Glen Franklin - Academia.edu (original) (raw)

Papers by Glen Franklin

The journal of trauma and acute care surgery, Sep 1, 2014

BACKGROUND: The success of damage-control surgery (DCS) for the treatment of trauma has led to it... more BACKGROUND: The success of damage-control surgery (DCS) for the treatment of trauma has led to its use in other surgical problems such as abdominal sepsis. Previous studies using direct peritoneal resuscitation (DPR) for the treatment of trauma have yielded promising results. We present the results of the application of this technique to patients experiencing abdominal sepsis. METHODS: We enrolled 88 DCS patients during a 5 year-period (January 2008 to December 2012) into a propensity-matched study to evaluate the utility of using DPR in addition to standard resuscitation. DPR consisted of peritoneal lavage with 2.5% DELFLEX, and abdominal closure was standardized across both groups. Patients were matched using Acute Physiology and Chronic Health Evaluation II (APACHE II) variables. Univariate and multivariate analyses were performed. RESULTS: There were no differences between the control and experimental groups with regard to age, sex, ethnicity, or APACHE II at 24 hours. Indications for damage control included pancreatitis, perforated hollow viscous, bowel obstruction, and ischemic enterocolitis. Patients undergoing DPR had both a higher rate of (68% vs. 43%, p G 0.03) and a shorter time to definitive fascial closure (5.9 [3.2] days vs. 7.7 [4.1] days, p G 0.02). DPR patients had a decreased APACHE II and Sequential Organ Failure Assessment (SOFA) score compared with the controls at 48 hours. In addition, DPR patients had fewer abdominal complications compared with the controls (RR, 0.57; 95% confidence interval, 0.32Y1.01; p = 0.038). Ventilator days and intensive care unit length of stay were both significantly reduced in the DPR group. The DPR group showed a lower overall mortality at 30 days (16% vs. 27%, p = 0.15). CONCLUSION: DPR reduces time to definitive abdominal closure, increases primary fascial closure, and reduces intra-abdominal complications following DCS. DPR may also attenuate progressive physiologic injury as demonstrated by a reduction in 48-hour intensive care unit severity scores. As a result, DPR following DCS may afford better outcomes to patients experiencing shock.

Journal of The American College of Surgeons, Apr 1, 2012

The metabolic syndrome and associated fatty liver disease are thought to contribute to poor outco... more The metabolic syndrome and associated fatty liver disease are thought to contribute to poor outcomes in trauma patients. Experimentally, obesity compromises liver blood flow. We sought to correlate the effect of obesity, injury severity, and liver dysfunction with trauma outcomes. We hypothesized that obesity-related liver dysfunction could be mitigated with the novel technique of adjunctive direct peritoneal resuscitation (DPR). This study has clinical and experimental arms. The clinical study was a case-controlled retrospective analysis of ICU trauma patients (n = 72 obese, n = 187 nonobese). The experimental study was a hemorrhagic shock model in obese rats to assess the effect of DPR on liver blood flow, liver function, and inflammatory mediators. In trauma patients, univariate and multivariate analyses demonstrated increasing mortality (p < 0.05), septic complications (p < 0.05), liver dysfunction (p < 0.001), and renal impairment (p < 0.05) with increasing body mass index and injury severity score. Obesity in rats impairs liver blood flow, liver function, renal function, and inflammation (interleukin [IL]-1β, IL-6, high mobility group protein B1[HMGB-1]). The addition of DPR to shock resuscitation restores liver blood flow, improves organ function, and reverses the systemic proinflammatory response. Our clinical review substantiates that obesity worsens trauma outcomes regardless of injury severity. Obesity-related liver and renal dysfunction is aggravated by injury severity. In an obese rat model of resuscitated hemorrhagic shock, the addition of DPR abrogates trauma-induced liver, renal, and inflammatory responses. We conclude that the addition of DPR to the clinical resuscitation regimen will benefit the obese trauma patient.

Journal of The American College of Surgeons, Apr 1, 2017

Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trau... more Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trauma patients requiring damage control surgery (DCS). These data represent the outcome of a single institution RCT into the efficacy of PR as a management option in these patients. From 2011-2015, 103 patients were enrolled in a prospective RCT evaluating the utility of PR in the treatment of patients undergoing DCS compared to conventional resuscitation (CR) alone. Patient demographics, clinical variables and outcomes were collected. Univariate and multivariate analysis was performed with a priori significance at p ≤ 0.05. After initial screening 52 randomized to PR group and 51 to the CR group. Age, gender, initial pH, and mechanism of injury were used for randomization. Method of abdominal closure was standardized across groups. Time to definitive abdominal closure was reduced in the PR group compared to the CR group (4.1 ± 2.2 days vs 5.9 ± 3.5 days, p ≤ 0.002). Volume of resuscitation and blood products transfused in the initial 24 hours was not different between the groups. Primary fascial closure rate was higher in the PR group (83% vs. 66%, p ≤ 0.05). Intraabdominal complications were lower in the PR compared to the CR group (8% vs 18%) with abscess formation rate (3% vs 14% , p < 0.05) being significant. Patients in the PR group had lower 30 day mortality despite similar ISS scores (13% vs 28%, p=0.06) CONCLUSIONS: Peritoneal resuscitation enhances the management of DCS patients via reducing time to definitive abdominal closure, reducing intra-abdominal infections and reducing mortality.

Surgery, Oct 1, 2009

Background. Obese patients (BMI>35) after blunt trauma are at increased risk compared to non-obes... more Background. Obese patients (BMI>35) after blunt trauma are at increased risk compared to non-obese for organ dysfunction, prolonged hospital stay, infection, prolonged mechanical ventilation, and mortality. Obesity and non-alcoholic fatty liver disease (NAFLD) produce a low grade systemic inflammatory response syndrome (SIRS) with compromised hepatic blood flow, which increases with body mass index. We hypothesized that obesity further aggravates liver dysfunction by reduced hepatic perfusion following resuscitated hemorrhagic shock (HEM). Methods. Age-matched Zucker rats (Obese, 314-519 g & Lean, 211-280 g) were randomly assigned to 4 groups (n = 10-12/group): (1) Lean-Sham; (2) Lean, HEM, and resuscitation (HEM/RES); (3) Obese-Sham; and (4) Obese-HEM/RES. HEM was 40% of mean arterial pressure (MAP) for 60 min; RES was return of shed blood/5 min and 2 volumes of saline/25 min. Hepatic blood flow (HBF) using galactose clearance, liver enzymes and complete metabolic panel were measured over 4 h after completion of RES. Results. Obese rats had increased MAP, heart rate, and fasting blood glucose and BUN concentrations compared to lean controls, required less blood withdrawal (mL/g) to maintain 40% MAP, and RES did not restore BL MAP. Obese rats had decreased HBF at BL and during HEM/RES, which persisted 4 h post RES. ALT and BUN were increased compared to Lean-HEM/RES at 4 h post-RES. Conclusion. These data suggest that obesity significantly contributes to trauma outcomes through compromised vascular control or through fat-induced sinusoidal compression to impair hepatic blood flow after HEM/RES resulting in a greater hepatic injury. The pro-inflammatory state of NAFLD seen in obesity appears to prime the liver for hepatic ischemia after resuscitated hemorrhagic shock, perhaps intensified by insidious and ongoing hepatic hypoperfusion established prior to the traumatic injury or shock.

Journal of Burn Care & Research

Introduction The United States continues to suffer from a serious epidemic of opioid use. Exposur... more Introduction The United States continues to suffer from a serious epidemic of opioid use. Exposure to opioids is a known risk factor for long-term use and dependence. This is of particular importance to burn care, as opioids are frequently essential to manage the pain associated with burn injuries. The purpose of this study was to characterize opioid use among burn patients after hospitalization and to identify any risk factors for long-term dependence. Methods All patients admitted to a burn center during a single year period (2/1/2020-2/1/21) were examined. Patients who died were excluded. A controlled substance reporting system was utilized to determine opioid use over a time period from 6 months prior to injury and up to 12 months post-hospital discharge. Reporting to this database is mandated by law and therefore includes all prescriptions regardless of prescriber, insurance, location, etc. Duration of opioid use was recorded for all patients in the study. Long-term use was def...

The American Surgeon, 2005

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdomina... more It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and χ2were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantl...

The American Surgeon, 2007

Chest wall fractures, including injuries to the ribs and sternum, usually heal spontaneously with... more Chest wall fractures, including injuries to the ribs and sternum, usually heal spontaneously without specific treatment. However, a small subset of patients have fractures that produce overlying bone fragments that may produce severe pain, respiratory compromise, and, if untreated mechanically, result in nonunion. We performed open reduction and internal fixation on seven patients with multiple rib fractures—five in the initial hospitalization and two delayed—as well as 35 sternal fractures (19 immediate fixation and 16 delayed). Operative fixation was accomplished using titanium plates and screws in both groups of patients. All patients with rib fractures did well; there were no major complications or infections, and no plates required removal. Clinical results were excellent. There was one death in the sternal fracture group in a patient who was ventilator-dependent preoperatively and extubated himself in the early postoperative period. Otherwise, the results were excellent, with ...

The American Surgeon, 2007

One of the major lessons learned in the World War II experience with liver injuries was that bile... more One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2–18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic...

The American Surgeon, 2008

Nonoperative management of splenic trauma is now the most common treatment modality for splenic i... more Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with he...

The American Surgeon, 2009

The need for transplantable organs exceeds the available supply. Organ procurement organizations ... more The need for transplantable organs exceeds the available supply. Organ procurement organizations (OPOs) have undergone both voluntary and mandated changes to optimize available organs. The data from a single statewide OPO was reviewed from 1993 to 2008 and tracked with implementation of new protocols. During the study, 5548 organs were recovered with 4875 transplanted from 1441 donors (3.38 organs transplanted/donor (OTPD)). The conversion rate (CR) for consent rose from 42 to 72 per cent whereas the average age of donors increased from 33 to 45 years. After implementation of a family support liaison program, a higher performing hospital in the OPO realized an increase in CR from 57 to 97 per cent over 8 years. Implementation of an intensivist program improved OTPD. The number of standard criteria donors and extended criteria donors (ECD) increased. The increase in standard criteria donors yielded a large number of thoracic organs. ECD increased as did the organ discard rate from 8 ...

The American Surgeon, 2007

Blunt chest trauma produces a variety of injuries. We present a case report of a hemodynamically ... more Blunt chest trauma produces a variety of injuries. We present a case report of a hemodynamically stable patient after blunt chest trauma with radiographic images suggestive of the left fifth rib penetration to the heart. The diagnosis, surgical approach, and course of the patient are discussed.

Journal of the American College of Surgeons, Jan 27, 2017

Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trau... more Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trauma patients requiring damage control surgery (DCS). These data represent the outcome of a single institution RCT into the efficacy of PR as a management option in these patients. From 2011-2015, 103 patients were enrolled in a prospective RCT evaluating the utility of PR in the treatment of patients undergoing DCS compared to conventional resuscitation (CR) alone. Patient demographics, clinical variables and outcomes were collected. Univariate and multivariate analysis was performed with a priori significance at p ≤ 0.05. After initial screening 52 randomized to PR group and 51 to the CR group. Age, gender, initial pH, and mechanism of injury were used for randomization. Method of abdominal closure was standardized across groups. Time to definitive abdominal closure was reduced in the PR group compared to the CR group (4.1 ± 2.2 days vs 5.9 ± 3.5 days, p ≤ 0.002). Volume of resuscitation...

Transplant Research and Risk Management, 2016

There is a disparity between the number of kidneys available for transplantation and the number o... more There is a disparity between the number of kidneys available for transplantation and the number of patients awaiting an organ while on dialysis. The current kidney waiting list in the US contains more than 100,000 patients. This need has led to the inclusion of older donors with worsening renal function, as well as greater utilization of kidneys from non-heartbeating (donation after cardiac death) donors. Coinciding with this trend has been a growing interest in technology to improve the function of these more marginal organs, the most important of which currently is machine perfusion (MP) of donated kidneys after procurement. While this technology has no standard guidelines currently for comprehensive use, there are many studies that demonstrate higher organ yield and function after a period of MP. Particularly with the older donor and during donation after cardiac death cases, MP may offer some significant benefits. This manuscript reviews all of the current literature regarding MP and its role in renal transplantation. We will discuss both the experience in Europe and the US using machine perfusion for donated kidneys.

B52. VENTILATOR ASSOCIATED AND NOSOCOMIAL PNEUMONIA, 2010

Background: Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring more than 48 ... more Background: Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring more than 48 hours after initiation of mechanical ventilation. It is the most common nosocomial infection in the ICU, and increases mortality. Guidelines for therapy of VAP suggest the use of narrow spectrum antibiotics in patients for early-onset VAP, because multi-drug resistant bacteria are unlikely in these patients. However, data is limited to support such recommendations. The objective of this study was to define the incidence and etiology of early-VAP versus late-VAP. Methods: With the IRB approval of University of Louisville, we reviewed the medical records of 168 patients who were mechanically ventilated for more than 48 hours. VAP was diagnosed by the CDC criteria. Early-VAP was defined as development of VAP during the initial 6 days of intubation, and late-VAP was considered >6 days of intubation and mechanical ventilation. VAP incidence was calculated using 1,000 ventilator-days and compared using Z-statistics. Incidence of multi-drug resistsant bacteria was calculated for patients with early-VAP and late-VAP, Results: The incidence of early-VAP was 40/1,000 vent-days, and late-VAP incidence was 14/1,000 vent-days (P=0.002). Multi-drug resistant organisms were identified in 46% of early-VAP and 77% of late-VAP. Conclusion: The risk for the development of VAP is significantly higher during the initial days of mechanical ventilation. Interestingly, multi-drug resistant organisms caused early-VAP very frequently. Therefore, the presence of early-VAP by itself cannot support the use of narrow-spectrum empiric antibiotherapy.

Journal of Trauma and Acute Care Surgery, 2014

BACKGROUND: The success of damage-control surgery (DCS) for the treatment of trauma has led to it... more BACKGROUND: The success of damage-control surgery (DCS) for the treatment of trauma has led to its use in other surgical problems such as abdominal sepsis. Previous studies using direct peritoneal resuscitation (DPR) for the treatment of trauma have yielded promising results. We present the results of the application of this technique to patients experiencing abdominal sepsis. METHODS: We enrolled 88 DCS patients during a 5 year-period (January 2008 to December 2012) into a propensity-matched study to evaluate the utility of using DPR in addition to standard resuscitation. DPR consisted of peritoneal lavage with 2.5% DELFLEX, and abdominal closure was standardized across both groups. Patients were matched using Acute Physiology and Chronic Health Evaluation II (APACHE II) variables. Univariate and multivariate analyses were performed. RESULTS: There were no differences between the control and experimental groups with regard to age, sex, ethnicity, or APACHE II at 24 hours. Indications for damage control included pancreatitis, perforated hollow viscous, bowel obstruction, and ischemic enterocolitis. Patients undergoing DPR had both a higher rate of (68% vs. 43%, p G 0.03) and a shorter time to definitive fascial closure (5.9 [3.2] days vs. 7.7 [4.1] days, p G 0.02). DPR patients had a decreased APACHE II and Sequential Organ Failure Assessment (SOFA) score compared with the controls at 48 hours. In addition, DPR patients had fewer abdominal complications compared with the controls (RR, 0.57; 95% confidence interval, 0.32Y1.01; p = 0.038). Ventilator days and intensive care unit length of stay were both significantly reduced in the DPR group. The DPR group showed a lower overall mortality at 30 days (16% vs. 27%, p = 0.15). CONCLUSION: DPR reduces time to definitive abdominal closure, increases primary fascial closure, and reduces intra-abdominal complications following DCS. DPR may also attenuate progressive physiologic injury as demonstrated by a reduction in 48-hour intensive care unit severity scores. As a result, DPR following DCS may afford better outcomes to patients experiencing shock.

Journal of the American College of Surgeons, 2015

Brain dead organ donors have altered central hemodynamic performance, impaired hormone physiology... more Brain dead organ donors have altered central hemodynamic performance, impaired hormone physiology, exaggerated systemic inflammatory response, end-organ microcirculatory dysfunction, and tissue hypoxia. A new treatment, direct peritoneal resuscitation (DPR), stabilizes vital organ blood flow after conventionally resuscitated shock to improve these derangements. A prospective case-control study of adjunctive DPR compared 26 experimental patients (brain dead organ donors) to 52 controls (protocolized conventionally resuscitated donors). Actual organ procurement rates were compared with the Scientific Registry of Transplant Recipient predicted organ yield per patient. Achievement of donor management goals and effective hepatic blood flow were recorded. Fourteen of 26 (53.8%) patients treated with DPR achieved all donor management goals compared with 17 of 52 (32.7%) patients treated with conventionally resuscitated (odds ratio = 2.4; 95% CI, 0.92-6.3; p = 0.06). Patients treated with DPR were more than 2 times as likely to achieve final pO2 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;100 on 40% FiO2 compared with controls (odds ratio = 2.8; 95% CI, 1-7.69; p = 0.03). Also, DPR-treated patients required less IV crystalloid during the first 12 hours of management (DPR: 3,167 ± 1,893 mL vs 4,154 ± 2,100 mL; p = 0.046) and required less vasopressor agents at 12 hours post resuscitation (odds ratio = 7.7; 95% CI, 0.82-42; p = 0.02). Direct peritoneal resuscitation patients had enhanced effective hepatic blood flow and significantly higher organs transplanted per donor rates compared with controls (3.7 ± 1.7 vs 3.1 ± 1.3; p = 0.024). Direct peritoneal resuscitation reduced IV fluid requirement and IV pressor use as well as increased hepatic blood flow and organs transplanted per donor. Direct peritoneal resuscitation studies show it to be a safe, effective method to augment organ donor resuscitation and additional large-scale trials should be conducted to validate these findings.

JPEN. Journal of parenteral and enteral nutrition, Jan 4, 2014

Background: Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize tha... more Background: Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize that targeted physician education should help reduce caloric deficits and improve patient outcomes. Materials and Methods: We performed a prospective trial of patients (n = 121) assigned to 1 of 2 trauma groups. The experimental group (EG) received targeted education consisting of strategies to increase delivery of early enteral nutrition. Strategies included early enteral access, avoidance of nil per os (NPO) and clear liquid diets (CLD), volume-based feeding, early resumption of feeds postprocedure, and charting caloric deficits. The control group (CG) did not receive targeted education but was allowed to practice in a standard ad hoc fashion. Both groups were provided with dietitian recommendations on a multidisciplinary nutrition team per standard practice. Results: The EG received a higher percentage of measured goal calories (30.1 ± 18.5%, 22.1 ± 23.7%, P = .024) compared with the CG....

The American Journal of Surgery, 2014

BACKGROUND: Stops at nontrauma centers for severely injured patients are thought to increase deat... more BACKGROUND: Stops at nontrauma centers for severely injured patients are thought to increase deaths and costs, potentially because of unnecessary imaging and indecisive/delayed care of traumatic brain injuries (TBIs). METHODS: We studied 754 consecutive blunt trauma patients with an Injury Severity Score greater than 20 with an emphasis on 212 patients who received care at other sites en route to our level 1 trauma center. RESULTS: Referred patients were older, more often women, and had more severe TBI (all P , .05). After correction for age, sex, and injury pattern, there was no difference in the type of TBI, Glasgow Coma Scale (GCS) upon arrival at the trauma center, or overall mortality between referred and directly admitted patients. GCS at the outside institution did not influence promptness of transfer. CONCLUSIONS: Interhospital transfer does not affect the outcome of blunt trauma patients. However, the unnecessarily prolonged stay of low GCS patients in hospitals lacking neurosurgical care is inappropriate.

Surgery, 2009

Background. Obese patients (BMI>35) after blunt trauma are at increased risk compared to non-obes... more Background. Obese patients (BMI>35) after blunt trauma are at increased risk compared to non-obese for organ dysfunction, prolonged hospital stay, infection, prolonged mechanical ventilation, and mortality. Obesity and non-alcoholic fatty liver disease (NAFLD) produce a low grade systemic inflammatory response syndrome (SIRS) with compromised hepatic blood flow, which increases with body mass index. We hypothesized that obesity further aggravates liver dysfunction by reduced hepatic perfusion following resuscitated hemorrhagic shock (HEM). Methods. Age-matched Zucker rats (Obese, 314-519 g & Lean, 211-280 g) were randomly assigned to 4 groups (n = 10-12/group): (1) Lean-Sham; (2) Lean, HEM, and resuscitation (HEM/RES); (3) Obese-Sham; and (4) Obese-HEM/RES. HEM was 40% of mean arterial pressure (MAP) for 60 min; RES was return of shed blood/5 min and 2 volumes of saline/25 min. Hepatic blood flow (HBF) using galactose clearance, liver enzymes and complete metabolic panel were measured over 4 h after completion of RES. Results. Obese rats had increased MAP, heart rate, and fasting blood glucose and BUN concentrations compared to lean controls, required less blood withdrawal (mL/g) to maintain 40% MAP, and RES did not restore BL MAP. Obese rats had decreased HBF at BL and during HEM/RES, which persisted 4 h post RES. ALT and BUN were increased compared to Lean-HEM/RES at 4 h post-RES. Conclusion. These data suggest that obesity significantly contributes to trauma outcomes through compromised vascular control or through fat-induced sinusoidal compression to impair hepatic blood flow after HEM/RES resulting in a greater hepatic injury. The pro-inflammatory state of NAFLD seen in obesity appears to prime the liver for hepatic ischemia after resuscitated hemorrhagic shock, perhaps intensified by insidious and ongoing hepatic hypoperfusion established prior to the traumatic injury or shock.

The Journal of Trauma: Injury, Infection, and Critical Care, 2005

Background: The implementation of revised surgical resident work hours has led many teaching hosp... more Background: The implementation of revised surgical resident work hours has led many teaching hospitals to integrate health care extenders into the trauma service. We undertook this review to assess the effectiveness of these individuals in meeting the goals of the work hour restrictions and whether they impact other hospital and patient outcomes. Methods: During the year 2002, we integrated two nurse practitioners into the trauma service of a teaching hospital. We prospectively collected data a year before (2001), during (2002), and a year after (2003) the integration that included number of admissions, hospital length of stay, intensive care stay, floor length of stay, mortality, direct cost per case, and weekly resident work hours on 44 residents at all levels. Results: After the incorporation of physician extenders, we observed statistically significant reductions in floor, intensive care unit, and overall hospital lengths of stay. Patient mortality and cost per patient remained unchanged. Furthermore, we were able to obtain compliance with the Accreditation Council for Graduate Medical Education requirements for residency work hour limitations, as the average number of hours worked per resident on the trauma service decreased from 86 hours to 79 hours per week. Conclusion: As graduate medical education becomes ever more regulated, physician extenders can be successfully integrated into busy academic Level I trauma centers. This integration positively impacts patient flow and resident work hours without altering patient outcomes or direct hospital cost.

The journal of trauma and acute care surgery, Sep 1, 2014

BACKGROUND: The success of damage-control surgery (DCS) for the treatment of trauma has led to it... more BACKGROUND: The success of damage-control surgery (DCS) for the treatment of trauma has led to its use in other surgical problems such as abdominal sepsis. Previous studies using direct peritoneal resuscitation (DPR) for the treatment of trauma have yielded promising results. We present the results of the application of this technique to patients experiencing abdominal sepsis. METHODS: We enrolled 88 DCS patients during a 5 year-period (January 2008 to December 2012) into a propensity-matched study to evaluate the utility of using DPR in addition to standard resuscitation. DPR consisted of peritoneal lavage with 2.5% DELFLEX, and abdominal closure was standardized across both groups. Patients were matched using Acute Physiology and Chronic Health Evaluation II (APACHE II) variables. Univariate and multivariate analyses were performed. RESULTS: There were no differences between the control and experimental groups with regard to age, sex, ethnicity, or APACHE II at 24 hours. Indications for damage control included pancreatitis, perforated hollow viscous, bowel obstruction, and ischemic enterocolitis. Patients undergoing DPR had both a higher rate of (68% vs. 43%, p G 0.03) and a shorter time to definitive fascial closure (5.9 [3.2] days vs. 7.7 [4.1] days, p G 0.02). DPR patients had a decreased APACHE II and Sequential Organ Failure Assessment (SOFA) score compared with the controls at 48 hours. In addition, DPR patients had fewer abdominal complications compared with the controls (RR, 0.57; 95% confidence interval, 0.32Y1.01; p = 0.038). Ventilator days and intensive care unit length of stay were both significantly reduced in the DPR group. The DPR group showed a lower overall mortality at 30 days (16% vs. 27%, p = 0.15). CONCLUSION: DPR reduces time to definitive abdominal closure, increases primary fascial closure, and reduces intra-abdominal complications following DCS. DPR may also attenuate progressive physiologic injury as demonstrated by a reduction in 48-hour intensive care unit severity scores. As a result, DPR following DCS may afford better outcomes to patients experiencing shock.

Journal of The American College of Surgeons, Apr 1, 2012

The metabolic syndrome and associated fatty liver disease are thought to contribute to poor outco... more The metabolic syndrome and associated fatty liver disease are thought to contribute to poor outcomes in trauma patients. Experimentally, obesity compromises liver blood flow. We sought to correlate the effect of obesity, injury severity, and liver dysfunction with trauma outcomes. We hypothesized that obesity-related liver dysfunction could be mitigated with the novel technique of adjunctive direct peritoneal resuscitation (DPR). This study has clinical and experimental arms. The clinical study was a case-controlled retrospective analysis of ICU trauma patients (n = 72 obese, n = 187 nonobese). The experimental study was a hemorrhagic shock model in obese rats to assess the effect of DPR on liver blood flow, liver function, and inflammatory mediators. In trauma patients, univariate and multivariate analyses demonstrated increasing mortality (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05), septic complications (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05), liver dysfunction (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), and renal impairment (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) with increasing body mass index and injury severity score. Obesity in rats impairs liver blood flow, liver function, renal function, and inflammation (interleukin [IL]-1β, IL-6, high mobility group protein B1[HMGB-1]). The addition of DPR to shock resuscitation restores liver blood flow, improves organ function, and reverses the systemic proinflammatory response. Our clinical review substantiates that obesity worsens trauma outcomes regardless of injury severity. Obesity-related liver and renal dysfunction is aggravated by injury severity. In an obese rat model of resuscitated hemorrhagic shock, the addition of DPR abrogates trauma-induced liver, renal, and inflammatory responses. We conclude that the addition of DPR to the clinical resuscitation regimen will benefit the obese trauma patient.

Journal of The American College of Surgeons, Apr 1, 2017

Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trau... more Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trauma patients requiring damage control surgery (DCS). These data represent the outcome of a single institution RCT into the efficacy of PR as a management option in these patients. From 2011-2015, 103 patients were enrolled in a prospective RCT evaluating the utility of PR in the treatment of patients undergoing DCS compared to conventional resuscitation (CR) alone. Patient demographics, clinical variables and outcomes were collected. Univariate and multivariate analysis was performed with a priori significance at p ≤ 0.05. After initial screening 52 randomized to PR group and 51 to the CR group. Age, gender, initial pH, and mechanism of injury were used for randomization. Method of abdominal closure was standardized across groups. Time to definitive abdominal closure was reduced in the PR group compared to the CR group (4.1 ± 2.2 days vs 5.9 ± 3.5 days, p ≤ 0.002). Volume of resuscitation and blood products transfused in the initial 24 hours was not different between the groups. Primary fascial closure rate was higher in the PR group (83% vs. 66%, p ≤ 0.05). Intraabdominal complications were lower in the PR compared to the CR group (8% vs 18%) with abscess formation rate (3% vs 14% , p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) being significant. Patients in the PR group had lower 30 day mortality despite similar ISS scores (13% vs 28%, p=0.06) CONCLUSIONS: Peritoneal resuscitation enhances the management of DCS patients via reducing time to definitive abdominal closure, reducing intra-abdominal infections and reducing mortality.

Surgery, Oct 1, 2009

Background. Obese patients (BMI>35) after blunt trauma are at increased risk compared to non-obes... more Background. Obese patients (BMI>35) after blunt trauma are at increased risk compared to non-obese for organ dysfunction, prolonged hospital stay, infection, prolonged mechanical ventilation, and mortality. Obesity and non-alcoholic fatty liver disease (NAFLD) produce a low grade systemic inflammatory response syndrome (SIRS) with compromised hepatic blood flow, which increases with body mass index. We hypothesized that obesity further aggravates liver dysfunction by reduced hepatic perfusion following resuscitated hemorrhagic shock (HEM). Methods. Age-matched Zucker rats (Obese, 314-519 g & Lean, 211-280 g) were randomly assigned to 4 groups (n = 10-12/group): (1) Lean-Sham; (2) Lean, HEM, and resuscitation (HEM/RES); (3) Obese-Sham; and (4) Obese-HEM/RES. HEM was 40% of mean arterial pressure (MAP) for 60 min; RES was return of shed blood/5 min and 2 volumes of saline/25 min. Hepatic blood flow (HBF) using galactose clearance, liver enzymes and complete metabolic panel were measured over 4 h after completion of RES. Results. Obese rats had increased MAP, heart rate, and fasting blood glucose and BUN concentrations compared to lean controls, required less blood withdrawal (mL/g) to maintain 40% MAP, and RES did not restore BL MAP. Obese rats had decreased HBF at BL and during HEM/RES, which persisted 4 h post RES. ALT and BUN were increased compared to Lean-HEM/RES at 4 h post-RES. Conclusion. These data suggest that obesity significantly contributes to trauma outcomes through compromised vascular control or through fat-induced sinusoidal compression to impair hepatic blood flow after HEM/RES resulting in a greater hepatic injury. The pro-inflammatory state of NAFLD seen in obesity appears to prime the liver for hepatic ischemia after resuscitated hemorrhagic shock, perhaps intensified by insidious and ongoing hepatic hypoperfusion established prior to the traumatic injury or shock.

Journal of Burn Care & Research

Introduction The United States continues to suffer from a serious epidemic of opioid use. Exposur... more Introduction The United States continues to suffer from a serious epidemic of opioid use. Exposure to opioids is a known risk factor for long-term use and dependence. This is of particular importance to burn care, as opioids are frequently essential to manage the pain associated with burn injuries. The purpose of this study was to characterize opioid use among burn patients after hospitalization and to identify any risk factors for long-term dependence. Methods All patients admitted to a burn center during a single year period (2/1/2020-2/1/21) were examined. Patients who died were excluded. A controlled substance reporting system was utilized to determine opioid use over a time period from 6 months prior to injury and up to 12 months post-hospital discharge. Reporting to this database is mandated by law and therefore includes all prescriptions regardless of prescriber, insurance, location, etc. Duration of opioid use was recorded for all patients in the study. Long-term use was def...

The American Surgeon, 2005

It has been previously reported that trauma patients with cirrhosis undergoing emergency abdomina... more It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and χ2were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantl...

The American Surgeon, 2007

Chest wall fractures, including injuries to the ribs and sternum, usually heal spontaneously with... more Chest wall fractures, including injuries to the ribs and sternum, usually heal spontaneously without specific treatment. However, a small subset of patients have fractures that produce overlying bone fragments that may produce severe pain, respiratory compromise, and, if untreated mechanically, result in nonunion. We performed open reduction and internal fixation on seven patients with multiple rib fractures—five in the initial hospitalization and two delayed—as well as 35 sternal fractures (19 immediate fixation and 16 delayed). Operative fixation was accomplished using titanium plates and screws in both groups of patients. All patients with rib fractures did well; there were no major complications or infections, and no plates required removal. Clinical results were excellent. There was one death in the sternal fracture group in a patient who was ventilator-dependent preoperatively and extubated himself in the early postoperative period. Otherwise, the results were excellent, with ...

The American Surgeon, 2007

One of the major lessons learned in the World War II experience with liver injuries was that bile... more One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2–18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic...

The American Surgeon, 2008

Nonoperative management of splenic trauma is now the most common treatment modality for splenic i... more Nonoperative management of splenic trauma is now the most common treatment modality for splenic injuries and splenectomy has almost disappeared in some trauma centers. Splenectomy for cancer staging is infrequently performed suggesting that the indications for splenectomy continue to evolve. We evaluated a state database to assess a communitywide experience with splenic surgery. International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were used to determine the indication for splenic surgery. Indications for splenic surgery were listed as trauma (injury codes), medical (hematological diseases, neoplasms, or procedures in which the spleen might be removed contiguously like distal pancreatectomy), or incidental (noncontiguous procedures). Splenectomies for medical indications (n = 607, 43%) were more common than splenectomies for trauma (n = 518, 37%) or incidental splenectomies (n = 276, 20%). Splenectomy for medical reasons was associated with he...

The American Surgeon, 2009

The need for transplantable organs exceeds the available supply. Organ procurement organizations ... more The need for transplantable organs exceeds the available supply. Organ procurement organizations (OPOs) have undergone both voluntary and mandated changes to optimize available organs. The data from a single statewide OPO was reviewed from 1993 to 2008 and tracked with implementation of new protocols. During the study, 5548 organs were recovered with 4875 transplanted from 1441 donors (3.38 organs transplanted/donor (OTPD)). The conversion rate (CR) for consent rose from 42 to 72 per cent whereas the average age of donors increased from 33 to 45 years. After implementation of a family support liaison program, a higher performing hospital in the OPO realized an increase in CR from 57 to 97 per cent over 8 years. Implementation of an intensivist program improved OTPD. The number of standard criteria donors and extended criteria donors (ECD) increased. The increase in standard criteria donors yielded a large number of thoracic organs. ECD increased as did the organ discard rate from 8 ...

The American Surgeon, 2007

Blunt chest trauma produces a variety of injuries. We present a case report of a hemodynamically ... more Blunt chest trauma produces a variety of injuries. We present a case report of a hemodynamically stable patient after blunt chest trauma with radiographic images suggestive of the left fifth rib penetration to the heart. The diagnosis, surgical approach, and course of the patient are discussed.

Journal of the American College of Surgeons, Jan 27, 2017

Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trau... more Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trauma patients requiring damage control surgery (DCS). These data represent the outcome of a single institution RCT into the efficacy of PR as a management option in these patients. From 2011-2015, 103 patients were enrolled in a prospective RCT evaluating the utility of PR in the treatment of patients undergoing DCS compared to conventional resuscitation (CR) alone. Patient demographics, clinical variables and outcomes were collected. Univariate and multivariate analysis was performed with a priori significance at p ≤ 0.05. After initial screening 52 randomized to PR group and 51 to the CR group. Age, gender, initial pH, and mechanism of injury were used for randomization. Method of abdominal closure was standardized across groups. Time to definitive abdominal closure was reduced in the PR group compared to the CR group (4.1 ± 2.2 days vs 5.9 ± 3.5 days, p ≤ 0.002). Volume of resuscitation...

Transplant Research and Risk Management, 2016

There is a disparity between the number of kidneys available for transplantation and the number o... more There is a disparity between the number of kidneys available for transplantation and the number of patients awaiting an organ while on dialysis. The current kidney waiting list in the US contains more than 100,000 patients. This need has led to the inclusion of older donors with worsening renal function, as well as greater utilization of kidneys from non-heartbeating (donation after cardiac death) donors. Coinciding with this trend has been a growing interest in technology to improve the function of these more marginal organs, the most important of which currently is machine perfusion (MP) of donated kidneys after procurement. While this technology has no standard guidelines currently for comprehensive use, there are many studies that demonstrate higher organ yield and function after a period of MP. Particularly with the older donor and during donation after cardiac death cases, MP may offer some significant benefits. This manuscript reviews all of the current literature regarding MP and its role in renal transplantation. We will discuss both the experience in Europe and the US using machine perfusion for donated kidneys.

B52. VENTILATOR ASSOCIATED AND NOSOCOMIAL PNEUMONIA, 2010

Background: Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring more than 48 ... more Background: Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring more than 48 hours after initiation of mechanical ventilation. It is the most common nosocomial infection in the ICU, and increases mortality. Guidelines for therapy of VAP suggest the use of narrow spectrum antibiotics in patients for early-onset VAP, because multi-drug resistant bacteria are unlikely in these patients. However, data is limited to support such recommendations. The objective of this study was to define the incidence and etiology of early-VAP versus late-VAP. Methods: With the IRB approval of University of Louisville, we reviewed the medical records of 168 patients who were mechanically ventilated for more than 48 hours. VAP was diagnosed by the CDC criteria. Early-VAP was defined as development of VAP during the initial 6 days of intubation, and late-VAP was considered >6 days of intubation and mechanical ventilation. VAP incidence was calculated using 1,000 ventilator-days and compared using Z-statistics. Incidence of multi-drug resistsant bacteria was calculated for patients with early-VAP and late-VAP, Results: The incidence of early-VAP was 40/1,000 vent-days, and late-VAP incidence was 14/1,000 vent-days (P=0.002). Multi-drug resistant organisms were identified in 46% of early-VAP and 77% of late-VAP. Conclusion: The risk for the development of VAP is significantly higher during the initial days of mechanical ventilation. Interestingly, multi-drug resistant organisms caused early-VAP very frequently. Therefore, the presence of early-VAP by itself cannot support the use of narrow-spectrum empiric antibiotherapy.

Journal of Trauma and Acute Care Surgery, 2014

BACKGROUND: The success of damage-control surgery (DCS) for the treatment of trauma has led to it... more BACKGROUND: The success of damage-control surgery (DCS) for the treatment of trauma has led to its use in other surgical problems such as abdominal sepsis. Previous studies using direct peritoneal resuscitation (DPR) for the treatment of trauma have yielded promising results. We present the results of the application of this technique to patients experiencing abdominal sepsis. METHODS: We enrolled 88 DCS patients during a 5 year-period (January 2008 to December 2012) into a propensity-matched study to evaluate the utility of using DPR in addition to standard resuscitation. DPR consisted of peritoneal lavage with 2.5% DELFLEX, and abdominal closure was standardized across both groups. Patients were matched using Acute Physiology and Chronic Health Evaluation II (APACHE II) variables. Univariate and multivariate analyses were performed. RESULTS: There were no differences between the control and experimental groups with regard to age, sex, ethnicity, or APACHE II at 24 hours. Indications for damage control included pancreatitis, perforated hollow viscous, bowel obstruction, and ischemic enterocolitis. Patients undergoing DPR had both a higher rate of (68% vs. 43%, p G 0.03) and a shorter time to definitive fascial closure (5.9 [3.2] days vs. 7.7 [4.1] days, p G 0.02). DPR patients had a decreased APACHE II and Sequential Organ Failure Assessment (SOFA) score compared with the controls at 48 hours. In addition, DPR patients had fewer abdominal complications compared with the controls (RR, 0.57; 95% confidence interval, 0.32Y1.01; p = 0.038). Ventilator days and intensive care unit length of stay were both significantly reduced in the DPR group. The DPR group showed a lower overall mortality at 30 days (16% vs. 27%, p = 0.15). CONCLUSION: DPR reduces time to definitive abdominal closure, increases primary fascial closure, and reduces intra-abdominal complications following DCS. DPR may also attenuate progressive physiologic injury as demonstrated by a reduction in 48-hour intensive care unit severity scores. As a result, DPR following DCS may afford better outcomes to patients experiencing shock.

Journal of the American College of Surgeons, 2015

Brain dead organ donors have altered central hemodynamic performance, impaired hormone physiology... more Brain dead organ donors have altered central hemodynamic performance, impaired hormone physiology, exaggerated systemic inflammatory response, end-organ microcirculatory dysfunction, and tissue hypoxia. A new treatment, direct peritoneal resuscitation (DPR), stabilizes vital organ blood flow after conventionally resuscitated shock to improve these derangements. A prospective case-control study of adjunctive DPR compared 26 experimental patients (brain dead organ donors) to 52 controls (protocolized conventionally resuscitated donors). Actual organ procurement rates were compared with the Scientific Registry of Transplant Recipient predicted organ yield per patient. Achievement of donor management goals and effective hepatic blood flow were recorded. Fourteen of 26 (53.8%) patients treated with DPR achieved all donor management goals compared with 17 of 52 (32.7%) patients treated with conventionally resuscitated (odds ratio = 2.4; 95% CI, 0.92-6.3; p = 0.06). Patients treated with DPR were more than 2 times as likely to achieve final pO2 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;100 on 40% FiO2 compared with controls (odds ratio = 2.8; 95% CI, 1-7.69; p = 0.03). Also, DPR-treated patients required less IV crystalloid during the first 12 hours of management (DPR: 3,167 ± 1,893 mL vs 4,154 ± 2,100 mL; p = 0.046) and required less vasopressor agents at 12 hours post resuscitation (odds ratio = 7.7; 95% CI, 0.82-42; p = 0.02). Direct peritoneal resuscitation patients had enhanced effective hepatic blood flow and significantly higher organs transplanted per donor rates compared with controls (3.7 ± 1.7 vs 3.1 ± 1.3; p = 0.024). Direct peritoneal resuscitation reduced IV fluid requirement and IV pressor use as well as increased hepatic blood flow and organs transplanted per donor. Direct peritoneal resuscitation studies show it to be a safe, effective method to augment organ donor resuscitation and additional large-scale trials should be conducted to validate these findings.

JPEN. Journal of parenteral and enteral nutrition, Jan 4, 2014

Background: Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize tha... more Background: Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize that targeted physician education should help reduce caloric deficits and improve patient outcomes. Materials and Methods: We performed a prospective trial of patients (n = 121) assigned to 1 of 2 trauma groups. The experimental group (EG) received targeted education consisting of strategies to increase delivery of early enteral nutrition. Strategies included early enteral access, avoidance of nil per os (NPO) and clear liquid diets (CLD), volume-based feeding, early resumption of feeds postprocedure, and charting caloric deficits. The control group (CG) did not receive targeted education but was allowed to practice in a standard ad hoc fashion. Both groups were provided with dietitian recommendations on a multidisciplinary nutrition team per standard practice. Results: The EG received a higher percentage of measured goal calories (30.1 ± 18.5%, 22.1 ± 23.7%, P = .024) compared with the CG....

The American Journal of Surgery, 2014

BACKGROUND: Stops at nontrauma centers for severely injured patients are thought to increase deat... more BACKGROUND: Stops at nontrauma centers for severely injured patients are thought to increase deaths and costs, potentially because of unnecessary imaging and indecisive/delayed care of traumatic brain injuries (TBIs). METHODS: We studied 754 consecutive blunt trauma patients with an Injury Severity Score greater than 20 with an emphasis on 212 patients who received care at other sites en route to our level 1 trauma center. RESULTS: Referred patients were older, more often women, and had more severe TBI (all P , .05). After correction for age, sex, and injury pattern, there was no difference in the type of TBI, Glasgow Coma Scale (GCS) upon arrival at the trauma center, or overall mortality between referred and directly admitted patients. GCS at the outside institution did not influence promptness of transfer. CONCLUSIONS: Interhospital transfer does not affect the outcome of blunt trauma patients. However, the unnecessarily prolonged stay of low GCS patients in hospitals lacking neurosurgical care is inappropriate.

Surgery, 2009

Background. Obese patients (BMI>35) after blunt trauma are at increased risk compared to non-obes... more Background. Obese patients (BMI>35) after blunt trauma are at increased risk compared to non-obese for organ dysfunction, prolonged hospital stay, infection, prolonged mechanical ventilation, and mortality. Obesity and non-alcoholic fatty liver disease (NAFLD) produce a low grade systemic inflammatory response syndrome (SIRS) with compromised hepatic blood flow, which increases with body mass index. We hypothesized that obesity further aggravates liver dysfunction by reduced hepatic perfusion following resuscitated hemorrhagic shock (HEM). Methods. Age-matched Zucker rats (Obese, 314-519 g & Lean, 211-280 g) were randomly assigned to 4 groups (n = 10-12/group): (1) Lean-Sham; (2) Lean, HEM, and resuscitation (HEM/RES); (3) Obese-Sham; and (4) Obese-HEM/RES. HEM was 40% of mean arterial pressure (MAP) for 60 min; RES was return of shed blood/5 min and 2 volumes of saline/25 min. Hepatic blood flow (HBF) using galactose clearance, liver enzymes and complete metabolic panel were measured over 4 h after completion of RES. Results. Obese rats had increased MAP, heart rate, and fasting blood glucose and BUN concentrations compared to lean controls, required less blood withdrawal (mL/g) to maintain 40% MAP, and RES did not restore BL MAP. Obese rats had decreased HBF at BL and during HEM/RES, which persisted 4 h post RES. ALT and BUN were increased compared to Lean-HEM/RES at 4 h post-RES. Conclusion. These data suggest that obesity significantly contributes to trauma outcomes through compromised vascular control or through fat-induced sinusoidal compression to impair hepatic blood flow after HEM/RES resulting in a greater hepatic injury. The pro-inflammatory state of NAFLD seen in obesity appears to prime the liver for hepatic ischemia after resuscitated hemorrhagic shock, perhaps intensified by insidious and ongoing hepatic hypoperfusion established prior to the traumatic injury or shock.

The Journal of Trauma: Injury, Infection, and Critical Care, 2005

Background: The implementation of revised surgical resident work hours has led many teaching hosp... more Background: The implementation of revised surgical resident work hours has led many teaching hospitals to integrate health care extenders into the trauma service. We undertook this review to assess the effectiveness of these individuals in meeting the goals of the work hour restrictions and whether they impact other hospital and patient outcomes. Methods: During the year 2002, we integrated two nurse practitioners into the trauma service of a teaching hospital. We prospectively collected data a year before (2001), during (2002), and a year after (2003) the integration that included number of admissions, hospital length of stay, intensive care stay, floor length of stay, mortality, direct cost per case, and weekly resident work hours on 44 residents at all levels. Results: After the incorporation of physician extenders, we observed statistically significant reductions in floor, intensive care unit, and overall hospital lengths of stay. Patient mortality and cost per patient remained unchanged. Furthermore, we were able to obtain compliance with the Accreditation Council for Graduate Medical Education requirements for residency work hour limitations, as the average number of hours worked per resident on the trauma service decreased from 86 hours to 79 hours per week. Conclusion: As graduate medical education becomes ever more regulated, physician extenders can be successfully integrated into busy academic Level I trauma centers. This integration positively impacts patient flow and resident work hours without altering patient outcomes or direct hospital cost.