Greater preoperative cytokine and CRP production in younger infants did not correlate with postoperative outcomes; correlation between postoperative inflammatory mediator production and clinical course was statistically significant but clinically modest. We conclude that in infants undergoing low-to-moderate-complexity cardiac surgery in a single high-volume center, the contribution of inflammatory mediator production to postoperative morbidity is relatively limited.

Background Necrotizing soft tissue infections (NSTI) are rare, potentially fatal surgical emergencies. We studied a national cohort of patients to determine recent trends in incidence, treatment, and outcomes for NSTI. Methods We queried the Nationwide Inpatient Sample (1998–2010) for patients with a primary diagnosis of NSTI. Temporal trends in patient characteristics, treatment (debridement, amputation, hyperbaric oxygen therapy (HBOT)), and outcomes were determined using Cochran-Armitage Trend Tests and Linear Regression. To account for trends in case mix (age group, sex, race, insurance, Elixhauser index) or receipt of HBOT on outcomes, multivariable analyses were conducted to determine the independent effect of year of treatment on mortality, any major complication, and length of stay for NSTI. Results We identified 56,527 weighted NSTI admissions; incidence ranging from approximately 3,800–5,800 cases annually. The number of cases peaked in 2004 and then decreased for an overall statistically significant decrease between 1998 and 2010 (p<0.0001). The percentage of female patients decreased slightly over time (38.6 to 34.1%, p<0.0001). Patients were increasingly in the 18–34 year old (8.8 to 14.6% p<0.0001) and 50–64 year old age groups (33.2 to 43.5, p<0.0001), Hispanic (6.8 to 10.5%, p<0.0001), obese (8.9 to 24.6%, p<0.0001), and admitted with >3 co-morbidities (14.5 to 39.7%, p<0.0001). The percentage of patients requiring only one surgical debridement increased (43.2 to 46.2%, p<0.0001) while the utilization of HBOT was rare and decreasing (1.6 to 0.8%, p<0.0001). The percentage of patients requiring operative wound closure decreased (23.5 to 20.8%, p<0.0001). Although major complication rates increased (30.9 to 48.2%, p<0.0001), LOS remained stable (18–19 days) and mortality decreased (9.0 to 4.9%, p<0.0001) on univariate analyses. On multivariable analyses each one-year incremental increase in year was associated with a 5% increased odds of complication (OR 1.05), 0.4 times decrease in hospital LOS (coefficient −0.41), and 11% decreased odds of mortality (OR 0.89) Conclusions There were significant national trends in patient characteristics and treatment patterns for NSTI between 1998 and 2010. Importantly, though patient acuity worsened and complication rates increased, LOS remained relatively stable and mortality decreased. Improvements in early diagnosis, wound care, and critical care delivery may be the cause.

Background: The utility of hyperbaric oxygen therapy (HBOT) in the treatment of necrotizing soft tissue infections (NSTIs) has not been proved. Previous studies have been subject to substantial selection bias because HBOT is not available universally at all medical centers, and there is often considerable delay associated with its initiation. We examined the utility of HBOT for the treatment of NSTI in the modern era by isolating centers that have their own HBOT facilities. Methods: We queried all centers in the University Health Consortium (UHC) database from 2008 to 2010 that have their own HBOT facilities (n = 14). Cases of NSTI were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes, which included Fournier gangrene (608.83), necrotizing fasciitis (728.86), and gas gangrene (040.0). Status of HBOT was identified by the presence (HBOT) or absence (control) of ICD-9 procedure code 93.95. Our cohort was risk-stratified and matched by UHC's validated severity of illness (SOI) score. Comparisons were then made using univariate tests of association and multivariable logistic regression. Results: There were 1,583 NSTI cases at the 14 HBOT-capable centers. 117 (7%) cases were treated with HBOT. Univariate analysis showed that there was no difference between HBOT and control groups in hospital length of stay, direct cost, complications, and mortality across the three less severe SOI classes (minor, moderate, and major). However, for extreme SOI the HBOT group had fewer complications (45% vs. 66%; p < 0.01) and fewer deaths (4% vs. 23%; p < 0.01). Multivariable analysis showed that patients who did not receive HBOT were less likely to survive their index hospitalization (odds ratio, 10.6; 95% CI 5.2-25.1). Conclusion: At HBOT-capable centers, receiving HBOT was associated with a significant survival benefit. Use of HBOT in conjunction with current practices for the treatment of NSTI can be both a cost-effective and life-saving therapy, in particular for the sickest patients.

The three biologics exhibited different patterns and rates of cellular and vascular permeation in our rat model. AlloDerm implants exhibited the most rapid and extensive cellular infiltration, followed by Permacol. However, on gross examination, the AlloDerm implants thinned significantly by 6 months. In contrast, the Permacol and CollaMend implants appeared to be largely intact.

BACKGROUND: Patterns of death after trauma are changing due to advances in critical care. We examined mortality in critically injured patients who survived index hospitalization. METHODS: Retrospective analysis of adults admitted to a Level-1 trauma center (1/1/2000-12/31/2010) with critical injury was conducted comparing patient characteristics, injury, and resource utilization between those who died during follow-up and survivors. RESULTS: Of 1,695 critically injured patients, 1,135 (67.0%) were discharged alive. As of 5/1/2012, 977/1,135 (86.0%) remained alive; 75/158 (47.5%) patients who died during follow-up, died in the first year. Patients who died had longer hospital stays (24 vs. 17 days) and ICU LOS (17 vs. 8 days), were more likely to undergo tracheostomies (36% vs. 16%) and gastrostomies (39% vs. 16%) and to be discharged to rehabilitation (76% vs. 63%) or skilled nursing (13% vs. 5.8%) facilities than survivors. In multivariable models, male sex, older age, and longer ICU LOS predicted mortality. Patients with ICU LOS \u3e16 days had 1.66 odds of 1-year mortality vs. those with shorter ICU stays. CONCLUSIONS: ICU LOS during index hospitalization is associated with post-discharge mortality. Patients with prolonged ICU stays after surviving critical injury may benefit from detailed discussions about goals of care after discharge

Helicopter transport does not impart a survival benefit for trauma patients when geographic considerations are taken into account.

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Mycotic abdominal aortic aneurysms (AAAs) are a clinical challenge for vascular surgeons due to their critical location, surrounding inflammation, risk of rupture, and danger of reinfection following treatment. We present a case of Mycobacterium bovis AAA in a 69-year-old male after treatment with intravesicular bacillus Calmette-Guérin (BCG) therapy for bladder carcinoma. The classical approach for mycotic AAA entails extra-anatomic reconstruction followed by resection with oversewing of the proximal and distal aortic stumps. Alternative in-line reconstruction options have also been advocated. This case illustrates a technically straightforward, durable, in-line repair within an infected field utilizing cryopreserved aortic allograft.