A Comparison Between the Teg 6s and Teg 5000 Analyzers to Assess Coagulation in Trauma Patients

BACKGROUND Trauma-induced coagulopathy is a major driver of mortality following severe injury. Viscoelastic goal-directed resuscitation can reduce mortality after injury. The TEG 5000 system is widely used for viscoelastic testing. However, the TEG 6s system incorporates newer technology, with encouraging results in cardiovascular interventions. The purpose of this study was to validate the TEG 6s system for use in trauma patients. METHODS Multicenter noninvasive observational study for method comparison conducted at 12 US Levels I and II trauma centers. Agreement between the TEG 6s and TEG 5000 systems was examined using citrated kaolin reaction time (CK.R), citrated functional fibrinogen maximum amplitude (CFF.MA), citrated kaolin percent clot lysis at 30 minutes (CK.LY30), citrated RapidTEG maximum amplitude (CRT.MA), and citrated kaolin maximum amplitude (CK.MA) parameters in adults meeting full or limited trauma team criteria. Blood was drawn ≤1 hour after admission. Assays were repeated in duplicate. Reliability (TEG 5000 vs. TEG 6s analyzers) and repeatability (interdevice comparison) was quantified. Linear regression was used to define the relationship between TEG 6s and TEG 5000 devices. RESULTS A total of 475 patients were enrolled. The cohort was predominantly male (68.6%) with a median age of 49 years. Regression line slope estimates (ß) and linear correlation estimates (p) were as follows: CK.R (ß = 1.05, ρ = 0.9), CFF.MA (ß = 0.99, ρ = 0.95), CK.LY30 (ß = 1.01, ρ = 0.91), CRT.MA (TEG 6s) versus CK.MA (TEG 5000) (ß = 1.06, ρ = 0.86) as well as versus CRT.MA (TEG 5000) (ß = 0.93, ρ = 0.93), indicating strong reliability between the devices. Overall, within-device repeatability was better for TEG 6s versus TEG 5000, particularly for CFF.MA and CK.LY30. CONCLUSION The TEG 6s device appears to be highly reliable for use in trauma patients, with close correlation to the TEG 5000 device and equivalent/improved within-device reliability. Given the potential advantages of using the TEG 6s device at the site of care, confirmation of agreement between the devices represents an important advance in diagnostic testing. LEVEL OF EVIDENCE Diagnostic test, level II

Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury

Purpose: Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI. Methods: Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD). Results: We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43 years (IQR, 29–58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90 days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90 days (BTAI vs. TBAD; 13% vs. 29%; p &lt;.001). Conclusion: We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.</p

Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury

Purpose: Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI. Methods: Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD). Results: We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43 years (IQR, 29–58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90 days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90 days (BTAI vs. TBAD; 13% vs. 29%; p &lt;.001). Conclusion: We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.</p

Developing a decision instrument to guide abdominal-pelvic imaging of blunt trauma patients: Methodology and protocol of the NEXUS abdominal-pelvic imaging study.

Although computed tomography (CT) of the abdomen and pelvis (A/P) can provide crucial information for managing blunt trauma patients, liberal and indiscriminant imaging is expensive, can delay critical interventions, and unnecessarily exposes patients to ionizing radiation. Currently no definitive recommendations exist detailing which adult blunt trauma patients should receive A/P CT imaging and which patients may safely forego CT. Considerable benefit could be realized by identifying clinical criteria that reliably classify the risk of abdominal and pelvic injuries in blunt trauma patients. Patients identified as "very low risk" by such criteria would be free of significant injury, receive no benefit from imaging and therefore could be safely spared the expense and radiation exposure associated with A/P CT. The goal of this two-phase nationwide multicenter observational study is to derive and validate the use of clinical criteria to stratify the risk of injuries to the abdomen and pelvis among adult blunt trauma patients. We estimate that nation-wide implementation of a rigorously developed decision instrument could safely reduce CT imaging of adult blunt trauma patients by more than 20%, and reduce annual radiographic charges by $180 million, while simultaneously expediting trauma care and decreasing radiation exposure with its attendant risk of radiation-induced malignancy. Prior to enrollment we convened an expert panel of trauma surgeons, radiologists and emergency medicine physicians to develop a consensus definition for clinically significant abdominal and pelvic injury. In the first derivation phase of the study, we will document the presence or absence of preselected candidate criteria, as well as the presence or absence of significant abdominal or pelvic injuries in a cohort of blunt trauma victims. Using recursive partitioning, we will examine combinations of these criteria to identify an optimal "very low risk" subset that identifies injuries with a sensitivity exceeding 98%, excludes injury with a negative predictive value (NPV) greater than 98%, and retains the highest possible specificity and potential to decrease imaging. In Phase 2 of the study we will validate the performance of a decision rule based on these criteria among a new cohort of patients to ensure that the criteria retain high sensitivity, NPV and optimal specificity. Validating the sensitivity of the decision instrument with high statistical precision requires evaluations on 317 blunt trauma patients who have significant abdominal-pelvic injuries, which will in turn require evaluations on approximately 6,340 blunt trauma patients. We will estimate potential reductions in CT imaging by counting the number of abdominal-pelvic CT scans performed on "very low risk" patients. Reductions in charges and radiation exposure will be determined by respectively summing radiographic charges and lifetime decreases in radiation morbidity and mortality for all "very low risk" cases. Trial registration: Clinicaltrials.gov trial registration number: NCT04937868

Developing a decision instrument to guide abdominal-pelvic imaging of blunt trauma patients: Methodology and protocol of the NEXUS abdominal-pelvic imaging study

Although computed tomography (CT) of the abdomen and pelvis (A/P) can provide crucial information for managing blunt trauma patients, liberal and indiscriminant imaging is expensive, can delay critical interventions, and unnecessarily exposes patients to ionizing radiation. Currently no definitive recommendations exist detailing which adult blunt trauma patients should receive A/P CT imaging and which patients may safely forego CT. Considerable benefit could be realized by identifying clinical criteria that reliably classify the risk of abdominal and pelvic injuries in blunt trauma patients. Patients identified as “very low risk” by such criteria would be free of significant injury, receive no benefit from imaging and therefore could be safely spared the expense and radiation exposure associated with A/P CT. The goal of this two-phase nationwide multicenter observational study is to derive and validate the use of clinical criteria to stratify the risk of injuries to the abdomen and pelvis among adult blunt trauma patients. We estimate that nation-wide implementation of a rigorously developed decision instrument could safely reduce CT imaging of adult blunt trauma patients by more than 20%, and reduce annual radiographic charges by $180 million, while simultaneously expediting trauma care and decreasing radiation exposure with its attendant risk of radiation-induced malignancy. Prior to enrollment we convened an expert panel of trauma surgeons, radiologists and emergency medicine physicians to develop a consensus definition for clinically significant abdominal and pelvic injury. In the first derivation phase of the study, we will document the presence or absence of preselected candidate criteria, as well as the presence or absence of significant abdominal or pelvic injuries in a cohort of blunt trauma victims. Using recursive partitioning, we will examine combinations of these criteria to identify an optimal “very low risk” subset that identifies injuries with a sensitivity exceeding 98%, excludes injury with a negative predictive value (NPV) greater than 98%, and retains the highest possible specificity and potential to decrease imaging. In Phase 2 of the study we will validate the performance of a decision rule based on these criteria among a new cohort of patients to ensure that the criteria retain high sensitivity, NPV and optimal specificity. Validating the sensitivity of the decision instrument with high statistical precision requires evaluations on 317 blunt trauma patients who have significant abdominal-pelvic injuries, which will in turn require evaluations on approximately 6,340 blunt trauma patients. We will estimate potential reductions in CT imaging by counting the number of abdominal-pelvic CT scans performed on “very low risk” patients. Reductions in charges and radiation exposure will be determined by respectively summing radiographic charges and lifetime decreases in radiation morbidity and mortality for all “very low risk” cases. Trial registration: Clinicaltrials.gov trial registration number: NCT04937868

Spontaneous Retroperitoneal and Rectus Sheath HemorrhageManagement, Risk Factors and Outcomes

BackgroundSpontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The objective of this study was to identify early predictors of the need for angiographic or surgical intervention (ASI) in patients with SRRSH and define risk factors for mortality.MethodsWe conducted a retrospective cohort study at a tertiary academic hospital. All patients with computed tomography-identified SRRSH between 2012 to 2017 were included. Exclusion criteria were age below 18years, possible mechanical cause of SRRSH, aortic aneurysm rupture or dissection, and traumatic or iatrogenic sources of SRRSH. The primary outcome was the incidence of ASI and/or mortality.ResultsOf 100 patients included (median age 70years, 52% males), 33% were transferred from another hospital, 82% patients were on therapeutic anticoagulation, and 90% had serious comorbidities. Overall mortality was 22%, but SRRSH-related mortality was only 6%. Sixteen patients underwent angiographic intervention (n=10), surgical intervention (n=5), or both (n=1). Flank pain (OR 4.15, 95% CI 1.21-14.16, p=0.023) and intravenous contrast extravasation (OR 3.89, 95% CI 1.23-12.27, p=0.020) were independent predictors of ASI. Transfer from another hospital (OR 3.72, 95% CI 1.30-10.70, p=0.015), age above 70years (OR 4.24, 95% CI 1.25-14.32, p=0.020), and systolic blood pressure below 110mmHg at the time of diagnosis (OR 4.59, 95% CI 1.19-17.68, p=0.027) were independent predictors of mortality.ConclusionsSRRSH is associated with high mortality but is typically not the direct cause. Most SRRSHs are self-limited and require no intervention. Pattern identification of ASI is hard

Bile Spillage as a Risk Factor for Surgical Site Infection after Laparoscopic Cholecystectomy: A Prospective Study of 1,001 Patients

BACKGROUND: Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. We hypothesized that BS increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. STUDY DESIGN: Patients older than 18, who were admitted to an academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy, from May 2010 to March 2017, were prospectively included. Open cholecystectomies were excluded. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge. We compared those who had BS during the operation with those who did not. Our primary endpoint was the rate of SSI. Stepwise logistic regression was used to identify independent predictors of SSI. RESULTS: Of 1,001 patients, 49.9% underwent laparoscopic cholecystectomy for acute cholecystitis, 20.9% for symptomatic cholelithiasis or biliary colic, 12.8% for gallstone pancreatitis, and 16.4% for other indications. Bile was spilled intraoperatively in 591 patients (59.0%), with hydrops noted in 10.5% and empyema in 14.6% of them. In 202 (20.2%) patients, BS was accompanied by stone spillage. Patients with BS were older (median age of 52 vs 42, p 2 were independent predictors of SSI (odds ratios: 2.29, 2.46, and 2.1 respectively, p < 0.05). CONCLUSIONS: Bile spillage is associated with SSI, and surgeons should take extra caution to avoid it during laparoscopic cholecystectomy. (C) 2018 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved