Biomedical subjects

Charles C Miller

Publications and source records attributed to Charles C Miller.

At least 19 recordsLinked to original sources

PubMed2007

Improved survival with pulmonary metastasectomy: an analysis of 1720 patients with pulmonary metastatic melanoma.

OBJECTIVES: The outcomes of patients with metastatic melanoma are poor. Although prognostic models have been developed to predict the occurrence of pulmonary metastasis from cutaneous melanoma, few data exist to define the outcomes of these patients once metastasis has occurred. The objective of this study was to discriminate predictors of survival for patients with pulmonary metastatic melanoma. METHODS: We found 1720 patients with pulmonary metastasis listed in a prospective comprehensive cancer center database of 14,057 consecutive patients with melanoma (Jan 1, 1970-June 1, 2004). Demographic and histopathologic data, time and location of recurrences, number of pulmonary nodules, and subsequent therapies were collected. Univariate and multivariate Cox proportional hazards models were used to identify predictors of survival for patients with pulmonary metastatic melanoma. RESULTS: The median survival was 7.3 months after development of pulmonary metastasis. Significant predictors of survival from the multivariate model included nodular histologic type (P = .033), disease-free interval (P < .001), number of pulmonary metastases (P = .012), presence of extrathoracic metastasis (P < .001), and performance of pulmonary metastasectomy (P < .001). Interactions were identified between metastasectomy and disease-free interval and presence of extrathoracic metastasis. Surgery was associated with a survival advantage of 12 months for patients with a disease-free interval longer than 5 years (19 vs 7 months, P < .01) and of 10 months for patients without extrathoracic metastasis (18 vs 8 months, P < .01). CONCLUSIONS: When all other identified risk factors were controlled for mathematically, metastasectomy maintained a significant survival advantage for patients with pulmonary metastatic melanoma. These data support the role of surgery for a select subset of patients with pulmonary metastasis.

Disease-Free Survival↗

PubMed2007

Fresh frozen plasma should be given earlier to patients requiring massive transfusion.

BACKGROUND: Acidosis, hypothermia, and coagulopathy were identified more than 20 years ago as a deadly triad for patients presenting with exsanguinating hemorrhage. This led to fundamental changes in initial management of severely injured patients. Despite major advances, hemorrhage remains a leading cause of early death in trauma patients. Recent studies report most severely injured patients to be coagulopathic at admission, before resuscitation interventions, and that traditional massive transfusion practice grossly underestimates needs. The hypothesis for this study is that our pre-intensive care unit (ICU) massive transfusion (MT) protocol does not adequately correct coagulopathy, and that early uncorrected coagulopathy is predictive of mortality. METHODS: Data maintained in our Trauma Research Database were reviewed. Univariate logistic regression analysis was used to analyze the association of early ICU international normalized ratio (INR) and outcomes, including survival. RESULTS: Ninety-seven of 200 patients admitted during 51 months (ending January 2003) and resuscitated using our standardized ICU shock resuscitation protocol received MT (> or =10 units packed red blood cells [PRBC]) during hospital day 1 (age, 39 +/- 2; ISS, 29 +/- 1; survival, 70%.) All patients required emergency operating room and/or interventional radiology procedures and arrived in the ICU 6.8 +/- 0.3 hours after admission. Coagulopathy, present at hospital admission (pre-ICU INR, 1.8 +/- 0.2), persisted at ICU admission (initial ICU INR, 1.6 +/- 0.1). Pre-ICU resuscitation, 9 +/- 1 L crystalloid fluid, 12 +/- 1 units PRBC, 5 +/- 0.4 units fresh frozen plasma (FFP), was consistent with our MT protocol by which FFP was not given until after 6 units PRBC. ICU resuscitation involved 11 +/- 1 L lactated Ringer's solution (LR) and 10 +/- 1 units PRBC. Mean pH was normal within 8 hours. Mean temperature increased from approximately 35 degrees C to >37 degrees C within 4 hours. In the ICU during resuscitation, patients received 10 +/- 1 units FFP for coagulopathy; the ratio of FFP:PRBC was 1:1. Mean INR decreased to 1.4 +/- 0.03 within 8 hours and remained nearly constant for the remaining 16 hours of ICU resuscitation, indicating moderate coagulopathy. Statistical analysis found severity of coagulopathy (INR) at ICU admission associated with survival outcome (p = 0.02; area under receiver operator curve [ROC] = 0.71.) CONCLUSION: These data indicate acidosis and hypothermia to be well managed. Coagulopathy was not corrected in the ICU despite adherence to pre-ICU MT and ICU protocols, likely because of inadequate pre-ICU intervention. More aggressive pre-ICU intervention to correct coagulopathy may be effective in decreasing PRBC requirement during ICU resuscitation, and, because of the association with increased mortality, could improve outcome. We have revised our pre-ICU MT protocol to emphasize early FFP in a FFP:PRBC ratio of 1:1. We think that treatment of coagulopathy can be improved with the development of standardized protocols, both empiric and data driven.

Adult↗

PubMed2006

Outcomes of medical management of acute type B aortic dissection.

BACKGROUND: Currently, the optimal treatment of acute type B aortic dissection remains controversial. The purpose of this study was to report early clinical outcomes of medical management for acute type B aortic dissection. METHODS AND RESULTS: Between January 2001 and March 2005, 129 consecutive patients with the confirmed diagnosis of acute type B aortic dissection were studied. Mean age was 61 years (range, 29 to 94), with 33.3% (43/129) female. Acute type B aortic dissection protocol was instituted with the intent to manage all patients medically. Indications for surgical intervention included rupture, aortic expansion, malperfusion, and intractable pain. All patients were followed-up after discharge. Hospital mortality was 10.1% (13/129), 19% (4/21) when vascular intervention was required, and 8.3% (9/108) when medical management was maintained. Early intervention was required in 21 cases (16.2%), 19 (14.7%) open vascular/aortic cases and 2 cases (1.6%) of percutaneous aortic interventions. Morbidity included rupture (4.7%), stroke (4.7%), paraplegia (8.5%), bowel ischemia (7%), acute renal failure (21%), dialysis requirement (13%), and peripheral ischemia (4.7%). Late vascular-related procedures were performed in 5.2% (6/116) of cases. Univariate risk factors for early mortality were rupture (P<0.0001), need for laparotomy (P<0.008), acute renal failure (P<0.0001), need for dialysis (P<0.0001), and lower extremity ischemia (P<0.0004). The only independent risk factors for hospital mortality by multiple logistic regression was rupture (P<0.0009), and independent risk factors for midterm death were history of chronic obstructive pulmonary disease (P<0.002) and low glomerular filtration rate (<57 mL/min; P<0.0001). CONCLUSIONS: Medical management for acute type B aortic dissection is associated acceptable outcomes. Outcomes of other management strategies, eg, endovascular stenting, for acute type B aortic dissection need to be compared with these results.

Acute Disease↗

PubMed2006

Risk factors for hepatic morbidity following nonoperative management: multicenter study.

HYPOTHESIS: Early risk factors for hepatic-related morbidity in patients undergoing initial nonoperative management of complex blunt hepatic injuries can be accurately identified. DESIGN: Multicenter historical cohort. SETTING: Seven urban level I trauma centers. PATIENTS: Patients from January 2000 through May 2003 with complex (grades 3-5) blunt hepatic injuries not requiring laparotomy in the first 24 hours. INTERVENTION: Nonoperative treatment of complex blunt hepatic injuries. MAIN OUTCOME MEASURES: Complications and treatment strategies. RESULTS: Of 699 patients with complex blunt hepatic injuries, 453 (65%) were treated nonoperatively. Overall, 61 patients (13%) developed 87 hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary-venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), which required 86 multimodality treatments (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy, 24; and laparoscopy, 4). Hepatic complications developed in 5% (13 of 264) of patients with grade 3 injuries, 22% (36 of 166) of patients with grade 4 injuries, and 52% (12 of 23) of patients with grade 5 injuries. Univariate analysis revealed 24-hour crystalloid, total and first 24-hour packed red blood cells, fresh frozen plasma, platelet, and cryoprecipitate requirements and liver injury grade to be significant but only liver injury grade (grade 4 odds ratio, 4.439; grade 5 odds ratio, 12.001) and 24-hour transfusion requirement (odds ratio, 6.446) predicted complications by multivariable analysis. CONCLUSIONS: Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury. Screening patients with transfusion requirements and high-grade injuries may result in earlier diagnosis and treatment of hepatic-related complications.

Abdominal Injuries↗

PubMed2006

Acute type A aortic dissection complicated by stroke: can immediate repair be performed safely?

OBJECTIVE: Emergency surgical intervention for acute type A aortic dissection complicated by stroke remains controversial. The urgency of immediate repair in this setting is tempered by the concern that cerebral reperfusion may worsen neurologic outcome. The purpose of this study was to report and analyze our results with acute type A aortic dissection complicated by stroke. METHODS: Between September 1999 and March 2005, 151 consecutive patients presented with acute type A aortic dissection. Of this group, 16 (10.6%) patients had sustained a preoperative stroke. Mean age was 56 years (range 43-73 years), with 6 (38%) women. Right hemispheric, left hemispheric, and bilateral strokes occurred in 81%, 13%, and 6%, respectively. Computed tomographic scan or transesophageal echocardiography diagnosed aortic dissection; clinical examination, computed tomographic scan, or transcranial Doppler ultrasound diagnosed stroke. Aortic repair was performed with cardiopulmonary bypass, profound hypothermic circulatory arrest, and retrograde cerebral perfusion. One patient with complete neurologic devastation (coma) was not operated on. RESULTS: Overall hospital mortality was 18.8% (3/16). Mortality in 2 patients who did not undergo surgery (1 patient who was neurologically devastated, and 1 patient whose aorta ruptured while awaiting surgery) was 100% (2/2). Operative mortality was 7% (1/14). Among patients undergoing surgery, neurologic status completely recovered in 2 (14%) patients, improved in 6 (43%) patients, remained the same in 6 (43%) patients, and worsened in none. Median time from onset of stroke to surgery was 9 hours (range 1-240 hours). Eighty percent of patients who underwent surgical repair within 10 hours had improvement in neurologic status, where as none operated on beyond 10 hours improved (P < .02). CONCLUSIONS: In our experience, surgical repair of acute type A aortic dissection can be performed in the setting of preoperative stroke with acceptable mortality. Moreover, no worsening of neurologic condition was observed after surgical repair. Immediate surgical repair is warranted even if acute type A aortic dissection is complicated by stroke.

Acute Disease↗

PubMed2006

Glomerular filtration rate is a predictor of mortality after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Clinically evident renal disease is a risk factor for mortality after aneurysm repair. Serum creatinine is widely used as a measure of renal function in the preoperative evaluation of patients. Unfortunately, serum creatinine concentration is influenced by muscle mass, hydration status, and glomerular filtration rate (GFR). Calculated GFR, which takes predictors of muscle mass such as age, gender, and weight into account, is a more sensitive determinant of renal function than serum creatinine. We hypothesized that GFR would more accurately predict mortality after EVAR than serum creatinine. METHODS: We retrospectively evaluated our database of 398 patients who underwent EVAR with the AneuRx device between October 1999 and October 2004. There were 340 men and 58 women with a mean age of 73. GFR was calculated using the Cockcroft-Gault equation. The patients were divided into four quartiles by preoperative GFR: I (7 to 45), II (45 to 60), III (61 to 79), and IV (> or =80). Survival was estimated with the Kaplan-Meier method, and heterogeneity of mortality across strata was evaluated using the log-rank test. The GFR quartiles were compared with clinically accepted criteria for abnormal renal function (serum creatinine level > or =1.7). RESULTS: Actuarial survival at 48 months was 61.5%, 70.5%, 86.0%, and 85.7% for GFR quartiles I to IV, respectively (P < .003). Thirty-day mortality was 2.2% in quartile I, 3.2% in quartile II, and 0 in quartiles III and IV (P = .03 for q1 + q2 vs q3 + q4, P < .02 for q2 vs q3 + q4). Survival curves for quartiles II to IV were statistically indistinguishable, with quartile II running tangential to the two higher quartiles after the perioperative period. Quartile I fared significantly worse than the other three quartiles for the entire follow-up period (P < .005). According to American Kidney Foundation criteria (GFR <90), 83.3% of patients had abnormal renal function compared with 16.1% with abnormal serum creatinine (>1.7) (P < .0002). CONCLUSION: The risk of perioperative and long-term mortality in patients undergoing EVAR is more accurately stratified by using calculated GFR than serum creatinine alone. A GFR <45 is associated with decreased survival after EVAR. Perioperative mortality at a GFR of 45 to 60 is comparable with that of the lower quartile (GFR <45), but late survival is comparable with that of patients with GFR >60. The finding of increased risk of early mortality in patients in the 45 to 60 GFR range, with survivors enjoying good long-term outcome, suggests that these patients may most benefit from the use of alternative contrast agents and periprocedural renal protection techniques.

Aged↗

PubMed2006

Gastrointestinal complications after descending thoracic and thoracoabdominal aortic repairs: a 14-year experience.

OBJECTIVE: There is a paucity of data regarding gastrointestinal (GI) complications after descending thoracic and thoracoabdominal aortic (DTA/TAA) surgical repairs. We examined our 14-year experience with these repairs to determine the incidence, outcomes, and risk factors for postoperative GI complications. METHODS: Between February 1991 and February 2005, we repaired 1,159 DTA/TAA. Data were prospectively collected. The mean patient age was 68 years and 36% were women. Complications were classified as biliary disease, hepatic dysfunction, pancreatitis, GI bleeding, peptic ulcer disease, bowel ischemia, and ileus. Risk factors for the occurrence of GI complications were ascertained by univariate and multivariable analysis. RESULTS: Of the 1,159 patients, 81 had 109 GI complications, for a 7% incidence. The mortality associated with GI complications was 39.5% compared with 13.5% (P < .0001) in patients without GI complications. The incidences of complications were bowel ischemia, 2.5% with 62% mortality; biliary disease, 0.3% with 75% mortality; hepatic dysfunction, 1.6% with 38% mortality; acute pancreatitis, 0.3% with 20% mortality; GI bleeding, 1.5% with 29% mortality; peptic ulcer disease, 0.9% with 30% mortality; and ileus, 2.2% with 26% mortality. Postoperative biliary disease (odds ratio [OR], 16.58; P = .001), hepatic dysfunction (OR, 3.58; P = .006), and bowel ischemia (OR, 10.03; P = .0001) were significantly associated with an increased postoperative mortality. Risk factors for the occurrence of GI complications were visceral involvement of the aortic repair (TAA extent II, III, and IV) (OR, 2.08; P = .002) and low preoperative glomerular filtration rate (OR, .98; P = .0002). CONCLUSION: Biliary disease, hepatic dysfunction, and bowel ischemia after DTA/TAA surgical repairs were associated with an increased mortality. Visceral involvement and preoperative renal insufficiency were risk factors for the occurrence of GI complications.

Adolescent↗

PubMed2006

Chylothorax complicating repairs of the descending and thoracoabdominal aorta.

BACKGROUND: Chylothorax occurring during thoracic aortic surgery is an infrequent but serious complication. The purpose of this study was to analyze our experience with this complication and the resulting outcomes. METHODS: From January 1991 to July 2005, we performed 1,233 descending thoracic and thoracoabdominal aortic surgical procedures. A retrospective review was performed to analyze and identify preoperative and operative risk factors as well as management outcomes of postoperative chylothorax (PCT). RESULTS: PCT developed in five patients (0.4%). All five cases occurred with descending thoracic aortic aneurysm repair, and 80% (four of five patients) were undergoing aortic reoperation. All patients were managed successfully with no mortality. Risk factors for the development of chylothorax were descending thoracic aortic repair (p = 0.006) and thoracic aortic reoperations (p = 0.0003). Nonoperative management was successful in 60% (three of five patients). Two patients required left thoracotomy with direct ligation. Mean hospital length of stay was 35 days (range, 15 to 60 days). Mean follow-up was 33 months (range, 3 to 69 months) with no recurrence of chylothorax or additional morbidity or mortality. CONCLUSIONS: Chylothorax is more likely to occur with reoperations and repairs involving the descending thoracic aorta. Although PCT is associated with longer hospital length of stay, it is not associated with increased infectious complications. Early identification and prompt treatment may decrease both early and late morbidity and mortality.

Aged↗

PubMed2005

Correlations of cerebrospinal fluid pressure with hemodynamic parameters during thoracoabdominal aortic aneurysm repair.

Central venous pressure (CVP) has long been thought to correlate with cerebrospinal fluid (CSF) pressure during thoracoabdominal aortic aneurysm repair. We examined hemodynamic factors during thoracoabdominal aortic aneurysm surgery to determine their relationship with CSF pressure and aortic cross-clamping. Hemodynamic parameters and CSF pressure were measured in 124 patients at six different stages during repair of descending thoracic or thoracoabdominal aortic aneurysms: skin incision, left lung collapse, pump on, aortic clamp on, aortic clamp off, and pump off. Stepwise multiple regression analysis was used for statistical analysis. CVP was a weak predictor for CSF pressure at the beginning of surgery and when the pump was initiated. At the onset of left lung collapse, cardiac output correlated with CSF pressure. There were no predictors during aortic cross-clamping. Model r2 values were low, ranging 0.03-0.15. We found no hemodynamic predictors of CSF pressure throughout the period of aortic cross-clamping during descending thoracic or thoracoabdominal aortic aneurysm surgery. Model r2 values were low, indicating generally poor prediction of CSF pressure.

Aged↗

PubMed2005

Descending thoracic aortic aneurysm repair: 12-year experience using distal aortic perfusion and cerebrospinal fluid drainage.

BACKGROUND: The benefit of distal aortic perfusion and cerebrospinal fluid drainage over the "clamp and sew" technique during repairs of the descending thoracic aorta is still being debated. The purpose of this report is to analyze our experience with regard to neurologic deficit (paraplegia and paraparesis) and mortality using the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage. METHODS: Between February 1991 and September 2004, we repaired 355 descending thoracic aortic aneurysms. Excluded from analysis were 29 patients who required profound hypothermic circulatory arrest as a result of transverse arch involvement and 26 patients with aortic rupture, leaving a group of 300 patients for which outcomes were analyzed. Mean patient age was 67 years, and 102 (34%) of the patients were women. The adjunct group of distal aortic perfusion and cerebrospinal fluid drainage used in 238 (79.3%) patients was compared with a group of 62 patients who underwent simple cross-clamp with or without the addition of a single adjunct. Multivariable data were analyzed by Cox regression. RESULTS: The incidence of neurologic deficit after all repairs was 2.3% (7 of 300 patients). The incidence of neurologic deficit (immediate and delayed) in the adjunct group was 1.3% (3 of 238 patients), and in the nonadjunct group was 6.5% (4 of 62 patients; p < 0.02). One case of delayed paraplegia occurred in each group. All neurologic deficits occurred in patients with aneurysmal involvement of the entire descending thoracic aorta (extent C; p < 0.02). Statistically significant predictors for neurologic deficit were the use of the adjunct (odds ratio [OR], 0.19; p = 0.02), previous repaired abdominal aortic aneurysm (OR, 7.0; p = 0.005), type C aneurysm (OR, 13.73; p = 0.02), and cerebrovascular disease history (OR, 4.7; p < 0.03). Thirty-day mortality was 8% (24 of 300 patients). Significant multivariate predictors of 30-day mortality were preoperative renal dysfunction (OR, 4.6; p < 0.01) and female sex (OR, 2.9; p < 0.03). CONCLUSIONS: Repairs of the descending thoracic aorta using the adjunct of distal aortic perfusion and cerebrospinal fluid drainage can be performed with a low incidence of neurologic deficit and an acceptable mortality. The use of the adjuncts should be considered during elective repairs of the descending thoracic aorta.

Adolescent↗

PubMed2005

Evolution of risk for neurologic deficit after descending and thoracoabdominal aortic repair.

BACKGROUND: Cross-clamp time has been reported to correlate with risk of neurologic deficit after thoracoabdominal aortic aneurysm repair. Introduction of cerebrospinal fluid drainage and distal aortic perfusion (adjunct) has greatly reduced the incidence of neurologic deficit. We reevaluated the effect of cross-clamp time before and after introduction of adjunct during a 13-year period. METHODS: Between 1991 and 2004, we repaired 1,106 thoracic and thoracoabdominal aortic aneurysms. Four hundred one patients were female and 705 were male (median age, 67 years). Selective use of adjunct was begun in late 1992, with its routine use by 1993. RESULTS: Aortic cross-clamp times have increased significantly (34 seconds/year; p < 0.0001) since 1991. Despite this increase in cross-clamp time, neurologic deficit rates have declined from the first to the fourth quartile (p < 0.02). This decrease in neurologic deficit is most pronounced with the extent II thoracoabdominal aortic aneurysms (21.1% to 3.3%). The use of the adjunct increased the cross-clamp time by a mean of 12 minutes (p < 0.0001), but was associated with a significant protective effect against neurologic deficit (odds ratio = 0.4; p < 0.0002). Although other previously established risk factors remained significantly associated with neurologic deficit, cross-clamp time is no longer significant. CONCLUSIONS: Adjunct significantly reduced the risk of neurologic deficit, despite increasing cross-clamp time. The use of the adjunct appears to blunt the effect of the cross-clamp time and may provide the surgeon the ability to operate without being hurried. Because cross-clamp time has been effectively eliminated as a risk factor with the use of the adjunct, using this variable to construct risk models becomes irrelevant in our experience.

Adolescent↗

PubMed2005

Potential targets to encourage a surgical career.

BACKGROUND: Our goal was to identify factors that can be targeted during medical education to encourage a career in surgery. STUDY DESIGN: We conducted a cross-sectional survey of first and fourth year classes in a Liaison Committee on Medical Education-accredited medical school. Students scored 19 items about perceptions of surgery using a Likert-type scale. Students also indicated their gender and ranked their top three career choices. RESULTS: There were 121 of 210 (58%) first year and 110 of 212 (52%) fourth year students who completed the survey. First year students expressed a positive correlation between surgery and career opportunities, intellectual challenge, performing technical procedures, and obtaining a residency position, although length of training, work hours, and lifestyle during and after training were negatively correlated with choosing surgery. Fourth year student responses correlated positively with career and academic opportunities, intellectual challenge, technical skills, role models, prestige, and financial rewards. Factors that correlated negatively were length of training, residency lifestyle, hours, call schedule, and female gender of the student respondent. Forty-four percent of first year male students expressed an interest in surgery versus 27% of fourth year male students (p < 0.04). Eighteen percent of first year female students expressed an interest in surgery versus 5% of fourth year female students (p < 0.006). CONCLUSIONS: Lifestyle issues remain at the forefront of student concerns. Intellectual challenge, career opportunities, and technical skills are consistently recognized as strengths of surgery. Additionally, fourth year students identify role models, prestige, and financial rewards as positive attributes. Emphasizing positive aspects may facilitate attracting quality students to future careers in surgery.

Algorithms↗

PubMed2005

Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection.

OBJECTIVE: Neurologic complications after repair of acute type A aortic dissection remain significant. The use of power M-mode transcranial Doppler monitoring to verify cerebral blood flow during these repairs might decrease cerebral ischemia by correcting malperfusion. The purpose of this study was to analyze the use of power M-mode transcranial Doppler monitoring during repairs of acute type A dissection with regard to neurologic outcome. METHODS: We performed a prospective study of patients undergoing repairs of acute type A aortic dissection. Repairs included profound hypothermic circulatory arrest and retrograde cerebral perfusion. Patients in whom transcranial Doppler monitoring was used to monitor cerebral blood flow and modify operative technique during repair (study group) were compared with those without monitoring and modification (control group). RESULTS: Between September 2001 and October 2003, we repaired 56 cases of acute type A dissection. Power M-mode transcranial Doppler monitoring was used in 50% (28/56) of cases. Power M-mode transcranial Doppler monitoring altered operative cannulation and guided retrograde cerebral perfusion flow in 28.5% (8/28) and 78.6% (22/28) of cases, respectively. Two patients presented with preoperative stroke, one in each group. One operative death occurred in each group. In-hospital mortality and the occurrence of new stroke were not significantly different between the 2 groups. Temporary neurologic dysfunction occurred less often in the study group (14.8% [4/27] vs 51.8% [14/27], P = .008). CONCLUSIONS: Identification of cerebral malperfusion requires cerebral monitoring. By ensuring cerebral blood flow by using power M-mode transcranial Doppler monitoring and correcting cerebral malperfusion by modifying operative technique, neurologic outcome was improved during repairs of acute type A aortic dissection.

Acute Disease↗

PubMed2005

Glomerular filtration rate is superior to serum creatinine for prediction of mortality after thoracoabdominal aortic surgery.

BACKGROUND: Clinically evident renal disease (dialysis, history of renal insufficiency, or serum creatinine >2.0 mg/dL) is a known risk factor for mortality after thoracoabdominal aortic aneurysm repair. We extended this concept to the questions of whether subclinical renal disease is also a risk factor and how best to identify subclinical disease. We hypothesized that the glomerular filtration rate (GFR) would be a more sensitive determinant of renal function than serum creatinine alone. METHODS: Between 1991 and 2004, we repaired 1106 thoracoabdominal aortic aneurysms and descending thoracic aortic aneurysms. The median age was 67 years. There were 400 (36%) women and 706 (64%) men. We estimated GFR by using the Cockcroft-Gault equation. We divided baseline serum creatinine and baseline GFR into quartiles and estimated the association of the quartiles with 30-day postoperative mortality by chi2 testing. We further subdivided the population into patients with and without clinically evident renal disease and repeated the analysis in the patients without clinically apparent disease (n = 869). RESULTS: Clinically apparent renal disease was highly associated with 30-day mortality (odds ratio, 3.2; P < .0001). In all patients, serum creatinine quartile and GFR quartile were also both highly significantly associated with 30-day mortality (P < .0001). In patients without clinically apparent renal disease, both creatinine and GFR predicted additional mortality, but GFR was a much stronger predictor (P < .02 for creatinine vs < .0001 for GFR). In these patients, mortality ranged from 5% in the best GFR quartile to 27% in the worst. Taken as continuous variables in logistic regression equations, serum creatinine had no discrimination in patients without clinical disease (P = .73), whereas GFR remained strong (P < .0001). CONCLUSIONS: Preoperative renal function is an important determinant of early mortality even in patients without clinically evident disease. Estimated GFR is a much more powerful determinant of mortality risk than serum creatinine alone.

Adolescent↗

PubMed2005

Manual vital signs reliably predict need for life-saving interventions in trauma patients.

OBJECTIVE: Various types of diagnostic and monitoring techniques are available in the prehospital environment. It is unclear how increasing complexity of diagnostic equipment improves the ability to predict the need for a life-saving intervention (LSI). In this study, we determined whether the addition of diagnostic equipment improved the predictive power of vital signs and scores obtained only by physical examination. METHODS: Institutional review board approval was obtained for an analysis of 793 prehospital trauma patient records collected during helicopter transport by Emergency Medical Services personnel. Exclusion of severe head injuries and patients with incomplete data resulted in 381 patients available for analysis. Data sets were classified on the basis of the instrumentation requirements for capturing the given measurements and were defined by three groups: Group 1, vital signs obtained with no equipment (radial, femoral, and carotid pulse character; capillary refill; motor and verbal components of the Glasgow Coma Scale [GCS]); Group 2, Group 1 plus eye component of the GCS and pulse oximetry (Spo(2)); and Group 3, Group 2 plus fully automated noninvasive blood pressure measurements, heart rate, end-tidal carbon dioxide, and respiratory rate. LSIs performed during transport and in the hospital were recorded. Data were analyzed using a multivariate logistic regression model to determine which vital signs were the best predictors of LSI. RESULTS: Radial pulse character and GCS verbal and motor components had the best predictive power for the need of a prehospital LSI in Group 1 (receiver operating characteristic [ROC] curve, 0.97). Radial pulse character together with the eye component of the GCS and the motor component of the GCS provided the best prediction of a need for a prehospital LSI for Group 2 (ROC curve, 0.97). Addition of all supplementary vital signs measured by an automated monitor (Group 3) resulted in an ROC curve of 0.97. Given an abnormal radial pulse character (weak or absent) and abnormal GCS verbal and motor components, the probability of needing an LSI was greater than 88%. CONCLUSION: In this cohort of patients, predicting the need for an LSI could have been achieved from GCS motor and verbal components and radial pulse character without automated monitors. These data show that simple and rapidly acquired manual measurements could be used to effectively triage non-head-injured trauma casualties. Similar results were obtained from manual measurements compared with those recorded from automated medical instrumentation that may be unavailable or difficult to use in the field.

Adult↗

PubMed2005

Surgical repair of extensive aortic aneurysms.

We present our 14-year experience in the management of extensive aortic aneurysms. Significant progress has been made in reducing the morbidity and mortality associated with these procedures. Our strategies for organ protection, operative techniques, including the elephant trunk technique, and surgical results are discussed.

Aortic Aneurysm↗

PubMed2005

Prehospital physiologic data and lifesaving interventions in trauma patients.

BACKGROUND: The ability to accurately triage trauma patients can be difficult in the prehospital environment. Prehospital trauma scoring systems have been developed with a goal of determining which patients should be transported immediately to a trauma center, thus benefiting from critical personnel and resource-intensive lifesaving interventions (LSIs). A resource-based endpoint, LSIs, therefore might be the optimal endpoint of prehospital triage scoring and could be used to determine where patients are transported. We hypothesized that simple physiologic data available immediately upon scene arrival would prove predictive of the need for a LSI. METHODS: Trauma patients transported from the injury scene by helicopter were eligible for entry into the study. Prehospital physiologic data and interventions were timed and recorded by flight medical personnel, whereas hospital vital signs, injuries, and interventions were prospectively recorded from the inpatient records. The motor component of the Glasgow Coma Scale was used as an indicator of neurologic function. LSIs were procedures deemed lifesaving by a multidisciplinary panel of trauma experts. RESULTS: Physiologic data were collected from August 2001 to February 2002. Data were collected for 216 random patients transported by the Life Flight helicopter service. There were no differences between LSI and non-LSI patients in age, gender, or transport time, and 80 patients underwent 197 LSIs. The mean age was 33 +/- 17 years, 73% of patients were male, 90% suffered blunt injury, the injury severity score was 14 +/- 9, hypotension (systolic blood pressure of < 90 mm Hg) was present in 14% of cases, and the mortality rate was 6%. Penetrating injury and increasing injury severity score were associated with LSI. Univariate analysis of the physiologic data immediately available in the field revealed that SBP of < 90 mm Hg, motor score of < 6, delayed capillary refill, and increasing pulse were significantly associated with a LSI. However, multivariate analysis revealed that only SBP of < 90 mm Hg and motor score of < 6 were associated with a LSI. When both variables were abnormal, 95% of patients required a LSI; when both variables were normal, 21% of patients required a LSI. CONCLUSIONS: The presence of hypotension or decreased motor score was correlated with the need for LSIs. However, normotensive patients with normal motor scores still frequently required LSIs. Optimal discrimination of this group of patients will require new analytic approaches.

Adolescent↗

PubMed2004

Determinants of early and late outcome for reoperations of the proximal aorta.

BACKGROUND: The purpose of this study was to investigate the cause of ascending aorta and aortic arch reoperations and to identify determinants of early and late outcome. METHODS: Between January 1991 and March 2003 we repaired aneurysms of the proximal aorta in 597 patients. Of these patients, 104 had reoperations for replacement of the ascending aorta, aortic root, or transverse aortic arch. Previous surgery was defined as any previous cardiac or proximal aortic repair. Median age was 60 years, and 29 of the patients (28%) were female. Indications for reoperation and replacement of the proximal aorta included acute type A dissection in 6 patients (5.8%), aneurysm with chronic dissection in 60 (57.7%), progression of aneurysm in 23 (22.1%), infection in 12 (1.5%), inflammatory disease in 2 (1.9%), and atheromatous disease in 1 (1.0%). Reoperations included aortic root replacement in 20 patients (19.2%), total arch replacement with elephant trunk in 28 (26.7%), ascending and proximal arch in 39 (37.5%), and ascending aorta in 27 (26.0%). The median interval between operations was 69 months. Retrograde cerebral perfusion was used in 80 (77%) cases. RESULTS: Chronic dissection was the most common indicator for reoperation in our population, followed by progression of aneurysm and infection. Thirty-day and in-hospital mortality was 13.5% (14 of 104) and 15.4% (16 of 104), respectively. Chronic obstructive pulmonary disease, renal dysfunction, and increased pump time were risk factors for mortality. Median follow-up was 5.02 years. Eight patients died during that period. Estimated survival at 1, 5, and 10 years was 83%, 80%, and 62%, respectively. Freedom from second proximal reoperations was 97.1% (10 of 104). Freedom from subsequent distal thoracic aortic repair was 84.6% (8 of 104). CONCLUSIONS: Reoperations of the ascending aorta and aortic arch can be performed safely with good long-term results. Patients with previous proximal aortic dissection repair need long-term surveillance. Renal dysfunction and chronic obstructive pulmonary disease must be carefully considered before reoperations of the proximal aorta.

Adolescent↗