Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

2022 ◽  
pp. 000313482110502
Author(s):  
Patrick F. Walker ◽  
Joseph D. Bozzay ◽  
David W. Schechtman ◽  
Faraz Shaikh ◽  
Laveta Stewart ◽  
...  
Keyword(s):  
Medical Center ◽  
Damage Control ◽  
Surgical Site Infections ◽  
Trauma Patients ◽  
Intestinal Anastomoses ◽  
Military Hospitals ◽  
Anastomotic Failure ◽  
Significant Difference ◽  
Regional Medical Center ◽  
Outcome Differences

Background Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars. Methods Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals. Results Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality. Discussion Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

The Impact of In-house Attending Surgeon Supervision on the Rates of Preventable and Potentially Preventable Complications and Death at the Start of the New Academic Year

2013 ◽  
Vol 79 (11) ◽  
pp. 1134-1139 ◽  
Author(s):  
Kenji Inaba ◽  
Adam Hauch ◽  
Bernardino C. Branco ◽  
Stephen Cohn ◽  
Pedro G. R. Teixeira ◽  
...  
Keyword(s):  
Los Angeles ◽  
Trauma Center ◽  
Medical Center ◽  
Trauma Patients ◽  
University Of Southern California ◽  
Academic Level ◽  
Significant Difference ◽  
Level I ◽  
The Impact ◽  
Academic Year

The purpose of this study was to examine the impact of in-house attending surgeon supervision on the rate of preventable deaths (PD) and complications (PC) at the beginning of the academic year. All trauma patients admitted to the Los Angeles County 1 University of Southern California Medical Center over an 8-year period ending in December 2009 were reviewed. Morbidity and mortality reports were used to extract all PD/PC. Patients admitted in the first 2 months (July/ August) of the academic year were compared with those admitted at the end of the year (May/June) for two distinct time periods: 2002 to 2006 (before in-house attending surgeon supervision) and 2007 to 2009 (after 24-hour/day in-house attending surgeon supervision). During 2002 to 2006, patients admitted at the beginning of the year had significantly higher rates of PC (1.1% for July/ August vs 0.6% for May/June; adjusted odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1 to 3.2; P < 0.001). There was no significant difference in mortality (6.5% for July/August vs 4.6% for May/ June; adjusted OR, 1.1; 95% CI,0.8 to 1.5; P = 0.179). During 2007 to 2009, after institution of 24-hour/day in-house attending surgeon supervision of fellows and housestaff, there was no significant difference in the rates of PC (0.7% for July/August vs 0.6% for May/June; OR, 1.1; 95% CI, 0.8 to 1.3; P = 0.870) or PD (4.6% for July/August vs 3.7% for May/June; OR, 1.3; 95% CI, 0.9 to 1.7; P = 0.250) seen at the beginning of the academic year. At an academic Level I trauma center, the institution of 24-hour/day in-house attending surgeon supervision significantly reduced the spike of preventable complications previously seen at the beginning of the academic year.

scholarly journals The Method and Results of a Treatment Targeting SARS-CoV-2-Activated Inflammasomes

2021 ◽  
Author(s):  
Badar Kanwar ◽  
Asif Khattak ◽  
Chul Joong Lee ◽  
Jenny Balentine ◽  
R. E. Kast ◽  
...  
Keyword(s):  
Medical Center ◽  
Response To Treatment ◽  
Entire Study ◽  
Significant Difference ◽  
Regional Medical ◽  
Regional Medical Center ◽  
Chemically Reacting ◽  
Second Period ◽  
The Brain ◽  
Onset Group

Abstract In COVID-19 patients, clinicians should consider an increase in the oxygen requirement from 6 l/min to as high as 100% with a high-flow nasal cannula, as well as dapsone administration. A COVID-19 committee at Hunt Regional Medical Center reviewed the use of dapsone as an off-label medication in the first period. The hospital then revalidated its effectiveness by reporting the findings of 44 (22 cases/22 controls) patients with ARDS treated with dapsone in the second period. In ARDS-onset patients treated with dapsone, there was a decrease in FIO2 requirements in 7 patients and no worsening in 1 patient. In aggravated ARDS patients treated with dapsone, there was a decrease in FIO2 requirements in 6 patients and no worsening in 3 patients. In patients with severe ARDS treated with dapsone, no response to treatment was observed in 2 patients. In the ARDS-onset group not treated with dapsone, eight of twenty patients died, but in the ARDS-onset group treated with dapsone, no one of seventeen patients died throughout the entire study period. There was a significant difference in dapsone treatment results in the ARDS-onset group. We clinically diagnosed transient bulbar palsy of medulla oblongata in the brain associated with SARS-CoV-2 infection in the ARDS-onset group. We confirmed that dapsone clinically treated the onset of ARDS by targeting SARS-CoV-2-activated inflammasomes. Like chemically reacting substances, inflammasome and dapsone are competing, proving that it is only effective in treating early ARDS.

Massive Transfusion Protocols: Indications, Ratios and Mortality in the Non-Trauma Setting

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 2348-2348 ◽  
Author(s):  
Robert A. DeSimone ◽  
Cheryl A. Goss ◽  
Yen-Michael S. Hsu ◽  
Thorsten Haas ◽  
Melissa M. Cushing
Keyword(s):  
Blood Product ◽  
Massive Transfusion ◽  
Conflicts Of Interest ◽  
Medical Center ◽  
Binary Logistic Regression ◽  
Blood Bank ◽  
P Value ◽  
Trauma Patients ◽  
Number Of Patients ◽  
Significant Difference

Abstract Background: Many institutions have implemented massive transfusion protocols (MTPs) to prevent hemodilution and to restore normal coagulation function, with the ultimate goal of controlling hemorrhage and reducing complications. Our institution issues two different MTPs: trauma (T-) and non-trauma (NT-). T-MTPs have a 1:1 ratio for red blood cell (RBC):plasma issued by the blood bank, whereas NT-MTPs have a 1.8:1 ratio. Appropriate blood product ratios, indications and patient outcomes in the NT-MTP setting are not well studied. To determine how various MTP parameters impact 24-hour patient mortality, we retrospectively reviewed MTP activations at our large academic urban medical center. Methods: All activated MTPs over a 3-year period (2012-2014) were reviewed. Data was collected from blood bank quality assurance and inpatient electronic medical records. NT-MTPs were sub-classified into indication by type of hemorrhage. All statistical analyses (binary logistic regression, Kruskal-Wallis) were performed using STATA version 11. A p value of <0.05 was considered significant. Results: From 2012-2014, there were 177 MTP activations for 167 patients, of which 98 were male (59%) and 69 were female (41%). The average age of all patients was 56 years, with a range of 7 months to 95 years. Trauma patients (mean age 40 years) tended to be younger than non-trauma patients (mean age 60 years). Refer to Table 1 for types of hemorrhage and ratios of blood products transfused. Thirty-eight patients (22.8%) died within 24 hours of MTP activation, including 10 (30.3%) of the trauma patients and 28 (21.7%) of the non-trauma patients (Figure 1). Mortality did not vary significantly by type of hemorrhage or by ratio of RBC:plasma transfused, including patients receiving no plasma. For each additional RBC unit transfused, patients had a higher chance of dying (odds ratio [OR] 1.17; p=0.002, confidence interval 1.1-1.3) within 24 hours, after controlling for number of platelet, plasma, and cryoprecipitate units received. The overall median RBC:plasma ratio transfused was 1.7 (interquartile range [IQR] 1.3-2); T-MTPs had a median ratio of 1.4 (IQR 1.1-1.9) and NT-MTPs had a median ratio of 1.7 (IQR 1.3-2.1). There was no significant difference in RBC:plasma ratios clinicians transfused for different types of hemorrhage, despite the blood bank issuing different ratios to the clinicians for T-MTPs and NT-MTPs. The total number of RBCs, platelet units, and plasma units transfused did not differ by type of hemorrhage. In all MTPs, transfusion of platelets did not have a significant impact on 24-hour survival. Conclusions: We found that only the number of RBC units transfused had a significant association (OR 1.17) with 24-hour mortality during an MTP. The RBC:plasma ratio, number of platelets or plasma, and use of platelets during an MTP did not affect 24-hour mortality. The number of RBC units transfused most likely reflects the clinician's assessment of the severity of the situation, and does not imply that the RBCs affected the 24-hour mortality. We found the ratio of products issued during an MTP was not what was actually transfused to patients, indicating that clinicians were not transfusing according to protocol. Specifically, for NT-MTPs overall, the RBC:plasma ratio transfused was lower than what the blood bank issued, indicating clinicians are choosing to infuse more plasma despite a lack of evidence in the non-trauma setting. Prospective randomized trials comparing different RBC:plasma:platelet ratios in NT-MTPs are warranted. Table 1. Blood Product Ratios Transfused by Type of Hemorrhage Type of Hemorrhage Number of Patients (%) RBC:Plasma - Median (IQR) RBC:Platelets - Median (IQR) Overall 167 (100%) 1.7 (1.3-2) 5 (4-7) Trauma 33 (20%) 1.4 (1.1-1.9) 5.5 (3.7-8.4) Postoperative 50 (30%) 1.6 (1.3-1.8) 5 (3.5-6) Gastrointestinal 29 (17%) 2 (1.7-2) 5 (4-7) Intraoperative 20 (12%) 1.6 (1.3-2.7) 6.2 (3.3-7.5) Abdominal 11 (7%) 2 (1.3-3.3) 6 (4-7) Vascular 9 (5%) 1.3 (1-2) 5 (2-5) Obstetrical 8 (5%) 2.2 (2-2.3) 5 (4-7) Central Nervous System 4 (2%) 1.8 (1.2-4) 4.2 (4-4.3) Pulmonary 2 (1%) 2 2 Superficial Soft Tissue 1 (0.5%) 1 N/A Figure 1. 24-Hour Mortality by Type of Hemorrhage Figure 1. 24-Hour Mortality by Type of Hemorrhage Disclosures No relevant conflicts of interest to declare.

scholarly journals Whole blood transfusion versus component therapy in adult trauma patients with acute major haemorrhage

2020 ◽  
Vol 37 (6) ◽  
pp. 370-378 ◽  
Author(s):  
Pascale Avery ◽  
Sarah Morton ◽  
Harriet Tucker ◽  
Laura Green ◽  
Anne Weaver ◽  
...  
Keyword(s):  
Whole Blood ◽  
Statistical Difference ◽  
Damage Control ◽  
Controlled Trial ◽  
Primary Objective ◽  
Major Haemorrhage ◽  
Blood Component ◽  
Trauma Patients ◽  
Transfusion Strategy ◽  
Significant Difference

ObjectiveIn the era of damage control resuscitation of trauma patients with acute major haemorrhage, transfusion practice has evolved to blood component (component therapy) administered in a ratio that closely approximates whole blood (WB). However, there is a paucity of evidence supporting the optimal transfusion strategy in these patients. The primary objective was therefore to establish if there is an improvement in survival at 30 days with the use of WB transfusion compared with blood component therapy in adult trauma patients with acute major haemorrhage.MethodologyA systematic literature search was performed on 15 December 2019 to identify studies comparing WB transfusion with component therapy in adult trauma patients and mortality at 30 days. Studies which did not report mortality were excluded. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development and Evaluation approach.ResultsSearch of the databases identified 1885 records, and six studies met the inclusion criteria involving 3255 patients. Of the three studies reporting 30-day mortality (one randomised controlled trial (moderate evidence) and two retrospective (low and very low evidence, respectively)), only one study demonstrated a statistically significant difference between WB and component therapy, and two found no statistical difference. Two retrospective studies reporting in-hospital mortality found no statistical difference in unadjusted mortality, but both reported statistically significant logistic regression analyses demonstrating that those with a WB transfusion strategy were less likely to die.ConclusionRecognising the limitations of this systematic review relating to the poor-quality evidence and limited number of included trials, it does not provide evidence to support or reject use of WB transfusion compared with component therapy for adult trauma patients with acute major haemorrhage.PROSPERO registration numberCRD42019131406.

Comparing the Cost and Outcomes of Laparoscopic versus Open Appendectomy for Perforated Appendicitis in Children

2013 ◽  
Vol 79 (9) ◽  
pp. 861-864 ◽  
Author(s):  
Leslie B Groves ◽  
Mitchell R. Ladd ◽  
Jared R. Gallaher ◽  
John Swanson ◽  
Robert D. Becher ◽  
...  
Keyword(s):  
Medical Center ◽  
Open Appendectomy ◽  
Perforated Appendicitis ◽  
Surgical Site Infections ◽  
Patient Characteristics ◽  
Inclusion Criteria ◽  
Patient Demographics ◽  
Significant Difference ◽  
The Cost ◽  
Laparoscopic Versus Open Appendectomy

Although laparoscopic appendectomy (LA) is accepted treatment for perforated appendicitis (PA) in children, concerns remain whether it has equivalent outcomes with open appendectomy (OA) and increased cost. A retrospective review was conducted of patients younger than age 17 years treated for PA over a 12.5-year period at a tertiary medical center. Patient characteristics, pre-operative indices, and postoperative outcomes were analyzed for patients undergoing LA and OA. Of 289 patients meeting inclusion criteria, 86 had LA (29.8%) and 203 OA (70.2%), the two groups having equivalent patient demographics and preoperative indices. Inpatient costs were not significantly different between LA and OA. LA had a lower rate of wound infection (1.2 vs 8.9%, P = 0.017), total parenteral nutrition use (23.3 vs 50.7%, P < 0.0001), and length of stay (5.56 ± 2.38 days vs 7.25 ± 3.77 days, P = 0.0001). There was no significant difference in the rate of postoperative organ space abscess, surgical re-exploration, or rehospitalization. In children with PA, LA had fewer surgical site infections and shorter lengths of hospital stay compared with OA without an increase in inpatient costs.

scholarly journals SARS-CoV-2 Seroprevalence among Health Care Workers—A Voluntary Screening Study in a Regional Medical Center in Southern Germany

2021 ◽  
Vol 18 (8) ◽  
pp. 3910
Author(s):  
Katharina Müller ◽  
Philipp Girl ◽  
Michaela Ruhnke ◽  
Mareike Spranger ◽  
Klaus Kaier ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Workers ◽  
Close Contact ◽  
Medical Center ◽  
Limited Information ◽  
Specific Antibodies ◽  
Care Workers ◽  
Significant Difference ◽  
Regional Medical ◽  
Regional Medical Center

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is associated with a potentially severe clinical manifestation, coronavirus disease 2019 (COVID-19), and currently poses a worldwide challenge. Health care workers (HCWs) are at the forefront of any health care system and thus especially at risk for SARS-CoV-2 infection due to their potentially frequent and close contact with patients suffering from COVID-19. Serum samples from 198 HCWs with direct patient contact of a regional medical center and several outpatient facilities were collected during the early phase of the pandemic (April 2020) and tested for SARS-CoV-2-specific antibodies. Commercially available IgA- and IgG-specific ELISAs were used as screening technique, followed by an in-house neutralization assay for confirmation. Neutralizing SARS-CoV-2-specific antibodies were detected in seven of 198 (3.5%) tested HCWs. There was no significant difference in seroprevalence between the regional medical center (3.4%) and the outpatient institution (5%). The overall seroprevalence of neutralizing SARS-CoV-2-specific antibodies in HCWs in both a large regional medical center and a small outpatient institution was low (3.5%) at the beginning of April 2020. The findings may indicate that the timely implemented preventive measures (strict hygiene protocols, personal protective equipment) were effective to protect from transmission of an airborne virus when only limited information on the pathogen was available.

scholarly journals 86. Ventilator-Associated Pneumonia in Trauma Intensive Care Unit, a Dilemma in Quality Metrics

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S5-S5
Author(s):  
Rajendra Karnatak ◽  
Lisa Schlitzkus ◽  
Lauren Hinkle ◽  
Elizabeth Lyden ◽  
Kelly Cawcutt ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Medical Center ◽  
Statistical Significance ◽  
Quality Metrics ◽  
Primary Objective ◽  
Trauma Patients ◽  
Ventilator Associated Pneumonia ◽  
Improvement Project ◽  
Significant Difference

Abstract Background Ventilator-associated pneumonia (VAP) definition remains controversial. Ventilator-associated event (VAE) and probable/possible VAPs are reported to the National Healthcare Network (NHSN). In trauma patients, VAPs are also reported to the Trauma Quality Improvement Project (TQIP) utilizing the National Trauma Data Bank (NTDB)’s definition. Methods We reviewed all VAPs reported to NHSN and TQIP in trauma patients at the University of Nebraska Medical Center between January 1, 2015 and June 30, 2018. The primary objective was to determine the discordance rates between NHSN and NTDB definitions. VAPs identified by both NHSN+NTDB considered concordant; if identified by only one definition, considered discordant. Secondary objectives were mortality, intensive care unit (ICU) length of stay (LOS), and ventilator (vent) days. Fisher’s exact test and the Kruskal–Wallis test were used where appropriate; P < 0.05 = statistical significance. Results In total, 998 patients had 5,624 days of vent support during the study period. One hundred and one patients were diagnosed with VAP. The median age was 43 years (range 2–92), median vent days were 14 days (range 3–128), and median ICU LOS was 16 days (range 6–47). Of the 101 patients, 28 (27%) met VAP definition by NHSN and 88 (87%) by NTDB. Of the 101 patients, 15 (15%) were concordant and 85 (85%) were discordant. Cumulative all-cause mortality was 23/101 (23%). Composite analysis showed mortality 5/15 (33%) in concordant group, 3/13 (23%) in NHSN group, and 15/73 (20%) in NTDB group (P = 0.52). Median vent days between concordant, NHSN, and NTDB groups were 14 days, 16 days, and 14 days, respectively (P = 0.71). Median ICU LOS was 17 days in concordant, 21 days in NHSN, and 14 days in NTDB group (P = 0.094). Similarly, comparison of NHSN VAE with NTDB VAP definition showed 67/101 (66%) were discordant. There was no statistically significant difference in mortality between concordant (NHSN VAE+NDTB VAP) 9/34 (26%), NHSN VAE 3/13 (23%), and NTDB VAP 11/54 (20%) (P = 0.84). Conclusion Our study showed very high discordant (85%) reporting of VAP to different agencies. No difference in mortality, ICU LOS, and vent days was noted. The high discordance of reported VAPs results in inconsistency in quality metrics and hinders initiatives to decrease VAPs depending on which definition is followed. Improved standardization is needed. Disclosures All Authors: No reported Disclosures.

scholarly journals An Endovascular Surgery Experience in Far-Forward Military Healthcare—A Case Series

2020 ◽  
Vol 185 (11-12) ◽  
pp. 2183-2188
Author(s):  
Daniel J Coughlin ◽  
Jason H Boulter ◽  
Charles A Miller ◽  
Brian P Curry ◽  
Jacob Glaser ◽  
...  
Keyword(s):  
Case Series ◽  
Interventional Neuroradiology ◽  
Military Hospital ◽  
Lingual Artery ◽  
Trauma Patients ◽  
Military Hospitals ◽  
Life Saving ◽  
Military Healthcare ◽  
Internal Iliac ◽  
First World

Abstract Summary   Introduction The advancement of interventional neuroradiology has drastically altered the treatment of stroke and trauma patients. These advancements in first-world hospitals, however, have rarely reached far forward military hospitals due to limitations in expertise and equipment. In an established role III military hospital though, these life-saving procedures can become an important tool in trauma care. Materials and Methods We report a retrospective series of far-forward endovascular cases performed by 2 deployed dual-trained neurosurgeons at the role III hospital in Kandahar, Afghanistan during 2013 and 2017 as part of Operations Resolute Support and Enduring Freedom. Results A total of 15 patients were identified with ages ranging from 5 to 42 years old. Cases included 13 diagnostic cerebral angiograms, 2 extremity angiograms and interventions, 1 aortogram and pelvic angiogram, 1 bilateral embolization of internal iliac arteries, 1 lingual artery embolization, 1 administration of intra-arterial thrombolytic, and 2 mechanical thrombectomies for acute ischemic stroke. There were no complications from the procedures. Both embolizations resulted in hemorrhage control, and 1 of 2 stroke interventions resulted in the improvement of the NIH stroke scale. Conclusions Interventional neuroradiology can fill an important role in military far forward care as these providers can treat both traumatic and atraumatic cerebral and extracranial vascular injuries. In addition, knowledge and skill with vascular access and general interventional radiology principles can be used to aid in other lifesaving interventions. As interventional equipment becomes more available and portable, this relatively young specialty can alter the treatment for servicemen and women who are injured downrange.

scholarly journals Retrospective analysis of pediatric patients with multiple rare-earth magnets ingestion: a single-center experience from China

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Yucan Zheng ◽  
Zhihua Zhang ◽  
Kunlong Yan ◽  
Hongmei Guo ◽  
Mei Li ◽  
...  
Keyword(s):  
Rare Earth ◽  
Digestive Tract ◽  
Foreign Bodies ◽  
Clinical Symptoms ◽  
Medical Center ◽  
Rare Earth Magnet ◽  
Gastrointestinal Obstruction ◽  
Asymptomatic Patients ◽  
Significant Difference ◽  
Surgical Group

Abstract Background The aim of this study was to characterize patients who ingested multiple rare-earth magnets, reveal the harm of rare-earth magnet foreign bodies in the digestive tract, and develop a clinical management algorithm. Methods This was a retrospective review of patients with rare-earth magnet foreign bodies in the digestive tract admitted to a university-affiliated pediatric medical center in China, between January 2016 and December 2019; the subset of medical data evaluated included clinical symptoms, signs, treatments and outcomes. Results A total of 51 cases were included in this study, including 36(70.6%) males and 15(29.4%) females. The magnets were passed naturally in 24(47.1%) patients and removed by intervention in 27(52.9%) patients, including 5(9.8%) cases by endoscopy and 22(43.1%) cases by surgery. Twenty-two (43.1%)cases had gastrointestinal obstruction, perforation, and fistula. Compared with the non-surgical group, the time of the surgical group from ingestion to arriving at the hospital was longer([80(5–336) vs 26(2–216)]hours, p < 0.001) while there was no significant difference in the mean age or the number of magnets swallowed. Conclusions Magnets are attractive to children, but lead to catastrophic consequences including gastrointestinal obstruction, perforation, and surgical interventions when ingested multiple magnets. Endoscopic resection should be urgently performed in the presence of multiple magnets as early as possible within 24 h, even in asymptomatic patients.

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