Ara Ko, MD, MPH

All Publications

• Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma. The American surgeon Ko, A., Radding, S., Feliciano, D. V., DuBose, J. J., Kozar, R. A., Morrison, J., Kundi, R., Maddox, J., Scalea, T. M. 2021: 31348211050591

  Abstract

  BACKGROUND: Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy.METHODS: The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369).RESULTS: From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared.CONCLUSION: The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be "lost arts" in modern trauma care.

  View details for DOI 10.1177/00031348211050591

  View details for PubMedID 34732074

• Advances in Appropriate Postoperative Triage and the Role of Real-time Machine-Learning Models: The Goldilocks Dilemma. JAMA network open Ko, A., Wren, S. M. 2021; 4 (11): e2133843

  View details for DOI 10.1001/jamanetworkopen.2021.33843

  View details for PubMedID 34757414

• LASER Fenestration of Thoracic Endoluminal Stent Grafts for Preservation of the Left Subclavian Artery. The journal of trauma and acute care surgery Keville, M. P., Ko, A., Dubose, J. J., Kundi, R., Scalea, T. M., Morrison, J. J. 2021; 91 (1): e13-e17

  View details for DOI 10.1097/TA.0000000000003212

  View details for PubMedID 34144569

• Chest Wall Analgesia-Where Do We Go From Here? JAMA network open Bessoff, K. E., Ko, A., Forrester, J. D. 2021; 4 (11): e2133839

  View details for DOI 10.1001/jamanetworkopen.2021.33839

  View details for PubMedID 34779854

• Transfusion of blood components containing ABO-incompatible plasma does not lead to higher mortality in civilian trauma patients. Transfusion Seheult, J. N., Dunbar, N. M., Hess, J. R., Tuott, E. E., Bahmanyar, M., Campbell, J., Fontaine, M., Khan, J., Ko, A., Mi, J., Murphy, M. F., Nykoluk, T., Poisson, J., Raval, J. S., Shih, A., Sperry, J. L., Staves, J., Wong, M., Yan, M. T., Ziman, A., Yazer, M. H. 2020; 60 (11): 2517-2528

  Abstract

  This study investigated the effect on mortality of transfusing ABO-incompatible plasma from all sources during trauma resuscitation.Demographic, transfusion, and survival data were retrospectively extracted on civilian trauma patients. Patients were divided by receipt of any quantity of ABO-incompatible plasma from any blood product (incompatible group) or receipt of solely ABO-compatible plasma (compatible group). The primary outcome was 30-day mortality, while other outcomes included 6- and 24-hour mortality. Mixed-effects logistic regression was used to model the effect of various predictor variables, including receipt of incompatible plasma, on mortality outcomes.Nine hospitals contributed data on a total of 2618 trauma patients. There were 1282 patients in the incompatible group and 1336 patients in the compatible group. In both the unadjusted and adjusted models, the 6-hour, 24-hour, and 30-day mortality rates were not significantly different between these groups. The patients in the incompatible group were then divided into high volume (>342 mL) and low volume (≤342 mL) incompatible plasma recipients. In the adjusted model, the high-volume group had higher 24-hour mortality when the Trauma Injury Severity Score survival prediction was >50%. Mortality at 6 hours and 30 days was not higher in this model. The low-volume group did not have increased mortality at any of the time points in this adjusted model.The transfusion of incompatible plasma in civilian trauma resuscitation does not lead to higher 30-day mortality. The finding of higher mortality in a select group of recipients in the secondary analysis warrants further study.

  View details for DOI 10.1111/trf.16008

  View details for PubMedID 32901965

• Endovascular adjuncts for hybrid liver surgery. The journal of trauma and acute care surgery Belyayev, L., Herrold, J. A., Ko, A., Kundi, R., DuBose, J. J., Scalea, T. M., Morrison, J. J. 2020; 89 (3): e51-e54

  View details for DOI 10.1097/TA.0000000000002817

  View details for PubMedID 32472903

• Helicopter Transport Use for Trauma Patients Is Decreasing Significantly Nationwide but Remains Overutilized. The American surgeon Dhillon, N. K., Linaval, N. T., Patel, K. A., Colovos, C., Ko, A., Margulies, D. R., Ley, E. J., Barmparas, G. 2018; 84 (10): 1630-1634

  Abstract

  Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 (P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period (P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.

  View details for PubMedID 30747684

• Failure to rescue the elderly: a superior quality metric for trauma centers. European journal of trauma and emergency surgery : official publication of the European Trauma Society Barmparas, G., Ley, E. J., Martin, M. J., Ko, A., Harada, M., Weigmann, D., Catchpole, K. R., Gewertz, B. L. 2018; 44 (3): 377-384

  Abstract

  Trauma centers require reliable metrics to better compare the quality of care delivered. We compared mortality after a reported complication, termed failure to rescue (FTR), and FTR in the elderly (age >65 years) (FTRE) to determine which is a superior metric to assess quality of care delivered by trauma centers.This was a retrospective review of the National Trauma Databank (NTDB) research data sets 2010 and 2011. Patients ≥16 years admitted to centers reporting ≥80% of AIS and/or ≥ 20% of comorbidities with > 200 subjects in the NTDB were selected. Centers were classified based on the rate of FTR and FTRE (<5 vs. 5-14 vs. ≥15%). The primary outcome was adjusted mortality for each group of trauma centers based on FTR and FTRE classifications.The overall mean ± SD FTR rate was 7.2 ± 5.2% and FTRE was 10.4 ± 7.9%. The adjusted odds ratio (AOR) for mortality was not different when centers with FTR <5% were compared to those with FTR of 5-14 or ≥15%. In contrast, a stepwise increase in FTRE predicted a significantly higher mortality when centers with FTRE 5% were compared to those with 5-14% (AOR: 1.05, p = 0.031) and ≥15% (AOR: 1.13, p < 0.001). Similarly, stepwise increase in FTRE predicted higher adjusted mortality for severely and critically injured patients, whereas FTR did not.Higher FTRE predicts increased adjusted mortality better than FTR after trauma and should, therefore, be considered an important metric when comparing quality care delivered by trauma centers.

  View details for DOI 10.1007/s00068-017-0782-x

  View details for PubMedID 28331951

• The Effect of Early Positive Cultures on Mortality in Ventilated Trauma Patients. Surgical infections Barmparas, G., Harada, M. Y., Ko, A., Dhillon, N. K., Smith, E. J., Li, T., Mohseni, S., Ley, E. J. 2018; 19 (4): 410-416

  Abstract

  The purpose was to examine the incidence of positive cultures in a highly susceptible subset of trauma patients admitted to the surgical intensive care unit (SICU) for mechanical ventilation and to examine the impact of their timing on outcomes.A retrospective review was conducted of blunt trauma patients admitted to the SICU for mechanical ventilation at a level I trauma center over a five-year period. All urine, blood, and sputum cultures were abstracted. Patients with at least one positive culture were compared with those with negative or no cultures. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to calculate the adjusted hazard ratio (AHR).The median age of 635 patients meeting inclusion criteria was 46 and 74.2% were male. A total of 298 patients (46.9%) had at least one positive culture, with 28.9% occurring within two days of admission. Patients with positive cultures were more likely to be severely injured with an injury severity score (ISS) ≥16 (68.5% vs. 45.1%, p < 0.001). Overall mortality was 22%. Patients who had their first positive culture within two and three days from admission had a significantly higher AHR for mortality (AHR: 14.46, p < 0.001 and AHR: 10.59, p = 0.028, respectively) compared to patients with a positive culture at day six or later.Early positive cultures are common among trauma patients requiring mechanical ventilation and are associated with higher mortality. Early identification with "damage control cultures" obtained on admission to aid with early targeted treatment might be justified.

  View details for DOI 10.1089/sur.2017.268

  View details for PubMedID 29608419

• Impact of early positive cultures in the elderly with traumatic brain injury. The Journal of surgical research Dhillon, N. K., Tseng, J., Barmparas, G., Harada, M. Y., Ko, A., Smith, E. J., Thomsen, G. M., Ley, E. J. 2018; 224: 140-145

  Abstract

  Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in the United States, especially in the elderly, who have the highest rates of TBI-related hospitalizations and deaths among all age groups. Sepsis is one of many risk factors that is associated with higher mortality and longer length of hospital stay in this population partially due to the immunosuppressive effects of TBI. The significance of early indicators of infection, such as a positive blood, sputum, or urine culture, is not well described. The purpose of this study was to determine if early positive cultures predict higher mortality in elderly patients with TBI.All trauma patients aged ≥65 years with TBI, admitted between January 1, 2009 and December 31, 2013 to the surgical intensive care unit, were retrospectively reviewed. Clinical data including results from sputum, blood, and urine cultures were reviewed.Overall, 288 elderly patients with TBI were identified, and 92 (32%) had a positive culture. Patients with positive cultures had longer intensive care unit (median 6.0 versus 2.0 days, P < 0.001) and ventilation days (median 7.0 versus 2.0 days, P < 0.001). Patients who had positive cultures within 2-3 days of admission had a higher adjusted hazard ratio for mortality than those patients who had positive cultures after 6 or more days.In elderly patients with TBI, early positive cultures are associated with a higher risk of mortality. Further research is required to determine the role of obtaining cultures on admission in this subpopulation of trauma patients.

  View details for DOI 10.1016/j.jss.2017.11.031

  View details for PubMedID 29506830

• The risk factors of venous thromboembolism in massively transfused patients. The Journal of surgical research Dhillon, N. K., Smith, E. J., Ko, A., Harada, M. Y., Yang, A. R., Patel, K. A., Barmparas, G., Ley, E. J. 2018; 222: 115-121

  Abstract

  Massive transfusion protocols (MTPs) are necessary for hemodynamically unstable trauma patients with active bleeding. Thrombotic events have been associated with blood transfusion; however, the risk factors for the development of venous thromboembolism (VTE) in trauma patients receiving MTP are unknown.A retrospective review was conducted by reviewing the electronic medical records of all trauma patients admitted to a Level I trauma center who received MTP from 2011 to 2016. Data were collected on patient demographics, mechanism of injury, injury severity scores, quantity of blood products transfused during MTP activation, incidence of VTE, intensive care unit length of stay (LOS), hospital LOS, and ventilator days. The primary outcome was VTE.Of the 59 patients who had MTP activated, 15 (25.4%) developed a VTE during their hospital admission. Patients who developed VTE were compared with those who did not. Age (40 y versus 35 y, P = 0.59), sex (60% versus 73% male, P = 0.52), and mechanism of injury (47% versus 59% blunt, P = 0.40) were similar. Intensive care unit LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE. Multivariable analysis revealed an increase in the odds for developing a VTE with increasing packed red blood cell transfusion (adjusted odds ratio = 2.61, P = 0.03).The risk for VTE in trauma patients requiring massive transfusion is proportional to the number of packed red blood cells transfused. Liberal screening protocols and maintenance of a high index of suspicion for VTE in these high-risk patients is justified.

  View details for DOI 10.1016/j.jss.2017.09.038

  View details for PubMedID 29273362

• Weaker gun state laws are associated with higher rates of suicide secondary to firearms. The Journal of surgical research Alban, R. F., Nuño, M., Ko, A., Barmparas, G., Lewis, A. V., Margulies, D. R. 2018; 221: 135-142

  Abstract

  Firearm-related suicides comprise over two-thirds of gun-related violence in the United States, and gun laws and policies remain under scrutiny, with many advocating for revision of the regulatory map for lawful gun ownership, aiming at restricting access and distribution of these weapons. However, the quantitative relationship between how strict gun laws are and the incidence of firearm violence with their associated mortality is largely unknown. We therefore, sought to explore the impact of firearm law patterns among states on the incidence and outcomes of firearm-related suicide attempts, utilizing established objective criteria.The National Inpatient Sample for the years 1998-2011 was queried for all firearm-related suicides. Discharge facilities were stratified into five categories (A, B, C, D, and F, with A representing states with the most strict and F representing states with the least strict laws) based on the Brady Campaign to prevent Gun Violence that assigns scorecards for every state. The primary outcomes were suicide attempts and in-hospital mortality per 100,000 populations by Brady state grade.During the 14-year study period, 34,994 subjects met inclusion criteria. The mean age was 42.0 years and 80.1% were male. A handgun was utilized by 51.8% of patients. The overall mortality was 33.3%. Overall, 22.0% had reported psychoses and 19.3% reported depression. After adjusting for confounding factors and using group A as reference, there were higher adjusted odds for suicide attempts for patients admitted in group C, D, and F category states (1.73, 2.09, and 1.65, respectively, all P < 0.001).Firearm-related suicide attempt injuries are more common in states with less strict gun laws, and these injuries tend to be associated with a higher mortality. Efforts aimed at nationwide standardization of firearm state laws are warranted, particularly for young adults and suicide-prone populations.III.Trauma Outcomes study.

  View details for DOI 10.1016/j.jss.2017.08.027

  View details for PubMedID 29229119

• Is Routine Continuous EEG for Traumatic Brain Injury Beneficial? The American surgeon Aquino, L., Kang, C. Y., Harada, M. Y., Ko, A., Do-Nguyen, A., Ley, E. J., Margulies, D. R., Alban, R. F. 2017; 83 (12): 1433-1437

  Abstract

  Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and subclinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of "routine" cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.

  View details for PubMedID 29336768

• Limit Crystalloid Resuscitation after Traumatic Brain Injury. The American surgeon Ko, A., Harada, M. Y., Barmparas, G., Smith, E. J., Birch, K., Barnard, Z. R., Yim, D. A., Ley, E. J. 2017; 83 (12): 1447-1452

  Abstract

  Patients with traumatic brain injury (TBI) are often resuscitated with crystalloids in the emergency department (ED) to maintain cerebral perfusion. The purpose of this study was to evaluate whether crystalloid resuscitation volume impacts mortality in TBI patients. This was a retrospective study of trauma patients with head abbreviated injury scale score ≥2, who received crystalloids during ED resuscitation between 2004 and 2013. Clinical characteristics and volume of crystalloids received in the ED were collected. Patients who received <2 L of crystalloids were categorized as low volume (LOW), whereas those who received ≥2 L were considered high volume (HIGH). Mortality and outcomes were compared. Multivariable regression analysis was used to determine the odds of mortality while controlling for confounders. Over 10 years, 875 patients met inclusion criteria. Overall mortality was 12.5 per cent. Seven hundred and forty-two (85%) were in the LOW cohort and 133 (15%) in the HIGH cohort. Gender and age were similar between the groups. The HIGH cohort had lower admission systolic blood pressure (128 vs 138 mm Hg, P = 0.001), lower Glasgow coma scale score (10 vs 12, P < 0.001), higher head abbreviated injury scale (3.8 vs 3.3, P < 0.001), and higher injury severity score (25 vs 18, P < 0.001). The LOW group had a lower unadjusted mortality (10 vs 26%, P < 0.001). Multivariable analysis adjusting for confounders demonstrated that those resuscitated with ≥2 L of crystalloids had increased odds of mortality (adjusted odds ratio 2.25, P = 0.005). Higher volume crystalloid resuscitation after TBI is associated with increased mortality, thus limited resuscitation for TBI patients may be indicated.

  View details for PubMedID 29336770

• Refusal of cervical spine immobilization after blunt trauma: Implications for initial evaluation and management: A retrospective cohort study. International journal of surgery (London, England) Tatum, J. M., Dhillon, N. K., Ko, A., Smith, E. J., Melo, N., Barmparas, G., Ley, E. J. 2017; 48: 228-231

  Abstract

  Rigid cervical collars are routinely placed in the pre-hospital setting after significant blunt trauma. Patients who are deemed competent by field personnel (Glasgow Coma Scale (GCS) ≥13, no major distracting injury and not grossly intoxicated) may refuse cervical collar placement.A retrospective review was conducted of all adult trauma patients presenting to a Level 1 trauma center after blunt trauma with a GCS≥13 and no distracting injury or gross intoxication from January 2014 to December 2014. Pre-hospital data was collected from emergency medical service reports and hospital data from patient charts. Cervical spine injury was identified by International Classification of Disease-9th Revision codes. Patients refusing cervical spine immobilization prior to arrival are compared to those who were compliant.A total of 629 patients met inclusion criteria. Cervical spine immobilization was refused by 28 patients, while 601 complied. There were 16 cervical spine injuries (2.5%), with 3 (10.7%) in noncompliant patients and 13 (2.2%) among those who were complaint (p = 0.03).The incidence of cervical spine injuries in patients refusing cervical collar immobilization is higher than in compliant patients. Patients arriving for initial evaluation having refused cervical collar immobilization should be treated with caution.

  View details for DOI 10.1016/j.ijsu.2017.11.027

  View details for PubMedID 29155232

• Potentially Avoidable Surgical Intensive Care Unit Admissions and Disposition Delays. JAMA surgery Dhillon, N. K., Ko, A., Smith, E. J., Kharabi, M., Castongia, J., Nurok, M., Gewertz, B. L., Ley, E. J. 2017; 152 (11): 1015-1022

  Abstract

  High health care costs encourage initiatives that avoid overuse of resources and identify opportunities to promote appropriate care.To investigate the causes of potentially avoidable surgical intensive care unit (SICU) admissions and disposition delays to determine whether targeted interventions could decrease these stays.This prospective, observational study focused on potentially avoidable SICU days, as determined by observers with input from the rounding intensivists at a 24-bed open SICU at an urban, academic hospital. The preintervention phase occurred from April 6 through June 21, 2015; after implementation of targeted interventions, the postintervention phase occurred from April 4 through June 28, 2016. Data collected included demographic characteristics, reason for admission, and length of stay. All patients admitted to the SICU during the preintervention and postintervention phases were included in the analysis.Based on results collected in the preintervention phase, targeted interventions were designed and implemented from July 1, 2015, through March 31, 2016, including (1) reducing SICU care for minor traumatic brain injury, (2) optimizing postoperative airway management, (3) enhancing communication between services regarding transfers to the SICU, (4) identifying and facilitating more timely end-of-life conversations and supportive care consultations, and (5) encouraging early disposition of patients to floor beds.Changes in the proportion of potentially avoidable SICU days owing to potentially avoidable admissions and/or disposition delays.A total of 459 patients (253 men [55.1%] and 206 women [44.9%]; median age, 62 years [interquartile range, 46-75 years]) were admitted during the preintervention and postintervention phases. Of 261 patients admitted during the preintervention period and 245 during the postintervention period, median SICU and hospital length of stay remained unchanged. A reduction was noted in the percentage of postintervention SICU days owing to potentially avoidable admissions (152 of 1168 days [13%] vs 118 of 1338 days [8.8%]; P = .001) and disposition delays (138 of 1168 days [11.8%] vs 97 of 1338 days [7.2%]; P < .001). During the postintervention period, decreases were noted in the SICU days related to the most common sources of potentially avoidable admissions (SICU stay ≤24 hours, airway concerns, and somnolence) and disposition delays (end-of-life decisions and floor bed unavailable) as well as in the overall rate of potentially avoidable days (269 of 1168 days [23%] vs 205 of 1338 days [15.3%]; P < .001).Nearly one-fourth of SICU days could be categorized as potentially avoidable. Targeted interventions resulted in a significant reduction of potentially avoidable SICU days.

  View details for DOI 10.1001/jamasurg.2017.2165

  View details for PubMedID 28724143

  View details for PubMedCentralID PMC5710417

• Extreme Interventions for Trauma Patients in Extremis: Variations among Trauma Centers. The American surgeon Barmparas, G., Ko, A., Dhillon, N. K., Tatum, J. M., Choi, M., Ley, E. J., Margulies, D. R. 2017; 83 (10): 1033-1039

  Abstract

  Although guidelines for the performance of an emergency department thoracotomy (EDT) are available, high level evidence remains scarce potentially leading to variation in decisions and practices among trauma surgeons. The National Trauma Databank was queried for all subjects who died in the emergency department (ED) between 2007 and 2011. Trauma centers were divided into four quartiles based on the rate of EDT among ED deaths. A total of 31,623 subjects admitted to 729 trauma centers met inclusion criteria. Most of of these centers (n = 328, 53%) never performed an EDT during the study period. Very few outlier centers (1.1%) performed this procedure in 50.0 per cent or more of all patients who died in the ED. Trauma centers in the highest quartiles in performing EDT were more likely to intervene with both surgical and nonsurgical procedures in patients who died in the ED, independent of the performance of an EDT. There are significant variations among trauma centers in the management of trauma patients who expire in the ED. Further research at a national level toward standardizing the management of the trauma patient in extremis and the decision to perform an EDT is necessary, given the extremely low survival associated with this procedure.

  View details for PubMedID 29391090

• Analysis of Survival After Initiation of Continuous Renal Replacement Therapy in a Surgical Intensive Care Unit. JAMA surgery Tatum, J. M., Barmparas, G., Ko, A., Dhillon, N., Smith, E., Margulies, D. R., Ley, E. J. 2017; 152 (10): 938-943

  Abstract

  Continuous renal replacement therapy (CRRT) benefits patients with renal failure who are too hemodynamically unstable for intermittent hemodialysis. The duration of therapy beyond which continued use is futile, particularly in a population of patients admitted to and primarily cared for by a surgical service (hereinafter referred to as surgical patients), is unclear.To analyze proportions of and independent risk factors for survival to discharge after initiation of CRRT among patients in a surgical intensive care unit (SICU).This retrospective cohort study included all patients undergoing CRRT from July 1, 2012, through January 31, 2016, in an SICU of an urban tertiary medical center. The population included patients treated before or after general surgery and patients admitted to a surgical service during inpatient evaluation and care before liver transplant. The pretransplant population was censored from further survival analysis on receipt of a transplant.Continuous renal replacement therapy.Hospital mortality among patients in an SICU after initiation of CRRT.Of 108 patients (64 men [59.3%] and 44 women [40.7%]; mean [SD] age, 62.0 [12.7] years) admitted to the SICU, 53 were in the general surgical group and 55 in the pretransplant group. Thirteen of the 22 patients in the pretransplant group who required 7 or more days of CRRT died (in-hospital mortality, 59.1%); among the 12 patients in the general surgery group who required 7 or more days of CRRT, 12 died (in-hospital mortality, 100%). In the general surgical group, each day of CRRT was associated with an increased adjusted odds ratio of death of 1.39 (95% CI, 1.01-1.90; P = .04).Continuous renal replacement therapy is valuable for surgical patients with an acute and correctable indication; however, survival decreases significantly with increasing duration of CRRT. Duration of CRRT does not correlate with survival among patients awaiting liver transplant.

  View details for DOI 10.1001/jamasurg.2017.1673

  View details for PubMedID 28636702

  View details for PubMedCentralID PMC5710279

• Extubation to high-flow nasal cannula in critically ill surgical patients. The Journal of surgical research Dhillon, N. K., Smith, E. J., Ko, A., Harada, M. Y., Polevoi, D., Liang, R., Barmparas, G., Ley, E. J. 2017; 217: 258-264

  Abstract

  High-flow nasal cannula (HFNC) is increasingly used to reduce reintubations in patients with respiratory failure. Benefits include providing positive end expiratory pressure, reducing anatomical dead space, and decreasing work of breathing. We sought to compare outcomes of critically ill surgical patients extubated to HFNC versus conventional therapy.A retrospective review was conducted in the surgical intensive care unit of an academic center during August 2015 to February 2016. Data including demographics, ventilator days, oxygen therapy after extubation, reintubation rates, surgical intensive care unit and hospital length of stay, and mortality were collected. Self and palliative extubations were excluded. Characteristics and outcomes, with the primary outcome being reintubation, were compared between those extubated to HFNC versus cool mist/nasal cannula (CM/NC).Of the 184 patients analyzed, 46 were extubated to HFNC and 138 to CM/NC. Mean age and days on ventilation before extubation were 57.8 years and 4.3 days, respectively. Both cohorts were similar in age, sex, and had a similar prevalence of cardiopulmonary diagnoses at admission. Although prior to extubation HFNC had lengthier ventilation requirements (7.1 versus 3.4 days, P < 0.01) and ICU stays (7.8 versus 4.1 days, P < 0.01), the rate of reintubation was similar to CM/NC (6.5% versus 13.8%, P = 0.19). Multivariable analysis demonstrated HFNC to be associated with a lower risk of reintubation (adjusted odds ratio = 0.15, P = 0.02). Mortality rates were similar.Ventilated patients at risk for recurrent respiratory failure have reduced reintubation rates when extubated to HFNC. Patients with prolonged intubation or those with high-risk comorbidities may benefit from extubation to HFNC.

  View details for DOI 10.1016/j.jss.2017.06.026

  View details for PubMedID 28711371

• Decreased transport time to the surgical intensive care unit. International journal of surgery (London, England) Ko, A., Harada, M. Y., Dhillon, N. K., Patel, K. A., Kirillova, L. R., Kolus, R. C., Torbati, S., Ley, E. J. 2017; 42: 54-57

  Abstract

  Extended stay in the emergency department (ED) is associated with worse outcomes in critically ill trauma patients. We conducted a human factors analysis to better understand impediments for patient flow when a surgical ICU (SICU bed is available in order to reduce ED LOS.This is a retrospective review of all trauma patients admitted to a protected SICU through the ED during 2011 and 2014. In 2010, a 24-hour protected SICU bed protocol was implemented to make a bed readily available. During 2013 human factors analysis helped to describe flow disruptions; related interventions were introduced to facilitate rapid transport from the ED to SICU. The interventions required the following prior to CT scanning: immediate ICU bed orders placed by the ED physician and ED to ICU personnel communication. Direct transport from the CT scanner to the ICU was mandated. Data including patient demographics, injury severity, ED LOS, ICU LOS, and hospital LOS was collected and compared between 2011 (PRE) and 2014 (POST).A total of 305 trauma patients admitted from the ED to the SICU were analyzed; 174 patients in 2011 (PRE) and 131 in 2014 (POST). Average age was 46 years and patients had a mean admission GCS and injury severity score (ISS) of 12.3 and 15.9, respectively. The cohorts were similar in age, mechanism of injury, initial vital signs, and injury severity. After implementing the human factors interventions, decreases were noted in the mean ED LOS (2.4 v. 3.0 hours, p=0.005) and ICU LOS (4.0 v. 4.8 days, p=0.023). No differences in hospital LOS or mortality were observed.While an open SICU bed protocol may facilitate rapid transport of trauma patients from the ED to the ICU, additional human factors interventions emphasizing improved communication and coordination can further reduce time spent in the ED.Level IV, Economic/Decision.

  View details for DOI 10.1016/j.ijsu.2017.04.030

  View details for PubMedID 28428064

• Clinical correlates to assist with chronic traumatic encephalopathy diagnosis: Insights from a novel rodent repeat concussion model. The journal of trauma and acute care surgery Thomsen, G. M., Ko, A., Harada, M. Y., Ma, A., Wyss, L., Haro, P., Vit, J. P., Avalos, P., Dhillon, N. K., Cho, N., Shelest, O., Ley, E. J. 2017; 82 (6): 1039-1048

  Abstract

  Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease linked to repetitive head injuries. Chronic traumatic encephalopathy symptoms include changes in mood, behavior, cognition, and motor function; however, CTE is currently diagnosed only postmortem. Using a rat model of recurrent traumatic brain injury (TBI), we demonstrate rodent deficits that predict the severity of CTE-like brain pathology.Bilateral, closed-skull, mild TBI was administered once per week to 35 wild-type rats; eight rats received two injuries (2×TBI), 27 rats received five injuries (5×TBI), and 13 rats were sham controls. To determine clinical correlates for CTE diagnosis, TBI rats were separated based on the severity of rotarod deficits and classified as "mild" or "severe" and further separated into "acute," "short," and "long" based on age at euthanasia (90, 144, and 235 days, respectively). Brain atrophy, phosphorylated tau, and inflammation were assessed.All eight 2×TBI cases had mild rotarod deficiency, 11 5×TBI cases had mild deficiency, and 16 cases had severe deficiency. In one cohort of rats, tested at approximately 235 days of age, balance, rearing, and grip strength were significantly worse in the severe group relative to both sham and mild groups. At the acute time period, cortical thinning, phosphorylated tau, and inflammation were not observed in either TBI group, whereas corpus callosum thinning was observed in both TBI groups. At later time points, atrophy, tau pathology, and inflammation were increased in mild and severe TBI groups in the cortex and corpus callosum, relative to sham controls. These injury effects were exacerbated over time in the severe TBI group in the corpus callosum.Our model of repeat mild TBI suggests that permanent deficits in specific motor function tests correlate with CTE-like brain pathology. Assessing balance and motor coordination over time may predict CTE diagnosis.

  View details for DOI 10.1097/TA.0000000000001443

  View details for PubMedID 28520686

• Validation of a field spinal motion restriction protocol in a level I trauma center. The Journal of surgical research Tatum, J. M., Melo, N., Ko, A., Dhillon, N. K., Smith, E. J., Yim, D. A., Barmparas, G., Ley, E. J. 2017; 211: 223-227

  Abstract

  Spinal motion restriction (SMR) after traumatic injury has been a mainstay of prehospital trauma care for more than 3 decades. Recent guidelines recommend a selective approach with cervical spine clearance in the field when criteria are met.In January 2014, the Department of Health Services of the City of Los Angeles, California, implemented revised guidelines for cervical SMR after blunt mechanism trauma. Adult patients (aged ≥18 y) with an initial Glasgow Coma Scale (GCS) score of ≥13 presented to a single level I trauma center after blunt mechanism trauma over the following 1-y period were retrospectively reviewed. Demographics, injury data, and prehospital data were collected. Cervical spine injury (CSI) was identified by International Classification of Disease, Ninth Revision, codes.Emergency medical services transported 1111 patients to the emergency department who sustained blunt trauma. Patients were excluded if they refused c-collar placement or if documentation was incomplete. A total of 997 patients were included in our analysis with 172 (17.2%) who were selective cleared of SMR per protocol. The rate of Spinal Cord Injury was 2.2% (22/997) overall and 1.2% (2/172) in patients without SMR. The sensitivity and specificity of the protocol are 90.9% (95% confidence interval: 69.4-98.4) and 17.4% (95% confidence interval: 15.1-20.0), respectively, for CSI. Patients with CSI who arrived without immobilization having met field clearance guidelines, were managed without intervention, and had no neurologic compromise.Guidelines for cervical SMR have high sensitivity and low specificity to identify CSI. When patients with injuries were not placed on motion restrictions, there were no negative clinical outcomes.

  View details for DOI 10.1016/j.jss.2016.12.030

  View details for PubMedID 28501121

• Predictors of Mortality in the Critically Ill Cirrhotic Patient: Is the Model for End-Stage Liver Disease Enough? Journal of the American College of Surgeons Annamalai, A., Harada, M. Y., Chen, M., Tran, T., Ko, A., Ley, E. J., Nuno, M., Klein, A., Nissen, N., Noureddin, M. 2017; 224 (3): 276-282

  Abstract

  Critically ill cirrhotics require liver transplantation urgently, but are at high risk for perioperative mortality. The Model for End-stage Liver Disease (MELD) score, recently updated to incorporate serum sodium, estimates survival probability in patients with cirrhosis, but needs additional evaluation in the critically ill. The purpose of this study was to evaluate the predictive power of ICU admission MELD scores and identify clinical risk factors associated with increased mortality.This was a retrospective review of cirrhotic patients admitted to the ICU between January 2011 and December 2014. Patients who were discharged or underwent transplantation (survivors) were compared with those who died (nonsurvivors). Demographic characteristics, admission MELD scores, and clinical risk factors were recorded. Multivariate regression was used to identify independent predictors of mortality, and measures of model performance were assessed to determine predictive accuracy.Of 276 patients who met inclusion criteria, 153 were considered survivors and 123 were nonsurvivors. Survivor and nonsurvivor cohorts had similar demographic characteristics. Nonsurvivors had increased MELD, gastrointestinal bleeding, infection, mechanical ventilation, encephalopathy, vasopressors, dialysis, renal replacement therapy, requirement of blood products, and ICU length of stay. The MELD demonstrated low predictive power (c-statistic 0.73). Multivariate analysis identified MELD score (adjusted odds ratio [AOR] = 1.05), mechanical ventilation (AOR = 4.55), vasopressors (AOR = 3.87), and continuous renal replacement therapy (AOR = 2.43) as independent predictors of mortality, with stronger predictive accuracy (c-statistic 0.87).The MELD demonstrated relatively poor predictive accuracy in critically ill patients with cirrhosis and might not be the best indicator for prognosis in the ICU population. Prognostic accuracy is significantly improved when variables indicating organ support (mechanical ventilation, vasopressors, and continuous renal replacement therapy) are included in the model.

  View details for DOI 10.1016/j.jamcollsurg.2016.11.005

  View details for PubMedID 27887981

  View details for PubMedCentralID PMC6698376

• 10-Year trend in crystalloid resuscitation: Reduced volume and lower mortality. International journal of surgery (London, England) Harada, M. Y., Ko, A., Barmparas, G., Smith, E. J., Patel, B. K., Dhillon, N. K., Thomsen, G. M., Ley, E. J. 2017; 38: 78-82

  Abstract

  Liberal emergency department (ED) resuscitation after trauma may lead to uncontrolled hemorrhage, reduced organ perfusion, and compartment syndrome. Recent guidelines reduced the standard starting point for crystalloid resuscitation from 2 L to 1 L and emphasized "balanced" resuscitation. The purpose of this study was to characterize how an urban, Level 1 trauma center has responded to changes in crystalloid resuscitation practices over time and to describe associated patient outcomes.This is a retrospective review of trauma patients who sustained moderate to severe injury (ISS > 9) and received crystalloid resuscitation in the ED during 1/2004-12/2013 at an urban, Level 1 trauma center. Patient data collected included age, gender, Glasgow Coma Scale (GCS) score, initial systolic blood pressure (SBP), mechanism of injury, regional Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), volume of blood products and crystalloids administered in the ED. Patients who received <2 L of crystalloid were considered low-volume while those who received ≥2 L were high-volume patients. Clinical characteristics and outcomes were compared between high- and low-volume cohorts, and multivariate regression was used to adjust for confounders. Trend analysis examined changes in variables over time.1571 moderate to severely injured patients received crystalloid resuscitation; 1282 (82%) were low-volume and 289 (18%) were high-volume. Compared to high-volume patients, low-volume patients presented with a higher median SBP (134 vs. 122 mmHg, p < 0.001) and GCS (15 vs. 14, p < 0.001). Low-volume patients also had lower median ISS (15 vs. 19, p < 0.001). Unadjusted mortality was lower in the low-volume cohort (7% vs. 19%, p < 0.001). Multivariate analysis demonstrated that high-volume patients had increased odds of mortality compared to low-volume patients (AOR 1.88, p = 0.008). Decreased rates of high-volume resuscitation and overall mortality were demonstrated over the 10-year study period.The observed decrease in high-volume crystalloid resuscitations in the ED paralleled a reduction in mortality over the ten-year period. In addition, adjusted mortality was higher in those receiving high-volume resuscitation.

  View details for DOI 10.1016/j.ijsu.2016.12.073

  View details for PubMedID 28040501

• Surgical outcomes and failure-to-rescue events after colectomy in teaching hospitals: a nationwide analysis. American journal of surgery Ko, A., Aquino, L., Melo, N., Alban, R. F. 2016; 212 (6): 1133-1139

  Abstract

  The relationship between failure-to-rescue (FTR) after colectomy is not well understood, particularly in teaching institutions. We sought to examine this relationship using a large national database.Patients undergoing colectomy from 2010 to 2012 were identified in the Nationwide Inpatient Sample database. FTR events were defined as deaths following deep vein thrombosis or pulmonary embolism, sepsis, gastrointestinal bleed, acute myocardial infarction, acute kidney injury, pneumonia, respiratory failure, shock. We compared outcomes between teaching hospitals (TH) and nonteaching hospitals (NTH).A total of 220,369 patients underwent colectomy; 50.2% were performed at TH. Overall mortality was 3.7% with 96% of deaths attributed to at least one FTR event. More complications occurred in NTH, but there was no difference in mortality or FTR rates. However, TH had higher incidences of deep vein thrombosis or pulmonary embolism and sepsis leading to postoperative mortality, whereas NTH had higher rates of acute myocardial infarction and gastrointestinal bleed.A substantial proportion of mortality is attributed to FTR events after colectomy in both TH and NTH. Further investigation targeting specific complications is warranted.

  View details for DOI 10.1016/j.amjsurg.2016.08.019

  View details for PubMedID 27765178

• A model of recurrent concussion that leads to long-term motor deficits, CTE-like tauopathy and exacerbation of an ALS phenotype. The journal of trauma and acute care surgery Thomsen, G. M., Ma, A. M., Ko, A., Harada, M. Y., Wyss, L., Haro, P. S., Vit, J. P., Shelest, O., Rhee, P., Svendsen, C. N., Ley, E. J. 2016; 81 (6): 1070-1079

  Abstract

  Concussion injury is the most common form of traumatic brain injury (TBI). How recurrent concussions alter long-term outcomes is poorly understood, especially as related to the development of neurodegenerative disease. We evaluated the functional and pathological consequences of repeated TBI over time in wild type (WT) rats as well as rats harboring the human SOD1 mutation ("SOD1"), a model of familial amyotrophic lateral sclerosis (ALS).A total of 42 rats, 26 WT and 16 SOD1, were examined over a study period of 25 weeks (or endpoint). At postnatal day 60, 20 WT and 7 SOD1 rats were exposed to mild, bilateral TBI once per week for either 2 weeks (2×TBI) or 5 weeks (5×TBI) using a controlled cortical impact device. Six WT and nine SOD1 rats underwent sham injury with anesthesia alone. Twenty WT rats were euthanized at 12 weeks after first injury and six WT rats were euthanized at 25 weeks after first injury. SOD1 rats were euthanized when they reached ALS disease endpoint. Weekly body weights and behavioral assessments were performed. Tauopathy in brain tissue was analyzed using immunohistochemistry.2XTBI injured rats initially demonstrated recovery of motor function but failed to recover to baseline within the 12-week study period. Relative to both 2XTBI and sham controls, 5XTBI rats demonstrated significant deficits that persisted over the 12-week period. SOD1 5XTBI rats reached a peak body weight earlier than sham SOD1 rats, indicating earlier onset of the ALS phenotype. Histologic examination of brain tissue revealed that, in contrast with sham controls, SOD1 and WT TBI rats demonstrated cortical and corpus collosum thinning and tauopathy, which increased over time.Unlike previous models of repeat brain injury, which demonstrate only transient deficits in motor function, our concussion model of repeat, mild, bilateral TBI induced long-lasting deficits in motor function, decreased cortical thickness, shrinkage of the corpus callosum, increased brain tauopathy, and earlier onset of ALS symptoms in SOD1 rats. This model may allow for a greater understanding of the complex relationship between TBI and neurodegenerative diseases and provides a potential method for testing novel therapeutic strategies.

  View details for DOI 10.1097/TA.0000000000001248

  View details for PubMedID 27602892

• Association Between Enoxaparin Dosage Adjusted by Anti-Factor Xa Trough Level and Clinically Evident Venous Thromboembolism After Trauma. JAMA surgery Ko, A., Harada, M. Y., Barmparas, G., Chung, K., Mason, R., Yim, D. A., Dhillon, N., Margulies, D. R., Gewertz, B. L., Ley, E. J. 2016; 151 (11): 1006-1013

  Abstract

  Trauma patients are at high risk for developing venous thromboembolism (VTE). The VTE rate when enoxaparin sodium is dosed by anti-factor Xa (anti-Xa) trough level is not well described.To determine whether targeting a prophylactic anti-Xa trough level by adjusting the enoxaparin dose would reduce the VTE rate in trauma patients.Single-institution, historic vs prospective cohort comparison study at an urban, academic, level I trauma center. The prospective cohort was enrolled from August 2014 to May 2015 and compared with a historic cohort admitted from August 2013 to May 2014. Trauma patients who received enoxaparin adjusted by anti-Xa trough level (adjustment group) were compared with those who received enoxaparin sodium at a dosage of 30 mg twice daily (control group). Patients were excluded if they were younger than 18 years, had a length of hospital stay less than 2 days, or had preexisting deep vein thrombosis. Patients were excluded from the adjustment group for changes in the choice of thromboprophylaxis (heparin, enoxaparin once-daily dosing, early ambulation), hospital discharge before initial trough levels could be drawn, or incorrect timing of trough levels.Anti-Xa trough levels were monitored in patients in the adjustment group receiving 3 or more consecutive doses of enoxaparin sodium, 30 mg twice daily. Patients with a trough level of 0.1 IU/mL or lower received enoxaparin sodium increased by 10-mg increments. After providing 3 adjusted doses of enoxaparin, the trough level was redrawn and the dosage was adjusted as necessary. Patients in the control group received enoxaparin sodium at a dosage of 30 mg twice daily without adjustments.Rates of symptomatic VTE (deep vein thrombosis and pulmonary embolism, confirmed by duplex ultrasonography and chest computed tomographic angiography, respectively) and bleeding risk.A total of 205 patients (mean [SD] age, 41.3 [18.2] years; 75.1% male) were studied, 87 in the adjustment group and 118 in the control group, with similar baseline characteristics and injury profiles. Subprophylactic anti-Xa troughs were noted in 73 of 87 patients (83.9%) in the adjustment group, and the majority of patients (57 of 87 patients [65.5%]) required dosage adjustment of enoxaparin sodium to 40 mg twice daily. Incidence of VTE was significantly lower in the adjustment group than in the control group (1.1% vs 7.6%, respectively; P = .046). When the adjustment group was compared with the control group, no significant difference was noted in the rate of packed red blood cell transfusion (6.9% vs 12.7%, respectively; P = .18) or mean (SD) hematocrit at discharge (34.5% [6.3%] vs 33.4% [6.8%], respectively [to convert to proportion of 1.0, multiply by 0.01]; P = .19).In this study, subprophylactic anti-Xa trough levels were common in trauma patients. Enoxaparin dosage adjustment may lead to a reduced rate of VTE without an increased risk of bleeding.

  View details for DOI 10.1001/jamasurg.2016.1662

  View details for PubMedID 27383732

• Pain Assessment and Control in the Injured Elderly. The American surgeon Ko, A., Harada, M. Y., Smith, E. J., Scheipe, M., Alban, R. F., Melo, N., Margulies, D. R., Ley, E. J. 2016; 82 (10): 867-871

  Abstract

  Elderly trauma patients may be at increased risk for underassessment and inadequate pain control in the emergency department (ED). We sought to characterize risk factors for oligoanalgesia in the ED in elderly trauma patients and determine whether it impacts outcomes in elderly trauma patients. We included elderly patients (age ≥55 years) with Glasgow Coma Scale scores 13 to 15 and Injury Severity Score (ISS) ≥9 admitted through the ED at a Level I trauma center. Patient characteristics and outcomes were compared between those who reported pain and received analgesics medication in the ED (MED) and those who did not (NO MED). A total of 183 elderly trauma patients were identified over a three-year study period, of whom 63 per cent had pain assessed via verbal pain score; of those who reported pain, 73 per cent received analgesics in the ED. The MED and NO MED groups were similar in gender, race, ED vitals, ISS, and hospital length of stay. However, NO MED was older, with higher head Abbreviated Injury Scale score and longer intensive care unit length of stay. Importantly, as patients aged they reported lower pain and were less likely to receive analgesics at similar ISS. Risk factors for oligoanalgesia may include advanced age and head injury.

  View details for PubMedID 27779962

• Reducing acute kidney injury due to vancomycin in trauma patients. The journal of trauma and acute care surgery Ko, A., Harada, M. Y., Barmparas, G., Jay, J., Sun, B. J., Chen, E., Mehrzadi, D., Patel, B., Mason, R., Ley, E. J. 2016; 81 (2): 352-7

  Abstract

  Supratherapeutic vancomycin trough levels are common after trauma and associated with both increased acute kidney injury (AKI) and mortality. We sought to limit the adverse effects of vancomycin in trauma patients through more frequent trough monitoring.Beginning in January 2011, trauma patients treated with vancomycin had trough levels (VT) monitored daily until steady state was reached. Trauma patients admitted from January 2011 to May 2015 (POST) were compared with those admitted from January 2006 to December 2010 (PRE). Inclusion criteria required administration of intravenous vancomycin, admission serum creatinine (SCr), and SCr within 72 hours of highest VT. Acute kidney injury was defined as an increase in SCr of at least 0.3 mg/dL or 50% from admission to post-vancomycin administration. Those in the POST group were prospectively followed up until discharge or death.Two hundred sixty-three patients met inclusion criteria in the PRE-phase and 115 in the POST-phase. The two groups were similar in age, gender, race, body mass index, pre-existing comorbidities, admission systolic blood pressure, Glasgow Coma Scale, and head Abbreviated Injury Scale. Injury Severity Score was higher in the POST cohort (18 PRE vs. 25 POST, p < 0.001). Compared with PRE, the POST cohort had lower rates of supratherapeutic VT (>20 mg/L) (34.6% PRE vs. 22.6% POST, p = 0.02) and AKI (30.4% PRE vs. 19.1% POST, p = 0.026). After adjusting for confounders, the POST group had a significantly lower risk of AKI with an adjusted odds ratio of 0.457 (p = 0.027). There was a trend toward decreased mortality in the POST cohort, but this did not reach significance (10% PRE vs. 5.2% POST, p = 0.162).A reduction in AKI was observed in trauma patients with daily vancomycin trough levels monitored until steady state. Increased awareness regarding closer surveillance of VT in trauma patients may limit the incidence of vancomycin-related nephrotoxicity.Therapeutic study, level IV.

  View details for DOI 10.1097/TA.0000000000001105

  View details for PubMedID 27192471

• Thromboelastography After Murine TBI and Implications of Beta-Adrenergic Receptor Knockout. Neurocritical care Liou, D. Z., Ko, A., Volod, O., Barmparas, G., Harada, M. Y., Martin, M. J., Salim, A., Dhillon, N., Thomsen, G. M., Ley, E. J. 2016; 25 (1): 145-52

  Abstract

  The source of coagulopathy in traumatic brain injury (TBI) is multifactorial and may include adrenergic stimulation. The aim of this study was to assess coagulopathy after TBI using thromboelastography (TEG), and to investigate the implications of β-adrenergic receptor knockout.Adult male wild type c57/bl6 (WT) and β1/β2-adrenergic receptor knockout (BKO) mice were assigned to either TBI (WT-TBI, BKO-TBI) or sham injury (WT-sham, BKO-sham). Mice assigned to TBI were subject to controlled cortical impact (CCI). At 24 h post-injury, whole blood samples were obtained and taken immediately for TEG.At 24 h after injury, a trend toward increased fibrinolysis was seen in WT-TBI compared to WT-sham although this did not reach significance (EPL 8.1 vs. 0 %, p = 0.18). No differences were noted in fibrinolysis in BKO-TBI compared to BKO-sham (LY30 2.6 vs. 2.5 %, p = 0.61; EPL 3.4 vs. 2.9 %, p = 0.61). In addition BKO-TBI demonstrated increased clot strength compared to BKO-sham (MA 76.6 vs. 68.6, p = 0.03; G 18.2 vs. 11.3, p = 0.03).In a mouse TBI model, WT mice sustaining TBI demonstrated a trend toward increased fibrinolysis at 24 h after injury while BKO mice did not. These findings suggest β-blockade may attenuate the coagulopathy of TBI and minimize progression of intracranial hemorrhage by reducing fibrinolysis and increasing clot strength.

  View details for DOI 10.1007/s12028-015-0223-9

  View details for PubMedID 26666545

• Predictors of improved functional outcome following inpatient rehabilitation for patients with traumatic brain injury. NeuroRehabilitation McLafferty, F. S., Barmparas, G., Ortega, A., Roberts, P., Ko, A., Harada, M., Nuño, M., Black, K. L., Ley, E. J. 2016; 39 (3): 423-30

  Abstract

  To determine factors associated with response to inpatient rehabilitation treatment among TBI patients.Inpatient rehabilitation service at a Level I trauma center.Moderate-severe TBI patients ages ≥ 18years old admitted between January 1, 2002 and December 31, 2012.Response to inpatient rehabilitation, measured by the Functional Independence Measure (FIM) score.Retrospective cohort study.Of 1,984 patients treated for TBI, 184 (10.8%) underwent inpatient rehabilitation. The largest proportion of patients improved in mobility (98.9%), followed by self-care (93.7%), communication/social cognition (84.0%), and sphincter control (65.7%). Of these, 99 (53.8%) improved by 2 or more levels of functional independence and were considered rehabilitation responders. Responders were younger (53.1 years vs. 63.8, p < 0.01), had longer average rehabilitation stays (15.4 days vs. 12.2, p < 0.01), and were less likely to have an admission SBP <100 mmHg (7.1% vs. 17.1%, p = 0.01). On multivariate analysis, normotension at admission (AOR 0.06, p = 0.01) and longer rehabilitation LOS (AOR 1.11, p < 0.01) were associated with a response to inpatient rehabilitation.Of the TBI patients who qualified for same-center inpatient rehabilitation, approximately half responded to treatment. Longer rehabilitation time and normotension at admission predicted response to rehabilitation. Further efforts are necessary to identify and optimize TBI patients for inpatient rehabilitation.

  View details for DOI 10.3233/NRE-161373

  View details for PubMedID 27589512

• High-value care in the surgical intensive care unit: effect on ancillary resources. The Journal of surgical research Ko, A., Murry, J. S., Hoang, D. M., Harada, M. Y., Aquino, L., Coffey, C., Sax, H. C., Alban, R. F. 2016; 202 (2): 455-60

  Abstract

  Changes in health care policies have influenced transformations in hospital systems to be cost-efficient while maintaining robust outcomes. This is particularly important in intensive care units where significant resources are used to care for critically ill patients. We sought to determine whether high-value care processes (HVCp) implemented in a surgical intensive care unit (SICU) have an impact on commonly used ancillary tests.An implementation phase using a Lean Six Sigma approach was performed in October 2014 at a 24-bed large academic center SICU with aims to decrease orders of excessive daily laboratory tests and X-rays. The HVCp implemented included use of daily checklists, staff education, and visual reminders emphasizing the importance of appropriate laboratory tests and chest X-rays. Preintervention (July 2014-October 2014) and post-intervention (November 2014-June 2015) phases were compared.Average SICU census, case mix index (4.3 versus 4.4, P = 0.57), all patient refined severity of illness (3.2 versus 3.2, P = 0.91), and SICU mortality (7.1% versus 5.1%, P = 0.18) were similar in both phases. A significant reduction of excessive laboratory tests was evident after the implementation period. Eight hundred sixty-five arterial blood gases/mo were obtained in the preintervention phase compared with 420 arterial blood gases/mo after intervention (P = 0.004), representing a 51.4% reduction. Similar results were obtained with complete blood counts, basic metabolic profiles, coagulation profiles, and chest X-rays (12%, 17.8%, 30.2%, and 20.3% reductions, respectively), a total estimated cost savings of $59,137/mo and prevention of excess phlebotomy of approximately 4 L of blood/mo.By implementing an HVCp including a checklist, visual reminders, and provider education, we significantly reduced the use of commonly ordered ancillary tests in the SICU without affecting outcomes, resulting in an annual cost savings of $710,000.

  View details for DOI 10.1016/j.jss.2016.01.040

  View details for PubMedID 27041599

• Early propranolol after traumatic brain injury is associated with lower mortality. The journal of trauma and acute care surgery Ko, A., Harada, M. Y., Barmparas, G., Thomsen, G. M., Alban, R. F., Bloom, M. B., Chung, R., Melo, N., Margulies, D. R., Ley, E. J. 2016; 80 (4): 637-42

  Abstract

  β-Adrenergic receptor blockers (BBs) administered after trauma blunt the cascade of immune and inflammatory changes associated with injury. BBs are associated with improved outcomes after traumatic brain injury (TBI). Propranolol may be an ideal BB because of its nonselective inhibition and ability to cross the blood-brain barrier. We determined if early administration of propranolol after TBI is associated with lower mortality.All adults (age ≥ 18 years) with moderate-to-severe TBI (head Abbreviated Injury Scale [AIS] score, 3-5) requiring intensive care unit (ICU) admission at a Level I trauma center from January 1, 2013, to May 31, 2015, were prospectively entered into a database. Administration of early propranolol was dosed within 24 hours of admission at 1 mg intravenous every 6 hours. Patients who received early propranolol after TBI (EPAT) were compared with those who did not (non-EPAT). Data including demographics, hospital length of stay (LOS), ICU LOS, and mortality were collected.Over 29 months, 440 patients with moderate-to-severe TBI met inclusion criteria. Early propranolol was administered to 25% (109 of 440) of the patients. The EPAT cohort was younger (49.6 years vs. 60.4 years, p < 0.001), had lower Glasgow Coma Scale (GCS) score (11.7 vs. 12.4, p = 0.003), had lower head AIS score (3.6 vs. 3.9, p = 0.001), had higher admission heart rate (95.8 beats/min vs. 88.4 beats/min, p = 0.002), and required more days on the ventilator (5.9 days vs. 2.6 days, p < 0.001). Similarities were noted in sex, Injury Severity Score (ISS), admission systolic blood pressure, hospital LOS, ICU LOS, and mortality rate. Multivariate regression showed that EPAT was independently associated with lower mortality (adjusted odds ratio, 0.25; p = 0.012).After adjusting for predictors of mortality, early administration of propranolol after TBI was associated with improved survival. Future studies are needed to identify additional benefits and optimal dosing regimens.Therapeutic study, level IV.

  View details for DOI 10.1097/TA.0000000000000959

  View details for PubMedID 26808028

• Heart rate in pediatric trauma: rethink your strategy. The Journal of surgical research Ko, A., Harada, M. Y., Murry, J. S., Nuño, M., Barmparas, G., Ma, A. A., Thomsen, G. M., Ley, E. J. 2016; 201 (2): 334-9

  Abstract

  The optimal heart rate (HR) for children after trauma is based on values derived at rest for a given age. As the stages of shock are based in part on HR, a better understanding of how HR varies after trauma is necessary. Admission HRs of pediatric trauma patients were analyzed to determine which ranges were associated with lowest mortality.The National Trauma Data Bank was used to evaluate all injured patients ages 1-14 years admitted between 2007 and 2011. Patients were stratified into eight groups based on age. Clinical characteristics and outcomes were recorded, and regression analysis was used to determine mortality odds ratios (ORs) for HR ranges within each age group.A total of 214,254 pediatric trauma patients met inclusion criteria. The average admission HR and systolic blood pressure were 104.7 and 120.4, respectively. Overall mortality was 0.8%. The HR range associated with lowest mortality varied across age groups and, in children ages 7-14, was narrower than accepted resting HR ranges. The lowest risk of mortality for patients ages 5-14 was captured at HR 80-99.The HR associated with lowest mortality after pediatric trauma frequently differs from resting HR. Our data suggest that a 7y old with an HR of 115 bpm may be in stage III shock, whereas traditional HR ranges suggest that this is a normal rate for this child. Knowing when HR is critically high or low in the pediatric trauma population will better guide treatment.

  View details for DOI 10.1016/j.jss.2015.11.011

  View details for PubMedID 27020816

• Field intubation in civilian patients with hemorrhagic shock is associated with higher mortality. The journal of trauma and acute care surgery Chou, D., Harada, M. Y., Barmparas, G., Ko, A., Ley, E. J., Margulies, D. R., Alban, R. F. 2016; 80 (2): 278-82

  Abstract

  Field intubation (FI) by emergency medical service personnel on severely injured trauma patients remains a contentious practice. Clinical studies suggest an association between FI and adverse outcomes in patients with traumatic brain injury. Military tactical emergency casualty care recommends deferring intubation and providing supplemental oxygenation until reaching a more equipped destination. In addition, animal models with penetrating hemorrhagic shock demonstrate increased acidosis with intubation before resuscitation. The purpose of this study was to evaluate the impact of FI on outcomes in trauma patients with hemorrhagic shock requiring massive transfusion.The Los Angeles County Trauma System Database was retrospectively queried for all trauma patients 16 years or older with hemorrhagic shock requiring massive transfusion (≥6 U packed red blood cells in the first 24 hours) between January 1, 2012, and June 30, 2014. Demographics, clinical and transfusion data, and outcomes were compared between patients who received FI and those who did not (NO-FI). Multivariate regression analysis was used to adjust for confounders.Of 552 trauma patients meeting inclusion criteria, 63 (11%) received FI, and the remaining 489 (89%) were NO-FI. Age, sex, and incidence of blunt injury were similar between the FI and the NO-FI group. The FI cohort presented with a lower median Glasgow Coma Scale (GCS) score (3 vs. 14, p < 0.001), a lower median systolic blood pressure (86 mm Hg vs. 104 mm Hg, p < 0.001), and a higher median Injury Severity Score (ISS) (41 vs. 29, p < 0.001). Mortality was significantly higher in FI patients (83% vs. 43%, p < 0.001). Transfusion patterns and total field times were similar in both groups. After adjusting for confounders, FI patients had increased odds of mortality (adjusted odds ratio, 2.89; 95% confidence interval, 1.08-7.78; p = 0.035). In addition, FI was identified as an independent predictor of mortality (adjusted odds ratio, 3.41; 95% confidence interval, 1.35-8.59; p = 0.009).FI may be associated with higher mortality in trauma patients with hemorrhagic shock requiring massive transfusion. Less invasive airway interventions and rapid transport might improve outcomes for these patients.Therapeutic study, level IV; epidemiologic study, level III.

  View details for DOI 10.1097/TA.0000000000000901

  View details for PubMedID 26491803

• Decreasing maintenance fluids in normotensive trauma patients may reduce intensive care unit stay and ventilator days. Journal of critical care Barmparas, G., Ko, A., Harada, M. Y., Zaw, A. A., Murry, J. S., Smith, E. J., Ashrafian, S., Sun, B. J., Ley, E. J. 2016; 31 (1): 201-5

  Abstract

  The purpose of the study is to determine if excessive fluid administration is associated with a prolonged hospital course and worse outcomes.In July 2013, all normotensive trauma patients admitted to the surgical intensive care unit (ICU) were administered crystalloids at 30 mL/h ("to keep open [TKO]") and were compared to patients admitted during the preceding 6 months who were placed on a rate between 125 mL/h to 150 mL/h (non-TKO). The primary outcomes were ICU, hospital, and ventilator days.A total of 101 trauma patients met inclusion criteria: 56 (55.4%) in the TKO and 45 (44.6%) in the non-TKO group. Overall, the 2 groups were similar in regard to age, Injury Severity Score, Acute Physiology and Chronic Health Evaluation IV scores, and the need for mechanical ventilation. TKO had no effect on renal function compared to non-TKO with similarities in maximum hospital creatinine. TKO patients had lower ICU stay (2.7 ± 1.5 vs 4.1 ± 4.6 days; P = .03) and ventilator days (1.4 ± 0.5 vs 5.5 ± 4.8 days; P < .01).A protocol that encourages admission basal fluid rate of TKO or 30 mL/h in normotensive trauma patients is safe, reduces fluid intake, and may be associated with a shorter intensive care unit course and fewer ventilator days.

  View details for DOI 10.1016/j.jcrc.2015.09.030

  View details for PubMedID 26643858

• Bicycle trauma and alcohol intoxication INTERNATIONAL JOURNAL OF SURGERY Harada, M. Y., Gangi, A., Ko, A., Liou, D. Z., Barmparas, G., Li, T., Hotz, H., Stewart, D., Ley, E. J. 2015; 24: 14–19

  Abstract

  As bicycling has become more popular, admissions after bicycle trauma are on the rise. The impact of alcohol use on bicycle trauma has not been well studied. The aim of this study was to examine the effect of alcohol intoxication on injury burden following bicycle-related crashes.A retrospective review of trauma patients presenting to a Level I trauma center after bicycle-related crashes from January 2002 to December 2011 was conducted. Demographics, injury data, alcohol intoxication, helmet use, and clinical outcomes were reviewed. Blood alcohol level (BAL) was considered positive if >0.01 g/dL. Variables were compared between patients based on BAL: negative, 0.01-0.16 g/dL, and >0.16 g/dL.During the 10 year study period, 563 patients met study criteria; mean age was 33.5 ± 16.5 years, 87% were male, and mortality was 1%. On average, bicycle crashes increased over the study period by 4.4 collisions per year. BAL was tested in 211 (38%) patients. Mean BAL was 0.24 g/dL, with 37% of these patients being intoxicated (BAL ≥ 0.010 g/dL). Intoxicated patients were significantly less likely to wear a helmet (4.7% vs. 22.2%, p = 0.002) and to be involved in motor vehicle crash (59.0% vs. 81.2%, p < 0.001). There was no difference noted in the injury burden including ISS ≥ 16 (14.3% vs. 19.5%, p = 0.335) and AIS Head ≥ 3 (17.9% vs. 21.8%, p = 0.502). When comparing patients according to their BAL, there was a decreasing risk of motor vehicle collision with increasing BAL (81.2% for undetected, 76.5% for BAL ≤ 0.16 g/dL and 54.1% for BAL >0.16 g/dL, p < 0.001). The risk for a severe head injury (AIS Head ≥ 3) was significantly lower in helmeted patients (8.4% vs. 15.8%, p = 0.035).The incidence of bicycle-related crashes is increasing and more than a third of patients tested for alcohol after bicycle-related crashes are found to be intoxicated. The injury burden in intoxicated patients, including head trauma, was not different compared to non-intoxicated patients. In addition, the risk for a collision with a motor vehicle was significantly lower. Nonetheless, these patients rarely utilize a helmet. The findings from this study can be used for the development and implementation of preventive strategies to minimize the injury burden associated with bicycle crashes and intoxicated cyclists.

  View details for DOI 10.1016/j.ijsu.2015.10.013

  View details for Web of Science ID 000366662600004

  View details for PubMedID 26493212

• Abdominal Injuries in the "Found Down": Is Imaging Indicated? Journal of the American College of Surgeons Ko, A., Zaw, A. A., Barmparas, G., Hoang, D. M., Murry, J. S., Li, T., Ashrafian, S., McNeil, N. J., Margulies, D. R., Ley, E. J. 2015; 221 (1): 17-24

  Abstract

  We sought to investigate the incidence of abdominal injuries in "found down" trauma patients to better understand the value of emergency department (ED) imaging. Found down patients are at high risk for injuries to the head or neck and low risk to the abdomen or pelvis, so imaging with CT of the abdomen/pelvis (AP) or Focused Assessment with Sonography for Trauma (FAST) is of questionable value.The trauma registry was queried over a 10-year period ending December 2013 for found down patients. Demographics, CT AP, FAST scans, and injuries were abstracted from the trauma registry and then through a confirmatory chart review. The primary outcome was significant abdominal or pelvis injury, defined as abdomen/pelvis Abbreviated Injury Scale (AIS) ≥ 3 or an abdominal injury that required operative intervention. The secondary outcome was mortality due to abdominal injury.Of the 342 patients who met inclusion criteria, mean Glasgow Coma Scale (GCS) was 11.0, and 189 (60%) of those tested for alcohol were intoxicated. Abdominal imaging included: CT AP only, 88 (57%); FAST only, 37 (24%); and CT AP and FAST, 29 (19%). Neither CT AP nor FAST scan led to a change in treatment and no patient had abdomen/pelvis AIS ≥ 3. Overall mortality was 33 (10%).The 24 trauma deaths were attributed to serious head trauma (n = 16) or traumatic arrest in the ED (n = 8); the 9 medical deaths were due to cerebral vascular accident (n = 5) or sepsis (n = 4).Although patients found down have a high mortality, abdominal injuries identified by imaging are highly unlikely. Efforts should focus on rapidly identifying and treating other causes of mortality, especially trauma to the head and neck, or medical diagnoses such as cerebral vascular accident or sepsis.

  View details for DOI 10.1016/j.jamcollsurg.2015.03.025

  View details for PubMedID 25899735

• Polycystic ovary syndrome is associated with an increased prevalence of irritable bowel syndrome. Digestive diseases and sciences Mathur, R., Ko, A., Hwang, L. J., Low, K., Azziz, R., Pimentel, M. 2010; 55 (4): 1085-9

  Abstract

  Polycystic ovary syndrome (PCOS) affects 5-10% of reproductive-aged women. Irritable bowel syndrome (IBS) is a chronic intestinal disorder that affects up to 20% of adults, more often women. We evaluate if there is a relationship between these common conditions.Polycystic ovary syndrome and control subjects were prospectively recruited. A questionnaire was given to determine their gastrointestinal symptoms. Body mass index (BMI) and percent body fat were also calculated.About 65 female subjects completed the study. Among the 36 PCOS patients, 15 subjects (42%) had IBS, compared to 3 subjects (10%) among controls (p < 0.01). Control subjects were leaner (BMI: 27.5 +/- 1.1 vs. 31.4 +/- 1.2 kg/m(2), p < 0.05) than PCOS patients. Among women with PCOS, those with IBS had a higher BMI (32.9 +/- 2.0 kg/m(2)) compared to those with PCOS but no IBS (30.3 +/- 1.6 kg/m(2)) and controls (27.5 +/- 1.1 kg/m(2); p < 0.05). This difference was true even after correcting for BMI and age (p < 0.01).Women with PCOS have a higher prevalence of IBS compared to healthy controls. When IBS is present with PCOS, a higher BMI and percent body fat is seen compared to PCOS alone.

  View details for DOI 10.1007/s10620-009-0890-5

  View details for PubMedID 19697132