[Show abstract][Hide abstract]ABSTRACT: Background:
Emergent REBOA(Resuscitative Endovascular Balloon Occlusion of the Aorta) insertion for critically injured patients in hemorrhagic shock is performed blindly with fluoroscopic imaging confirmation. The aim of this study was to determine a reliable method for initial REBOA catheter insertion with balloon deployment between the left subclavian artery takeoff and celiac trunk.
Human cadaver study. External surface (sternal notch, mid-sternum, xiphoid) and intravascular (left subclavian artery(LSA), celiac trunk(CT)) landmarks were measured from standardized left and right common femoral artery puncture sites. The landing zone (LZ, distance between LSA and CT) and margins of safety (distance from distal balloon edge to LSA and proximal balloon edge to CT) were calculated using intravascular landmarks. The probability of balloon deployment in the LZ using external landmarks was compared in univariate analysis using Fisher's exact test.
10 cadavers were analyzed (7 male, mean BMI 19.4 kg/m2). Mean intravascular distances from femoral puncture sites to the LSA and CT were 54.8cm (SD 1.9) and 32.9cm (SD 1.9). The mean LZ was 21.8cm (SD 3.8). Mean surface distances from femoral puncture sites to the xiphoid, mid-sternum and sternal notch were 31.8cm (SD 3.9), 41.8cm (SD 3.3) and 51.8cm (SD 3.2). Inserting the catheter to a distance approximated by surface distance from the femoral puncture site to mid-sternum resulted in a 100% likelihood balloon deployment in the LZ for both sides. This was superior to the xiphoid and sternal notch (left site p=0.005, right site p=0.036, mean of both sites p=0.083). Using the mid-sternum landmark, the mean margin of safety to the LSA and CT was 10.7cm (SD 4.3) and 3.1cm (SD 3.4).
Using the mid-sternum landmark for REBOA balloon placement, the likelihood of balloon deployment in the LZ was 100% with an acceptable margin of safety LEVEL OF EVIDENCE: III, diagnostic test.
No preview · Article · May 2016 · Journal of Trauma and Acute Care Surgery
[Show abstract][Hide abstract]ABSTRACT: Objective The purpose of this article is to present a unique training model using a perfused human cadaver for central line placement training with the ultimate goal of reducing central venous catheter mechanical complications. Design The applicability of the fresh tissue cadaver model for central line placement was assessed using a 10-item questionnaire with a 5-point Likert-type scale. Respondents were asked to rate their opinions as strongly agree, agree, neutral, disagree, or strongly disagree. Setting All participants received a didactic lecture followed by supervised practice on a commercially available simulator. The students were then relocated to the Fresh Tissue Dissection Laboratory where they practiced central vein catheterization on a fresh perfused human cadaver. Participants Course participants included 87 physicians from various medical specialties at different stages of training. Results Results of the survey demonstrated that 91% of the participating physicians found the perfused cadaveric model to be a true simulation of conditions that exist in live patients, and 98% reported that the use of this model promoted acquisition of technical skills. Conclusion The integration of central line placement training on perfused cadavers into residency and fellowship training provides an unparalleled realistic simulation to participants. Further study is needed to assess whether realistic simulation translates into objective end points such as decreased mechanical complications.
No preview · Article · Aug 2014 · Journal of Surgical Education
[Show abstract][Hide abstract]ABSTRACT: Background:
The harmful effects of smoking have been well-documented in the medical literature for decades. To further the support of smoking cessation, we investigate the effect of smoking on a less studied population, the trauma patient.
All trauma patients admitted to the surgical intensive care unit at the LAC + University of Southern California medical center between January 2007 and December 2011 were included. Patients were stratified into two groups - current smokers and non-smokers. Demographics, admission vitals, comorbidities, operative interventions, injury severity indices, and acute physiology and chronic health evaluation (APACHE) II scores were documented. Uni- and multi-variate modeling was performed. Outcomes studied were mortality, duration of mechanical ventilation, and length of hospitalization.
A total of 1754 patients were available for analysis, 118 (6.7%) patients were current smokers. The mean age was 41.4±20.4, 81.0% male and 73.5% suffered blunt trauma. Smokers had a higher incidence of congestive heart failure (4.2% vs. 0.9%, p=0.007) and alcoholism (20.3% vs. 5.9%, p<0.001), but had a significantly lower APACHE II score. After multivariate regression analysis, there was no significant mortality difference. Patients who smoked spent more days mechanically ventilated (beta coefficient: 4.96 [1.37, 8.55, p=0.007]).
Smoking is associated with worse outcome in the critically ill trauma patient. On an average, smokers spent 5 days longer requiring mechanical ventilation than non-smokers.
No preview · Article · Jul 2014 · Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery: TJTES
[Show abstract][Hide abstract]ABSTRACT: Introduction: Emerging data suggests that Acute Care Nurse Practioners (ACNP) have successfully been integrated into Intensive Care Units (ICU) across the United States. While the ACNP scope of practice and how to bill for procedures has been described, the ideal method to train and credential ACNPs to perform invasive procedures has not. We describe our initial experience training ACNPs to perform invasive critical care procedures utilizing our Fresh Tissue Dissection Lab (FTDL) and simulation program. Methods: Seven ACNP were given a self-directed didactic followed by a four-hour practicum utilizing perfused fresh tissue cadavers. The cadavers were perfused via femoral artery and vein cannulation with colored pressurized fluids simulating arterial and venous blood. Procedures performed included central venous landmark guided subclavian (SC) and ultrasound (US) guided internal jugular (IJ) vein catheter insertion, orotracheal intubation, tube thoracostomy, thoracentesis, and paracentesis. Pretest and posttest knowledge assessments were administered. Overall and specific procedural confidence was evaluated utilizing a retrospective pre-practicum and post-practicum analysis with a 5-point Likert scale (1, least confident and 5, most confident). Results: The mean years of clinical experience for the group was 4.1 years (range 4 months to 13 years). Each ACNP scored a 100% on both the pretest and posttest knowledge assessment. The overall procedural confidence for all procedures improved by 1.44, from 2.53 (SD+/- 0.629) to 3.97 (SD+/- 0.320) (p <0.001). For the insertion of central lines, overall confidence improved by 1.17 (p=0.013), for all other procedures confidence improved by 1.5 (p=0.01). Conclusions: Our initial experience utilizing our FTDL and simulation program to train ACNPs showed improved confidence scores after both the self-directed didactic and the FTDL practicum. The FTDL perfused pressurized model allowed differentiation of venous and arterial vessels during landmark guided SC vein and US guided IJ vein catheterization. This practicum has been integrated into our ACNP credentialing process to perform ICU procedures independently. Further study is needed to determine the ideal method to train and credential ACNPs to perform invasive procedures independently in the intensive care unit.
[Show abstract][Hide abstract]ABSTRACT: Necrotizing soft tissue infections (NSTIs) are associated with a high mortality rate. There is a lack of literature examining outcomes in NSTI when surgical redébridements are performed in early versus delayed intervals. We hypothesized that early redébridement is associated with improved survival. Patients with NSTIs were prospectively enrolled between January 2006 and December 2011. Patient demographics, comorbidities, primary infection site, laboratory values, tissue cultures, time to surgery, and time between subsequent débridements were obtained. Two study groups with divergent redébridement protocols were observed: a short interval redébridement (SIRD) and an extended interval redébridement (EIRD). Univariate and multivariate statistics were performed. The primary outcome evaluated was in-hospital mortality. Sixty-four patients (46 SIRD, 18 EIRD) were included in the analysis. The two groups had comparable demographics. Polymicrobial NSTI was noted in 61 per cent of patients with Staphylococcus species being the predominant causative organism (59%). Multivariate analysis showed the EIRD protocol to be associated with a significantly increased incidence of acute kidney injury (adjusted odds ratio, 4.9 [1.1 to 22.5]; P = 0.04) and worse overall survival (hazard ratio, 10.6 [2.1 to 53.9]; P = 0.004). Delayed redébridement after initial source control in NSTIs results in worse survival and an increased incidence of acute kidney injury. Further studies to identify the optimal time interval for redébridement are warranted.
No preview · Article · Oct 2013 · The American surgeon
[Show abstract][Hide abstract]ABSTRACT: Scant literature investigates potential outcome differences between Level I trauma centers. We compared overall survival and survival after acute respiratory distress syndrome (ARDS) in patients admitted to American College of Surgeons (ACS)-verified versus state-verified Level I trauma centers. Using the National Trauma Data Bank Version 7.0, incident codes associated with admission to an ACS-verified facility were extracted and compared with the group admitted to state-verified centers. Overall, there were 382,801 (73.7%) patients admitted to ACS and 136,601 (26.3%) admitted to state centers. There was no adjusted survival advantage after admission to either type (4.9% for ACS vs 4.8% for state centers; 1.014 [95% CI, 0.987 to 1.042], P = 0.311). However, in the 3,088 cases of ARDS, mortality for admission to the ACS centers was 20.3 per cent (451 of 2,220) versus 27.1 per cent (235 of 868) for state centers. Adjusting for injury severity and facility size, admission to an ACS center was associated with a significantly greater survival after ARDS (0.75 [0.654 to 0.860]; P < 0.001). Level I verification does not necessarily imply similar outcomes in all subgroups. Federal oversight may become necessary to ensure uniformity of care, maximizing outcomes across all United States trauma systems. Further study is needed.
No preview · Article · Oct 2011 · The American surgeon