Trust but Verify? Utility of Intraoperative Angiography After Revascularization for Vascular Trauma

BACKGROUND

Trauma surgical dogma teaches that patients should have intraoperative angiography (IA) if the surgeon cannot identify a pulse in the injured extremity following a vascular repair. This study was undertaken to assess the utility of IA in trauma patients who underwent open brachial or femoral artery revascularization.

METHODS

Retrospective analysis of the Prospective Observational Vascular Injury Trial (PROOVIT) database from 2013 to 2021 evaluated patients >15 years with penetrating or blunt injuries requiring operative intervention of the brachial, superficial femoral, or common femoral arteries. Prospective Observational Vascular Injury Trial data evaluated included documented pulse in the injured extremity at revascularization completion, adjunctive IA, immediate revision, and vascular reintervention during the hospitalization.

RESULTS

Of the 5057 patients with vascular injury, 185 patients met our inclusion criteria. The majority were male (86.5%) with a median age, injury severity score, and systolic blood pressure of 29, 12, and 117, respectively. Of the study patients, 39% underwent IA, 14% had immediate revision, and 8% required vascular reoperation during their admission. Patients who underwent IA and with no documented palpable pulse after repair were significantly more likely to require immediate revision before leaving the operating room (22% vs 9%, P = .013) and were not more likely to require reoperation, than those who did not undergo IA (7% vs 9%, P = .613).

CONCLUSIONS

Intraoperative angiography is a valuable tool for surgeons for vascular extremity trauma and is associated with a greater rate of immediate revision. Familiarity with angiographic technique is essential for vascular trauma and should be a focal point of training.

Performance Improvement Program Review of Institutional Massive Transfusion Protocol Adherence: An Opportunity for Improvement

BACKGROUND

Given the acuity of patients who receive MTPs and the resources they require, MTPs are a compelling target for performance improvement. This study evaluated adherence with our MTP's plasma:red blood cell ratio (FFPR) of 1:2 and platelet:red blood cell ratio (PLTR) of 1:12, to test the hypothesis that ratio adherence is associated with lower inpatient mortality.

MATERIALS AND METHODS

The registry of an urban level I trauma center was queried for adult patients who received at least 6 units of packed red blood cells within 4 hours of presentation. Patients were excluded for interfacility transfer, cardiac arrest during the prehospital phase or within one hour of arrival, or for head AIS ≥5. Univariate analysis and multiple logistic regressions were performed to identify variables associated with early transfusion protocol noncompliance and the effect on inpatient mortality.

RESULTS

Three hundred and eighty-three patients were included, with mean ISS of 25.9 ± 13.3 and inpatient mortality of 28.5%. Increasing age, ISS, INR, and total units of blood product transfused were associated with increased odds of mortality, while an increase in revised trauma score was associated with a decreased odds ratio of mortality. Achieving our goal ratios were protective against mortality, with OR of .451 (P = .013) and .402 (P=.003), respectively.

DISCUSSION

Large proportions of critically injured patients were transfused fewer units of plasma and platelets than our MTP dictated; failure to achieve intended ratios at 4 hours was strongly associated with inpatient mortality. MTP processes and outcomes should be critically assessed on a regular basis as part of a mature performance improvement program to ensure protocol adherence and optimal patient outcome.

Key Findings on Computed Tomography of the Head that Predict Death or the Need for Neurosurgical Intervention From Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) requires rapid management to avoid secondary injury or death. This study evaluated if a simple schema for quickly interpreting CT head (CTH) imaging by trauma surgeons and trainees could be validated to predict need for neurosurgical intervention (NSI) or death from TBI within 24 hours.

METHODS

We retrospectively reviewed TBI patients presenting to our trauma center in 2020 with blunt mechanism and GCS ≤ 12. Primary independent variables were presence of 7 normal findings on CTH (CSF at foramen magnum, open fourth ventricle, CSF around quadrigeminal plate, CSF around cerebral peduncles, absence of midline shift, visible sulci/gyri, and gray-white differentiation). Trauma surgeons and trainees separately evaluated each patient's CTH, scoring findings as normal or abnormal. Primary outcome was NSI/death in 24 hours.

RESULTS

Our population consisted of 444 patients; 21.4% received NSI or died within 24 hours. By trainees' interpretation, 5.8% of patients without abnormal findings had NSI/death vs 52.0% of patients with ≥1 abnormality; attending interpretation was 8.7% and 54.9%, respectively (P < .001). Sulci/gyri effacement, midline shift, and cerebral peduncle effacement maximized sensitivity and specificity for predicting NSI/death. Considering pooled results, when ≥1 of those 3 findings was abnormal, sensitivity was 77.89%, specificity was 80.80%, positive predictive value was 52.48%, and negative predictive value was 93.07%.

DISCUSSION

Any single abnormality in this schema significantly predicted a large increase in NSI/death in 24 hours in TBI patients, and three particular findings were most predictive. This schema may help predict need for intervention and expedite management of moderate/severe TBI.

Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis

BACKGROUND

Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation.

METHODS

Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE.

RESULTS

A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation.

CONCLUSION

Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.

Failure rates of nonoperative management of low-grade splenic injuries with active extravasation: an Eastern Association for the Surgery of Trauma multicenter study

Objectives

There is little evidence guiding the management of grade I-II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I-II splenic injuries with CB in hemodynamically stable patients.

Methods

A multicenter, retrospective cohort study examining all grade I-II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not.

Results

A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I-II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05).

Conclusion

NOM of grade I-II splenic injuries with CB fails in 20% of patients.

Level of evidence

IV.

A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology

BACKGROUND

Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling.

METHODS

A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3.

RESULTS

Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus.

CONCLUSION

An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria; Level V.

Impact of Patient and Procedural Factors on Outcomes Following Mesenteric Bypass

BACKGROUND

Mesenteric bypass (MB) for patients with acute (AMI) and chronic mesenteric ischemia (CMI) is associated with cardiovascular (CV) and pulmonary morbidity.

METHODS

Patients with AMI and CMI from 2008 to 2019 were identified to determine independent predictors of CV (cardiac arrest, MI, DVT, and stroke) and pulmonary (pneumonia and ventilator time>48 h) morbidities in patients undergoing MB.

RESULTS

377 patients were identified. Patients with AMI had higher rates of preoperative SIRS/sepsis (28 vs 12%, P < .0001), were more likely to be ASA class 4/5 (55 vs 42%, P = .005), were more likely to require bowel resection (19 vs 3%, P < .0001), and were more likely to have vein utilized as their bypass conduit (30 vs 14%, P < .0001). There were no differences in use of aortic or iliac inflow (P = .707) nor in return to the OR (24 vs 19%, P = .282). Both postoperative sepsis (12 vs 2.6%, P = .003) and mortality (31.4% vs 9.8%, P < .0001) were significantly increased in patients with AMI. After adjusting for both patient and procedural factors, multivariable logistic regression (MLR) identified international normalized ratio (INR) (OR 3.16; 95% CI 1.56-6.40, P = .001) and chronic heart failure (CHF) (OR 5.88; 95% CI 1.15-29.97, P = .033) to be independent predictors of pulmonary morbidity, while preoperative sepsis (OR 1.96; 95% CI 1.45-2.66, P < .0001) alone was predictive of CV morbidity in all patients undergoing MB.

DISCUSSION

Mesenteric bypass for mesenteric ischemia leads to high rates of morbidity and mortality, whether done in an acute or chronic setting. Preoperative sepsis, independent of AMI or CMI, predicts CV morbidity, regardless of bypass configuration or conduit, while elevated INR or underlying CHF carries a higher risk of pulmonary morbidity.

A Core Outcome Set for Acute Necrotizing Pancreatitis: an Eastern Association for the Surgery of Trauma Modified Delphi Method Consensus Study

BACKGROUND

The management of acute necrotizing pancreatitis (ANP) has changed dramatically over the past 20 years including the use of less invasive techniques, the timing of interventions, nutritional management, and anti-microbial management. This study sought to create a core outcome set (COS) to help shape future research by establishing a minimal set of essential outcomes that will facilitate future comparisons and pooling of data, while minimizing reporting bias.

METHODS

A modified Delphi process was performed though involvement of ANP content experts. Each expert proposed a list of outcomes for consideration and the panel anonymously scored the outcomes on a 9-point Likert scale. Core outcome consensus defined a priori as >70% of scores receiving 7-9 points and < 15% of scores receiving 1-3 points. Feedback and aggregate data were shared between rounds with inter-class correlation trends used to determine the end of the study.

RESULTS

A total of 19 experts agreed to participate in the study with 16 (84%) participating through study completion. Forty-three outcomes were initially considered with 16 reaching consensuses after four rounds of the modified Delphi process. The final COS included outcomes related to mortality, organ failure, complications, interventions/management, and social factors.

CONCLUSION

Through an iterative consensus process, content experts agreed on a COS for the management of ANP. This will help shape future research to generate data suitable for pooling and other statistical analyses that may guide clinical practice.

STUDY TYPE

Diagnostic Tests or Criteria.

LEVEL OF EVIDENCE

Diagnostic test or criteria, V.

Synchronous tracheostomy and gastrostomy placement results in shorter length of stay in traumatic brain injury patients

BACKGROUND

American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend gastrostomy for patients suspected to require enteral access device for 4-6 weeks. Our hypothesis was that traumatic brain injury (TBI) patients undergoing synchronous tracheostomy/gastrostomy (SYNC) compared to tracheostomy first (DELAY) have shorter length of stay (LOS) but higher rates of unnecessary gastrostomy.

METHODS

Retrospective review of TBI patients requiring tracheostomy in 2017-2022 ​at a Level 1 trauma center was conducted. SYNC and DELAY patients were compared, and CoxPH analysis was performed for LOS.

RESULTS

394 patients were included [mean age: 42 (SD:18); mortality: 9 ​%]. The DELAY group had longer LOS (39 vs 32 days, p ​< ​0.001). There was no significant difference in unnecessary gastrostomy rate between groups (p ​= ​0.1331). In adjusted hazard analysis, SYNC predicted shorter LOS (HR:1.54; 95 ​% CI:1.20-1.98, p ​< ​0.001).

CONCLUSIONS

Synchronous gastrostomy was associated with shorter length of stay and similar rates of unnecessary gastrostomy in TBI patients.

Risk Factors for Acute Renal Failure After Endovascular Aneurysm Repair

BACKGROUND

Acute kidney injury (AKI) after endovascular aortic aneurysm repair (EVAR) is uncommon though carries significant morbidity. Procedural risk factors are not well established for acute renal failure (ARF) that requires initiation of dialysis. The goal of this study was to examine the impact of ARF on patients undergoing EVAR and identify risk factors for ARF using a large, national dataset.

METHODS

Patients undergoing EVAR were identified from the National Surgical Quality Improvement Program (NSQIP) database over 9 years, ending in 2019. Demographics, indication for repair, comorbidities, procedural details, complications, hospital and ICU LOS, and mortality were recorded. Patients were stratified by presence of ARF and compared. Patients were further stratified by indication for EVAR and presence of ARF. Multivariable logistic regression (MLR) analysis was performed to determine the independent predictors of ARF.

RESULTS

18 347 patients were identified. Of these 234 (1.3%) developed ARF requiring dialysis. Mortality (40 vs 1.8%, P < .0001), ICU LOS (5 vs 0 days, P < .0001), and hospital LOS (11 vs 2 days, P < .0001) were all significantly increased in patients with ARF. Multivariable logistic regression identified increasing diameter, creatinine, operative time, preoperative transfusions, ASA class, emergent repair, female gender, and juxtarenal/suprarenal proximal landing zone as predictors of ARF.

CONCLUSIONS

ARF after EVAR causes significant morbidity, prolongs hospitalizations, and increases mortality rates. Those patients at risk of ARF after EVAR should be closely monitored to reduce both morbidity and mortality.

Enteral feeding tolerance during pharmacologic neuromuscular blockade

A common misperception is that critically ill patients who receive paralytic therapy will not tolerate enteral nutrition. As a result, some clinicians empirically withhold enteral feedings for critically ill patients who receive neuromuscular blocker pharmacotherapy (NMB). The intent of this review is to examine the evidence regarding enteral feeding tolerance for critically ill patients given NMB. Studies evaluating enteral feeding during paralytic therapy are provided and critiqued. Evidence examining enteral feeding tolerance during NMB is limited. Enteral feeding intolerance is more likely attributable to the underlying illnesses and concurrent opioid analgesia, sedation, and vasopressor therapies. Most critically ill patients can be successfully fed during NMB. Prokinetic pharmacotherapy may be warranted in some patients.

Management of Traumatic Radial and Ulnar Artery Injuries and Risk Factors for Amputation

INTRODUCTION

Traumatic injuries to the radial and/or ulnar arteries represent a subset of arterial injuries. In the absence of injury to both forearm arteries, treatment was historically ligation if perfusion was maintained to the hand via the uninjured vessels or adequate collateral vessels. We sought to determine management of traumatic forearm arterial injuries in 2019 and to identify risk factors for major upper extremity amputation.

METHODS

The American College of Surgeons Trauma Quality Improvement Program database was queried by International Classification of Diseases 10 code for patients with traumatic radial and/or ulnar artery injuries within the year 2019. Patient demographics, Injury Severity Score, time to operating room, type of repair, outcomes, and mortality were collected. Multivariable logistic regression was used to identify risk factors for major upper extremity amputation.

RESULTS

A total of 4048 patients with traumatic radial and/or ulnar artery injuries were identified. A total of 1907 radial artery operations were performed including repair (59%), ligation (29%), and interposition bypass (12%). A total of 1637 ulnar artery operations were completed including repair (67%), ligation (21%), and interposition bypass (12%). Major upper extremity amputation occurred in 0.6%. Older age (adjusted odds ratio [AOR]: 1.014, 95% confidence interval [CI]: 1.004-1.024, P = 0.0048), blunt mechanism (AOR: 2.457, 95% CI: 1.730-3.497, P < 0.0.0001), and ipsilateral radial and ulnar artery injury (AOR: 2.148, 95% CI: 1.298-3.553, P = 0.0029) were associated with major amputation. Surgical revascularization, time to operating room, fasciotomy, and compartment syndrome were not associated with major amputation, but this may be secondary to Type II error.

CONCLUSIONS

In the operating room, radial and ulnar artery injuries were managed more often with restoration of flow versus ligation. Older age, blunt mechanism, and ipsilateral radial and ulnar artery injury were associated with major amputation. Amputation rate was low at 3% overall and 0.6% for amputation of the hand or a more proximal level. Upper extremity fracture, upper extremity nerve injury, and ipsilateral radial and ulnar artery injury were associated with need for revision operation.

Persistent Hypoxia After Blunt Thoracic Trauma due to Flail Tricuspid Valve Leaflet and Patent Foramen Ovale

Structural cardiac injury after blunt trauma is uncommon but usually life-threatening. While tricuspid injury is very rare and potentially lethal, the right heart can accommodate larger volumes and higher pressures in acute tricuspid insufficiency and facilitate initial stabilization prior to definitive valvular repair. ECMO may be used to ameliorate resulting right heart failure. The traumatic force required to cause cardiac structural injury is also associated with pulmonary complications related to pneumothorax, hemothorax, effusion, acute pain secondary to rib fractures, and pulmonary contusions causing hypoxia. We present an unusual case of hypoxia in a trauma patient caused by acute tricuspid regurgitation with pre-existing patent foramen ovale.

Body Mass Index and Pharmacologic Venous Thromboembolism Prophylaxis in Traumatic Brain Injury

INTRODUCTION

Patients with traumatic brain injury (TBI) are at risk for developing venous thromboembolic complications. Previous work suggests venous thromboembolism (VTE) prophylaxis with low molecular weight heparin (LMWH) is protective compared to unfractionated heparin (UH) in trauma patients. The purpose of this study was to evaluate the role of body mass index (BMI) and type of pharmacological VTE prophylaxis in patients who develop VTE with severe TBI.

METHODS

Patients with a severe TBI who received VTE prophylaxis were queried from the 2019 American College of Surgeons Trauma Quality Improvement Program database. Demographics, injury characteristics, timing of VTE prophylaxis, and BMI were collected. Outcome measures include VTE, mortality, and neurosurgical interventions.

RESULTS

Of the 39,520 patients with severe TBI included in the study, 25,671 received LMWH and 13,849 received UH. Multivariable logistic regression found patients with a BMI 25-29.9 kg/m2 (odds ratio [OR] 1.375; 95% confidence interval [CI] 1.180-1.603; P < 0.0001) and a BMI>30 kg/m2 (OR 1.831; 95% CI 1.570-2.137; P < 0.0001) were independent predictors of VTE. Patients with BMI of 25-29.9 kg/m2 (OR 1.145; 95% CI 1.016-1.289; P = 0.0265) have a higher risk of mortality. For every hour delay in initiation to VTE prophylaxis, patients were 0.2% more likely to develop VTE (OR 1.002; 95% CI 1.002-1.003; P < 0.0001). Patients treated with UH were more likely to develop VTE complications (OR 1.085; 95% CI 1.058-1.112; P < 0.0001) and have increased mortality (OR 1.116; 95% CI 1.094-1.139; P < 0.0001), regardless of BMI and time to initiation of prophylaxis, compared to patients treated with LMWH.

CONCLUSIONS

In patients with severe TBI, higher BMI was associated with an increased risk of VTE and death. Delay in VTE prophylaxis initiation was associated with an increased risk of VTE. LMWH had a protective association with VTE.

Epidemiology, repair technique, and predictors of stroke and mortality in penetrating carotid artery injuries

OBJECTIVE

Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI.

METHODS

PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management.

RESULTS

There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality.

CONCLUSIONS

PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality.

Establishing a core outcome set for blunt cerebrovascular injury: an EAST modified Delphi method consensus study

Objectives

Our understanding of blunt cerebrovascular injury (BCVI) has changed significantly in recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature which is not suitable for data pooling. Therefore, we endeavored to develop a core outcome set (COS) to help guide future BCVI research and overcome the challenge of heterogeneous outcomes reporting.

Methods

After a review of landmark BCVI publications, content experts were invited to participate in a modified Delphi study. For round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score the proposed outcomes for importance. Core outcomes consensus was defined as >70% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds, and four rounds of deliberation were performed to re-evaluate the variables not achieving predefined consensus criteria.

Results

From an initial panel of 15 experts, 12 (80%) completed all rounds. A total of 22 items were considered, with 9 items achieving consensus for inclusion as core outcomes: incidence of postadmission symptom onset, overall stroke incidence, stroke incidence stratified by type and by treatment category, stroke incidence prior to treatment initiation, time to stroke, overall mortality, bleeding complications, and injury progression on radiographic follow-up. The panel further identified four non-outcome items of high importance for reporting: time to BCVI diagnosis, use of standardized screening tool, duration of treatment, and type of therapy used.

Conclusion

Through a well-accepted iterative survey consensus process, content experts have defined a COS to guide future research on BCVI. This COS will be a valuable tool for researchers seeking to perform new BCVI research and will allow future projects to generate data suitable for pooled statistical analysis with enhanced statistical power.

Level of evidence

Level IV.

Establishing a core outcomes set for massive transfusion: An Eastern Association for the Surgery of Trauma modified Delphi method consensus study

BACKGROUND

The management of severe hemorrhage has changed significantly over recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature, which is not suitable for data pooling. Therefore, we sought to develop a core outcome set (COS) to help guide future massive transfusion (MT) research and overcome the challenge of heterogeneous outcomes reporting.

METHODS

Massive transfusion content experts were invited to participate in a modified Delphi study. For Round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score proposed outcomes for importance. Core outcomes consensus was defined as >85% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds.

RESULTS

From an initial panel of 16 experts, 12 (75%) completed three rounds of deliberation to reevaluate variables not achieving predefined consensus criteria. A total of 64 items were considered, with 4 items achieving consensus for inclusion as core outcomes: blood products received in the first 6 hours, 6-hour mortality, time to mortality, and 24-hour mortality.

CONCLUSION

Through an iterative survey consensus process, content experts have defined a COS to guide future MT research. This COS will be a valuable tool for researchers seeking to perform new MT research and will allow future trials to generate data that can be used in pooled analyses with enhanced statistical power.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria; Level V.

An Analysis of Injured Patients Treated at Level 1 Trauma Centers Versus Other Centers: A Scoping Review

INTRODUCTION

Trauma systems continue to evolve to create the best outcomes possible for patients who have undergone traumatic injury.

OBJECTIVE

This review aims to evaluate the existing research on outcomes based on field triage to a Level 1 trauma center (L1TC) compared to other levels of hospitals and nontrauma centers.

METHODS

A structured literature search was conducted using PubMed, CINAHL, Embase, and the Cochrane Database. Studies analyzing measures of morbidity, mortality, and cost after receiving care at L1TCs compared to lower-level trauma centers and nontrauma centers in the United States and Canada were included. Three independent reviewers reviewed abstracts, and two independent reviewers conducted full-text review and quality assessment of the included articles.

RESULTS

Twelve thousand five hundred fourteen unique articles were identified using the literature search. 61 relevant studies were included in this scoping review. 95.2% of included studies were national or regional studies, and 96.8% were registry-based studies. 72.6% of included studies adjusted their results to account for injury severity. The findings from receiving trauma care at L1TCs vary depending on severity of injury, type of injury sustained, and patient characteristics. Existing literature suffers from limitations inherent to large de-identified databases, making record linkage between hospitals impossible.

CONCLUSIONS

This scoping review shows that the survival benefit of L1TC care is largest for patients with the most severe injuries. This scoping review demonstrates that further research using high-quality data is needed to elucidate more about how to structure trauma systems to improve outcomes for patients with different severities of injuries and in different types of facilities.

Gastric feeding intolerance in critically ill patients during sustained pharmacologic neuromuscular blockade

BACKGROUND

The purpose of this study was to assess gastric feeding intolerance for critically ill patients who received sustained neuromuscular blocker (NMB) pharmacotherapy.

METHODS

Adult patients (>17 years of age) admitted to the trauma intensive care unit who received continuous intravenous NMB pharmacotherapy (rocuronium, cisatracurium, vecuronium, or pancuronium) for ≥48 h during continuous intragastric enteral nutrition (EN) were retrospectively evaluated. Gastric feeding intolerance was defined by initiation of a prokinetic agent (metoclopramide, erythromycin, or both) for an elevated gastric residual volume (GRV) >300 ml and with distention of the abdomen by physical examination, observation of regurgitation or emesis, temporary discontinuation of EN with low intermittent gastric suctioning, or initiation of parenteral nutrition (PN). Patients were evaluated for gastric feeding intolerance for the first 3 days of combined EN and NMB pharmacotherapy. A P value < 0.05 was considered statistically significant.

RESULTS

Ten patients of the 47 patients (21%) were intolerant to EN during NMB pharmacotherapy. No statistically or clinically relevant differences in patient characteristics were found between patients who tolerated EN vs those who experienced gastric feeding intolerance, except for a higher median maximum GRV of 125 ml (28, 200) vs 300 (250, 400) ml, respectively (P < 0.001). Five patients responded to prokinetic therapy and five required PN.

CONCLUSION

Most patients tolerated intragastric EN during sustained NMB pharmacotherapy. Presence of NMB pharmacotherapy is not an absolute contraindication for EN.

Delayed Tracheostomy After Cervical Fixation is Not Associated With Improved Outcomes: A Trauma Quality Improvement Program Analysis

BACKGROUND

Patients with unstable cervical spine (C-spine) fractures are at a significant risk of respiratory failure. There is no consensus on the optimal timing of tracheostomy in the setting of recent operative cervical fixation (OCF). This study evaluated the impact of tracheostomy timing on surgical site infections (SSIs) in patients undergoing OCF and tracheostomy.

METHODS

Trauma Quality Improvement Program (TQIP) was used to identify patients with isolated cervical spine injuries who underwent OCF and tracheostomy between 2017 and 2019. Early tracheostomy (<7 days from OCF) was compared with delayed tracheostomy (≥7 days from OCF). Logistic regressions identified variables associated with SSI, morbidity, and mortality. Pearson correlations evaluated time to tracheostomy and length of stay (LOS).

RESULTS

Of 1438 patients included, 20 had SSI (1.4%). There was no difference in SSI between early vs delayed tracheostomy (1.6% vs 1.2%, P = .5077). Delayed tracheostomy was associated with increased ICU LOS (23.0 vs 17.0 days, P < .0001), ventilator days (19.0 vs 15.0, P < .0001), and hospital LOS (29.0 vs 22.0 days, P < .0001). Increased ICU LOS was associated with SSI (OR 1.017; CI 0.999-1.032; P = .0273). Increased time to tracheostomy was associated with increased morbidity (OR 1.003; CI 1.002-1.004; P < .0001) on multivariable analysis. Time from OCF to tracheostomy correlated with ICU LOS (r (1354) = .35, P < .0001), ventilator days (r (1312) = .25, P < .0001), and hospital LOS (r (1355) = .25, P < .0001).

CONCLUSION

In this TQIP study, delayed tracheostomy after OCF was associated with longer ICU LOS and increased morbidity without increased SSI. This supports the TQIP best practice guidelines recommending that tracheostomy should not be delayed for concern of increased SSI risk.

Isolated facial fractures transferred for higher level of care

BACKGROUND

Isolated facial fractures (IFF) have been identified as overtriaged injuries in multiple single-center studies. We sought to describe IFF in a national database.

METHODS

The 2019 Trauma Quality Improvement Program database was queried for all patients with facial fractures and Abbreviated Injury Score<1 for other body regions. Descriptive statistics were performed.

RESULTS

Of 1,097,190 trauma patients, 36,077 (3.3%) had IFF. Median age was 39 [26-89], 92% had blunt mechanism, median Glasgow Coma Scale 15 [15-15], and vital signs were normal (ED systolic blood pressure 137 [125-153], ED pulse 86 [73-99]). 0.3% required unplanned intubation. 25.7% underwent operation after a median interval 26.4 [14.4-47.9] hours. IFF patients represented 4.4% of interfacility transfers and were more likely to have been transferred (34.4% vs 25%, p < 0.001). Hospital stay was 3 [2-4] days.

CONCLUSIONS

IFF are rarely surgical emergencies and frequently nonoperative, yet are disproportionately represented among transfers. IFFs may represent an opportunity for outpatient follow-up or telehealth consultation to decrease resource utilization.

Risk factors for clostridium difficile infection in general surgery patients

BACKGROUND

Clostridium Difficile Infection (CDI) is a significant cause of mortality. This study aims to identify predictors of CDI in general surgery patients.

METHODS

Patients who underwent general surgery operations in the 2019 National Surgical Quality Improvement Program database were identified with demographic, intervention, and outcome data abstracted. Patients with CDI and no CDI were compared by univariate analysis. Multivariable logistic regression (MLR) was performed to determine independent predictors of CDI.

RESULTS

Of 436,831 surgical patients, 1,840 patients were diagnosed with CDI (0.4%). Patients with CDI have a higher mortality (2.1% vs 0.76%,p < 0.0001), longer length of stay (7 days vs 1 day, p < 0.0001), and are less likely to undergo a laparoscopic procedure (29.9% vs 37.5%, p < 0.0001). MLR identified older age, emergent operation, increased time to operation, surgical site infection, deep organ space infection, steroid use, metastatic cancer, smoking, and decreased body mass index (BMI) as independent predictors of CDI.

CONCLUSIONS

CDI is rare following general surgery. Infections, delay to operation, and emergency operations are associated with CDI.

Association Between Child Access Prevention and State Firearm Laws With Pediatric Firearm-Related Deaths

INTRODUCTION

We aim to study the association between state child access prevention (CAP) and overall firearm laws with pediatric firearm-related mortality.

METHODS

The Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System was queried for pediatric (aged < 18 y) all-intent (accidental, suicide, and homicide) firearm-related crude death rates (CDRs) among the 50 states from 1999 to 2019. States were into three groups: Always CAP (throughout the 20-year period), Never CAP, and New CAP (enacted CAP during study period). We used the Giffords Law Center Annual Gun Law Scorecard (A, B, C, D, F) to group states into strict (A, B) and lenient (C, D, F) firearm laws. A scatter plot was constructed to display state CDR based on CAP laws by year. The top 10 states by CDR per year were tabulated based on CAP law status. Wilcoxon rank-sum was used to compare CDR between strict and lenient scorecard states in 2019.

RESULTS

There were 12 Always CAP, 21 Never CAP, and 17 New CAP states from 1999 to 2019. No states changed from CAP laws to no CAP laws. Never CAP and New CAP states dominated the high outliers in CDR compared to Always CAP. The top 10 states with the highest CDR per year were most commonly Never CAP. Strict firearm laws states had lower median CDR in 2019 than lenient states (0.79 [0-1.67] versus 2.59 [1.66-3.53], P = 0.007).

CONCLUSIONS

Stricter overall gun laws are associated with three-fold lower all-intent pediatric firearm-related deaths. For 2 decades, the 10 states with the highest CDR were almost universally those without CAP laws. Our findings support the RAND Gun Policy in America initiative's claims on the importance of CAP laws in reducing suicide, unintentional deaths, and violent crime among children, but more research is needed.

Environmental Factors Impacting Wellness in the Trauma Provider

Purpose of Review

The purpose of this review is to evaluate the recent literature on environmental factors impacting wellness for the acute care surgeon. This includes factors influencing physical, mental, and emotional well-being.

Recent Findings

Recent studies have identified challenges to surgeon wellness including increased incidence of sleep deprivation, musculoskeletal pain and injuries, pregnancy complications, moral injury, posttraumatic stress disorder (PTSD), and burnout. Qualitative studies have characterized the surgeon's emotional response to occupational stress, adverse events, and surgical complications. Further descriptive studies offer interventions to prevent moral injury after adverse events and to improve surgeon work environment.

Summary

Acute care surgeons are at increased risk of sleep deprivation, musculoskeletal pain and injury, pregnancy complications, moral injury, PTSD, and burnout. Surgeons experience feelings of isolation and personal devaluation after adverse events or complications, and this may lead to practice limitation and progression to PTSD and/or burnout. Interventions to provide mentorship, peer support, and education may help surgeons recover after adverse events. Further study is necessary to evaluate institution-driven interventional opportunities to improve surgeon well-being and to foster an inclusive and supportive environment.

Severe Short Bowel Syndrome: Prognosis for Nutritional Independence Through Management by a Multidisciplinary Nutrition Service and Surgery

INTRODUCTION

Short bowel syndrome (SBS) is a debilitating condition associated with significant morbidity and mortality. Historically, SBS patients require indefinite parenteral nutrition (PN) and endure lifelong nutritional challenges. The purpose of this study was to review the outcomes, specifically nutritional independence, of a multidisciplinary nutrition service.

METHODS

A retrospective analysis of SBS patients followed by our surgical nutrition service was performed. Patients without 1-year follow-up were excluded. Demographics and nutritional parameters were collected at 4 intervals: initial presentation, 1-year, 2-year, and 5-year follow-up. Short bowel syndrome anatomical subtypes identified through operative reports were characterized as end jejunostomy, jejunocolonic, or jejuno-ileocolonic with ileo-cecal valve intact. Intestinal failure was defined by the requirement of PN, while intestinal insufficiency was defined by enteral support requirement. Clinical outcomes examined included mortality, fistula closure, and nutritional independence.

RESULTS

The study cohort comprised 89 patients, 50 of whom had ≤ 100 cm intestinal length. Mean age was 57 ± 17y, 55 (62%) were female, and median initial intestinal length was 77 [60-120] cm. Short bowel syndrome was complicated by fistulas in 47 (53%) of patients. Overall mortality was 13%, and 67 (75%) were liberated from PN. A total of 58 (65%) underwent operative intervention and fistula closure was achieved in 37 of 47 (79%) patients.

CONCLUSIONS

Short bowel syndrome patients can experience significant benefit under treatment by a multidisciplinary nutrition service. By incorporating surgical intervention, the majority of patients previously relegated to lifelong PN have the opportunity to become nutritionally independent within 5 years.

Reduction in Hypercalcemia Following Readjustment of Target Serum 25-Hydroxy Vitamin D Concentration during Cholecalciferol Therapy in Vitamin D-Deficient Critically Ill Patients

The intent of this study was an evaluation of our effort to reduce the incidence of hypercalcemia in critically ill vitamin D-deficient patients with multiple traumatic injuries given cholecalciferol. Vitamin D deficiency was defined as a serum 25-hydroxy vitamin D concentration (25-OH vit D) of <20 ng/mL. Adult patients (>17 years of age) were given 10,000 IU of cholecalciferol daily with an intended target 25-OH vit D of >19.9 ng/mL. These patients were compared to a historical control group that underwent therapy with a higher target of >29.9 ng/mL. Patients received cholecalciferol via the feeding tube along with enteral nutrition (EN) until the target 25-OH vit D was achieved, EN discontinued, the nutrition support service signed off the patient, or the patient was discharged from the TICU. Patients were included if two consecutive weekly 25-OH vit D were measured. One hundred and three critically ill trauma patients were retrospectively studied. Fifty were given cholecalciferol therapy with the new lower target 25-OH vit D, and 53 were from a historical cohort aiming for the higher target. Hypercalcemia (serum ionized calcium concentration > 1.32 mmol/L) was reduced from 40% (21 out of 53 patients) to 4% (2 out of 50 patients; p < 0.001). None of the hypercalcemic patients were symptomatic. Readjustment of target 25-OH vit D concentration resulted in a ten-fold decrease in the rate of hypercalcemia and improved the safety of cholecalciferol therapy for critically ill patients with traumatic injuries.

Radiographic and Clinical Predictors of Therapeutic Pelvic Angiography

BACKGROUND

Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures.

METHODS

All patients with blunt pelvic fractures who underwent angiography following admission CT scan were identified over a 6-year period. A radiologist reviewed the CT scans to identify potential predictors of pelvic hemorrhage. Patients were stratified by intervention [therapeutic angiography (TA) vs non-therapeutic angiography (NTA)] and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of TA. Youden's index was used to identify the optimal value of selected predictors identified on MLR.

RESULTS

177 patients were identified: 42% underwent TA and 58% underwent NTA. Patients undergoing TA were more likely to have a higher injury burden and greater resuscitative transfusion requirements, display both a brighter blush density on arterial phase CT and a larger % change in arterial to venous phase blush density. The optimal arterial blush density was determined to be 250 HU. MLR identified pre-angiography transfusion requirements (OR 1.175; 95% CI 1.054-1.311, P = .0189) and arterial blush density (OR 1.011; 95% CI 1.005-1.016, P < .0001) as independent predictors of therapeutic angiography.

CONCLUSION

CT imaging remains vital in assessing patients with pelvic fractures and associated hemorrhage following blunt trauma. For patients requiring multiple resuscitative transfusions with CT findings of an arterial blush measuring ≥250 HU, early angiography should be the preferred approach.

Risk factors for stroke in penetrating carotid trauma-An analysis from the PROOVIT Registry

BACKGROUND

Penetrating carotid injuries are associated with an up to 20% risk of stroke. This study evaluated patients in the American Association for Surgery of Trauma PROspective Observational Vascular Injury Trial, with the aim of determining factors associated with stroke and stroke or death.

METHODS

Penetrating extracranial carotid injuries in the American Association for Surgery of Trauma PROspective Observational Vascular Injury Trial registry from 2012 to 2020 were queried. Isolated external carotid injuries were excluded. Patients with documented postinjury in-hospital stroke were compared with those without. Significant predictors (p < 0.1) for stroke and stroke or death on univariate analysis were included in multivariate analyses.

RESULTS

One hundred two patients from 17 institutions were included. Mean age was 35 ± 18 years, and 80% were male. Average Glasgow Coma Scale (GCS) score on presentation was 9 ± 5, with an Injury Severity Score [ISS] of 22 ± 13. Operative management occurred in 51% of patients who were significantly more hypotensive (systolic blood pressure: 109 vs. 131 mm Hg; p = 0.015) with a lower initial pH (7.17 vs. 7.31; p = 0.001) and presented with hard signs of vascular injury (74% vs. 26%; p < 0.001). Overall stroke rate was 17% (23% operative vs. 10% nonoperative, p = 0.076). Rate of stroke or death was 27% (64% operative and 36% nonoperative). On multivariate analysis, lower GCS (p = 0.05) and completion angiography (p = 0.04) were associated with stroke. Likewise lower GCS (p = 0.015) and ISS (p = 0.04) were associated with stroke or death.

CONCLUSION

Penetrating carotid trauma undergoing operative management had a stroke rate of 23%. Low GCS on arrival and need for completion angiography are independently associated with postinjury in-hospital stroke, whereas low GCS on arrival and ISS were associated with stroke or death. The ideal treatment strategy remains elusive, thus a dedicated multicenter study may help to achieve higher fidelity data on this rare but devastating injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological, Level III.

A core outcome set for damage control laparotomy via modified Delphi method

OBJECTIVES

Damage control laparotomy (DCL) remains an important tool in the trauma surgeon's armamentarium. Inconsistency in reporting standards have hindered careful scrutiny of DCL outcomes. We sought to develop a core outcome set (COS) for DCL clinical studies to facilitate future pooling of data via meta-analysis and Bayesian statistics while minimizing reporting bias.

METHODS

A modified Delphi study was performed using DCL content experts identified through Eastern Association for the Surgery of Trauma (EAST) 'landmark' DCL papers and EAST ad hoc COS task force consensus.

RESULTS

Of 28 content experts identified, 20 (71%) participated in round 1, 20/20 (100%) in round 2, and 19/20 (95%) in round 3. Round 1 identified 36 potential COS. Round 2 achieved consensus on 10 core outcomes: mortality, 30-day mortality, fascial closure, days to fascial closure, abdominal complications, major complications requiring reoperation or unplanned re-exploration following closure, gastrointestinal anastomotic leak, secondary intra-abdominal sepsis (including anastomotic leak), enterocutaneous fistula, and 12-month functional outcome. Despite feedback provided between rounds, round 3 achieved no further consensus.

CONCLUSIONS

Through an electronic survey-based consensus method, content experts agreed on a core outcome set for damage control laparotomy, which is recommended for future trials in DCL clinical research. Further work is necessary to delineate specific tools and methods for measuring specific outcomes.

LEVEL OF EVIDENCE

V, criteria.

A core outcome set for resuscitative endovascular balloon occlusion of the aorta: A consensus based approach using a modified Delphi method

BACKGROUND

The utilization of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma has grown exponentially in recent years. However, inconsistency in reporting of outcome metrics related to this intervention has inhibited the development of evidence-based guidelines for REBOA application. This study sought to attain consensus on a core outcome set (COS) for REBOA.

METHODS

A review of "landmark" REBOA articles was performed, and panelists (first and senior authors) were contacted for participation in a modified Delphi study. In round 1, panelists provided a list of potential core outcomes. In round 2, using a Likert scale (1 [not important] to 9 [very important]), panelists scored the importance of each potential outcome. Consensus for core outcomes was defined a priori as greater than 70% of scores receiving 7 to 9 and less than 15% of scores receiving 1 to 3. Feedback was provided after round 2, and a third round was performed to reevaluate variables not achieving consensus and allow a final "write-in" round by the experts.

RESULTS

From 17 identified panelists, 12 participated. All panelists (12 of 12, 100%) participated in each subsequent round. Panelists initially identified 34 unique outcomes, with two outcomes later added upon write-in request after round 2. From 36 total potential outcomes, 20 achieved consensus as core outcomes, and this was endorsed by 100% of the participants.

CONCLUSION

Panelists successfully achieved consensus on a COS for REBOA-related research. This REBOA-COS is recommended for all clinical trials related to REBOA and should help enable higher-quality study designs, valid aggregation of published data, and development of evidence-based practice management guidelines.

LEVEL OF EVIDENCE

Diagnostic test or criteria, level V.

TRIAL REGISTRATION

Core Outcomes in Trauma Surgery: Development of a Core Outcome Set for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) http://www.comet-initiative.org/Studies/Details/1709.

Machine Learning and Artificial Intelligence for Surgical Decision Making

Background: The use of machine learning (ML) and artificial intelligence (AI) in medical research continues to grow as the amount and availability of clinical data expands. These techniques allow complex interpretation of data and capture non-linear relations not immediately apparent by classic statistical techniques. Methods: This review of the ML/AI literature provides a brief overview for practicing surgeons and clinicians of the current and future roles these methods will have within surgical infection research. Results: A conceptual overview of the techniques is provided along with concrete examples in the surgical infections literature. Further examples of ML/AI techniques in clinical decision support as well as therapy discovery with model-based deep reinforcement learning are illustrated. Conclusions: Artificial intelligence and ML are important and increasingly utilized techniques within the expanding body of surgical infection research. This article provides a minimal baseline literacy in ML/AI to be able to view such projects in an appropriately critical fashion.

Discordance in Appendicitis Grading and the Association with Outcomes: A Post-Hoc Analysis of an EAST Multicenter Study

BACKGROUND

The American Association for the Surgery of Trauma (AAST) appendicitis severity grading criteria use independent subscales for radiologists (Rad), surgeons (Surg), and pathologists (Path). We reviewed the EAST Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database to determine rates of discordance and clinical consequences of inaccuracy.

MATERIALS AND METHODS

A confusion matrix was constructed for pairs among Rad, Surg, and Path. Accuracy was reported using chronologically latest diagnosis as gold standard. "Concordance" (C) was achieved when both agreed on the severity grade and "Discordance"(D) when they disagreed. A composite endpoint("COMP"= 30-d incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED[Emergency Department] visit, hospital readmission, and mortality) was compared between C versus D groups via χ² test with Bonferroni correction to define statistical significance(P = 0.05/9 = 0.005).

RESULTS

For each pair and diagnosis, subjects were categorized as C or D and compared for the incidence of COMP. Incidence of COMP for Surg and/or Path in C versus D: 16% versus. 26% (p = 0.006, NS by Bonferroni) for acute (A), 39% versus 33% (p = 0.39) for gangrenous (G), and 48% versus 37% (p = 0.035, NS by Bonferroni) for perforated (P). For Rad and/or Path in C versus. D: 17% versus 42% (p < 0.001) for A, 27% versus 31% (p = 0.95) for G, and 56% versus 48% (p = 0.48) for P. For C versus D: 17% versus 40% (p < 0.001) for A, 36% versus 26% (p = 0.43) for G, and 51% versus 39% (p = 0.29) for P.

CONCLUSIONS

In appendicitis treated by appendectomy, surgeons are most accurate at diagnosing acute appendicitis and least accurate at diagnosing gangrenous. Radiologists are less accurate for all categories. When the surgeon is wrong, clinical outcomes are not significantly worse. However, when the radiologist is wrong about acute appendicitis, patients have worse clinical outcomes.

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries

BACKGROUND

Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time.

METHODS

Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate.

RESULTS

Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs.

CONCLUSION

Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice.

LEVEL OF EVIDENCE

Retrospective diagnostic/therapeutic study, level III.

Impact of Delay in Appendectomy on the Outcome of Appendicitis: A Post Hoc Analysis of an EAST Multicenter Study

Background: Association between time-to-appendectomy and clinical outcomes is controversial with conflicting data regarding risk of perforation. The purpose of this study was to explore the associations between in-hospital delay in treatment of simple appendicitis with the incidence of complicated appendicitis discovered at appendectomy. Methods: The Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG) database was queried and patients with acute appendicitis diagnosed on imaging were included. Upgrade was defined as gangrenous or perforated finding at appendectomy. Time intervals from emergency department (ED) triage to appendectomy were recorded in six-hour groups. Upgrade percentage for each group was presented and rates of a composite end point (30-day incidence of surgical site infection, abscess, wound complication, Clavien-Dindo complication, secondary intervention, ED visit, hospital re-admission, and mortality) were compared with Bonferroni correction to determine statistical significance (p = 0.05/9 = 0.005). Results: Of 3,004 included subjects, 484 (16%) experienced upgrade at appendectomy. Upgrade rates (%, 95% confidence interval [CI]) were: group 0-6 hours, 17% (95% CI, 14-19); group 6-11 hours, 15% (95% CI, 13-17%); group 12-17 hours, 16% (95% CI, 13-19); group 18-23 hours, 17% (95% CI, 12-23); group 24-29 hours, 30% (95% CI, 20-43); and group 30+ hours, 24% (95% CI, 14-37) (p = 0.014, NS by Bonferroni). Of 484 subjects with upgrade, 200 (41%; 95% CI, 37-46) had a worse composite outcome compared with 518 (21%; CI, 19-22) of 2,520 subjects with no upgrade (p < 0.001). The upgrade group was older (49 ± 17 years vs 39 ± 16 years), had a higher Charlson comorbidity index (CCI; 1.6 ± 1.9 vs 0.7 ± 1.4) and was more likely to have positive smoking history (20% vs 14%), and prior surgery (30% vs 22%; p < 0.001). Conclusions: We propose that ≥24-hour delay from ED triage to appendectomy is not associated with increased rate of severity upgrade from simple to complicated appendicitis. When upgrade occurs, it is correlated with older age, higher CCI, smoking history, and prior surgery and is associated with worse clinical outcomes.

Transfusion-Related Hypocalcemia After Trauma

BACKGROUND

Hypocalcemia is cited as a complication of massive transfusion. However, this is not well studied as a primary outcome in trauma patients. Our primary outcome was to determine if transfusion of packed red blood cells (pRBC) was an independent predictor of severe hypocalcemia (ionized calcium ≤ 3.6 mg/dL).

METHODS

Retrospective, single-center study (01/2004-12/2014) including all trauma patients ≥ 18 yo presenting to the ED with an ionized calcium (iCa) level drawn. Variables extracted included demographics, interventions, outcomes, and iCa. Regression models identified independent risk factors for severe hypocalcemia (SH).

RESULTS

Seven thousand four hundred and thirty-one included subjects, 716 (9.8%) developed SH within 48 h of admission. Median age: 39 (Range: 18-102), systolic blood pressure: 131 (IQR: 114-150), median Glasgow Coma Scale (GCS): 15 (IQR: 10-15), Injury Severity Score (ISS): 14 (IQR: 9-24). SH patients were more likely to have depressed GCS (13 vs 15, p < 0.0001), hypotension (23.2% vs 5.1%, p < 0.0001) and tachycardia (57.0% vs 41.9%, p < 0.0001) compared to non-SH patients. They also had higher emergency operative rate (71.8% vs 29%, p < 0.0001) and higher blood administration prior to minimum iCa [pRBC: (8 vs 0, p < 0.0001), FFP: (4 vs 0, p < 0.0001), platelet: (1 vs 0, p < 0.0001)]. Multivariable analysis revealed penetrating mechanism (AOR: 1.706), increased ISS (AOR: 1.029), and higher pRBC (AOR: 1.343) or FFP administered (AOR: 1.097) were independent predictors of SH. SH was an independent predictor of mortality (AOR: 2.658). Regression analysis identified a significantly higher risk of SH at pRBC + FFP administration of 4 units (AOR: 18.706, AUC:. 897 (0.884-0.909).

CONCLUSION

Transfusion of pRBC is an independent predictor of SH and is associated with increased mortality. The predicted probability of SH increases as pRBC + FFP administration increases.

Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix wider than 10 mm on computed tomography scan: A post hoc analysis of an EAST multicenter study

BACKGROUND

The incidence of underlying malignancy in appendicitis ranges between 0.5% and 1.7%. We sought to identify the subset of patients with appendicitis who are at increased risk of appendiceal malignancy.

METHODS

Using the Eastern Association for the Surgery of Trauma Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, we included all patients from 28 centers undergoing immediate, delayed, or interval appendectomy between 2017 and 2018. Univariate then multivariable analyses were performed to compare patients with and without malignancy and to identify independent demographic, clinical, laboratory, and/or radiological predictors of malignancy. Akaike information criteria for regression models were used to evaluate goodness of fit.

RESULTS

A total of 3,293 patients were included. The median age was 38 (27-53) years, and 46.5% were female patients. On pathology, 48 (1.5%) had an underlying malignancy (adenocarcinoma [60.4%], neuroendocrine [37.5%], and lymphoma [2.1%]). Patients with malignancy were older (56 [34.5-67] vs 37 [27-52] years, P < .001), had longer duration of symptoms before presentation (36-41 vs 18-23 hours, P = .03), and were more likely to have a phlegmon on imaging (6.3% vs 1.3%, P = .03). Multivariable analyses showed that an enlarged appendiceal diameter was independently associated with malignancy (odds ratio = 1.06, 95% confidence interval = 1.01-1.12; P = .01). The incidence of malignancy in patients >40 years with an appendiceal diameter >10 mm on computed tomography was 2.95% compared with 0.97% in patients ≤40 years old with appendiceal diameter ≤10 mm. The corresponding risk ratio for that population was 3.03 (95% confidence interval: 1.24-7.42; P = .02).

CONCLUSION

The combination of age >40 and an appendiceal diameter >10 mm is associated with a greater than 3-fold increased risk of malignancy in patients presenting with appendicitis.

Descriptive Analysis of Federal and State Interventional Pain Malpractice Litigation in the United States: A Pilot Investigation

BACKGROUND

The aim of this study was to examine and appreciate characteristics of malpractice lawsuits brought against interventional pain specialists.

OBJECTIVES

To examine and appreciate characteristics of malpractice lawsuits brought against interventional pain specialists.

STUDY DESIGN

Retrospective review.

SETTING

Jury verdicts and settlement reports of state and federal malpractice cases involving interventional pain practitioners from January 1, 1988, to January 1, 2018 were gathered from the Westlaw online legal database.

METHODS

Jury verdicts and settlement reports of state and federal malpractice cases involving interventional pain practitioners from January 1, 1988, to January 1, 2018 were gathered from the Westlaw online legal database. Data collected for each case included year, state, patient age, patient gender, defendant specialty, legal outcome, award amount, alleged cause of malpractice, and factors in plaintiff's decision to file. After elimination of duplicates and applying inclusion/exclusion criteria to our initial search yielding over 1,500 cases, a total of 82 cases were included in this study.

RESULTS

A total of 57.3% of cases resulted in a jury verdict in favor of the defendant, whereas 41.5% favored the plaintiff. When comparing cases that were performed in the operating room to cases performed outside the operating room, we found the jury verdicts to favor the plaintiff 83.3% of the time for operating room procedures (P = 0.003). In other words, interventional pain practitioners were more likely to be found at fault for complications from procedures performed in the operating room. To eliminate confounders, a logistical regression was performed and confirmed operating room procedures were an independent predictor of a verdict awarded to the plaintiff (P = 0.008). The median amount awarded to the plaintiff for all cases was $333,000, and the single highest award amount was $36,636,288. The median payout for operating room procedures was $450,000 (P = 0.010), which was significantly different from the median payout for nonoperating room procedures. Procedure categorization demonstrated a statistically significant difference in jury verdicts (P = 0.01411) and procedural error was the leading reason for pursuing litigation, followed by lack of informed consent and unnecessary procedure performed.

LIMITATIONS

There is more than one database that captures medicolegal claims brought against practitioners. Westlaw, which has been previously utilized by other studies, is only one of them and the extent to which overlap exists in unclear. For each, data input are not necessarily consistent and data capture are not complete. As a result, there could exist a skew toward more severe complications and the details of individual cases likely vary. During data extraction, we found that all details of the procedure were not always included. For example, not all cases specified the type of injectate utilized for epidural injection (i.e., local anesthetic, steroid, mixture, and others) or route of injection (i.e., transforaminal vs. interlaminar). Moreover, as previously mentioned, cases that are settled out of court or finalized prior to trial are not necessarily reported by the Westlaw database, and therefore were not always included in our data search.

CONCLUSIONS

Overall, interventional pain medicine physicians were favored by jury verdicts for malpractice claims. However, when filtering by procedure or setting, jury verdicts favored the plaintiff in some cases.

KEY WORDS

Interventional pain, medical, malpractice, anesthesiology.

Rapid Diagnosis of Altered Mental Status in Home Parenteral Nutrition Patient

This report describes the application of a routine lab test to confirm a diagnosis of hypernatremia suspected to be secondary to an error in parenteral nutrition compounding. The novel aspect of this case is the use of the "urine electrolytes" laboratory test to verify that the electrolyte concentration of the mixture is consistent with what was printed on the bag label.

Early Hypermetabolism is Uncommon in Trauma Intensive Care Unit Patients

BACKGROUND

Classic experiments demonstrating hypermetabolism after major trauma were performed in a different era of critical care. We aim to describe the modern posttraumatic metabolic response in the trauma intensive care unit (TICU).

METHODS

This prospective observational study enrolled TICU mechanically ventilated adults (aged ≥18) from 3/2018-2/2019. Multiple, daily resting energy expenditure (REE) measurements were recorded. Basal energy expenditure (BEE) was calculated by the Harris-Benedict equation. Hypometabolism was defined as average daily REE < 0.85*BEE and hypermetabolism defined as average daily REE > 1.15*BEE. Demographics, interventions, and clinical outcomes were abstracted. Descriptive statistics and multivariable logistical regression models evaluating demographics with the outcome variable of hypermetabolism for the first 3 days ("sustained hypermetabolism") were performed, along with group-based trajectory modeling (GBTM).

RESULTS

Fifty-five patients were analyzed: median age was 38 (28-56) years; 38 (69%) were male; body mass index (kg/m² ) was 28 (26-32); and Injury Severity Score was 27 (19-34), with (38 [71%] blunt, 8 [15%] penetrating, 7 [13%] burn) injury mechanism. Overall, 19 (35%) had hypermetabolism on day 1 ("immediate hypermetabolism"), and 11 (21%) had sustained hypermetabolism for the first 3 days. Logistic regression analysis identified penetrating mechanism (adjusted odds ratio [AOR], 16.4; 95% CI, 1.9-199.6; p = .015), burn mechanism (AOR, 11.1; 95% CI, 1.3-116.8; p =.029), and maximum temperature (AOR, 4.2; 95% CI, 1.3-20.3; p= .041) as independent predictors of sustained hypermetabolism. GBTM identified 4 nutrition phenotypes, with 2 hyperconsumptive phenotypes associated with increased risk of malnutrition at discharge.

CONCLUSION

Only a minority of injured patients is hypermetabolic in the first week after injury. Elevated temperature, penetrating mechanism, and burn mechanism are independently associated with sustained hypermetabolism. Hyperconsumptive phenotype patients are more likely to develop malnutrition during hospitalization.

Comparing Machine Learning Algorithms for Predicting Acute Kidney Injury

Prior studies have used vital signs and laboratory measurements with conventional modeling techniques to predict acute kidney injury (AKI). The purpose of this study was to use the trend in vital signs and laboratory measurements with machine learning algorithms for predicting AKI in ICU patients. The eICU Collaborative Research Database was queried for five consecutive days of laboratory measurements per patient. Patients with AKI were identified and trends in vital signs and laboratory values were determined by calculating the slope of the least-squares-fit linear equation using three days for each value. Different machine learning classifiers (gradient boosted trees [GBT], logistic regression, and deep learning) were trained to predict AKI using the laboratory values, vital signs, and slopes. There were 151,098 ICU stays identified and the rate of AKI was 5.6 per cent. The best performing algorithm was GBT with an AUC of 0.834 ± 0.006 and an F-measure of 42.96 per cent ± 1.26 per cent. Logistic regression performed with an AUC of 0.827 ± 0.004 and an F-measure of 28.29 per cent ± 1.01 per cent. Deep learning performed with an AUC of 0.817 ± 0.005 and an F-measure of 42.89 per cent ± 0.91 per cent. The most important variable for GBT was the slope of the minimum creatinine (30.32%). This study identifies the best performing machine learning algorithms for predicting AKI using trends in laboratory values in ICU patients. Early identification of these patients using readily available data indicates that incorporating machine learning predictive models into electronic medical record systems is an inevitable requisite for improving patient outcomes.

Multi-Center Outcomes of Chlorhexidine Oral Decontamination in Intensive Care Units

Background: The efficacy of oral chlorhexidine (oCHG) for decontamination in intensive care unit (ICU) patients is controversial. The purpose of this study was to evaluate the effect of oCHG decontamination on the incidence of pneumonia, sepsis, and death in ICU patients. Methods: The Philips eICU database version 2.0 was queried for patients admitted to the ICU for ≥48 hours in 2014-2015. The primary outcome of interest was death in the ICU. Secondary outcomes were a diagnosis of pneumonia or sepsis. Patients with pneumonia or sepsis diagnosed within the first 48 hours of ICU admission were excluded from the outcome analyses. Univariable analysis was performed comparing age, gender, race, severity of illness scores, hospital characteristics, and oCHG order. Multivariable logistic regression was performed using univariable results with p < 0.05. Results: Of the 64,904 patients from 186 hospitals, 22.1% (n = 14,333) had oCHG ordered. The overall mortality rate was 6.9% (n = 4,449) and the mortality rate in patients receiving oCHG was 10.6% (n = 1,518; p < 0.001). After controlling for confounding factors, oCHG remained an independent risk factor for death (odds ratio [OR] 1.25; 95% confidence interval [CI] 1.16-1.34). After excluding patients with an early diagnosis of pneumonia, the overall pneumonia incidence was 2.6% (n = 1,431) and the incidence in patients having oCHG was 4.2% (n = 517; p < 0.001). However, multivariable logistic regression revealed no significant difference in the risk of pneumonia with oCHG (OR 0.97; 95% CI 0.85-1.09). After excluding patients with an early diagnosis of sepsis, the overall rate of sepsis was 1.8% (n = 949) and for patients with oCHG, the rate was 3.3% (n = 388; p < 0.001). After controlling for other confounders, oCHG remained an independent risk factor for sepsis (OR 1.37; 95% CI 1.19-1.59). Conclusions: A chlorhexidine mouthwash order is associated with increased odds of death and sepsis without decreased odds of pneumonia in a heterogeneous cohort of ICU patients. Additional studies are needed to understand better the effect of oCHG on outcomes.

Impact of ligation versus repair of isolated popliteal vein injuries on in-hospital outcomes in trauma patients

BACKGROUND

Popliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery injuries (PAI), there is little available evidence regarding popliteal venous injuries (PVI). As such, substantial debate remains regarding the benefit of repair over ligation of PVI. The objectives of this study were to compare in-hospital outcomes of repair versus ligation of isolated PVI, as well as to determine nonvascular factors associated with worse outcomes.

METHODS

Patients in the National Trauma Databank from 2007 to 2014 with at least one PVI were evaluated. First, patients with concomitant PVI and PAI were compared with patients with isolated PVI. Second, outcomes were compared between ligation and repair of isolated PVI. To limit the impact of concomitant injuries and focus on the impact of venous injury management, we defined isolated PVI as cases without concomitant PAI and with Abbreviated Injury Scale severity score of less than 3 for all body regions other than lower extremity. Patients dead on arrival and those with less than 18 years of age were excluded. The primary outcomes were in-hospital mortality, amputation, and in-hospital amputation-free survival (AFS). Secondary outcomes included lower extremity compartment syndrome, fasciotomy, acute kidney injury, pulmonary embolism, deep venous thrombosis, and inferior vena cava filter placement.

RESULTS

Overall, 1819 patients (0.03%) had a PVI and after exclusion 1213 met the criteria for initial analysis. Of those, 308 had isolated PVI, and 905 had combined PVI and PAI. Patients with combined PVI and PAI had higher rates of amputation (15.2% vs 6.8%; P < .001), fasciotomy (64.5% vs 30.8%; P < .001), compartment syndrome (14.8% vs 8.8%; P = .006), and a lower AFS (82.9% vs 91.8%; P < .001) than patients with isolated PVI. There was no difference in in-hospital mortality, amputation, or in-hospital AFS between ligation and repair of isolated PVI. On multivariable logistic regression of isolated PVI, ligation was not independently associated with in-hospital AFS, amputation, or mortality.

CONCLUSIONS

Ligation of isolated PVI was not an independent predictor of in-hospital mortality, lower extremity amputation, or in-hospital AFS. Ligation also did not result in higher rates of fasciotomy, acute kidney injury, or pulmonary embolism.

Comparing Machine Learning Algorithms for Predicting Acute Kidney Injury

Prior studies have used vital signs and laboratory measurements with conventional modeling techniques to predict acute kidney injury (AKI). The purpose of this study was to use the trend in vital signs and laboratory measurements with machine learning algorithms for predicting AKI in ICU patients. The eICU Collaborative Research Database was queried for five consecutive days of laboratory measurements per patient. Patients with AKI were identified and trends in vital signs and laboratory values were determined by calculating the slope of the least-squares-fit linear equation using three days for each value. Different machine learning classifiers (gradient boosted trees [GBT], logistic regression, and deep learning) were trained to predict AKI using the laboratory values, vital signs, and slopes. There were 151,098 ICU stays identified and the rate of AKI was 5.6 per cent. The best performing algorithm was GBT with an AUC of 0.834 ± 0.006 and an F-measure of 42.96 per cent ± 1.26 per cent. Logistic regression performed with an AUC of 0.827 ± 0.004 and an F-measure of 28.29 per cent ± 1.01 per cent. Deep learning performed with an AUC of 0.817 ± 0.005 and an F-measure of 42.89 per cent ± 0.91 per cent. The most important variable for GBT was the slope of the minimum creatinine (30.32%). This study identifies the best performing machine learning algorithms for predicting AKI using trends in laboratory values in ICU patients. Early identification of these patients using readily available data indicates that incorporating machine learning predictive models into electronic medical record systems is an inevitable requisite for improving patient outcomes.

Hit by a Train: Injury Burden and Clinical Outcomes

BACKGROUND

Few data exist regarding the train vs. pedestrian (TVP) injury burden and outcomes.

OBJECTIVE

This study aimed to examine the epidemiology and outcomes associated with TVP injuries.

METHODS

This is a retrospective National Trauma Databank study (January 2007 to July 2012) including trauma patients sustaining TVP injury. Demographics, injury data, interventions, and outcomes were abstracted. Patients injured by a train were compared to patients who sustained an automobile vs. pedestrian (AVP) injury.

RESULTS

Of the 152,631 patients struck by ground transportation during the study time frame, 1863 (1.2%) were TVP. Median TVP age was 38 years (interquartile range [IQR] 24-50 years), 81.6% were male, median Injury Severity Score (ISS) was 13 (IQR 6-24). TVP patients were more severely injured (ISS 13 vs. 9; p < 0.001) and required more proximal amputations (13.4% vs. 0.2%; p < 0.001) and cavitary operations (18.2% vs. 2.8%; p < 0.001). TVP patients had higher rates of intensive care unit admission, mechanical ventilation and transfusion, longer length of stay, and higher in-hospital mortality. On multivariable logistical regression, TVP was an independent predictor for higher injury burden, ISS ≥25 (adjusted odds ratio [AOR] 1.650), immediate operative need (AOR 7.535), and complications (AOR 1.317).

CONCLUSIONS

TVP is associated with a significant injury burden. These patients have a significantly higher need for immediate operation and more complicated hospital course.