Quite a lot of research has been done on the efficacy of prophylactic antibiotics in the prevention of infectious complications after surgical procedures. Antibiotics are now routinely given prior to most elective surgical procedures. In the US, the Centers for Medicare and Medicaid Services has formalized this into part of the Surgical Care Improvement Project (SCIP), which mandates the use of an appropriate antibiotic within 1 hour preop and stopping it within 24 hours postop.
But what about emergent cases, like trauma laparotomy? Ensuring timely antibiotic administration is difficult due to the rapid events leading up to the operation. And sometimes it is not clear whether a hollow viscus injury has occurred until after start of operation, so the antibiotic choice may change in the middle of the case.
Two busy urban trauma centers with high penetrating injury rates looked at one year of experience in patients undergoing trauma laparotomy. They compared surgical site infections (SSI) in patients who received SCIP-compliant antibiotic administration vs those who did not.
Here are the factoids:
Patient mix was 30% blunt, 44% gunshot, 27% stab wounds
There were 151 SCIP-compliant patients and 155 noncompliant ones
Half of the noncompliant group did not receive the appropriate antibiotic (usually Cefazolin in hollow viscus injury), and half had antibiotics given for more than 24 hours
SCIP-compliant patients had significantly fewer wound infections and shorter length of stay. Mortality was the same.
Bottom line: I recommend adhering to SCIP prophylactic antibiotic guidelines for trauma laparotomy. There is no reason why this subset of patients should be treated any differently, and this study presents evidence that it is beneficial. Using the SCIP guidelines in emergent surgery reinforces the usual preop routine in hospitals that have already embraced them. In general, blunt trauma patients undergoing laparotomy should receive prophylaxis that covers skin organisms. Since penetrating trauma has a much higher chance of involving the intestinal tract, broader spectrum antibiotics should be selected. In either case, use the antibiotic that has been selected for this purpose by your hospital. And be sure they are stopped during the first 24 hours.
Reference: “SCIP"ping antibiotic prophylaxis guidelines in trauma: the consequences of noncompliance. J Trauma 73(2):452-456, 2012.
For trauma centers, it’s a zero sum game. The number of trauma patients in a given geographic location is fixed. (Actually, it goes up slowly over time as the population increases). So if a new center opens, those patients are redistributed. The new center gets more patients because they are now “designated.” And the existing centers get fewer because there are not as many patients left.
This is a phenomenon that is growing more widespread as more lower level trauma centers come online. Areas like Phoenix, Denver, and parts of Florida are particularly hard hit. Established Level I and II centers are complaining because their volumes are down, which can cause a hit to the financial bottom line.
Seems to make sense. But is it true? A time series analysis was carried out using Pennsylvania trauma system data to gauge the impact of opening new Level II and III centers on an existing Level I center. Ten years of data were gathered, looking at volume and mortality changes during the following sequence of designations:
A new Level II opens 70 months into the study period
A new Level III opens at 95 months, then closed 11 months later
A new Level II and Level III open at 107 months
Here are the factoids, from the perspective of the Level I center:
Volume at the Level I center grew slowly over the 70 months that no new trauma centers were operating
Volume dropped 10% when the first Level II opened, and 13% when the Level II and III opened simultaneously
There was no change when the temporarily accredited Level III opened
Overall, the Level I center treated 1,903 fewer patients than expected after the other centers opened, an overall decrease of 10%
Average injury severity and revised trauma score remained the same at the Level I, but mortality decreased (!)
Bottom line: More trauma centers generally equals fewer patients for existing ones. Unfortunately, the decision to become a trauma center these days, especially levels II and III, tends to be based on business factors. The American College of Surgeons Committee on Trauma (ACSCOT) released a position statement early this year regarding the designation of multiple trauma centers in a geographic location. They basically have left it up to the individual states or trauma systems to optimize placement or limit numbers. They also emphasize that the numbers need to support best patient care, not necessarily best business strategy. Unfortunately, politics will not let this happen. I believe that the tightening of verification requirements for centers that are verified by the ACSCOT (as in the new Orange book criteria) will serve to shake out the centers that barely meet them. But only time will tell.
Impact of adding Level II and III trauma centers on volume and disease severity at a nearby Level I trauma center. J Trauma 77(5):764-768, 2015
The legal drinking age in the US is 21. Yeah. But taking that first drink frequently happens well before that age. An interesting observation I have made is that the younger the age at which the first is taken, the more likely the individual is to have significant addiction problems later. I just read a paper that seems to quantify this phenomenon.
Over a thousand adolescents (6th through 8th grade) were already participating in a 3 year study of alcohol initiation and progression in the state of Rhode Island. A subset of these students were contacted and consented, and underwent a series of monthly and semiannual surveys. The goal was to see if alcohol use at the beginning of high school could be predicted based on earlier experience with it.
Here are the factoids:
30% of students admitted to sipping alcohol by the beginning of 6th grade
Nearly two thirds of these experiences occurred in children aged 7-10 (!!)
The first sip was usually wine (40%) or beer (35%)
The most common location was at home, and the provider was usually the mother (39%) or father (34%)
In 76% of cases, the beverage was intentionally offered
Students who sipped alcohol by 6th grade had significantly higher odds of consuming a full drink, getting drunk, and drinking heavily by 9th grade
When common factors were controlled for (temperament, behavior, environment), this association was still significant
Bottom line: Offering drinks to kids has a major impact on their future use of alcohol. Contrary to what some believe, supervising the use of alcohol at home does not protect against future problems. Conversely, it may be creating more problems. The incidence of risky behaviors and other drug use in the “sippers” was significantly higher. And exposing the young brain to the abnormal reward stimuli from alcohol use may put them at risk for even more severe problems as they grow older.
Many trauma hospitals provide in-house trauma attendings to improve the timeliness of care and to provide housestaff supervision. In many centers, this is required in order to meet the surgeon response requirements for trauma activations. Frequently, this involves some expense for the hospital if they provide an on-call stipend. A study in the Journal of Trauma examined the financial impact housing the surgeons in the hospital at an urban Level I trauma center.
Bellevue Hospital in New York City implemented an in-house attending policy in October of 2007. The study looked at the year prior to and the year after implementation. It focused primarily on the number of operative cases performed during nights and on weekends. The biggest changed noted was a four-fold increase in the number of cholecystectomies performed and 1.2 day decrease in the length of stay for those patients.
Using several financial approximations, they concluded that the hospital received an increased revenue of $854K, while the in-house attending program cost the hospital $750K during the year. The study raises a number of questions, though. The average length of stay, even after in-house attending presence, was 5 days! It would seem that additional savings could be accrued by working on LOS for these patients, as well as other surgical groups. There were other procedures that were done at night that were not analyzed, so there are probably more benefits to be accrued.
The downside of the in-house attendings performing these acute care surgery cases was that their availability for incoming trauma patients was reduced. There were also questions about the possibility of errors when performing surgery at 4AM.
Bottom line: This study shows evidence that there is a financial benefit to having an in-house surgeon. This will be important to hospital administrators who must grapple with the cost of moving to this type of coverage. However, higher quality financial research of this type is also needed.
Reference: In-house trauma attendings: A new financial benefit for hospitals. Pachter, Simon et al. J Trauma 2010;68(5) 1032-1037.
The trauma season is officially open in Minnesota. Motorcycles are out on the (still) sanded roads, and cars are once again driving too fast. It’s also the season for crash victims to come to us with mangled extremities.
In days of old, management was simple: take it off. But we’ve become wiser over the years and are now able to salvage a good number of these threatened limbs. The Mangled Extremity Severity Score (MESS) has helped greatly with this.
As I mentioned yesterday, it’s beginnings were humble, almost looking like guesswork on the part of the authors. But this system has withstood the test of time.
There are four components to MESS: limb ischemia, patient age, presence of shock, and mechanism of injury. Each component is assigned an integer value depending on severity. The possible values range from 1 to 14. Here’s the breakdown of each component:
Add 3 points if limb ischemia has been present more than 6 hours
+0 <30 years
+1 30-50 years
+2 >50 years
+0 SBP >90 consistently
+1 Transient hypotension
+2 Persistent hypotension
Mechanism (kinetic energy)
+1 Low (stab, gunshot, simple fracture)
+2 Medium (dislocation, open or multiple fractures)
+3 High (high speed MVC, rifle)
+4 Very high (high energy trauma with gross contamination)
Per the original study, values of 7 or greater predict low salvageability. However, with advancing technology, drugs, and operative techniques, the threshold has been creeping higher. But not that much higher, probably 8 or so.
Bottom line: Use the MESS score as one tool in your armamentarium to help address mangled extremities. But remember, it is not the final answer. In the OR, confer with your orthopedic and vascular colleagues. Decide if immediate amputation is necessary, or whether a second look in a day or two is in order. Use MESS as a tiebreaker. But remember, don’t let your desire to save the extremity jeopardize your patient’s life (rhabdomyolysis, renal failure, acidosis). If systemic signs begin to occur, cut your (and their) losses and amputate!