Category Archives: Abstracts

Best of EAST #1: Ultramassive Transfusion Survival

All right, let’s kick of this EASTfest with an abstract from one of the Eastern Association for the Surgery of Trauma multicenter studies. This one looked at outcomes after what they term “ultra-massive” resuscitation.

There are a number of definitions for “massive transfusion” which I’ve discussed before. They are basically trauma resuscitations in which the massive transfusion protocol is triggered. The group that designed this study defined ultra-massive resuscitation as one that entails transfusing at least 20 units of packed red cells within 24 hours.

The study focused on factors predicting survival in these patients. They used multivariate logistic regression as well as another regression tool, classification and regression tree analysis (CART). They used these tools to control for age, ISS, mechanism of injury, base deficit, and crystalloid use.

Here are the factoids:

  • A total of 400 patients were studied at 15 trauma centers over an eleven year period
  • Subjects were young (mean 37 years), male (81%), severely injured (mean ISS 34) and in shock
  • Median transfused products were 29u PRBCc, 23u FFP, and 24u platelets
  • Mortality was high with half dying in 24 hours and two thirds not surviving to discharge
  • Transfusion ratios > 1.5:1 for both RBC to plasma and RBC to platelets were strongly association with death
  • CART identified severe head injury, resuscitative thoracotomy, and low platelet count (< 169K / microliter) we association with high mortality
  • The best chance for survival occurred in those without a head injury, no thoracotomy, and higher platelet count

The authors concluded that the failure to meet balanced resuscitation goals was the main concern for mortality, and recommended more attention to meeting ratios.

My comments: I’m not so sure I’ve learned a lot from this abstract. I think we already knew that people with severe TBI or thoracotomy don’t do very well, especially if they need that much blood.

I also worry about the heterogeneity of the population. The variables that were controlled still offer quite a bit of variability in the injuries and condition of these trauma patients. I think this will make it difficult to come to many solid conclusions when looking at something as crude as mortality. 

Here are my questions for the authors and presenter:

  1. Why are there so few patients? An eleven year study with 15 centers participating means that each submitted less than 3 cases per year. Most busy Level I centers have many more than that in a single year. Was there some other kind of data selection or limitation that is not described in the abstract? Do you think there is enough power? See question 3 for more on this.
  2. How did you arrive at an admission platelet count threshold of 169,000/ul? This would seem to be a surrogate for something else going on, and I’m not sure what. But it just seems so arbitrary.
  3. The transfusion ratios are a bit confusing. For ratios less than 1.5:1, there are no error bars. Does this mean that every one of those patients survived? That’s remarkable if so. And the error bars for the groups with a ratio > 1.5:1 are perilously close to the 1 line, and they have quite a range. Is the statistical power really there to convincingly show a difference? This is the most interesting part of the abstract, so please expound upon it.
  4. Explain your use of CART. How did you determine the specific  determine the specific thresholds used in the CART model? Why did you choose to use this tool? For my readers, here is the tree presented in the abstract.
  5. What is the real message of the abstract? We already know that if patients who have a severe head injury or get their chest cracked are probably not going to make it. The transfusion ratio information is somewhat interesting, but there is better quality data out there that defines acceptable ratios. The platelet count information… interesting. What more do you have?

I think there is a lot of potential in this dataset once you overcome the small numbers. I’m very interested in the authors’ presentation!

Reference: Ultra-massive transfusion outcomes in a modern era: an EAST multicenter study. EAST 2021, Paper 1.

 

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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!

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Best Of AAST #14: Trauma Patient Health Literacy

When is the last time this has happened to you? You are called to the ED for a trauma activation. The patient was involved in a motorcycle crash and is doing fine, but he has a large midline scar on his abdomen. You inquire as to what it is. He tells you that he had been involved in another motorcycle crash about five years ago and needed an operation. When questioned about what his injuries were and what was done, he has no idea.

This is an example of health (il)literacy at its best. An earlier study from the Presley trauma center in Memphis demonstrated that less than half of their trauma patients could correctly recall their injuries or their operations.

This is not really surprising. Have you ever taken a minute to look at the sheaf of paper given to hospital patients when they are discharged? They are usually computer-generated gobbledygook and are not easily understood by any human on this earth. It is hard enough to figure out the discharge medications and followup visits. And any diagnosis or surgical procedure information is never in patient-friendly language.

The Memphis group designed a simple discharge information form to provide to their patients:

Here are the factoids:

  • Patients admitted to the trauma service over a 6-month period were studied and surveyed during their first post-discharge clinic visit
  • A total of 153 surveys were distributed, asking about income, education, and patient satisfaction and their understanding of what happened to them; 146 were returned
  • Income levels were low, with about 60% of them less than $25K and 85% less than $50K
  • About 75% had a high school education or less
  • Implementation of the form increased injury recall some or all of patient injuries from 55% to 85%, and recall of operations from 43% to 76%
  • The number of patients who could recall any of their providers’ names increased from 11% to 31% (!)
  • Injury understanding, satisfaction with injury understanding, and the overall impact on hospitalization was significantly positive

The authors concluded that introducing this simple form dramatically improved their patients’ health literacy, and their patients were able to provide more details to providers they visited post-discharge.

Here are my comments: I think the bottom line here is to know your patients! Socioeconomic and education status vary dramatically by geographic location. This certainly has an impact on the understanding and recall of hospital events by our patients. It can help us optimize processes to provide meaningful and important information that they need to know in the future.

The form used in this study was very simple, consisting of a series of blanks to be filled in by a healthcare provider. But who was this provider? All medical professionals tend to use the lingo that we learned in training. But our patients have zero understanding of them. Consider the lowly Foley catheter. Tell a patient you are going to insert one, and they will say “uh-huh.” But tell them that you are preparing to stick a big rubber tube in their penis, and the response will be much more vocal. Make sure the language is simple and lingo-free.

The recall of provider names improved only modestly. This may be due to the typical “interchangeable head” model where the various healthcare professionals change on a frequent bases. Additionally, patients are seen by a horde of nurses, physicians, APPs, residents, techs, and others during their stay so it’s easy to forget a name.

Overall, the results were very promising. This is a significant advance in patient health education and literacy. I think the next step is to provide a library of information sheets based on the common injury diagnoses and operations that occur at the trauma center. This, coupled with a more intelligible set of discharge papers in general will be of great help to our patients.

Here are my questions for the presenter and authors:

  • Why so few surveys? Your center is very busy, and the study data only involved about 25 patients per month. How did you select them, and might information obtained from all the other patients have changed your results?
  • Did you independently review the discharge forms to ensure understandable language? The intelligibility could vary significantly based on the provider filling it out.
  • How did your care model affect the patient recall of their providers? Do your residents or attending surgeons rotate on a frequent basis? What other factors might have influenced this?
  • What next? How has this information changed how you educate your patients now? What additional changes might you make in the future? How will you roll it out to more than just 25 patients per month?

This is excellent work! I’m looking forward to your live presentation later this week.

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Best Of AAST #13: Work-Life Balance

Okay, so this abstract is a bit more on the touchy-feely side. But it is extremely important because it speaks to the balancing act we all have to perform in order to achieve a satisfying harmony between work and everything else.

Older generations of surgeons threw nearly all of their energy into work, and ended up with lesser amounts of involvement with their family and everything else outside of work. At the time, , though, people seemed to be (mostly) satisfied. That’s just the way it was.

But now, there is much more emphasis on a healthy lifestyle, and this includes a healthy delineation of work and not-work. An AAST-approved survey was sent to the membership which tried to parse out the various factors involved in work-life balance, happiness, and burnout.

Here are some very interesting factoids:

  • Of more than 1300 questionnaires sent out, only 291 (21%) returned them (wish I had a sad face icon here)
  • Only 43% were satisfied with their work-life balance
  • There was no difference in satisfaction based on age, sex, or practice type
  • Here are the factors that set the satisfied surgeons apart from the dissatisfied:
    • Early (<10 years) or late in career (>20 years)
    • Fewer hours spent at work
    • More hours spent (awake) at home
    • Enjoy their job
    • Enjoy their partners
    • Better at saying no or delegating work tasks
    • Feel they are fairly compensated
    • Engage in hobbies (86% vs 68%)
    • Exercise regularly (49% vs 20%)
    • Eat a healthy diet (74$ vs 48%)
    • Get more sleep (7 hrs vs 6 hrs)
  • Despite getting the same amount of vacation time, the satisfied surgeons actually used it
  • Dissatisfied surgeons reported significantly more feelings of burnout (77% vs 39%)

The authors concluded that trauma programs should concentrate on optimizing the modifiable factors listed above to improve satisfaction and decrease burnout.

Here are my comments: Well, I don’t have many, nor do I have any questions for the authors. This is a purely descriptive study that paints a general picture outlining what seems to be important in enhancing satisfaction with one’s career path. It is an interesting read, and outlines many of the factors that influence this. I’m sure it’s not all of the factors, but they hit the big ones.

All trauma professionals should look at this data and read the final manuscript. It may help you make changes to optimize your own work-life balance and career satisfaction.

Reference: Modifiable factors to improve work-life balance for trauma surgeons. AAST 2020, Oral abstract #50.

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Best of AAST #12: Embolization Of Splenic Pseudoaneurysm

The management of blunt spleen injury has evolved significant over the time I’ve been in practice. Initially, the usual formula was:

Spleen injury = splenectomy

This began to change in the late 1980’s, and beginning in the early 90’s nonoperative management became the rage. We spent the next 10-15 years tweaking the details, gradually reducing bed rest and NPO times, and increasing the success rate through smart patient selection and discovering new adjuncts.

One of these adjuncts was angiography with embolization. The ShockTrauma Center in Maryland was an early adopter and protocolized its use in patients with high-grade injuries.

But now, they are questioning the utility of this tool in certain patients: those with splenic pseudoaneurysms (PSA). They theorized that modern, high resolution CT identifies relatively unimportant pseudoaneurysms. They conducted a 5-year retrospective review of their experience.

Here are the factoids:

  • They identified 717 splenic injuries, of whom 155 were embolized but only 140 patients had adequate records and imaging for review
  • The majority of patients had high grade injury: 31% Grade 3, 61% Grade 4, 1% Grade 5
  • Extravasation was seen in 17% and PSA in 52%
  • About 44% of patients went to angiography within 6 hours, but the mean was 17 hours indicating quite a few outliers
  • Among the 73 patients with an initial PSA , a third of them did not have a detectable lesion during angiography
  • Patients who underwent embolization for PSA had a followup CT 48-72 hours afterwards, persistently perfused PSA were seen in 40% (!)
  • No patients with PSA who were only observed required delayed splenectomy

The authors conclude that a third of pseudoaneurysms may be clinically insignificant, and that 40% of them persist after embolization. They do not, however, offer any recommendations based on their data.

Here are my comments: This is an interesting study. My read of the abstract and slides would indicate that this group routinely sends all Grade 3 and 4 injuries to angio, and Grade 5 could go to either angio or OR. They take their good time going to interventional radiology (mean 17 hours from arrival), and get a routine followup CT 48-72 hours from hitting the door if they didn’t go to the OR.

If I were to play the devil’s advocate, I might think that interventional radiology was being de-emphasized for some reason. Was there some reluctance to send patients there, or limited availability? This might explain the long access times. And how are the radiologists not shutting down 40% of PSA that are seen?

I am intrigued by the study, but there are a lot more details needed to get some good takeaways from it.

Here are my questions for the presenter and authors:

  • Please explain why it takes so long to send patients to angiography. Less than half got there in less than 6 hours, and the mean of 17 hours means that many didn’t get there until the next day.
  • Does this small study have the statistical power to say that some PSA are benign? The groups are very small, and I would speculate that the group size needed to show significance is in the high hundreds.
  • What was the reason for splenectomy in the 2 patients who underwent embolization? Was it related to the pseudoaneurysm or something else?
  • How can you be sure that these PSA are insignificant? Frequently, pseudoaneurysms don’t explode for 7-10 days. Do you have any data on patients who returned to a hospital with delayed bleeding?
  • If you believe that many pseudoaneurysms are benign, how do you propose to manage the patients? Observe until they explode? Repeat a contrast CT scan, with the associated contrast and radiation re-dose? And how long would you wait to do this? What would your new protocol be?

I’ll be all ears on Friday when this abstract is presented live.

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