Infection after penetrating brain injury—An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15–19, 2019, in Austin, Texas

2019 EAST PODIUM PAPER Infection after penetrating brain injury—An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15–19, 2019, in Austin, Texas Harmon, Laura A. MD; Haase, Daniel J. MD; Kufera, Joseph A. MA; Adnan, Sakib BS; Cabral, Donna BNS; Lottenberg, Lawrence MD; Cunningham, Kyle W. MD, MPH; Bonne, Stephanie MD; Burgess, Jessica MD; Etheridge, James MD; Rehbein, Jennifer L. MD; Semon, Gregory DO; Noorbakhsh, Matthew R. MD; Cragun, Benjamin N. MD; Agrawal, Vaidehi PhD; Truitt, Michael MD; Marcotte, Joseph MD; Goldenberg, Anna DO; Behbahaninia, Milad MD; Keric, Natasha MD; Hammer, Peter M. MD; Nahmias, Jeffry MD; Grigorian, Areg MD; Turay, Dave MD; Chakravarthy, Vikram MD; Lalchandani, Priti MD; Kim, Dennis MD; Chapin, Trinette; Dunn, Julie MD; Portillo, Victor MD; Schroeppel, Thomas MD, MS; Stein, Deborah M. MD, MPH Author Information Journal of Trauma and Acute Care Surgery 87(1):p 61-67, July 2019. | DOI: 10.1097/TA.0000000000002327 Buy CME Test Erratum Abstract BACKGROUND Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ2 and Wilcoxon\u27s rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = \u3c0.001) and in patients with surgical intervention (10% vs. 3%; p \u3c 0.001). CONCLUSION There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE Therapeutic, level IV

Infection after penetrating brain injury—An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15–19, 2019, in Austin, Texas

2019 EAST PODIUM PAPER Infection after penetrating brain injury—An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15–19, 2019, in Austin, Texas Harmon, Laura A. MD; Haase, Daniel J. MD; Kufera, Joseph A. MA; Adnan, Sakib BS; Cabral, Donna BNS; Lottenberg, Lawrence MD; Cunningham, Kyle W. MD, MPH; Bonne, Stephanie MD; Burgess, Jessica MD; Etheridge, James MD; Rehbein, Jennifer L. MD; Semon, Gregory DO; Noorbakhsh, Matthew R. MD; Cragun, Benjamin N. MD; Agrawal, Vaidehi PhD; Truitt, Michael MD; Marcotte, Joseph MD; Goldenberg, Anna DO; Behbahaninia, Milad MD; Keric, Natasha MD; Hammer, Peter M. MD; Nahmias, Jeffry MD; Grigorian, Areg MD; Turay, Dave MD; Chakravarthy, Vikram MD; Lalchandani, Priti MD; Kim, Dennis MD; Chapin, Trinette; Dunn, Julie MD; Portillo, Victor MD; Schroeppel, Thomas MD, MS; Stein, Deborah M. MD, MPH Author Information Journal of Trauma and Acute Care Surgery 87(1):p 61-67, July 2019. | DOI: 10.1097/TA.0000000000002327 Buy CME Test Erratum Abstract BACKGROUND Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ2 and Wilcoxon\u27s rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = \u3c0.001) and in patients with surgical intervention (10% vs. 3%; p \u3c 0.001). CONCLUSION There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE Therapeutic, level IV

An observation-first strategy for liver injuries with blush on computed tomography is safe and effective.

INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II