Forced vital capacity less than 1: A mark for high-risk patients

BACKGROUND: Rib fractures (RFx) continue to be a source of morbidity and mortality. A RFx care pathway has been used based on forced vital capacity (FVC). The objective of this study was to test the hypothesis that deterioration of FVC to less than 1 after admission is a marker for high-risk patients and affects outcomes. METHODS: A retrospective study of patients enrolled in an RFx care pathway at a Level 1 trauma center from 2009 to 2014. All patients had an admission FVC greater than 1. 2 groups were analyzed: patients with a lowest inpatient FVC less than 1 (Group A) compared to patients with lowest inpatient FVC of 1 or greater (Group B). Complications [pneumonia, upgrade to the intensive care unit, readmission, and intubation] and demographics were examined. Patients without documented admission FVCs were excluded. p \u3c 0.05 was considered significant. RESULTS: A total of 1,106 patients were analyzed (Group A, 187; Group B, 919). Patients whose FVC dropped less than 1 (Group A) had a higher complication rate [15% (Group A) vs 3.2% (Group B); p \u3c 0.001]. Rates of pneumonia, readmission, unplanned upgrade, and intubation were all significantly higher in Group A [pneumonia: 9% (Group A) vs 1.4% (Group B), p \u3c 0.001; readmission: 4% (Group A) vs 1.7% (Group B), p = 0.04; upgrade; 3.7% (Group A) vs 0.2% (Group B), p \u3c 0.001; intubation: 1.6% (Group A) vs 0.1% (Group B), p = 0.02]. Hospital length of stay was longer in Group A [10 days (Group A) vs 4 days (Group B), p \u3c 0.001]. CONCLUSIONS: Forced vital capacity predicts complications in patients with RFx. Patients whose FVC falls less than 1 during admission are at high risk for pulmonary complications. Daily FVC testing for patients admitted with RFx can predict outcomes. Forced vital capacity less than 1 should be considered as a marker for complications. Once FVC drops less than 1, patients should be considered for increased interventions. Even if the patient has not yet clinically deteriorated, consideration for higher level of care is warranted

Are roadside pedestrian injury patterns predictable in a densely populated, urban setting?

BACKGROUND: Roadside pedestrian injuries represent a significant portion of trauma team activations, especially at urban trauma centers. Patient demographics and severity of injury vary greatly in this patient population. Herein, we hypothesize that injury patterns may be predictable, especially with respect to age. MATERIALS AND METHODS: All patients with roadside pedestrian injuries evaluated at our urban, level one trauma center from January 2006 through December 2008 were retrospectively reviewed. Data were collected from the institutional trauma registry. Age was used as an independent variable and compared with injury type, substance abuse, discharge setting, and mortality. RESULTS: There were 226 roadside pedestrian injuries during the study period. Patients were divided into groups according to age, under 20 y, 21-40 y, 41-65 y, and over 65 y. Head injuries were more prevalent in patients over age 65, 30.4% versus 14.0% (P = 0.05). There was a trend for increasing alcohol use in the younger population. The likelihood of discharge to a rehab facility increased with age, 0%, 11.8%, 38.2%, 50.0%, respectively (P \u3c 0.001). Mortality was significantly higher in patients older than 65 y, 15.2% versus 3.3% (P = 0.049). CONCLUSIONS: Roadside pedestrian injuries have predictable injury patterns based on age. Older patients are more likely to have a head injury, longer length of stay, need for a rehab stay, and have a higher mortality. Further studies are needed to correlate precise injuries with collision mechanism and evaluate specific risk factors in this high risk population

Linear Shear Conditioning Improves Vascular Graft Retention of Adipose-Derived Stem Cells by Upregulation of the α5β1 Integrin

Use of adult adipose-derived stem cells (ASCs) as endothelial cell substitutes in vascular tissue engineering is attractive because of their availability. However, when seeded onto decellularized vascular scaffolding and exposed to physiological fluid shear force, ASCs are physically separated from the graft lumen. Herein we have investigated methods of increasing initial ASC attachment using luminal precoats and a novel protocol for the gradual introduction of shear stress to optimize ASC retention. Fibronectin coating of the graft lumen increased ASC attachment by nearly sixfold compared with negative controls. Gradual introduction of near physiological fluid shear stress using a novel bioreactor whereby flow rate was increased every second at a rate of 1.5 dynes/cm2 per day resulted in complete luminal coverage compared with near complete cell loss following conventional daily abrupt increases. An upregulation of the α5β1 integrin was evinced following exposure to shear stress, which accounts for the observed increase in ASC retention on the graft lumen. These results indicated a novel method for seeding, conditioning, and retaining of adult stem cells on a decellularized vein scaffold within a high-shear stress microenvironment

Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study

BACKGROUND: The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS: Patients enrolled in the Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS: There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy ( = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION: The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research

Colorectal resection in emergency general surgery: An EAST multicenter trial

OBJECTIVE Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. ?2, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p \u3c 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p \u3c 0.001), on vasopressors (61 vs. 13, p \u3c 0.001), have pneumoperitoneum (131 vs. 41, p \u3c 0.001) or fecal contamination (114 vs. 33, p \u3c 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p \u3c 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE Therapeutic study, level IV