Publications by authors named "Lauren A Raff"

5 Publications

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Time to Cannulation after ICU Admission Increases Mortality for Patients Requiring Veno-Venous ECMO for COVID-19 Associated Acute Respiratory Distress Syndrome.

Ann Surg 2020 Dec 22. Epub 2020 Dec 22.

*University of North Carolina at Chapel Hill, Division of Acute Care Surgery, Department of Surgery, Chapel Hill, NC †University of North Carolina at Chapel Hill School of Medicine ‡University of North Carolina at Chapel Hill, Division of Hospital Medicine, Department of Medicine, Chapel Hill, NC §University of North Carolina at Chapel Hill, Division of Acute Care Surgery, Department of General Surgery, Chapel Hill, NC.

Objective: COVID-19 can cause acute respiratory distress syndrome (ARDS) that is rapidly progressive, severe, and refractory to conventional therapies. Extracorporeal membrane oxygenation (ECMO) can be used as a supportive therapy to improve outcomes but evidence-based guidelines have not been defined.

Summary Background Data: Initial mortality rates associated with ECMO for ARDS in COVID-19 were high, leading some to believe that there was no role for ECMO in this viral illness. With more experience, outcomes have improved. The ideal candidate, timing of cannulation, and best post-cannulation management strategy, however, has not yet been defined.

Methods: We conducted a retrospective review from April 1 to July 31 2020 of the first 25 patients with COVID-19 associated ARDS placed on V-V ECMO at our institution. We analyzed the differences between survivors to hospital discharge and those who died. Modified Poisson regression was used to model adjusted risk factors for mortality.

Results: 44% of patients (11/25) survived to hospital discharge. Survivors were significantly younger (40.5 years vs. 53.1 years; p < 0.001) with no differences between cohorts in mean body mass index, diabetes, or PaO2:FiO2 at cannulation. Survivors had shorter duration from symptom onset to cannulation (12.5 days vs. 19.9 days, p = 0.028) and shorter duration of intensive care unit (ICU) length of stay (LOS) prior to cannulation (5.6 days vs. 11.7 days, p = 0.045). Each day from ICU admission to cannulation increased the adjusted risk of death by 4% and each year increase in age increased the adjusted risk 6%.

Conclusions: ECMO has a role in severe, refractory ARDS associated with COVID-19. Increasing age and time from ICU admission were risk factors for mortality and should be considered in patient selection. Further studies are needed to define best practices for V-V ECMO use in COVID-19.
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http://dx.doi.org/10.1097/SLA.0000000000004683DOI Listing
December 2020

Veno-Venous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome During Hemorrhagic Shock.

ASAIO J 2020 Nov 9. Epub 2020 Nov 9.

From the Department of General Surgery, Division of Trauma and Acute Care Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Despite overall improvements in critical care, mortality from acute respiratory distress syndrome (ARDS) remains high. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is used to rescue patients with severe ARDS. Although V-V ECMO can be life-saving, there are significant risks associated with this therapy. Hemorrhage is one of the most common complications. Therefore, some providers are reluctant to use V-V ECMO in patients with severe ARDS who concurrently have a high risk of bleeding or recent active hemorrhage. Several studies have been published detailing the safety of heparin-sparing or completely heparin-free anticoagulation strategies in patients on V-V ECMO. We present the cases of two patients with hemorrhagic shock and ongoing transfusion requirements who developed severe and refractory ARDS while in the operating room for hemorrhage control. After the massive bleeding was stopped, both patients were placed on V-V ECMO and were managed with minimal or no therapeutic anticoagulation for the duration of their course on V-V ECMO. Both patients required multiple operations and procedures while on V-V ECMO and there were no significant hemorrhagic complications. In conclusion, V-V ECMO can be considered for use in select patients with severe ARDS and high risk of hemorrhage, active hemorrhage, or ongoing transfusion requirements.
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http://dx.doi.org/10.1097/MAT.0000000000001305DOI Listing
November 2020

Contemporary management of traumatic cervical and thoracic esophageal perforation: The results of an Eastern Association for the Surgery of Trauma multi-institutional study.

J Trauma Acute Care Surg 2020 10;89(4):691-697

From the Division of Acute Care Surgery, Department of Surgery (L.A.R.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Ascension St. John Medical Center Trauma Services (E.A.S.), Tulsa, Oklahoma; Department of Surgery (R.G.M., B.R.H.R.), Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington; Division of Acute Care Surgery, Department of Surgery (J.J.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (M.R.N., Z.S.), Allegheny General Hospital, Pittsburgh, Pennsylvania; Department of General Surgery (E.C., J.C.), Denver Health Medical Center, Denver, Colorado; University of Nevada at Las Vegas School of Medicine (S.S., J.T.C.), Las Vegas, Nevada; Department of Trauma (L.E.J., J.W.), St. Vincent Indianapolis Hospital, Indianapolis, Indiana; Department of Surgery (A.J.Y., J.P.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (S.B., D.G.), Loma Linda Medical Center, Loma Linda, California; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery (J.N.), University of California at Irvine, Orange, California; Department of Surgery (M.E.K.), University of Mississippi Medical Center, Jackson, Mississippi; Division of Trauma and Acute Care Surgery, Department of Surgery (N.B., K.J.), Tufts Medical Center, Boston, Massachusetts; and Division of Acute Care Surgery, Department of Surgery (P.B.), Banner University Medical Center, University of Arizona College of Medicine, Phoenix, Arizona.

Background: Traumatic esophageal perforation is rare and associated with significant morbidity and mortality. There is substantial variability in diagnosis and treatment. Esophageal stents have been increasingly used for nontraumatic perforation; however, stenting for traumatic perforation is not yet standard of care. The purpose of this study was to evaluate current management of traumatic esophageal perforation to assess the frequency of and complications associated with esophageal stenting.

Methods: This was an Eastern Association for the Surgery of Trauma multi-institutional retrospective study from 2011 to 2016 of patients with traumatic cervical or thoracic esophageal injury admitted to one of 11 participating trauma centers. Data were collected and sent to a single institution where it was analyzed. Patient demographics, injury characteristics, initial management, complications, and patient mortality were collected. Primary outcome was mortality; secondary outcomes were initial treatment, esophageal leak, and associated complications.

Results: Fifty-one patients were analyzed. Esophageal injuries were cervical in 69% and thoracic in 31%. Most patients were initially managed with operative primary repair (61%), followed by no intervention (19%), esophageal stenting (10%), and wide local drainage (10%). Compared with patients who underwent operative primary repair, patients managed with esophageal stenting had an increased rate of esophageal leak (22.6% vs. 80.0%, p = 0.02). Complication rates were higher in blunt compared with penetrating mechanisms (100% vs. 31.8%, p = 0.03) despite similar Injury Severity Score and neck/chest/abdomen Abbreviated Injury Scale. Overall mortality was 9.8% and did not vary based on location of injury, mechanism of injury, or initial management.

Conclusion: Most patients with traumatic esophageal injuries still undergo operative primary repair; this is associated with lower rates of postoperative leaks as compared with esophageal stenting. Patients who have traumatic esophageal injury may be best managed by direct repair and not esophageal stenting, although further study is needed.

Level Of Evidence: Therapeutic, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002841DOI Listing
October 2020

Identification of Risk Factors for the Development of Pressure Ulcers Despite Standard Screening Methodology and Prophylaxis in Trauma Patients.

Adv Skin Wound Care 2016 Jul;29(7):329-34

Lauren A. Raff, MD • Chief Resident • Department of Surgery • University of Alabama at BirminghamHolly Waller, MPH, RN • Director • Trauma and Burn Services • University of Alabama at BirminghamRussell L. Griffin, PhD • Assistant Professor of Epidemiology • University of Alabama at Birmingham Center for Injury SciencesJeffrey D. Kerby, MD, PhD • Director • Division of Acute Care Surgery Care • University of Alabama at Birmingham Patrick L. Bosarge, MD • Assistant Professor • Department of Surgery • Director • Trauma Critical Care Fellowship.

Purpose: To present information about a study of risk factors for development of pressure ulcers (PrUs) in trauma patients.

Target Audience: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

Objectives/outcomes: After participating in this educational activity, the participant should be better able to:1. Describe the previous PrU research, scope of the problem, and methodology of the study.2. Explain the results of the study identifying PrU risk factors for trauma patients.

Abstract:

Objective: Pressure ulceration prevention has been emphasized  over the past several years in inpatient hospital settings with  subsequent decreases in the development of pressure ulcers (PrUs).  However, there remains a subset of trauma and burn patients  that develop PrUs despite standard screening methodology and  prophylaxis. This study determines the conditions that predict  development of pressure ulcers (PrUs) despite conventional  prophylaxis and screening. 

Methods: Demographic and PrU data were collected over a  5-year period from June 2008 to May 2013. Patients diagnosed  with PrUs upon arrival in the trauma bay were excluded from  analysis. An ordinal logistic regression of PrU stage was used to  estimate odds ratios (ORs) and associated 95% confidence intervals  (CIs) for the association between characteristics of interest and  odds of a PrU. A backward selection process was used to select the  most parsimonious model. 

Results: During the study period, 14,616 trauma patients were  admitted and had available data. A total of 124 patients (0.85%) that met inclusion criteria went on to develop PrUs during their hospital course. Factors associated with the development of PrUs included spine Abbreviated Injury Scale (AIS) >3 (OR, 5.72; CI, 3.63-9.01), mechanical ventilation (OR, 1.95; CI, 1.23-3.10) and age 40 to 64 (OR, 2.09; CI, 1.24-3.52) and age ≥ 65 (OR, 4.48; CI, 2.52-7.95). Interestingly, head injury AIS >3 was protective from the development of PrUs (OR, 0.56; CI, 0.32-0.96). Hypotension and shock defined as systolic BP <90 mm Hg and base deficit less than -6 were not associated with the development of PrUs. In addition, body mass index was not associated with PrU development. 

Conclusions: Spinal injuries, older than age 40, and mechanical  ventilation predict the development of PrUs for a subset of  patients, despite conventional prophylaxis and screening. Advanced  prevention methods, such as low-air-loss mattresses for these patient  subgroups should be considered immediately upon identification  of these risk factors during the hospital course.
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http://dx.doi.org/10.1097/01.ASW.0000484064.86180.18DOI Listing
July 2016

Management of penetrating extraperitoneal rectal injuries: An Eastern Association for the Surgery of Trauma practice management guideline.

J Trauma Acute Care Surg 2016 Mar;80(3):546-51

From the Departments of Surgery (P.L.B., L.A.R.), and Epidemiology (G.M.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (J.J.C., N.J.P., A.A.M.), Metrohealth Medical Center, Case Western Reserve University; and Division of Gastroenterology (Y.F.-Y.), Case Western Reserve University, Case and VA Medical Center, Cleveland; Department of Surgery (H.A.D.), Mercy Health St. Elizabeth Youngstown Hospital, Youngstown; and Department of Surgery (A.R.), Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery (N.F.), Cooper University Health Care, Camden, New Jersey; Department of Surgery (E.R.H.), The Johns Hopkins Hospital, Baltimore, Maryland; Department of Surgery (B.R.H.R.), Harborview Medical Center, University of Washington, Seattle, Washington; and Department of Surgery (R.P.G.), Loyola University Medical Center, Maywood, Illinois.

Background: The management of penetrating rectal trauma invokes a complex decision tree that advocates the principles of proximal diversion (diversion) of the fecal stream, irrigation of stool from the distal rectum, and presacral drainage based on data from World War II and the Vietnam War. This guideline seeks to define the initial operative management principles for nondestructive extraperitoneal rectal injuries.

Methods: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding penetrating rectal trauma from January 1900 to July 2014. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included the management principles of diversion, irrigation of stool from the distal rectum, and presacral drainage using the GRADE methodology.

Results: A total of 306 articles were screened leading to a full-text review of 56 articles. Eighteen articles were used to formulate the recommendations of this guideline.

Conclusion: This guideline consists of three conditional evidence-based recommendations. First, we conditionally recommend proximal diversion for management of these injuries. Second, we conditionally recommend the avoidance of routine presacral drains and distal rectal washout in the management of these injuries.
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http://dx.doi.org/10.1097/TA.0000000000000953DOI Listing
March 2016