The American Association for the Surgery of Trauma renal injury grading scale: Implications of the 2018 revisions for injury reclassification and predicting bleeding interventions.

BackgroundIn 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions.MethodsData on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared.ResultsOf the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34).ConclusionAbout one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions.Level of evidencePrognostic and Epidemiological Study, level III

Handsewn Bowel Anastomosis Video Demonstration

Dr. Nirula demonstrating techniques for a Handsewn Bowel Anastomosis

The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator

<div><p>Published guidelines have helped to standardize the care of patients with traumatic brain injury; however, there remains substantial variation in the decision to pursue or withhold aggressive care. The International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic calculator offers the opportunity to study and decrease variability in physician aggressiveness. The authors wish to understand how IMPACT’s prognostic calculations currently influence patient care and to better understand physician aggressiveness. The authors conducted an anonymous international, multidisciplinary survey of practitioners who provide care to patients with traumatic brain injury. Questions were designed to determine current use rates of the IMPACT prognostic calculator and thresholds of age and risk for death or poor outcome that might cause practitioners to consider withholding aggressive care. Correlations between physician aggressiveness, putative predictors of aggressiveness, and demographics were examined. One hundred fifty-four responses were received, half of which were from physicians who were familiar with the IMPACT calculator. The most frequent use of the calculator was to improve communication with patients and their families. On average, respondents indicated that in patients older than 76 years or those with a >85% chance of death or poor outcome it might be reasonable to pursue non-aggressive care. These thresholds were robust and were not influenced by provider or institutional characteristics. This study demonstrates the need to educate physicians about the IMPACT prognostic calculator. The consensus values for age and prognosis identified in our study may be explored in future studies aimed at reducing variability in physician aggressiveness and should not serve as a basis for withdrawing care.</p></div

Neuro, trauma, or med/surg intensive care unit

Patients with non-traumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without TBI fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU) and trauma intensive care units (TICU) in the management of TBI patients, and it remains unclear which TBI patients are best served in NICU, TICU, or general (Med/Surg) ICU.This study is a secondary analysis of The American Association for the Surgery of Trauma Multi-Institutional Trials Committee (AAST-MITC) decompressive craniectomy study. Twelve Level 1 trauma centers provided clinical data and head CT scans of patients with Glasgow Coma Scale (GCS) ≤13 and CT evidence of TBI. Non-ICU admissions were excluded. Multivariate logistic regression was performed to measure the association between ICU-type and survival and calculate the probability of death for increasing ISS. Polytrauma patients (ISS &gt; 15) with TBI and isolated TBI patients (other AIS &lt; 3) were analyzed separately.There were 3641 patients with CT evidence of TBI with 2951 admitted to an ICU. Prior to adjustment, patient demographics, injury severity, and survival differed significantly by unit type. After adjustment, unit-type, age and ISS remained independent predictors of death. Unit-type modified the effect of ISS on mortality. TBI-polytrauma patients admitted to a TICU had improved survival across increasing ISS (Fig1). Survival for isolated TBI patients was similar between TICU and NICU. Med/Surg ICU carried the greatest probability of death.Polytrauma patients with TBI have lower mortality risk when admitted to a Trauma ICU. This survival benefit increases with increasing injury severity. Isolated TBI patients have similar mortality risk when admitted to a Neuro ICU compared to a Trauma ICU. Med/Surg ICU admission carries the highest mortality risk.III

The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator - Fig 2

<p><b>Responses to survey questions 12, 13, 14, and 15 (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0183552#pone.0183552.s001" target="_blank">S1 Survey</a>, Supplemental Digital Content 1) are presented in A, B, C, and D, respectively.</b> General surgeons returned a larger number of survey responses (109), neurosurgeons returned 37 responses; the remaining practitioners (neither GS nor NS) returned 7 surveys. <b>A)</b> The proportion of respondents that reported awareness of the IMPACT prognostic calculator by specialty. <b>B)</b> Reported frequency of use of the IMPACT prognostic calculator in patient management by specialty (p = 0.236). Over 45% of all respondents that were aware of the calculator “Never” use it in practice. <b>C)</b> Influence of IMPACT prognostic calculations on patient care by specialty. <b>D)</b> Reported uses of the IMPACT prognostic calculator by specialty. Respondents could select more than one option.</p

Characteristics of survey respondents.

<p>Characteristics of survey respondents.</p

The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator - Fig 3

<p><b>Responses to survey questions 18, 19, 17, and 16 (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0183552#pone.0183552.s001" target="_blank">S1 Survey</a>, Supplemental Digital Content 1) are presented in A, B, C, and D, respectively.</b> In our survey, we posed a series of questions that assumed the calculator produced results that were 100% accurate. <b>A)</b> Reported extent to which age influences aggressive care among different specialties, by specialty. Just over 10% of all respondents said that age had no influence on their decision making. <b>B)</b> Reported age threshold at which one might consider withholding aggressive care, by specialty. <b>C)</b> Reported chance of poor outcome that prompts comfort care considerations, by specialty. <b>D)</b> Reported chance of mortality that prompts comfort care considerations, by specialty. Error bars represent standard error.</p

Effect of variables on physician aggressiveness.

<p><b>A)</b> Chance of mortality that prompts withholding aggressive care by years in practice. <b>B)</b> Chance of mortality that prompts withholding aggressive care by trauma center level. <b>C)</b> Chance of mortality that prompts withholding aggressive care by trauma volume per year. <b>D)</b> Chance of mortality that prompts withholding aggressive care by frequency of TBI care provided.</p