Dr. Paul Maggio is Associate Chief Medical Officer of Operational Effectiveness, Associate Director of the Adult Intensive Care Unit, and Associate Trauma Medical Director at Stanford. He trained in General Surgery at Brown University and obtained advanced training in Adult Surgical Critical Care and Trauma at the University of Michigan. He holds a Masters of Business Administration from the University of Michigan and is triple board certified in General Surgery, Critical Care, and Medical Informatics. In addition to being a clinician and surgeon, Dr. Maggio participates in the National Committee on Healthcare Engineering for the American College of Surgeons, and his research interests are focused on the delivery of high-value care.

Dr. Maggio received the SHC Board of Hospital Director’s Denise O’Leary Award for Clinical Excellence in 2013

Clinical Focus

  • General Surgery
  • Surgical Critical Care
  • Trauma Surgery

Academic Appointments

Administrative Appointments

  • Vice- Chair of Clinical Affairs for the Department of Surgery, Stanford University (2018 - Present)
  • Associate Chief Medical Officer, Stanford University Hospital (2015 - Present)
  • Co-Director Critical Care Medicine, Stanford University Hospital (2009 - Present)
  • Service Medical Director, Stanford University Hospital (2012 - Present)
  • Director, Medical Informatics, Stanford University Hospital (2010 - Present)

Honors & Awards

  • Denise O'Leary Award for Excellence, Stanford University Hospital (2013)

Professional Education

  • Board Certification: Clinical Informatics, American Board of Preventive Medicine (2015)
  • Medical Education:State University of New York at Buffalo School of Medicine (1997) NY
  • Board Certification, Clinical Informatics, ABMS (2014)
  • Board Certification: Surgical Critical Care, American Board of Surgery (2005)
  • MBA, University of Michigan (2007)
  • Board Certification:, Surgical Critical Care (2006)
  • Board Certification: Surgery, American Board of Surgery (2005)
  • Fellowship:University of Michigan Hospital (2005) MI
  • Residency:Brown University (2004) RI


2018-19 Courses


All Publications

  • The association between angioembolization and splenic salvage for isolated splenic injuries. The Journal of surgical research Rosenberg, G. M., Weiser, T. G., Maggio, P. M., Browder, T. D., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. 2018; 229: 150–55


    BACKGROUND: Recent data suggest improved splenic salvage rates when angioembolization (AE) is routinely employed for high-grade splenic injuries; however, protocols and salvage rates vary among centers.MATERIALS/METHODS: Adult patients with isolated splenic injuries were identified using the National Trauma Data Bank, 2013-2014. Patients were excluded if they underwent immediate splenectomy or died in the emergency department. To characterize patterns of AE, trauma centers were grouped into quartiles based on frequency of AE use. Unadjusted analyses and mixed-effects logistical regression controlling for center effects were performed.RESULTS: Five thousand and ninety three adult patients were identified. Overall, 705 (13.8%) underwent AE and 290 (5.7%) required a splenectomy. In unadjusted comparisons, splenectomy rates were lower for patients with severe spleen injuries who underwent AE (7% versus 11%, P=0.02). In mixed-effect logistical regression patients with severe splenic injuries undergoing AE had a lower odds ratio (OR) for splenectomy (OR = 0.67, P=0.04). Patients treated at centers in the highest quartile of AE use had a lower OR for splenectomy (OR = 0.58, P=0.02).CONCLUSIONS: The use of AE in patients with isolated severe splenic injuries is associated with decreased splenectomy rates. There is an association between centers that perform AE frequently and reduced splenectomy rates.

    View details for DOI 10.1016/j.jss.2018.03.013

    View details for PubMedID 29936983

  • Night-time communication at Stanford University Hospital: perceptions, reality and solutions BMJ QUALITY & SAFETY Sun, A., Wang, L., Go, M., Eggers, Z., Deng, R., Maggio, P., Shieh, L. 2018; 27 (2): 156–62


    Resident work hour restrictions have led to the creation of the 'night float' to care for the patients of multiple primary teams after hours. These residents are often inundated with acute issues in the numerous patients they cover and are less able to address non-urgent issues that arise at night. Further, non-urgent pages may contribute to physician alarm fatigue and negatively impact patient outcomes.To delineate the burden of non-urgent paging at night and propose solutions.We performed a resident review and categorisation of 1820 pages to night floats between September 2014 and December 2014. Both attending and nursing review of 10% of pages was done and compared.Of reviewed pages, 62.1% were urgent and 27.7% were non-urgent. Attending review of random page samples correlated well with resident review. Common reasons for non-urgent pages were non-urgent patient status updates, low-priority order requests and non-critical lab values.A significant number of non-urgent pages are sent at night. These pages likely distract from acute issues that arise at night and place an unnecessary burden on night floats. Both behavioural and systemic adjustments are needed to address this issue. Possible interventions include integrating low-priority messaging into the electronic health record system and use of charge nurses to help determine urgency of issues and batch non-urgent pages.

    View details for DOI 10.1136/bmjqs-2017-006727

    View details for Web of Science ID 000423231600011

    View details for PubMedID 29055898

  • Real-Time Clinical Decision Support Decreases Inappropriate Plasma Transfusion AMERICAN JOURNAL OF CLINICAL PATHOLOGY Shah, N., Baker, S. A., Spain, D., Shieh, L., Shepard, J., Hadhazy, E., Maggio, P., Goodnough, L. T. 2017; 148 (2): 154–60


    To curtail inappropriate plasma transfusions, we instituted clinical decision support as an alert upon order entry if the patient's recent international normalized ratio (INR) was 1.7 or less.The alert was suppressed for massive transfusion and within operative or apheresis settings. The plasma order was automatically removed upon alert acceptance while clinical exception reasons allowed for continued transfusion. Alert impact was studied comparing a 7-month control period with a 4-month intervention period.Monthly plasma utilization decreased 17.4%, from a mean ± SD of 3.40 ± 0.48 to 2.82 ± 0.6 plasma units per hundred patient days (95% confidence interval [CI] of difference, -0.1 to 1.3). Plasma transfused below an INR of 1.7 or less decreased from 47.6% to 41.6% (P = .0002; odds ratio, 0.78; 95% CI, 0.69-0.89). The alert recommendation was accepted 33% of the time while clinical exceptions were chosen in the remaining cases (active bleeding, 31%; other clinical indication, 33%; and apheresis, 2%). Alert acceptance rate varied significantly among different provider specialties.Clinical decision support can help curtail inappropriate plasma use but needs to be part of a comprehensive strategy including audit and feedback for comprehensive, long-term changes.

    View details for DOI 10.1093/AJCP/AQX061

    View details for Web of Science ID 000407112100007

    View details for PubMedID 28898990

  • National Readmission Patterns of Isolated Splenic Injuries Based on Initial Management Strategy. JAMA surgery Rosenberg, G. M., Knowlton, L., Rajasingh, C., Weng, Y., Maggio, P. M., Spain, D. A., Staudenmayer, K. L. 2017; 152 (12): 1119–25


    Options for managing splenic injuries have evolved with a focus on nonoperative management. Long-term outcomes, such as readmissions and delayed splenectomy rate, are not well understood.To describe the natural history of isolated splenic injuries in the United States and determine whether patterns of readmission were influenced by management strategy.The Healthcare Cost and Utilization Project's Nationwide Readmission Database is an all-payer, all-ages, longitudinal administrative database that provides data on more than 35 million weighted US discharges yearly. The database was used to identify patients with isolated splenic injuries and the procedures that they received. Adult patients with isolated splenic injuries admitted from January 1 through June 30, 2013, and from January 1 through June 30, 2014, were included. Those who died during the index hospitalization or who had an additional nonsplenic injury with an Abbreviated Injury Score of 2 or greater were excluded. Univariate and mixed-effects logistic regression analysis controlling for center effect were used. Weighted numbers are reported.Initial management strategy at the time of index hospitalization, including nonprocedural management, angioembolization, and splenectomy.All-cause 6-month readmission rate. Secondary outcome was delayed splenectomy rate.A weighted sample of 3792 patients (2146 men [56.6%] and 1646 women [43.4%]; mean [SE] age, 48.5 [0.7] years) with 5155 admission events was included. During the index hospitalization, 825 (21.8%) underwent splenectomy, 293 (7.7%) underwent angioembolization, and 2673 (70.5%) had no procedure. The overall readmission rate was 21.1% (799 patients). Readmission rates did not differ based on initial management strategy (195 patients undergoing splenectomy [23.6%], 70 undergoing angioembolism [23.9%], and 534 undergoing no procedure [20%]; P = .33). Splenectomy was performed in 36 of 799 readmitted patients (4.5%) who did not have a splenectomy at their index hospitalization, leading to an overall delayed splenectomy rate of 1.2% (36 of 2967 patients). In mixed-effects logistic regression analysis controlling for patient, injury, clinical, and hospital characteristics, the choice of splenectomy (odds ratio, 0.93; 95% CI, 0.66-1.31) vs angioembolization (odds ratio, 1.19; 95% CI, 0.72-1.97) as initial management strategy was not associated with readmission.This national evaluation of the natural history of isolated splenic injuries from index admission through 6 months found that approximately 1 in 5 patients are readmitted within 6 months of discharge after an isolated splenic injury. However, the chance of readmission for splenectomy after initial nonoperative management was 1.2%. This finding suggests that the current management strategies used for isolated splenic injuries in the United States are well matched to patient need.

    View details for DOI 10.1001/jamasurg.2017.2643

    View details for PubMedID 28768329

  • Trends in open vascular surgery for trauma: implications for the future of acute care surgery. journal of surgical research Forrester, J. D., Weiser, T. G., Maggio, P., Browder, T., Tennakoon, L., Spain, D., Staudenmayer, K. 2016; 205 (1): 208-212


    Trauma patients with vascular injuries have historically been within a general surgeon's operative ability. Changes in training and decline in operative trauma have decreased trainees' exposure to these injuries. We sought to determine how frequently vascular procedures are performed at US trauma centers to quantify the need for general surgeons trained to manage vascular injuries.We conducted a retrospective analysis of the National Trauma Data Base (NTDB) from 2012 compared with 2002. Patients with general surgical and vascular procedures were identified using International Classification of Diseases, Ninth Revision, procedure codes 38.0-39.99, excluding 38.9-38.99.General surgery or vascular operations were performed on 12,099 (24%) of 50,248 severely injured adult patients in 2002 and 21,854 (16%) of 138,009 injured patients in 2012. Nineteen percent to 26% of all patients underwent vascular procedures. Patients with combined general surgery and vascular procedures were less likely to be discharged home and more likely to die. In 2002, 6% of severely injured adult trauma patients underwent open vascular procedures at level III/IV trauma centers; by 2012, only 1% of vascular surgery procedures were performed at level III/IV centers (P < 0.001).Need for emergent vascular surgery remains common for severely injured patients. Future trauma systems and surgical training programs will need to account for the need for open vascular skills. The findings suggest that there is already a trend away from open vascular procedures at level III/IV trauma centers, which may be a sign of system compensation for changes in the workforce.

    View details for DOI 10.1016/j.jss.2016.06.032

    View details for PubMedID 27621021

  • Trends in the management of pelvic fractures, 2008-2010 JOURNAL OF SURGICAL RESEARCH Chu, C. H., Tennakoon, L., Maggio, P. M., Weiser, T. G., Spain, D. A., Staudenmayer, K. L. 2016; 202 (2): 335-340


    Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time.The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality.A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001).AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.

    View details for DOI 10.1016/j.jss.2015.12.052

    View details for Web of Science ID 000376334700014

    View details for PubMedID 27229108

  • The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination AMERICAN SURGEON Staudenmayer, K., Wang, N. E., Weiser, T. G., Maggio, P., Mackersie, R. C., Spain, D., Hsia, R. Y. 2016; 82 (4): 356-361


    The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.

    View details for Web of Science ID 000377853800022

    View details for PubMedID 27097630

  • Trauma center care is associated with reduced readmissions after injury. journal of trauma and acute care surgery Staudenmayer, K., Weiser, T. G., Maggio, P. M., Spain, D. A., Hsia, R. Y. 2016; 80 (3): 412-418


    Trauma center care has been associated with improved mortality. It is not known if access to trauma center care is also associated with reduced readmissions. We hypothesized that receiving treatment at a trauma center would be associated with improved care and therefore would be associated with reduced readmission rates.We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from 2007-2008. All hospital admissions and emergency department visits associated with injury were longitudinally linked. Regions were categorized by whether or not they had trauma centers. We excluded all patients younger than 18 years of age. We performed univariate and multivariate regression analyses to determine if readmissions were associated with patient characteristics, length of stay for initial hospitalization, trauma center access, and triage patterns.A total of 211,504 patients were included in the analysis. Of these, 5,094 (2%) died during the index hospitalization. Of those who survived their initial hospitalization, 79,123 (38%) experienced one or more readmissions to any hospital within one year. The majority of these were one-time readmissions (62%) but 38% experienced multiple readmissions. Over 67% of readmissions were unplanned and 8% of readmissions were for a trauma. After controlling for patient variables known to be associated with readmissions, primary triage to a trauma center was associated with a lower odds of readmission (OR 0.89, p<0.001). The effect of transport to a trauma center remained significantly associated with decreased odds of readmission at one year (OR 0.96, p<0.001).Readmissions after injury are common and are often unscheduled. While patient factors play a role in this, care at a trauma center is also associated with decreased odds for re-admission, even when controlling for severity of injury. This suggests that the benefits of trauma center care extend beyond improvements in mortality to improved long-term outcomes.Economic/Decision LEVEL OF EVIDENCE: Level IV.

    View details for DOI 10.1097/TA.0000000000000956

    View details for PubMedID 26713975

  • Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach. Journal of hospital medicine Shieh, L., Go, M., Gessner, D., Chen, J. H., Hopkins, J., Maggio, P. 2015; 10 (9): 599-607


    The Agency for Healthcare Research and Quality has adopted iatrogenic pneumothorax (IAP) as a Patient Safety Indicator. In 2006, in response to a low performance ranking for IAP rate from the University Healthsystem Consortium (UHC), the authors established a multidisciplinary team to reduce our institution's IAP rate. Root-cause analysis found that subclavian insertion of central venous catheterization (CVC) was the most common procedure associated with IAP OBJECTIVE: Our short-term goal was a 50% reduction of both CVC-associated and all-cause IAP rates within 18 months, with long-term goals of sustained reduction.Observational study.Academic tertiary care hospital.Consecutive inpatients from 2006 to 2014.Our multifaceted intervention included: (1) clinical and documentation standards based on evidence, (2) cognitive aids, (3) simulation training, (4) purchase and deployment of ultrasound equipment, and (5) feedback to clinical services.CVC-associated IAP, all-cause IAP rate.We achieved both a short-term (years 2006 to 2008) and long-term (years 2006 to 2008-2014) reduction in our CVC-associated and all-cause IAP rates. Our short-term reduction in our CVC-associated IAP was 53% (P = 0.088), and our long-term reduction was 85% (P < 0.0001). Our short-term reduction in the all-cause IAP rate was 26% (P < 0.0001), and our long-term reduction was 61% (P < 0.0001).A multidisciplinary team, focused on evidence, patient safety, and standardization, can use a set of multifaceted interventions to sustainably improve patient outcomes for several years after implementation. Our hospital was in the highest performance UHC quartile for all-cause IAP in 2012 to 2014. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine.

    View details for DOI 10.1002/jhm.2388

    View details for PubMedID 26041246

  • Improving and sustaining a reduction in iatrogenic pneumothorax through a multifaceted quality-improvement approach JOURNAL OF HOSPITAL MEDICINE Shieh, L., Go, M., Gessner, D., Chen, J. H., Hopkins, J., Maggio, P. 2015; 10 (9): 599-607

    View details for DOI 10.1002/jhm.2388

    View details for Web of Science ID 000360836000007

  • Septris: a novel, mobile, online, simulation game that improves sepsis recognition and management. Academic medicine Evans, K. H., Daines, W., Tsui, J., Strehlow, M., Maggio, P., Shieh, L. 2015; 90 (2): 180-184


    Annually affecting over 18 million people worldwide, sepsis is common, deadly, and costly. Despite significant effort by the Surviving Sepsis Campaign and other initiatives, sepsis remains underrecognized and undertreated.Research indicates that educating providers may improve sepsis diagnosis and treatment; thus, the Stanford School of Medicine has developed a mobile-accessible, case-based, online game entitled Septris ( Septris, launched online worldwide in December 2011, takes an innovative approach to teaching early sepsis identification and evidence-based management. The free gaming platform leverages the massive expansion over the past decade of smartphones and the popularity of noneducational gaming.The authors sought to assess the game's dissemination and its impact on learners' sepsis-related knowledge, skills, and attitudes. In 2012, the authors trained Stanford pregraduate (clerkship) and postgraduate (resident) medical learners (n = 156) in sepsis diagnosis and evidence-based practices via 20 minutes of self-directed game play with Septris. The authors administered pre- and posttests.By October 2014, Septris garnered over 61,000 visits worldwide. After playing Septris, both pre- and postgraduate groups improved their knowledge on written testing in recognizing and managing sepsis (P < .001). Retrospective self-reporting on their ability to identify and manage sepsis also improved (P < .001). Over 85% of learners reported that they would or would maybe recommend Septris.Future evaluation of Septris should assess its effectiveness among different providers, resource settings, and cultures; generate information about how different learners make clinical decisions; and evaluate the correlation of game scores with sepsis knowledge.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

    View details for DOI 10.1097/ACM.0000000000000611

    View details for PubMedID 25517703

  • A nurse-driven screening tool for the early identification of sepsis in an intermediate care unit setting. Journal of hospital medicine Gyang, E., Shieh, L., Forsey, L., Maggio, P. 2015; 10 (2): 97-103


    Use of a screening tool as a decision support mechanism for early detection of sepsis has been widely advocated, yet studies validating tool performance are scarce, especially in non-intensive care unit settings.For this pilot study we prospectively screened consecutive patients admitted to a medical/surgical intermediate care unit at an academic medical center over a 1-month period and retrospectively analyzed their clinical data. Patients were screened with a 3-tiered, paper-based, nurse-driven sepsis assessment tool every 8 hours. For patients screening positive for sepsis or severe sepsis, the primary treatment team was notified and the team's clinical actions were recorded. Results of the screening test were then compared to patient International Classification of Diseases, Ninth Revision (ICD-9) codes for sepsis, severe sepsis, and septic shock identified during the study time period, and performance of the screening test was assessed.A total of 2143 screening tests were completed in 245 patients (169 surgical, 76 medical). ICD-9 codes confirmed sepsis incidence was 9%. Of the 39 patients who screened positive, 51% were positive for sepsis, and 49% screened positive for severe sepsis. Screening tool sensitivity and specificity were 95% and 92%, respectively. Negative predictive value was 99% and positive predictive value was 54%. Overall test accuracy was 92%. There was no statistically significant difference in tool performance between medical and surgical patients.A simple screening tool for sepsis utilized as part of nursing assessment may be a useful way of identifying early sepsis in both medical and surgical patients in an intermediate care unit setting. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine.

    View details for DOI 10.1002/jhm.2291

    View details for PubMedID 25425449

  • Restrictive blood transfusion practices are associated with improved patient outcomes TRANSFUSION Goodnough, L. T., Maggio, P., Hadhazy, E., Shieh, L., Hernandez-Boussard, T., Khari, P., Shah, N. 2014; 54 (10): 2753-2759


    Blood transfusion has been cited as one of the five most overutilized therapeutic procedures in the United States. We assessed the impact of clinical decision support at computerized physician order entry and education on red blood cell (RBC) transfusions and clinical patient outcomes at our institution.Clinical patient outcomes and RBC transfusions were assessed before and after implementation of a best practice alert triggered for transfusions when the hemoglobin level was higher than 7 g/dL for all inpatient discharges from January 2008 through December 2013. Retrospective clinical and laboratory data related to RBC transfusions were extracted: case-mix complexity, patient discharges and selected surgical volumes, and patient outcomes (mortality, 30-day readmissions, length of stay).There was a significant improvement in RBC utilization as assessed by RBC units transfused per 100 patient-days-at-risk. Concurrently, hospital-wide clinical patient outcomes showed improvement (mortality, p = 0.034; length of stay, p = 0.003) or remained stable (30-day readmission rates, p = 0.909). Outcome improvements were even more pronounced in patients who received blood transfusions, with decreased mortality rate (55.2 to 33.0, p < 0.001), length of stay (mean, 10.1 to 6.2 days, p < 0.001), and 30-day readmission rate (136.9 to 85.0, p < 0.001). The mean number of units transfused per patient also declined (3.6 to 2.7, p < 0.001). Acquisition costs of RBC units per 1000 patient discharges decreased from $283,130 in 2009 to $205,050 in 2013 with total estimated savings of $6.4 million and likely far greater impact on total transfusion-related costs.Improved blood utilization is associated with improved clinical patient outcomes.

    View details for DOI 10.1111/trf.12723

    View details for Web of Science ID 000343821100023

  • Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion Goodnough, L. T., Maggio, P., Hadhazy, E., Shieh, L., Hernandez-Boussard, T., Khari, P., Shah, N. 2014; 54 (10): 2753-2759


    Blood transfusion has been cited as one of the five most overutilized therapeutic procedures in the United States. We assessed the impact of clinical decision support at computerized physician order entry and education on red blood cell (RBC) transfusions and clinical patient outcomes at our institution.Clinical patient outcomes and RBC transfusions were assessed before and after implementation of a best practice alert triggered for transfusions when the hemoglobin level was higher than 7 g/dL for all inpatient discharges from January 2008 through December 2013. Retrospective clinical and laboratory data related to RBC transfusions were extracted: case-mix complexity, patient discharges and selected surgical volumes, and patient outcomes (mortality, 30-day readmissions, length of stay).There was a significant improvement in RBC utilization as assessed by RBC units transfused per 100 patient-days-at-risk. Concurrently, hospital-wide clinical patient outcomes showed improvement (mortality, p = 0.034; length of stay, p = 0.003) or remained stable (30-day readmission rates, p = 0.909). Outcome improvements were even more pronounced in patients who received blood transfusions, with decreased mortality rate (55.2 to 33.0, p < 0.001), length of stay (mean, 10.1 to 6.2 days, p < 0.001), and 30-day readmission rate (136.9 to 85.0, p < 0.001). The mean number of units transfused per patient also declined (3.6 to 2.7, p < 0.001). Acquisition costs of RBC units per 1000 patient discharges decreased from $283,130 in 2009 to $205,050 in 2013 with total estimated savings of $6.4 million and likely far greater impact on total transfusion-related costs.Improved blood utilization is associated with improved clinical patient outcomes.

    View details for DOI 10.1111/trf.12723

    View details for PubMedID 24995770

  • Improved blood utilization using real-time clinical decision support. Transfusion Goodnough, L. T., Shieh, L., Hadhazy, E., Cheng, N., Khari, P., Maggio, P. 2014; 54 (5): 1358-1365


    We analyzed blood utilization at Stanford Hospital and Clinics after implementing real-time clinical decision support (CDS) and best practice alerts (BPAs) into physician order entry (POE) for blood transfusions.A clinical effectiveness (CE) team developed consensus with a suggested transfusion threshold of a hemoglobin (Hb) level of 7 g/dL, or 8 g/dL for patients with acute coronary syndromes. The CDS was implemented in July 2010 and consisted of an interruptive BPA at POE, a link to relevant literature, and an "acknowledgment reason" for the blood order.The percentage of blood ordered for patients whose most recent Hb level exceeded 8 g/dL ranged at baseline from 57% to 66%; from the education intervention by the CE team August 2009 to July 2010, the percentage decreased to a range of 52% to 56% (p = 0.01); and after implementation of CDS and BPA, by end of December 2010 the percentage of patients transfused outside the guidelines decreased to 35% (p = 0.02) and has subsequently remained below 30%. For the most recent interval, only 27% (767 of 2890) of transfusions occurred in patients outside guidelines. Comparing 2009 to 2012, despite an increase in annual case mix index from 1.952 to 2.026, total red blood cell (RBC) transfusions decreased by 7186 units, or 24%. The estimated net savings for RBC units (at $225/unit) in purchase costs for 2012 compared to 2009 was $1,616,750.Real-time CDS has significantly improved blood utilization. This system of concurrent review can be used by health care institutions, quality departments, and transfusion services to reduce blood transfusions.

    View details for DOI 10.1111/trf.12445

    View details for PubMedID 24117533

  • Logistics of transfusion support for patients with massive hemorrhage CURRENT OPINION IN ANESTHESIOLOGY Goodnough, L. T., Spain, D. A., Maggio, P. 2013; 26 (2): 208-214


    Traditionally, trauma resuscitation protocols have advocated sequential administration of therapeutic components, beginning with crystalloid solutions infused to replace lost intravascular volume. However, rapid restoration of the components of blood is essential for ensuring adequate tissue perfusion and for preventing acidosis, coagulopathy, and hypothermia, referred to as the 'lethal triad' in trauma settings. The review summarizes practical approaches for transfusion support of patients with massive hemorrhage.Massive transfusion protocols for blood transfusion support are reviewed, including practical considerations from our own. We maintain an inventory of thawed, previously frozen plasma (four units each of blood group O and A), which can be issued immediately for patients in whom the blood type is known. As frozen plasma requires 45 min to thaw, liquid AB plasma (26 day outdate) functions as an excellent alternative, particularly for patients with unknown or blood group B or AB types.Close monitoring of bleeding and coagulation in trauma patients allows goal-directed transfusions to optimize patients' coagulation, reduce exposure to blood products, and to improve patient outcomes. Future studies are needed to understand and demonstrate improved patient outcomes.

    View details for DOI 10.1097/ACO.0b013e32835d6f8f

    View details for Web of Science ID 000316310800018

    View details for PubMedID 23446185

  • Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients SURGERY Pickham, D. M., Callcut, R. A., Maggio, P. M., Mell, M. W., Spain, D. A., Bech, F., Staudenmayer, K. 2012; 152 (2): 232-237


    It is controversial whether patients at high risk for pulmonary embolism (PE) should receive prophylactic inferior vena cava filters (IVC) filters. This lack of clarity creates the potential for variability and disparities in care. We hypothesized there would be differential use of prophylactic IVC filters for patients at high risk for PE on the basis of insurance status.We performed a retrospective analysis using the National Trauma Databank (2002-2007). We included adult patients at high risk for PE (traumatic brain injury or spinal cord injury) and excluded patients with a diagnosis of deep venous thrombosis (DVT) or PE. Logistic regression was performed to control for confounders and a hierarchical mixed effects model was used to control for center.A prophylactic filter was placed in 3,331 (4.3%) patients in the study cohort. Patients without insurance had an IVC filter placed less often compared with those with any form of insurance (2.7% vs 4.9%, respectively). After adjusting for confounders, we found that patients without insurance were less likely to receive a prophylactic IVC filter, even when we controlled for center (OR 5.3, P < .001).When guidelines lack clarity, unconscious bias has the potential to create a system with different levels of care based on socioeconomic disparities.

    View details for DOI 10.1016/j.surg.2012.05.041

    View details for Web of Science ID 000307157500013

    View details for PubMedID 22828145

  • Early outcomes of deliberate nonoperative management for blunt thoracic aortic injury in trauma JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Caffarelli, A. D., Mallidi, H. R., Maggio, P. M., Spain, D. A., Miller, D. C., Mitchell, R. S. 2010; 140 (3): 598-605


    Traumatic blunt aortic injury has traditionally been viewed as a surgical emergency, whereas nonoperative therapy has been reserved for nonsurgical candidates. This study reviews our experience with deliberate, nonoperative management for blunt thoracic aortic injury.A retrospective chart review with selective longitudinal follow-up was conducted for patients with blunt aortic injury. Surveillance imaging with computed tomography angiography was performed. Nonoperative patients were then reviewed and analyzed for survival, evolution of aortic injury, and treatment failures.During the study period, 53 patients with an average age of 45 years (range, 18-80 years) were identified, with 28% presenting to the Stanford University School of Medicine emergency department and 72% transferred from outside hospitals. Of the 53 patients, 29 underwent planned, nonoperative management. Of the 29 nonoperative patients, in-hospital survival was 93% with no aortic deaths in the remaining patients. Survival was 97% at a median of 1.8 years (range, 0.9-7.2 years). One patient failed nonoperative management and underwent open repair. Serial imaging was performed in all patients (average = 107 days; median, 31 days), with 21 patients having stable aortic injuries without progression and 5 patients having resolved aortic injuries.This experience suggests that deliberate, nonoperative management of carefully selected patients with traumatic blunt aortic injury may be a reasonable alternative in the polytrauma patient; however, serial imaging and long-term follow-up are necessary.

    View details for DOI 10.1016/j.jtcvs.2010.02.056

    View details for Web of Science ID 000281116000016

    View details for PubMedID 20579668

  • Outcomes and complications of open abdomen technique for managing non-trauma patients. Journal of emergencies, trauma, and shock Kritayakirana, K., M Maggio, P., Brundage, S., Purtill, M., Staudenmayer, K., A Spain, D. 2010; 3 (2): 118-122


    Damage control surgery and the open abdomen technique have been widely used in trauma. These techniques are now being utilized more often in non-trauma patients but the outcomes are not clear. We hypothesized that the use of the open abdomen technique in non-trauma patients 1) is more often due to peritonitis, 2) has a lower incidence of definitive fascial closure during the index hospitalization, and 3) has a higher fistula rate.Retrospective case series of patients treated with the open abdomen technique over a 5-year period at a level-I trauma center. Data was collected from the trauma registry, operating room (OR) case log, and by chart review. The main outcome measures were number of operations, definitive fascial closure, fistula rate, complications, and length of stay.One hundred and three patients were managed with an open abdomen over the 5-year period and we categorized them into three groups: elective (n = 31), urgent (n = 35), and trauma (n = 37). The majority of the patients were male (69%). Trauma patients were younger (39 vs 53 years; P < 0.05). The most common indications for the open abdomen technique were intraabdominal hypertension in the elective group (n = 18), severe intraabdominal infection in the urgent group (n = 19), and damage control surgery in the trauma group (n = 28). The number of abdominal operations was similar (3.1-3.7) in the three groups, as was the duration of intensive care unit (ICU) stay (average: 25-31 days). The definitive fascial closure rates during initial hospitalization were as follows: 63% in the elective group, 60% in the urgent group, and 54% in the trauma group. Intestinal fistula formation occurred in 16%, 17%, and 11%, respectively, in the three groups, with overall mortality rates of 35%, 31%, and 11%.Intra-abdominal infection was a common reason for use of the open abdomen technique in non-trauma patients. However, the definitive fascial closure and fistula rates were similar in the three groups. Despite differences in indications, damage control surgery and the open abdomen technique have been successfully transitioned to elective and urgent non-trauma patients.

    View details for DOI 10.4103/0974-2700.62106

    View details for PubMedID 20606786

  • Massive Transfusion Protocols: The Role of Aggressive Resuscitation Versus Product Ratio in Mortality Reduction JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Riskin, D. J., Tsai, T. C., Riskin, L., Hernandez-Boussard, T., Purtill, M., Maggio, P. M., Spain, D. A., Brundage, S. I. 2009; 209 (2): 198-205


    Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP).In July 2005, our American College of Surgeons-verified Level I trauma center implemented an MTP supporting a 1:1.5 FFP:PRBC ratio, improved communications, and enhanced systems flow to optimize rapid blood product availability. During the 4 years surrounding protocol implementation, we reviewed data on trauma patients directly admitted through the emergency department and requiring 10 or more units PRBCs during the first 24 hours.For the 2 years before and subsequent to MTP initiation, there were 4,223 and 4,414 trauma activations, of which 40 and 37 patients, respectively, met study criteria. The FFP:PRBC ratios were identical, at 1:1.8 and 1:1.8 (p = 0.97). Despite no change in FFP:PRBC ratio, mortality decreased from 45% to 19% (p = 0.02). Other significant findings included decreased mean time to first product: cross-matched RBCs (115 to 71 minutes; p = 0.02), FFP (254 to 169 minutes; p = 0.04), and platelets (418 to 241 minutes; p = 0.01).MTP implementation is associated with mortality reductions that have been ascribed principally to increased plasma use and decreased FFP:PRBC ratios. Our study found a significant reduction in mortality despite unchanged FFP:PRBC ratios and equivalent overall mean numbers of transfusions. Our data underscore the importance of expeditious product availability and emphasize that massive transfusion is a complex process in which product ratio and time to transfusion represent only the beginning of understanding.

    View details for DOI 10.1016/j.jamcollsurg.2009.04.016

    View details for Web of Science ID 000268747300006

    View details for PubMedID 19632596

  • Commitment to COT Verification Improves Patient Outcomes and Financial Performance 67th Annual Meeting of the American-Association-for-the-Surgery-of-Trauma/Meeting of the Association-for-Acute-Medicine Maggio, P. M., Brundage, S. I., Hernandez-Boussard, T., Spain, D. A. LIPPINCOTT WILLIAMS & WILKINS. 2009: 190–95


    After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances.The Trauma Registry was used to derive data for all trauma patients evaluated in the emergency department from 2001 to 2007. Clinical data analyzed included number of admissions, interfacility transfers, injury severity scores (ISS), length of stay, and mortality for 2001 to 2007. Financial performance was assessed for fiscal years 2001 to 2007. Data were divided into patients discharged from the emergency department and those admitted to the hospital.Admissions increased 30%, representing a 7.6% annual increase (p = 0.004), mostly due to a nearly fivefold increase in interfacility transfers. Severe trauma patients (ISS >24) increased 106% and mortality rate for ISS >24 decreased by 47% to almost half the average of the National Trauma Database. There was a 78% increase in revenue and a sustained increase in hospital profitability.A major hospital commitment to Committee on Trauma verification had several salient outcomes; increased admissions, interfacility transfers, and acuity. Despite more seriously injured patients, there has been a major, sustained reduction in mortality and a trend toward decreased intensive care unit length of stay. This resulted in a substantial increase in contribution to margin (CTM), net profit, and revenues. With a high level of commitment and favorable payer mix, trauma center verification improves outcomes for both patients and the hospital.

    View details for DOI 10.1097/TA.0b013e3181a51b2f

    View details for Web of Science ID 000267953100035

    View details for PubMedID 19590334

  • Intensive insulin therapy is associated with reduced infectious complications in burn patients 65th Annual Meeting of the Central-Surgical-Association Hemmila, M. R., Taddonio, M. A., Arbabi, S., Maggio, P. M., Wahl, W. L. MOSBY-ELSEVIER. 2008: 629–37


    Intensive insulin therapy to control blood glucose levels has reduced mortality in surgical, but not medical, intensive care unit (ICU) patients. Control of blood glucose levels has also been shown to reduce morbidity in surgical ICU patients. There is very little data for use of intensive insulin therapy in the burn patient population. We sought to evaluate our experience with intensive insulin therapy in burn-injured ICU patients with regard to mortality, morbidity, and use of hospital resources.Burn patients admitted to our American College of Surgeons verified burn center ICU from 7/1/2004 to 6/30/2006 were studied. An intensive insulin therapy protocol was initiated for ICU patients admitted starting 7/1/2005 with a blood glucose target of 100-140 mg/dL. The 2 groups of patients studied were control (7/1/2004 to 6/30/2005) and intensive insulin therapy (7/1/2005 to 6/30/2006). All glucose values for the hospitalization were analyzed. Univariate and multivariate analyses were performed.Overall, 152 ICU patients admitted with burn injury were available for study. No difference in mortality was evident between the control and intensive insulin therapy groups. After adjusting for patient risk, the intensive insulin therapy group was found to have a decreased rate of pneumonia, ventilator-associated pneumonia, and urinary tract infection. In patients with a maximum glucose value of greater than 140 mg/dL, the risk for an infection was significantly increased (OR 11.3, 95% CI 4-32, P-value < .001). The presence of a maximum glucose value greater than 140 mg/dL was associated with a sensitivity of 91% and specificity of 62% for an infectious complication.Intensive insulin therapy for burn-injured patients admitted to the ICU was associated with a reduced incidence of pneumonia, ventilator-associated pneumonia, and urinary tract infection. Intensive insulin therapy did not result in a change in mortality or length of stay when adjusting for confounding variables. Measurement of a blood glucose level greater than 140 mg/dL should heighten the clinical suspicion for the presence of an infection in patients with burn injury.

    View details for DOI 10.1016/j.surg.2008.07.001

    View details for Web of Science ID 000259751000020

    View details for PubMedID 18847648

  • Real money: Complications and hospital costs in trauma patients SURGERY Hemmila, M. R., Jakubus, J. L., Maggio, P. M., Wahl, W. L., Dimick, J. B., Campbell, D. A., Taheri, P. A. 2008; 144 (2): 307-316


    Major postoperative complications are associated with a substantial increase in hospital costs. Trauma patients are known to have a higher rate of complications than the general surgery population. We used the National Surgical Quality Improvement Program (NSQIP) methodology to evaluate hospital costs, duration of stay, and payment associated with complications in trauma patients.Using NSQIP principles, patient data were collected for 512 adult patients admitted to the trauma service for > 24 hours at a Level 1 trauma center (2004-2005). Patients were placed in 1 of 3 groups: no complications (none), >or=1 minor complication (minor, eg, urinary tract infection), or >or=1 major complication (major, eg, pneumonia). Total hospital charges, costs, payment, and duration of stay associated with each complication group were determined from a cost-accounting database. Multiple regression was used to determine the costs of each type of complication after adjusting for differences in age, sex, new injury severity score, Glasgow coma scale score, maximum head abbreviated injury scale, and first emergency department systolic blood pressure.A total of 330 (64%) patients had no complications, 53 (10%) had >or= 1 minor complication, and 129 (25%) had >or= 1 major complication. Median hospital charges increased from $33,833 (none) to $81,936 (minor) and $150,885 (major). The mean contribution to margin per day was similar for the no complication and minor complication groups ($994 vs $1,115, P = .7). Despite higher costs, the patients in the major complication group generated a higher mean contribution to margin per day compared to the no complication group ($2,168, P < .001). The attributable increase in median total hospital costs when adjusted for confounding variables was $19,915 for the minor complication group (P < .001), and $40,555 for the major complication group (P < .001).Understanding the costs associated with traumatic injury provides a window for assessing the potential cost reductions associated with improved quality care. To optimize system benefits, payers and providers should develop integrated reimbursement methodologies that align incentives to provide quality care.

    View details for DOI 10.1016/j.surg.2008.05.003

    View details for Web of Science ID 000258308400026

    View details for PubMedID 18656640

  • Mean glucose values predict trauma patient mortality 66th Annual Meeting of the American-Association-for-the-Surgery-of-Trauma Wahl, W. L., Taddonio, M., Maggio, P. M., Arbabi, S., Hemmila, M. R. LIPPINCOTT WILLIAMS & WILKINS. 2008: 42–47


    Tight glycemic control in a mixed surgical intensive care unit patient population has been associated with improved survival. We postulated targeted therapy to achieve glucose levels <140 mg/dL would reduce infectious complications and mortality in trauma patients admitted to the intensive care unit (ICU).Adult trauma patients admitted to our American College of Surgeons Level I Trauma Center ICU from July 2004 through June 30, 2006 were studied. Insulin therapy was instituted for ICU patients admitted after July 1, 2005 with glucose >140 mg/dL. Data on infections and all glucose values were collected. Multivariate analysis adjusting for age, Injury Severity Score, Glasgow Coma Scale Score, admit blood pressure, and intubation status was performed.Five thirty-one ICU patients were admitted with a mean Injury Severity Score of 23 +/- 13 and mean age of 45 years +/- 19 years. The admission, mean, and maximum glucoses were 141, 129, and 192 respectively. In multivariate analyses, increases in all three glucose values were associated with a significantly higher mortality, with the best model achieved using mean glucose with a receiver operating curve of 0.90. For mean glucose categories of >200 mg/dL, 141 mg/dL to 200 mg/dL, and

    View details for DOI 10.1097/TA.0b013e318176c54e

    View details for Web of Science ID 000257767300007

    View details for PubMedID 18580507

  • Restrictive red blood cell transfusion: not just for the stable intensive care unit patient AMERICAN JOURNAL OF SURGERY Wahl, W. L., Hemmila, M. R., Maggio, P. M., Arbabi, S. 2008; 195 (6): 803-806


    Multiple studies report that patients receiving red blood cell (RBC) transfusion in the intensive care unit (ICU) are more likely to experience complications. Despite these findings, surgical patients are frequently transfused for operative procedures, trauma, and burns. We hypothesized that a RBC transfusion guideline would safely decrease our use of RBC transfusions in the ICU and lower the hematocrit at which our trauma and burn patients were transfused, both in the stable and symptomatic patient.For each episode of RBC transfusion, the pretransfusion vital signs and reasons for transfusion were recorded prospectively from August 2003 through April 2004. Before institution of the transfusion guideline, which stressed withholding transfusion for hematocrit over 23 in asymptomatic patients, intensive education of all caregivers occurred. Data from all transfusions during 2005 were also reviewed for long-term compliance with the guideline.Eighty-two of 316 ICU patients (26%) had 315 RBC transfusion events during the initial study period. Mean transfusion hematocrits decreased from 26.6 +/- 4.7 to 23.9 +/- 2.6 (P < .0003) for all patients. For the follow-up period in 2005, 94 of 523 patients (18%) were transfused in the ICU at a mean transfusion hematocrit of 24.1 for symptomatic (P < .0001) and 22.5 for asymptomatic patients (P < .0001). Low hematocrit was the most frequently cited reason for transfusion for all patients in the first part of the study, whereas hemodynamic instability (n = 91 events) and perioperative losses (n = 49 events) ranked highest for symptomatic patients.A transfusion guideline accompanied by intensive education is effective in reducing RBC transfusions in a trauma-burn ICU. A lower hematocrit was well tolerated in both the symptomatic and asymptomatic groups of surgical patients. With education and follow-up, the changes in transfusion practices were durable and affected transfusion practices for both asymptomatic and symptomatic patients.

    View details for DOI 10.1016/j.amjsurg.2007.05.047

    View details for Web of Science ID 000256585700014

    View details for PubMedID 18355792

  • Trauma center downstream revenue: The impact of incremental patients within a health system JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Taheri, P. A., Maggio, P. M., Dougherty, J., Neil, C., Fetyko, S., Harkins, D. R., Butz, D. A. 2007; 62 (3): 615-619


    The purpose of this study is to assess the downstream clinical and financial impact of a trauma, burn, and emergency surgery service at an academic Level I trauma center.All patients admitted to the trauma, burn, and emergency surgery service from fiscal years 2002 to 2004 were identified. Clinical and financial data including inpatient and outpatient activity were analyzed for 365 days (downstream) after initial service admission. Data were divided into total service, trauma and burn, inpatient, outpatient, hospital, and professional revenue.In all, 3,679 patients were admitted during the study period with total initial revenue approaching $103 million. Of these, 1,566 patients were subsequently admitted for downstream inpatient activity, resulting in almost $26 million in subsequent inpatient revenue. The initial patient admissions resulted in over 17,000 clinic visits during the course of the 3 study years. Professional revenue resulted in over $14 million for the initial admission and $6.1 million in downstream revenue during the study period.Trauma, burn, and emergency surgical services result in both substantial initial and downstream revenue for the hospital (inpatient and outpatient) and professional components. Services committed to caring for the injured and emergent patients substantially contribute to the institutional financial strength.

    View details for DOI 10.1097/TA.0b013e31802ee532

    View details for Web of Science ID 000244877300013

    View details for PubMedID 17414337

  • Extracorporeal life support for massive pulmonary embolism JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Maggio, P., Hemmila, M., Haft, J., Bartlett, R. 2007; 62 (3): 570-576


    Massive pulmonary embolism is frequently lethal because of acute irreversible pulmonary and cardiac failure. Extracorporeal life support (ECLS) has been used for cardiopulmonary failure in our institution since 1988, and we reviewed our experience with its use in the management of massive pulmonary emboli.We reviewed our complete experience with ECLS for massive pulmonary emboli from January 1992 through December 2005. The records of 21 patients were examined and data extracted.During the study period, 21 patients received ECLS for massive pulmonary emboli. All patients were on vasoactive drugs, acidemic, and hypoxic at the time of institution of ECLS. Eight were in active cardiac arrest. Five were trauma patients, eight had recently undergone an operation, and six had a hypercoagulable disorder. Nineteen of the 21 patients were cannulated for venoarterial bypass and two were placed on venovenous bypass. The average duration of support for survivors was 5.4 days, ranging from 5 hours to 12.5 days. Emboli resolved with anticoagulation in 10 of 13 survivors and 4 of 13 survivors underwent surgical pulmonary embolectomy. Catastrophic neurologic events were the most common cause of mortality in our series; four patients died from intracranial hemorrhage. The overall survival rate was 62% (13/21).We conclude that emergent ECLS provides an opportunity to improve the prognosis of an otherwise near-fatal condition, and should be considered in the algorithm for management of a massive pulmonary embolism in an unstable patient.

    View details for DOI 10.1097/TA.0b013e318031cd0c

    View details for Web of Science ID 000244877300005

    View details for PubMedID 17414330

  • Perioperative issues: Myocardial ischemia and protection - Beta-blockade SURGICAL CLINICS OF NORTH AMERICA Maggio, P. M., Taheri, P. A. 2005; 85 (6): 1091-?


    Approximately one third of patients undergoing noncardiac surgery have coronary artery disease, and cardiovascular complications are an important cause of perioperative morbidity and mortality. Several algorithms are available to assess the risk for peri-operative cardiac events. Although preoperative risk assessment is useful in identifying patients at greatest risk for cardiac complications, recent investigations have provided additional guidance in choosing interventions to improve perioperative outcomes. These investigations show that perioperative beta-blockers significantly reduce morbidity and mortality in noncardiac surgery and appear to offer the greatest benefit to high-risk patients. Because of the lower complication rate in intermediate- and low-risk patients and the absence of large randomized controlled trials, the role of beta-blockers in this population is less well-defined.

    View details for DOI 10.1016/j.suc.2005.09.016

    View details for Web of Science ID 000234386500005

    View details for PubMedID 16326195