Adherence to guideline of venous thromboembolism prophylaxis in a level 1 Trauma center in Thailand

Objective: Venous thromboembolism (VTE) which includes deep vein thrombosis (DVT) and pulmonary embolism is a preventable complication in hospitalized trauma patients. Currently, the VTE guideline is the standard of care. However, underutilization of the guideline was reported. This study aimed to report the adherence to the VTE guideline in a Level 1 trauma center in Thailand. Methods: A retrospective review was performed on adult trauma patients admitted between January and December 2013. The inclusion criteria were Injury Severity Score 9 and admission in the hospital 7 days. The patients were classified into very high risk of DVT, high risk of DVT, and high risk of bleeding groups according to the hospital guideline. Adherence to the guideline, utility of the prophylaxis, and VTE occurrence were recorded. Results: During a 12-month period, 352 cases met the inclusion criteria. The overall adherence to the guideline was 28.9, 5.2 in the very high risk of DVT group, 18.4 in the high risk of DVT group, and 57.9 in the high risk of bleeding group. VTE occurrence was 11 incidences in 10 patients (2.8). The high risk of bleeding group had the highest in VTE occurrence (10 of 11 incidences). Conclusions: The adherence to the VTE prophylaxis guideline in Thailand was higher than previous studies. The pharmacological prophylaxis should be initiated as soon as possible

Massive Blood Transfusion for Trauma Score to Predict Massive Blood Transfusion in Trauma

Background. Massive blood loss is the most common cause of immediate death in trauma. A massive blood transfusion (MBT) score is a prediction tool to activate blood banks to prepare blood products. The previously published scoring systems were mostly developed from settings that had mature prehospital systems which may lead to a failure to validate in settings with immature prehospital systems. This research aimed to develop a massive blood transfusion for trauma (MBTT) score that is able to predict MBT in settings that have immature prehospital care. Methods. This study was a retrospective cohort that collected data from trauma patients who met the trauma team activation criteria. The predicting parameters included in the analysis were retrieved from the history, physical examination, and initial laboratory results. The significant parameters from a multivariable analysis were used to develop a clinical scoring system. The discrimination was evaluated by the area under a receiver operating characteristic (AuROC) curve. The calibration was demonstrated with Hosmer–Lemeshow goodness of fit, and an internal validation was done. Results. Among 867 patients, 102 (11.8%) patients received MBT. Four factors were associated with MBT: a score of 3 for age ≥60 years; 2.5 for base excess ≤–10 mEq/L; 2 for lactate >4 mmol/L; and 1 for heart rate ≥105 /min. The AuROC was 0.85 (95% CI: 0.78–0.91). At the cut point of ≥4, the positive likelihood ratio of the score was 6.72 (95% CI: 4.7–9.6, p < 0.001), the sensitivity was 63.6%, and the specificity was 90.5%. Internal validation with bootstrap replications had an AuROC of 0.83 (95% CI: 0.75–0.91). Conclusions. The MBTT score has good discrimination to predict MBT with simple and rapidly obtainable parameters

Combination of blood lactate level with assessment of blood consumption (ABC) scoring system: A more accurate predictor of massive transfusion requirement

Purpose: Exsanguination is the most common leading cause of death in trauma patients. The massive transfusion (MT) protocol may influence therapeutic strategies and help provide blood components in timely manner. The assessment of blood consumption (ABC) score is a popular MT protocol but has low predictability. The lactate level is a good parameter to reflect poor tissue perfusion or shock states that can guide the management. This study aimed to modify the ABC scoring system by adding the lactate level for better prediction of MT. Methods: The data were retrospectively collected from 165 trauma patients following the trauma activated criteria at Songklanagarind Hospital from January 2014 to December 2014. The ABC scoring system was applied in all patients. The patients who had an ABC score ≥2 as the cut point for MT were defined as the ABC group. All patients who had a score ≥2 with a lactate level >4 mmol/dL were defined as the ABC plus lactate level (ABC + L) group. The prediction for the requirement of massive blood transfusion was compared between the ABC and ABC + L groups. The ability of ABC and ABC + L groups to predict MT was estimated by the area under the receiver operating characteristic curve (AUROC). Results: Among 165 patients, 15 patients (9%) required massive blood transfusion. There were no significant differences in age, gender, mechanism of injury or initial vital signs between the MT group and the non-MT group. The group that required MT had a higher Injury Severity Score and mortality. The sensitivity and specificity of the ABC scoring system in our institution were low (81%, 34%, AUC 0.573). The sensitivity and specificity were significantly better in the ABC + L group (92%, 42%, AUC = 0.745). Conclusion: The ABC scoring system plus lactate increased the sensitivity and specificity compared with the ABC scoring system alone. Keywords: Assessment of blood consumption scoring system, Blood lactate level, Massive transfusio

Results of Gastric Pull-up Reconstruction for Pharyngolaryngo-oesophagectomy in Advanced Head and Neck Cancer and Cervical Oesophageal Squamous Cell Carcinoma

To study long-term clinical swallowing function and survival outcome in head and neck and cervical oesophageal cancer patients who underwent pharyngolaryngo-oesophagectomy (PLE). Methods: The clinical data of 48 patients who were treated with PLE were analysed. All patients had advanced disease, so the construction required a transposed stomach. Body weight and clinical swallowing function were evaluated postoperatively. The swallowing function was assessed at an interview concerning food ingestion and regurgitation. The survival group was studied using a Kaplan-Meier survival curve. Results: Forty-one cases of hypopharyngeal cancer and four cases of cervical oesophageal cancer were studied. In three cases (6%), hypopharyngeal and thoracic oesophageal squamous cell carcinoma occurred together. Most cases had good-to-fair results. The average body weight gain was increased after surgery. There was one hospital death. The most common complications were pulmonary (4%). Median survival was 27 months. Conclusion: A pharyngogastric anastomosis after PLE can be performed with low morbidity and good swallowing function

Scapular fractures and concomitant injuries

【Abstract】 Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized. Few studies have investigated this presumed association. In this study, we investigated the incidence of significant associated injuries with scapular fracture and their outcomes. Methods: A retrospective study was conducted from 2005 to 2009 in a level I trauma center in Thailand. All blunt trauma patients were identified. Patients’ demographics, injury mechanism, associated injuries, Injury Severity Score (ISS), and survival outcomes were recorded. The manage-ment of associated injuries with scapular fracture was reviewed, and the risk factors for mortality were identified. Results: Among the 7 345 trauma patients admitted, scapular fractures occurred in 84 cases (1.1%). The mean age was (37.98±15.21) years. Motorcycle crash was the most fre-quent mechanism of injury, occurring in 51 cases (60.7%). Seventy-four patients (88.1%) suffering from scapular frac-tures had associated injuries: 5 (6.0%) had significant chest injuries, but none of them had blunt thoracic aortic injury. Two patients (2.4%) with scapular fractures died. Factors determining the likelihood of mortality were: (1) ISS&gt;25 (LR=8.5, P&lt;0.05); (2) significant associated chest injury (AIS&gt;3, LR=5.3, P&lt;0.05) and (3) significant associated ab-dominal injury (AIS&gt;3, LR=5.3, P&lt;0.05). Conclusion: A blunt scapular fracture may not accom-pany a blunt thoracic aortic injury but it is strongly related to other injuries like chest injury, extremity injury, head injury, etc. If a scapular fracture is found with a high ISS score, high chest or abdomen AIS score, the patient would have a high risk of mortality. Key words: Aortic rupture; Shoulder fractures; Mul-tiple trauma; Mortalit