Browsing by Author "Murphy, Patrick"

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    Damage Control Thoracotomy: A Systematic Review of Techniques and Outcomes
    (Elsevier, 2021-05) Douglas, Anthony, II; Puzio, Thaddeuss; Murphy, Patrick; Menard, Laura; Meagher, Ashley D.; Surgery, School of Medicine
    Background : Damage control surgery is the practice of delaying definitive management of traumatic injuries by controlling hemorrhage in the operating room and restoring normal physiology in the intensive care unit prior to definitive therapy. Presently, damage control or “abbreviated” laparotomy is used extensively for abdominal trauma in an unstable patient. The application of a damage control approach in thoracic trauma is less established and there is a paucity of literature supporting or refuting this practice. We aimed to systematically review the current data on damage control thoracotomy (DCT), to identify gaps in the literature and techniques in temporary closure. Methods : An electronic literature search of Pubmed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972-2018 was performed using the keywords “thoracic,” “damage control,” and “thoracotomy.” Studies were included if they reported the use of DCT following thoracic trauma and included survival as an outcome. Results : Of 723 studies, seven met inclusion criteria for a total of a 130 DCT operations. Gauze packing with temporary closure of the skin with suture was the most frequently reported form of closure. The overall survival rate for the seven studies was 67%. Survival rates ranged from 42-77%. Average injury severity score was 30, and 64% of injuries were penetrating in nature. The most common complications included infections (57%; pneumonia, empyema, wound infection, bacteremia), respiratory failure (21%), ARDS (8%), and renal failure (18%). Conclusion : DCT may be associated with improved survival in the critically injured patient population. Delaying definitive operation by temporarily closing the thorax in order to allow time to restore normal physiology may be considered as a strategy in the unstable thoracic trauma patient population. The impact an open chest has on respiratory physiology remains inconclusive as well as best mechanisms of temporary closure. Multi-center studies are required to elucidate these important questions.
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    Early or Late Gastrografin Challenge for the Non-Operative Management of Small Bowel Obstruction
    (2020-09-10) Holder, Erik; Murphy, Patrick; Meagher, Ashley; Rodriguez, Rachel
    Introduction: Gastrogafin (GG) challenge is becoming the standard of care for the non-operative management of adhesive small bowel obstruction (aSBO). Protocols vary in the timing of GG challenge from early (≤ 24 hours) to late (> 24 hours). Concerns remain regarding the safety of early GG due to inadequate stomach and bowel decompression raising fear of complication such as aspiration. Few studies have investigated the relationship between the timing of GG and patient outcomes, including time to OR, length of stay or complication rate. We hypothesized early GG challenge would be non-inferior to late GG challenge and would have shorter length of stay. Methods: A retrospective cohort study of 215 patients over two years (2018-2019) who underwent non-operative management of adhesive SBO. We stratified patients by timing of GG challenge, ≤ 24 hours (Early GG) or > 24hours (Late GG). Our primary outcome was success of GG challenge defined by discharge without an operation. Secondary outcomes included bowel resection, re-admission rate, hospital length of stay, and mortality. Our non-inferiority margin was 4%. We used the Chen Quasi-Exact method to determine confidence intervals for small sample sizes to determine non-inferiority. Continuous data was assessed by one-way ANOVA and categorical data with Fischer’s Exact test. Results: A total of 215 patients underwent planned non-operative management of adhesive SBO over the study period, of whom 102 received a GG challenge. Early GG was administered in 33 (32%), Late GG was administered in 79 (68%). There was no difference in age or gender, but more African Americans received Late GG (40% vs 15%, p = 0.01). The need for operative intervention was lowest in the early group, 6.1% compared to 17.7% in the late group. The difference of -11.6% [95% CI -22.9% - 3.3%] was non-inferior (p=0.03) but did not meet superiority. No patient receiving Early GG required bowel resection compared to 5 (35%) in the Late GG group (p = 0.45). Hospital length of stay was a median of 3 (IQR 2) for Early GG compared to 4 (IQR 8) for Late GG (p < 0.001). There was no difference in mortality, re-admission rates, ICU admission or ICU length of stay between groups. Conclusion: Early GG challenge (≤ 24 hours) is non-inferior to late GG challenge (> 24 hours) for the non-operative management of adhesive SBO. Patients who received early GG had a shorter length of stay, and no complications associated with early GG. Additionally, fewer patients who received early GG received a bowel resection, although this is not statistically significant. This indicates need for multi-center evaluation of GG administration and development of practice management guidelines for patients with adhesive SBO. We recommend early GG challenge to decrease the time for operative decision making and reduce length of stay. A prospective study comparing early versus late GG challenge is needed to determine optimal timing.
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    Extending Trauma Quality Improvement Beyond Trauma Centers: Hospital Variation in Outcomes Among Nontrauma Hospitals
    (Wolters Kluwer, 2022) Jenkins, Peter C.; Timsina, Lava; Murphy, Patrick; Tignanelli, Christopher; Holena, Daniel N.; Hemmila, Mark R.; Newgard, Craig; Surgery, School of Medicine
    Objective: The American College of Surgeons (ACS) conducts a robust quality improvement program for ACS-verified trauma centers, yet many injured patients receive care at non-accredited facilities. This study tested for variation in outcomes across non-trauma hospitals and characterized hospitals associated with increased mortality. Summary background data: The study included state trauma registry data of 37,670 patients treated between January 1, 2013, and December 31, 2015. Clinical data were supplemented with data from the American Hospital Association and US Department of Agriculture, allowing comparisons among 100 nontrauma hospitals. Methods: Using Bayesian techniques, risk-adjusted and reliability-adjusted rates of mortality and interfacility transfer, as well as Emergency Departments length-of-stay (ED-LOS) among patients transferred from EDs were calculated for each hospital. Subgroup analyses were performed for patients ages >55 years and those with decreased Glasgow coma scores (GCS). Multiple imputation was used to address missing data. Results: Mortality varied 3-fold (0.9%-3.1%); interfacility transfer rates varied 46-fold (2.1%-95.6%); and mean ED-LOS varied 3-fold (81-231 minutes). Hospitals that were high and low statistical outliers were identified for each outcome, and subgroup analyses demonstrated comparable hospital variation. Metropolitan hospitals were associated increased mortality [odds ratio (OR) 1.7, P = 0.004], decreased likelihood of interfacility transfer (OR 0.7, P ≤ 0.001), and increased ED-LOS (coef. 0.1, P ≤ 0.001) when compared with nonmetropolitan hospitals and risk-adjusted. Conclusions: Wide variation in trauma outcomes exists across nontrauma hospitals. Efforts to improve trauma quality should include engagement of nontrauma hospitals to reduce variation in outcomes of injured patients treated at those facilities.
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    Extracorporeal life support in pediatric trauma: a systematic review
    (BMJ, 2019-09-13) Puzio, Thaddeus; Murphy, Patrick; Gazzetta, Josh; Phillips, Michael; Cotton, Bryan A.; Hartwell, Jennifer L.; Surgery, School of Medicine
    Introduction Extracorporeal membrane oxygenation (ECMO) was once thought to be contraindicated in trauma patients, however ECMO is now used in adult patients with post-traumatic acute respiratory distress syndrome (ARDS) and multisystem trauma. Despite acceptance as a therapy for the severely injured adult, there is a paucity of evidence supporting ECMO use in pediatric trauma patients. Methods An electronic literature search of PubMed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972 to 2018 was performed. Included studies reported on ECMO use after trauma in patients ≤18 years of age and reported outcome data. The Institute of Health Economics quality appraisal tool for case series was used to assess study quality. Results From 745 studies, four met inclusion criteria, reporting on 58 pediatric trauma patients. The age range was <1–18 years. Overall study quality was poor with only a single article of adequate quality. Twenty-nine percent of patients were cannulated at adult centers, the remaining at pediatric centers. Ninety-one percent were cannulated for ARDS and the remaining for cardiovascular collapse. Overall 60% of patients survived and the survival rate ranged from 50% to 100%. Seventy-seven percent underwent venoarterial cannulation and the remaining underwent veno-venous cannulation. Conclusion ECMO may be a therapeutic option in critically ill pediatric trauma patients. Consideration should be made for the expansion of ECMO utilization in pediatric trauma patients including its application for pediatric patients at adult trauma centers with ECMO capabilities.
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    Impact of a Daytime Operating Room on Resource Use and Outcomes in Emergency General Surgery
    (2020-02-05) Murphy, Patrick; Patterson, Alicia; Holder, Erik; Scifres, Aaron; Rodriguez, Rachel
    Introduction: The implementation of acute care surgery (ACS) services has not been standardized. There is no known “best” model or optimal infrastructure required to care for emergency general surgery (EGS) patients. The addition of dedicated daytime operative room (OR) resources may increase patient access and reduce overnight operations. Methods: We performed a retrospective cohort study of patients who underwent emergency appendectomy, cholecystectomy, or hernia repair at a tertiary care center from Feb 1, 2015 to Dec 31, 2018. A daytime ACS room was implemented on Jan 18, 2017, dividing patients into two cohorts: the “Pre-Access” period prior to and “Post-Access” period after implementation. Resources were allocated to the ACS room only if cases were booked by 430 PM the day prior. Outcomes included after-hour ORs (5 pm – 7 am), time to OR, time of scheduled ORs (AM or PM) and relevant patient outcomes. Results: Over 4-years, 925 patients underwent appendectomy (42%), cholecystectomy (50%) or hernia repair (8%) on an emergent basis. There was a 49% increase in volume in the Post-Access period, without an increase in time to OR [14 h, IQR 38 for both groups], after-hours OR (42.1% v 42.1%, p=0.99) or timing of ORs (28.3% v 29.1% AM start and 29.4% v 28.7% PM start, p=0.96). There was no change in hospital length of stay [2 d, IQR 4 v 3 d, IQR 4, p=0.39] or complication rates (14% v 18%, p=0.15). On subgroup analysis, only delayed cholecystectomies for gallstone pancreatitis (GSP) showed a reduction in after-hours ORs (13% v 0%, p=0.03) and an increase in AM OR start times (43% v 71%, p=0.02), suggesting that pre-scheduled cases are most affected by this OR allocation model. Conclusion: Despite a significant increase in volume there was no increase in after-hours resource utilization, hospital length of stay, or worse patient outcomes. The addition of an ACS room improved daytime access for GSP but not for other diagnoses. Dedicated infrastructure results in efficient use of resources and the ability to manage increasing patient volumes. Efficiency may be further improved by dedicated staffing of ACS rooms.
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    Optimal Timing of Venous Thromboembolic Chemoprophylaxis Initiation Following Blunt Solid Organ Injury: Meta-Analysis and Systematic Review
    (2021-04-22) Murphy, Patrick; de Moya, Marc; Karam, Basil; Menard, Laura; Holder, Erik; Inaba, Kenji; Schellenberg, Morgan
    PURPOSE: The need to prevent venous thromboembolism (VTE) following blunt solid organ injury must be balanced against the concern for exacerbation of hemorrhage. The optimal timing for initiation of VTE chemoprophylaxis is not known. The objective was to determine the safety and efficacy of early (≤48 hours) VTE chemoprophylaxis initiation following blunt solid organ injury. METHODS: An electronic search was performed of medical libraries for English-language studies on timing of VTE chemoprophylaxis initiation following blunt solid organ injury published from inception to April 2020. Included studies compared early (≤48 hours) versus late (>48 hours) initiation of VTE chemoprophylaxis in adults with blunt splenic, liver and/or kidney injury. Estimates were pooled using random-effects meta-analysis. Odds ratios were utilized to quantify differences in failure of nonoperative management, need for blood transfusion and rates of VTE. RESULTS: The search identified 2,111 studies. Of these, ten studies comprising 14,675 patients were included. All studies were non-randomized and only one was prospective. The overall odds of failure of nonoperative management were no different between early and late groups, OR 1.09 (95%CI 0.92-1.29). Similarly, there was no difference in the need for blood transfusion either during overall hospital stay, OR 0.91 (95%CI 0.70-1.18), or post prophylaxis initiation, OR 1.23 (95%CI 0.55-2.73). There were significantly lower odds of VTE when patients received early VTE chemoprophylaxis, OR 0.51 (95%CI 0.33-0.81). CONCLUSIONS: Patients undergoing nonoperative management for blunt solid organ injury can be safely and effectively prescribed early VTE chemoprophylaxis. This results in significantly lower VTE rates without demonstrable harm.
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    Short-term Outcomes for Patients and Providers After Elective Tracheostomy in COVID-19–Positive Patients
    (Elsevier, 2021-04) Murphy, Patrick; Holler, Emma; Lindroth, Heidi; Laughlin, Michelle; Simons, Clark J.; Streib, Erik W.; Boustani, Malaz; Ortiz, Damaris; Surgery, School of Medicine
    Background Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. The objective of the study was to demonstrate that percutaneous dilational tracheostomy (PDT) with a period of apnea in patients requiring prolonged mechanical ventilation due to COVID-19 is safe and can be performed for the usual indications in the intensive care unit. Methods This study involves an observational case series at a single-center medical intensive care unit at a level-1 trauma center in patients diagnosed with COVID-19 who were assessed for tracheostomy. Success of a modified technique included direct visualization of tracheal access by bronchoscopy and a blind dilation and tracheostomy insertion during a period of patient apnea to reduce aerosolization. Secondary outcomes include transmission rate of COVID-19 to providers and patient complications. Results From April 6th, 2020 to July 21st, 2020, 2030 patients were admitted to the hospital with COVID-19, 615 required intensive care unit care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. Eighteen patients were assessed for PDT, and 11 (61%) underwent the procedure. The majority had failed extubation at least once (72.7%), and the median duration of intubation before tracheostomy was 15 d (interquartile range 13-24). The median positive end-expiratory pressure at time of tracheostomy was 10.8. The median partial pressure of oxygen (PaO2)/FiO2 ratio on the day of tracheostomy was 142.8 (interquartile range 104.5-224.4). Two patients had bleeding complications. At 1-week follow-up, eight patients still required ventilator support (73%). At the most recent follow-up, eight patients (73%) have been liberated from the ventilator, one patient (9%) died as a result of respiratory/multiorgan failure, and two were discharged on the ventilator (18%). Average follow-up was 20 d. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19. Conclusions and relevance: PDT for patients with COVID-19 is safe for health care workers and patients despite higher positive end-expiratory pressure requirements and should be performed for the same indications as other causes of respiratory failure.