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The objective of this study was to evaluate the risk of mortality and complications associated with cirrhosis in trauma patients. This is an IRB-approved retrospective trauma registry study of patients admitted to an academic level 1 trauma center from 1997 to 2006. The following parameters were abstracted for analysis: age, gender, mechanism of injury, Abbreviated Injury Score, Injury Severity Score, Glasgow Coma Scale, mortality, and complications (ARDS, acute renal failure, pneumonia, intra-abdominal abscess, trauma-associated coagulopathy). Multivariable analysis was utilized to compare the mortality and complication rates between cirrhotic and noncirrhotic trauma patients. The subgroup of patients who underwent laparotomy was also analyzed. During the 10-year study period there were 36,038 trauma registry patients, of which 468 (1.3%) had a diagnosis of cirrhosis. The mortality in the cirrhotic group was 12% vs. 6% in the noncirrhotic group [adjusted odds ratio = 5.65 (95% CI = 3.72 − 8.41, p < 0.0001)]. ARDS, trauma-associated coagulopathy, and septic complications were significantly more common in the cirrhotic group. The overall severe complication rate in the two groups was 10 and 4%, respectively [adjusted odds ratio = 2.05 (95% CI = 1.45 − 2.84, p < 0.0001)]. For the subgroup of patients who underwent emergent abdominal exploration, the mortality rate increased to 40% compared with that of noncirrhotics at 15% [adjusted odds ratio = 4.35 (95% CI = 2.00 − 9.18, p = 0.0002)]. Cirrhosis is an independent risk factor for increased mortality and higher complication rate following trauma. Injured patients who undergo laparotomy are significantly more likely to die than noncirrhotic patients. Injured patients with cirrhosis warrant aggressive monitoring and treatment. [ABSTRACT FROM AUTHOR]

Background Admission hypothermia (core temperature ≤ 35°C) is an independent risk factor for mortality after trauma. The predictive value of perioperative core temperatures during acute trauma surgery, however, although widely employed as a criterion for initiating damage control, is unknown. We hypothesized that for trauma patients undergoing laparotomy or thoracotomy, early postoperative hypothermia is a predictor of mortality.Methods After institutional review board (IRB) approval, all critically ill trauma patients undergoing cavitary surgery (laparotomy or thoracotomy) at a level 1 trauma center from 01/1998 to 07/2006 were identified from the trauma registry. Immediate postoperative core temperature (Tc) was used to classify patients as hypothermic (Tc ≤ 35°C) or normothermic (Tc > 35°C). The profoundly hypothermic subgroup of patients with a Tc < 33°C was also analyzed.Results During the study period, 2,489 patients required cavitary surgery, 1,252 of whom (50%) were admitted to the intensive care unit (ICU). On arrival in the ICU 15% of the patients had a Tc ≤ 35°C and were more likely to be ≥ 55 years old (12% versus 7%; p = 0.04); in addition, they were hypotensive on admission (25% versus 13%; p < 0.001), had a lower admission Glasgow Coma Score (GCS; 11 ± 5 versus 14 ± 3; p < 0.001), a higher Injury Severity Score (ISS; 29 ± 15 versus 22 ± 12; p < 0.001), higher head and chest Abbreviated Injury Scale (AIS), and greater intraoperative blood loss (2.6 ± 2.4 l versus 1.7 ± 1.8 l; p < 0.001). When compared to patients who were normothermic at the end of their operation, hypothermic patients had a significantly higher mortality (35% versus 8%; p < 0.001). With decreasing Tc, there was a stepwise increase in mortality. Compared to patients with a Tc > 35°C, the relative risk of death for patients with a Tc between 35°C and 33°C was 4.0, and that for patients with a Tc ≤ 33°C it was 7.1. After adjusting for multiple differences between groups, postoperative hypothermia remained an independent predictor of mortality (adjusted odds ratio [OR] 3.2; 95% confidence interval [CI] 1.9–5.3; p < 0.001).Conclusions Postoperative hypothermia is common in critically injured patients requiring cavitary surgery and is an independent predictor of mortality. The impact of measures to maintain or restore normothermia in the operating room warrants further investigation. [ABSTRACT FROM AUTHOR]

The present study examines the current management, closure rate, and complications of open abdomens in trauma patients admitted to an Academic Level I trauma center between May 2004 and April 2007. Variables examined include mechanism, injuries, use of antibiotics and paralytics, type of abdominal closure, days to closure, complications, ICU and hospital length of stay, and mortality. Stepwise logistic regression was performed to identify independent predictors of failed abdominal closure. Of 900 laparotomies, 93 (10%) were left open. Eighty-five (91%) patients survived for closure opportunity. Definitive fascial closure was achieved in 72 (85%) at 3.9 &plumsn; 3.7 days (range 1-21 days). Of the remaining 13 patients, seven were closed with biologic material, five by skin grafting, and one had skin-only closure. Entero-atmospheric fistulas occurred in 14 (15%) patients. Two independent risk factors associated with failed abdominal closure were the presence of deep surgical site infection [odds ratio (OR) 17.4; 95% confidence interval (CI) 2.6- 115.8, P = 0.003] and intra-abdominal abscess (OR 7.4; 95% CI 1.1-51.0, P = 0.04). In conclusion, open abdomens are commonly necessary after trauma laparotomies. Definitive fascial closure can be achieved in 85 per cent of cases. In conjunction with biologics, closure can be achieved in 93 per cent of cases. Failure to primarily close the abdomen is associated with a significantly higher risk for entero-atmospheric fistula occurrence. [ABSTRACT FROM AUTHOR]

Trauma patients are thought to be at high risk for iatrogenic retained foreign bodies (RFBs). The objective of this study was to evaluate this incidence. All cases of RFB after cavitary trauma surgery were identified by review of Morbidity and Mortality reports at a Level 1 trauma center from January 1998 to December 2005 and confirmed by the Octagon Risk Management System. Over 8 years, 10,053 trauma operations were performed (2075 laparotomies, 377 thoracotomies, and 74 sternotomies). Three cases (0.1%) of RFB (all sponges) occurred during one single-stage and two damage control laparotomies. The counts were correct before definitive closure in two of three cases. No postoperative x-rays were obtained in any of the cases. RFB diagnosis occurred between days 3 and 9, one on a routine chest x-ray and the other two on abdominal computed tomography scans during a septic workup. Four-month to 8-year follow up documented one pleural effusion and one abscess resulting from the RFB. Iatrogenic RFBs after emergent cavitary trauma surgery occur at a rate of 0.12 per cent and are associated with significant morbidity. In addition to standard preventive strategies, in emergent cases with risk factors such as requiring damage control, before final cavity closure, even with a correct sponge count, radiographic evaluation is warranted. [ABSTRACT FROM AUTHOR]

Enterocutaneous fistula (ECF) is an uncommon and poorly studied postoperative complication. The objective of this study was to analyze the incidence and resource utilization of patients who developed an ECF after trauma laparotomy. All patients with an ECF occurring after trauma laparotomy at a Level I trauma center were identified through a review of both the Trauma Registry and the Morbidity and Mortality reports for a 9-year period ending in December 2006. Each ECF case was matched with a control (non-ECF) that did not develop this complication after laparotomy. The matching criteria were: age, gender, mechanism of injury, Injury Severity Score, Abbreviated Injury Score, and damage control laparotomy requiring an open abdomen. Outcomes analyzed were intensive care unit (ICU) and hospital length of stay, mortality, and total hospital charges. During the 9-year period, of 2373 acute trauma laparotomies performed, 36 (1.5%) patients developed an enterocutaneous fistula, and were matched to 36 controls. Patients with an ECF were 31 ± 12 years of age, were 97 per cent male, had a mean Injury Severity Score of 21 + 10, and 75 per cent were penetrating. Eighty-nine per cent of the ECF patients had a hollow viscus injury. The most common was colon (69%), followed by small bowel (53%), duodenum (36%), and stomach (19%). Fifty-six per cent of the ECF patients had multiple hollow viscus injuries. The development of an ECF was associated with significantly increased ICU length of stay (28.5 ± 30.5 vs 7.6 ± 9.3 days, P = 0.004), hospital length of stay (82.1 + 100.8 vs 16.2 ± 17.3 days, P < 0.001), and hospital charges ($539,309 vs $126,996, P < 0.001). In conclusion, the development of an enterocutaneous fistula after laparotomy for trauma resulted in a significant impact on resource utilization including longer ICU and hospital length of stay and higher hospital charges. Further investigation into the prevention and treatment of this costly complication is warranted. [ABSTRACT FROM AUTHOR]