EAST 2015

LAKE BUENA VISTA, FLA. – Base deficit and lactate after resuscitation were measurably different based on the type of crystalloid solution used in a class I hemorrhage model.

Further, an award-winning prospective study found that, compared with lactated Ringer’s or no intravenous fluid, normal saline results in significantly higher postresuscitation sodium and chloride levels and significantly lower ionized calcium and bicarbonate.

Taken together, these derangements are important because blood gases are one of the first objective measurements performed in acute trauma patients, Dr. Samuel Wade Ross said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Patrice Wendling/Frontline Medical News

“We might actually be overestimating the amount of shock due specifically to the iatrogenic cause of crystalloid solutions,” he said. “Additionally, this goes beyond just trauma because all medicine – surgery, anesthesia, and critical care – use crystalloid. And it should be in the back of our minds when using normal saline that this contributes to acidosis and that lactated Ringer’s can falsely elevate lactate levels.”

The analysis involved 157 voluntary blood donors, who donated 0.5 L and were then randomly assigned to normal saline, lactated Ringer’s (LR), or no IV fluid. The percentage of total blood volume lost was about 11%, which is consistent with a class I hemorrhage model, said Dr. Ross of the Carolinas Medical Center in Charlotte, N.C.

Base deficit, which is used to guide the volume of fluid needed for trauma patients’ resuscitation, was similar before administration of normal saline, lactated Ringer’s, or no IV fluid (–0.24 vs. 0.33 vs. 0.04).

After fluid administration, however, the normal saline group had almost five times the base deficit of the no IV fluid group (–3.06 vs. –0.65) and almost 10 times the base deficit of the LR group (–3.06 vs. –0.34). The differences were statistically significant, even using a conservative statistical correction with a P value cutoff of 0.0167, he said.

Preresuscitation lactate levels also were similar in the LR, normal saline, and no IV groups (1.05 mmol/L vs. 1.12 mmol/L vs. 1.10 mmol/L).

Postresuscitation, however, lactate increased by roughly 50% in the LR group vs. the normal saline group (1.54 mmol/L vs. 1.0 mmol/L) and was elevated compared with no IV fluid (1.54 mmol/L vs. 1.36 mmol/L). Both findings were statistically significant (P < .0167).

This is the first time these differences have been quantified and runs contrary to the dogma that serum lactate does not increase with the use of LR because of enzymatic clearance of the molecule in the liver, said Dr. Ross, the EAST 2015 Raymond Alexander Residents Paper Competition winner.

“With ongoing shock, lactate rises and clinicians use that as a guide for further fluid resuscitation. Thus, lactate levels could be falsely elevated with LR use, and drive further decisions for unnecessary and potentially harmful additional resuscitation and procedures,” he said in an interview.

As noted above, use of normal saline rather than LR or no IV fluid resulted in significantly higher postresuscitation sodium (141.7 mmol/L vs. 139.8 mmol/L vs. 139.8 mmol/L) and chloride (107.3 mmol/L vs. 102.3 mmol/L vs. 102.9 mmol/L), and significantly lower ionized calcium (1.15 vs. 1.22 vs. 1.24), pH (7.32 vs. 7.34 vs. 7.36), and bicarbonate (23 mmol/L vs. 25.3 mmol/L vs. 24.6 mmol/L; all P values < .001).

“The two recommended isotonic crystalloid fluids used for hemorrhagic and other forms of shock – normal saline and lactated Ringer’s – have been in use since the 19th century and early 20th century,” senior author Dr. Ronald F. Sing said in an interview. “Despite the tremendous advances in shock and resuscitation, we have identified, and actually confirmed, potentially confounding factors related to both LR and [normal saline] for resuscitation. Our next goal is to examine other crystalloid solutions and their impacts not only on shock markers, but inflammatory markers,” he added.

Future studies also will use animal models to look at class II-IV hemorrhage and increased follow-up time.

The study was supported by the Carolinas Trauma Network. Dr. Ross and his coauthors reported having no financial disclosures.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – Base deficit and lactate after resuscitation were measurably different based on the type of crystalloid solution used in a class I hemorrhage model.

Further, an award-winning prospective study found that, compared with lactated Ringer’s or no intravenous fluid, normal saline results in significantly higher postresuscitation sodium and chloride levels and significantly lower ionized calcium and bicarbonate.

Taken together, these derangements are important because blood gases are one of the first objective measurements performed in acute trauma patients, Dr. Samuel Wade Ross said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Patrice Wendling/Frontline Medical News

“We might actually be overestimating the amount of shock due specifically to the iatrogenic cause of crystalloid solutions,” he said. “Additionally, this goes beyond just trauma because all medicine – surgery, anesthesia, and critical care – use crystalloid. And it should be in the back of our minds when using normal saline that this contributes to acidosis and that lactated Ringer’s can falsely elevate lactate levels.”

The analysis involved 157 voluntary blood donors, who donated 0.5 L and were then randomly assigned to normal saline, lactated Ringer’s (LR), or no IV fluid. The percentage of total blood volume lost was about 11%, which is consistent with a class I hemorrhage model, said Dr. Ross of the Carolinas Medical Center in Charlotte, N.C.

Base deficit, which is used to guide the volume of fluid needed for trauma patients’ resuscitation, was similar before administration of normal saline, lactated Ringer’s, or no IV fluid (–0.24 vs. 0.33 vs. 0.04).

After fluid administration, however, the normal saline group had almost five times the base deficit of the no IV fluid group (–3.06 vs. –0.65) and almost 10 times the base deficit of the LR group (–3.06 vs. –0.34). The differences were statistically significant, even using a conservative statistical correction with a P value cutoff of 0.0167, he said.

Preresuscitation lactate levels also were similar in the LR, normal saline, and no IV groups (1.05 mmol/L vs. 1.12 mmol/L vs. 1.10 mmol/L).

Postresuscitation, however, lactate increased by roughly 50% in the LR group vs. the normal saline group (1.54 mmol/L vs. 1.0 mmol/L) and was elevated compared with no IV fluid (1.54 mmol/L vs. 1.36 mmol/L). Both findings were statistically significant (P < .0167).

This is the first time these differences have been quantified and runs contrary to the dogma that serum lactate does not increase with the use of LR because of enzymatic clearance of the molecule in the liver, said Dr. Ross, the EAST 2015 Raymond Alexander Residents Paper Competition winner.

“With ongoing shock, lactate rises and clinicians use that as a guide for further fluid resuscitation. Thus, lactate levels could be falsely elevated with LR use, and drive further decisions for unnecessary and potentially harmful additional resuscitation and procedures,” he said in an interview.

As noted above, use of normal saline rather than LR or no IV fluid resulted in significantly higher postresuscitation sodium (141.7 mmol/L vs. 139.8 mmol/L vs. 139.8 mmol/L) and chloride (107.3 mmol/L vs. 102.3 mmol/L vs. 102.9 mmol/L), and significantly lower ionized calcium (1.15 vs. 1.22 vs. 1.24), pH (7.32 vs. 7.34 vs. 7.36), and bicarbonate (23 mmol/L vs. 25.3 mmol/L vs. 24.6 mmol/L; all P values < .001).

“The two recommended isotonic crystalloid fluids used for hemorrhagic and other forms of shock – normal saline and lactated Ringer’s – have been in use since the 19th century and early 20th century,” senior author Dr. Ronald F. Sing said in an interview. “Despite the tremendous advances in shock and resuscitation, we have identified, and actually confirmed, potentially confounding factors related to both LR and [normal saline] for resuscitation. Our next goal is to examine other crystalloid solutions and their impacts not only on shock markers, but inflammatory markers,” he added.

Future studies also will use animal models to look at class II-IV hemorrhage and increased follow-up time.

The study was supported by the Carolinas Trauma Network. Dr. Ross and his coauthors reported having no financial disclosures.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – Base deficit and lactate after resuscitation were measurably different based on the type of crystalloid solution used in a class I hemorrhage model.

Further, an award-winning prospective study found that, compared with lactated Ringer’s or no intravenous fluid, normal saline results in significantly higher postresuscitation sodium and chloride levels and significantly lower ionized calcium and bicarbonate.

Taken together, these derangements are important because blood gases are one of the first objective measurements performed in acute trauma patients, Dr. Samuel Wade Ross said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Patrice Wendling/Frontline Medical News

“We might actually be overestimating the amount of shock due specifically to the iatrogenic cause of crystalloid solutions,” he said. “Additionally, this goes beyond just trauma because all medicine – surgery, anesthesia, and critical care – use crystalloid. And it should be in the back of our minds when using normal saline that this contributes to acidosis and that lactated Ringer’s can falsely elevate lactate levels.”

The analysis involved 157 voluntary blood donors, who donated 0.5 L and were then randomly assigned to normal saline, lactated Ringer’s (LR), or no IV fluid. The percentage of total blood volume lost was about 11%, which is consistent with a class I hemorrhage model, said Dr. Ross of the Carolinas Medical Center in Charlotte, N.C.

Base deficit, which is used to guide the volume of fluid needed for trauma patients’ resuscitation, was similar before administration of normal saline, lactated Ringer’s, or no IV fluid (–0.24 vs. 0.33 vs. 0.04).

After fluid administration, however, the normal saline group had almost five times the base deficit of the no IV fluid group (–3.06 vs. –0.65) and almost 10 times the base deficit of the LR group (–3.06 vs. –0.34). The differences were statistically significant, even using a conservative statistical correction with a P value cutoff of 0.0167, he said.

Preresuscitation lactate levels also were similar in the LR, normal saline, and no IV groups (1.05 mmol/L vs. 1.12 mmol/L vs. 1.10 mmol/L).

Postresuscitation, however, lactate increased by roughly 50% in the LR group vs. the normal saline group (1.54 mmol/L vs. 1.0 mmol/L) and was elevated compared with no IV fluid (1.54 mmol/L vs. 1.36 mmol/L). Both findings were statistically significant (P < .0167).

This is the first time these differences have been quantified and runs contrary to the dogma that serum lactate does not increase with the use of LR because of enzymatic clearance of the molecule in the liver, said Dr. Ross, the EAST 2015 Raymond Alexander Residents Paper Competition winner.

“With ongoing shock, lactate rises and clinicians use that as a guide for further fluid resuscitation. Thus, lactate levels could be falsely elevated with LR use, and drive further decisions for unnecessary and potentially harmful additional resuscitation and procedures,” he said in an interview.

As noted above, use of normal saline rather than LR or no IV fluid resulted in significantly higher postresuscitation sodium (141.7 mmol/L vs. 139.8 mmol/L vs. 139.8 mmol/L) and chloride (107.3 mmol/L vs. 102.3 mmol/L vs. 102.9 mmol/L), and significantly lower ionized calcium (1.15 vs. 1.22 vs. 1.24), pH (7.32 vs. 7.34 vs. 7.36), and bicarbonate (23 mmol/L vs. 25.3 mmol/L vs. 24.6 mmol/L; all P values < .001).

“The two recommended isotonic crystalloid fluids used for hemorrhagic and other forms of shock – normal saline and lactated Ringer’s – have been in use since the 19th century and early 20th century,” senior author Dr. Ronald F. Sing said in an interview. “Despite the tremendous advances in shock and resuscitation, we have identified, and actually confirmed, potentially confounding factors related to both LR and [normal saline] for resuscitation. Our next goal is to examine other crystalloid solutions and their impacts not only on shock markers, but inflammatory markers,” he added.

Future studies also will use animal models to look at class II-IV hemorrhage and increased follow-up time.

The study was supported by the Carolinas Trauma Network. Dr. Ross and his coauthors reported having no financial disclosures.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – Screening for intimate partner and sexual violence occurs sporadically in trauma centers, typically among women and when there is a suspicious mechanism of injury.

In hopes of reaching a broader population, investigators at the Ryder Trauma Center at the University of Miami conducted a prospective pilot study to determine the feasibility of universal screening for intimate partner and sexual violence in all patients presenting at the level I trauma center.

In all, 399 consecutive patients were eligible, with 40% screened using a four-item questionnaire that asks patients how often their partner physically hurt, insulted, threatened with harm, and screamed at them (HITS) and the SAVE (screen, ask, validate, evaluate) method developed in Florida to screen for sexual violence. Both instruments were available in English, Spanish, and Haitian French.

Over a 4-month period, 14% of patients scored positive for physical and psychological abuse – and even more surprising, 8% scored positive for sexual violence, lead study author Dr. Tanya Zakrison reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

“Interestingly, there was no significant difference between men and women. They were all scoring at an equal rate,” Dr. Zakrison said. Patients who scored positive on HITS or SAVE were also found across all ethnicities and all age groups.

“The last thing that was quite surprising for us to find was that only 14% of patients who were HITS positive were actually admitted as a result of intimate partner or interpersonal violence, and none of the patients who scored positive for SAVE were admitted to trauma because of this,” she added. “Again, they’re coming in for the motor vehicle collisions, falls from standing, or other mechanisms of injury.”

To learn more about the intervention and its impact at Ryder Trauma, watch our video interview.

Dr. Zakrison and her coauthors reported no relevant financial conflicts.

LAKE BUENA VISTA, FLA. – Screening for intimate partner and sexual violence occurs sporadically in trauma centers, typically among women and when there is a suspicious mechanism of injury.

In hopes of reaching a broader population, investigators at the Ryder Trauma Center at the University of Miami conducted a prospective pilot study to determine the feasibility of universal screening for intimate partner and sexual violence in all patients presenting at the level I trauma center.

In all, 399 consecutive patients were eligible, with 40% screened using a four-item questionnaire that asks patients how often their partner physically hurt, insulted, threatened with harm, and screamed at them (HITS) and the SAVE (screen, ask, validate, evaluate) method developed in Florida to screen for sexual violence. Both instruments were available in English, Spanish, and Haitian French.

Over a 4-month period, 14% of patients scored positive for physical and psychological abuse – and even more surprising, 8% scored positive for sexual violence, lead study author Dr. Tanya Zakrison reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

“Interestingly, there was no significant difference between men and women. They were all scoring at an equal rate,” Dr. Zakrison said. Patients who scored positive on HITS or SAVE were also found across all ethnicities and all age groups.

“The last thing that was quite surprising for us to find was that only 14% of patients who were HITS positive were actually admitted as a result of intimate partner or interpersonal violence, and none of the patients who scored positive for SAVE were admitted to trauma because of this,” she added. “Again, they’re coming in for the motor vehicle collisions, falls from standing, or other mechanisms of injury.”

To learn more about the intervention and its impact at Ryder Trauma, watch our video interview.

Dr. Zakrison and her coauthors reported no relevant financial conflicts.

LAKE BUENA VISTA, FLA. – Screening for intimate partner and sexual violence occurs sporadically in trauma centers, typically among women and when there is a suspicious mechanism of injury.

In hopes of reaching a broader population, investigators at the Ryder Trauma Center at the University of Miami conducted a prospective pilot study to determine the feasibility of universal screening for intimate partner and sexual violence in all patients presenting at the level I trauma center.

In all, 399 consecutive patients were eligible, with 40% screened using a four-item questionnaire that asks patients how often their partner physically hurt, insulted, threatened with harm, and screamed at them (HITS) and the SAVE (screen, ask, validate, evaluate) method developed in Florida to screen for sexual violence. Both instruments were available in English, Spanish, and Haitian French.

Over a 4-month period, 14% of patients scored positive for physical and psychological abuse – and even more surprising, 8% scored positive for sexual violence, lead study author Dr. Tanya Zakrison reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

“Interestingly, there was no significant difference between men and women. They were all scoring at an equal rate,” Dr. Zakrison said. Patients who scored positive on HITS or SAVE were also found across all ethnicities and all age groups.

“The last thing that was quite surprising for us to find was that only 14% of patients who were HITS positive were actually admitted as a result of intimate partner or interpersonal violence, and none of the patients who scored positive for SAVE were admitted to trauma because of this,” she added. “Again, they’re coming in for the motor vehicle collisions, falls from standing, or other mechanisms of injury.”

To learn more about the intervention and its impact at Ryder Trauma, watch our video interview.

Dr. Zakrison and her coauthors reported no relevant financial conflicts.

LAKE BUENA VISTA, FLA. – Contrary to prior results, use of onabotulinumtoxinA did not improve primary fascial closure rates after damage control laparotomy in a multicenter, prospective study.

“Botox injections were safe, but they did not have any effect on our primary or secondary endpoints,” Dr. Martin D. Zielinski said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Patrice Wendling/Frontline Medical News

Dr. Zielinski and his colleagues at Mayo Clinic, Rochester, Minn., previously published retrospective data showing that use of Botox-induced paralysis of the abdominal wall musculature resulted in a primary fascial closure rate of 83% among 18 patients with open abdomen (OA) and 89% if injected within 24 hours of the initial OA procedure (Hernia 2013;17:101-7).

In contrast, the primary closure rate was just 66% in a prospective American Association for the Surgery of Trauma study involving 572 patients requiring OA management after damage control laparotomy (J. Trauma Acute Care Surg. 2013;74:113-20).

Though negative pressure dressings and use of patches have been shown to increase primary closure by facilitating the midline tension, up to 30% of patients will not achieve primary fascial closure. Botox injections block the release of acetylcholine, thereby preventing a rush of calcium to the abdomen and inducing flaccid paralysis of the lateral abdominal wall muscles, Dr. Zielinski explained.

To test their hypothesis that Botox would improve rates of primary fascial closure, decrease hospital stay, and enhance pain control, 46 patients who had undergone damage control laparotomy were randomly assigned to six separate injections of their external, oblique, internal oblique, and transverse abdominal muscles with 150 cc/injection of Botox A or sodium chloride 0.9%.

The two groups were well matched, with the exception of Botox patients having a significantly lower body mass index (BMI) than did controls (30 kg/m²vs. 26.3 kg/m²) and receiving more intraoperative packed red blood cells (8 units vs. 4.8 units).

Primary fascial closure rates were unexpectedly high, but did not differ between the Botox and control groups (96% vs. 93%; hazard ratio, 1.0), Dr. Zielinski said.

Secondary endpoints were also similar between the Botox and control groups including average time until closure (5 days vs. 2 days; P = .15), hospital stay (24 days vs. 19 days; P = .19), median ICU duration (8 days vs. 6 days; P = 32), and wound infection rate (8% vs. 0%; P > .99).

Given the potential pain effects of Botox, the investigators anticipated a difference in pain medication use, but morphine equivalents were actually slightly higher in the Botox group on postoperative day 1 (120 mg vs. 81.8 mg; P = .27) through day 5 (57.3 vs. 49.0 mg; P = .47), he said.

In trying to explain why the injections failed to prove beneficial, Dr. Zielinski said, “The question that crosses my mind is did we exclude the wrong patients?”

A total of 181 trauma or emergency general surgery patients, aged 18 years and older, with a damage-control laparotomy per the surgeon’s discretion were eligible for the double-blind study, but 87 were excluded because they had one or more exclusion criterion: a body mass index ≥ 50, hemodynamic instability, complicated chronic obstructive pulmonary disease, impaired neuromuscular transmission, aminoglycoside use, international normalized ratio < 1.5, trunk necrotizing fasciitis, metastatic malignancy, or were pregnant or a prisoner.

Patrice Wendling/Frontline Medical News

Discussant Michael Rotondo of the University of Rochester (New York) Medical Center, applauded the authors for presenting a negative study and called it “impeccably designed” and “a great piece of work.”

Dr. Rotondo went on to ask whether there was any relationship between degree of advancement, abdominal breach, or lateral diameter that predicts success with Botox.

Despite the use of surface wave elastography to measure abdominal tension in eight patients and use of a handheld durometer, Dr. Zielinski said they were unable to accurately measure degree of advancement. Future work may look at the relationship between these factors and will include long-term follow-up to evaluate hernia rates and quality of life. In the one patient with full elastography measurements, abdominal tension trended lower for 2 days after the Botox injection before increasing after primary closure, he said.abdominal tension trended lower for 2 days after the Botox injection before increasing after primary closure, he said.

The study was funded by the EAST Scholar program. Dr. Zielinski, his coauthors, and Dr. Rotondo reported having no financial disclosures.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – Contrary to prior results, use of onabotulinumtoxinA did not improve primary fascial closure rates after damage control laparotomy in a multicenter, prospective study.

“Botox injections were safe, but they did not have any effect on our primary or secondary endpoints,” Dr. Martin D. Zielinski said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Patrice Wendling/Frontline Medical News

Dr. Zielinski and his colleagues at Mayo Clinic, Rochester, Minn., previously published retrospective data showing that use of Botox-induced paralysis of the abdominal wall musculature resulted in a primary fascial closure rate of 83% among 18 patients with open abdomen (OA) and 89% if injected within 24 hours of the initial OA procedure (Hernia 2013;17:101-7).

In contrast, the primary closure rate was just 66% in a prospective American Association for the Surgery of Trauma study involving 572 patients requiring OA management after damage control laparotomy (J. Trauma Acute Care Surg. 2013;74:113-20).

Though negative pressure dressings and use of patches have been shown to increase primary closure by facilitating the midline tension, up to 30% of patients will not achieve primary fascial closure. Botox injections block the release of acetylcholine, thereby preventing a rush of calcium to the abdomen and inducing flaccid paralysis of the lateral abdominal wall muscles, Dr. Zielinski explained.

To test their hypothesis that Botox would improve rates of primary fascial closure, decrease hospital stay, and enhance pain control, 46 patients who had undergone damage control laparotomy were randomly assigned to six separate injections of their external, oblique, internal oblique, and transverse abdominal muscles with 150 cc/injection of Botox A or sodium chloride 0.9%.

The two groups were well matched, with the exception of Botox patients having a significantly lower body mass index (BMI) than did controls (30 kg/m²vs. 26.3 kg/m²) and receiving more intraoperative packed red blood cells (8 units vs. 4.8 units).

Primary fascial closure rates were unexpectedly high, but did not differ between the Botox and control groups (96% vs. 93%; hazard ratio, 1.0), Dr. Zielinski said.

Secondary endpoints were also similar between the Botox and control groups including average time until closure (5 days vs. 2 days; P = .15), hospital stay (24 days vs. 19 days; P = .19), median ICU duration (8 days vs. 6 days; P = 32), and wound infection rate (8% vs. 0%; P > .99).

Given the potential pain effects of Botox, the investigators anticipated a difference in pain medication use, but morphine equivalents were actually slightly higher in the Botox group on postoperative day 1 (120 mg vs. 81.8 mg; P = .27) through day 5 (57.3 vs. 49.0 mg; P = .47), he said.

In trying to explain why the injections failed to prove beneficial, Dr. Zielinski said, “The question that crosses my mind is did we exclude the wrong patients?”

A total of 181 trauma or emergency general surgery patients, aged 18 years and older, with a damage-control laparotomy per the surgeon’s discretion were eligible for the double-blind study, but 87 were excluded because they had one or more exclusion criterion: a body mass index ≥ 50, hemodynamic instability, complicated chronic obstructive pulmonary disease, impaired neuromuscular transmission, aminoglycoside use, international normalized ratio < 1.5, trunk necrotizing fasciitis, metastatic malignancy, or were pregnant or a prisoner.

Patrice Wendling/Frontline Medical News

Discussant Michael Rotondo of the University of Rochester (New York) Medical Center, applauded the authors for presenting a negative study and called it “impeccably designed” and “a great piece of work.”

Dr. Rotondo went on to ask whether there was any relationship between degree of advancement, abdominal breach, or lateral diameter that predicts success with Botox.

Despite the use of surface wave elastography to measure abdominal tension in eight patients and use of a handheld durometer, Dr. Zielinski said they were unable to accurately measure degree of advancement. Future work may look at the relationship between these factors and will include long-term follow-up to evaluate hernia rates and quality of life. In the one patient with full elastography measurements, abdominal tension trended lower for 2 days after the Botox injection before increasing after primary closure, he said.abdominal tension trended lower for 2 days after the Botox injection before increasing after primary closure, he said.

The study was funded by the EAST Scholar program. Dr. Zielinski, his coauthors, and Dr. Rotondo reported having no financial disclosures.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – Contrary to prior results, use of onabotulinumtoxinA did not improve primary fascial closure rates after damage control laparotomy in a multicenter, prospective study.

“Botox injections were safe, but they did not have any effect on our primary or secondary endpoints,” Dr. Martin D. Zielinski said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Patrice Wendling/Frontline Medical News

Dr. Zielinski and his colleagues at Mayo Clinic, Rochester, Minn., previously published retrospective data showing that use of Botox-induced paralysis of the abdominal wall musculature resulted in a primary fascial closure rate of 83% among 18 patients with open abdomen (OA) and 89% if injected within 24 hours of the initial OA procedure (Hernia 2013;17:101-7).

In contrast, the primary closure rate was just 66% in a prospective American Association for the Surgery of Trauma study involving 572 patients requiring OA management after damage control laparotomy (J. Trauma Acute Care Surg. 2013;74:113-20).

Though negative pressure dressings and use of patches have been shown to increase primary closure by facilitating the midline tension, up to 30% of patients will not achieve primary fascial closure. Botox injections block the release of acetylcholine, thereby preventing a rush of calcium to the abdomen and inducing flaccid paralysis of the lateral abdominal wall muscles, Dr. Zielinski explained.

To test their hypothesis that Botox would improve rates of primary fascial closure, decrease hospital stay, and enhance pain control, 46 patients who had undergone damage control laparotomy were randomly assigned to six separate injections of their external, oblique, internal oblique, and transverse abdominal muscles with 150 cc/injection of Botox A or sodium chloride 0.9%.

The two groups were well matched, with the exception of Botox patients having a significantly lower body mass index (BMI) than did controls (30 kg/m²vs. 26.3 kg/m²) and receiving more intraoperative packed red blood cells (8 units vs. 4.8 units).

Primary fascial closure rates were unexpectedly high, but did not differ between the Botox and control groups (96% vs. 93%; hazard ratio, 1.0), Dr. Zielinski said.

Secondary endpoints were also similar between the Botox and control groups including average time until closure (5 days vs. 2 days; P = .15), hospital stay (24 days vs. 19 days; P = .19), median ICU duration (8 days vs. 6 days; P = 32), and wound infection rate (8% vs. 0%; P > .99).

Given the potential pain effects of Botox, the investigators anticipated a difference in pain medication use, but morphine equivalents were actually slightly higher in the Botox group on postoperative day 1 (120 mg vs. 81.8 mg; P = .27) through day 5 (57.3 vs. 49.0 mg; P = .47), he said.

In trying to explain why the injections failed to prove beneficial, Dr. Zielinski said, “The question that crosses my mind is did we exclude the wrong patients?”

A total of 181 trauma or emergency general surgery patients, aged 18 years and older, with a damage-control laparotomy per the surgeon’s discretion were eligible for the double-blind study, but 87 were excluded because they had one or more exclusion criterion: a body mass index ≥ 50, hemodynamic instability, complicated chronic obstructive pulmonary disease, impaired neuromuscular transmission, aminoglycoside use, international normalized ratio < 1.5, trunk necrotizing fasciitis, metastatic malignancy, or were pregnant or a prisoner.

Patrice Wendling/Frontline Medical News

Discussant Michael Rotondo of the University of Rochester (New York) Medical Center, applauded the authors for presenting a negative study and called it “impeccably designed” and “a great piece of work.”

Dr. Rotondo went on to ask whether there was any relationship between degree of advancement, abdominal breach, or lateral diameter that predicts success with Botox.

Despite the use of surface wave elastography to measure abdominal tension in eight patients and use of a handheld durometer, Dr. Zielinski said they were unable to accurately measure degree of advancement. Future work may look at the relationship between these factors and will include long-term follow-up to evaluate hernia rates and quality of life. In the one patient with full elastography measurements, abdominal tension trended lower for 2 days after the Botox injection before increasing after primary closure, he said.abdominal tension trended lower for 2 days after the Botox injection before increasing after primary closure, he said.

The study was funded by the EAST Scholar program. Dr. Zielinski, his coauthors, and Dr. Rotondo reported having no financial disclosures.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – A multimodal intervention founded on prompt peer-to-peer review increased adherence to restrictive red blood cell transfusion guidelines without increasing mortality.

During the intervention, if patients were transfused outside of established hospital guidelines, all clinicians taking care of the patient received an e-mail notification within 72 hours of transfusion. This included the ICU staff, primary team, intern, resident, fellow, nurse practitioner, and attending, said Dr. Daniel Yeh, a trauma and critical care surgeon at Massachusetts General Hospital in Boston whose signature appears on the e-mail along with the endorsement of the surgeon-in-chief, anesthetist-in-chief, director of the MGH Critical Care Center, codirector of blood transfusion services, and the urology chief.

The e-mail blast was coupled with a 1-hour educational lecture during surgery grand rounds on the potential harms of and indications for blood transfusion, a surgical ICU didactic lecture, and monthly division-wide reports.

Patrice Wendling/Frontline Medical News

Prior to the intervention, providers felt they were probably doing pretty well in terms of using a more restrictive transfusion strategy, Dr. Yeh said. After all, there are strong guidelines in all the professional societies and 15 years of high-quality, level 1 evidence from the pivotal 1999 TRICC (Transfusion Requirements in Critical Care) trial to last year’s data in traumatic brain injury (TBI) patients (JAMA 2014;312:36-47) showing that a lower transfusion threshold is noninferior, if not superior, to a higher transfusion threshold.

“Yet, anecdotally in my own practice and objectively in observational data, we see what can only be euphemistically described as a knowledge-practice gap,” he said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST). “Basically, we weren’t practicing what we were preaching.”

A record review of 144 patients from January to June 2013 found that fully 25% of all transfusions in stable, low-risk ICU patients had a pretransfusion hemoglobin (Hb) trigger > 8.0 g/dL.

Further, 5% of patients received the old standby 2-unit transfusion without an intervening hemoglobin measurement, which has been recommended against by all major medical societies, Dr. Yeh said.

The overtransfusion rate, defined as a post-transfusion level > 10 g/dL, was 11%. Most of this was accounted for by these 2-unit patients, he added.

Stable, low-risk patients comprised 33% of all transfusions during the review period and were identified using liberal exclusion criteria including anyone with visible bleeding or suspected internal bleeding, hemodynamic instability, ischemia (myocardial, intestinal, or peripheral vascular), or who were high risk (defined by a history of coronary artery disease, coronary artery bypass grafting, or congestive heart failure).

After the October 2013 to March 2014 intervention, the percentage of stable, low-risk patients with a Hb trigger of > 8.0 g/dL declined from 25% to 2% (P < .001), with a 1-month audit of 15 patients showing a rebound up to 17% 6 months after the intervention ended, Dr. Yeh said.

“There was no difference in the patients who got a single transfusion; however, the ones who got multiple transfusions during their hospital stay decreased, so that is where we believe most of the decline came from,” he explained.

Among the 137 postintervention patients, the average pretransfusion trigger decreased significantly (7.6 g/dL vs. 7.1 g/dL; P < .001), before rising to 7.3 g/dL 6 months post intervention.

The number of monthly transfusions declined 35% from 47 units to 31 units (P = NS) and the overtransfusion rate fell from 11% to 3% (P = .004).

There were no significant differences in maximum lactate, maximum troponin, median ICU or hospital length of stay, although ICU discharge Hb (8.6 g/dL vs. 8.2 g/dL; P = .087) and hospital discharge Hb (9.0 g/dL vs. 8.6 g/dL; P = .006) were lower in the intervention period, Dr. Yeh said.

No significant differences were seen post intervention in 30-day readmission (23% vs. 16%; NS) or overall mortality (4% vs. 9%; NS).

“Transfusions were not really temporally related to the death nor did we attribute any of these deaths to symptomatic anemia,” he said.

Limitations of the intervention include the possibility of a Hawthorne effect, use of crude clinical outcomes, and the lack of concomitant control in the ICU, although the partial regression seen 6 months after the intervention suggests something about the intervention was working, Dr. Yeh observed.

Discussant Dr. Laura J. Moore of the University of Texas Health Science Center at Houston, congratulated the authors on an interesting and pertinent study, but questioned why they utilized a Hb threshold of 8 g/dL when the transfusion trigger was set at 7 g/dL in TRICC and in the Villanueva et al. study in acute upper gastrointestinal bleeders (N. Engl. J. Med. 2013;368:11-21).

“Certainly in my institution, we utilize a trigger of 7 [g/dL] and some of us might even push that down to 6 [g/dL],” she said.

Some of the landmark studies including FOCUS and TRACS used a trigger of 8 g/dL and the investigators wanted to give the clinicians a bit of a benefit of doubt, Dr. Yeh responded.

Results of the intervention were met with surprise, but were quickly reinforced with the publication of the TBI and Villanueva studies and an accompanying editorial (N. Engl. J. Med. 2014;371:1459-61) arguing that a transfusion threshold of 7 g/dL is the new normal, he noted.

“We’ve continued on daily rounds to really focus on that [trigger]. We’ve become empowered as the ICU team to say ‘No,’ to argue and at least put up roadblocks when the primary teams are requesting transfusions and ask them to justify why patients need the additional oxygen carrying capacity when they’re waiting on the floor for 3 days and doing totally fine,” Dr. Yeh said.

As for how they deal with offending providers or outliers, electronic records identify who signed each transfusion order, even if it’s in the dead of night, and simply showing physicians where they stack up with their peers can be the biggest driver of practice change. The team no longer performs monthly audits due to time constraints, but hopes to resume e-mail interventions once MGH’s transition to a new electronic medical system is complete, Dr. Yeh said in an interview.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – A multimodal intervention founded on prompt peer-to-peer review increased adherence to restrictive red blood cell transfusion guidelines without increasing mortality.

During the intervention, if patients were transfused outside of established hospital guidelines, all clinicians taking care of the patient received an e-mail notification within 72 hours of transfusion. This included the ICU staff, primary team, intern, resident, fellow, nurse practitioner, and attending, said Dr. Daniel Yeh, a trauma and critical care surgeon at Massachusetts General Hospital in Boston whose signature appears on the e-mail along with the endorsement of the surgeon-in-chief, anesthetist-in-chief, director of the MGH Critical Care Center, codirector of blood transfusion services, and the urology chief.

The e-mail blast was coupled with a 1-hour educational lecture during surgery grand rounds on the potential harms of and indications for blood transfusion, a surgical ICU didactic lecture, and monthly division-wide reports.

Patrice Wendling/Frontline Medical News

Prior to the intervention, providers felt they were probably doing pretty well in terms of using a more restrictive transfusion strategy, Dr. Yeh said. After all, there are strong guidelines in all the professional societies and 15 years of high-quality, level 1 evidence from the pivotal 1999 TRICC (Transfusion Requirements in Critical Care) trial to last year’s data in traumatic brain injury (TBI) patients (JAMA 2014;312:36-47) showing that a lower transfusion threshold is noninferior, if not superior, to a higher transfusion threshold.

“Yet, anecdotally in my own practice and objectively in observational data, we see what can only be euphemistically described as a knowledge-practice gap,” he said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST). “Basically, we weren’t practicing what we were preaching.”

A record review of 144 patients from January to June 2013 found that fully 25% of all transfusions in stable, low-risk ICU patients had a pretransfusion hemoglobin (Hb) trigger > 8.0 g/dL.

Further, 5% of patients received the old standby 2-unit transfusion without an intervening hemoglobin measurement, which has been recommended against by all major medical societies, Dr. Yeh said.

The overtransfusion rate, defined as a post-transfusion level > 10 g/dL, was 11%. Most of this was accounted for by these 2-unit patients, he added.

Stable, low-risk patients comprised 33% of all transfusions during the review period and were identified using liberal exclusion criteria including anyone with visible bleeding or suspected internal bleeding, hemodynamic instability, ischemia (myocardial, intestinal, or peripheral vascular), or who were high risk (defined by a history of coronary artery disease, coronary artery bypass grafting, or congestive heart failure).

After the October 2013 to March 2014 intervention, the percentage of stable, low-risk patients with a Hb trigger of > 8.0 g/dL declined from 25% to 2% (P < .001), with a 1-month audit of 15 patients showing a rebound up to 17% 6 months after the intervention ended, Dr. Yeh said.

“There was no difference in the patients who got a single transfusion; however, the ones who got multiple transfusions during their hospital stay decreased, so that is where we believe most of the decline came from,” he explained.

Among the 137 postintervention patients, the average pretransfusion trigger decreased significantly (7.6 g/dL vs. 7.1 g/dL; P < .001), before rising to 7.3 g/dL 6 months post intervention.

The number of monthly transfusions declined 35% from 47 units to 31 units (P = NS) and the overtransfusion rate fell from 11% to 3% (P = .004).

There were no significant differences in maximum lactate, maximum troponin, median ICU or hospital length of stay, although ICU discharge Hb (8.6 g/dL vs. 8.2 g/dL; P = .087) and hospital discharge Hb (9.0 g/dL vs. 8.6 g/dL; P = .006) were lower in the intervention period, Dr. Yeh said.

No significant differences were seen post intervention in 30-day readmission (23% vs. 16%; NS) or overall mortality (4% vs. 9%; NS).

“Transfusions were not really temporally related to the death nor did we attribute any of these deaths to symptomatic anemia,” he said.

Limitations of the intervention include the possibility of a Hawthorne effect, use of crude clinical outcomes, and the lack of concomitant control in the ICU, although the partial regression seen 6 months after the intervention suggests something about the intervention was working, Dr. Yeh observed.

Discussant Dr. Laura J. Moore of the University of Texas Health Science Center at Houston, congratulated the authors on an interesting and pertinent study, but questioned why they utilized a Hb threshold of 8 g/dL when the transfusion trigger was set at 7 g/dL in TRICC and in the Villanueva et al. study in acute upper gastrointestinal bleeders (N. Engl. J. Med. 2013;368:11-21).

“Certainly in my institution, we utilize a trigger of 7 [g/dL] and some of us might even push that down to 6 [g/dL],” she said.

Some of the landmark studies including FOCUS and TRACS used a trigger of 8 g/dL and the investigators wanted to give the clinicians a bit of a benefit of doubt, Dr. Yeh responded.

Results of the intervention were met with surprise, but were quickly reinforced with the publication of the TBI and Villanueva studies and an accompanying editorial (N. Engl. J. Med. 2014;371:1459-61) arguing that a transfusion threshold of 7 g/dL is the new normal, he noted.

“We’ve continued on daily rounds to really focus on that [trigger]. We’ve become empowered as the ICU team to say ‘No,’ to argue and at least put up roadblocks when the primary teams are requesting transfusions and ask them to justify why patients need the additional oxygen carrying capacity when they’re waiting on the floor for 3 days and doing totally fine,” Dr. Yeh said.

As for how they deal with offending providers or outliers, electronic records identify who signed each transfusion order, even if it’s in the dead of night, and simply showing physicians where they stack up with their peers can be the biggest driver of practice change. The team no longer performs monthly audits due to time constraints, but hopes to resume e-mail interventions once MGH’s transition to a new electronic medical system is complete, Dr. Yeh said in an interview.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – A multimodal intervention founded on prompt peer-to-peer review increased adherence to restrictive red blood cell transfusion guidelines without increasing mortality.

During the intervention, if patients were transfused outside of established hospital guidelines, all clinicians taking care of the patient received an e-mail notification within 72 hours of transfusion. This included the ICU staff, primary team, intern, resident, fellow, nurse practitioner, and attending, said Dr. Daniel Yeh, a trauma and critical care surgeon at Massachusetts General Hospital in Boston whose signature appears on the e-mail along with the endorsement of the surgeon-in-chief, anesthetist-in-chief, director of the MGH Critical Care Center, codirector of blood transfusion services, and the urology chief.

The e-mail blast was coupled with a 1-hour educational lecture during surgery grand rounds on the potential harms of and indications for blood transfusion, a surgical ICU didactic lecture, and monthly division-wide reports.

Patrice Wendling/Frontline Medical News

Prior to the intervention, providers felt they were probably doing pretty well in terms of using a more restrictive transfusion strategy, Dr. Yeh said. After all, there are strong guidelines in all the professional societies and 15 years of high-quality, level 1 evidence from the pivotal 1999 TRICC (Transfusion Requirements in Critical Care) trial to last year’s data in traumatic brain injury (TBI) patients (JAMA 2014;312:36-47) showing that a lower transfusion threshold is noninferior, if not superior, to a higher transfusion threshold.

“Yet, anecdotally in my own practice and objectively in observational data, we see what can only be euphemistically described as a knowledge-practice gap,” he said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST). “Basically, we weren’t practicing what we were preaching.”

A record review of 144 patients from January to June 2013 found that fully 25% of all transfusions in stable, low-risk ICU patients had a pretransfusion hemoglobin (Hb) trigger > 8.0 g/dL.

Further, 5% of patients received the old standby 2-unit transfusion without an intervening hemoglobin measurement, which has been recommended against by all major medical societies, Dr. Yeh said.

The overtransfusion rate, defined as a post-transfusion level > 10 g/dL, was 11%. Most of this was accounted for by these 2-unit patients, he added.

Stable, low-risk patients comprised 33% of all transfusions during the review period and were identified using liberal exclusion criteria including anyone with visible bleeding or suspected internal bleeding, hemodynamic instability, ischemia (myocardial, intestinal, or peripheral vascular), or who were high risk (defined by a history of coronary artery disease, coronary artery bypass grafting, or congestive heart failure).

After the October 2013 to March 2014 intervention, the percentage of stable, low-risk patients with a Hb trigger of > 8.0 g/dL declined from 25% to 2% (P < .001), with a 1-month audit of 15 patients showing a rebound up to 17% 6 months after the intervention ended, Dr. Yeh said.

“There was no difference in the patients who got a single transfusion; however, the ones who got multiple transfusions during their hospital stay decreased, so that is where we believe most of the decline came from,” he explained.

Among the 137 postintervention patients, the average pretransfusion trigger decreased significantly (7.6 g/dL vs. 7.1 g/dL; P < .001), before rising to 7.3 g/dL 6 months post intervention.

The number of monthly transfusions declined 35% from 47 units to 31 units (P = NS) and the overtransfusion rate fell from 11% to 3% (P = .004).

There were no significant differences in maximum lactate, maximum troponin, median ICU or hospital length of stay, although ICU discharge Hb (8.6 g/dL vs. 8.2 g/dL; P = .087) and hospital discharge Hb (9.0 g/dL vs. 8.6 g/dL; P = .006) were lower in the intervention period, Dr. Yeh said.

No significant differences were seen post intervention in 30-day readmission (23% vs. 16%; NS) or overall mortality (4% vs. 9%; NS).

“Transfusions were not really temporally related to the death nor did we attribute any of these deaths to symptomatic anemia,” he said.

Limitations of the intervention include the possibility of a Hawthorne effect, use of crude clinical outcomes, and the lack of concomitant control in the ICU, although the partial regression seen 6 months after the intervention suggests something about the intervention was working, Dr. Yeh observed.

Discussant Dr. Laura J. Moore of the University of Texas Health Science Center at Houston, congratulated the authors on an interesting and pertinent study, but questioned why they utilized a Hb threshold of 8 g/dL when the transfusion trigger was set at 7 g/dL in TRICC and in the Villanueva et al. study in acute upper gastrointestinal bleeders (N. Engl. J. Med. 2013;368:11-21).

“Certainly in my institution, we utilize a trigger of 7 [g/dL] and some of us might even push that down to 6 [g/dL],” she said.

Some of the landmark studies including FOCUS and TRACS used a trigger of 8 g/dL and the investigators wanted to give the clinicians a bit of a benefit of doubt, Dr. Yeh responded.

Results of the intervention were met with surprise, but were quickly reinforced with the publication of the TBI and Villanueva studies and an accompanying editorial (N. Engl. J. Med. 2014;371:1459-61) arguing that a transfusion threshold of 7 g/dL is the new normal, he noted.

“We’ve continued on daily rounds to really focus on that [trigger]. We’ve become empowered as the ICU team to say ‘No,’ to argue and at least put up roadblocks when the primary teams are requesting transfusions and ask them to justify why patients need the additional oxygen carrying capacity when they’re waiting on the floor for 3 days and doing totally fine,” Dr. Yeh said.

As for how they deal with offending providers or outliers, electronic records identify who signed each transfusion order, even if it’s in the dead of night, and simply showing physicians where they stack up with their peers can be the biggest driver of practice change. The team no longer performs monthly audits due to time constraints, but hopes to resume e-mail interventions once MGH’s transition to a new electronic medical system is complete, Dr. Yeh said in an interview.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FL. – Older age, diabetes, and elevated bilirubin were significant risk factors for acute gangrenous cholecystitis in a retrospective study of 489 patients undergoing cholecystectomy.

Patients with acute gangrenous cholecystitis (AGC) were on average 15 years older than those with cholecystitis without necrosis (CN) were (55.8 vs. 40.8 years; P value ≤ .001), almost five times more likely to have comorbid diabetes (32% vs. 6.7%; P≤ .05), and had significantly higher bilirubin levels (1.96 mg/dL vs. 0.89 mg/dL; P≤ .001).

The findings are consistent with previous studies showing that all three risk factors are strongly associated with gangrenous cholecystitis, Seda Bourikian reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

“Future studies may explore how the pathophysiology of diabetes, or the duration of illness in each patient, plays a role in the development of AGC,” the authors suggested in the poster presentation.

The chart review included 489 patients admitted to an emergency general surgery service who underwent cholecystectomy between January 2009 and April 2014. Retrospectively evaluated pathological specimen reports identified 464 patients with CN and 25 patients with AGC.

Male patients had a significantly higher incidence of AGC than CN (56% vs. 26%; P≤ .05), whereas women were less likely to have AGC (44% vs. 74%; NS), Ms. Bourikian and her colleagues at Virginia Commonwealth University in Richmond wrote.

Previous studies also have shown that acute cholecystitis is more common in men and patients over the age of 50 years.

Notably, lactate, obesity, and systolic blood pressure below 100 mm Hg were not different between groups.

As expected, patients with AGC were significantly more likely to die than their counterparts with cholecystitis without necrosis (16% vs. 0.86%; P≤ .05), the authors reported.

People with diabetes with AGC were almost five times more likely to die than were diabetics with CN (32% vs. 6.7%; P≤ .05). according to the authors.

Mortality, however, was nearly identical between AGC and CN patients with a systolic BP ≤ 100 mm Hg (0% vs. 0.02%; NS).

Logistic regression analysis showed that increased age (P≤ .001) and male gender (P≤ .05) were strongly associated with the development of AGC. The failure of more risk factors to pan out in logistic regression is likely because of the small number of patients with gangrenous cholecystitis, senior author and colleague Dr. Paula Ferrada of Virginia Commonwealth University suggested.

“This is not a common disease,” she said in an interview. “That’s why it’s so hard to diagnose and triage. Clinicians need to have a higher suspicion” of AGC.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FL. – Older age, diabetes, and elevated bilirubin were significant risk factors for acute gangrenous cholecystitis in a retrospective study of 489 patients undergoing cholecystectomy.

Patients with acute gangrenous cholecystitis (AGC) were on average 15 years older than those with cholecystitis without necrosis (CN) were (55.8 vs. 40.8 years; P value ≤ .001), almost five times more likely to have comorbid diabetes (32% vs. 6.7%; P≤ .05), and had significantly higher bilirubin levels (1.96 mg/dL vs. 0.89 mg/dL; P≤ .001).

The findings are consistent with previous studies showing that all three risk factors are strongly associated with gangrenous cholecystitis, Seda Bourikian reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

“Future studies may explore how the pathophysiology of diabetes, or the duration of illness in each patient, plays a role in the development of AGC,” the authors suggested in the poster presentation.

The chart review included 489 patients admitted to an emergency general surgery service who underwent cholecystectomy between January 2009 and April 2014. Retrospectively evaluated pathological specimen reports identified 464 patients with CN and 25 patients with AGC.

Male patients had a significantly higher incidence of AGC than CN (56% vs. 26%; P≤ .05), whereas women were less likely to have AGC (44% vs. 74%; NS), Ms. Bourikian and her colleagues at Virginia Commonwealth University in Richmond wrote.

Previous studies also have shown that acute cholecystitis is more common in men and patients over the age of 50 years.

Notably, lactate, obesity, and systolic blood pressure below 100 mm Hg were not different between groups.

As expected, patients with AGC were significantly more likely to die than their counterparts with cholecystitis without necrosis (16% vs. 0.86%; P≤ .05), the authors reported.

People with diabetes with AGC were almost five times more likely to die than were diabetics with CN (32% vs. 6.7%; P≤ .05). according to the authors.

Mortality, however, was nearly identical between AGC and CN patients with a systolic BP ≤ 100 mm Hg (0% vs. 0.02%; NS).

Logistic regression analysis showed that increased age (P≤ .001) and male gender (P≤ .05) were strongly associated with the development of AGC. The failure of more risk factors to pan out in logistic regression is likely because of the small number of patients with gangrenous cholecystitis, senior author and colleague Dr. Paula Ferrada of Virginia Commonwealth University suggested.

“This is not a common disease,” she said in an interview. “That’s why it’s so hard to diagnose and triage. Clinicians need to have a higher suspicion” of AGC.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FL. – Older age, diabetes, and elevated bilirubin were significant risk factors for acute gangrenous cholecystitis in a retrospective study of 489 patients undergoing cholecystectomy.

Patients with acute gangrenous cholecystitis (AGC) were on average 15 years older than those with cholecystitis without necrosis (CN) were (55.8 vs. 40.8 years; P value ≤ .001), almost five times more likely to have comorbid diabetes (32% vs. 6.7%; P≤ .05), and had significantly higher bilirubin levels (1.96 mg/dL vs. 0.89 mg/dL; P≤ .001).

The findings are consistent with previous studies showing that all three risk factors are strongly associated with gangrenous cholecystitis, Seda Bourikian reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

“Future studies may explore how the pathophysiology of diabetes, or the duration of illness in each patient, plays a role in the development of AGC,” the authors suggested in the poster presentation.

The chart review included 489 patients admitted to an emergency general surgery service who underwent cholecystectomy between January 2009 and April 2014. Retrospectively evaluated pathological specimen reports identified 464 patients with CN and 25 patients with AGC.

Male patients had a significantly higher incidence of AGC than CN (56% vs. 26%; P≤ .05), whereas women were less likely to have AGC (44% vs. 74%; NS), Ms. Bourikian and her colleagues at Virginia Commonwealth University in Richmond wrote.

Previous studies also have shown that acute cholecystitis is more common in men and patients over the age of 50 years.

Notably, lactate, obesity, and systolic blood pressure below 100 mm Hg were not different between groups.

As expected, patients with AGC were significantly more likely to die than their counterparts with cholecystitis without necrosis (16% vs. 0.86%; P≤ .05), the authors reported.

People with diabetes with AGC were almost five times more likely to die than were diabetics with CN (32% vs. 6.7%; P≤ .05). according to the authors.

Mortality, however, was nearly identical between AGC and CN patients with a systolic BP ≤ 100 mm Hg (0% vs. 0.02%; NS).

Logistic regression analysis showed that increased age (P≤ .001) and male gender (P≤ .05) were strongly associated with the development of AGC. The failure of more risk factors to pan out in logistic regression is likely because of the small number of patients with gangrenous cholecystitis, senior author and colleague Dr. Paula Ferrada of Virginia Commonwealth University suggested.

“This is not a common disease,” she said in an interview. “That’s why it’s so hard to diagnose and triage. Clinicians need to have a higher suspicion” of AGC.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – Use of a multidisciplinary safety checklist prior to all bedside bronchoscopy-guided percutaneous tracheostomies was independently associated with a dramatic reduction in adverse procedural events, a study showed.

After adjustment for age, vitals, tracheostomy risk factors, and ICU duration after the procedure, multivariable logistic regression determined that no other factor – not age, baseline heart rate, baseline oxygen saturation, or difficult airway status – was significant against adverse procedural events except use of the checklist (odds ratio, 5.85; P = .022

Overall, in the postchecklist group, 3.2% experienced adverse events, compared with 14.7% in the prechecklist group.

Patrice Wendling/Frontline Medical News

“We feel this checklist could be used by other institutions with similar success and also could be modified for other invasive bedside procedures,” lead study author Dr. Joshua Hazelton said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Bedside bronchoscopy-guided percutaneous tracheostomies (BBPT) are safe, yet like many bedside procedures are seldom subject to the same safety checklists and timeout processes that have become standard in the operating room, he observed. When asked specifically how the checklist improved safety, Dr. Hazelton said the multidisciplinary aspect of the checklist distills a sense of ownership in every team member. A significant amount of evidence published on the benefits of World Health Organization checklists also shows checklists improve communication and empower members to speak up if something doesn’t feel right.

“Most of all, the checklist helped to focus the team on a procedure that really has very little margin of error,” he said. “As we do more of these procedures, I think the tendency for the entire team can be to look at these procedures as almost routine, and certainly with an airway procedure, I don’t think you should look at it as a routine thing.”

The safety checklist was created by a team of surgeons, critical care nurses, respiratory therapists, and trauma technicians at Cooper University Hospital in Camden, N.J., and focused on preprocedural setup, procedural steps, and a group timeout process.

In the equipment setup phase, the bedside nurse, respiratory therapist, and trauma technician must assemble and test all necessary equipment.

During the timeout process, team members are introduced, the nurse confirms the patient, the planned procedure, positioning of the patient, medications, and equipment, and the surgeon discusses any critical steps or steps that may be unique to the patient. Finally, each team member is given an opportunity to discuss any concerns or ask any questions prior to proceeding.

“The idea of this checklist is to bring the team together, so if there is one member of the team who doesn’t feel right about the procedure or has concerns, the procedure is stopped,” said Dr. Hazelton of the department of surgery at Cooper.

The last phase of the checklist is a postprocedural assessment to make sure the tracheostomy is properly secured and the patient is stable.

To assess its impact, the investigators prospectively analyzed all 63 patients who underwent bedside tracheostomy at the level I trauma center from checklist implementation July 1, 2013 to June 30, 2014 and compared them with 184 historical controls who underwent bedside tracheostomy without the checklist from July 1, 2011 to June 30, 2013. All tracheostomies were performed using the Blue Rhino Percutaneous Tracheostomy Kit (Cook Medical).

The pre- and postchecklist groups had similar numbers of patients with potentially difficult airways including those with cervical spine fracture (30 patients vs. 4 patients; P = .056), cervical ligamentous injury (3 vs. 0; not significant), occipital condyle fracture (3 vs. 0; NS), cervical spinal cord injury (4 vs. 2; NS), mandible fracture (8 vs. 2; NS), LeFort III fracture (5 vs. 1; NS), or oral cavity injury (5 vs. 1; NS).

Prechecklist patients were younger than postchecklist patients (48 years vs. 57 years; P = .001), but all other baseline characteristics were well matched including gender, body mass index, duration of mechanical ventilation, heart rate, mean arterial pressure, and oxygen saturation.

The pre- and postchecklist groups had the same occurrence of individual adverse procedural events including loss of airway (2 vs. 0; P = 1.0), deterioration in respiratory parameters during procedure (7 vs. 2; P = 1.0), hemodynamic compromise (19 vs. 2; P = .079), need for vasopressors or antiarrhythmics are (1 vs. 0; P = 1.0), and conversion to open procedure (5 vs. 0; P = .333). But overall, the postchecklist group experienced significantly fewer adverse events (3.2% vs. 14.7% prechecklist; P = .014), Dr. Hazelton said.

Discussant Dr. Bradley Dennis of Vanderbilt University Medical Center in Nashville, Tenn., said, “I don’t think we even need P values to identify this as a successful intervention, so I commend you for your excellent work.”

Patrice Wendling/Frontline Medical News

As bedside surgical procedures become more prevalent, it only stands to reason that the same patient safety measures used in the OR would be extended into the ICU, he said. Indeed, Vanderbilt has employed a preprocedure checklist for all procedures in the surgical trauma ICU since 2007, but unfortunately did not measure the outcomes prospectively.

Dr. Dennis went on to ask whether there were any patients in whom the checklist identified something that caused the team to abort the procedure.

Early in the process, there were several near-misses that were difficult to categorize, but typically revolved around not having a specific piece of rescue equipment in the room such as an airway box, Dr. Hazelton said. One particular case also raised concerns on the part of the respiratory therapist because of the patient’s large head, short neck, and body habitus, and after discussion, the procedure was halted.

“It was done in the operating room the next day and my colleague who performed that procedure told me it was somewhat challenging, a difficult cut down, a T-bar wing,” he said. “But certainly, that level of trust in your other colleagues, nursing, technicians, respiratory, is necessary for success of this kind of checklist.”

Dr. Hazelton and his coauthors reported having no financial disclosures.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – Use of a multidisciplinary safety checklist prior to all bedside bronchoscopy-guided percutaneous tracheostomies was independently associated with a dramatic reduction in adverse procedural events, a study showed.

After adjustment for age, vitals, tracheostomy risk factors, and ICU duration after the procedure, multivariable logistic regression determined that no other factor – not age, baseline heart rate, baseline oxygen saturation, or difficult airway status – was significant against adverse procedural events except use of the checklist (odds ratio, 5.85; P = .022

Overall, in the postchecklist group, 3.2% experienced adverse events, compared with 14.7% in the prechecklist group.

Patrice Wendling/Frontline Medical News

“We feel this checklist could be used by other institutions with similar success and also could be modified for other invasive bedside procedures,” lead study author Dr. Joshua Hazelton said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Bedside bronchoscopy-guided percutaneous tracheostomies (BBPT) are safe, yet like many bedside procedures are seldom subject to the same safety checklists and timeout processes that have become standard in the operating room, he observed. When asked specifically how the checklist improved safety, Dr. Hazelton said the multidisciplinary aspect of the checklist distills a sense of ownership in every team member. A significant amount of evidence published on the benefits of World Health Organization checklists also shows checklists improve communication and empower members to speak up if something doesn’t feel right.

“Most of all, the checklist helped to focus the team on a procedure that really has very little margin of error,” he said. “As we do more of these procedures, I think the tendency for the entire team can be to look at these procedures as almost routine, and certainly with an airway procedure, I don’t think you should look at it as a routine thing.”

The safety checklist was created by a team of surgeons, critical care nurses, respiratory therapists, and trauma technicians at Cooper University Hospital in Camden, N.J., and focused on preprocedural setup, procedural steps, and a group timeout process.

In the equipment setup phase, the bedside nurse, respiratory therapist, and trauma technician must assemble and test all necessary equipment.

During the timeout process, team members are introduced, the nurse confirms the patient, the planned procedure, positioning of the patient, medications, and equipment, and the surgeon discusses any critical steps or steps that may be unique to the patient. Finally, each team member is given an opportunity to discuss any concerns or ask any questions prior to proceeding.

“The idea of this checklist is to bring the team together, so if there is one member of the team who doesn’t feel right about the procedure or has concerns, the procedure is stopped,” said Dr. Hazelton of the department of surgery at Cooper.

The last phase of the checklist is a postprocedural assessment to make sure the tracheostomy is properly secured and the patient is stable.

To assess its impact, the investigators prospectively analyzed all 63 patients who underwent bedside tracheostomy at the level I trauma center from checklist implementation July 1, 2013 to June 30, 2014 and compared them with 184 historical controls who underwent bedside tracheostomy without the checklist from July 1, 2011 to June 30, 2013. All tracheostomies were performed using the Blue Rhino Percutaneous Tracheostomy Kit (Cook Medical).

The pre- and postchecklist groups had similar numbers of patients with potentially difficult airways including those with cervical spine fracture (30 patients vs. 4 patients; P = .056), cervical ligamentous injury (3 vs. 0; not significant), occipital condyle fracture (3 vs. 0; NS), cervical spinal cord injury (4 vs. 2; NS), mandible fracture (8 vs. 2; NS), LeFort III fracture (5 vs. 1; NS), or oral cavity injury (5 vs. 1; NS).

Prechecklist patients were younger than postchecklist patients (48 years vs. 57 years; P = .001), but all other baseline characteristics were well matched including gender, body mass index, duration of mechanical ventilation, heart rate, mean arterial pressure, and oxygen saturation.

The pre- and postchecklist groups had the same occurrence of individual adverse procedural events including loss of airway (2 vs. 0; P = 1.0), deterioration in respiratory parameters during procedure (7 vs. 2; P = 1.0), hemodynamic compromise (19 vs. 2; P = .079), need for vasopressors or antiarrhythmics are (1 vs. 0; P = 1.0), and conversion to open procedure (5 vs. 0; P = .333). But overall, the postchecklist group experienced significantly fewer adverse events (3.2% vs. 14.7% prechecklist; P = .014), Dr. Hazelton said.

Discussant Dr. Bradley Dennis of Vanderbilt University Medical Center in Nashville, Tenn., said, “I don’t think we even need P values to identify this as a successful intervention, so I commend you for your excellent work.”

Patrice Wendling/Frontline Medical News

As bedside surgical procedures become more prevalent, it only stands to reason that the same patient safety measures used in the OR would be extended into the ICU, he said. Indeed, Vanderbilt has employed a preprocedure checklist for all procedures in the surgical trauma ICU since 2007, but unfortunately did not measure the outcomes prospectively.

Dr. Dennis went on to ask whether there were any patients in whom the checklist identified something that caused the team to abort the procedure.

Early in the process, there were several near-misses that were difficult to categorize, but typically revolved around not having a specific piece of rescue equipment in the room such as an airway box, Dr. Hazelton said. One particular case also raised concerns on the part of the respiratory therapist because of the patient’s large head, short neck, and body habitus, and after discussion, the procedure was halted.

“It was done in the operating room the next day and my colleague who performed that procedure told me it was somewhat challenging, a difficult cut down, a T-bar wing,” he said. “But certainly, that level of trust in your other colleagues, nursing, technicians, respiratory, is necessary for success of this kind of checklist.”

Dr. Hazelton and his coauthors reported having no financial disclosures.

pwendling@frontlinemedcom.com

LAKE BUENA VISTA, FLA. – Use of a multidisciplinary safety checklist prior to all bedside bronchoscopy-guided percutaneous tracheostomies was independently associated with a dramatic reduction in adverse procedural events, a study showed.

After adjustment for age, vitals, tracheostomy risk factors, and ICU duration after the procedure, multivariable logistic regression determined that no other factor – not age, baseline heart rate, baseline oxygen saturation, or difficult airway status – was significant against adverse procedural events except use of the checklist (odds ratio, 5.85; P = .022

Overall, in the postchecklist group, 3.2% experienced adverse events, compared with 14.7% in the prechecklist group.

Patrice Wendling/Frontline Medical News

“We feel this checklist could be used by other institutions with similar success and also could be modified for other invasive bedside procedures,” lead study author Dr. Joshua Hazelton said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).

Bedside bronchoscopy-guided percutaneous tracheostomies (BBPT) are safe, yet like many bedside procedures are seldom subject to the same safety checklists and timeout processes that have become standard in the operating room, he observed. When asked specifically how the checklist improved safety, Dr. Hazelton said the multidisciplinary aspect of the checklist distills a sense of ownership in every team member. A significant amount of evidence published on the benefits of World Health Organization checklists also shows checklists improve communication and empower members to speak up if something doesn’t feel right.

“Most of all, the checklist helped to focus the team on a procedure that really has very little margin of error,” he said. “As we do more of these procedures, I think the tendency for the entire team can be to look at these procedures as almost routine, and certainly with an airway procedure, I don’t think you should look at it as a routine thing.”

The safety checklist was created by a team of surgeons, critical care nurses, respiratory therapists, and trauma technicians at Cooper University Hospital in Camden, N.J., and focused on preprocedural setup, procedural steps, and a group timeout process.

In the equipment setup phase, the bedside nurse, respiratory therapist, and trauma technician must assemble and test all necessary equipment.

During the timeout process, team members are introduced, the nurse confirms the patient, the planned procedure, positioning of the patient, medications, and equipment, and the surgeon discusses any critical steps or steps that may be unique to the patient. Finally, each team member is given an opportunity to discuss any concerns or ask any questions prior to proceeding.

“The idea of this checklist is to bring the team together, so if there is one member of the team who doesn’t feel right about the procedure or has concerns, the procedure is stopped,” said Dr. Hazelton of the department of surgery at Cooper.

The last phase of the checklist is a postprocedural assessment to make sure the tracheostomy is properly secured and the patient is stable.

To assess its impact, the investigators prospectively analyzed all 63 patients who underwent bedside tracheostomy at the level I trauma center from checklist implementation July 1, 2013 to June 30, 2014 and compared them with 184 historical controls who underwent bedside tracheostomy without the checklist from July 1, 2011 to June 30, 2013. All tracheostomies were performed using the Blue Rhino Percutaneous Tracheostomy Kit (Cook Medical).

The pre- and postchecklist groups had similar numbers of patients with potentially difficult airways including those with cervical spine fracture (30 patients vs. 4 patients; P = .056), cervical ligamentous injury (3 vs. 0; not significant), occipital condyle fracture (3 vs. 0; NS), cervical spinal cord injury (4 vs. 2; NS), mandible fracture (8 vs. 2; NS), LeFort III fracture (5 vs. 1; NS), or oral cavity injury (5 vs. 1; NS).

Prechecklist patients were younger than postchecklist patients (48 years vs. 57 years; P = .001), but all other baseline characteristics were well matched including gender, body mass index, duration of mechanical ventilation, heart rate, mean arterial pressure, and oxygen saturation.

The pre- and postchecklist groups had the same occurrence of individual adverse procedural events including loss of airway (2 vs. 0; P = 1.0), deterioration in respiratory parameters during procedure (7 vs. 2; P = 1.0), hemodynamic compromise (19 vs. 2; P = .079), need for vasopressors or antiarrhythmics are (1 vs. 0; P = 1.0), and conversion to open procedure (5 vs. 0; P = .333). But overall, the postchecklist group experienced significantly fewer adverse events (3.2% vs. 14.7% prechecklist; P = .014), Dr. Hazelton said.

Discussant Dr. Bradley Dennis of Vanderbilt University Medical Center in Nashville, Tenn., said, “I don’t think we even need P values to identify this as a successful intervention, so I commend you for your excellent work.”

Patrice Wendling/Frontline Medical News

As bedside surgical procedures become more prevalent, it only stands to reason that the same patient safety measures used in the OR would be extended into the ICU, he said. Indeed, Vanderbilt has employed a preprocedure checklist for all procedures in the surgical trauma ICU since 2007, but unfortunately did not measure the outcomes prospectively.

Dr. Dennis went on to ask whether there were any patients in whom the checklist identified something that caused the team to abort the procedure.

Early in the process, there were several near-misses that were difficult to categorize, but typically revolved around not having a specific piece of rescue equipment in the room such as an airway box, Dr. Hazelton said. One particular case also raised concerns on the part of the respiratory therapist because of the patient’s large head, short neck, and body habitus, and after discussion, the procedure was halted.

“It was done in the operating room the next day and my colleague who performed that procedure told me it was somewhat challenging, a difficult cut down, a T-bar wing,” he said. “But certainly, that level of trust in your other colleagues, nursing, technicians, respiratory, is necessary for success of this kind of checklist.”

Dr. Hazelton and his coauthors reported having no financial disclosures.

pwendling@frontlinemedcom.com