Publications by authors named "Valerie G Sams"

29 Publications

  • Page 1 of 1

Adjunct Use of Continuous Renal Replacement Therapy with Extracorporeal Membrane Oxygenation Achieves Negative Fluid Balance and Enhances Oxygenation Which Improves Survival in Critically Ill Patients without Kidney Failure.

Blood Purif 2021 Sep 2:1-8. Epub 2021 Sep 2.

Surgery and Trauma Critical Care, Brooke Army Medical Center, San Antonio, Texas, USA.

Introduction: Fluid overload in extracorporeal membrane oxygenation (ECMO) patients has been associated with increased mortality. Patients receiving ECMO and continuous renal replacement therapy (CRRT) who achieve a negative fluid balance have improved survival. Limited data exist on the use of CRRT solely for fluid management in ECMO patients.

Methods: We performed a single-center retrospective review of 19 adult ECMO patients without significant renal dysfunction who received CRRT for fluid management. These patients were compared to a cohort of propensity-matched controls.

Results: After 72 h, the treatment group had a fluid balance of -3840 mL versus + 425 mL (p ≤ 0.05). This lower fluid balance correlated with survival to discharge (odds ratio 2.54, 95% confidence interval 1.10-5.87). Improvement in the ratio of arterial oxygen content to fraction of inspired oxygen was also significantly higher in the CRRT group (102.4 vs. 0.7, p ≤ 0.05). We did not observe any significant difference in renal outcomes.

Conclusions: The use of CRRT for fluid management is effective and, when resulting in negative fluid balance, improves survival in adult ECMO patients without significant renal dysfunction.
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http://dx.doi.org/10.1159/000517896DOI Listing
September 2021

Argatroban for Anticoagulation in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019.

Crit Care Explor 2021 Sep 7;3(9):e0530. Epub 2021 Sep 7.

Trauma & Critical Care Service, Department of Surgery, Brooke Army Medical Center, San Antonio, TX.

A significant proportion of patients with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation at our institution demonstrated heparin resistance, which in combination with a heparin shortage resulted in the transition to argatroban with or without aspirin as an alternative anticoagulation strategy. The optimal anticoagulation strategy for coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation is unknown, and therefore, we sought to evaluate the efficacy and safety of argatroban with or without aspirin as an alternative anticoagulation strategy in this patient population.

Design: Retrospective cohort.

Setting: Single-center tertiary-care facility in Fort Sam Houston, TX, from 2020 to 2021.

Patients: Twenty-four patients who were cannulated for venovenous extracorporeal membrane oxygenation due to respiratory failure secondary to coronavirus disease 2019.

Interventions: Argatroban, with or without aspirin, was substituted for heparin in coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation.

Measurements And Main Results: Eighty percent of our coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation demonstrated heparin resistance, and patients who were initially started on heparin were significantly more likely to require a change to argatroban than vice versa due to difficulty achieving or maintaining therapeutic anticoagulation goals (93.4% vs 11.1%; < 0.0001). The time to reach the therapeutic anticoagulation goal was significantly longer for patients who were initially started on heparin in comparison with argatroban (24 vs 6 hr; = 0.0173). Bleeding and thrombotic complications were not significantly different between the two cohorts.

Conclusions: Argatroban, with or without aspirin, is an effective anticoagulation strategy for patients who require venovenous extracorporeal membrane oxygenation support secondary to coronavirus disease 2019. In comparison with heparin, this anticoagulation strategy was not associated with a significant difference in bleeding or thrombotic complications, and was associated with a significantly decreased time to therapeutic anticoagulation goal, likely as a result of high rates of heparin resistance observed in this patient population.
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http://dx.doi.org/10.1097/CCE.0000000000000530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8425840PMC
September 2021

A Case Report of Combat Blast Injury Requiring Combat Casualty Care, Far-Forward ECMO, Air Transport, and All Levels of Military Critical Care.

Mil Med 2021 Aug 28. Epub 2021 Aug 28.

Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA.

We describe a 34-year-old soldier who sustained a blast injury in Syria resulting in tracheal 5 cm tracheal loss, cervical spine and cord injury with tetraplegia, multiple bilateral rib fractures, esophageal injury, traumatic brain injury, globe evisceration, and multiple extremity soft tissue and musculoskeletal injuries including a left tibia fracture with compartment syndrome. An emergent intubation of the transected trachea was performed in the field, and the patient was resuscitated with whole blood prehospital. During transport to the Role 2, the patient required cardiopulmonary resuscitation for cardiac arrest. On arrival, he underwent a resuscitative thoracotomy and received a massive transfusion exclusively with whole blood. A specialized critical care team transported the patient to the Role 3 hospital in Baghdad, and the DoD extracorporeal membrane oxygenation (ECMO) team was activated secondary to his unstable airway and severe hypoxia secondary to pulmonary blast injury. The casualty was cannulated in Baghdad approximately 40 hours after injury with bifemoral cannulae in a venovenous configuration. He was transported from Iraq to the U.S. Army Institute of Surgical Research Burn Center in San Antonio without issue. Extracorporeal membrane oxygenation support was successfully weaned, and he was decannulated on ECMO day 4. The early and en route use of venovenous ECMO allowed for maintenance of respiratory support during transport and bridge to operative management and demonstrates the feasibility of prolonged ECMO transport in critically ill combat casualties.
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http://dx.doi.org/10.1093/milmed/usab354DOI Listing
August 2021

Rates of nosocomial infection associated with interhospital transfer of patients receiving extracorporeal membrane oxygenation.

Infect Control Hosp Epidemiol 2021 Jun 25:1-6. Epub 2021 Jun 25.

Infectious Disease Service, Department of Internal Medicine, JBSA-Ft Sam Houston, San Antonio, Texas.

Objectives: Critically ill patients requiring extracorporeal membrane oxygenation (ECMO) frequently require interhospital transfer to a center that has ECMO capabilities. Patients receiving ECMO were evaluated to determine whether interhospital transfer was a risk factor for subsequent development of a nosocomial infection.

Design: Retrospective cohort study.

Setting: A 425-bed academic tertiary-care hospital.

Patients: All adult patients who received ECMO for >48 hours between May 2012 and May 2020.

Methods: The rate of nosocomial infections for patients receiving ECMO was compared between patients who were cannulated at the ECMO center and patients who were cannulated at a hospital without ECMO capabilities and transported to the ECMO center for further care. Additionally, time to infection, organisms responsible for infection, and site of infection were compared.

Results: In total, 123 patients were included in analysis. For the primary outcome of nosocomial infection, there was no difference in number of infections per 1,000 ECMO days (25.4 vs 29.4; P = .03) by univariate analysis. By Cox proportional hazard analysis, transport was not significantly associated with increased infections (hazard ratio, 1.7; 95% confidence interval, 0.8-4.2; P = .20).

Conclusion: In this study, we did not identify an increased risk of nosocomial infection during subsequent hospitalization. Further studies are needed to identify sources of nosocomial infection in this high-risk population.
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http://dx.doi.org/10.1017/ice.2021.251DOI Listing
June 2021

Safety and efficacy of low-titer O whole blood resuscitation in a civilian level I trauma center.

J Trauma Acute Care Surg 2021 08;91(2S Suppl 2):S162-S168

From the Department of Surgery (P.M.K.B., P.M.M., A.M.A., R.C.C.), Brooke Army Medical Center, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences (M.E.W.), Bethesda, Maryland; and Department of Trauma and Acute Care Surgery (J.E.F., J.S.R., R.A.H., V.G.S.), Brooke Army Medical Center, Fort Sam Houston, Texas.

Background: Military experience has shown low-titer O whole blood (LTOWB) to be safe and beneficial in the resuscitation of hemorrhaging trauma patients. However, few civilian centers use LTOWB for trauma resuscitation. We evaluated the early experience and safety of a LTOWB program at a level 1 civilian trauma center.

Methods: We retrospectively reviewed our trauma registry from January 2018 to June 2020 for patients admitted in shock (defined as ≥1 of the following: heart rate, >120 beats per minute; systolic blood pressure, <90 mm Hg; or shock index, >0.9) who received blood products within 24 hours. Patients were grouped by resuscitation provided: LTOWB (group 1), component therapy (CT; group 2), and LTOWB-CT (group 3). Safety, outcomes, and variables associated with LTOWB transfusion and mortality were analyzed.

Results: 216 patients were included: 34 in Group 1, 95 in Group 2, and 87 in Group 3. Patientsreceiving LTOWB were more commonly male (p<0.001) and had a penetrating injury (p=0.005). Groups 1 and 3 had higher median ISS scores compared to Group 2 (19 and 20 vs 17; p=0.01). Group 3 received more median units of blood product in the first 4h (p<0.001) and in the first 24h (p<0.001). There was no difference between groups in 24h mortality or transfusion-related complications (all p>0.05). Arrival ED SBP was associated with LTOWB transfusion (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.95-1.00, p=0.03). ED lactate was independently associated with 24h mortality. (OR 1.27, CI 1.02-1.58, p=0.03). LTOWB transfusion was not associated with mortality (p=0.49). Abstract.

Conclusion: Severely injured patients received LTOWB-CT and more overall product units but had similar 24 h mortality when compared with the LTOWB or CT groups. No increase in transfusion-related complications was seen after LTOWB transfusion. Low-titer O whole blood should be strongly considered in the resuscitation of trauma patients at civilian centers.

Level Of Evidence: Retrospective, therapeutic, level IV.
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http://dx.doi.org/10.1097/TA.0000000000003289DOI Listing
August 2021

Elevated secondary infection rates in patients with coronavirus disease 2019 (COVID-19) requiring extracorporeal membrane oxygenation.

Infect Control Hosp Epidemiol 2021 06 9;42(6):770-772. Epub 2021 Feb 9.

Infectious Disease Service, Department of Internal Medicine, Joint Base San Antonio Fort Sam Houston, San Antonio, Texas.

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http://dx.doi.org/10.1017/ice.2021.61DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7925975PMC
June 2021

Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team.

Mil Med 2020 12;185(11-12):e2055-e2060

Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234.

Introduction: The use of extracorporeal membrane oxygenation (ECMO) for the care of critically ill adult patients has increased over the past decade. It has been utilized in more austere locations, to include combat wounded. The U.S. military established the Acute Lung Rescue Team in 2005 to transport and care for patients unable to be managed by standard medical evacuation resources. In 2012, the U.S. military expanded upon this capacity, establishing an ECMO program at Brooke Army Medical Center. To maintain currency, the program treats both military and civilian patients.

Materials And Methods: We conducted a single-center retrospective review of all patients transported by the sole U.S. military ECMO program from September 2012 to December 2019. We analyzed basic demographic data, ECMO indication, transport distance range, survival to decannulation and discharge, and programmatic growth.

Results: The U.S. military ECMO team conducted 110 ECMO transports. Of these, 88 patients (80%) were transported to our facility and 81 (73.6%) were cannulated for ECMO by our team prior to transport. The primary indication for ECMO was respiratory failure (76%). The range of transport distance was 6.5 to 8,451 miles (median air transport distance = 1,328 miles, median ground transport distance = 16 miles). In patients who were cannulated remotely, survival to decannulation was 76% and survival to discharge was 73.3%.

Conclusions: Utilization of the U.S. military ECMO team has increased exponentially since January 2017. With an increased tempo of transport operations and distance of critical care transport, survival to decannulation and discharge rates exceed national benchmarks as described in ELSO published data. The ability to cannulate patients in remote locations and provide critical care transport to a military medical treatment facility has allowed the U.S. military to maintain readiness of a critical medical asset.
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http://dx.doi.org/10.1093/milmed/usaa215DOI Listing
December 2020

Electronic trauma resuscitation documentation and decision support using T6 Health Systems Mobile Application: A combat trauma center pilot program.

J Trauma Acute Care Surg 2020 12;89(6):1172-1176

From the Department of Surgery, Division of Trauma Critical Care (L.M.A., R.A.H., D.A.V., J.S.F., V.G.S.), Department of Graduate Medical Education (J.K.A.), and Department of Emergency Medicine (K.R.B., J.M.N.), Brooke Army Medical Center, Fort Sam Houston, Texas; St. Louis University Center for Sustainment of Trauma and Readiness Skills, Department of Surgery (C.N.S.), Division of Traua Critical Care, St. Louis, MO.

Background: The care of trauma patients in combat operations is handwritten on a five-page flow sheet. The process requires the manual scanning and uploading of paper documents to bridge the gap between electronic and paper record management. There is an urgent operational need for an information technology solution that will enable medics to better capture patient treatment information, which will improve long-term health care without impacting short-term care responsibilities.

Methods: We conducted a process improvement project to evaluate the ability of T6 Health Systems Mobile Application to improve combat casualty care data collection at a deployed trauma hospital. We performed a head-to-head comparison of the completeness and accuracy of data capture of electronic versus handwritten records to determine noninferiority.

Results: During the 90-day pilot, there were 131 trauma evaluations of which 53 casualty resuscitations (40.5%) were also documented in the electronic application. We compared completeness and accuracy of admit, prehospital, primary survey, secondary survey, interventions, and trends data. We found an overall 13% increase in data capture at 96% accuracy compared with the written record, suggesting that the electronic record was superior. Completion of electronic documentation compared with paper by section was statistically significantly higher for admitting data, 119.7% (p < 0.0001); prehospital, 116.2% (p = 0.0039); primary, 109.6% (p < 0.001); and secondary, 125.5% (p < 0.001). We also had the medical evacuation teams document prehospital and en route care and then synchronize the record in the trauma bay, allowing the trauma teams there to continue documenting on the same casualty record, likely contributing to superiority because teams did not have to redocument based on an oral report.

Conclusion: Our pilot program in the deployed environment demonstrated a mobile technology that actually enhanced the completeness and accuracy of paper trauma documentation that has the capability of providing patient-specific decision support and real-time data analysis.

Level Of Evidence: Care Management, level IV.
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http://dx.doi.org/10.1097/TA.0000000000002909DOI Listing
December 2020

Expression of High Mobility Group Box 1 Protein in a Polytrauma Model During Ground Transport and Simulated High-Altitude Evacuation.

J Spec Oper Med 2020 ;20(1):65-70

Background: We investigated the expression of high mobility group box 1 (HMGB1) protein in a combat-relevant polytrauma/ acute respiratory distress syndrome (ARDS) model. We hypothesized that systemic HMGB1 expression is increased after injury and during aeromedical evacuation (AE) at altitude.

Methods: Female Yorkshire swine (n =15) were anesthetized and cannulated with a 23Fr dual-lumen catheter. Venovenous extracorporeal life support (VV ECLS) was initiated via the right jugular vein and carried out with animals uninjured on day 1 and injured by bilateral pulmonary contusion on day 2. On both days, animals underwent transport and simulated AE. Systemic HMGB1 expression was measured in plasma by ELISA. Plasma-free Hb (pfHb) was measured with the use of spectrophotometric methods.

Results: Plasma HMGB1 on day 1 was transiently higher at arrival to the AE chambers, increased significantly after injury, reaching highest values at 8,000 ft on day 2, after which levels decreased but remained elevated versus baseline at each time point. pfHb decreased on day 1 at 30,000 ft and significantly increased on day 2 at 8,000 ft and postflight.

Conclusions: Systemic HMGB1 demonstrated sustained elevation after trauma and altitude transport and may provide a useful monitoring capability during en route care.
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May 2020

Outcomes among Patients Treated with Renal Replacement Therapy during Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Study.

Blood Purif 2020 19;49(3):341-347. Epub 2019 Dec 19.

Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA.

Background: Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are modalities used in critically ill patients suffering organ failure and metabolic derangements. Although the effects of CRRT have been extensively studied, the impact of simultaneous CRRT and ECMO is less well described. The purpose of this study is to evaluate the incidence and the impact of CRRT on outcomes of patients receiving ECMO.

Methods: A single center, retrospective chart review was conducted for patients receiving ECMO therapy over a 6-year period. Patients who underwent combined ECMO and CRRT were compared to those who underwent ECMO alone. Intergroup -statistical comparisons were performed using Wilcoxon/Kruskal-Wallis and chi-square tests. Logistic regression was performed to identify independent risk factors for mortality.

Results: The demographic and clinical data of 92 patients who underwent ECMO at our center were reviewed including primary diagnosis, indications for and mode of ECMO support, illness severity, oxygenation index, vasopressor requirement, and presence of acute kidney injury. In those patients that required ECMO with CRRT, we reviewed urine output prior to initiation, modality used, prescribed dose, net fluid balance after 72 h, requirement of renal replacement therapy (RRT) at discharge, and use of diuretics prior to RRT initiation. Our primary endpoint was survival to hospital discharge. During the study period, 48 patients required the combination of ECMO with CRRT. Twenty-nine of these patients survived to hospital discharge. Of the 29 survivors, 6 were dialysis dependent at hospital discharge. The mortality rate was 39.5% with combined ECMO/CRRT compared to 31.4% among those receiving ECMO alone (p = 0.074). Of those receiving combined therapy, nonsurvivors were more likely to have a significantly positive net fluid balance at 72 h (p = 0.001). A multivariate linear regression analysis showed net positive fluid balance and increased age were independently associated with mortality.

Conclusions: Use of CRRT is prevalent among patients undergoing ECMO, with over 50% of our patient population receiving combination therapy. Fluid balance appears to be an important variable associated with outcomes in this cohort. Rates of renal recovery and overall survival were higher compared to previously published reports among those requiring combined ECMO/CRRT.
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http://dx.doi.org/10.1159/000504287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212702PMC
April 2021

Infections in patients with burn injuries receiving extracorporeal membrane oxygenation.

Burns 2019 12 7;45(8):1880-1887. Epub 2019 Oct 7.

Infectious Disease Service, MCHE-MDI, 3551 Roger Brooke Drive, JBSA Ft. Sam Houston, San Antonio, TX 78234, United States.

Introduction: Extracorporeal Membrane Oxygenation (ECMO) has only recently been described in patients with burn injuries. We report the incidence and type of infections in critically ill burn and non-burn patients receiving ECMO.

Methods: A retrospective chart review was performed on all patients at Brooke Army Medical Center who received ECMO between September 2012 and May 2018.

Results: 78 patients underwent ECMO. Approximately half were men with a median age of 34 years with a median time on ECMO of 237 h (IQR 121-391). Compared to patients without burns (n = 58), patients with burns (n = 20) had no difference in time on ECMO, but had more overall infections (86 vs. 31 per 1000 days, p = 0.0002), respiratory infections (40 vs. 15 per 1000 days, p = 0.01), skin and soft tissue infections (21 vs. 5 per 1000 days, p = 0.02) and fungal infections (35% vs 10%, p = 0.02). Twenty percent of bacterial burn infections were due to drug resistant organisms.

Conclusion: This is the first study to describe the incidence of infection in burn injury patients who are undergoing ECMO. We observed an increase in infections in burn patients on ECMO compared to non-burn patients. ECMO remains a viable option for critically ill patients with burn injuries.
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http://dx.doi.org/10.1016/j.burns.2019.04.023DOI Listing
December 2019

Predictive survival factors of the traumatically injured on venovenous extracorporeal membrane oxygenation: A Bayesian model.

J Trauma Acute Care Surg 2020 01;88(1):153-159

From the Department of Surgery (J.E.H., S.R.H.), Tripler Army Medical Center, United States Army; Baylor University (J.P.); United States Army (L.C.P.); and United States Air Force (V.G.S.), Honolulu, Hawaii.

Background: Venovenous extracorporeal membrane oxygenation (ECMO) has had encouraging evidence suggesting efficacy and acceptable safety in trauma patients with refractory respiratory failure. Given the obstacles of accruing adequate quality prospective data for a resource-intensive modality, it is unclear what is indicative of survival to discharge. We investigate pre-ECMO characteristics (age, Injury Severity Score [ISS], time from admission to cannulation, P:F ratio) in trauma patients to determine correlation with survival.

Methods: To address these challenges, we use Bayesian inference and patients from a level I trauma center and Extracorporeal Life Support Organization-designated Gold Center of Excellence (N = 12), published literature, and Markov chain Monte Carlo simulation to determine if there is strong predictive probability regarding survival to discharge.

Results: Bayesian inference probabilities expressed as odds ratios with 95% credible intervals (CrIs) were as follows: age (e = 0.981; CrI, 0.976-0.985), ISS (e = 0.996; CrI, 0.980-1.012), P:F ratio (e = 1.000; CrI, 0.996-1.003), and time from admission to ECMO (e = 0.988; CrI, 0.974-1.004). Bayes factors (BF) were as follows: BFage = 3.151, BFISS = 3.564 × 10, BFpf = 0.463, and BFtime = 913.758.

Conclusion: Age was the only pre-ECMO factor that demonstrated the most certain effect on hospital mortality for trauma patients placed on venovenous ECMO. The ISS and time to ECMO initiation had some appreciable impact on survival although less certain than age; P:F ratio likely had none. However, the pre-ECMO factors that were found to have any impact on mortality were relatively diminutive. More studies are necessary to update prior distributions and enhance accuracy.

Level Of Evidence: Prognostic, Level IV.
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http://dx.doi.org/10.1097/TA.0000000000002457DOI Listing
January 2020

Thromboelastography on-the-go: Evaluation of the TEG 6s device during ground and high-altitude Aeromedical Evacuation with extracorporeal life support.

J Trauma Acute Care Surg 2019 07;87(1S Suppl 1):S119-S127

From the The Geneva Foundation (T.R.R., J.A.J., J.-H.C., K.N.S., G.T.H., D.S.W., B.M.B., A.I.B.), Tacoma, Washington; Morsani College of Medicine, University of South Florida, Tampa, Florida; U.S. Army Institute of Surgical Research (T.R.R., J.-H.C., D.S.W., B.M.B., A.P.C., L.C.C., A.I.B.), JBSA, Fort Sam Houston, Texas; Department of Surgery (V.R.), University of Texas Health Science Center, San Antonio, Texas; U.S. Army Medical Research and Materiel Command (M.R.D.), Fort Detrick, Maryland; San Antonio Military Medical Center (V.G.S.), JBSA, Fort Sam Houston, Texas.

Background: Coagulation monitoring capabilities during transport are limited. Thromboelastography (TEG) is a whole-blood clotting test measuring clot formation, stabilization, and fibrinolysis and is traditionally performed in a laboratory. We evaluated a new point-of-care TEG analyzer, TEG 6s (Haemonetics, Braintree, MA), in a large animal model of combat-relevant trauma managed with extracorporeal life support during ground and high-altitude aeromedical evacuation. The objective was to compare TEG 6s used during transport versus the predicate device, TEG 5000, used in the laboratory. We hypothesized that TEG 6s would be comparable with TEG 5000 during dynamically changing transport conditions.

Methods: Thromboelastography parameters (R, K, angle, MA, LY30) derived by TEG 6s and TEG 5000 were compared during transport of 8 swine. TEG 6s was transported with animals during ground transport and flight. TEG 5000 was stationary in an adjacent building. TEG 6s activated clotting time (ACT) was compared with a Hemochron Junior ACT analyzer (Accriva Diagnostics, San Diego, CA). Statistics were performed using SAS 9.4 with Deming regressions, Spearman correlations, and average differences compared.

Results: Correlation between devices was stronger at sea-level (R, r = 0.7413; K, r = 0.7115; angle, r = 0.7192; MA, r = 0.8386; LY30, r = 0.9099) than during high-altitude transport (R, r = 0.4787; K, r = 0.4007; angle, r = 0.3706; MA, r = 0.6573; LY30, r = 0.8481). Method agreement was comparable during stationary operation (R, r = 0.7978; K, r = 0.7974; angle, r = 0.7574; MA, r = 0.7841; LY30, r = 0.9140) versus ground transport (R, r = 0.7927; K, r = 0.6246; angle, r = 0.6967; MA, r = 0.9163; LY30, r = 0.8603). TEG 6s ACT trended higher than Hemochron ACT when subjects were heparinized (average difference, 1,442 ± 1,703 seconds) without a methodological difference by Deming regression.

Conclusion: Mobile TEG 6s during ground and altitude transport is feasible and provides unprecedented information to guide coagulation management. Future studies should assess the precision and accuracy of TEG 6s during transport of critically ill.
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http://dx.doi.org/10.1097/TA.0000000000002224DOI Listing
July 2019

Prehospital adenosine, lidocaine, and magnesium has inferior survival compared with tactical combat casualty care resuscitation in a porcine model of prolonged hemorrhagic shock.

J Trauma Acute Care Surg 2019 07;87(1):68-75

From the Division of Trauma Critical Care (R.A.H., V.G.S.), San Antonio Military Medical Center, and Naval Medical Research Unit (J.J.G., L.J.S., D.M.F., K.M.O., C.G.M., S.C.) San Antonio, JBSA-Ft. Sam Houston, Texas.

Background: Adenosine, lidocaine, and magnesium (ALM) is a cardioplegic agent shown to improve survival by improving cardiac function, tissue perfusion, and coagulopathy in animal models of shock. We hypothesized prehospital ALM treatment in hemorrhagic shock would improve survival compared to current Tactical Combat Casualty Care (TCCC) resuscitation beyond the golden hour.

Methods: Swine were randomized to: (1) TCCC, (2) 2 mL·kg vehicle control (VC), (3) 2 mL·kg ALM + drip, (4) 4 mL·kg ALM + drip, 5) 4 mL·kg ALM + delayed drip at 0.5 mL·kg·h, 6) 4 mL/kg VC, 7) 4 mL·kg ALM for 15 minutes + delayed drip at 3 mL·kg·h. Animals underwent pressure controlled hemorrhage to mean arterial pressure (MAP) of 30 mm Hg (S = 0). Treatment was administered at T = 0. After 120 minutes of simulated prehospital care (T = 120) blood product resuscitation commenced. Physiologic variables were recorded and laboratories were drawn at specified time points.

Results: Tactical Combat Casualty Care demonstrated superior survival to all other agents. The VC and ALM groups had lower MAPs and systolic blood pressures compared with TCCC. Except for the VC groups, lactate levels remained similar with correction of base deficit after prehospital resuscitation in all groups. Kidney function and liver function remained comparable across all groups. Compared with baseline values, TCCC demonstrated significant hypocoagulability.

Conclusion: Adenosine, lidocaine, and magnesium, as administered in this study, are inferior to current Hextend-based resuscitation for survival from prolonged hemorrhagic shock in this model. In survivors, ALM groups had lower systolic blood pressures and MAPs, but provided a protective effect on coagulopathy as compared to TCCC. Adenosine, lidocaine, and magnesium do not appear to be a suitable low volume replacement to current TCCC resuscitation. The reduced coagulopathy compared to TCCC warrants future studies of ALM, perhaps as a therapeutic adjunct.
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http://dx.doi.org/10.1097/TA.0000000000002308DOI Listing
July 2019

Salvage extracorporeal membrane oxygenation in induction-associated acute respiratory distress syndrome in acute leukemia patients: A case series.

Int J Artif Organs 2019 Jan 17;42(1):49-54. Epub 2018 Sep 17.

3 Trauma/Critical Care Surgery Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA.

Background:: The prognosis of hematologic malignancies has improved over the past three decades. However, the prognosis in hematologic malignancies with severe acute respiratory distress syndrome has remained poor. Initial reports regarding the utility of extracorporeal membrane oxygenation in hematologic malignancies have been controversial, with limited evaluations of acute leukemia patients supported by extracorporeal membrane oxygenation.

Methods:: We conducted a retrospective review of patients with acute leukemia who developed acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation support at our facility from July 2015 through August 2017.

Results:: Four cases of acute myelogenous leukemia with respiratory failure and acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation while undergoing induction chemotherapy were identified. All patients completed induction therapy with addition of extracorporeal membrane oxygenation support, with two patients dying secondary to their acute leukemia and the other two surviving to allogeneic hematopoietic stem cell transplant. Overall, 75% (three of four) survived to decannulation with a 1-year survival rate following extracorporeal membrane oxygenation of 50% (two of four).

Conclusion:: Currently, the use of extracorporeal membrane oxygenation in patients with hematologic malignancies who develop severe acute respiratory distress syndrome remains controversial. Although extracorporeal membrane oxygenation in post-allogeneic hematopoietic stem cell transplant is associated with poorer outcomes, our data suggest that salvage extracorporeal membrane oxygenation support is a viable option to manage moderate to severe acute respiratory distress syndrome while completing therapeutic chemotherapy and following in the peri-induction phase of acute leukemia.
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http://dx.doi.org/10.1177/0391398818799160DOI Listing
January 2019

Roux-en-Y gastric bypass surgery alters serum metabolites and fatty acids in patients with morbid obesity.

Diabetes Metab Res Rev 2018 11 19;34(8):e3045. Epub 2018 Sep 19.

Department of Nutritional Sciences, Texas Tech University, Lubbock, TX, USA.

Aim: Bariatric surgery induces significant weight loss, increases insulin sensitivity, and reduces mortality, but the underlying mechanisms are not clear. It was hypothesized that Roux-en-Y gastric bypass (RYGB) surgery improves metabolic profile along with weight loss. The objective of this pilot study was to evaluate changes in serum metabolites and fatty acids (FA) at 2 weeks and 6 months after RYGB.

Materials And Methods: Serum samples were collected pre-surgery, at 2 weeks and 6 months post-surgery from 20 patients undergoing RYGB surgery. Serum non-esterified free FA (NEFA) were measured. Serum metabolites and FA were measured using nuclear magnetic resonance spectroscopy and improved direct fatty acid methyl ester synthesis and the gas chromatography/mass spectrometry method, respectively, in subjects who completed follow-up at 6 months (n = 8).

Results: Mean (standard deviation) percent total weight loss was 6.70% (1.7) and 24.91% (6.63) at 2 weeks (n = 15) and 6 months (n = 8) post-surgery, respectively. NEFA were significantly reduced at 6 months post-surgery (P = 0.001, n = 8). Serum branched chain amino acids, 2-aminobutyrate, butyrate, 2-hydroxybutyrate, 3-hydroxybutyrate, acetone, 2-methylglutarate, and 2-oxoisocaproate were significantly reduced, while serum alanine, glycine, pyruvate, and taurine were significantly elevated at 6 months post-surgery compared with pre-surgery (n = 8, P < 0.05). Also, serum FA C10:0, C13:0, C14:0, C15:0, and C18:0 increased significantly (n = 8, P < 0.05) by 6 months post-surgery.

Conclusions: Changes in serum metabolites and FA at 6 months post-RYGB surgery in this pilot study with limited number of participants are suggestive of metabolic improvement; larger studies are warranted for confirmation.
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http://dx.doi.org/10.1002/dmrr.3045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238211PMC
November 2018

Case Report of Extracorporeal Membrane Oxygenation and Aeromedical Evacuation at a Deployed Military Hospital.

Mil Med 2018 03;183(suppl_1):203-206

59th Medical Wing Extracorporeal Life Support Program, 2200 Bergquist Dr, San Antonio, TX 78236.

The U.S. Military no longer maintains overseas extracorporeal membrane oxygenation (ECMO) capability for patients with severe lung injury including acute respiratory distress syndrome (ARDS). The authors present a case of severe ARDS at a military hospital in Afghanistan with limited capability for rescue therapies to include presentation, treatment, transport, and use of ECMO in the deployed military environment at one Role 3 medical facility. Lack of ECMO in the overseas environment is a significant gap in U.S. Military medical capability. The authors propose a novel solution, "ECMO packs," for prepositioning at strategic Role 3 facilities for early intervention in patients with severe lung injury to close this lethal and unnecessary capability gap.
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http://dx.doi.org/10.1093/milmed/usx160DOI Listing
March 2018

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

J Trauma Acute Care Surg 2018 02;84(2):372-378

From the Division of Trauma Critical Care and General Surgery, Department of Surgery (M.C.H., N.N.H., M.D.Z., A.C.), Mayo Clinic, Rochester, Minnesota; Department of Surgery (D.C.C.), Marshfield Clinic, Marshfield, Wisconsin; Division of Trauma, Department of Surgery (D.T., J-M.Y.), Loma Linda University, Loma Linda, California; Division of Trauma Surgery, Department of Surgery (S.W.), Cooper University Hospital, New Jersey; Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Department of Surgery (D.D.Y.), Massachusetts General Hospital, Boston, Massachusetts; Division of Trauma Surgery, Department of Surgery (T.M.D.), John Peter Smith, Fort Worth, Texas; Department of Surgery (A.P.), Kern Medical Center, Baekrsfield, California; Division of Trauma, Department of Surgery (J.W.), Inova Fairfax Hospital, Annandale, Virginia; Division of Trauma, Department of Surgery (C.J.R.), Water Reed National Military Medical Center, Bethesda, Maryland; Department of Surgery (K.A.W.), Geisinger Medical Center, Danville, Pennsylvania; Department of Surgery (J.C.), Greenville Memorial Hospital, Greenville, South Carolina; Department of Surgery (J.D.), UC Health Northern Colorado, Fort Collins, Colorado; Department of Surgery (E.A.T.), East Carolina University, Greenville, North Carolina; and Department of Surgery (J.C.G.), San Antonio Military Medical Center, San Antonio, Texas.

Background: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study.

Methods: Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed.

Results: There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade.

Conclusion: The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms.

Level Of Evidence: Prognostic, level III.
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http://dx.doi.org/10.1097/TA.0000000000001736DOI Listing
February 2018

Multicenter retrospective study of noncompressible torso hemorrhage: Anatomic locations of bleeding and comparison of endovascular versus open approach.

J Trauma Acute Care Surg 2017 07;83(1):11-18

From the Center for Translational Injury Research (R.C., E.E.F., J.S.T., J.M.P., C.E.W., J.B.H.), Department of Surgery (R.C., E.E.F., C.E.W., J.B.H.), McGovern Medical School; Department of Biostatistics (T.J.G., S.M.D.), School of Public Health, Department of Surgery (B.J.E.), University of Texas Health Science Center at San Antonio, San Antonio; Michael E. DeBakey Department of Surgery (R.G., S.R.T.), Baylor College of Medicine, Houston; United States Army Institute of Surgical Research (K.K.C.); San Antonio Military Medical Center (V.G.S.), Fort Sam Houston; and Department of Cardiothoracic and Vascular Surgery (J.J.D., G.R.F., McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas).

Background: Rational development of technology for rapid control of noncompressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) management versus open (OPEN) management.

Methods: This is a retrospective study of adult trauma patients with NCTH admitted to four urban Level I trauma centers in the Houston and San Antonio metropolitan areas in 2008 to 2012. Inclusion criteria include named axial torso vessel disruption, Abbreviated Injury Scale chest or abdomen score of 3 or higher with shock (base excess, <-4) or truncal operation in 90 minutes or less, or pelvic fracture with ring disruption. Exclusion criteria include isolated hip fractures, falls from standing, or prehospital cardiopulmonary resuscitation. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, Injury Severity Score, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients.

Results: Five hundred forty-three patients with NCTH underwent ENDO (n = 166, 31%), OPEN (n = 309, 57%), or RT (n = 68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, whereas OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs. 34% vs. 32%); severe injuries (median Injury Severity Score, 34 vs. 27 vs. 21), and increased time to intervention (median, 298 vs. 92 vs. 51 minutes) compared with OPEN and RT. Mortality was 15% versus 20% versus 79%. ENDO was associated with decreased mortality compared to OPEN (relative risk, 0.58; 95% confidence interval, 0.46-0.73).

Conclusion: Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding.

Level Of Evidence: Therapeutic, level V.
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http://dx.doi.org/10.1097/TA.0000000000001530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5484539PMC
July 2017

Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study.

J Trauma Acute Care Surg 2017 07;83(1):25-29

From the Loma Linda University School of Medicine, Department of Pathology (W.T.S.) and Trauma Division, Department of Surgery (X.L.-O., D.T., Q.J.C.), Loma Linda, California; Emory School of Medicine, Department of Surgery-Grady Memorial Hospital (B.C.M., C.J.D., C.A.F.), Atlanta, Georgia; University of Kentucky (A.B., D.D.), Department of Surgery, Lexington, Kentucky; San Antonio Military Medical Center, Division of Trauma Critical Care (V.G.S.), Department of Pathology (J.G., J.Q.), and Uniformed Services University of the Health Sciences (P.M.C.), San Antonio, Texas; University of Cincinnati (M.G., T.P., D.G.), Cincinnati, Ohio; Department of Trauma Research, Medical City Plano, Plano, Texas; The Medical Center of Plano (R.D.), Plano, Texas; Conemaugh Memorial Medical Center (M.C.), Johnstown, Pennsylvania; Mayo Clinic, Department of Surgery; Division of Trauma, Critical Care and General Surgery; Rochester, Minnesota.

With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP).

Methods: As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB.

Results: Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p < 0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity.

Conclusion: Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality.

Level Of Evidence: Therapeutic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001532DOI Listing
July 2017

Multi-institutional, prospective, observational study comparing the Gastrografin challenge versus standard treatment in adhesive small bowel obstruction.

J Trauma Acute Care Surg 2017 07;83(1):47-54

From the Mayo Clinic (M.D.Z., N.N.H.), Rochester, Minnesota; Marshfield Clinic (D.C.C.), Marshfield, Wisconsin; University of Southern California (K.I.), Los Angeles, California; Massachusetts General Hospital (D.D.Y.), Chelsea, Massachusetts; Cooper University (S.W., J.P.H.), Camden, New Jersey; Loma Linda University (D.T., J.-M.Y.), Loma Linda, California; Kern Medical Center (A.P., R.S.), Bakersfield, California; John Peter Smith Hospital (T.M.D.), Ft. Worth, Texas; Inova Fairfax Hospital (J.W.), Falls Church, Virginia; Geisinger Medical Center (K.A.W.), Danville, Pennsylvania; Greenville Memorial Hospital (J.C.), Greenville, South Carolina; Walter Reed National Military Medical Center (C.J.R.), Bethesda, Maryland; East Carolina University (E.A.T.), Greenville, North Carolina; and San Antonio Military Medical Center (V.G.S., J.C.G.), San Antonio, Texas.

Introduction: Existing trials studying the use of Gastrografin for management of adhesive small bowel obstruction (SBO) are limited by methodological flaws and small sample sizes. We compared institutional protocols with and without Gastrografin (GG), hypothesizing that a SBO management protocol utilizing GG is associated with lesser rates of exploration, shorter length of stay, and fewer complications.

Methods: A multi-institutional, prospective, observational study was performed on patients appropriate for GG with adhesive SBO. Exclusion criteria were internal/external hernia, signs of strangulation, history of abdominal/pelvic malignancy, or exploration within the past 6 weeks. Patients receiving GG were compared to patients receiving standard care without GG.

Results: Overall, 316 patients were included (58 ± 18 years; 53% male). There were 173 (55%) patients in the GG group (of whom 118 [75%] successfully passed) and 143 patients in the non-GG group. There were no differences in duration of obstipation (1.6 vs. 1.9 days, p = 0.77) or small bowel feces sign (32.9% vs. 25.0%, p = 0.14). Fewer patients in the GG protocol cohort had mesenteric edema on CT (16.3% vs. 29.9%; p = 0.009). There was a lower rate of bowel resection (6.9% vs. 21.0%, p < 0.001) and exploration rate in the GG group (20.8% vs. 44.1%, p < 0.0001). GG patients had a shorter duration of hospital stay (4 IQR 2-7 vs. 5 days IQR 2-12; p = 0.036) and a similar rate of complications (12.5% vs. 17.9%; p = 0.20). Multivariable analysis revealed that GG was independently associated with successful nonoperative management.

Conclusion: Patients receiving Gastrografin for adhesive SBO had lower rates of exploration and shorter hospital length of stay compared to patients who did not receive GG. Adequately powered and well-designed randomized trials are required to confirm these findings and establish causality.

Level Of Evidence: Therapeutic, level III.
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http://dx.doi.org/10.1097/TA.0000000000001499DOI Listing
July 2017

Effect of bariatric surgery on systemic and adipose tissue inflammation.

Surg Endosc 2016 08 30;30(8):3499-504. Epub 2015 Oct 30.

Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA.

Background: Obese patients are predisposed to developing insulin resistance and associated metabolic diseases such as diabetes and cardiovascular disease. The objective of this study was to determine the effect of bariatric surgery on adipose-derived inflammatory cytokines (adipokines), which play a key role in insulin resistance and obesity. We hypothesized that there is a significant increase in serum and tissue anti-inflammatory adiponectin with a decrease in circulating pro-inflammatory TNF-α and MCP-1, leading to reduced inflammation post-bariatric surgery.

Methods: In this study, we investigated the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic gastric band on serum and tissue levels of adiponectin and serum levels of MCP-1 and TNF-α. Samples of serum and adipose tissue were collected at the time of surgery, 2 weeks and 6 months postoperatively. Adipokine levels were assayed by ELISA kits.

Results: A significant increase in adiponectin levels 2 weeks after surgery was observed in the subcutaneous adipose tissue in both groups combined. Serum adiponectin in LRYGB patients showed an increasing trend, while MCP-1 showed a decreasing trend post-surgery. There was no difference in TNF-α among the groups. The number of patients enrolled did not allow for statistical power to be reached.

Conclusion: Our results show significant and rapid increases in subcutaneous adipose adiponectin as early as 2 weeks post-bariatric surgery demonstrating reduced inflammation and possibly reduced insulin resistance. Future studies are warranted in larger cohorts with additional measurements of insulin sensitivity and inflammation.
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http://dx.doi.org/10.1007/s00464-015-4638-3DOI Listing
August 2016

An 8-year review of operation enduring freedom and operation iraqi freedom resuscitative thoracotomies.

Mil Med 2015 Mar;180(3 Suppl):33-6

U.S. Military General Surgery, San Antonio Military Medical Center, 3851 Roger Brooke Drive #3600, San Antonio, TX 78234.

Background: Appropriate indications for resuscitative thoracotomy (RT) in an austere environment continue to evolve; the aim of this study was to determine survival and to analyze demographics of survivors within U.S. military personnel undergoing RT.

Methods: A retrospective review was performed of all U.S. soldiers who underwent thoracotomy in theater during Operation Iraqi Freedom and Operation Enduring Freedom. After individualized review, patients in extremis or who lost pulses and had their thoracotomy performed within 10 minutes of arrival to the emergency department were included. The primary outcome was survival at final hospital discharge, and secondary outcomes included demographics associated with survival.

Results: Between January 2003 and May 2010, 81 U.S. military personnel met inclusion criteria for RT in theater. As low as 6.7% (3/45) of patients receiving prehospital cardiopulmonary resuscitation were alive at final hospital discharge. Survival from RT after explosive/blast injury, penetrating (gunshot wound), and blunt trauma were 16.3% (8/49), 0% (0/28), and 0% (0/4), respectively. Patients with primary explosive/blast extremity trauma undergoing RT had a survival of 27.3% (6/22). Higher initial oxygen saturations, larger volume of crystalloids and blood products infused, and higher extremity abbreviated injury score were all associated with survival.

Conclusions: Combat casualties who present pulseless or in extremis who were injured as a result of an explosive/blast injury mechanism resulting in a primary extremity injury may have a survival benefit from undergoing a RT in an austere environment.
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http://dx.doi.org/10.7205/MILMED-D-14-00440DOI Listing
March 2015

Nonsteroidal anti-inflammatory drugs' impact on nonunion and infection rates in long-bone fractures.

J Trauma Acute Care Surg 2014 Mar;76(3):779-83

From the Departments of Surgery (D.J., V.S., C.L., B.E., J.P., B.D.) and Pharmacy (D.W., L.K., J.M.) and University Orthopedic Surgeons (S.S., H.K.), University of Tennessee Medical Center; Department of Statistics (P.B.), Graduate School of Medicine, University of Tennessee, Knoxville, Tennessee.

Background: There is a dearth of clinical data regarding the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on long-bone fracture (LBF) healing in the acute trauma setting. The orthopedic community believes that the use of NSAIDs in the postoperative period will result in poor healing and increased infectious complications. We hypothesized that, first, NSAID use would not increase nonunion/malunion and infection rates after LBF. Second, we hypothesized that tobacco use would cause higher rates of these complications.

Methods: A retrospective study of all patients with femur, tibia, and/or humerus fractures between October 2009 and September 2011 at a Level 1 academic trauma center was performed . In addition to nonunion/malunion and infection rates, patient records were reviewed for demographic data, mechanism of fracture, type of fracture, tobacco use, Injury Severity Score (ISS), comorbidities, and medications given.

Results: During the 24-month period, 1,901 patients experienced LBF; 231 (12.1%) received NSAIDs; and 351 (18.4%) were smokers. The overall complication rate including nonunion/malunion and infection was 3.2% (60 patients). Logistic regression analysis with adjusted odds ratios were calculated on the risk of complications given NSAID use and/or smoking, and we found that a patient is significantly more likely to have a complication if he or she received an NSAID (odds ratio, 2.17; 95% confidence interval, 1.15-4.10; p < 0.016) in the inpatient postoperative setting. Likewise, smokers are significantly more likely to have complications (odds ratio, 3.19; 95% confidence interval, 1.84-5.53; p < 0.001).

Conclusion: LBF patients who received NSAIDs in the postoperative period were twice as likely and smokers more than three times likely to suffer complications such as nonunion/malunion or infection. We recommend avoiding NSAID in traumatic LBF.

Level Of Evidence: Epidemiologic & therapeutic study; level II.
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http://dx.doi.org/10.1097/TA.0b013e3182aafe0dDOI Listing
March 2014

Factors that impact patient outcome: nutrition assessment.

JPEN J Parenter Enteral Nutr 2013 Sep;37(5 Suppl):30S-8S

Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee.

Defining malnutrition and nutrition risk has been a topic of many papers and discussions throughout the modern literature. Multiple definitions have been proposed, ranging from simple body weight measurements to a more all-encompassing concept looking at disease-specific inflammatory states. Biochemical markers, elements of a history examination, physical examination findings, calculations, and technical tests have all been proposed to help further characterize and delineate those who might be at risk for malnutrition, translating to an increased risk of adverse outcomes after major surgery. The purpose of this paper is to summarize some of the most utilized and most reliable ways to determine nutrition status within the scope of the North American Surgical Nutrition Summit (2012) and discuss how to incorporate these methods into the way that patients are screened preoperatively for elective surgery.
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http://dx.doi.org/10.1177/0148607113499372DOI Listing
September 2013

Effect of rotational therapy on aspiration risk of enteral feeds.

Nutr Clin Pract 2012 Dec 19;27(6):808-11. Epub 2012 Oct 19.

Department of Surgery, University of Tennessee Medical Center, 1924 Alcoa Hwy, Box U-11, Knoxville, TN 37920, USA.

Background: Enteral nutrition has been demonstrated to reduce ventilator days and the incidence of pneumonia, but the safest route for providing enteral nutrition to mechanically ventilated patients is unclear. Our objective was to determine if there is a difference between the incidences of microaspiration of gastric secretions in patients fed via a nasogastric tube vs a postpyloric tube while undergoing rotational therapy for acute respiratory distress syndrome (ARDS).

Materials And Methods: Institutional review board approval was obtained for this prospective, randomized study. Patients were randomized to gastric or postpyloric enteral feedings. Daily tracheal secretion samples were collected, and we used an immunoassay to detect pepsin. Using the data for aspiration and tube type, a univariate unadjusted odds ratio was calculated to assess the risk of aspiration between the 2 tube types. An independent samples t test was used to analyze the hypothesis that microaspiration significantly affects lung recovery from ARDS.

Results: Of the 20 study patients, 9 (45%) received nasogastric feeds and 11 (55%) received postpyloric feeds. Western blot analysis for the presence of pepsin in each tracheal aspirate revealed microaspiration in 2 nasogastric (22%) and 2 (18%) postpyloric patients. The nasogastric tube provided a protective effect for aspirating with an odds ratio of .778 (95% confidence interval, .09-6.98). An independent samples t test was used and showed no significant change in PaO(2):FiO(2) ratio in the aspirating vs nonaspirating group (P = .552).

Conclusion: The results of this study indicate that enteral nutrition should not be delayed or stopped to position the tube in patients with ARDS on rotational therapy.
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December 2012

Effect of local anesthetic on microorganisms in a murine model of surgical site infection.

J Trauma Acute Care Surg 2012 Aug;73(2):441-5; discussion 445-6

Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee, USA.

Background: Surgical site infections are common, with an incidence of 1.5% to 5% for all types of surgery. In vitro studies suggest an antimicrobial effect of local anesthetic. We hypothesized that subcutaneous infiltration of local anesthetic before surgical incision would reduce the incidence of postoperative wound infection.

Methods: In a wound infection model using 4- to 6-week-old female mice, Staphylococcus aureus and Escherichia coli were inoculated in surgical wounds infiltrated with local anesthetic or saline. On day 5, the mice were killed and tissues were evaluated for viable bacterial numbers, presence of bacteria histologically, and degree of inflammation on a scale of 0 to 3 based on number and types of inflammatory cells and presence of necrosis.

Results: A one-way between-subjects analysis of variance with Tukey honestly significant difference post hoc comparisons showed no statistically significant difference in the degree of inflammation in mice infiltrated with lidocaine, lidocaine mixed with bupivacaine, or saline (p = 0.994, p = 0.337, and p = 0.792, respectively). A Tukey honestly significant difference post hoc analysis demonstrated that the saline (p = 0.038) and lidocaine mixed with bupivacaine (p = 0.006) had significantly lower degrees of inflammation than did the lidocaine group. A Bonferroni post hoc test demonstrated that those in the lidocaine (p = 0.003) and lidocaine mixed with bupivacaine (p = 0.008) groups had significantly higher inflammation than those in the saline group after controlling for the condition of the inocula.

Conclusions: Infiltrate, whether saline, lidocaine, or lidocaine mixed with Marcaine, did not result in significantly different bacterial presence or higher degree of inflammation when controlling for experimental condition of bacterial inocula. Thus, subcutaneous infiltration of local anesthetic before a surgical incision is made does not reduce the incidence of bacterial growth or influence the degree of inflammation which alters infection rates.
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August 2012

Umbilical Hernia Repair in Patient with Ascites with Incidental Finding of Pancreatic Adenocarcinoma Metastasis in Hernia Sac.

Am Surg 2010 Aug;76(8):144-145

University of Tennessee Medical Center Department of Surgery Knoxville, Tennessee, USA.

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August 2010
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