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Objectives Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair. Methods The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011-July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences. Results The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82-2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03-5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74-3.26), P = 0.244). Conclusion For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia. [ABSTRACT FROM AUTHOR]

Background Computerized tomography angiography is an important tool for endovascular repair of abdominal aortic aneurysm planning. This study aimed to evaluate the utility of computerized tomography angiography using direct intra-aortic injection of low volume of iodinated contrast in patients being considered for endovascular repair of abdominal aortic aneurysm. Design A 5F high-flow angiographic catheter was positioned in the mid-thoracic aorta through femoral percutaneous access. Computerized tomography angiography was performed with image acquisition starting simultaneously with power injection of 10 mL of iopamidol 76% diluted with normal saline to 50 mL, at 6 mL/s through the angiographic catheter. Aortic enhancement was assessed with a circular region-of-interest within the aorta. Values ≥150 HU were considered adequate. Results Nine patients with abdominal aortic aneurysm and chronic renal dysfunction underwent computerized tomography angiography with intra-arterial contrast injection for endovascular repair of abdominal aortic aneurysm planning. Mean age 78.8 ± 5.0 years, mean baseline creatinine 1.8 ± 0.4 mg/dL and mean glomerular filtration rate 36.8 ± 4.2 mL/min. Adequate computerized tomography angiography aortic enhancement was obtained in all cases (mean intra-aortic density: 300.4 ± 72.8 HU). The total contrast volume used for the computerized tomography angiography and the endovascular repair of abdominal aortic aneurysm combined was 30.0 ± 21.4 mL. Seventy-five percent of the patients received ≤30 mL of contrast. No significant renal function deterioration occurred (creatinine clearance pre- and post-procedure 36.8 ± 4.2 mL/min versus 38.6 ± 6.1 mL/min, p = 0.32). Successful endovascular repair of abdominal aortic aneurysm was achieved in eight patients. One patient underwent open treatment based on computerized tomography angiography information. No endoleak or aneurysm growth occurred (median follow-up: 121 days (range 36-1242)). Conclusion Direct intra-aortic injection of low volume of iodinated contrast provides adequate and reproducible pattern of aortic enhancement on computerized tomography angiography. The computerized tomography angiography so acquired can be used for endovascular repair of abdominal aortic aneurysm limiting the total volume of iodinated contrast required. [ABSTRACT FROM AUTHOR]

For over a decade, the Los Angeles County/University of Southern California Hospital has supported an international fellowship in trauma that provides research experience, education, and opportunity for clinical observation at a high-volume American College of Surgeons (ACS) designated Level I trauma center. We performed a descriptive study of the design, implementation, and results of an international fellowship in trauma and critical care. Fellows from 27 countries throughout the world have actively engaged in trauma research at Los Angeles County/University of Southern California Hospital. Our program involves intensive education and clinical observation components designed to facilitate dissemination of evidence-based trauma practices throughout the world by graduates. The majority of alumni responding to a survey returned to their countries of origin, remaining active in trauma care and research. Motivation for participation varied, but former fellows universally rated their experience highly and stated they would recommend the program to their colleagues. An international research fellowship in trauma and critical care provides foreign medical trainees opportunities for exposure to research and evidence-based practices at a high-volume trauma center. The program is designed to be beneficial to both the participating fellow and sponsoring institution; and is constructed to effectively promote improved trauma education and the dissemination of quality trauma practices internationally. [ABSTRACT FROM AUTHOR]

The objective of this study was to analyze the transfusion practices in trauma patients in one institution. A retrospective analysis of the Trauma Registry linked with the Blood Bank Database of a Level 1 trauma center was conducted. Over 6 years, 17 per cent of the 25,599 trauma patients received blood transfusions. The overall mortality in transfused patients was 20 per cent and remained the same during the study period. There was no change in the proportion of patients receiving transfusions throughout the years, however there was a significant 23.5 per cent reduction in the mean number of packed red blood cells (PRBC) units transfused (P < 0.001 for trend). This reduction in PRBC used remained true and even more evident in the group of more severely injured patients (Injury Severity Score ≥ 16), with a 27.9 per cent decrease in mean units of PRBC (P < 0.001 for trend). The highest reduction in PRBC transfusion was seen in blunt trauma patients (34.6%, P < 0.001). During the study period there was a concurrent increase in mean units of fresh frozen plasma used (60.7%, P < 0.001) and no change in the use of platelets and cryoprecipitate. In conclusion, transfusions of PRBC were significantly reduced over time in trauma patients without any evident negative impact on mortality. [ABSTRACT FROM AUTHOR]

CT Venography (CTV) performed at the time of CT pulmonary angiography (CTPA) images the central, pelvic, and extremity venous circulation with minimal additional time, radiation, and no added contrast. CTV has been added to CTPA routinely at our Level I trauma center since 2000, and we sought to determine if this addition had increased the diagnostic yield of CTPA in trauma patients. The attending radiologist's interpretation of all CTPA-CTV studies performed over a 5-year period ending in August 2006 were retrospectively reviewed. CTPAs and CTVs were categorized as "positive", "negative", or "indeterminate" for pulmonary embolus (PE) and deep venous thrombosis (DVT). During the study period, 3798 patients underwent both a CTPA and CTV; 309 (8%) of these were trauma patients. Forty-four (14%) had a PE diagnosed on CTPA. Seventeen (6%) had a DVT diagnosed on CTV. In eight (3%), the CTV added clinically relevant data, diagnosing a DVT in a patient without PE. As the consequences of a missed pelvic DVT are high and the added time burden, radiation, and contrast required for a CTV are low, further investigation into optimizing the sensitivity of CTV performed at the time of CTPA is warranted. [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]

There are no independent computed tomography (CT) findings predictive of elevated intracranial pressure (ICP). The purpose of this study was to evaluate brain density measurement on CT as a predictor of elevated ICP or decreased cerebral perfusion pressure (CPP). A prospectively collected database of patients with acute traumatic brain injury was used to identify patients who had a brain CT followed within 2 hours by ICP measurement. Blinded reviewers measured mean density in Hounsfield Units (HU) within a 100-mm2 elliptical region at four standardized positions. Brain density measurement was compared for patients with an ICP of 20 or greater versus less than 20 mm Hg and CPP of 70 or greater versus less than 70 mm Hg. During a 2-year period, 47 patients had ICP monitoring after brain CT. Average age was 40 +/- 18 years old; 93.6 per cent were male; mean Injury Severity Score was 25 +/- 10; and Glasgow Coma Scale was 6 +/- 4. There was no difference in brain density measurement for observer 1, ICP less than 20 (26.3 HU) versus ICP 20 or greater (27.4 HU, P = 0.545) or for CPP less than 70 (27.1 HU) versus CPP 70 or greater (26.2, P = 0.624). Similarly, there was no difference for observer 2, ICP less than 20 (26.8 HU) versus ICP 20 or greater (27.4, P = 0.753) and CPP less than 70 (27.6 HU) versus CPP 70 or greater (26.2, P = 0.436). CT-measured brain density does not correlate with elevated ICP or depressed CPP and cannot predict patients with traumatic brain injury who would benefit from invasive ICP monitoring. [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]

The purpose of this study was to examine the epidemiology and outcomes of posttraumatic upper (UEA) and lower extremity amputations (LEA). The National Trauma Databank version 5 was used to identify all posttraumatic amputations. From 2000 to 2004 there were 8910 amputated patients (1.0% of all trauma patients). Of these, 6855 (76.9%) had digit and 2055 (23.1%) had limb amputation. Of those with limb amputation, 92.7 per cent (1904/2055) had a single limb amputation. LEA were more frequent than UEA among patients in the single limb amputation group (58.9% vs 41.1%). The mechanism of injury was blunt in 83 per cent; most commonly after motor vehicle collisions (51.0%), followed by machinery accidents (19.4%). Motor vehicle collision occupants had more UEA (54.5% vs 45.5%, P < 0.001), whereas motorcyclists (86.2% vs 13.8%, P < 0.001) and pedestrians (91.9% vs 8.1%, P < 0.001) had more LEA. Patients with LEA were more likely to require discharge to a skilled nursing facility; whereas those with UEA were more likely to be discharged home. Traumatic limb amputation is not uncommon after trauma in the civilian population and is associated with significant morbidity. Although single limb amputation did not impact mortality, the need for multiple limb amputation was an independent risk factor for death. [ABSTRACT FROM AUTHOR]

Pyloric exclusion (PEX) has traditionally been used in the management of complicated duodenal injuries to temporarily protect the duodenal repair and prevent septic abdominal complications. We used the American College of Surgeons National Trauma Data Bank (v 5.0) to evaluate adult patients with severe duodenal injuries [American Association for the Surgery of Trauma (AAST) Grade ≥3] undergoing primary repair only or repair with PEX within 24 hours of admission. Propensity scoring was used to adjust for relevant confounding factors during outcomes comparison. Among 147 patients with severe duodenal injuries, 28 (19.0%) underwent PEX [15.9% (11/69) Grade III vs 34.0% (17/50) Grade IV-V]. Despite similar demographics, PEX was associated with a longer mean hospital stay (32.2 vs 22.2 days, P = 0.003) and was not associated with a mortality benefit. There was a trend toward increased development of septic abdominal complications (intra-abdominal abscess, wound infection, or dehiscence) with PEX that was not statistically significant. After multivariable analysis using propensity score, no statistically significant differences in mortality or occurrence of septic abdominal complications was noted between those patients undergoing primary repair only or PEX. The use of PEX in patients with severe duodenal injuries may contribute to longer hospital stay and confers no survival or outcome benefit. [ABSTRACT FROM AUTHOR]

The rate of methicillin-resistant Staphylococcus aureus (MRSA) infections has increased significantly over the last years, especially from community-associated MRSA (CA-MRSA) sources. The true prevalence of these multidrug-resistant infections among the trauma patient population, however, is not well defined. A retrospective review of our surgical intensive care unit (SICU) database from April 2003 to April 2007 was performed to identify all trauma patients surviving 48 hours or more that had a positive culture result during their SICU stay. The results of the cultures were examined. A total of 582 SICU patients with 2,860 cultures were assessed for MRSA infection. Among these, 368 cultures (12.9%) in 36 patients were reported as MRSA positive. Thirteen of these patients fulfilled the criteria for a CA-MRSA infection. When outcomes were analyzed, no significant difference in mortality (8.7% vs 15.4%, P = 0.540) or hospital related charges ($364,231 ± 323,719 vs $242,458 ± 276,630, P = 0.091) was noted. Patients with a hospital-acquired MRSA infection, however, had longer hospital lengths of stay (42.7 ± 47.1 vs 25.3 ± 31.1, P = 0.037) than their community-associated counterparts. MRSA constitutes an important source of infection among critically ill trauma patients. CA-MRSA organisms may play an increasing pathogenic role in this population. [ABSTRACT FROM AUTHOR]