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The Best Of EAST 2021

The Eastern Association for the Surgery of Trauma annual meeting starts in just 2 weeks! Keeping to tradition, I’m going to start reviewing some of the more interesting (to me) abstracts to be presented at the meeting and sharing my thoughts with you.

There are 33 regular abstracts and 17 quick shot abstracts to be presented. I’m going to focus on the regular abstracts, since there will be an opportunity to question the authors (hopefully) at the virtual meeting. Quick shots are a very brief presentation only.

Let me share how I process a batch of abstracts like this. First, I capture the pdf file with all the abstracts and open it in a pdf markup program. Adobe Reader or Acrobat have basic capabilities, but I prefer a more full-featured product so I can scribble notes and stuff on it.

Now, I go through the file looking at titles. Keep in mind I am a clinical trauma surgeon. So right off the bat I will pretty much discard any bench type research. No matter how interesting it may sound, it will be years before it may (or more likely won’t) be clinically relevant. Invariably, I will pay no further attention to these.

If the title, suggests it is an animal study, I may consider it. But probably not. The research idea had better be a very interesting or intriguing one that should definitely stimulate further thought and research. If it’s just making an incremental advance, there won’t be any clinical relevance to humans for a few more years. There are some REBOA abstracts in the current batch that fall into this category. I do keep the research concept in my mind for future consideration when I see related papers, but for now I ignore.

Now, I am left with mostly clinically relevant papers. As I read the title I ask myself:

  • Did I know this already? If I did, I read the intro and conclusion to see if this abstract adds anything different to what I thought I knew. If it does, I’ll read the whole thing and analyze it. But most of the time, there is not enough novelty to keep me interested.
  • Is this truly something new and different? This is a very unusual occurrence. Most work adds incrementally to previous research. But if it really is new and different, I will latch onto this and read it in great detail.
  • Might it refine our approach to certain clinical problems? Could we improve the usual way we take care of our patients? These are of great interest to me. However, remember that no single paper (or certainly abstract) should ever make you change your practice. There are so many exciting things that have been published exactly once that don’t just pan out. Beware the one-hit wonder. And unfortunately, you don’t know it is one until months or years later when the concept has been disproven or no one else has been interested enough to duplicate it.
  • Have the authors used a new approach to tackle a problem? Exploring a new way to look at a specific problem may be generalized to other problems as well. So in this case I will forgive a boring or already known result so I can scrutinize a new research tool.

By now, I’ve cut the number of abstracts roughly in half. That’s still too many to write about. So finally, I have to narrow down the field by ranking in order of my interest level. I fully recognize that my interests will not be necessarily be perfectly aligned with yours. But I do know my audience, and most of you share the same areas of curiosity. Unfortunately, some good abstracts will be ignored. But there is one thing you can do: look over the abstract collection yourself and let me know about specific abstracts you would like to see discussed! I am happy to oblige.

So beginning tomorrow, I’ll post the most interesting EAST abstracts in program book order. I’ll provide the author’s description and my analysis. I will also list some questions that I (and probably you) have that the authors should consider. I always make a point of notifying the authors each day when I post about their abstract so they can study the questions and potentially address them in their virtual presentation.

And as always, if you have questions, suggestions, or abstracts you would like discussed, just reply here or on Twitter. I hope to “see” you at EAST!

Chest Tube Repositioning – Final Answer

So you’re faced with a chest tube that “someone else” inserted, and the followup chest xray shows that the last drain hole is outside the chest. What to do?

Well, as I mentioned, there is very little written on this topic, just dogma. So here are some practical tips on avoiding or fixing this problem:

  • Don’t let it happen to you! When inserting the tube, make sure that it’s done right! I don’t recommend making large skin incisions just to inspect your work. Most tubes can be inserted through a 2cm incision, but you can’t see into the depths of the wound. There are two tricks:
    • In adults with a reasonable BMI, the last hole is in when the tube markings show 12cm (bigger people need bigger numbers, though)
    • After insertion, get into the habit of running a finger down the radiopaque stripe on the tube all the way to the chest wall. If you don’t feel a hole (which is punched through the stripe), this will confirm that the it is inside, and that the tube actually goes into the chest. You may laugh, but I’ve seen them placed under the scapula. This even looks normal on chest xray!
  • Patients with a high BMI may not need anything done. The soft tissue will probably keep the hole occluded. If there is no air leak, just watch it.
  • If the tube was just put in and the wound has just been prepped and dressed, and the hole is barely outside the rib line, you might consider repositioning it a centimeter or two. Infection is a real concern, so if in doubt, go to the next step.
  • Replace the tube, using a new site. Yes, it’s a nuisance and requires more anesthetic and possibly sedation, but it’s better than treating an empyema in a few days.

Chest Tube Repositioning – Part 2

Yesterday I presented the problem of the malpositioned chest tube, specifically one that is not completely in the pleural space. This one is way out:

So what do the doctor books say? Well, the first thing you will discover if you try to look it up is that THERE IS NO LITERATURE ON THIS COMMON PROBLEM! There are a few papers on tubes placed in the fissure and tubes inserted into the lung parenchyma. But there are only a few mentions of tubes with holes still outside the chest.

I’ve gotten a number of comments, including “you can push them in a little”, “take it out and put in another”, and “never push them in.” Since we don’t have any science to guide us, we have to use common sense. But remember, I’ve shown you plenty of examples where something seems reasonable, but turns out to be ineffective or downright harmful.

There are three principles that guide me when I face this problem:

  • Prevention is preferable to intervention
  • Do no (or as little as possible) further harm
  • Be creative

Tomorrow, I’ll finish this series and provide some tips and guidelines to help manage this problem using the principles outlined above.

What To Do When The Chest Tube Is Not In The Right Place

It happens from time to time. Your patient has a hemothorax or pneumothorax and you insert a chest tube. Well done! But then the xray comes back:

The last hole in the drain is outside the chest! What to do???

Here are the questions that need to be answered:

  • Pull it out, leave it, or push it in?
  • Does length of time the tube has been in make a difference?
  • Does BMI matter?

Leave comments below regarding what you do. Hints and final answers in my next post!

Can We Use Type A Plasma For Emergency Transfusion?

Trauma patients tend to try to bleed to death. And trauma professionals try to stop that bleeding. They also frequently have to replace the blood products that were lost, which includes red blood cells, plasma, platelets, and more.

From a red blood cell standpoint, we have a long history of using group O- packed red cells as the so-called universal donor product. The problem is that only about 5% of the world population has this blood type, so it can be scarce.

To address this, many centers have moved toward using O+ blood for select patients. This blood type is much more prevalent (about 50% worldwide). The only difference is the positive Rh factor which has little impact on males, or females who are not in their child-bearing years. If an allergic reaction occurs, it is typically mild.

But what about plasma? This is interesting stuff. When selecting red cells, we want them to have no ABO group antigens on them so they don’t provoke a reaction. But plasma is just the opposite. We don’t want any ABO group antibodies in it. And the only plasma without antibodies comes from people who have all of them (A and B) on their red cells. This means people with type AB+ blood. Unfortunately, this is the other rare blood type, so there’s not a lot to go around. Worldwide, about 5% of people are AB+ and less than 1% are AB-.

So why couldn’t we do something like we did with packed red cells and substitute a more common blood type that evokes little immune response? The American Association of Blood Banks (AABB) has authorized both AB and A plasma for use in emergency situations. Unfortunately, the safety profile for using group A has not been very well studied, particularly in trauma patients needing massive transfusion.

The authors of the PROPPR study re-analyzed the data from it to try to answer this question. As you may recall, PROPPR was published in 2015 and compared safety and effectiveness of transfusion ratios at 1:1:1 to 1:1:2 (plasma : platelets : red cells).

The study group selected patients from the dataset who received at least one unit of emergency release plasma (ERP), defined as product given before the patient’s ABO type had been determined. Nicely enough, 12 sites transfused group AB ERP and 9 sites gave group A. One site gave both A and AB.

The authors looked at in-hospital mortality at 30 days, and a host of complications. Here are the factoids:

  • A total of 584 of the 680 patients in the PROPPR study received emergency release plasma
  • The median number of units given was 4, and there was no difference between A and AB groups
  • There were statistically significant baseline differences between the groups, including blood type, SBP, percent in shock (SBP<90), blunt mechanism, positive FAST that were probably not very clinically significant
  • The number of transfusions of all products were significantly  higher in the A plasma group
  • Complications were significantly higher in the A plasma group, specifically from SIRS, pulmonary problems, and venous thromboembolism (VTE)
  • There were no acute hemolytic transfusion reactions and three febrile reactions

The authors concluded that, statistically, the use of group A plasma was not inferior to the use of group AB. The authors stated that cautious use of group A is an acceptable option, especially if group AB is not readily available.

Bottom line: Here we go again. Always be careful when reading a study that suggests non-inferiority of one thing compared to another. There are a lot of potential issues here:

  • The PROPPR trial data was not designed to answer questions about plasma usage, so the data is being highjacked a bit
  • Participating centers did not have a standardized way to determine the group that received ERP, so some data anomalies will be present
  • The A and AB study groups were different in many ways at baseline, particularly with respect to how much product they received
  • The primary outcome, 30-day mortality, was underpowered and could never show a significant difference

So with significant baseline differences in study groups and a potentially underpowered study, don’t read non-inferiority as meaning that use of group A plasma is okay. We still just don’t know. What this study really shows is that you can “get away with” using low titer group A plasma if you run out of AB. But it shouldn’t be your go to product yet. To figure out the real safety profile, we need to do a real “PROPPR” study. Get it?

Reference: Group A emergency-release plasma in trauma patients requiring massive transfusion, J Trauma 89(6):1961-1067, 2020.