

When it comes to cholecystectomy, acute cholecystitis (AC) patients appear to fare the best when operations are conducted on day 2 after admission, according to a study of patients registered in the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).

The retrospective study of 15,760 AC patients found that the rate of 30-day mortality of AC patients was significantly higher for patients who underwent a cholecystectomy on day of (odds ratio = .42) 3 days after (OR = .34), and 4 days after admission (OR = 1.0), compared with those who were operated on between 1 day after (OR = .23), and 2 days after (OR = .29) admission.

Lead author My Blohm, MD, of the department of clinical sciences, intervention, and technology at the Karolinska Institutet, Stockholm, and fellow investigators hypothesized that waiting allows patients to be medically optimized for surgery (J Gastrointest Surg. 2017;21[1]: 33-40).

With 90-day mortality rates showing nearly identical results for day 1 and day 2, holding off on surgery may be the best move for the patient, even if it is not the ideal situation for a provider.

“Sure, as we all know by now, delayed cholecystectomy is seldom necessary, later surgery is more difficult, and more likely to be associated with complications at least with an equal conversion to an open procedure, but even more surprising is the higher mortality on the admissions day,” said Dr. Jones.

Antibiotics for abscess drainage patients

For patients requiring abscess drainage, antibiotics may be the best bet to keep infection at bay, according to a study published in the New England Journal of Medicine in June 2017.

The prospective, randomized, placebo-controlled, double-blind, study of 786 simple skin abscess drainage patients found clindamycin and Bactrim (sulfamethoxazole and trimethoprim) outperformed a placebo in an evaluation of symptoms of true ongoing infection in patients even 30 days after the procedure (N Engl J Med. 2017 Jun 29;376[26]:2545-55).

Patients studied had Staphylococcus aureus (527) or methicillin-resistant S. aureus (388).

After 10 days of therapy, cure rate of infection for the clindamycin and Bactrim groups were 83% and 82% respectively, compared with 70% in the placebo group, according to Robert S. Daum, MD, principal investigator at the MRSA Research Center, University of Chicago. After 30 days, cure rate for both antibiotic groups remained superior to that of the placebo group.

While these treatments were successful, concern of drug resistance is notable and should be taken into consideration when deciding on treatment options.

“This does get to our typical concern with increased antibiotic usage, and that’s the concern of the health of the community versus the health of the individual patient,” said Dr. Jones. “Is the increased rate of [antibiotic] resistance important enough to have a lower cure rate of simple abscess drainage? We don’t know the answer to that.”

Loop ileostomies look good for C. diff patients

This minimally invasive procedure has been the subject of some well-received studies with findings that indicate it is a promising choice for patients with a Clostridium difficile–associated disease (CDAD) over total colectomy, Dr. Jones said.

In a study published in the Journal of Trauma and Acute Care Surgery, a study group of patients with CDAD who had loop ileostomy had no statistical difference in almost any recorded characteristic compared with those who underwent a total colectomy, except mortality rate. The retrospective, multicenter study of 98 CDAD patients found the mortality rate of the loop ileostomy group to be 17.2%, compared with 39.7% in the total colectomy group (J Trauma Acute Care Surg. 2017 Jul;83[1]:36-40).

“The outcomes all favored loop ileostomy in a statistically significant fashion,” said Dr. Jones. “Unsurprisingly, estimated blood loss and need for transfusions were all significantly less in the loop ileostomy patients, and the adjusted overall mortality, even if requiring a reoperation, still favored doing the loop ileostomy first.”

The one difference between LI and colectomy patients was a longer time from initial diagnosis to operation among LI patients, with about 12 hours from diagnosis for the colectomy versus 24 hours for LI patients, according to lead author Paula Ferrada, MD, FACS, director of the surgical and trauma intensive care unit at Virginia Commonwealth University, Richmond, and her fellow investigators,

Contrary to previous findings, the study found that LI can be performed on sick patients as well, according to the researchers, and failure of the procedure is not associated with increased mortality.

While these findings are encouraging, “there are things that the individual patient may reveal to you on your examination that tell you they are not a candidate and that you should go to total colectomy,” said Dr. Jones. “Keep in mind that perhaps we can be a bit more aggressive in this less invasive procedure.”
 

The skin vac actually works

A study published in Annals of Surgery found prophylactic negative-pressure dressings are associated with a decreased rate of surgical site infections in laparotomy wounds.

“The biggest surprise to me out of all of these studies is that a new piece of technology actually seems to work,” said Dr. Jones.

The randomized study included 50 laparotomy patients with a stapled wound, half of whom received a skin vac over their incision while the other half had a standard OpSite occlusive dressing (Ann Surg. 2017 Jun;265[6]:1082-6).

Patients in both arms had the same type of wound and had their dressings on for 4 days before being switched.

Rate of surgical site infections for the skin vac group was 8.3% over 30 days from operation, compared with 32% in the OpSite group. Average length of stay for patients with the pressure dressing was 6.1 days, while patients with an OpSite dressing had a length of 14.7 days, more than double, according to lead author Donal Peter O’Leary, MD, surgeon at Cork University Hospital, Ireland.

The difference in length of stay does become insignificant if six OpSite patients who stayed longer than 20 days are discounted, only two of whom were delayed because of wound complications as opposed to placement issues or unassociated infections.

“But a surgical site infection difference of 50% or more using a skin vac instead of a standard dressing, whether you’re talking about clean, clean-contaminated, or contaminated cases with a skin closure, seems to be worthy of notice,” explained Dr. Jones.

[email protected]

LAKE BUENA VISTA, FLA. – Every year brings new studies, updates, and trials, and it can be a challenge to keep up.

Christian Jones, MD, FACS, a general surgeon in the division of acute care surgery at Johns Hopkins University, Baltimore, ranked some of the more notable trauma studies published in the past year and presented his perspective on them at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Day 2 is the “sweet spot” for cholecystectomy

When it comes to cholecystectomy, acute cholecystitis (AC) patients appear to fare the best when operations are conducted on day 2 after admission, according to a study of patients registered in the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).

The retrospective study of 15,760 AC patients found that the rate of 30-day mortality of AC patients was significantly higher for patients who underwent a cholecystectomy on day of (odds ratio = .42) 3 days after (OR = .34), and 4 days after admission (OR = 1.0), compared with those who were operated on between 1 day after (OR = .23), and 2 days after (OR = .29) admission.

Lead author My Blohm, MD, of the department of clinical sciences, intervention, and technology at the Karolinska Institutet, Stockholm, and fellow investigators hypothesized that waiting allows patients to be medically optimized for surgery (J Gastrointest Surg. 2017;21[1]: 33-40).

With 90-day mortality rates showing nearly identical results for day 1 and day 2, holding off on surgery may be the best move for the patient, even if it is not the ideal situation for a provider.

“Sure, as we all know by now, delayed cholecystectomy is seldom necessary, later surgery is more difficult, and more likely to be associated with complications at least with an equal conversion to an open procedure, but even more surprising is the higher mortality on the admissions day,” said Dr. Jones.

Antibiotics for abscess drainage patients

For patients requiring abscess drainage, antibiotics may be the best bet to keep infection at bay, according to a study published in the New England Journal of Medicine in June 2017.

The prospective, randomized, placebo-controlled, double-blind, study of 786 simple skin abscess drainage patients found clindamycin and Bactrim (sulfamethoxazole and trimethoprim) outperformed a placebo in an evaluation of symptoms of true ongoing infection in patients even 30 days after the procedure (N Engl J Med. 2017 Jun 29;376[26]:2545-55).

Patients studied had Staphylococcus aureus (527) or methicillin-resistant S. aureus (388).

After 10 days of therapy, cure rate of infection for the clindamycin and Bactrim groups were 83% and 82% respectively, compared with 70% in the placebo group, according to Robert S. Daum, MD, principal investigator at the MRSA Research Center, University of Chicago. After 30 days, cure rate for both antibiotic groups remained superior to that of the placebo group.

While these treatments were successful, concern of drug resistance is notable and should be taken into consideration when deciding on treatment options.

“This does get to our typical concern with increased antibiotic usage, and that’s the concern of the health of the community versus the health of the individual patient,” said Dr. Jones. “Is the increased rate of [antibiotic] resistance important enough to have a lower cure rate of simple abscess drainage? We don’t know the answer to that.”

Loop ileostomies look good for C. diff patients

This minimally invasive procedure has been the subject of some well-received studies with findings that indicate it is a promising choice for patients with a Clostridium difficile–associated disease (CDAD) over total colectomy, Dr. Jones said.

In a study published in the Journal of Trauma and Acute Care Surgery, a study group of patients with CDAD who had loop ileostomy had no statistical difference in almost any recorded characteristic compared with those who underwent a total colectomy, except mortality rate. The retrospective, multicenter study of 98 CDAD patients found the mortality rate of the loop ileostomy group to be 17.2%, compared with 39.7% in the total colectomy group (J Trauma Acute Care Surg. 2017 Jul;83[1]:36-40).

“The outcomes all favored loop ileostomy in a statistically significant fashion,” said Dr. Jones. “Unsurprisingly, estimated blood loss and need for transfusions were all significantly less in the loop ileostomy patients, and the adjusted overall mortality, even if requiring a reoperation, still favored doing the loop ileostomy first.”

The one difference between LI and colectomy patients was a longer time from initial diagnosis to operation among LI patients, with about 12 hours from diagnosis for the colectomy versus 24 hours for LI patients, according to lead author Paula Ferrada, MD, FACS, director of the surgical and trauma intensive care unit at Virginia Commonwealth University, Richmond, and her fellow investigators,

Contrary to previous findings, the study found that LI can be performed on sick patients as well, according to the researchers, and failure of the procedure is not associated with increased mortality.

While these findings are encouraging, “there are things that the individual patient may reveal to you on your examination that tell you they are not a candidate and that you should go to total colectomy,” said Dr. Jones. “Keep in mind that perhaps we can be a bit more aggressive in this less invasive procedure.”
 

The skin vac actually works

A study published in Annals of Surgery found prophylactic negative-pressure dressings are associated with a decreased rate of surgical site infections in laparotomy wounds.

“The biggest surprise to me out of all of these studies is that a new piece of technology actually seems to work,” said Dr. Jones.

The randomized study included 50 laparotomy patients with a stapled wound, half of whom received a skin vac over their incision while the other half had a standard OpSite occlusive dressing (Ann Surg. 2017 Jun;265[6]:1082-6).

Patients in both arms had the same type of wound and had their dressings on for 4 days before being switched.

Rate of surgical site infections for the skin vac group was 8.3% over 30 days from operation, compared with 32% in the OpSite group. Average length of stay for patients with the pressure dressing was 6.1 days, while patients with an OpSite dressing had a length of 14.7 days, more than double, according to lead author Donal Peter O’Leary, MD, surgeon at Cork University Hospital, Ireland.

The difference in length of stay does become insignificant if six OpSite patients who stayed longer than 20 days are discounted, only two of whom were delayed because of wound complications as opposed to placement issues or unassociated infections.

“But a surgical site infection difference of 50% or more using a skin vac instead of a standard dressing, whether you’re talking about clean, clean-contaminated, or contaminated cases with a skin closure, seems to be worthy of notice,” explained Dr. Jones.

[email protected]

LAKE BUENA VISTA, FLA. – Nearly one-quarter of geriatric trauma patients died within 1 year discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.

These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.

Thinkstock

[email protected]

SOURCE: EAST 2018, Abstract #47.

LAKE BUENA VISTA, FLA. – Nearly one-quarter of geriatric trauma patients died within 1 year discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.

These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.

Thinkstock

[email protected]

SOURCE: EAST 2018, Abstract #47.

LAKE BUENA VISTA, FLA. – Nearly one-quarter of geriatric trauma patients died within 1 year discharge, according to a study presented at the Eastern Association for the Surgery of Trauma Scientific Assembly.

These findings emphasize a need to know more about geriatric patient outcomes, especially as a tide of elderly trauma patients has begun to sweep through trauma centers, according to presenter Ciara Huntington, MD, a surgical resident at the Carolinas Healthcare System, Charlotte, N.C.

Thinkstock

[email protected]

SOURCE: EAST 2018, Abstract #47.

LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”

Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.

Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.

Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.

Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).

Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.

During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.

Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: EAST Scientific Assembly abstract No. 24.

LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”

Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.

Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.

Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.

Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).

Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.

During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.

Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: EAST Scientific Assembly abstract No. 24.

LAKE BUENA VISTA, FLA. – Gastrografin significantly decreased the need for an operation in small bowel obstruction (SBO) patients, even among patients who had never undergone abdominal surgery, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

“Small bowel obstruction is a common clinical problem in the United States, with 15 out of 100 admissions for abdominal pain related to SBO,” said Morgan Collom, DO, surgical resident at Medical City Fort Worth (Tex.). “Many studies conclude that [operative exploration] is not needed and it is feasible to perform nonoperative conservative management, yet still argue that small obstruction in a virgin abdomen patient should undergo mandatory exploration to avoid missing a diagnosis of malignancy.”

Investigators studied 601 SBO patients admitted to one of 14 institutions included in an EAST database between February 2015 and December 2016 for this prospective study.

Of those included, 500 had previous abdominal surgery and the others had never had surgery. Gastrografin (Bracco Diagnostics) was used to treat their bowel obstruction.

Those with previous abdominal surgery were more likely to be over age 65 years (48% vs. 36%), be female (50% vs. 25%), have a history of cancer (42.6% vs. 18.8%), and have a prior admission of SBO (41.2% vs 8.9%), according to Dr. Collom.

Among patients who previously had surgery, operative exploration was 50% less likely (odds ratio = .51, P = .04) than among those who had never had surgery. In a comparison of patients with and without previous surgery, introducing Gastrografin evened out the likelihood for an operation (OR = .17 and .21, respectively). Overall, those who received Gastrografin were 86% less likely to undergo bowel exploration(OR = .14, P less than .01).

Of the 36 NAS patients treated with Gastrografin, 33 underwent successful, nonoperative therapy, and 3 underwent a therapeutic laparotomy for a malignancy.

During a question-and-answer session, audience members called to attention the issue of the database used, which does not review complications or recurrences after 30 days or any missed abnormalities, indicating that some malignancies may have developed after the therapy.

Dr. Collom acknowledged the limitation and agreed that the next study would need to address this.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: EAST Scientific Assembly abstract No. 24.

ORLANDO – A new predictive method could limit unnecessary computed tomography scans on pediatric, blunt force trauma patients at low risk for intra-abdominal injury, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

With values for five clinical variables, the prediction rule would eliminate the need to subject some patients to unwarranted radiation exposure, which has become a growing health and financial concern for medical institutions.

“CT utilization rates in pediatric blunt trauma are very high, at a rate of 40%-60%, despite a relatively low incidence of intra-abdominal injury after abdominal trauma,” according to presenter Chase A. Arbra, MD, of the department of surgery at the Medical University of South Carolina, Charleston. “With increasing concerns regarding the cost and radiation exposure in children, our group is focusing on research to safely avoid these unnecessary scans.”

The rule, developed by the Pediatric Surgery Research Collaborative (PedSRC), evaluates abdominal wall trauma and tenderness, complaint of abdominal pain, aspartate aminotransferase level greater than 200 U/L, abnormal pancreatic enzymes, and abnormal chest x-rays to determine a patient’s risk of having an intra-abdominal injury (IAI). If none of the five variables in a patient is abnormal, the finding is considered negative and the patient is considered to be at very low risk for having an IAI or an IAI requiring acute intervention (IAI-I).

Investigators studied 2,435 pediatric blunt trauma patients with all five clinical variables documented within 6 hours of arrival, using data gathered from the Pediatric Emergency Care Applied Research Network.

Patients were an average of 9.4 years old, with an IAI rate of 9.7% (n = 235) and an IAI-I rate of 2.5% (n = 60); 61.1% of the patients had a CT scan.

Prediction sensitivity of the method was 97.5% for IAI and 100% for IAI-I, said Dr. Arbra. Negative predictive value for the model was 99.3% for IAI and 100% for IAI-I.

Patients who were found to have aspartate aminotransferase level greater than 200 U/L were at the highest risk of IAI (52.6%) and IAI-I (11.9%), according to investigators. One-third of the test population was found to be at very low risk after using the prediction model, according to Dr. Arbra, with 46.8% of them still undergoing a CT scan. Of those tested, six patients had IAI that was not predicted by the model, three of whom were intubated. Because CT scans were not required and there was no follow-up after discharge, investigators are not able to determine if any minor IAI was missed.

Despite these limitations, the highly sensitive rule shows great promise, according to Dr. Arbra.

“Patients with 0-5 variables, even patients who were involved in a high impact mechanism, could potentially forgo CT scans safely.”

A closer look at the 26 patients who only had abdominal pain showed that only 1 had IAI, suggesting that patients with only abdominal pain could be safely observed with only serial exams, according to Dr. Arbra.

Investigators plan to conduct a prospective study that will include older patients.

Dr. Arbra concluded, “The rule could potentially help centers to determine who could avoid imaging prior to transfer and potentially could one day be used to see who could be discharged.”

Dr. Arbra reported no relevant financial disclosures.

[email protected]

SOURCE: Arbra CA. EAST Scientific Assembly 2018, paper #7.

ORLANDO – A new predictive method could limit unnecessary computed tomography scans on pediatric, blunt force trauma patients at low risk for intra-abdominal injury, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

With values for five clinical variables, the prediction rule would eliminate the need to subject some patients to unwarranted radiation exposure, which has become a growing health and financial concern for medical institutions.

“CT utilization rates in pediatric blunt trauma are very high, at a rate of 40%-60%, despite a relatively low incidence of intra-abdominal injury after abdominal trauma,” according to presenter Chase A. Arbra, MD, of the department of surgery at the Medical University of South Carolina, Charleston. “With increasing concerns regarding the cost and radiation exposure in children, our group is focusing on research to safely avoid these unnecessary scans.”

The rule, developed by the Pediatric Surgery Research Collaborative (PedSRC), evaluates abdominal wall trauma and tenderness, complaint of abdominal pain, aspartate aminotransferase level greater than 200 U/L, abnormal pancreatic enzymes, and abnormal chest x-rays to determine a patient’s risk of having an intra-abdominal injury (IAI). If none of the five variables in a patient is abnormal, the finding is considered negative and the patient is considered to be at very low risk for having an IAI or an IAI requiring acute intervention (IAI-I).

Investigators studied 2,435 pediatric blunt trauma patients with all five clinical variables documented within 6 hours of arrival, using data gathered from the Pediatric Emergency Care Applied Research Network.

Patients were an average of 9.4 years old, with an IAI rate of 9.7% (n = 235) and an IAI-I rate of 2.5% (n = 60); 61.1% of the patients had a CT scan.

Prediction sensitivity of the method was 97.5% for IAI and 100% for IAI-I, said Dr. Arbra. Negative predictive value for the model was 99.3% for IAI and 100% for IAI-I.

Patients who were found to have aspartate aminotransferase level greater than 200 U/L were at the highest risk of IAI (52.6%) and IAI-I (11.9%), according to investigators. One-third of the test population was found to be at very low risk after using the prediction model, according to Dr. Arbra, with 46.8% of them still undergoing a CT scan. Of those tested, six patients had IAI that was not predicted by the model, three of whom were intubated. Because CT scans were not required and there was no follow-up after discharge, investigators are not able to determine if any minor IAI was missed.

Despite these limitations, the highly sensitive rule shows great promise, according to Dr. Arbra.

“Patients with 0-5 variables, even patients who were involved in a high impact mechanism, could potentially forgo CT scans safely.”

A closer look at the 26 patients who only had abdominal pain showed that only 1 had IAI, suggesting that patients with only abdominal pain could be safely observed with only serial exams, according to Dr. Arbra.

Investigators plan to conduct a prospective study that will include older patients.

Dr. Arbra concluded, “The rule could potentially help centers to determine who could avoid imaging prior to transfer and potentially could one day be used to see who could be discharged.”

Dr. Arbra reported no relevant financial disclosures.

[email protected]

SOURCE: Arbra CA. EAST Scientific Assembly 2018, paper #7.

ORLANDO – A new predictive method could limit unnecessary computed tomography scans on pediatric, blunt force trauma patients at low risk for intra-abdominal injury, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

With values for five clinical variables, the prediction rule would eliminate the need to subject some patients to unwarranted radiation exposure, which has become a growing health and financial concern for medical institutions.

“CT utilization rates in pediatric blunt trauma are very high, at a rate of 40%-60%, despite a relatively low incidence of intra-abdominal injury after abdominal trauma,” according to presenter Chase A. Arbra, MD, of the department of surgery at the Medical University of South Carolina, Charleston. “With increasing concerns regarding the cost and radiation exposure in children, our group is focusing on research to safely avoid these unnecessary scans.”

The rule, developed by the Pediatric Surgery Research Collaborative (PedSRC), evaluates abdominal wall trauma and tenderness, complaint of abdominal pain, aspartate aminotransferase level greater than 200 U/L, abnormal pancreatic enzymes, and abnormal chest x-rays to determine a patient’s risk of having an intra-abdominal injury (IAI). If none of the five variables in a patient is abnormal, the finding is considered negative and the patient is considered to be at very low risk for having an IAI or an IAI requiring acute intervention (IAI-I).

Investigators studied 2,435 pediatric blunt trauma patients with all five clinical variables documented within 6 hours of arrival, using data gathered from the Pediatric Emergency Care Applied Research Network.

Patients were an average of 9.4 years old, with an IAI rate of 9.7% (n = 235) and an IAI-I rate of 2.5% (n = 60); 61.1% of the patients had a CT scan.

Prediction sensitivity of the method was 97.5% for IAI and 100% for IAI-I, said Dr. Arbra. Negative predictive value for the model was 99.3% for IAI and 100% for IAI-I.

Patients who were found to have aspartate aminotransferase level greater than 200 U/L were at the highest risk of IAI (52.6%) and IAI-I (11.9%), according to investigators. One-third of the test population was found to be at very low risk after using the prediction model, according to Dr. Arbra, with 46.8% of them still undergoing a CT scan. Of those tested, six patients had IAI that was not predicted by the model, three of whom were intubated. Because CT scans were not required and there was no follow-up after discharge, investigators are not able to determine if any minor IAI was missed.

Despite these limitations, the highly sensitive rule shows great promise, according to Dr. Arbra.

“Patients with 0-5 variables, even patients who were involved in a high impact mechanism, could potentially forgo CT scans safely.”

A closer look at the 26 patients who only had abdominal pain showed that only 1 had IAI, suggesting that patients with only abdominal pain could be safely observed with only serial exams, according to Dr. Arbra.

Investigators plan to conduct a prospective study that will include older patients.

Dr. Arbra concluded, “The rule could potentially help centers to determine who could avoid imaging prior to transfer and potentially could one day be used to see who could be discharged.”

Dr. Arbra reported no relevant financial disclosures.

[email protected]

SOURCE: Arbra CA. EAST Scientific Assembly 2018, paper #7.

ORLANDO – A new grading system for cholecystectomies may offer an improved means of assessing operative difficulty, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.

“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”

Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.

To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.

To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.

Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.

Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.

Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.

Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.

Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).

Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).

Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.

“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”

Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.

In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.

Dr. Madni reported no relevant financial disclosures.

[email protected]

SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.

ORLANDO – A new grading system for cholecystectomies may offer an improved means of assessing operative difficulty, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.

“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”

Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.

To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.

To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.

Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.

Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.

Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.

Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.

Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).

Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).

Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.

“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”

Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.

In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.

Dr. Madni reported no relevant financial disclosures.

[email protected]

SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.

ORLANDO – A new grading system for cholecystectomies may offer an improved means of assessing operative difficulty, according to a study presented at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

As payment models shift toward bundled care, providers will be more closely evaluated on their postoperative outcomes, which can vary based on the difficulty of surgery, even for relatively common procedures.

“Gallbladder disease affects roughly 20 million people annually in the United States, with laparoscopic cholecystectomy being one of the most common operations performed by the typical surgeon,” said presenter Tarik Madni, MD, of the department of surgery, University of Texas Southwestern Medical Center, Dallas. “However not all cholecystectomies are created equal; increased inflammation can lead to increased operative times, increased conversion rates, as well as increased risk of complications.”

Given the increased scrutiny of surgical procedures, the current application of modifier 22, which allows surgeons to receive greater reimbursement for a more difficult surgery, is not enough, according to Dr. Madni.

To address this shortfall, investigators developed the Parkland grading scale, a five-tiered grading system that is designed to be easy to remember, limited in the number of grades, and correlated with clinical outcomes.

To determine the grades of the scale, Dr. Madni and his fellow investigators used 200 gallbladder images collected immediately before dissection and analyzed anatomy and inflammatory characteristics.

Gallbladders with a grade 1 would be relatively normal looking, while a grade 5 gallbladder would show perforation, necrosis, or not be clearly visible because of adhesions, according to Dr. Madni.

Between September 2016 and March 2017, investigators asked 11 acute care surgeons to prospectively grade gallbladders they saw before surgery using the Parkland scale and to fill out a questionnaire describing the difficulty of the procedure afterwards.

Of 667 gallbladders graded, 60 were assessed to be grade 1 (19%), 90 were grade 2 (28%), 102 were grade 3 (32%), 28 were grade 4 (9%), and 37 were grade 5 (12%) on the Parkland scale.

Grade 1 gallbladders had a mean procedure difficulty score of 1.43, while grade 5 gallbladders had a mean difficulty of 4.46. Grade 1 gallbladders also corresponded with the shortest mean surgery time of 63.31 minutes, compared with an average of 108.13 minutes for grade 5.

Acute cholecystitis diagnosis also increased by Parkland grade, from 36.7% in grade 1 gallbladders to 83.8% in grade 5 (P less than .0001), as did open conversion rates, from 0% to 21.6% (P less than .0001).

Mean length of stay rose fivefold between grade 1 and grade 5 procedures, from around 8 hours to 36 hours, respectively (P less than .0001).

Discussant Martin Zielinski, MD, FACS, director of medical trauma clinical research at the Mayo Clinic, Rochester, Minn., recognized the importance of having a grading scale but was curious why investigators did not analyze the American Association for the Surgery of Trauma’s (AAST) Emergency General Surgery anatomic grading scale, which is already in place.

“The AAST is a uniform, anatomic grading scale to measure the severity of diseases from the 16 most common [Emergency General Surgery] diseases,” Dr. Madni responded. “Unlike our operative-only finding scale, the AAST scale gives grades 1 through 5 definitions for four categories in each disease, not just operative, but clinical, imaging, operative, and pathologic categories.”

Comparatively, the Parkland scale is less cumbersome and covers a wider range of difficulty variation, according to Dr. Madni.

In the future, Dr. Madni and his colleagues will work to compare the Parkland scale to the AAST scale and look for ways to bridge the two.

Dr. Madni reported no relevant financial disclosures.

[email protected]

SOURCE: Madni T et al. EAST Scientific Assembly 2018 abstract #11.

ORLANDO – Deteriorating forced vital capacity (FVC) levels predict heightened risk of complications in rib fracture patients, according to a study presented at the annual scientific assembly Eastern Association for the Surgery of Trauma.

Daily, easily conducted, bedside FVC monitoring can help identify the first signs of a worsening condition and lead to earlier intervention, according to presenter Rachel Warner, DO, a surgical resident at West Virginia University, Morgantown.

“Unplanned upgrades to the ICU have been associated with prolonged hospital stay, mechanical ventilation, and even higher risk of mortality when compared to planned upgrades,” Dr. Warner explained. “We aim to decrease these events by creating a system where early decline can be recognized by any member of the health care team.”

In a retrospective study, investigators analyzed 1,106 rib fracture patients enrolled in a rib fracture care pathway at a Level I trauma center during 2009-2014, all of whom were admitted with an FVC greater than 1 L. Patients’ FVCs were assessed with spirometry in the ED, and the results were then used to determine their care placement. Then FVC was continually monitored throughout each patient’s stay at the hospital. The investigators hypothesized that those patients whose FVC level deteriorated to lower than 1 L were at higher risk for complications.

Two groups of patients were analyzed: Group A was composed of patients whose initial FVC scores were greater than or equal to 1 but deteriorated over time to below 1, while Group B was composed of patients whose scores remained above 1. Group A patients were an average age 58 years and were majority male (61%); their had FVC scores initially averaged 1.3 but dropped to a low of 0.7. Patients in group B were on average younger, at 48 years, but also majority male (79%); they had a slightly higher initial average FVC of 1.6, with a low of 1.4.

Rate of complications among patients whose FVC scores dropped below 1 was 15%, compared with 3.2% in the other group (P less than .001).

Group A patients were significantly more likely than were Group B patients to develop pneumonia (9% vs. 4%, respectively), be upgraded to the intensive care unit (3.7% vs. 0.2%), require intubation (1.6% vs. 0.1%), or be readmitted (4% vs. 1%).

Average length of stay for patients whose FVC score dropped below 1 was 10 days, compared with 4 days among the patients who maintained a higher FVC. Mortality rates were also significantly higher at 3%, compared with 0.2%. Dr. Warner said that FVC levels can be the first indication of worsening clinical status and should be treated as an early warning sign for which patients may need to be preemptively moved to a higher level of care.

Dr. Warner and her colleagues were limited by the retrospective nature of their analysis, as well as not including other injuries into their analysis.

In a discussion of the study, Bryce R.H. Robinson, MD, FACS, of Harborview Medical Center, Seattle, Wash., supported using data such as FVC to help identify at-risk patients early. “I am encouraged to see others utilize easily obtainable, objective measures for those at risk for pulmonary decompensation with rib fractures,” said Dr. Robinson.

While keeping the cutoff at 1 L for FVC testing regardless of other factors, like sex or weight, would make it easy to train all members of the medical team, this may be oversimplifying FVC measurements, cautioned Dr. Robinson.

“While it is a little bit less specific to the patient, broad adaptation across the health care team is much more feasible with standard values,” responded Dr. Warner. “Given this, we do intentionally accept a level of overtriaged patients. We have found these patients generally make up the geriatric population and have confounding factors that would otherwise make them high risk for complications.”

Investigators reported no relevant financial disclosures.
 

[email protected]

SOURCE: Warner R et al. EAST Scientific Assembly 2018 abstract #9

ORLANDO – Deteriorating forced vital capacity (FVC) levels predict heightened risk of complications in rib fracture patients, according to a study presented at the annual scientific assembly Eastern Association for the Surgery of Trauma.

Daily, easily conducted, bedside FVC monitoring can help identify the first signs of a worsening condition and lead to earlier intervention, according to presenter Rachel Warner, DO, a surgical resident at West Virginia University, Morgantown.

“Unplanned upgrades to the ICU have been associated with prolonged hospital stay, mechanical ventilation, and even higher risk of mortality when compared to planned upgrades,” Dr. Warner explained. “We aim to decrease these events by creating a system where early decline can be recognized by any member of the health care team.”

In a retrospective study, investigators analyzed 1,106 rib fracture patients enrolled in a rib fracture care pathway at a Level I trauma center during 2009-2014, all of whom were admitted with an FVC greater than 1 L. Patients’ FVCs were assessed with spirometry in the ED, and the results were then used to determine their care placement. Then FVC was continually monitored throughout each patient’s stay at the hospital. The investigators hypothesized that those patients whose FVC level deteriorated to lower than 1 L were at higher risk for complications.

Two groups of patients were analyzed: Group A was composed of patients whose initial FVC scores were greater than or equal to 1 but deteriorated over time to below 1, while Group B was composed of patients whose scores remained above 1. Group A patients were an average age 58 years and were majority male (61%); their had FVC scores initially averaged 1.3 but dropped to a low of 0.7. Patients in group B were on average younger, at 48 years, but also majority male (79%); they had a slightly higher initial average FVC of 1.6, with a low of 1.4.

Rate of complications among patients whose FVC scores dropped below 1 was 15%, compared with 3.2% in the other group (P less than .001).

Group A patients were significantly more likely than were Group B patients to develop pneumonia (9% vs. 4%, respectively), be upgraded to the intensive care unit (3.7% vs. 0.2%), require intubation (1.6% vs. 0.1%), or be readmitted (4% vs. 1%).

Average length of stay for patients whose FVC score dropped below 1 was 10 days, compared with 4 days among the patients who maintained a higher FVC. Mortality rates were also significantly higher at 3%, compared with 0.2%. Dr. Warner said that FVC levels can be the first indication of worsening clinical status and should be treated as an early warning sign for which patients may need to be preemptively moved to a higher level of care.

Dr. Warner and her colleagues were limited by the retrospective nature of their analysis, as well as not including other injuries into their analysis.

In a discussion of the study, Bryce R.H. Robinson, MD, FACS, of Harborview Medical Center, Seattle, Wash., supported using data such as FVC to help identify at-risk patients early. “I am encouraged to see others utilize easily obtainable, objective measures for those at risk for pulmonary decompensation with rib fractures,” said Dr. Robinson.

While keeping the cutoff at 1 L for FVC testing regardless of other factors, like sex or weight, would make it easy to train all members of the medical team, this may be oversimplifying FVC measurements, cautioned Dr. Robinson.

“While it is a little bit less specific to the patient, broad adaptation across the health care team is much more feasible with standard values,” responded Dr. Warner. “Given this, we do intentionally accept a level of overtriaged patients. We have found these patients generally make up the geriatric population and have confounding factors that would otherwise make them high risk for complications.”

Investigators reported no relevant financial disclosures.
 

[email protected]

SOURCE: Warner R et al. EAST Scientific Assembly 2018 abstract #9

ORLANDO – Deteriorating forced vital capacity (FVC) levels predict heightened risk of complications in rib fracture patients, according to a study presented at the annual scientific assembly Eastern Association for the Surgery of Trauma.

Daily, easily conducted, bedside FVC monitoring can help identify the first signs of a worsening condition and lead to earlier intervention, according to presenter Rachel Warner, DO, a surgical resident at West Virginia University, Morgantown.

“Unplanned upgrades to the ICU have been associated with prolonged hospital stay, mechanical ventilation, and even higher risk of mortality when compared to planned upgrades,” Dr. Warner explained. “We aim to decrease these events by creating a system where early decline can be recognized by any member of the health care team.”

In a retrospective study, investigators analyzed 1,106 rib fracture patients enrolled in a rib fracture care pathway at a Level I trauma center during 2009-2014, all of whom were admitted with an FVC greater than 1 L. Patients’ FVCs were assessed with spirometry in the ED, and the results were then used to determine their care placement. Then FVC was continually monitored throughout each patient’s stay at the hospital. The investigators hypothesized that those patients whose FVC level deteriorated to lower than 1 L were at higher risk for complications.

Two groups of patients were analyzed: Group A was composed of patients whose initial FVC scores were greater than or equal to 1 but deteriorated over time to below 1, while Group B was composed of patients whose scores remained above 1. Group A patients were an average age 58 years and were majority male (61%); their had FVC scores initially averaged 1.3 but dropped to a low of 0.7. Patients in group B were on average younger, at 48 years, but also majority male (79%); they had a slightly higher initial average FVC of 1.6, with a low of 1.4.

Rate of complications among patients whose FVC scores dropped below 1 was 15%, compared with 3.2% in the other group (P less than .001).

Group A patients were significantly more likely than were Group B patients to develop pneumonia (9% vs. 4%, respectively), be upgraded to the intensive care unit (3.7% vs. 0.2%), require intubation (1.6% vs. 0.1%), or be readmitted (4% vs. 1%).

Average length of stay for patients whose FVC score dropped below 1 was 10 days, compared with 4 days among the patients who maintained a higher FVC. Mortality rates were also significantly higher at 3%, compared with 0.2%. Dr. Warner said that FVC levels can be the first indication of worsening clinical status and should be treated as an early warning sign for which patients may need to be preemptively moved to a higher level of care.

Dr. Warner and her colleagues were limited by the retrospective nature of their analysis, as well as not including other injuries into their analysis.

In a discussion of the study, Bryce R.H. Robinson, MD, FACS, of Harborview Medical Center, Seattle, Wash., supported using data such as FVC to help identify at-risk patients early. “I am encouraged to see others utilize easily obtainable, objective measures for those at risk for pulmonary decompensation with rib fractures,” said Dr. Robinson.

While keeping the cutoff at 1 L for FVC testing regardless of other factors, like sex or weight, would make it easy to train all members of the medical team, this may be oversimplifying FVC measurements, cautioned Dr. Robinson.

“While it is a little bit less specific to the patient, broad adaptation across the health care team is much more feasible with standard values,” responded Dr. Warner. “Given this, we do intentionally accept a level of overtriaged patients. We have found these patients generally make up the geriatric population and have confounding factors that would otherwise make them high risk for complications.”

Investigators reported no relevant financial disclosures.
 

[email protected]

SOURCE: Warner R et al. EAST Scientific Assembly 2018 abstract #9