- Email: [email protected]
The effect of per-injury serotonin reuptake inhibitors on clinical outcomes in patients with traumatic brain injury
Vol. 219, No. 4S, October 2014
The progression of damage control resuscitation in severe penetrating trauma: a fourteen year experience in a level one trauma center Carlos Ordon˜ez, David Alejandro D Mejia Toro, MD, Marisol Badiel, MD, MSc, cPhD, MIchael W Parra, MD, Cristina Vernaza, MD, Fernando Rodriguez, MD, Luis L Pino, MD, Fernando Min˜an, MD, Alvaro I Sanchez-Ortiz, MD, PhD, Juan C Puyana, MD, FACS University of Pittsburgh, Pittsburgh, PA and Broward Surgical Associates, Fort Lauderdale, FL and Clinica Universitaria Rafael Uribe Uribe, Cali, Colombia and Fundacio´n Valle del Lili and Universidad del Valle, Cali, Valle Del Cauca, Colombia INTRODUCTION: The approach to managing severe penetrating injuries has undergone major changes over the last several years. Accumulated experience from war conflicts and from trauma centers in areas with high incidence of severe violence have generated significant modifications in many areas of resuscitation from prehospital care to the trauma bay, the operating room, damage control in the ICUs.The objective of this review is to compare major changes in trauma resuscitative management from two separate periods at a level one trauma center between the periods of 19982005 and 2005 -2013. METHODS: This is a retrospective review comparing patients with penetrating injuries that received at least 2 units of PRCs between these two periods. Comparisons were controlled by age and NISS. Missing data was managed by using 1000 simulations performed with the bootstrap method for data verification. RESULTS: A total of 401 patients were included. The median age was 3011.6 years and 92.8% were males. Three hundred and forty one (85%) suffered GSW. The median intravenous fluids infused in the first 24 hours prior to 2005 was 9200cc (IQR 5400e13600cc) and after 2005 was 5763cc (3700-8300cc [p¼0.0001]). The median intra-operative blood loss was 3000cc (2000-4650cc) prior to 2005 and of about 2000cc (10003000cc) after 2005 (p¼0.001). CONCLUSIONS: Significant differences were identified between the two periods. The amount of crystalloids decreased and the use of “adjuvant” pro-coagulation interventions including the number of patients receiving cryoprecipitate and tranexamic acid increased since 2005. These changes were associated with a decreased intra-operative bleeding and improved mortality. The impact of resuscitation strategy on successful abdominal closure following damage control: further support for colloid over crystalloid Linda Ding, MD INTRODUCTION: Damage control resuscitation (DCR) includes the correction of the acute coagulopathy of trauma using blood components over crystalloid. Current evidence indicates that high crystalloid resuscitation contributes to delayed abdominal closure. The purpose of this study was to investigate our institution’s
Scientific Poster Presentations: 2014 Clinical Congress
e191
DCRs. We hypothesized that lower volume of crystalloid resuscitation is associated with earlier fascial closure. METHODS: This was a retrospective review at an urban Level 1 trauma center. We reviewed the records of patients who underwent Damage Control Laparotomy (DCL) before and after institution of a Massive Transfusion Protocol (MTP): 2004-2009 (pre-MTP) and 2010-2013 (post-MTP). DCL was defined as a trauma laparotomy with resultant open abdomen. Primary outcome measures were volumes of resuscitation and days to primary closure. RESULTS: Fifty-three patients were included. There was no difference in Injury Severity Score (ISS) or mechanism. Wittmann patch was the most common type of temporary abdominal closure used (85%). More patients in the post-MTP group were able to be closed within 8 days when compared to the pre-MTP group (46 vs 27%). In patients requiring >2 laparotomies, the post-MTP group received lower volumes of crystalloid and higher volume of FFP in the 1st 24 hours and over the 1st week. CONCLUSIONS: Our institution transitioned to using more FFP and less crystalloid in DCRs resulting in earlier closure. Closures delayed more than 8 days were associated with higher crystalloid administration over the 1st week. Crystalloid administration beyond the first day and into the 1st week post injury clearly plays a role in fascial closure following DCR. The effect of per-injury serotonin reuptake inhibitors on clinical outcomes in patients with traumatic brain injury Gagan P Kaur II, MS, Bellal Joseph, MD, FACS, Ammar Hashmi, MD, Narong Kulvatunyou, MD, FACS, Terence O’Keeffe, MD, MBchB, Andrew L Tang, MD, FACS, Donald Green, MD, Gary A Vercruysse, MD, FACS, Randall S Friese, MD, FACS, Peter M Rhee, MD, FACS University of Arizona, Tuscon, AZ INTRODUCTION: Inhibition of platelet function in patients with traumatic brain injury (TBI) is known to be associated with worse outcomes. The anti-platelet effects of selective serotonin reuptake inhibitors (SSRI) in non-trauma patients are well established. The aim of our study was to evaluate clinical outcomes in TBI patients on pre-injury SSRI therapy. METHODS: A retrospective analysis of all patients with TBI with an intracranial hemorrhage (ICH) on initial computed tomography (CT) scan was performed. Patients on pre-injury SSRI were matched with patients exclusive of anti-platelet and anti-coagulation therapy using propensity score in a ratio of 1:1 for age, gender, Glasgow Coma Scare (GCS), head Abbreviated Injury Scale (hAIS) and Injury Severity Score (ISS). Outcome measures were progression on repeat head computed tomography (RHCT) scan and the need for neurosurgical intervention. RESULTS: A total of 128 patients (SSRI: 64, No-SSRI: 64) were included. The mean age was 4828, 51.6% were male, median GCS was 15 [3-15], median h-AIS was 3 [2-5]. There was no difference in age (p¼0.8), gender (p¼0.7) GCS (p¼0.8), h-AIS
e192
Scientific Poster Presentations: 2014 Clinical Congress
(p¼0.8) and ISS (p¼0.6) between the two groups after matching. Patients on SSRI therapy had a higher rate of progression on RHCT compared to patients not on SSRI therapy. (15.6% vs 4.7%, p¼0.03). There was no difference in the rate of neurosurgical intervention between the two groups (p¼0.4). CONCLUSIONS: Patients with TBI on pre-injury SSRI therapy are at increased risk of radiographic progression on repeat head CT scan. The anti-platelet effects of SSRI therapy on clinical outcomes in TBI patients require prospective evaluation. Striking a balance in massive transfusion for traumatic brain injury: do the crystalloid to blood product ratios matter? Adarsh Vijay, MD, Ruben Peralta, MD, FACS, Rafael J Consunji, MD, MPH, Ayman El Menyar, MD, HH Abdelrahman, MD, A Parchani, MD, Ahmad Zarour, MD, Hassan A Al Thani, MBBCh, FACS, Rifat Latifi, MD Hamad Medical Corporation, Doha, Qatar and University of Arizona, Tuscon, AZ INTRODUCTION: This study aims to explore the associations between the crystalloid to PRBC, FFP and Platelet ratios (C:PRBC, C:FFP and C:PLT respectively) and significant clinical outcomes in traumatic brain injury(TBI) patients needing massive transfusion(MT).
J Am Coll Surg
RWTH Aachen University, Aachen, Germany and Ludwig Maximilian University of Munich, Munich, Germany INTRODUCTION: A decrease in the mortality rates of car accident victims has been observed within the last decades. The effects of these changes on mortality patterns and injury distribution are unknown. We therefore assessed injury patterns and the time course of pre-clinical mortality in a consecutive series of autopsies in a metropolitan area. METHODS: All autopsies of car accident victims were performed (ISS 16) by a group of pathologists over a time course of 2 years. All injuries were coded according to the standardized MAIS classification (AAAM 2008). The location (inner city, rural road, and highway), the time point of death and the exact injury patterns and causes of death were documented. RESULTS: A total of 283 severely injured patients were included. Mean age: 47 23 years, 67.6 % males, 40% of the victims showed an ISS of 75 and 15% had an ISS between 16-32. The majority of accidents occurred on rural roads (61.5%). 62.5% of patient died on scene and 13.4% died between 1 and 6 hours after trauma. 37% of patients had a fatal trauma with MAIS of 6. The head was the most frequently injured body region (38.5 %), followed by the chest (26.5%) and combined head/chest injuries (11%) with equally highly traumatized MAIS levels.
METHODS: A retrospective data review from a prospectively collected MTP and Trauma registry, at a Level I trauma center, was conducted. All TBI patients who received 10 units PRBC in their 1st 24 hours were included. Patients were divided into two groups: survivors[S] and non-survivors[NS]. Demographic information, clinical characteristics and outcome measures were compared and tested for their association with the crystalloid to blood product ratios administered at 4 and 24 hours post-injury.
CONCLUSIONS: In our series, the majority of patients involved in car accidents died on scene from head and thoracic injuries. After that, a homogenous distribution of death after initial peak on scene was found. Up to 40 % of patient had a fatal trauma allowing no further treatment. More attention should gain preventable caused of death. Moreover, prevention of trauma is of immense importance to reduce the mortality.
RESULTS: Both groups were similar for baseline demographic and clinical characteristics. There were no significant differences in clinically significant outcomes:ACS, AKI, ARDS, VAP or MOF. The mean C:PRBC, C:FFP and C:Plt ratios attained in the S group were 2.2, 4.09 and 12.00 at 4 hours and 1.41, 2.84 and 9.60 at 24 hours. The mean ratios attained in the NS group were 2.03, 5.56 and 17.45 at 4 hours and 1.38, 3.00 and 17.20 at 24 hours. There was a trend towards lower C:FFP and C:Plt ratios for the S groups at 4 and 24 hours after arrival but this did not reach statistical significance.
Finally proving the maxim: quantifying the effect of hemodilution in prospective randomized control trial with blood donation as a model for hemorrhage Samuel W Ross, MD, MPH, A Britton Christmas, MD, FACS, Peter E Fischer, MD, MS, Haley E Holway, BS, Rachel Seymour, PhD, B Todd Heniford, MD, FACS, Ronald F Sing, DO, FACS Carolinas Medical Center, Charlotte, NC
CONCLUSIONS: This initial study did not show an advantage to maintaining a lower C:PRBC ratio at 4 and 24 hours post-injury. There is a need for further study of the effect of lower C:FFP and C:Plt ratios on TBI patients needing MT. Mortality pattern and causes of death: are they different in car accident victims? Hans-Christoph Pape, MD, Roman Pfeifer, Sylvia Schick, Dr med, MPH, Christopher Holzmann, Wolfram Hell, Fank Hildebrand, MD, PhD
INTRODUCTION: The concept of hemodilution in trauma and surgery makes sense, but this surgical maxim remains unproven in humans. We sought to quantify the effect of hemodilution after crystalloid administration in voluntary blood donors as a model for hemorrhage. METHODS: A prospective randomized control trial was conducted in conjunction with blood drives. Donor demographics, comorbidities, height and weight were collected; total blood volume (TBV) was calculated using Nadler’s formula. Donors were randomized to receive no IV fluid (no IVF), two liters normal saline (NS), or two liters lactated ringers (LR) after blood donation. Blood samples were taken before and after donation of 500 mL of blood and after
The progression of damage control resuscitation in severe penetrating trauma: a fourteen year experience in a level one trauma center Carlos Ordon˜ez, David Alejandro D Mejia Toro, MD, Marisol Badiel, MD, MSc, cPhD, MIchael W Parra, MD, Cristina Vernaza, MD, Fernando Rodriguez, MD, Luis L Pino, MD, Fernando Min˜an, MD, Alvaro I Sanchez-Ortiz, MD, PhD, Juan C Puyana, MD, FACS University of Pittsburgh, Pittsburgh, PA and Broward Surgical Associates, Fort Lauderdale, FL and Clinica Universitaria Rafael Uribe Uribe, Cali, Colombia and Fundacio´n Valle del Lili and Universidad del Valle, Cali, Valle Del Cauca, Colombia INTRODUCTION: The approach to managing severe penetrating injuries has undergone major changes over the last several years. Accumulated experience from war conflicts and from trauma centers in areas with high incidence of severe violence have generated significant modifications in many areas of resuscitation from prehospital care to the trauma bay, the operating room, damage control in the ICUs.The objective of this review is to compare major changes in trauma resuscitative management from two separate periods at a level one trauma center between the periods of 19982005 and 2005 -2013. METHODS: This is a retrospective review comparing patients with penetrating injuries that received at least 2 units of PRCs between these two periods. Comparisons were controlled by age and NISS. Missing data was managed by using 1000 simulations performed with the bootstrap method for data verification. RESULTS: A total of 401 patients were included. The median age was 3011.6 years and 92.8% were males. Three hundred and forty one (85%) suffered GSW. The median intravenous fluids infused in the first 24 hours prior to 2005 was 9200cc (IQR 5400e13600cc) and after 2005 was 5763cc (3700-8300cc [p¼0.0001]). The median intra-operative blood loss was 3000cc (2000-4650cc) prior to 2005 and of about 2000cc (10003000cc) after 2005 (p¼0.001). CONCLUSIONS: Significant differences were identified between the two periods. The amount of crystalloids decreased and the use of “adjuvant” pro-coagulation interventions including the number of patients receiving cryoprecipitate and tranexamic acid increased since 2005. These changes were associated with a decreased intra-operative bleeding and improved mortality. The impact of resuscitation strategy on successful abdominal closure following damage control: further support for colloid over crystalloid Linda Ding, MD INTRODUCTION: Damage control resuscitation (DCR) includes the correction of the acute coagulopathy of trauma using blood components over crystalloid. Current evidence indicates that high crystalloid resuscitation contributes to delayed abdominal closure. The purpose of this study was to investigate our institution’s
Scientific Poster Presentations: 2014 Clinical Congress
e191
DCRs. We hypothesized that lower volume of crystalloid resuscitation is associated with earlier fascial closure. METHODS: This was a retrospective review at an urban Level 1 trauma center. We reviewed the records of patients who underwent Damage Control Laparotomy (DCL) before and after institution of a Massive Transfusion Protocol (MTP): 2004-2009 (pre-MTP) and 2010-2013 (post-MTP). DCL was defined as a trauma laparotomy with resultant open abdomen. Primary outcome measures were volumes of resuscitation and days to primary closure. RESULTS: Fifty-three patients were included. There was no difference in Injury Severity Score (ISS) or mechanism. Wittmann patch was the most common type of temporary abdominal closure used (85%). More patients in the post-MTP group were able to be closed within 8 days when compared to the pre-MTP group (46 vs 27%). In patients requiring >2 laparotomies, the post-MTP group received lower volumes of crystalloid and higher volume of FFP in the 1st 24 hours and over the 1st week. CONCLUSIONS: Our institution transitioned to using more FFP and less crystalloid in DCRs resulting in earlier closure. Closures delayed more than 8 days were associated with higher crystalloid administration over the 1st week. Crystalloid administration beyond the first day and into the 1st week post injury clearly plays a role in fascial closure following DCR. The effect of per-injury serotonin reuptake inhibitors on clinical outcomes in patients with traumatic brain injury Gagan P Kaur II, MS, Bellal Joseph, MD, FACS, Ammar Hashmi, MD, Narong Kulvatunyou, MD, FACS, Terence O’Keeffe, MD, MBchB, Andrew L Tang, MD, FACS, Donald Green, MD, Gary A Vercruysse, MD, FACS, Randall S Friese, MD, FACS, Peter M Rhee, MD, FACS University of Arizona, Tuscon, AZ INTRODUCTION: Inhibition of platelet function in patients with traumatic brain injury (TBI) is known to be associated with worse outcomes. The anti-platelet effects of selective serotonin reuptake inhibitors (SSRI) in non-trauma patients are well established. The aim of our study was to evaluate clinical outcomes in TBI patients on pre-injury SSRI therapy. METHODS: A retrospective analysis of all patients with TBI with an intracranial hemorrhage (ICH) on initial computed tomography (CT) scan was performed. Patients on pre-injury SSRI were matched with patients exclusive of anti-platelet and anti-coagulation therapy using propensity score in a ratio of 1:1 for age, gender, Glasgow Coma Scare (GCS), head Abbreviated Injury Scale (hAIS) and Injury Severity Score (ISS). Outcome measures were progression on repeat head computed tomography (RHCT) scan and the need for neurosurgical intervention. RESULTS: A total of 128 patients (SSRI: 64, No-SSRI: 64) were included. The mean age was 4828, 51.6% were male, median GCS was 15 [3-15], median h-AIS was 3 [2-5]. There was no difference in age (p¼0.8), gender (p¼0.7) GCS (p¼0.8), h-AIS
e192
Scientific Poster Presentations: 2014 Clinical Congress
(p¼0.8) and ISS (p¼0.6) between the two groups after matching. Patients on SSRI therapy had a higher rate of progression on RHCT compared to patients not on SSRI therapy. (15.6% vs 4.7%, p¼0.03). There was no difference in the rate of neurosurgical intervention between the two groups (p¼0.4). CONCLUSIONS: Patients with TBI on pre-injury SSRI therapy are at increased risk of radiographic progression on repeat head CT scan. The anti-platelet effects of SSRI therapy on clinical outcomes in TBI patients require prospective evaluation. Striking a balance in massive transfusion for traumatic brain injury: do the crystalloid to blood product ratios matter? Adarsh Vijay, MD, Ruben Peralta, MD, FACS, Rafael J Consunji, MD, MPH, Ayman El Menyar, MD, HH Abdelrahman, MD, A Parchani, MD, Ahmad Zarour, MD, Hassan A Al Thani, MBBCh, FACS, Rifat Latifi, MD Hamad Medical Corporation, Doha, Qatar and University of Arizona, Tuscon, AZ INTRODUCTION: This study aims to explore the associations between the crystalloid to PRBC, FFP and Platelet ratios (C:PRBC, C:FFP and C:PLT respectively) and significant clinical outcomes in traumatic brain injury(TBI) patients needing massive transfusion(MT).
J Am Coll Surg
RWTH Aachen University, Aachen, Germany and Ludwig Maximilian University of Munich, Munich, Germany INTRODUCTION: A decrease in the mortality rates of car accident victims has been observed within the last decades. The effects of these changes on mortality patterns and injury distribution are unknown. We therefore assessed injury patterns and the time course of pre-clinical mortality in a consecutive series of autopsies in a metropolitan area. METHODS: All autopsies of car accident victims were performed (ISS 16) by a group of pathologists over a time course of 2 years. All injuries were coded according to the standardized MAIS classification (AAAM 2008). The location (inner city, rural road, and highway), the time point of death and the exact injury patterns and causes of death were documented. RESULTS: A total of 283 severely injured patients were included. Mean age: 47 23 years, 67.6 % males, 40% of the victims showed an ISS of 75 and 15% had an ISS between 16-32. The majority of accidents occurred on rural roads (61.5%). 62.5% of patient died on scene and 13.4% died between 1 and 6 hours after trauma. 37% of patients had a fatal trauma with MAIS of 6. The head was the most frequently injured body region (38.5 %), followed by the chest (26.5%) and combined head/chest injuries (11%) with equally highly traumatized MAIS levels.
METHODS: A retrospective data review from a prospectively collected MTP and Trauma registry, at a Level I trauma center, was conducted. All TBI patients who received 10 units PRBC in their 1st 24 hours were included. Patients were divided into two groups: survivors[S] and non-survivors[NS]. Demographic information, clinical characteristics and outcome measures were compared and tested for their association with the crystalloid to blood product ratios administered at 4 and 24 hours post-injury.
CONCLUSIONS: In our series, the majority of patients involved in car accidents died on scene from head and thoracic injuries. After that, a homogenous distribution of death after initial peak on scene was found. Up to 40 % of patient had a fatal trauma allowing no further treatment. More attention should gain preventable caused of death. Moreover, prevention of trauma is of immense importance to reduce the mortality.
RESULTS: Both groups were similar for baseline demographic and clinical characteristics. There were no significant differences in clinically significant outcomes:ACS, AKI, ARDS, VAP or MOF. The mean C:PRBC, C:FFP and C:Plt ratios attained in the S group were 2.2, 4.09 and 12.00 at 4 hours and 1.41, 2.84 and 9.60 at 24 hours. The mean ratios attained in the NS group were 2.03, 5.56 and 17.45 at 4 hours and 1.38, 3.00 and 17.20 at 24 hours. There was a trend towards lower C:FFP and C:Plt ratios for the S groups at 4 and 24 hours after arrival but this did not reach statistical significance.
Finally proving the maxim: quantifying the effect of hemodilution in prospective randomized control trial with blood donation as a model for hemorrhage Samuel W Ross, MD, MPH, A Britton Christmas, MD, FACS, Peter E Fischer, MD, MS, Haley E Holway, BS, Rachel Seymour, PhD, B Todd Heniford, MD, FACS, Ronald F Sing, DO, FACS Carolinas Medical Center, Charlotte, NC
CONCLUSIONS: This initial study did not show an advantage to maintaining a lower C:PRBC ratio at 4 and 24 hours post-injury. There is a need for further study of the effect of lower C:FFP and C:Plt ratios on TBI patients needing MT. Mortality pattern and causes of death: are they different in car accident victims? Hans-Christoph Pape, MD, Roman Pfeifer, Sylvia Schick, Dr med, MPH, Christopher Holzmann, Wolfram Hell, Fank Hildebrand, MD, PhD
INTRODUCTION: The concept of hemodilution in trauma and surgery makes sense, but this surgical maxim remains unproven in humans. We sought to quantify the effect of hemodilution after crystalloid administration in voluntary blood donors as a model for hemorrhage. METHODS: A prospective randomized control trial was conducted in conjunction with blood drives. Donor demographics, comorbidities, height and weight were collected; total blood volume (TBV) was calculated using Nadler’s formula. Donors were randomized to receive no IV fluid (no IVF), two liters normal saline (NS), or two liters lactated ringers (LR) after blood donation. Blood samples were taken before and after donation of 500 mL of blood and after