Kenji Inaba

Keck School of Medicine USC, Los Ángeles, California, United States

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Publications (347)773.14 Total impact

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    ABSTRACT: Multidetector computed tomographic angiography (MDCTA) has become the gold standard for the early assessment of lower extremity vascular injury. The objective of this study was to evaluate the predictive value of MDCTA documented vessel run-off to the foot on limb salvage rates after lower extremity vascular injury. All trauma patients undergoing lower extremity MDCTA for suspected vascular injury assessed at 2 high-volume Level I trauma centers between January 2009 and December 2012. Demographics, clinical data and outcomes (compartment syndrome requiring fasciotomy and limb salvage) were extracted. The predictive value of MDCTA vessel run-off was tested against an aggregate gold standard of operative intervention, clinical follow-up and all imaging obtained. During the 4-year study period, 398 patients sustained lower extremity trauma and were screened for inclusion into this study. Of those, 166 (41.7%) patients (72.9% at MHH and 27.1% at LAC+USC Medical Center) underwent initial evaluation with MDCTA, 86 (51.8%) had vascular injury below the knee identified by MDCTA. Among these, the average age was 38.0±15.8 years, 80.2% were men and 83.7% sustained a blunt injury mechanism. On admission, 8.1% were hypotensive and the median ISS was 10 (range 1-57). There was a direct correlation between the number of patent vessels to the foot and the need for operative intervention (86.4% with no patent vessels, 56.0% with 1 patent vessel, 33.3% with 2 and 0.0% with 3, p<0.001). When outcomes were analysed, the rates of fasciotomy for compartment syndrome decreased in a stepwise fashion as the number of patent vessels to the foot increased (63.6% with no patent vessels; 44.0% with 1; 21.2% with 2; and 0.0% with 3; p=0.003). No amputations occurred in patients with 2 or more patent vessels to the foot (68.2% for no patent vessel; 16.0% for 1; 0.0% for 2; and 0.0% for 3; p<0.001). In this multicenter evaluation of patients undergoing MDCTA for suspected below-the-knee vascular injury, there was a stepwise increase in the need for operative intervention, fasciotomy and amputation as the number of patent vessels to the foot decreased. Published by Elsevier Ltd.
    Injury 06/2015; DOI:10.1016/j.injury.2015.06.001 · 2.46 Impact Factor
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    ABSTRACT: There has been an increased interest in the use of viscoelastic testing to guide blood product replacement during the acute resuscitation of the injured patient. Currently, no uniformly accepted guidelines exist for how this technology should be integrated into clinical care. In September 2014, an international multidisciplinary group of leaders in the field of trauma coagulopathy and resuscitation was assembled for a 2-day consensus conference in Philadelphia, Pennsylvania. This panel included trauma surgeons, hematologists, blood bank specialists, anesthesiologists, and the lay public. Nine questions regarding the impact of viscoelastic testing in the early resuscitation of trauma patients were developed before the conference by panel consensus. Early use was defined as baseline viscoelastic test result thresholds obtained within the first minutes of hospital arrival—when conventional laboratory results are not available. The available data for each question were then reviewed in person using standardized presentations by the expert panel. A consensus summary document was then developed and reviewed by the panel in an open forum. Finally, a two-round Delphi poll was administered to the panel of experts regarding viscoelastic thresholds for triggering the initiation of specific treatments including fibrinogen, platelets, plasma, and prothrombin complex concentrates. This report summarizes the findings and recommendations of this consensus conference.
    Journal of Trauma and Acute Care Surgery 06/2015; 78(6):1220-1229. DOI:10.1097/TA.0000000000000657 · 1.97 Impact Factor
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    ABSTRACT: In surgery patients, low preoperative serum transthyretin (TTR) level is associated with greater rates of infection and mortality. However, the predictive value of TTR on surgical outcomes after major trauma has not yet been studied. Critically ill trauma patients who underwent surgery for trauma and had TTR preoperatively measured after admission to the surgical intensive care unit (ICU) at the LAC+USC Medical Center (01/2008-05/2014) were identified retrospectively. Univariable and multivariable regression analyses determined the significance of TTR on outcomes. We identified 348 patients. Univariable analysis indicated that patients with lower TTR had more infections (P < .001), higher mortality (P = .007), longer hospital stay (P < .001), longer ICU stay (P < .001), and increased ventilator days (P < .001). Even after adjusting for differences in patient characteristics, lower TTR level was associated with greater infectious complication rates (P = .001), greater mortality (P = .005), longer hospital stay (P = .013), longer ICU stay (P = .030), and increased ventilator days (P = .044). In critically ill trauma patients, low serum TTR level is associated with poorer clinical outcomes, and its prognostic utility warrants further study. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 05/2015; DOI:10.1016/j.surg.2015.02.019 · 3.11 Impact Factor
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    ABSTRACT: The American Association for the Surgery of Trauma (AAST) recently established a grading system for uniform reporting of anatomic severity of several emergency general surgery (EGS) diseases. There are five grades of severity for each disease, ranging from I (lowest severity) to V (highest severity). However, the grading process requires manual chart review. We sought to evaluate whether International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9-CM, ICD-10-CM) codes might allow estimation of AAST grades for EGS diseases. The Patient Assessment and Outcomes Committee of the AAST reviewed all available ICD-9-CM and ICD-10-CM diagnosis codes relevant to 16 EGS diseases with available AAST grades. We then matched grades for each EGS disease with one or more ICD codes. We used the Official Coding Guidelines for ICD-9-CM and ICD-10-CM and the American Hospital Association's "Coding Clinic for ICD-9-CM" for coding guidance. The ICD codes did not allow for matching all five AAST grades of severity for each of the 16 diseases. With ICD-9-CM, six diseases mapped into four categories of severity (instead of five), another six diseases into three categories of severity, and four diseases into only two categories of severity. With ICD-10-CM, five diseases mapped into four categories of severity, seven diseases into three categories, and four diseases into two categories. Two diseases mapped into discontinuous categories of grades (two in ICD-9-CM and one in ICD-10-CM). Although resolution is limited, ICD-9-CM and ICD-10-CM diagnosis codes might have some utility in roughly approximating the severity of the AAST grades in the absence of more precise information. These ICD mappings should be validated and refined before widespread use to characterize EGS disease severity. In the long-term, it may be desirable to develop alternatives to ICD-9-CM and ICD-10-CM codes for routine collection of disease severity characteristics.
    05/2015; 78(5):1059-1065. DOI:10.1097/TA.0000000000000608
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    ABSTRACT: There is no consensus on the optimal management of pediatric patients with suspected trauma brain injury and a normal head CT. This study characterizes the clinical outcomes of patients with a normal initial CT scan of the head. A retrospective chart review of pediatric blunt trauma patients who underwent head CT for closed head injury at two trauma centers was performed. Charts were reviewed for demographics, neurologic function, CT findings, and complications. 631 blunt pediatric trauma patients underwent a head CT. 63% had a negative CT, 7% had a non-displaced skull fracture, and 31% had an intracranial hemorrhage and/or displaced skull fracture. For patients without intracranial injury, the mean age was 8years, mean ISS was 5, and 92% had a GCS of 13-15 on arrival. All patients with an initial GCS of 13-15 and no intracranial injury were eventually discharged to home with a normal neurologic exam and no patient required craniotomy. Not admitting those children with an initial GCS of 13-15, normal CT scan, and no other injuries would have saved 1.8±1.5 hospital days per patient. Pediatric patients who have sustained head trauma, have a negative CT scan, and present with a GCS 13-15 can safely be discharged home without admission. Copyright © 2015. Published by Elsevier Inc.
    Journal of Pediatric Surgery 04/2015; DOI:10.1016/j.jpedsurg.2015.03.067 · 1.31 Impact Factor
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    ABSTRACT: The practice of transfusing ones' own shed whole blood has obvious benefits such as reducing the need for allogeneic transfusions and decreasing the need for other fluids that are typically used for resuscitation in trauma. It is not widely adopted in the trauma setting because of the concern of worsening coagulopathy and the inflammatory process. The aim of this study was to assess outcomes in trauma patients receiving whole blood autotransfusion (AT) from hemothorax. This is a multi-institutional retrospective study of all trauma patients who received autologous whole blood transfusion from hemothorax from two Level I trauma centers. Patients who received AT were matched to patients who did not receive AT (No-AT) using propensity score matching in a 1:1 ratio for admission age, sex, mechanism, type of injury, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, systolic blood pressure, heart rate, hemoglobin, international normalized ratio (INR), prothrombin time, partial prothrombin time, and lactate. AT was defined as transfusion of autologous blood from patient's hemothorax, which was collected from the chest tubes and anticoagulated with citrate phosphorous dextrose. Outcome measures were in-hospital complications, 24-hour INR, and mortality. In-hospital complications were defined as adult respiratory distress syndrome, sepsis, disseminated intravascular coagulation, renal insufficiency, and transfusion-related acute lung injury. A total of 272 patients (AT, 136; No-AT, 136) were included. There was no difference in admission age (p = 0.6), ISS (p = 0.56), head Abbreviated Injury Scale (AIS) score (p = 0.42), systolic blood pressure (p = 0.88), and INR (p = 0.62) between the two groups. There was no significant difference in in-hospital complications (p = 0.61), mortality (p = 0.51), and 24-hour postadmission INR (0.31) between the AT and No-AT groups. Patients who received AT had significantly lower packed red blood cell (p = 0.01) and platelet requirements (p = 0.01). Cost of transfusions (p = 0.01) was significantly lower in the AT group compared with the No-AT group. The autologous transfusion of the patient's shed blood collected through chest tubes for hemothorax was found to be safe without complications in this study. It also reduced the need for allogeneic transfusions and decreased hospital costs. This study demonstrates safety data that would help in designing larger prospective multicenter studies to determine whether this practice is truly safe and effective. Epidemiologic/prognostic study, level III.
    04/2015; 78(4):729-34. DOI:10.1097/TA.0000000000000599
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    ABSTRACT: The Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial was a randomized clinical trial comparing survival after transfusion of two different blood component ratios for emergency resuscitation of traumatic massive hemorrhage. Transfusion services supporting the study were expected to provide thawed plasma, platelets, and red blood cells within 10 minutes of request. At the 12 Level 1 trauma centers participating in PROPPR, blood components transfused and delivery times were tabulated, with a focus on universal donor (UD) plasma management. The adequacy of site plans was assessed by comparing the bedside blood availability times to study goals and the new American College of Surgeons guidelines. Eleven of 12 sites were able to consistently deliver 6 units of thawed UD plasma to their trauma-receiving unit within 10 minutes and 12 units in 20 minutes. Three sites used blood group A plasma instead of AB for massive transfusion without complications. Approximately 4700 units of plasma were given to the 680 patients enrolled in the trial. No site experienced shortages of AB plasma that limited enrollment. Two of 12 sites reported wastage of thawed AB plasma approaching 25% of AB plasma prepared. Delivering UD plasma to massively hemorrhaging patients was accomplished consistently and rapidly and without excessive wastage in high-volume trauma centers. The American College of Surgeons Trauma Quality Improvement Program guidelines for massive transfusion protocol UD plasma availability are practicable in large academic trauma centers. Use of group A plasma in trauma resuscitation needs further study. © 2015 AABB.
    Transfusion 03/2015; 55(6). DOI:10.1111/trf.13098 · 3.57 Impact Factor
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    ABSTRACT: The optimal timing of same-admission laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) in elderly patients, especially those with significant comorbidities, is not clear. This is a National Surgical Quality Improvement Program study, which included patients older than 65 years undergoing LC for AC. Patients with choledocholithiasis were excluded. Patients were divided into two subgroups as follows: no significant comorbidities (American Society of Anesthesiologists [ASA] score ≤ 2) and significant comorbidities (ASA score > 2). Patients undergoing LC within 24 hours of admission (early LC) were compared with patients undergoing LC later than 24 hours after admission (delayed LC), using univariable and multivariable regression analyses. A total of 4,011 patients were included in the study. Early LC was performed in 38.0% and delayed LC in 62.0% of the patients. Regression analysis identified early LC as an independent predictor for shorter anesthesia time and postoperative length of stay, overall and in the subgroup with an ASA score greater than 2. Early, within 24 hours of admission, LC for AC in patients older than 65 years with significant comorbidities is associated with shorter postoperative stay and no increase in postoperative complications or conversion to open cholecystectomy. Level II.
    Journal of Trauma and Acute Care Surgery 03/2015; 78(4). DOI:10.1097/TA.0000000000000577 · 1.97 Impact Factor
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    ABSTRACT: Patients with paraplegia or quadriplegia presenting with abdominal surgical emergencies pose major clinical challenges. Difficulties in prompt diagnosis and treatment may influence patient outcomes. This is an American College of Surgeons National Surgical Quality Improvement Program study of patients undergoing an emergent abdominal operation. Patients were stratified into paraplegic (PARA), quadriplegic (QUAD), and control (CONT). PARA and QUAD groups were matched with controls by 1:2 ratio. Regression models were used to analyze the effect of paraplegia and quadriplegia on outcome. A total of 76,766 patients underwent emergent abdominal operations: 274 PARA, 132 QUAD, and 76,356 CONT patients. Lower gastrointestinal operations were the most common procedures in PARA and QUAD groups; appendectomy was the most common in the CONT group. After cohort matching, patients with cord paralysis were significantly more likely to present with severe sepsis, have "infected" wounds at operation, and have increased rates of postoperative sepsis and need for reoperation. Patients with paraplegia or quadriplegia with acute abdominal surgical emergencies are more likely to present late and have a significantly higher incidence of postoperative septic complications and longer hospital stay. Early surgical consultation and aggressive evaluation and postoperative management are warranted in these populations. Evidence study, level III.
    Journal of Trauma and Acute Care Surgery 03/2015; 78(4). DOI:10.1097/TA.0000000000000575 · 1.97 Impact Factor
  • The American surgeon 03/2015; 81(3). · 0.92 Impact Factor
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    ABSTRACT: Unlike the cervical spine (C-spine), where National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rules can be used, evidence-based thoracolumbar spine (TL-spine) clearance guidelines do not exist. The aim of this study was to develop a clinical decision rule for evaluating the TL-spine after injury. Adult (≥15 years) blunt trauma patients were prospectively enrolled at 13 US trauma centers (January 2012 to January 2014). Exclusion criteria included the following: C-spine injury with neurologic deficit, preexisting paraplegia/tetraplegia, and unevaluable examination. Remaining evaluable patients underwent TL-spine imaging and were followed up to discharge. The primary end point was a clinically significant TL-spine injury requiring TL-spine orthoses or surgical stabilization. Regression techniques were used to develop a clinical decision rule. Decision rule performance in identifying clinically significant fractures was tested. Of 12,479 patients screened, 3,065 (24.6%) met inclusion criteria (mean [SD] age, 43.5 [19.8] years [range, 15-103 years]; male sex, 66.3%; mean [SD] Injury Severity Score [ISS], 8.8 [7.5]). The majority underwent computed tomography (93.3%), 6.3% only plain films, and 0.2% magnetic resonance imaging exclusively. TL-spine injury was identified in 499 patients (16.3%), of which 264 (8.6%) were clinically significant (29.2% surgery, 70.8% TL-spine orthosis). The majority was AO Type A1 282 (56.5%), followed by 67 (13.4%) A3, 43 (8.6%) B2, and 32 (6.4%) A4 injuries. The predictive ability of clinical examination (pain, midline tenderness, deformity, neurologic deficit), age, and mechanism was examined; positive clinical examination finding resulted in a sensitivity of 78.4% and a specificity of 72.9%. Addition of age of 60 years or older and high-risk mechanism (fall, crush, motor vehicle crash with ejection/rollover, unenclosed vehicle crash, auto vs. pedestrian) increased sensitivity to 98.9% with specificity of 29.0% for clinically significant injuries and 100.0% sensitivity and 27.3% specificity for injuries requiring surgery. Clinical examination alone is insufficient for determining the need for imaging in evaluable patients at risk of TL-spine injury. Addition of age and high-risk mechanism results in a clinical decision-making rule with a sensitivity of 98.9% for clinically significant injuries. Diagnostic test, level III.
    Journal of Trauma and Acute Care Surgery 03/2015; 78(3):459-67. DOI:10.1097/TA.0000000000000560 · 1.97 Impact Factor
  • Journal of Trauma and Acute Care Surgery 03/2015; 78(3):465-467. · 1.97 Impact Factor
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    ABSTRACT: The standard practice of irrigation and debridement (I&D) of open fractures within 6 hours of injury remains controversial. To prospectively evaluate the effect of the time from injury to the initial I&D on infectious complications. A total of 315 patients who were admitted to a level 1 trauma center with open extremity fractures from September 22, 2008, through June 21, 2011, were enrolled in a prospective observational study and followed up for 1 year after discharge (mean [SD] age, 33.9 [16.3] years; 79% were male; and 78.4% were due to blunt trauma). Demographics, mechanism of injury, time to I&D, operative intervention, and incidence of local infectious complications were documented. Patients were stratified into 4 groups based on the time of I&D (<6 hours, 7-12 hours, 13-18 hours, and 19-24 hours after injury). Univariate and multivariable analysis were used to determine the effect of time to I&D on outcomes. Development of local infectious complications at early (<30 days) or late (>30 days and <1 year) intervals from admission. The most frequently injured site was the lower extremity (70.2%), and 47.9% of all injuries were Gustilo classification type III. There was no difference in fracture location, degree of contamination, or antibiotic use between groups. All patients underwent I&D within 24 hours. Overall, 14 patients (4.4%) developed early wound infections, while 10 (3.2%) developed late wound infections (after 30 days). The infection rate was not statistically different on univariate (<6 hours, 4.7%; 7-12 hours, 7.5%; 13-18 hours, 3.1%; and 19-24 hours, 3.6%; P = .65) or multivariable analysis (<6-hour group [reference], P = .65; 7- to 12-hour group adjusted odds ratio [AOR] [95% CI], 2.1 [0.4-10.2], P = .37; 13- to 18-hour group AOR [95% CI], 0.8 [0.1-4.5], P = .81; 19- to 24-hour group AOR [95% CI], 1.1 [0.2-6.2], P = .90). Time to I&D did not affect the rate of nonunion, hardware failure, length of stay, or mortality. In this prospective analysis, time to I&D did not affect the development of local infectious complications provided it was performed within 24 hours of arrival.
    02/2015; 150(4). DOI:10.1001/jamasurg.2014.2022
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    ABSTRACT: Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications. Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. Identifier: NCT01545232.
    JAMA The Journal of the American Medical Association 02/2015; 313(5):471-82. DOI:10.1001/jama.2015.12 · 30.39 Impact Factor
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    ABSTRACT: There is a need for a prospective registry designed to capture trauma-specific, in-hospital, and long-term outcomes related to vascular injury. The American Association for the Surgery of Trauma PROspective Vascular Injury Treatment (PROOVIT) registry was used to collect demographic, diagnostic, treatment, and outcome data on vascular injuries. A total of 542 injuries from 14 centers (13 American College of Surgeons-verified Level I and 1 American College of Surgeons-verified Level II) have been captured since February 2013. The majority of patients are male (70.5%), with an Injury Severity Score (ISS) of 15 or greater among 32.1%. Penetrating mechanisms account for 36.5%. Arterial injuries to the head/neck (26.7%), thorax (10.4%), abdomen/pelvis (7.8%), upper extremity (18.4%), and lower extremity (26.0%) were identified, along with 98 major venous injuries. Hard signs of vascular injury, including hypotension (systolic blood pressure < 90 mm Hg, 11.8%), were noted in 28.6%. Prehospital tourniquet use for extremity injuries occurred in 20.2% (47 of 233). Diagnostic modalities included exploration (28.8%), computed tomographic angiography (38.9%), duplex ultrasound (3.1%), and angiography (10.7%). Arterial injuries included transection (24.3%), occlusion (17.3%), partial transection/flow limiting defect (24.5%), pseudoaneurysm (9.0%), and other injuries including intimal defects (22.7%). Nonoperative management was undertaken in 276 (50.9%), with failure in 4.0%. Definitive endovascular and open repair were used in 40 (7.4%) and 126 (23.2%) patients, respectively. Damage-control maneuvers were used in 57 (10.5%), including ligation (31, 5.7%) and shunting (14, 2.6%). Reintervention of initial repair was required in 42 (7.7%). Amputation was performed in 7.7% of extremity vascular injuries, and overall hospital mortality was 12.7%. Follow-up ranging from 1 month to 7 months is available for 48 patients via a variety of modalities, with reintervention required in 1 patient. The PROOVIT registry provides a contemporary picture of the management of vascular injury. This resource promises to provide needed information required to answer questions about optimal diagnosis and management of these patients-including much needed long-term outcome data. Epidemiologic study, level V.
    Journal of Trauma and Acute Care Surgery 02/2015; 78(2):215-223. DOI:10.1097/TA.0000000000000520 · 1.97 Impact Factor
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    ABSTRACT: Background The Mirasol system has been demonstrated to effectively inactivate white blood cells (WBCs) and reduce pathogens in whole blood in vitro. The purpose of this study was to compare the safety and efficacy of Mirasol-treated fresh whole blood (FWB) to untreated FWB in an in vivo model of surgical bleeding.Study Design and MethodsA total of 18 anesthetized pigs (40 kg) underwent a 35% total blood volume bleed, cooling to 33°C, and a standardized liver injury. Animals were then randomly assigned to resuscitation with either Mirasol-treated or untreated FWB, and intraoperative blood loss was measured. After abdominal closure, the animals were observed for 14 days, after which the animals were euthanized and tissues were obtained for histopathologic examination. Mortality, tissue near-infrared spectroscopy, red blood cell (RBC) variables, platelets (PLTs), WBCs, and coagulation indices were analyzed.ResultsTotal intraoperative blood loss was similar in test and control arms (8.3 ± 3.2 mL/kg vs. 7.7 ± 3.9 mL/kg, p = 0.720). All animals survived to Day 14. Trended values over time did not show significant differences—tissue oxygenation (p = 0.605), hemoglobin (p = 0.461), PLTs (p = 0.807), WBCs (p = 0.435), prothrombin time (p = 0.655), activated partial thromboplastin time (p = 0.416), thromboelastography (TEG)–reaction time (p = 0.265), or TEG–clot formation time (p = 0.081). Histopathology did not show significant differences between arms.Conclusions Mirasol-treated FWB did not impact survival, blood loss, tissue oxygen delivery, RBC indices, or coagulation variables in a standardized liver injury model. These data suggest that Mirasol-treated FWB is both safe and efficacious in vivo.
    Transfusion 02/2015; 55(3). DOI:10.1111/trf.12894 · 3.57 Impact Factor
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    ABSTRACT: Increasing ambient temperature to prevent intraoperative patient hypothermia remains widely advocated despite unconvincing evidence of efficacy. Heat stress is associated with decreased cognitive and psychomotor performance across multiple tasks but remains unexamined in an operative context. We assessed the impact of increased ambient temperature on laparoscopic operative performance and surgeon cognitive stress. Forty-two performance measures were obtained from 21 surgery trainees participating in the counter-balanced, within-subjects study protocol. Operative performance was evaluated with adaptations of the validated, peg-transfer, and intracorporeal knot-tying tasks from the Fundamentals of Laparoscopic Surgery program. Participants trained to proficiency before enrollment. Task performance was measured at two ambient temperatures, 19 and 26°C (66 and 79°F). Participants were randomly counterbalanced to initial hot or cold exposure before crossing over to the alternate environment. Cognitive stress was measured using the validated Surgical Task Load Index (SURG-TLX). No differences in performance of the peg-transfer and intracorporeal knot-tying tasks were seen across ambient conditions. Assessed via use of the six bipolar scales of the SURG-TLX, we found differences in task workload between the hot and cold conditions in the areas of physical demands (hot 10 [3-12], cold 5 [2.5-9], P = .013) and distractions (hot 8 [3.5-15.5], cold 3 [1.5-5.5], P = .001). Participant perception of distraction remained greater in the hot condition on full scoring of the SURG-TLX. Increasing ambient temperature to levels advocated for prevention of intraoperative hypothermia does not greatly decrease technical performance in short operative tasks. Surgeons, however, do report increased perceptions of distraction and physical demand. The impact of these findings on performance and outcomes during longer operative procedures remains unclear. Copyright © 2015 Elsevier Inc. All rights reserved.
    Surgery 01/2015; 157(1):87-95. DOI:10.1016/j.surg.2014.06.012 · 3.11 Impact Factor
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    ABSTRACT: Recent military studies demonstrated an association between prehospital tourniquet use and increased survival. The benefits of this prehospital intervention in a civilian population remain unclear. The aims of our study were to evaluate tourniquet use in the civilian population and to compare outcomes to previously published military experience. We hypothesized that incorporation of tourniquet use in the civilian population will result in an overall improvement in mortality. This is a preliminary multi-institutional retrospective analysis of prehospital tourniquet (MIA-T) use of patients admitted to nine urban Level 1 trauma centers from January 2010 to December 2013. Patient demographics and mortality from a previous military experience by Kragh et al. (Ann Surg. 2009;249:1-7) were used for comparison. Patients younger than 18 years or with nontraumatic bleeding requiring tourniquet application were excluded. Data were analyzed using a two-tailed unpaired Student's t test with p < 0.05 as significant. A total of 197 patients were included. Tourniquets were applied effectively in 175 (88.8%) of 197 patients. The average Injury Severity Score (ISS) for MIA-T versus military was 11 ± 12.5 versus 14 ± 10.5, respectively (p = 0.02). The overall mortality and limb amputation rates for the MIA-T group were significantly lower than previously seen in the military population at 6 (3.0%) of 197 versus 22 (11.3%) of 194 (p = 0.002) and 37 (18.8%) of 197 versus 97 (41.8%) of 232 (p = 0.0001), respectively. Our study is the largest evaluation of prehospital tourniquet use in a civilian population to date. We found that tourniquets were applied safely and effectively in the civilian population. Adaptation of this prehospital intervention may convey a survival benefit in the civilian population. Epidemiologic study, level V.
    01/2015; 79(1):10-14. DOI:10.1097/TA.0000000000000689
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    ABSTRACT: The traditional theory that pulmonary emboli (PE) originate from the lower extremity has been challenged. All autopsies performed in Los Angeles County between 2002 and 2010 where PE was the cause of death were reviewed. Of the 491 PE deaths identified, 36% were surgical and 64% medical. Venous dissection for clots was performed in 380 patients; the PE source was the lower extremity (70.8%), pelvic veins (4.2 %), and upper extremity (1.1%). No source was identified in 22.6% of patients. Body mass index (adjusted odds ratio [AOR] 1.044, 95% confidence interval [CI] 1.011 to 1.078, P = .009) and age (AOR 1.018, 95% CI 1.001 to 1.036, P = .042) were independent predictors for identifying a PE source. Chronic obstructive pulmonary disease (AOR .173, 95% CI .046 to .646, P = .009) was predictive of not identifying a PE source. Most medical and surgical patients with fatal PE had a lower extremity source found, but a significant number had no source identified. Age and body mass index were positively associated with PE source identification. However, a diagnosis of chronic obstructive pulmonary disease was associated with no PE source identification. Copyright © 2015 Elsevier Inc. All rights reserved.
    The American Journal of Surgery 12/2014; 209(6). DOI:10.1016/j.amjsurg.2014.09.027 · 2.41 Impact Factor
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    ABSTRACT: Thoracoabdominal firearm injuries present major diagnostic and therapeutic challenges because of the risk for potential injury in multiple anatomic cavities and the attendant dilemma of determining the need for and correct sequencing of cavitary intervention. Injury patterns, management strategies, and outcomes of thoracoabdominal firearm trauma remain undescribed across a large population. All patients with thoracoabdominal firearm injury admitted to a major Level I trauma center during a 16-year period were reviewed. The 984 study patients experienced severe injury burden; 25% (243 of 984) presented in cardiac arrest, and 75% (741 of 984) had an Abbreviated Injury Scale (AIS) score of 3 or greater in both the chest and the abdomen. Operative management occurred in 86% (638 of 741). Of the patients arriving alive, 68% (507 of 741) underwent laparotomy alone, 4% (27 of 741) underwent thoracotomy alone, and 14% (104 of 741) underwent dual-cavitary intervention. Negative laparotomy occurred in 3%. Diaphragmatic injury (DI) occurred in 63%. Seventy-five percent had either DI or hollow viscus injury. Cardiac injury was present in 33 patients arriving alive. Despite the use of trauma bay ultrasound, 44% of the patients with cardiac injury underwent initial laparotomy. In half of this group, ultrasound did not detect pericardial blood. The need for thoracotomy, either alone or as part of dual-cavitary intervention, was the strongest independent risk factor for mortality in those arriving alive. Greater kinetic destructive potential drives the peril of thoracoabdominal firearm trauma, producing clinical challenges qualitatively and quantitatively different from nonfirearm injuries. Severe injury, on both sides of the diaphragm, generates high operative need with low rates of negative exploration. The need for emergent intervention and a high incidence of DI or hollow viscus injury limit opportunity for nonoperative management. Even with ultrasound, emergent preoperative diagnosis remains challenging, as the complex combination of intra-abdominal, thoracic, and diaphragmatic injuries can provoke misinterpretation of both radiologic and clinical data. Successful emergent management requires thorough assessment of all anatomic spaces, integrating ultrasonographic, radiologic, and clinical findings. Epidemiologic study, level III.
    Journal of Trauma and Acute Care Surgery 11/2014; 77(5):684-691. DOI:10.1097/TA.0000000000000436 · 1.97 Impact Factor

Publication Stats

4k Citations
773.14 Total Impact Points


  • 2011–2015
    • Keck School of Medicine USC
      Los Ángeles, California, United States
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      Torrance, California, United States
  • 2006–2015
    • University of Southern California
      • Department of Surgery
      Los Ángeles, California, United States
  • 2014
    • Fraunhofer Institute for Production Technology IPT
      Aachen, North Rhine-Westphalia, Germany
  • 2008–2013
    • University of California, Los Angeles
      • Department of Surgery
      Los Ángeles, California, United States
  • 2012
    • University of Maryland, Baltimore
      Baltimore, Maryland, United States
  • 2008–2011
    • The University of Arizona
      • Department of Surgery
      Tucson, AZ, United States
    • Cedars-Sinai Medical Center
      • • Cedars Sinai Medical Center
      • • Department of Surgery
      Los Angeles, CA, United States
  • 2007–2008
    • University of Miami
      • Department of Surgery
      كورال غيبلز، فلوريدا, Florida, United States
  • 2001
    • London Health Sciences Centre
      London, Ontario, Canada