Publications by authors named "Donald H Jenkins"

104 Publications

Prehospital whole blood reduces early mortality in patients with hemorrhagic shock.

Transfusion 2021 07;61 Suppl 1:S15-S21

Department of Surgery, UT Health San Antonio, San Antonio, Texas, USA.

Background: Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion.

Study Design And Methods: A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed.

Results: A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05).

Discussion: This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.
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http://dx.doi.org/10.1111/trf.16528DOI Listing
July 2021

Civilian walking blood bank emergency preparedness plan.

Transfusion 2021 07;61 Suppl 1:S313-S325

University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Background: The current global pandemic has created unprecedented challenges in the blood supply network. Given the recent shortages, there must be a civilian plan for massively bleeding patients when there are no blood products on the shelf. Recognizing that the time to death in bleeding patients is less than 2 h, timely resupply from unaffected locations is not possible. One solution is to transfuse emergency untested whole blood (EUWB), similar to the extensive military experience fine-tuned over the last 19 years. While this concept is anathema in current civilian transfusion practice, it seems prudent to have a vetted plan in place.

Methods And Materials: During the early stages of the 2020 global pandemic, a multidisciplinary and international group of clinicians with broad experience in transfusion medicine communicated routinely. The result is a planning document that provides both background information and a high-level guide on how to emergently deliver EUWB for patients who would otherwise die of hemorrhage.

Results And Conclusions: Similar plans have been utilized in remote locations, both on the battlefield and in civilian practice. The proposed recommendations are designed to provide high-level guidance for experienced blood bankers, transfusion experts, clinicians, and health authorities. Like with all emergency preparedness, it is always better to have a well-thought-out and trained plan in place, rather than trying to develop a hasty plan in the midst of a disaster. We need to prevent the potential for empty shelves and bleeding patients dying for lack of blood.
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http://dx.doi.org/10.1111/trf.16458DOI Listing
July 2021

Euglobulin clot lysis time reveals a high frequency of fibrinolytic activation in trauma.

Thromb Res 2021 08 31;204:22-28. Epub 2021 May 31.

Division of Hematology, Department of Medicine and Blood Research Center, University of North Carolina, Chapel Hill, NC, USA. Electronic address:

Activation of the fibrinolytic system plays a central role in the host response to trauma. There is significant heterogeneity in the degree of fibrinolysis activation at baseline that is usually assessed by whole blood thromboelastography (TEG). Few studies have focused on plasma markers of fibrinolysis that could add novel insights into the frequency and mechanisms of fibrinolytic activation in trauma. Global fibrinolysis in plasma was assessed using a modified euglobulin clot lysis time (ECLT) assay in 171 major trauma patients and compared to commonly assessed analytes of fibrinolysis. The median ECLT in trauma patients was significantly shorter at 8.5 h (IQR, 1.3-19.5) compared to 19.9 h (9.8-22.6) in healthy controls (p < 0.0001). ECLT values ≤2.5th percentile of the reference range were present in 83 (48.5%) of trauma patients, suggesting increased fibrinolytic activation. Shortened ECLT values were associated with elevated plasmin-antiplasmin (PAP) complexes and free tissue plasminogen activator (tPA) levels in plasma. Sixteen (9.2%) individuals met the primary outcome for massive transfusion, here defined as the critical administration threshold (CAT) of 3 units of packed red cells in any 60-minute period within the first 24 h. In a univariate screen, plasma biomarkers associated with CAT included D-dimer (p < 0.001), PAP (p < 0.05), free tPA (p < 0.05) and ECLT (p < 0.05). We conclude that fibrinolytic activation, measured by ECLT, is present in a high proportion of trauma patients at presentation. The shortened ECLT is partially driven by high tPA levels and is associated with high levels of circulating PAP complexes. Further studies are needed to determine whether ECLT is an independent predictor of trauma outcomes.
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http://dx.doi.org/10.1016/j.thromres.2021.05.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277746PMC
August 2021

Prehospital shock index and systolic blood pressure are highly specific for pediatric massive transfusion.

J Trauma Acute Care Surg 2021 May 10. Epub 2021 May 10.

University of Texas Health Science Center, Department of Trauma and Emergency Surgery, San Antonio, TX 78229-3900 Trauma Surgery, Naval Medical Center Camp Lejeune, Camp Lejeune, NC 28547 University Hospital in San Antonio, Trauma Services, San Antonio, TX 78229-3900 University of Texas Health Science Center, Department of Pathology, San Antonio, TX 78229-3900 Southwest Texas Regional Advisory Council, San Antonio, TX, 78227 University of Texas Health Science Center, Department of Emergency Health Sciences, San Antonio, TX 78229-3900.

Background: While massive transfusion protocols (MTP) are associated with decreased mortality in adult trauma patients, there is limited research on the impact of MTP on pediatric trauma patients. The purpose of this study was to compare pediatric trauma patients requiring massive transfusion to all other pediatric trauma patients to identify triggers for MTP activation in injured children.

Methods: Using our level I trauma center's registry, we retrospectively identified all pediatric trauma patients from January 2015 to January 2018. Massive transfusion (MT) was defined as infusion of 40 mL/kg of blood products in the first 24 hours of admission. Patients missing prehospital vital sign data were excluded from the study. We retrospectively collected data including: demographics, blood utilization, variable outcome data, prehospital vital signs, prehospital transport times, and injury severity scores (ISS). Statistical significance was determined using Mann-Whitney U test and chi-square test. P values less than 0.05 were considered significant.

Results: Thirty-nine of the 2,035 pediatric patients (1.9%) met criteria for MT. All-cause mortality in MT patients was 49% (19/39) versus 0.01% (20/1996) in Non-MT patients. The two groups significantly differed in ISS, prehospital vital signs, and outcome data.Both systolic blood pressure (SBP) <100 mmHg and shock index (SI) >1.4 were found to be highly specific for massive transfusion with specificities of 86% and 92%, respectively. The combination of SBP<100 mmHg and SI>1.4 had a specificity of 94%. The positive and negative predictive values of SBP<100 mmHg and SI >1.4 in predicting massive transfusion were 18% and 98%, respectively. Based on positive likelihood ratios, patients with both SBP<100 mmHg and SI>1.4 were 7.2 times more likely to require massive transfusion than patients who did not meet both of these vital sign criteria.

Conclusions: Pediatric trauma patients requiring early blood transfusion present with lower blood pressures and higher heart rates, as well as higher shock indexes and lower pulse pressures. We found that shock index and systolic blood pressure are highly specific tools with promising likelihood ratios that could be used to identify patients requiring early transfusion.

Levels Of Evidence And Study Type: Therapeutic/Care Management, Level V.
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http://dx.doi.org/10.1097/TA.0000000000003275DOI Listing
May 2021

Whole blood transfusion reduces overall component transfusion in cases of placenta accreta spectrum: a pilot program.

J Matern Fetal Neonatal Med 2021 Apr 26:1-6. Epub 2021 Apr 26.

Division of Maternal Fetal Medicine,University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA.

Objective: Placenta accreta spectrum (PAS) is a group of placental invasion pathologies associated with significant morbidity to both mother and fetus. The majority of patients with PAS will require a blood transfusion at time of delivery and subsequent cesarean hysterectomy. The optimal approach to maternal acute blood loss resuscitation is currently unknown.

Methods: Here, we present a cohort analysis of 34 patients with pathology-confirmed PAS treated with either whole blood ( = 16) or component therapy ( = 18) for initial intraoperative resuscitation.

Results: We observed comparable results in post-operative outcomes with fewer overall transfusions and subsequently, lower volumes of resuscitation (=.03) with whole blood initial resuscitation.

Conclusions: Whole blood transfusion may represent a viable option for initial resuscitation with lower resuscitation volumes and transfusion-associated complications without directly effecting post-operative outcomes in cases of PAS.
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http://dx.doi.org/10.1080/14767058.2021.1915275DOI Listing
April 2021

Low-Volume, High-Risk Surgical Procedures in the Military Health System: Time for a Volume Pledge?

Mil Med 2021 07;186(7-8):190-192

Defense Health Board, University of South Florida Morsani College of Medicine, Falls Church, VA 22042-5101, USA.

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http://dx.doi.org/10.1093/milmed/usaa576DOI Listing
July 2021

Risk of Harm Associated With Using Rapid Sequence Induction Intubation and Positive Pressure Ventilation in Patients With Hemorrhagic Shock.

J Spec Oper Med 2020 ;20(3):97-102

Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.
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November 2020

Thrombin Generation Kinetics are Predictive of Rapid Transfusion in Trauma Patients Meeting Critical Administration Threshold.

Shock 2021 Mar;55(3):321-325

Department of Surgery, Mayo Clinic, Rochester, Minnesota.

Introduction: We hypothesize that a patient (pt) with accelerated thrombin generation, time to peak height (ttPeak), will have a greater odds of meeting critical administration threshold (CAT) criteria (> 3 packed red blood cell [pRBC] transfusions [Tx] per 60 min interval), within the first 24 h after injury, independent of international normalized ratio (INR).

Methods: In a prospective cohort study, trauma patients were enrolled over a 4.5-year period and serial blood samples collected at various time points. We retrospectively stratified pts into three categories: CAT+, CAT- but receiving some pRBC Tx, receiving no Tx within the first 24 h. Blood collected prior to Tx was analyzed for thrombin generation parameters and prothrombin time (PT)/INR.

Results: A total of 484 trauma pts were analyzed: injury severity score = 13 [7,22], age = 48 [28, 64] years, and 73% male. Fifty pts met criteria for CAT+, 64 pts CAT-, and 370 received no Tx. Risk factors for meeting CAT+: decreased arrival systolic blood pressure (OR 2.82 [2.17, 3.67]), increased INR (OR 2.09, [1.66, 2.62]) and decreased time to peak OR 2.27 [1.74, 2.95]). These variables remained independently associated with increased risk of requiring Tx in a multivariable logistic model, after adjusting for sex and trauma type.

Conclusions: Pts in hemorrhagic shock, who meet CAT+ criteria, are characterized by accelerated thrombin generation. In our multivariable analysis, both ttPeak and PT/INR have a complementary role in predicting those injured patients who will require a high rate of Tx.
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http://dx.doi.org/10.1097/SHK.0000000000001633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970628PMC
March 2021

Delays in Surgical Intervention and Temporary Hemostasis Using Resuscitative Endovascular Balloon Occlusion of the aorta (REBOA): Influence of Time to Operating Room on Mortality.

Am J Surg 2020 12 25;220(6):1485-1491. Epub 2020 Jul 25.

Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.

Background: The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remain unclear. We hypothesized that patients who experience delays in surgical intervention would benefit from REBOA.

Methods: Using the Japan Trauma Databank (2014-2019), patients transferred to the operating room (OR) within 3 h were identified. Patients treated with REBOA were matched with those without REBOA using propensity scores, and further divided based on the transfer time to OR: ≤ 1 h (early), 1-2 h (delayed), and >2 h (significantly-delayed). Survival to discharge was compared.

Results: Among 5258 patients, 310 underwent REBOA. In 223 matched pairs, patients treated with REBOA had improved survival (56.5% vs. 31.8%; p < 0.01), although in-hospital mortality was reduced by REBOA only in the delayed and significantly-delayed subgroups (HR = 0.43 [0.28-0.65] and 0.42 [0.25-0.71]).

Conclusions: REBOA-treated trauma patients who experience delays in surgical intervention (>1 h) have improved survival.
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http://dx.doi.org/10.1016/j.amjsurg.2020.07.017DOI Listing
December 2020

Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial.

J Trauma Acute Care Surg 2020 10;89(4):679-685

From the Division of Trauma and Acute Care Surgery, Department of Surgery, University of Chicago Medical Center (P.S.P.), Chicago, IL; Division of Acute Care Surgery, Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM (S.A.M.); St. Michael's Hospital, University of Toronto, Department of Trauma & Acute Care Surgery (J.B.R-N., S.T.); UCHealth North, Medical Center of the Rockies, Loveland, CO (J.A.D., B.S.); Division of Trauma and Emergency Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio (D.H.J.); Department of Surgery, University of Texas at Austin Dell Medical School, Austin, TX (T.C.); Division of Acute Care Surgery, Loma Linda University (K.M., J.F.), Loma Linda, CA; Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Riverside University Health System, Moreno Valley, CA (R.C.); Department of General Surgery, Geisinger Medical Center, Danville, PA (J. Wild., K.Y.); Department of Surgery, University of Colorado School of Medicine, UCHealth Memorial Hospital, Colorado Springs, CO (T.J.S.); FACS Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Riverside University Health System (R.C.), Moreno Valley, CA; Division of Trauma, Surgical Critical Care, and Burns, University of California San Diego, San Diego, CA (J.L.); University of Florida College of Medicine, Department of Surgery, Jacksonville, FL (D.J.S., M.J.S.); Envision Surgical Services, Medical City Plano Hospital, Plano, TX (M.M.C.); John Peter Smith Health Network, Associate Professor of Surgery, TCU & UNTHSC School of Medicine, Fort Worth, TX (F.O.M.); Arizona State University (J. Ward), Tempe, AZ; Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, Tower Health, Reading Hospital, West Reading, PA (T.G., D.L.); LAC+USC Medical Center, Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles, CA (A.P., K.I.); Division of Trauma and Critical Care, Medical College of Wisconsin, Milwaukee, WI (C.D.); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (B.G.); Kings County Hospital SUNY Downstate Medical Center, Brooklyn NY (T.S., S.S.); Ascension Via Christi Hospitals St. Francis, Department of Trauma Services, Wichita, KS (J.M.H., K.L.); Trauma, Acute Care Surgery & Surgical Critical Care, Methodist Dallas Medical Center (J.B., V.A.); and Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia (M.J.S., J.W.C.).

Background: The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH.

Methods: We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX.

Results: A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08-1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up.

Conclusion: Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management.

Level Of Evidence: Therapeutic/care management study, level III.
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http://dx.doi.org/10.1097/TA.0000000000002881DOI Listing
October 2020

Whole blood for postpartum hemorrhage: early experience at two institutions.

Transfusion 2020 06 1;60 Suppl 3:S31-S35. Epub 2020 Jun 1.

Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas.

Background: Death from postpartum hemorrhage (PPH) remains a significant preventable problem worldwide. Cold-stored, low-titer, type-O whole blood (LTOWB) is increasingly being used for resuscitation of injured patients, but it is uncommon in PPH patients, and it is unclear what its role may be in this population.

Study Design And Methods: Brief report of the early experience of WB use for PPH in two institutions, one university hospital and one private hospital.

Results: Different approaches have been implemented at the two institutions, one designed for emergency release, uncrossmatched transfusion of LTOWB as part of a massive transfusion protocol (MTP) and one for high-risk obstetric patients with known placental abnormalities. A total of 7 PPH patients have received a total of 17 units of LTOWB between the two institutions. No severe adverse transfusion reactions were observed clinically in either institution and the clinical outcomes were favorable in all cases.

Conclusion: In our early experience, LTOWB can be implemented for two different PPH clinical scenarios. Larger studies are needed to compare outcomes between LTOWB and traditional component resuscitation strategies.
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http://dx.doi.org/10.1111/trf.15731DOI Listing
June 2020

From battlefront to homefront: creation of a civilian walking blood bank.

Transfusion 2020 06 1;60 Suppl 3:S167-S172. Epub 2020 Jun 1.

Department of Surgery, UT Health San Antonio, San Antonio, Texas.

Hemorrhagic shock remains the leading cause of preventable death on the battlefield, despite major advances in trauma care. Early initiation of balanced resuscitation has been shown to decrease mortality in the hemorrhaging patient. To address transfusion limitations in austere environments or in the event of multiple casualties, walking blood banks have been used in the combat setting with great success. Leveraging the success of the region-wide whole blood program in San Antonio, Texas, we report a novel plan that represents a model response to mass casualty incidents.
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http://dx.doi.org/10.1111/trf.15694DOI Listing
June 2020

Blood transfusion preparedness for mass casualty incidents: Are we truly ready?

Am J Disaster Med 2019 Summer;14(3):201-218

Department of Surgery, Division of Trauma, UT Health, San Antonio, Texas.

Mass casualty incidents (MCI) are high profile contributors to the number of annual trauma-related deaths in the United States. A critical aspect of MCI care is the ability to provide blood components in sufficient types and quantities to prevent deaths due to hemorrhage. For transfusions to play an optimal role in the prevention of trauma-related hemorrhagic death, including MCI, there appears to be a very tight time window after injury to initiate transfusion therapy. In order to meet this tight window, blood components of appropriate numbers and quantities must be immediately available. Currently, it is questionable whether standing blood inventories at US healthcare facilities are sufficient to appropriately meet the transfusion needs of a surge of MCI victims. Previous models of blood supply adequacy have focused on the availability of red blood cells, and the ability to move blood components quickly from blood suppliers to impacted healthcare facilities. These models have not considered the adequacy of other critically necessary blood components, such as platelets. A recent simulation of blood product demand after MCI showed that, in order to meet the defined RBC needs of 100 percent of casualties, a hospital would need 13-14 units in inventory per casualty. This simulation did not evaluate requirements for platelets and plasma, which would likely be extensive. Meeting balanced resuscitation demands in the timeframe necessary to minimize the number of preventable hemorrhagic deaths is probably not realistically achievable for most healthcare facilities in the United States. Alternative approaches to treat hemorrhage are likely necessary to solve this problem.
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http://dx.doi.org/10.5055/ajdm.2019.0332DOI Listing
May 2020

The gut microbiome distinguishes mortality in trauma patients upon admission to the emergency department.

J Trauma Acute Care Surg 2020 05;88(5):579-587

From the Division of Trauma and Emergency Surgery, Department of Surgery (D.M.B., T.R.J., S.S., M.D., R.B.J., C.Z., E.S., R.M.S., M.G.S., D.H.J., B.J.E., S.E.N.), Greehey Children's Cancer Research Institute (Z.L.), and Department of Molecular Medicine (Z.L.), UT Health San Antonio, San Antonio, Texas; Department of Medicine, Uniformed Services University of the Health Sciences (D.M.B), Bethesda, MD and US Army Institute of Surgical Research (D.M.B., S.E.N.), Fort Sam Houston, Texas.

Background: Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients.

Methods: We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and β-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses.

Results: Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission β-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). β-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05).

Conclusion: Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients.

Level Of Evidence: Prognostic and epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002612DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905995PMC
May 2020

Survey of medical center employees' willingness and availability to donate blood in support of a civilian warm fresh whole blood program.

Am J Disaster Med 2019 Spring;14(2):101-111

Department of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, Minnesota.

Objectives: In military settings, utilizing warm fresh whole blood (WFWB) was associated with reduced mortality; however, there are multiple challenges for administering WFWB to civilians. The authors aimed to determine barriers to hospital employees emergently donating to civilian WFWB programs.

Methods: We surveyed hospital employee willingness to donate emergently, familiarity with blood donation, and queried baseline demographics. The electronic survey was disseminated to a random sample of employees. Descriptive and univariate analyses were performed.

Results: Three thousand surveys were sent; 883 were returned (28 percent). The majority of respondents were female (n = 630, 71 percent). Respondent familiarity with WFWB donation included very/somewhat familiar (n = 381, 43 percent) and somewhat-not/not-at-all familiar (n = 356, 40 percent). Most were definitely or somewhat willing to emergently donate (n = 660, 75 percent). Four hundred and sixty would drive from home to donate (52 percent). The majority worked day-time shifts (n = 754, 85 percent). In regards to donation history, 366 (41 percent) had donated blood more than ten times, but 138 (16 percent) had never donated. Barriers to emergent donation were identified (55 percent), with the most common being childcare responsibilities (n = 242; 27 percent).

Conclusions: Hospital employees are willing to donate WFWB emergently, but program implementation must address donor availability and logistical barriers. Future research should assess feasibility of a civilian WFWB program by determining regulatory challenges, development of a quality system for emergency donations, assessment of optimal workforce structure, potential impact to the general blood inventory, as well as patient and community perspectives regarding untested blood units.
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http://dx.doi.org/10.5055/ajdm.2019.0321DOI Listing
November 2019

Shock index and pulse pressure as triggers for massive transfusion.

J Trauma Acute Care Surg 2019 07;87(1S Suppl 1):S159-S164

From the Department of Trauma and Emergency Surgery (C.S.Z., R.B.J., D.P., R.C., S.E.N., B.J.E., D.H.J.), University of Texas Health Science Center, San Antonio, Texas; Department of Surgery (D.C.), Louisiana State University School of Medicine, Baton Rouge, Louisiana; Department of Transplant Surgery (M.R.), University of Texas Health Science Center, San Antonio, Texas; Trauma Services (T.C.-P., J.O.), University Hospital in San Antonio, San Antonio, Texas; and US Army Institute of Surgical Research (A.C.), San Antonio, Texas.

Background: Hemorrhage is the most common cause of preventable death in trauma patients. These mortalities might be prevented with prehospital transfusion. We sought to characterize injured patients requiring massive transfusion to determine the potential impact of a prehospital whole blood transfusion program. The primary goal of this analysis was to determine a method to identify patients at risk of massive transfusion in the prehospital environment. Many of the existing predictive models require laboratory values and/or sonographic evaluation of the patient after arrival at the hospital. Development of an algorithm to predict massive transfusion protocol (MTP) activation could lead to an easy-to-use tool for prehospital personnel to determine when a patient needs blood transfusion.

Methods: Using our Level I trauma center's registry, we retrospectively identified all adult trauma patients from January 2015 to August 2017 requiring activation of the MTP. Patients who were younger than 18 years, older than 89 years, prisoners, pregnant women, and/or with nontraumatic hemorrhage were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data (survival, length of stay, intensive care unit days, ventilator days), prehospital vital signs, prehospital transport times, and Injury Severity Score. The independent-samples t test and χ test were used to compare the group who died to the group who survived. p < 0.05 was considered significant. Based on age and mechanism of injury, relative risk of death was calculated. Graphs were generated using Microsoft Excel software to plot patient variables.

Results: Our study population of 102 MTP patients had an average age of 42 years and average Injury Severity Score of 29, consisted of 80% males (82/102), and was 66% blunt trauma (67/102). The all-cause mortality was 67% (68/102). The positive predictive value of death for patients with pulse pressure of less than 45 and shock index of greater than 1 was 0.78 for all patients, but was 0.79 and 0.92 for blunt injury and elderly patients, respectively.

Conclusions: Our data demonstrate a high mortality rate in trauma patients who require MTP despite short transport times, indicating the need for early intervention in the prehospital environment. Given our understanding that the most severely injured patients in hemorrhagic shock require blood resuscitation, this study demonstrates that this subset of trauma patients requiring massive transfusion can be identified in the prehospital setting. We recommend using Emergency Medical Services pulse pressure in combination with shock index to serve as a trigger for initiation of prehospital whole blood transfusion.

Level Of Evidence: Therapeutic/care management, level V.
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http://dx.doi.org/10.1097/TA.0000000000002333DOI Listing
July 2019

Give the trauma patient what they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low-titer O+ whole blood.

Transfusion 2019 04;59(S2):1429-1438

Department of Surgery, The University of Texas Health Science Center, San Antonio, Texas.

Background: Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured.

Materials And Methods: Our regional trauma network (Southwest Texas Regional Advisory Council) developed and implemented a multiphased approach toward facilitating remote damage control resuscitation. This approach required placing low-titer O+ whole blood (LTO+ WB) at helicopter emergency medical service bases, transitioning hospital-based trauma resuscitation from component therapy to the use of whole blood, modifying select ground-based units to carry and administer whole blood at the scene of an accident, and altering the practices of our blood bank to support our new initiative. In addition, we had to provide information and training to an entire large urban emergency medical system regarding changes in policy.

Results: Through a thorough, structured program we were able to successfully implement point-of-injury resuscitation with LTO+ WB. Preliminary evaluation of our first 25 patients has shown a marked decrease in mortality compared to our historic rate using component therapy or crystalloid solutions. Additionally, we have had zero transfusion reactions or seroconversions.

Conclusion: Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.
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http://dx.doi.org/10.1111/trf.15264DOI Listing
April 2019

Outcomes after splenectomy in children: a 48-year population-based study.

Pediatr Surg Int 2019 May 2;35(5):575-582. Epub 2019 Feb 2.

Division of Trauma, Critical Care and General Surgery, Department of Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA.

Purpose: In children who have undergone splenectomy, there may be impaired immunologic function and an increased risk of infection. We aimed to define the long-term rate of and risk factors for post-splenectomy infection using a population-based cohort study.

Methods: All children (< 18 years) who underwent splenectomy from 1966 to 2011 in Olmsted County, MN were identified using the Rochester Epidemiology Project (REP). Descriptive statistics, Kaplan-Meier estimates, and Cox Proportional hazard ratios were performed to evaluate for risk factors associated with developing infection.

Results: Ninety patients underwent splenectomy and 46% were female. Indications included trauma (42%), benign hematologic disease (33%), malignancy (13%), and other (11%). Most were performed open. Vaccination was completed in (72%) for pneumococcal, H. influenza, and meningococcal vectors. Nineteen patients developed infection, and associated factors included non-traumatic, non-malignant disease [HR 4.83 (1.18-19.85)], and performance of multiple surgical procedures [HR 2.80 (1.09-7.21)]. Estimated survival free of infection rates at 15 and 20 years following surgery was both 97%.

Conclusions: After splenectomy in children, most patients do not develop infection. Nearly three-quarters of patients were vaccinated with the lowest rates in patients that underwent a splenectomy for trauma. In patients who received multiple procedures during a splenectomy, the infection risk was higher.
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http://dx.doi.org/10.1007/s00383-019-04439-8DOI Listing
May 2019

A prospective study in severely injured patients reveals an altered gut microbiome is associated with transfusion volume.

J Trauma Acute Care Surg 2019 04;86(4):573-582

From the Department of Surgery (S.E.N., T.R.J., S.S., M.D.R., R.B.J., D.R.M., C.Z., L.M.N., R.M.S., M.G.S., D.H.J., B.J.E.), UT Health San Antonio; Greehey Children's Cancer Research Institute (Y.Z., Z.L.), Department of Molecular Medicine (Z.L.), UT Health San Antonio; and the U.S. Army Institute of Surgical Research (D.M.B.), Fort Sam Houston, San Antonio, Texas.

Background: Traumatic injury can lead to a compromised intestinal epithelial barrier and inflammation. While alterations in the gut microbiome of critically injured patients may influence clinical outcomes, the impact of trauma on gut microbial composition is unknown. Our objective was to determine if the gut microbiome is altered in severely injured patients and begin to characterize changes in the gut microbiome due to time and therapeutic intervention.

Methods: We conducted a prospective, observational study in adult patients (n = 72) sustaining severe injury admitted to a Level I Trauma Center. Healthy volunteers (n = 13) were also examined. Fecal specimens were collected on admission to the emergency department and at 3, 7, 10, and 13 days (±2 days) following injury. Microbial DNA was isolated for 16s rRNA sequencing, and α and β diversities were estimated, according to taxonomic classification against the Greengenes database.

Results: The gut microbiome of trauma patients was altered on admission (i.e., within 30 minutes following injury) compared to healthy volunteers. Patients with an unchanged gut microbiome on admission were transfused more RBCs than those with an altered gut microbiome (p < 0.001). Although the gut microbiome started to return to a β-diversity profile similar to that of healthy volunteers over time, it remained different from healthy controls. Alternatively, α diversity initially increased postinjury, but subsequently decreased during the hospitalization. Injured patients on admission had a decreased abundance of traditionally beneficial microbial phyla (e.g., Firmicutes) with a concomitant decrease in opportunistic phyla (e.g., Proteobacteria) compared to healthy controls (p < 0.05). Large amounts of blood products and RBCs were both associated with higher α diversity (p < 0.001) and a β diversity clustering closer to healthy controls.

Conclusion: The human gut microbiome changes early after trauma and may be aided by early massive transfusion. Ultimately, the gut microbiome of trauma patients may provide valuable diagnostic and therapeutic insight for the improvement of outcomes postinjury.

Level Of Evidence: Prognostic and Epidemiological, level III.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6433524PMC
April 2019

Enhanced readability of discharge summaries decreases provider telephone calls and patient readmissions in the posthospital setting.

Surgery 2019 04 19;165(4):789-794. Epub 2018 Nov 19.

Department of Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Introduction: Hospital discharge instructions provide critical information necessary for patients to manage their own care; however, often they are written at a substantially higher readability level than recommended (ie, 6th-grade level) by the American Medical Association and the National Institutes of Health. We hypothesize that improving the reading level of discharge instructions will decrease the number of patient telephone calls and readmissions in the posthospital setting.

Methods: We conducted a prospective observational study. Patient discharge instructions were edited and incorporated to enhance the readability level in August 2015. Return telephone call and readmissions of patients admitted before the intervention from August 1, 2014, to January 31, 2015, were compared with the prospective cohort studied from September 1, 2015, to September 30, 2016.

Results: A total of 1,072 patients were included (preintervention: n = 493, postintervention: n = 579). Patient demographics, injury characteristics, and education level were similar among both groups. The median discharge instruction readability level in the postintervention group was significantly lower (10.0, 95% CI 10.0-10.2 vs 8.6, 95% CI 8.8-8.9; P < .0001). The proportion of patients calling after hospital discharge was significantly reduced after the intervention (21.9% vs 9.0%; P < .0001). Monthly hospital readmissions were decreased by 50% for every 100 patients discharged after the intervention (1.9% vs 0.9%; P = .002). The proportion of patients calling and readmissions for poor pain control significantly decreased after the intervention (7.1% vs 2.59%; P = .0005 and 2.8% vs 1.0%; P = .029, respectively).

Conclusion: Enhanced readability of discharge instructions was associated with a decrease in the number of telephone calls and readmissions in the posthospital setting, enhancing health literacy and simultaneously reducing the burden on providers. Improved patient instructions written to an appropriate level may also allow for better pain control in the posthospital setting.
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April 2019

Undertriage after severe injury among United States trauma centers and the impact on mortality.

Am J Surg 2018 10 14;216(4):813-818. Epub 2018 Sep 14.

Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.

Introduction: Severely injured patients should receive definitive care at high acuity trauma centers. The purposes of this study were to determine the undertriage (UT) rate within a national sample of trauma centers and to identify characteristics of UT patients.

Methods: Severely injured adults ≥16 years were identified from the 2010-2012 NTDB. UT was defined as those who received definitive care or died at hospitals without state or ACS level I or II verification. Risk factors for UTT and the impact of UT on mortality were determined.

Results: Of 348,394 severely injured patients, 11,578 (3.3%) were UT. Older, less severely injured, and certain minority patients were most likely to be UT. After risk adjustment, predictors of UT included increased age and minority race. Increased injury severity and comorbidity were protective (all p < .05). Mortality was greater in UT patients regardless of ISS (OR = 1.32, p < .001).

Conclusion: The low UT rate in this study demonstrates the effectiveness of triage practices amongst ACS and state verified centers however age, race, and insurance disparities in UT should be improved.
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http://dx.doi.org/10.1016/j.amjsurg.2018.07.061DOI Listing
October 2018

Get ready: whole blood is back and it's good for patients.

Transfusion 2018 08 24;58(8):1821-1823. Epub 2018 Aug 24.

Division of Trauma and Emergency Surgery, Vice Chair for Quality, Department of Surgery, Betty and Bob Kelso Distinguished Chair in Burn and Trauma Surgery, Associate Deputy Director, Military Health Institute, UT Health, San Antonio, Texas.

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http://dx.doi.org/10.1111/trf.14818DOI Listing
August 2018

Validation of the AAST EGS grading system for perforated peptic ulcer disease.

Surgery 2018 10 4;164(4):738-745. Epub 2018 Aug 4.

Department of Surgery, Pietermaritzburg Metropolitan Complex, University of Kwa-Zulu Natal, South Africa. Electronic address:

Introduction: Perforated peptic ulcer disease (PPUD) including both duodenl and gastric ulcers is a severe disease and outcomes are influenced by comorbidities and physiology. We validated the AAST EGS grading system at two diverse centers (Mayo Clinic, USA and Pietermaritzburg, South Africa).

Methods: Dual-center review of historic data (2010-2016) of adults with PPUD was performed. Preoperative, procedural, and postoperative data were abstracted. ASA, Boey, PULP and AAST EGS grades were generated. Comparative, multivariable, and pairwise analyses were performed.

Results: There were 306 patients, 42% female with a mean (±SD) age of 56 ±20 years. Overall, the patints were categorized into the following AAST EGS grades: I (30, 10%), II (38, 12%), III (104, 34%), IV (76, 2e%), V (58, 18.9%). Initial management included: midline laparotomy (51%, n=157), laparoscopy (18%, n=58), laparoscopy converted to laparotomy (1%, n=3), and endoscopy (30%, n=88). Duration of stay increased with AAST EGS grade. In United States cohort, factors predictive for 30-day mortality included AAST EGS grade and patient comorbidity status. The AAST EGS grade was comparable to other scoring systems (Boey, PULP, and ASA).

Conclusions: Differences exist between centers for management of PPUD and their outcomes; however, the AAST EGS grade can be utilized to stratify thedisease severity of the patient and this demonstrates initial construct validity in a United States but not in a South African population.
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October 2018

Early Hospital Discharge After Helicopter Transport of Pediatric Trauma Patients: Analysis of Rates of Over and Undertriage.

Pediatr Emerg Care 2020 Dec;36(12):e709-e714

Division of Trauma, Critical Care and General Surgery.

Objectives: Helicopter air ambulance (HAA) of pediatric trauma patients is a life-saving intervention. Triage remains a challenge for both scene transport and interhospital transfer of injured children. We aimed to understand whether overtriage or undertriage was a feature of scene or interhospital transfer and how in or out of state transfers affected these rates.

Methods: Children (<18 years) who underwent trauma activation at a level I trauma center between 2011 and 2013 were identified and reviewed. Patients transported by HAA were compared with those transported by ground ambulance (GA).

Results: Of 399 pediatric patients (median age, 10.4 years; range, 0.1-17 years; 264 male [66%]), 71 (18%) were transported by HAA. Seventy-two percent of HAA patients went to the intensive care unit or the operating room from the trauma bay or suffered in-hospital mortality (vs 42% GA, P < 0.001). More patients were overtriaged (HAA with injury severity score [ISS] of <15) from interhospital transfers than from the scene (25% vs 3%, P = 0.002). Undertriage (GA with ISS >15) was acceptable at 5% from the scene and 14% from interhospital transfers (P = 0.08). Overtriage of patients with ISS less than 15 to HAA was significantly lower from in-state hospitals (22%) than out-of-state hospitals (45%) (P = 0.02). Undertriage of patients with ISS greater than 15 to GA was also lower from in-state hospitals (20%) versus out-of-state hospitals (38%) (P = 0.03).

Conclusions: Triage of pediatric trauma patients to HAA remains difficult. There remains potential for improvement, particularly as regards interhospital HAA overtriage, but well developed transfer protocols (such in-state protocols) may help.
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December 2020

Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS - A Descriptive Study.

Prehosp Disaster Med 2018 Jun 19;33(3):230-236. Epub 2018 Apr 19.

1Department of Emergency Medicine,Mayo Clinic,Rochester,MinnesotaUSA.

IntroductionHemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS).

Methods: This was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90).

Results: A total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort.

Conclusions: In this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system. MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital blood product administration opportunities in ground transport ALS EMS - a descriptive study. Prehosp Disaster Med. 2018;33(3):230-236.
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June 2018

Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury.

J Trauma Acute Care Surg 2018 06;84(6S Suppl 1):S115-S119

From the Department of Surgery (A.C.M., R.J., S.E.N., B.J.E., R.M.S., D.H.J.), UT Health San Antonio; College of Sciences (C.S.Z.), UT San Antonio; Department of Pathology (L.G.), Department of Obstetrics and Gynecology (E.X.), UT Health San Antonio; The Blood & Tissue Center Foundation South Texas Blood and Tissue Center (E.W.); Southwest Texas Regional Advisory Council (E.E.), San Antonio, Texas; and General Surgery (D.C.), Louisiana State University School of Medicine, New Orleans, Louisiana.

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our prehospital whole blood initiative-using low-titer cold-stored O RhD-positive whole blood. The main concern with use of RhD-positive blood is the potential development of isoimmunization in RhD-negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD-negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that the utilization of low-titer cold-stored O RhD-positive whole blood would be safe and best serve our community.
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June 2018

Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines.

Surgery 2018 04 8;163(4):739-746. Epub 2018 Jan 8.

Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA.

Background: Acute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes.

Methods: Adults (≥18 years) with acute cholecystitis during 2013-2016 were identified. Baseline demographic characteristics, comorbidity severity as defined by Charlson Comorbidity Index score, procedure types, and AAST and Tokyo Guidelines 2013 grades were abstracted. Outcomes included duration of stay, 30-day mortality, and complications. Comparison of the Tokyo Guidelines and AAST grading system was performed using receiver operating characteristic (AUROC) curve C statistics.

Results: There were 443 patients, with a mean (±standard deviation) age of 64.8 (±18) years, 59% male. The median (interquartile ratio) Charlson Comorbidity score was 3 (0-6). Management included laparoscopic (n = 307, 69.3%), open (n = 26, 6%), laparoscopy converted to laparotomy (n = 53, 12%), and cholecystostomy (n = 57, 12.7%). Comparison of AAST with Tokyo Guidelines AUROC C statistics indicated (P < .05) mortality (0.86 vs 0.73), complication (0.76 vs 0.63), and cholecystostomy tube utilization (0.80 vs 0.68).

Conclusion: Emergency general surgery grading systems improve disease severity assessment, may improve documentation, and guide management. Discrimination of disease severity using the AAST grading system outperforms the Tokyo Guidelines for key clinical outcomes. The AAST grading system requires prospective validation and further comparison.
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April 2018

Association of postoperative organ space infection after intraoperative irrigation in appendicitis.

J Trauma Acute Care Surg 2018 04;84(4):628-635

From the Division of Trauma Critical Care and General Surgery, Department of Surgery, Rochester, Minnesota (M.C.H., J.M.A., M.D.Z.); Mayo Clinic School of Medicine, Rochester, Minnesota (E.J.F.); Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, Rochester, Minnesota (J.M.A.); and Division Trauma and Emergency Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas (D.H.J.).

Background: The benefit of intraoperative irrigation on postoperative abscess rates compared to suction alone is unclear. The American Association for the Surgery of Trauma grading system provides distinct disease severity stratification to determine if prior analyses were biased by anatomic severity. We hypothesized that for increasing appendicitis severity, patients receiving (high, ≥2 L) intraoperative irrigation would have increased postoperative organ space infection (OSI) rate compared to (low, <2 L) irrigation.

Methods: Single-institution review of adults (>18 years) undergoing appendectomy for appendicitis during 2010-2016. Demographics, operative details, irrigation volumes, duration of stay, and complications (Clavien-Dindo classification) were collected. American Association for the Surgery of Trauma grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and area under the receiver operating curve analyses were performed.

Results: Patients (n = 1187) were identified with a mean (SD) age of 41.6 (18.4) years (45% female). Operative approach included laparoscopy (n = 1122 [94.5%]), McBurney incision (n = 10 [0.8%]), midline laparotomy (n = 16 [1.3 %]), and laparoscopy converted to laparotomy (n = 39 [3.4%)]. The mean (SD) volume of intraoperative irrigation was 410 (1200) mL. Complication rate was 26.1%. Median volume of intraoperative irrigation in patients who developed postoperative OSI was 3 [0-4] compared to 0 [0-0] in those without infection (p < 0.0001). Area under the receiver operating curve analysis determined that 2 or more liters of irrigation was associated with postoperative OSI (c statistic: 0.83, 95% confidence interval, 0.76-0.89; p < 0.001).

Conclusion: Irrigation is used for increasingly severe appendicitis with wide variation. Irrigation volumes of 2 L or greater are associated with postoperative OSI. Improving standardization of irrigation volume (<2 L) may prevent morbidity associated with this high-volume disease.

Level Of Evidence: Therapeutic, level IV.
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April 2018
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