Sound Clinical Judgment Research Articles

Psychometric Markers of Genuine and Feigned Neurodevelopmental Disorders in the Context of Applying for Academic Accommodations

The article reviews systemic and context-specific challenges of psychoeducational assessment using two case studies: a 19-year-old woman with feigned attention-deficit/hyperactivity disorder and a 50-year-old man with genuine dyslexia. These cases demonstrate that providing a thorough evaluation of performance validity is an essential component of determining eligibility for academic accommodations in both clinical and higher education settings. At the same time, discounting failure on certain performance validity tests may be necessary to protect against false positive errors. In addition, empirically based test selection and interpretation has the potential to enhance the clinical confidence during differential diagnosis. Examining the internal consistency of a given neurocognitive profile provides valuable clinical information to determine both the credibility of the overall presentation and applying established diagnostic criteria. Although clinical research has yet to identify definitive markers of non-credible neurocognitive profiles, a multivariate approach to performance validity assessment that combines empirically validated indicators and sound clinical judgment can improve detection rates while simultaneously protecting against false positive errors.

Monitoring Hospitalized Adult Patients for Opioid-Induced Sedation and Respiratory Depression

: Opioid analgesics are commonly administered to hospitalized patients to treat acute pain, but these drugs put patients at risk for serious adverse events, such as unintended advancing sedation, respiratory depression, and death. Nurses play an important role in keeping patients safe by making clinical decisions about the frequency and intensity with which patients receiving IV and epidural opioids should be monitored. To make sound clinical judgments, nurses must be aware of the factors that place patients at elevated risk for adverse opioid-related effects and know how to screen and assess patients for these risks. The authors review the literature on unintended advancing sedation and respiratory depression associated with opioid administration and present evidence-based recommendations for clinical decision making and patient monitoring, using both nursing assessments and electronic technologies.

Management of necrotizing pancreatitis and its outcome in a secondary healthcare institution

Background: Surgical debridement is the “gold standard” for infected pancreatic necrosis. Advances in imaging methods and minimal access techniques have changed the management of many surgical conditions and even infected pancreatic necrosis has successfully been treated in selected patients. However, technical advances don’t obviate sound clinical judgment. Aim was to consider recent advances in minimal access surgery, this article retrospectively analyses the role of open surgery and laparoscopic techniques in the management of necrotizing pancreatitis.Methods: A retrospective study of 30 cases of pancreatic necrosectomy admitted and managed during 2012-2016 was carried out and compared with results available in the existing literature.Results: Out of 30 cases, 20 were men and 10 were women. Patients' age ranged from 23 to 70 years (mean age - 49.8 years). The mean operating time was 103.8 min (range, 60-120 min). Timing of necrosectomy was 21-32 days (average - 25.5 days). The average duration of hospital stay after the procedure was 17.4 days (range, 10-21 days).Conclusions: Comparative analysis of results of different surgical techniques reveals that there is no significant difference in terms of mortality. However, overall rate of complications and failure (inadequate debridement and drainage) are still higher with minimally invasive techniques.

Performance of Health Professionals

A nurse is a healthcare professional who is focused on caring for individuals, families, and communities, ensuring that they attain, maintain, or recover optimal health and functioning. Role of nurses in India is not limited to the provision of care only but in many hospitals across the country nurses are also performing the managerial duties such as indenting medications, maintaining stock and patient records, coordinating with the functioning of health team members etc.“Nursing is a profession in which the element of service to humanity is very strong and is characterized by distinctive traditions, skills, knowledge, values and qualities of a discipline. Articulating this value to the community is one of the challenges nursing faces as it evolves responding to very different practice environments”. The purpose of the study is to examine Performance of health professionals. A sample of 300 Nurses was selected for the presents study. Nursing Performance Scale (Ward and Fetler, 1979) was administered on the sample. The data was subjected to THREE WAY ANOVA (between group factorial designs). Results clearly shows that the performance of nurses has been found varying significantly in relation to Sector (private & public), ward (Emergency & ICU) & experience. Performance of nurses can be enhanced by clearly communicating and organizing their work to ensure that they have the freedom to act on nursing decisions using sound clinical judgment.

Drug Interaction Database Sensitivity With Oral Antineoplastics: An Exploratory Analysis.

Drug interactions are a concern in oncology with the shift toward oral antineoplastics (OAs). Using electronic databases to screen for drug interactions with OAs is a common practice. There is little literature to guide clinicians on the reliability of these systems with OAs. The primary objective of this study was to explore the sensitivity of commonly available drug interaction databases in detecting drug interactions with OAs. A list of 20 drug interactions with OAs was developed by two Board-certified oncology pharmacists. The list included multiple types of drug interactions. The sensitivity in detecting these interactions by MicroMedex, Facts & Comparisons, Lexi-Interact, and Epocrates were evaluated. These databases were chosen based on their local availability and widespread use in practice. Drugs.com was evaluated as a surrogate for a patient-accessible drug interaction database. The Cochran Q test was used to assess the sensitivity distribution across the five groups. Lexi-Interact and Drugs.com had a sensitivity of 95% for the 20 tested drug interaction pairs. Epocrates had a sensitivity of 90%, and both Micromedex and Facts & Comparisons had a sensitivity of 70%. There was a statistically significant difference ( P = .016) in the distribution across the databases in detecting clinically significant drug interactions. Commonly used databases for identifying drug interactions with oral antineoplastics vary significantly in their sensitivity. Clinicians should not rely on a single database and should consider using multiple resources as well as sound clinical judgment. Further work is needed in this area.

Etiology and management of splenic injuries: The experience at Federal Teaching Hospital, Gombe, Northeast Nigeria

Objective: To appraise the current management of splenic trauma with the available resources in our environment and re-emphasizing the role of a sound clinical judgment and early intervention. Methodology: This is a prospective cross-sectional study in which patients that sustained splenic injuries were resuscitated and optimized for laparotomy. Broad spectrum antibiotics and generous analgesia were given. Laparotomy was carried out in all patients and treatment was given according to the grade of injury sustained. Other systemic injuries were co-managed with other subspecialties. Results: Patients in the study were aged 7–52 years (male: female = 3.4:1). The modal age group was 11–20 years. All patients were managed operatively. The majority (51.5%) of splenic trauma in our study were due to vehicular accidents. There was no statistical association between sonographic and intraoperative findings (P = 0.218). Splenectomy was the most common procedure carried out. Complications encountered include surgical site infection (9, 27.3%), respiratory tract infection (6, 18.2%), and deep vein thrombosis (1, 3.0%). The duration of hospital stay for patients was 9–26 days (mean = 12.69 ± 6.30 days). Conclusion: The management of splenic injuries has evolved over the years. The role of a sound clinical judgment is crucial to a successful management outcome, especially in the third world countries.

SUGGESTED COMPETENCES FOR A PRECEPTOR TRAINING PROGRAMME

Purpose: Facilitating learning in the clinical context is a complex act for which preceptors should be trained. However, there is no consensus on what should be included in a training programme for preceptors. The purpose of the article is to describe the competences of a preceptor that emanated from a consensus reaching process among nurse educators in South Africa. Methodology: Nurse educators reached consensus on the core competences of a preceptor through nominal groups. Non-probability convenient sampling was used to sample nurse educators from universities as well as public and private nursing colleges. The two nominal groups generated data that were combined to identify the content of preceptor training programme. Results: Key findings were that preceptors should be able to facilitate learning through a variety of techniques and perform valid and reliable assessment. Preceptors should support students in finding and implementing best available evidence of care for a specific patient. Conclusion and recommendation: It is the responsibility of nursing education institutions to produce clinically competent nurses. A competent nurse is able to think critically, reason clinically, make sound clinical judgments, and reflect on the thinking processes applied. Preceptors, therefore, should support nursing students in these thinking processes and create opportunities where they can practice under supervision to become competent nurses. The training programme should enable preceptors to facilitating learning in the clinical environment through a variety of techniques, conduct valid and reliable assessments, and support students in implementing best practice guidelines.

Clinical Reasoning in the Assessment and Intervention Planning for Major Depression

Accurate assessment and effective treatment of mood disorders, particularly depression, is critically important for the millions of youth who are experiencing such symptomatology and who are at risk for a multitude of deleterious outcomes. Although the extant empirical literature provides substantial guidance for the assessment and treatment of depression, real-life complexities necessitate the inclusion of sound clinical judgment throughout the diagnostic, treatment planning and intervention phases. The purpose of this article is to present an example of a real-life case study reliant on evidence-based practices and sound clinical judgment in the assessment and treatment of depression. We first review the extant diagnostic, epidemiological, assessment, and treatment literature. The case study is intended to highlight the therapist’s use of evidence-based treatment (i.e., Cognitive Behavioral Therapy), while also considering points during treatment at which the therapist was required to use clinical judgment. Outcomes of the case are described and limitations reviewed.

Measuring Nontechnical Aspects of Surgical Clinician Development in an Otolaryngology Residency Training Program.

Surgical competency requires sound clinical judgment, a systematic diagnostic approach, and integration of a wide variety of nontechnical skills. This more complex aspect of clinician development has traditionally been difficult to measure through standard assessment methods. This study was conducted to use the Clinical Practice Instrument (CPI) to measure nontechnical diagnostic and management skills during otolaryngology residency training; to determine whether there is demonstrable change in these skills between residents who are in postgraduate years (PGYs) 2, 4, and 5; and to evaluate whether results vary according to subspecialty topic or method of administration. Prospective study using the CPI, an instrument with previously established internal consistency, reproducibility, interrater reliability, discriminant validity, and responsiveness to change, in an otolaryngology residency training program. The CPI was used to evaluate progression in residents' ability to evaluate, diagnose, and manage case-based clinical scenarios. A total of 248 evaluations were performed in 45 otolaryngology resident trainees at regular intervals. Analysis of variance with nesting and postestimation pairwise comparisons were used to evaluate total and domain scores according to training level, subspecialty topic, and method of administration. Longitudinal residency educational initiative. Assessment with the CPI during PGYs 2, 4, and 5 of residency. Among the 45 otolaryngology residents (248 CPI administrations), there were a mean (SD) of 5 (3) administrations (range, 1-4) during their training. Total scores were significantly different among PGY levels of training, with lower scores seen in the PGY-2 level (44 [16]) compared with the PGY-4 (64 [13]) or PGY-5 level (69 [13]) (P < .001). Domain scores related to information gathering and organizational skills were acquired earlier in training, while knowledge base and clinical judgment improved later in residency. Trainees scored higher in general otolaryngology (mean [SD], 72 [14]) than in subspecialties (range, 55 [12], P = .003, to 56 [19], P < .001). Neither administering the examination with an electronic scoring system, rather than a paper-based scoring system, nor the calendar year of administration affected these results. Standardized interval evaluation with the CPI demonstrates improvement in qualitative diagnostic and management capabilities as PGY levels advance.

Impact of concept mapping on the development of clinical judgment skills in nursing students

Helping nursing students learn to use sound clinical judgment has become a primary goal of nursing programs. Concept mapping has been shown to promote meaningful learning and critical thinking. The purpose of this study was to explore how junior baccalaureate nursing students perceive the effect of a concept mapping educational strategy on the development of clinical judgment skills. Concept mapping was taught using an adaptation of Gerdeman, Lux, and Jacko's (2013) Clinical Judgment Self-Evaluation Rubric (CJSR) that uses simplified wording. One hundred six students developed concept maps and completed a CJSR rubric to evaluate their concept maps each week during their clinical experience in a medical–surgical nursing course. The CJSRs were reviewed and evaluated by the clinical instructors. Students also completed a clinical evaluation tool at the end of the course. First, students did a self-evaluation, and then, the clinical instructor evaluated them. A descriptive data analysis was performed after the course was completed. The findings revealed that the use of concept mapping provided an interactive way to foster the growth of clinical judgment skills in nursing students.

Invited Commentary

It’s not the years…it’s the mileage.Indiana Jones, Raiders of the Lost Ark, 1981Sorabella and colleagues [1Sorabella R.A. Wu Y.S. Bader A. et al.Aortic root replacement in octogenarians offers acceptable perioperative and late outcomes.Ann Thorac Surg. 2016; 101: 967-973Abstract Full Text Full Text PDF Scopus (12) Google Scholar] present a small series (n = 34) of octogenarians undergoing aortic root replacement between 2005 and 2012 and compare the early and late outcomes with a larger (n = 592) contemporaneously operated cohort of younger patients. The authors found “moderately worse but acceptable perioperative mortality and late survival” among the older cohort and reasonably concluded that further studies are needed “to determine which subset of octogenarians are at the highest operative risk and may benefit from a conservative approach.” Despite the fact that age greater than or equal to 80 years was not associated with the composite outcome of in-hospital death or stroke in this underpowered study, more robust data such as those from Williams and colleagues [2Williams J.B. Peterson E.D. Zhao Y. et al.Contemporary results for proximal aortic replacement in North America.J Am Coll Cardiol. 2012; 60: 1156-1162Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar] on nearly 46,000 patients undergoing proximal aortic operations (including more than 17,000 root replacements) in North America and captured in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database found age greater than 70 years to be a significant predictor of both mortality and major morbidity among patients undergoing elective repair; risk increased further with each additional 5-year increment after 70 years. However, this does not mean that we should deny aged patients otherwise indicated complex open aortic operations but rather, as Sorabella and colleagues suggest, we should select our patients wisely. Unfortunately, the STS risk calculator does not provide guidance in this regard at the present time because aortic procedures are not currently modeled. However, sound clinical judgment, including assessment of other predictors of adverse outcome with proximal aortic operations as demonstrated in the Williams study [2Williams J.B. Peterson E.D. Zhao Y. et al.Contemporary results for proximal aortic replacement in North America.J Am Coll Cardiol. 2012; 60: 1156-1162Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar]—such as chronic kidney disease, severe lung disease, New York Heart Association class IV heart failure, redo procedures, or previous coronary bypass grafting—as well as published frailty assessments [3Ganapathi A.M. Englum B.R. Hanna J.M. et al.Frailty and risk in proximal aortic surgery.J Thorac Cardiovasc Surg. 2014; 147: 186-191Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar] and the all-important “eyeball test” should lead us to select those octogenarians most fit for operation. When teaching our residents about risk assessment around surgical procedures, I often paraphrase the Indiana Jones quote at the beginning of this article that “it’s not the years but the miles,” with the point being that there are many “low-mileage” octogenarians fit for operation just as there are “high-mileage” younger patients who are unfit. As Sorabella and colleagues have shown, selection of these “low-mileage” older patients is possible, and their 81.9% actuarial 5-year survival demonstrates clear clinical benefit for this properly chosen cohort. Aortic Root Replacement in Octogenarians Offers Acceptable Perioperative and Late OutcomesThe Annals of Thoracic SurgeryVol. 101Issue 3PreviewAs the proportion of the population more than 80 years of age increases, cardiac surgeons will increasingly be consulted to operate on this high-risk patient group. The aim of this study is to evaluate the perioperative and late outcomes of octogenarians undergoing aortic root replacement in comparison with younger patients. Full-Text PDF

How to Establish Clinical Prediction Models.

A clinical prediction model can be applied to several challenging clinical scenarios: screening high-risk individuals for asymptomatic disease, predicting future events such as disease or death, and assisting medical decision-making and health education. Despite the impact of clinical prediction models on practice, prediction modeling is a complex process requiring careful statistical analyses and sound clinical judgement. Although there is no definite consensus on the best methodology for model development and validation, a few recommendations and checklists have been proposed. In this review, we summarize five steps for developing and validating a clinical prediction model: preparation for establishing clinical prediction models; dataset selection; handling variables; model generation; and model evaluation and validation. We also review several studies that detail methods for developing clinical prediction models with comparable examples from real practice. After model development and vigorous validation in relevant settings, possibly with evaluation of utility/usability and fine-tuning, good models can be ready for the use in practice. We anticipate that this framework will revitalize the use of predictive or prognostic research in endocrinology, leading to active applications in real clinical practice.

A Content Incontinent: Report of Liposomal Bupivacaine Induced Fecal Incontinence.

Proper surgical management of anal fistula demands sound clinical judgment and extraordinary care to prevent incontinence and adequate postoperative pain control and provide satisfactory resolution to optimize quality of life. Fecal incontinence can be a devastating complication of procedures performed for fistula in ano. We report a unique case in which temporary incontinence (for less than 4 days) followed injection of liposomal bupivacaine for postoperative pain control after draining seton placement for fistula in ano. Patients and physicians should be aware as it may be mistaken for a more serious anatomical and permanent cause of fecal incontinence.

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Preamble, Principles, and General Considerations: A Scientific Statement From the American Heart Association and American College of Cardiology.

This document addresses medical issues related to trained athletes with cardiovascular abnormalities. The objective is to present, in a readily useable format, consensus recommendations and guidelines principally addressing criteria for eligibility and disqualification from organized competitive sports for the purpose of ensuring the health and safety of young athletes. Recognizing certain medical risks imposed on athletes with cardiovascular disease, it is our aspiration that the recommendations that constitute this document will serve as a useful guide to the practicing community for clinical decision making. The ultimate goal is prevention of sudden death in the young, although it is also important not to unfairly or unnecessarily remove people from a healthy athletic lifestyle or competitive sports (that may be physiologically and psychologically intertwined with good quality of life and medical well-being) because of fear of litigation. It is our goal that the recommendations in this document, together with sound clinical judgment, will lead to a healthier, safer playing field for young competitive athletes. There have been 3 prior documents, all sponsored by the American College of Cardiology (ACC),1–3 that addressed eligibility and disqualification criteria for competitive athletes with cardiovascular diseases: Bethesda Conferences 16 (1985), 26 (1994), and 36 (2005), published and used over a 30-year period. Each of the 3 initiatives (and the present American Heart Association (AHA)/ACC scientific statement) were driven by the tenet that young trained athletes with underlying cardiovascular abnormalities are likely at some increase in risk for sudden cardiac death (usually on the athletic field) compared to nonathletes or competitive athletes without cardiovascular disease.4–8 All 3 Bethesda Conferences and the present derived AHA/ACC document provide expert consensus recommendations. These insights use (1) the experience and expertise of the panelists (ie, individual and collective judgments, using the “art of medicine”) and (2) …

Updated Beers Criteria: A more comprehensive guide to medication safety in older adults

P from all practice settings are likely familiar with the American Geriatric Society’s (AGS) Beers Criteria of Potentially Inappropriate Drugs, last published in 20121 and recently revised and updated in 2015.2 The AGS Beers Criteria—Beers Criteria for short—have proven useful in identifying drugs to potentially avoid in older adults, to reduce adverse drug events and drug-related problems, and to improve medication selection and overall medication safety in older adults. The Beers Criteria are designed for use in any clinical setting and can also be used as an educational quality measure and research tool. The latest version of the Beers Criteria uses a more comprehensive, systematic review and grading of evidence.

Middle East respiratory syndrome coronavirus (MERS-CoV): what lessons can we learn?

SummaryThe Middle East Respiratory Coronavirus (MERS-CoV) was first isolated from a patient who died with severe pneumonia in June 2012. As of 19 June 2015, a total of 1,338 MERS-CoV infections have been notified to the World Health Organization (WHO). Clinical illness associated with MERS-CoV ranges from mild upper respiratory symptoms to rapidly progressive pneumonia and multi-organ failure. A significant proportion of patients present with non-respiratory symptoms such as headache, myalgia, vomiting and diarrhoea. A few potential therapeutic agents have been identified but none have been conclusively shown to be clinically effective. Human to human transmission is well documented, but the epidemic potential of MERS-CoV remains limited at present. Healthcare-associated clusters of MERS-CoV have been responsible for the majority of reported cases. The largest outbreaks have been driven by delayed diagnosis, overcrowding and poor infection control practices. However, chains of MERS-CoV transmission can be readily interrupted with implementation of appropriate control measures. As with any emerging infectious disease, guidelines for MERS-CoV case identification and surveillance evolved as new data became available. Sound clinical judgment is required to identify unusual presentations and trigger appropriate control precautions.Evidence from multiple sources implicates dromedary camels as natural hosts of MERS-CoV. Camel to human transmission has been demonstrated, but the exact mechanism of infection remains uncertain. The ubiquitously available social media have facilitated communication and networking amongst healthcare professionals and eventually proved to be important channels for presenting the public with factual material, timely updates and relevant advice.

Retrospective Analysis of Thoracolumbar Junction Injuries Using the Thoracolumbar Injury Severity and Classification Score, American Spinal Injury Association Class, Injury Severity Score, Age, Sex, and Length of Hospitalization.

Retrospective review of patient cohort. Our goal was to assess the validity of the Thoracolumbar Injury Classification and Severity (TLICS) score system by comparing the TLICS system to prior management of thoracolumbar injuries at our institution between January 1, 2006 to March 31, 2011. TLICS was introduced in 2005 to classify and assign treatment recommendations for injuries based on 3 axes: mechanism of injury, integrity of the posterior ligamentous complex, and neurological status. We retrospectively obtained and analyzed patient data regarding thoracolumbar junction injuries at a major academic medical center servicing level I trauma. In addition, we compared the American Spinal Injury Association (ASIA) class at time of injury to last follow-up to determine if there was any change in neurological status after intervention. We also compared sex, injury severity score (ISS), length of hospitalization, and age between nonoperatively and operatively treated patients. Included in our study were 201 patients (70% male and 30% female). We found the TLICS system agreed with prior thoracolumbar junction injury management at our institution 98% of the time in nonoperatively treated patients and 78% of the time in operatively treated patients. Age, sex, and ISS were not statistically significant factors in patients who were treated operatively versus nonoperatively, however, there was a trend towards higher ISS in operatively treated patients. Average TLICS score between nonoperative and operative groups was 1.56 and 4.8, respectively, and was a statistically significant difference. There was no statistically significant difference in ASIA class improvement between operative and nonoperative treatment, however, this is likely because of having only 20 patients in this subcohort. Of note, about 50% of the 17 operatively treated patients had improvement in ASIA class. Our data suggest that TLICS is a valuable tool in a spine surgeon's armamentarium in treating thoracolumbar junction injuries. Some surgeons might be more likely to operate on thoracolumbar junction injuries that should be treated nonoperatively according to the TLICS score. As with all classification schemes, the TLICS system should be used in conjunction with sound clinical judgment.

Focused abdominal sonography for trauma in the clinical evaluation of children with blunt abdominal trauma.

IntroductionIn pediatric care, the role of focused abdominal sonography in trauma (FAST) remains ill defined. The objective of this study was to assess the sensitivity and specificity of FAST for detecting free peritoneal fluid in children.MethodsThe trauma registry of a single level I pediatric trauma center was queried for the results of FAST examination of consecutive pediatric (<18 years) blunt trauma patients over a period of 36 months, from January 2010 to December 2012. Demographics, type of injuries, FAST results, computerized tomography (CT) results, and operative findings were reviewed.ResultsDuring the study period, 543 injured pediatric patients (mean age 8.2 ± 5 years) underwent FAST examinations. In 95 (17.5 %) FAST was positive for free peritoneal fluid. CT examination was performed in 219 (40.3 %) children. Positive FAST examination was confirmed by CT scan in 61/73 (83.6 %). CT detected intra-peritoneal fluid in 62/448 (13.8 %) of the patients with negative FAST results. These findings correspond to a sensitivity of 50 %, specificity of 88 %, positive predictive value (PPV) of 84 %, and a negative predictive value (NPV) of 58 %. In patients who had negative FAST results and no CT examination (302), no missed abdominal injury was detected on clinical ground. FAST examination in the young age group (<2 years) yielded lower sensitivity and specificity (36 and 78 % respectively) with a PPV of only 50 %.ConclusionsThis study shows that although a positive FAST evaluation does not necessarily correlate with an IAI, a negative one strongly suggests the absence of an IAI, with a high NPV. These findings are emphasized in the analysis of the subgroup of children less than 2 years of age. FAST examination tempered with sound clinical judgment seems to be an effective tool to discriminate injured children in need of further imaging evaluation.

PC12. Does the Physician Quality Reporting System (PQRS) Successfully Demonstrate Quality of Care for Elective Open or Endovascular Aortic Aneurysm Repair?

underwent open repair (n 1⁄4 48). The remaining patients were grouped as follows: i-TEVAR (n 1⁄4 32), d-TEVAR (n 1⁄4 16), and nonop (n 1⁄4 37). ISS was similar in all three groups (P 1⁄4 NS). TEVAR was performed a median of 5 days and a mean of 30 days after injury in the d-TEVAR group. Overall mortality was 15.6% in the i-TEVAR group at 3.1 years’ mean follow-up, 6% in the d-TEVAR group at 1.5 years, and 18.9% in the nonop group at 1.7 years (P 1⁄4 NS). Aortic-related mortality was 6% for i-TEVAR, 0% for d-TEVAR, and 3% in the nonoperative group (P 1⁄4 NS). Mean maximum pseudoaneurysm dimension was 33 mm for i-TEVAR,33mmford-TEVAR, and23mmin thenonop group (P 1⁄4 .0003 vs i-TEVAR, P 1⁄4 .005 vs d-TEVAR). Conclusions: Patients presenting with grade III BAI may be safely managed with a delayed operative or nonoperative approach in selected circumstances with minimal associated mortality. Delayed TEVAR provides a window of opportunity for selection of patients for TEVAR who do not succumb to their other traumatic injuries. Nonoperative management may be appropriate for patients presenting with smaller pseudoaneurysms, as we did not observe rupture in pseudoaneurysms measuring #31 mm in maximum diameter in patients managed nonoperatively. Mortality in all these groups was high, primarily as a result of other traumatic injuries, and therefore, appropriate selection of patients for TEVAR must rely on sound clinical judgement.

PC10. Selective Nonoperative and Delayed Operative Approaches for the Management of Grade III Blunt Traumatic Aortic Injury

Blunt traumatic aortic injury (BAI) is a condition associated with high morbidity and mortality. Nonoperative management is advocated for patients with minimal aortic injury (grade I), but for grade II-IV, BAI operative repair remains the standard of care as recommended by the Society for Vascular Surgery (SVS). The SVS classifies blunt traumatic aortic pseudoaneurysms as grade III injuries and recommends repair using thoracic endovascular aortic repair (TEVAR). We have observed significant variability among severity of grade III BAI and have adopted a management strategy consisting of immediate TEVAR (<24 hours), delayed TEVAR (>24 hours), and selective nonoperative approaches for the management of these injuries. We therefore evaluated outcomes with these approaches in comparison with immediate TEVAR. We retrospectively identified all BAI presenting to an academic level I trauma center over a 15-year period (2000-2014). Computed tomography cross-sectional images were reviewed by a radiologist and graded according to SVS guidelines (grade I-IV). Pseudoaneurysm size was measured in three dimensions. Demographics, injury severity score (ISS), and outcomes were recorded. Patients were selected for operative intervention based on the size and morphology of the pseudoaneurysm, coexisting burden of traumatic injury, age, and comorbidities, at the discretion of the vascular surgeon. Patients were grouped according to management strategy: immediate TEVAR (i-TEVAR, ≤24 hours of admission), delayed TEVAR (d-TEVAR, >24 hours from admission), and nonoperative management (nonop). Outcomes in these groups were compared. Primary outcome measures were overall mortality and aortic-related mortality (death due to aortic injury). We identified 153 patients with grade III BAI. Mean age was 39.3 years, and mean ISS was 38.6. Patients were excluded if they did not have meaningful possibility of recovery from traumatic injuries (n = 18) or if they underwent open repair (n = 48). The remaining patients were grouped as follows: i-TEVAR (n = 32), d-TEVAR (n = 16), and nonop (n = 37). ISS was similar in all three groups (P = NS). TEVAR was performed a median of 5 days and a mean of 30 days after injury in the d-TEVAR group. Overall mortality was 15.6% in the i-TEVAR group at 3.1 years’ mean follow-up, 6% in the d-TEVAR group at 1.5 years, and 18.9% in the nonop group at 1.7 years (P = NS). Aortic-related mortality was 6% for i-TEVAR, 0% for d-TEVAR, and 3% in the nonoperative group (P = NS). Mean maximum pseudoaneurysm dimension was 33 mm for i-TEVAR, 33 mm for d-TEVAR, and 23 mm in the nonop group (P = .0003 vs i-TEVAR, P = .005 vs d-TEVAR). Patients presenting with grade III BAI may be safely managed with a delayed operative or nonoperative approach in selected circumstances with minimal associated mortality. Delayed TEVAR provides a window of opportunity for selection of patients for TEVAR who do not succumb to their other traumatic injuries. Nonoperative management may be appropriate for patients presenting with smaller pseudoaneurysms, as we did not observe rupture in pseudoaneurysms measuring ≤31 mm in maximum diameter in patients managed nonoperatively. Mortality in all these groups was high, primarily as a result of other traumatic injuries, and therefore, appropriate selection of patients for TEVAR must rely on sound clinical judgement.