CHANGING TIDE OF SURGERY
| THE ORGAN DONATION BREAKTHROUGH COLLABORATIVE: HOW FAR HAVE WE COME ?—Bradley J.
Roth, MD, Assistant Clinical Professor, Department of Surgery, Keck School of Medicine at the University of Southern
California, Los Angeles
|
| Introduction: organ donation major problem; >6000 patients with end-stage disease die every year while waiting for organ
transplants; actually, more organs available than needed, but donation system inefficient; transplant provides additional 30 yr
of life
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| Supply and demand relationship: United Network for Organ Sharing (UNOS) data show ≈95,000 people waiting
for organ transplantation; waiting period for heart 350 days, lungs 788 days, and liver 817 days; conversion rate (percentage
of time family says “yes”) varies in different hospitals; 19% of hospitals accounted for 80% of potential donors (busy
neurosurgery services and emergency departments [EDs]; trauma centers); 25% increase in organ transplants since 2002,
and deaths for those on waiting lists declining; solution to set goals of 75% donor conversion rate, and 3.75 organs transplanted
per donor; mechanics of solution called “University of Southern California (USC) triad”; need resuscitation protocol,
organ procurement organization (OPO) coordinator, and trauma service’s adoption of care; main goal to decrease
risk for deceleration of care after death occurs
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| Physiology of severe brain injury: intravascular volume depletion secondary to diuretics and mannitol; catecholamine
storm; endocrine imbalance that causes deceleration of organ function and cardiac arrest
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| Resuscitation: if mean arterial pressure >70 mm Hg, give maintenance fluids; if <70 mm Hg, aggressive fluid resuscitation
and pressors as needed; common problems during resuscitation—disseminated intravascular coagulation (DIC); 75%
develop diabetes insipidus (sodium increases rapidly if >165 mEq/L; give fluids); tachycardia and hypertension; pneumothorax
secondary to neurogenic pulmonary edema and ventilator; almost all develop hypokalemia and hyperglycemia;
as brain dies, it becomes hypothermic (place warming blanket); resuscitate if patient goes into cardiac arrest (run advanced
cardiac life support [ACLS] code; can still donate lungs, liver, and heart); T4 donor protocol sometimes performed (thought
to help heart)
|
| Case: man presented with gunshot wound to head; fractured skull and base of skull; bleeding through mouth into lungs; received
epinephrine and blood products; went into cardiac arrest twice in ED; taken to intensive care unit (ICU), where abdomen
decompressed (30 U of blood products); parents wanted son to be organ donor; patient taken to operating room
(OR), where ventilator turned off and pressors stopped; patient again went into cardiac arrest and pronounced dead by
cardiac criteria; kidneys and liver removed; older patients now one of groups most responsible for large increase in organ
donations; if patient 50 yr of age, eg, will not get kidney from 20-yr-old (probably get kidney from 65-yr-old); brain
death declared in different ways
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| OPO coordinator: clinical triggers developed for calling OPO early (mandated by Joint Commission on Accreditation
of Healthcare Organizations [JCAHO]); follow elements of performance required by JCAHO
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| When family should be approached: never; studies show that when caregiver approaches family, likelihood of
agreeing to organ donation decreases
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| Donation at end of life: discharging patients from critical care units as important as admitting them; in donation after
cardiac death, quality end-of-life care absolute priority (vs harvesting organs); once family decides to terminate life, OPO
called to ask family about organ donation; patient evaluated to determine whether good candidate for organ donation;
transplant team notified; patient taken to OR and allowed to die in OR; transplant team should not be in room when patient
dies; JCAHO mandates that all hospitals become relatively aggressive at pursuing organ donation; national standards
apply
|
| THE ACUTE CARE SURGEON: HAS ITS TIME COME ?—David B. Hoyt, MD, Professor and Chairman, Department
of Surgery, University of California, Irvine, College of Medicine
|
| Introduction: incidence of gunshot wounds decreased from 800,000 annually to <400,000; trauma and surgery inseparable;
40 yr ago, trauma identified as epidemic; best disease management model that has been developed for hospital-based
program includes paramedic training, regional emergency medical services (EMS), 911, Advanced Trauma Life Support
(ATLS), trauma care standards, verification, and external trauma data bank; infrastructure created for disaster management;
study shows 25% mortality reduction if patients <55 yr of age taken to trauma center
|
| Threats to trauma care: challenges include reimbursement, lack of funding, and physician costs; decrease in violence
and penetrating trauma affecting operative experience in trauma centers; trauma in elderly and complexities of taking
care of elderly patients changed profile of patients that characterize trauma center; fewer operations—decreased injury
and injury death rates due to prevention of, and diminution in, interpersonal violence; evolution (primarily based on imaging
technology) to nonoperative management; also led to loss of operative identity; resident perceptions—study
showed that residents found trauma surgery exciting (enjoyed it) and felt duty to patients, but found amount of work disproportionate
to number of operations, heavy degree of night work, and detracted from elective schedule; other forces—
pressure to perform; with decrease in work hours, finding gaps in care process; clinicians must close gaps; potential
threat to continuity of care; errors as surgeons move toward new model of health care; specialization of general surgery
led surgeons out of emergency work; problem not unique to general surgery (also seen in orthopedics and neurosurgery)
|
| Qualities of trauma surgeons: duty-driven (stimulated by energy of process; fighter-pilot mentality); enjoy being
team captain (creating order out of complexity); real question is who will be there for patient going forward?
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| Requirements for change: include vision, skills, incentives, resources, and action plan; requirements for trauma
care to evolve as specialty—satisfy major patient or public need; disease management–focused and not operative– or
technology–focused; create viable and attractive lifestyle; correct present deficits; must not trespass on other areas of
practice; should merge with evolving specialties, eg, hospitalists, ICU specialists; enhance safety and quality; ensure financial
viability; solutions—looked at models; emergency surgery model in United States already in place in many
trauma centers; effective subspecialty model; broadened trauma model (not practical in United States)
|
| Acute care surgery: new surgical specialty created; hospital-based specialist who would practice trauma, critical care,
and emergency surgery of all types; requires developing criteria for current programs, creating training programs, and developing
comprehensive model for lifelong learning to avoid practice isolation; proposed acute care surgeon—broadly
trained in surgical emergencies; leads multidisciplinary team for spectrum of problems dictated by presentation and timing;
hospital-based team (multidisciplinary); similar to surgical oncology model; reviewed by American Board of Surgery;
has become structure (Advisory Council); American Association for the Surgery of Trauma (AAST) has taken lead in developing
curriculum (now written) and training oversight; 24-mo curriculum
|
| TRAUMA PATIENTS SHOULD BE TREATED WITH β-BLOCKERS —M. Margaret Knudson, MD, Professor of Surgery,
University of California, San Francisco, School of Medicine
|
| Introduction: once injured or potentially injured, 10-fold increase in catecholamines; “fight or flight” response; heart rate
and contractility increase to deliver more blood to muscles, should individual choose “flight”; smooth muscles in pulmonary
system dilated to allow in more air; blood pressure (BP) increases; platelets ready to heal wound; prolonged catecholamine
response associated with severe injury and correlates with Glasgow Coma Scale (GCS) score; complications include cardiac
stress and infarction, increase in amount of protein and fat catabolism, and insulin resistance; ways of destressing after injury
include yoga, herbal teas, aromatherapy, massage, or β-blockers
|
| β-blockade: randomized controlled study—looked at mortality after major noncardiac surgery; found decrease in in-
hospital deaths when β-blockade initiated; in-hospital myocardial infarction (MI) also decreased; American Heart Association
(AHA) gives Class 1 recommendation for perioperative β-blockade in patients who had taken β-blockers in
past for angina, arrhythmia, or hypertension and ischemia on preoperative testing for vascular surgery
|
 | In burn patients: randomized trial—children with total body surface area burns of 40% to 70%; propranolol vs placebo;
children on β-blockade had decreased myocardial work and resting energy expenditure and increased muscle protein
balance; also decrease in infectious complications and sepsis noted; retrospective study—adult burn patients; cohorts
include those on β-blockade before injury, those who received β-blockade at hospital (average >8 days), and those who
did not receive β-blockade at any time (control group); those previously on β-blockade had decrease in mortality; those
who received in-hospital β-blockade even worse than controls; argument that β-blocker probably given too late
|
| In blunt aortic injury: if known or suspected, start β-blockade immediately; demonstrated that titrating esmolol to systolic
BP <100 mm Hg and pulse rate <100 beats/min did not result in in-hospital aortic ruptures in patients with documented
aortic injuries
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| In traumatic brain injury: study demonstrated association between severe traumatic brain injury and cardiac necrosis; patients
placed on atenolol or placebo; those on placebo had higher creatine kinase myocardial band (MB) isoform (CK-
MB) elevation; those on placebo who died had abnormal electrocardiography; another study showed that β-blockers improved
survival after traumatic brain injury; retrospective review of patients with abbreviated injury scale (AIS) ≥3; β-
blocker exposure included anyone who received β-blocker in hospital for ≥2 days; those on β-blockade more severely injured,
had higher infection rate, higher rate of adult respiratory distress syndrome, and longer ICU stay, but only half mortality
rate
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| In multiple injuries: University of Michigan study—303 patients who received β-blockers in hospital vs those who did
not; adjusted for injury severity score (ISS), age, BP, GCS score, and respiratory status; slight improvement (but not
dramatic) in odds ratio for fatal outcome if on β-blockade; significant only for patients with traumatic brain injury;
study from Wisconsin suggests that elderly patients on β-blockade before injury had 14.7% mortality vs 13.4% for
those not previously on β-blockade
|
| In myocardial injury: study from USC stated that if troponin leak present, patient must be on β-blockade; >1000 patients;
30% had elevated troponin >1.2 µg/L; mortality 38% if troponin level elevated but patient not on β-blockade (16% if
patient on β-blockade); 50% reduction in mortality
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| In posttraumatic stress disorder (PTSD): prevented if β-blockers taken early enough; benefit depends on how much stress
present at time of event that could potentially provoke PTSD
|
| β-BLOCKERS IN TRAUMA PATIENTS ARE NOTHING BUT HERESY —Jay A. Johannigman, MD, Associate Professor
of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, OH
|
| Literature: limited studies to date; results of studies on β-blockade in different patients cannot be applied broadly; problem
with retrospective review of β-blockade in adult trauma patients that all β-blockade applications lumped into one
group; mortality rate higher in patients put on β-blockers in hospital; mortality difference eliminated if early deaths excluded;
β-blockers, depending on which used, may or may not cross blood-brain barrier; patients who survive trauma
uniformly have elevation in cardiac output performance parameters; trauma patients had greater chance for survival when
cardiac index increased (but β-blocker negative inotrope)
|
| Rebuttal (Dr. Knudson): demonstrated that β-blockers improve outcome in patients with burn injury, head injury, and
myocardial injury, and in those undergoing surgery with cardiac risks (significant reduction in mortality); downside that
high doses can precipitate shock; nonselective β2 -blockers can precipitate asthma and increase lung water
|
| Limitations of literature: all retrospective chart data reviews spanning 10 yr; significant changes in 10 yr and worrisome
to apply results to present; prospective trials needed
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| PTSD and β-blockade: anecdotally, β-blockade effective in patients with thalamic “storm”; need to define end points
before prospective trials done
|
| BATTLEFIELD MEDICINE: LESSONS LEARNED FROM IRAQ —C. William Schwab, MD, Professor of Surgery, and
Chief of Traumatology and Surgical Critical Care, University of Pennsylvania, School of Medicine, Philadelphia
|
| Introduction: problem—uncontrolled bleeding due to weapons or explosive devices in dangerous hostile environment,
with limited resources; theater—desert with multiple rapid-moving forces exposed to hidden fire and high-energy ordnance;
plot—minimal acceptable care applied at intervals until arrival at trauma center in Germany and few days later in
United States; battlefield clearing using global trauma system; introduction of damage control as concept and critical care
under battlefield and air transport conditions new; improved body armor, helmet, and shield saving more people in battlefield;
data as of March 2006 show that of ≈12,000 soldiers wounded, 9,000 injuries due to individual explosive devices;
only way to respond to these exsanguinating devastating injuries through far forward teams and surgeons; killed-in-action
rate decreasing solely due to getting surgical care far forward
|
| Echelons of care: levels 1 to 3—far forward team with advanced medic; has proximity to forward surgical hospital;
larger or casualty hospital unit located farther away as back-up; some teams fully mobile; from time of injury, only matter
of minutes (if properly triaged to surgeon who can impose damage control, start blood transfusion, and perform minimal
operation); battlefield cleared within hours, and entire theater cleared within days, due to ability to transport by air with
critical care teams; other levels offer higher care with superspecialists (in Germany); philosophy damage control with
critical care throughout; minimal acceptable care applied at intervals from time of injury until back in United States (level
5); if battlefield overrun, triage performed in casualty receiving hospital; resources available for as many as 20 to 25 patients;
level 4—after stabilization in-theater, patient moved via flying ICU within hours (≤1 day on average) to Landstuhl
Regional Medical Center (LARMC) in Germany; time at Landstuhl averages few days; level 5—sent to National
Naval Medical Center (Bethesda), Walter Reed Army Medical Center, or Brooke Army Medical Center in third leg of
journey (flying ICU with critical care air transport [CCAT] team)
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| Battlefield trauma system: includes training, tourniquets, far forward surgeons, hemostatic resuscitation (using aggressive
and early administration of blood components, whole blood, or factor VIIa), and ICU in battlefield; in exsanguinating
injury, person who can help wounded combat casualty is “buddy” (fellow soldier); after first Gulf War, major
effort made to better train troops to administer first aid; standard pack of combat solider includes 2 tourniquets; immediate
application of tourniquet to exploded extremity most significant advance in combat surgery; advances in hemostatics,
with new products developed due to stimulus in battlefield
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| Resuscitation: changed because of findings in war; presently using hemostatic resuscitation and damage-control resuscitation
(special type of resuscitation for exsanguinated patients with massive tissue destruction and absent BP); involves
early use of whole blood, factor VIIa at high doses, and 1:1 ratio of components (platelets and plasma to
blood); exsanguinating injuries comprise 3% to 4% of combat casualties; training civilian surgeons to go into combat
remains one of biggest problems, as well as constant supply and demand imbalance
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Suggested Reading
Arbabi S et al: Beta-blocker use is associated with improved outcomes in adult trauma patients. J Trauma 62:56, 2007;
Arthurs Z et al: The use of damage-control principles for penetrating pelvic battlefield trauma. Am J Surg 191:604,
2006; Berger E: Lessons from Afghanistan and Iraq: the costly benefits from the battlefield for emergency medicine. Ann
Emerg Med 49:486, 2007; Ciesla DJ et al: The academic trauma center is a model for the future trauma and acute care
surgeon. J Trauma 58:657, 2005; Ciesla DJ: Trauma systems and access to emergency medical care. J Trauma 62:S51,
2007; Committee to Develop the Reorganized Specialty of Trauma et al: Acute care surgery: trauma, critical
care, and emergency surgery. J Trauma 58:614, 2005; Cotton BA et al: Beta-blocker exposure is associated with improved
survival after severe traumatic brain injury. J Trauma 62:26, 2007; Eastridge BJ et al: Trauma system development
in a theater of war: Experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 61:1366,
2006; Martin M et al: Troponin increases in the critically injured patient: mechanical trauma or physiologic stress? J
Trauma 59:1086, 2005; Patel TH et al: A U.S. Army Forward Surgical Team's experience in Operation Iraqi Freedom.
J Trauma 57:201, 2004; Pothula V et al: Care of battlefield injuries. N Engl J Med 351:97, 2004; Rady MY et al:
Solicitation of deceased and living organ donors. N Engl J Med 356:2427, 2007; Salim A et al: Improving consent rates
for organ donation: the effect of an inhouse coordinator program. J Trauma 62:1411, 2007; Spain DA et al: Education
and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery. Am J Surg
190:212, 2005; Spital A: Ethically increasing the supply of transplantable organs. Ann Intern Med 146:537, 2007;
Steinbrook R: Organ donation after cardiac death. N Engl J Med 357:209, 2007; Tisherman SA et al: Structure of
surgical critical care and trauma fellowships. Crit Care Med 34:2282, 2006; Verheijde JL et al: Recovery of transplantable
organs after cardiac or circulatory death: the end justifying the means. Crit Care Med 35:1439, 2007.
Educational Objectives
| The goal of this program is to improve surgical practice in trauma and critical care. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Discuss the supply and demand relationship in organ donation.
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| 2. Describe the requirements for the creation of acute care surgery as a subspecialty.
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| 3. Debate the advantages and disadvantages of β-blockade in trauma patients.
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| 4. Describe the problem of uncontrolled bleeding in the battlefield and the steps taken by the military to solve it.
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| 5. Explain the concept of damage-control resuscitation in the battlefield.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Roth, Hoyt, Knudson, and Johannigman were recorded at the 14th Annual USC Trauma/Critical Care Symposium,
held May 16-17, 2007, in Pasadena, CA, and sponsored by the Division of Trauma/Critical Care and the Office of Continuing
Medical Education at the Keck School of Medicine at the University of Southern California, Los Angeles, and the Institute
of Continuing Education for Nurses, Department of Nursing, Los Angeles County USC Medical Center. Dr. Schwab
was recorded at the 36th Annual Postgraduate Course in Surgery, held April 12-14, 2007, in Charleston, SC, and sponsored
by the Department of Surgery, Medical University of South Carolina. The Audio-Digest Foundation thanks the
speakers and sponsors for their cooperation in the production of this program.
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