Journal of the American College of Surgeons
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Comparative Study
Lactate is a better predictor than systolic blood pressure for determining blood requirement and mortality: could prehospital measures improve trauma triage?
Standard hemodynamic evaluation of patients in shock may underestimate severity of hemorrhage given physiologic compensation. Blood lactate (BL) is an important adjunct in characterizing shock, and point-of-care devices are currently available for use in the prehospital (PH) setting. The objective of this study was to determine if BL levels have better predictive value when compared with systolic blood pressure (SBP) for identifying patients with an elevated risk of significant transfusion and mortality in a hemodynamically indeterminant cohort. ⋯ ED-BL is a better predictor than SBP in identifying patients requiring significant transfusion and mortality in this cohort with indeterminant SBP. These findings suggest that point-of-care BL measurements could improve trauma triage and better identify patients for enrollment in interventional trials. Further studies using BL measurement in the PH environment are warranted.
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Scheduled repeat brain CT (SRBCT) is used to monitor progression of traumatic brain injury (TBI). Previous studies have suggested that routine SRBCT can be replaced by an unscheduled repeat brain CT after deterioration on serial neurological examination. In this study, we evaluated if SRBCT has a role in the management of TBI. ⋯ A worse SRBCT is more likely to result in neurologic intervention. SRBCT remains useful in assessing patients with TBI.
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Although studies have demonstrated clinical advantages in high-volume (HV) centers performing esophageal and pancreatic resections, thoracic aortic aneurysm repair has not been studied in the same fashion. We sought to determine if HV centers have better outcomes after thoracic aortic aneurysm surgery relative to lower-volume (LV) centers. ⋯ Although LV centers had lower stroke rates, HV centers had overall better outcomes, lower mortality rates, and considerably lower cost compared with LV centers.
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For logistics, the US Army recommends Hextend (Hospira; 6% hetastarch in buffered electrolyte, HET) for battlefield resuscitation. To support this practice, there are laboratory data, but none in humans. To test the hypothesis that HET is safe and effective in trauma, we reviewed our first 6 months of use at a civilian level 1 trauma center. ⋯ In the first trial to date in hemodynamically unstable trauma patients, and the largest trial to date in any population of surgical patients, initial resuscitation with HET was associated with reduced mortality and no obvious coagulopathy. A randomized blinded trial is necessary before these results can be accepted with confidence.
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The National Surgical Quality Improvement Program (NSQIP) began with the Veterans Affairs system to reduce morbidity and mortality by evaluating preoperative risk factors, postoperative occurrences, mortality reports, surgical site infections, and patient variable statistics. Our institution enrolled in NSQIP July 2006. The Surgical Care Improvement Project (SCIP) was developed to reduce surgical complications, including surgical infections. We began instituting SCIP protocols in July 2007. ⋯ Participation in NSQIP can identify areas of increased morbidity and mortality. Our institution was a high outlier in superficial SSI in colorectal patients during the first NSQIP evaluations. SCIP guidelines were instituted and a statistically significant reduction in our rates of SSI was realized. As our compliance with SCIP improved, our rates of superficial SSI decreased. Reduction in superficial SSI decreases cost to the patient and decreases length of stay.