Resuscitative transesophageal echocardiography during the acute resuscitation of trauma: A retrospective observational study

BACKGROUND

Resuscitative transesophageal echocardiography (TEE) is an emerging POCUS modality that can be used to guide trauma resuscitation.

METHODS

Trauma patients who underwent TEE within 24 h of admission from 2013 to 2022 were prospectively identified. We retrospectively analyzed resuscitative TEE reports and patient charts in duplicate.

RESULTS

29 providers performed TEE for 54 acute trauma patients. 28 (52%) died in hospital; 33 (61%) required operative intervention (<24 h). Median injury severity score was 29 [IQR 22-43]. The most common indications for TEE were hemodynamic instability (34, 63%), inadequate windows for transthoracic echocardiography (14, 26%) and cardiac arrest (11, 20%). There were no identified complications. A new diagnosis was made in 31 (57%) cases: most commonly right ventricular dysfunction (10, 19%), pericardial effusion (9, 17%), and hypovolemia (6, 11%). TEE ruled out major cardiac injury in 83% of cases. TEE changed resuscitative strategy, in 17 (32%) patients, diagnostic imaging approach in 6 (11%) patients, procedural or operative approach in 5 (9%) patients and disposition from the trauma bay in 4 (7%) patients.

CONCLUSION

Resuscitative TEE during acute trauma care has an additional diagnostic yield to existing diagnostic pathways and may impact definitive management for some patients in the trauma bay.

Delayed Versus Early Laparoscopic Appendectomy for Adult Patients With Acute Appendicitis: A Randomized Controlled Trial

OBJECTIVE

To assess whether delaying appendectomy until the following morning is non-inferior to immediate surgery in those with acute appendicitis presenting at night.

BACKGROUND

Despite a lack of supporting evidence, those with acute appendicitis who present at night frequently have surgery delayed until the after morning.

METHODS

The delay trial is a noninferiority randomized controlled trial conducted between 2018 and 22 at 2 tertiary care hospitals in Canada. Adults with imaging confirmed acute appendicitis who presented at night (8:00 pm -4:00 am ). Delaying surgery until after 6:00 am was compared with immediate surgery. The primary outcome was 30-day postoperative complications. An a prior noninferiority margin of 15% was deemed clinically relevant.

RESULTS

One hundred twenty-seven of the planned 140 patients were enrolled in the Delayed Versus Early Laparoscopic Appendectomy (DELAY) trial (59 in the delayed group and 68 in the immediate group). The two groups were similar at baseline. The mean time between the decision to operate and surgery was longer in the delayed group (11.0 vs 4.4 hours, P < 0.0001). The primary outcome occurred in 6/59 (10.2%) of those in the delayed group versus 15/67 (22.4%) of those in the immediate group ( P = 0.07). The difference between groups met the a priori noninferiority criteria of +15% (risk difference -12.2%, 95% CI: -24.4% to +0.4%, test of noninferiority P < 0.0001).

CONCLUSIONS

The DELAY study is the first trial to assess delaying appendectomy in those with acute appendicitis. We demonstrate the noninferiority of delaying surgery until the after morning.

Are retrievable vena cava filters placed in trauma patients really retrievable?

PURPOSE

Concerns have arisen regarding the use of retrievable inferior vena cava filters (rIVCFs) in trauma patients due to increasing reports of low retrieval rates. We hypothesized that complete follow-up with a dedicated trauma nurse practitioner would be associated with a higher rate of retrievability. This study was undertaken to determine the rate of retrievability of rIVCFs placed in a Canadian Lead Trauma Centre, and to compare the rate of retrievability in our trauma population to our non-trauma patients.

METHODS

We performed a retrospective cohort study of all patients with rIVCF placed between Jan 1 2000 and June 30 2014. Data were collected on demographics, indication for filter placement, retrieval status, and reasons for non-retrieval. Comparison was made between trauma patients and non-trauma patients.

RESULTS

A total of 374 rIVCFs were placed (61 in trauma patients and 313 in non-trauma patients) and follow-up was complete for the entire cohort. Filter retrieval was achieved in 86.9 % of trauma patients. Reasons for non-retrieval were technical in two patients, and death before retrieval in six patients. Retrieval was successful in 48.9 % of non-trauma patients.

CONCLUSIONS

This study demonstrates that rIVCFs can be successfully retrieved amongst trauma patients. We demonstrated a higher rate of successful retrieval amongst trauma patients than non-trauma patients in our institution. Careful patient follow-up may play a role in successful retrieval of rIVCFs.

Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?

BACKGROUND

We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation.

METHODS

A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005-2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled.

RESULTS

The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage.

CONCLUSION

Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.