Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome

BACKGROUND

Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy adverse effect profile. Recently, benzodiazepine-sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols use phenobarbital, while ours primarily uses gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population.

METHODS

In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (conventional) and after (benzodiazepine-sparing [BS]) protocol implementation were compared. Outcomes examined include morphine milligram equivalent dosing rates and lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay, intensive care unit length of stay, and ventilator days.

RESULTS

A total of 387 conventional and 134 benzodiazepine sparing patients were compared. Injury Severity Score (13 vs. 16, p = 0.10) and admission alcohol levels (99 vs. 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs. 1.5, p = 0.04). While mean morphine milligram equivalent per day was not different between groups (31.5 vs. 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs. 0.2, p < 0.01). Length of stay and vent days were not different between the groups.

CONCLUSION

Implementation of a benzodiazepine-sparing pathway that uses primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Use of magnetic source imaging to assess recovery after severe traumatic brain injury-an MEG pilot study

Rationale

Severe TBI (sTBI) is a devastating neurological injury that comprises a significant global trauma burden. Early comprehensive neurocritical care and rehabilitation improve outcomes for such patients, although better diagnostic and prognostic tools are necessary to guide personalized treatment plans.

Methods

In this study, we explored the feasibility of conducting resting state magnetoencephalography (MEG) in a case series of sTBI patients acutely after injury (~7 days), and then about 1.5 and 8 months after injury. Synthetic aperture magnetometry (SAM) was utilized to localize source power in the canonical frequency bands of delta, theta, alpha, beta, and gamma, as well as DC-80 Hz.

Results

At the first scan, SAM source maps revealed zones of hypofunction, islands of preserved activity, and hemispheric asymmetry across bandwidths, with markedly reduced power on the side of injury for each patient. GCS scores improved at scan 2 and by scan 3 the patients were ambulatory. The SAM maps for scans 2 and 3 varied, with most patients showing increasing power over time, especially in gamma, but a continued reduction in power in damaged areas and hemispheric asymmetry and/or relative diminishment in power at the site of injury. At the group level for scan 1, there was a large excess of neural generators operating within the delta band relative to control participants, while the number of neural generators for beta and gamma were significantly reduced. At scan 2 there was increased beta power relative to controls. At scan 3 there was increased group-wise delta power in comparison to controls.

Conclusion

In summary, this pilot study shows that MEG can be safely used to monitor and track the recovery of brain function in patients with severe TBI as well as to identify patient-specific regions of decreased or altered brain function. Such MEG maps of brain function may be used in the future to tailor patient-specific rehabilitation plans to target regions of altered spectral power with neurostimulation and other treatments.

Reclaiming the management of common duct stones in acute care surgery

BACKGROUND

Acute care surgery (ACS) is well positioned to manage choledocholithiasis at the time of laparoscopic cholecystectomy, but barriers to laparoscopic common bile duct exploration (LCBDE) include experience and the perceived need for specialized equipment. The technical complexity of this pathway is generally seen as challenging. As such, LCBDE is historically relegated to the "enthusiast." However, a simplified, effective LCBDE technique as part of a "surgery first" strategy could drive wider adoption in the specialty most often managing these patients. To determine efficacy and safety, we sought to compare our initial ACS-driven experience with a simple, fluoroscopy-guided, catheter-based LCBDE approach during laparoscopic cholecystectomy (LC) to LC with endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

We reviewed ACS patients who underwent LCBDE or LC + ERCP (pre-/postoperative) at a tertiary care center in the 4 years since starting this surgery first approach. Demographics, outcomes, and length of stay (LOS) were compared on an intention to treat basis. Laparoscopic common bile duct exploration was performed via using wire/catheter Seldinger techniques under fluoroscopic guidance with flushing or balloon dilation of the sphincter as needed. Our primary outcomes were LOS and successful duct clearance.

RESULTS

One hundred eighty patients were treated for choledocholithiasis with 71 undergoing LCBDE. The success rate of catheter-based LCBDE was 70.4%. Length of stay was significantly reduced for the LCBDE group compared with the LC + ERCP group (48.8 vs. 84.3 hours, p < 0.01). Of note, there were no intraoperative or postoperative complications in the LCBDE group.

CONCLUSION

A simplified catheter-based approach to LCBDE is safe and associated with decreased LOS when compared with LC + ERCP. This simplified step-up approach may help facilitate wider LCBDE utilization by ACS providers who are well positioned for a timely surgery first approach in the management of uncomplicated choledocholithiasis.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

ENDOTHELIAL GLYCOCALYX SHEDDING IN INTRA-ABDOMINAL SEPSIS: A FEASIBILITY STUDY

ABSTRACT

Background: The endothelial glycocalyx layer (EGL) is a complex meshwork of glycosaminoglycans and proteoglycans that protect the vascular endothelium. Cleavage or shedding of EGL-specific biomarkers, such as hyaluronic acid (HA) and syndecan-1 (SDC-1, CD138) in plasma, have been shown to be associated with poor clinical outcomes. However, it is unclear whether levels of circulating EGL biomarkers are representative of the EGL injury within the tissues. The objective of the present feasibility study was to describe a pathway for plasma and tissue procurement to quantify EGL components in a cohort of surgical patients with intra-abdominal sepsis. We sought to compare differences between tissue and plasma EGL biomarkers and to determine whether EGL shedding within the circulation and/or tissues correlated with clinical outcomes. Methods: This was a prospective, observational, single-center feasibility study of adult patients (N = 15) with intra-abdominal sepsis, conducted under an approved institutional review boards. Blood and resected tissue (pathologic specimen and unaffected peritoneum) samples were collected from consented subjects at the time of operation and 24-48 hours after surgery. Endothelial glycocalyx layer biomarkers (i.e., HA and SDC-1) were quantified in both tissue and plasma samples using a CD138 stain and ELISA kit, respectively. Pairwise comparisons were made between plasma and tissue levels. In addition, we tested the relationships between measured EGL biomarkers and clinical status and patient outcomes. Results: Fifteen patients with intra-abdominal sepsis were enrolled in the study. Elevations in EGL-specific circulating biomarkers (HA, SDC-1) were positively correlated with postoperative SOFA scores and weakly associated with resuscitative volumes at 24 hours. Syndecan-1 levels from resected pathologic tissue significantly correlated with SOFA scores at all time points ( R = 0.69 and P < 0.0001) and positively correlated with resuscitation volumes at 24 hours ( R = 0.41 and P = 0.15 for t = 24 hours). Tissue and circulating HA and SDC-1 positively correlated with SOFA >6. Conclusions: Elevations in both circulating and tissue EGL biomarkers were positively correlated with postoperative SOFA scores at 24 hours, with resected pathologic tissue EGL levels displaying significant correlations with SOFA scores at all time points. Tissue and circulating EGL biomarkers were positively correlated at higher SOFA scores (SOFA > 6) and could be used as indicators of resuscitative needs within 24 hours of surgery. The present study demonstrates the feasibility of tissue and plasma procurement in the operating room, although larger studies are needed to evaluate the predictive value of these EGL biomarkers for patients with intra-abdominal sepsis.

Resolution of Liver Function Tests After Laparoscopic Common Bile Duct Exploration Versus Endoscopic Retrograde Cholangiopancreatography

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is gaining traction for the management of choledocholithiasis. Liver function tests (LFTs) are often used to determine the success of ductal clearance, yet the impact of differing therapeutic interventions, endoscopic retrograde cholangiopancreatography (ERCP) or LCBDE, have on postprocedure LFT is insufficiently described. We hypothesize that these interventions have different postoperative LFT profiles. The preprocedural and postprocedural total bilirubin (Tbili), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were analyzed of 167 patients who had successful ERCPs (117) or LCBDEs (50). Endoscopic retrograde cholangiopancreatography patients demonstrated a significant decrease in all LFTs postprocedure (n = 117; P = <0.001 for all) with a continued downtrend when a second set of LFTs was obtained (n = 102; P = <0.001 for all). For successful LC+LCBDEs, there was no significant change between preoperative and 1st postoperative Tbili, AST, ALT, and ALP and the 2nd postoperative labs.

The COST of liver disease: The Cirrhosis Outcomes Score in Trauma Study

BACKGROUND

Cirrhosis in trauma patients is an indicator of poor prognosis, but current trauma injury grading systems do not take into account liver dysfunction as a risk factor. Our objective was to construct a simple clinical mortality prediction model in cirrhotic trauma patients: Cirrhosis Outcomes Score in Trauma (COST).

METHODS

Trauma patients with pre-existing cirrhosis or liver dysfunction who were admitted to our ACS Level I trauma center between 2013 and 2021 were reviewed. Patients with significant acute liver trauma (AAST Grade ≥ 3) or those that developed acute liver dysfunction while admitted were excluded. Demographics as well as ISS, MELD, complications, and mortality were evaluated. COST was defined as the sum of age, ISS, and MELD. Univariate and multivariable analysis was used to determine independent predictors of mortality. The area under the receiver operating curve (AUROC) was calculated to assess the ability of COST to predict mortality.

RESULTS

A total of 318 patients were analyzed of which the majority were males 214 (67.3%) who suffered blunt trauma 305 (95.9%). Mortality at 30-days, 60-days, and 90-days was 20.4%, 23.6%, and 25.5%, respectively. COST was associated with inpatient, 30-day, and 90-day mortality on regression analyses and the AUROC for COST predicting mortality at these respective time points was 0.810, 0.801, and 0.813.

CONCLUSION

Current trauma injury grading systems do not take into account liver dysfunction as a risk factor. COST is highly predictive of mortality in cirrhotic trauma patients. The simplicity of the score makes it useful in guiding clinical care and in optimizing goals of care discussions. Future studies to validate this prediction model are required prior to clinical use.

Win or lose, nighttime transcystic laparoscopic common bile duct exploration is a win

Objectives

Although controversial, recent data suggest nighttime versus daytime laparoscopic cholecystectomy (LC) have comparable outcomes. Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis decreases length of stay (LOS) as compared with LC with endoscopic retrograde cholangiopancreatography (ERCP) but increases case complexity/time. The influence of time of day on LCBDE outcomes has not been evaluated. Our aim was to examine outcomes and LOS for nighttime (PM) compared with daytime LC+LCBDE (DAY).

Methods

Consecutive patients who underwent LCBDE were reviewed. Demographics, operative duration, success of LCBDE, time to postoperative ERCP (if required), LOS, and complications were compared. PM procedures were defined as beginning 19:00-07:00 hours.

Results

Between 2018 and 2022, sixty patients underwent LCBDE (PM 42%). Groups had equivalent age/sex and preoperative liver function tests (LFTs). LCBDE success was 69% PM versus 71% DAY (p=0.78). Operative duration did not differ (2.8 IQR: 2.2-3.3 hours vs. 2.8 IQR: 2.3-3.2 hours, p=0.9). LOS was compared, and PM LOS was shorter (p=0.03). Time to ERCP after a failed LCBDE at night was compared with daytime (13.8 IQR: 10.6-29.5 hours vs. 19.9 IQR: 18.7-54.4 hours, p=0.07). LOS for failed PM LCBDE requiring ERCP was similar to successful DAY LCBDE (p=0.29). One complication (transient hyperbilirubinemia) was reported in the DAY group, none in PM.

Conclusion

PM LCBDE cases are equivalent in safety and success rate to DAY cases but have reduced LOS. Widespread adoption of acute care surgery-driven management of choledocholithiasis via LCBDE during cholecystectomy may decrease LOS, especially in PM cases.

Level of evidence

Level IV.

The value of compassion: Healthcare savings of palliative care consults in trauma

BACKGROUND

The effects of palliative care (PC) consultation on patient costs and hospitalization metrics in the adult trauma population are unclear.

STUDY DESIGN

We interrogated our Level I trauma center databases from 1/1/19 to 3/31/21 for patients age ≥18 admitted to the trauma service. Patients undergoing PC consult were matched using propensity scoring to those without PC consultation based on age, admission Glasgow Coma Scale score, Injury Severity Score and Head Abbreviated Injury Scale. Total costs, total cost per day, hospital length of stay (LOS), ICU LOS, intubation days, discharge disposition, and rates of nephrology consultation and tracheostomy/feeding tube placements were compared.

RESULTS

140 unique patients underwent PC consultation and were matched to a group not receiving PC consult during the same period. Median total costs in the PC cohort were $39,532 compared to $70,330 in the controls (p<0.01).  Median costs per day in the PC cohort were $3,495 vs $17,970 in the controls (p<0.01).  Median costs per ICU day in the PC cohort were $3,774 vs $17,127 in the controls (p<0.01).  Mean hospital LOS (15.7 vs 7 days), ICU LOS (7.9 vs 2.9 days), and ventilator days (5.1 vs 1.5) were significantly higher in the PC cohort (all p<0.01).  Rates of nephrology consultation (8.6 vs 2.1%, p = 0.03) and tracheostomy/feeding tube placements (12.1 vs 1.4%, p<0.01) were also higher in the PC group.  Patients were more likely to discharge to hospice if they received a PC consult (33.6 vs 2.1%, p<0.01).  Mean time to PC consult was 7.2 days (range 1 hour to 45 days). LOS post-consult correlated positively with time to PC consultation (r = 0.27, p<0.01).

CONCLUSION

Expert PC services are known to alleviate suffering and avert patient goal- and value-incongruent care. While trauma patients demand significant resources, PC consultation offered in concordance with life-sustaining interventions is associated with significant savings to patients and the healthcare system. Given the correlation between LOS following PC consult and time to PC consult, savings may be amplified by earlier PC consultation in appropriate patients.

Above the Clavicle: A Simplified Screening Method for Asymptomatic Blunt Cerebral Vascular Injury

INTRODUCTION

Blunt cerebrovascular injury (BCVI) is an increasingly detected pattern in trauma with significant morbidity, putting patients at risk for subsequent stoke. Complex screening protocols exist to determine who should undergo CT angiography of the neck (CTAN) to evaluate for BCVI. Once identified, stroke incidence may be reduced with appropriate treatment across grades. We hypothesize that an expanded and simplified method for identifying patients with clinical suspicion for BCVI based upon injury above the clavicle (ATC) will illustrate a previously undiagnosed cohort of patients.

METHODS

A single-institution retrospective review of adult (age ≥18 years) blunt trauma patients with BCVI from January 1, 2010 to December 31, 2019 was conducted at a tertiary academic medical center. Patients undergoing CTAN were divided into 2 groups based upon qualification by either the expanded Denver criteria or clinical evidence of any injury ATC.

RESULTS

A total of 219 patients were diagnosed with BCVI (25 566 blunt trauma admissions, .9% incidence). Seventeen patients (8%) who did not satisfy expanded Denver were diagnosed with BCVI by ATC, most commonly undergoing CTAN due to facial trauma (n = 8). There were no differences in distribution of carotid artery injuries (CAI) and vertebral artery injuries (VAI) in the expanded Denver criteria group compared to the ATC group.

CONCLUSIONS

CTAN for blunt trauma with any injury ATC is an easy-to-use screening tool and may be seamlessly included with initial whole-body imaging.

Outcomes following balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy is an efficient pathway for management of choledocholithiasis. Performing this safely under one anesthetic offers advantages over a two-step process with cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP). Despite the proven efficacy of LCBDE, endoscopy continues to be predominantly utilized. Simplifying the intervention may drive LCBDE adoption. To this end, we refined a stepwise intraoperative pathway that utilizes over the wire balloon catheters to dilate the Sphincter of Oddi to facilitate stone passage into the duodenum. To determine the efficacy during the initial adoption phase on a general surgery service, we reviewed our experience with LCBDE balloon sphincteroplasty as part of this pathway.

METHODS

We retrospectively reviewed the records of patients who underwent LCBDE with balloon sphincteroplasty at a single tertiary care center over a three-year period. Preoperative demographics, imaging/laboratory results, intra and postoperative outcomes were reviewed.

RESULTS

Choledocholithiasis was managed with transcystic balloon sphincteroplasty during LCBDE in 28 cases over a three-year period. The cohort included 16 women and 12 men with a mean age of 47 years (range = 19-89). Operative indications included cholecystitis (n = 11, 39%), choledocholithiasis (n = 13, 47%), cholelithiasis (n = 2, 7%), and gallstone pancreatitis (n = 2, 7%). The stones were successfully cleared by the balloon sphincteroplasty technique in 75% of the cases. The average fluoroscopy time during LCBDE was 338 s (± 214). The average operating room time was 173 min (± 35). Mean length of stay was 58 h (± 46). There were no intra- or postoperative complications.

CONCLUSION

Wire ready cholangiography followed by balloon sphincteroplasty with saline/contrast flush is a simple and safe way to clear the common bile duct. This technique is a gateway for further expansion and adoption of LCBDE.

Improving the Culture of Safety: A Prospective Handoff Initiative from the Operating Room to the Trauma Intensive Care Unit

A recent EAST publication emphasized the importance of handoffs to ensure safe and effective care for trauma patients. In this work, we evaluated our existing handoffs from the operating room (OR) to the trauma intensive care unit (TICU) and implemented a formal process at our level 1 trauma center. Pre and post-intervention surveys were offered to the stakeholders. Responses were recorded in a Likert scaled format and results were compared using Student's t-test with statistical significance was set to .05. 57 surveys were completed (30 pre, 27 post) and 139 handoffs occurred. There was significant improvement in "overall satisfaction" and "understanding of information expected." Standardizing an OR to intensive care unit handoff clarifies expectations and improves care team satisfaction. While future studies are needed to evaluate the impact of structured handoffs on patient outcomes, provider satisfaction likely serves as an indicator for culture shift towards safer transitions of care for injured patients.

Duration of Antibiotic Therapy in Necrotizing Soft Tissue Infections: Shorter is Safe

Background: Early debridement improves outcome in necrotizing soft tissue infection (NSTI), but there is no consensus on duration of antimicrobial therapy. We recently changed practice to discontinue antibiotic agents early with a goal of 48 hours after adequate source control. We hypothesized that discontinuing antibiotic agents after a short course is safe in the treatment of NSTI. Patients and Methods: This was a prospective study of patients with NSTI comparing short duration of antibiotic agents to a control population after a change in practice. In 2018 we began discontinuing antibiotic agents within 48 hours of source control (absence of cellulitis and no evidence of active infection). Previously, antibiotic duration was at the discretion of the attending surgeon (generally 7-10 days). Patients were excluded from analysis if they were initially debrided at a referring facility, immune compromised, or died prior to source control. Patient characteristics and outcomes were evaluated. The primary outcome was treatment failure requiring antibiotic agents to be restarted with or without further debridement of infected tissue. Secondary outcomes included the duration of antibiotic therapy after source control. Results: We evaluated 151 patients; 119 admitted between January 1, 2011 and January 31, 2018 (PRE) and 32 admitted after January 31, 2018 (POST). Patients were not statistically different regarding characteristics, admission physiologic variables, and comorbidities. The median duration of antibiotic agents after source control in the PRE group was 180.3 hours (interquartile range [IQR], 100.7-318.8) versus 48 hours (IQR, 32.3-100.8) in the POST group (p < 0.01). Patients in each group were treated as described above, and treatment failure occurred in seven (5.9%) PRE patients and two (6.3%) POST (99.3% post hoc power at non-inferiority limit 20%, significance p < 0.05). Thirty-day all-cause mortality was not different between groups (6.7% vs. 6.3%; p = 0.94). Conclusions: Short-duration (48 hours) antibiotic agents after NSTI source control is as safe and effective as a longer course.

Diagnostic Inaccuracies Using Extended Focused Assessment With Sonography in Trauma for Traumatic Pneumothorax

BACKGROUND

Traumatic pneumothorax (PTX) can be deadly, and rapid diagnosis is vital. Ultrasound (US) is rapidly gaining acceptance as an accurate bedside diagnostic tool. While making the diagnosis is important, not all PTX require tube thoracostomy. Our goal was to evaluate the predictive ability of ultrasound in identifying clinically significant PTX.

METHODS

Over 13 months, data was collected on patients undergoing evaluation for trauma. Patients were included if they underwent US, radiograph chest X-ray (CXR), and computed tomography of the chest. Predictive ability of ultrasound was evaluated in identifying clinically significant PTX.

RESULTS

Ninety-four patients received evaluation by all 3 modalities. Of these, 32% were diagnosed with PTX. Sixteen patients (17%) had a clinically significant PTX. Chest X-ray and US both had a sensitivity of 75%; however, US had more than twice as many false positives, resulting in a much lower positive predictive value (63% vs 80%).

CONCLUSIONS

While US can reliably rule out PTX, it may be overly sensitive diagnosing clinically significant PTX. Ultrasound alone should not be used in determining the need for tube thoracostomy as many patients will not require acute intervention.

Screening for Bacteremia in Trauma Patients: Traditional Markers Fall Short

BACKGROUND

Deranged physiology in trauma complicates the clinical identification of sepsis, resulting in overscreening for bacteremia. No clinical signs or biomarkers accurately diagnose sepsis in this population. Our objective was to evaluate the accuracy of the current criteria used to prompt screening for bacteremia in trauma patients and determine independent predictors of bacteremia.

MATERIALS AND METHODS

Adult trauma patients admitted to our level I academic trauma center who had blood cultures (BCs) drawn were identified. Those with positive BCs were compared to those with negative or false positive BCs. False positive was defined as a BC deemed contaminated and not treated at the discretion of the attending physician.

RESULTS

Over a 2-year period, 366 trauma patients had BCs drawn. After excluding surveillance cultures (those drawn to demonstrate bacteremia clearance), 492 unique BC sets were evaluated; 104 (21.1%) BC sets were positive; 30 (28.8%) of these were falsely positive, resulting in a true-positive rate of 15% in the screened population. Univariate analysis suggested temperature and heart rate were associated with positive BC, while multivariable analysis found only the presence of a central line and lactic acid to be predictive. Procalcitonin (PCT) was poorly predictive, with a positive predictive value of 18% and a negative predictive value of 91%.

CONCLUSION

Current tools for identifying bacteremia in trauma patients result in overscreening. PCT may have a limited role as a negative predictor for bacteremia. Given that false-positive BCs have negative patient and economic consequences, future study should focus on development of alternative screening modalities.

Undertriage Despite Use of Geriatric-Specific Trauma Team Activation Guidelines : Who Are We Missing?

BACKGROUND

Elderly trauma patients are at risk for undertriage, resulting in substantial morbidity and mortality. The objective of this study was to determine whether implementation of geriatric-specific trauma team activation (TTA) protocols appropriately identified severely-injured elderly patients.

METHODS

This single-center retrospective study evaluated all severely injured (injury severity score [ISS] >15), geriatric (≥65 years) patients admitted to our Level 1 tertiary-care hospital between January 2014 and September 2017. Undertriage was defined as the lack of TTA despite presence of severe injuries. The primary outcome was all-cause in-hospital mortality; secondary outcomes were mortality within 48 hours of admission and urgent hemorrhage control. A multivariable logistic regression analysis was performed to identify predictors of appropriate triage in this study.

RESULTS

Out of 1039 severely injured geriatric patients, 628 (61%) did not undergo TTA. Undertriaged patients were significantly older and had more comorbidities. In-hospital mortality was 5% and 31% in the undertriaged and appropriately triaged groups, respectively (P < .0001). One percent of undertriaged patients needed urgent hemorrhage control, compared to 6% of the appropriately triaged group (P < .0001). One percent of undertriaged patients died within 48 hours compared to 19% in the appropriately triaged group (P < .0001). Predictors of appropriate triage include GCS, heart rate, systolic blood pressure, lactic acid, ISS, shock, and absence of dementia, stroke, or alcoholism.

DISCUSSION

Geriatric-specific TTA guidelines continue to undertriage elderly trauma patients when using ISS as a metric to measure undertriage. However, undertriaged patients have much lower morbidity and mortality, suggesting the geriatric-specific TTA guidelines identify those patients at highest risk for poor outcomes.

Weight-Based Enoxaparin Achieves Adequate Anti-Xa Levels More Often in Trauma Patients: A Prospective Study

BACKGROUND

Previous research demonstrates that twice-daily enoxaparin is inadequate for venous thromboembolic (VTE) prophylaxis in critically ill trauma patients prompting dose adjustment based on anti-Xa levels. Most studies evaluate peak anti-Xa levels; however, data suggest that trough levels are associated with decreased VTE. We evaluated trough anti-Xa levels in noncritically ill trauma patients receiving fixed or weight-based enoxaparin.

METHODS

Peak and trough anti-Xa levels were prospectively collected from patients receiving at least 3 consecutive doses of enoxaparin (PRE). A performance improvement project prompted a change to weight-based dosing. Peak and trough levels were subsequently prospectively collected from the weight-based group (POST). Adequate peak was defined as ≥0.2 IU/mL and adequate trough as ≥0.1 IU/mL. PRE and POST groups were compared.

RESULTS

200 patients were evaluated (100 PRE, 100 POST). In the PRE group, only 34% of trough and 61% of peak anti-Xa levels were adequate compared with 82% and 97%, respectively, in the POST group (P < .01). Median trough improved from 0.07 IU/mL to 0.2 IU/mL (P < .01). Median peak improved from 0.22 IU/mL to 0.47 IU/mL (P < .01). More patients achieved adequate peak and trough levels in the POST group (79% vs 31%, P < .01). 95% of patients with adequate troughs also had adequate peaks, whereas 75% with adequate peaks had adequate troughs.

DISCUSSION

Traditional enoxaparin dosing in noncritically ill trauma patients results in suboptimal anti-Xa levels. Weight-based enoxaparin improves both trough and peak anti-Xa levels obviating dose adjustment. Furthermore, troughs better predict adequate anti-Xa levels.

Live Quality Assurance: Using a Multimedia Messaging Service Group Chat to Instantly Grade Intraoperative Images

BACKGROUND

The technique for attaining photographic evidence of the critical view of safety (CVS) in laparoscopic cholecystectomy (LC) has previously been defined; however, the consistency, accuracy, and feasibility of CVS in practice is unknown. The aim of this study was to use an already established image sharing and grading system to determine the feasibility of timely feedback after sharing intraoperative images of the CVS and to evaluate if and how cholecystitis affects the ability to attain a CVS.

STUDY DESIGN

We studied 193 laparoscopic cholecystectomies performed by 14 surgeons between August 2017 and January 2019. Anterior and posterior intraoperative CVS images were shared using a standard multimedia messaging system (MMS). Images were graded remotely by members of the group using an established scoring system, and their times to response and scores were recorded. Response data were analyzed for the ability to attain timely and consistent CVS scores.

RESULTS

There were 74 urgent laparoscopic cholecystectomies for acute cholecystitis and 119 nonurgent cholecystectomies performed during the study period. Scoring of shared images occurred in less than 5 minutes, and peer review (mean 3 responses) showed agreement that was not significantly different. In patients with acute cholecystitis, a small but significant difference was observed between anterior and posterior image scoring agreement.

CONCLUSIONS

An established image sharing and grading system for CVS can be used for real-time intraoperative feedback without increasing operative time or compromising private health information. The CVS is almost always attainable; however, decreases in CVS quality and grading agreement are observed in patients with acute cholecystitis.

Boarding ICU patients: Are our rounding practices subpar?

INTRODUCTION

Surgical Intensive Care Unit (SICU) patients "boarding" in ICUs other than the designated home unit have been shown to suffer increased rates of complications. We hypothesized that ICU rounding practices are different when SICU patients are housed in home vs. boarding ICUs.

MATERIAL AND METHODS

SICU rounds were observed at an academic quaternary medical center. Individual patient rounding time and order seen on rounds along with patient data and demographics were recorded. Multivariable regression analysis was used for comparison between patients.

RESULTS

Non-boarders were older, observed on a later post ICU admission day and were more likely to be mechanically ventilated. Boarded patients were often seen at the end of rounds and for less time. Not being a boarder, age, APACHE II score on admission, vasopressor use, and positive pressure ventilation all predicted increased rounding time.

CONCLUSIONS

Surgical ICU patients boarding in non-preferred units are often seen at the end of rounds, result in a greater reliance upon telephone communication, and receive less bedside attention from ICU provider teams.

Secondary extremity compartment syndrome after traumatic cardiac arrest

The objective of this case report is to investigate the pathophysiology, diagnosis, and surgical management of secondary extremity compartment syndrome. This case-based review documents the development of secondary extremity compartment syndrome in the setting of high-volume fluid resuscitation for a hemorrhagic cardiac arrest complicated by a global ischemia-reperfusion injury. A 21-year-old male presented with traumatic, hemorrhagic cardiac arrest. Following a resuscitative thoracotomy, massive transfusion and return of spontaneous circulation, the patient underwent damage control surgery. Over the first 48 h following the injury, the patient developed progressive diffuse interstitial edema ultimately culminating in compartment syndrome of the remaining three uninjured extremities as well as both uninjured gluteal compartments. The patient underwent bilateral lower extremity, thigh, gluteal, and right upper extremity compartment fasciotomies, with the left lower extremity being the single, traumatically injured extremity. To our knowledge, this is the only case of secondary extremity compartment syndrome in which bilateral gluteal compartments and bilateral thigh compartments were involved in addition to the bilateral upper and right lower extremities. The goal of this case report is to examine the pathophysiology of the development of secondary extremity compartment syndrome, with an emphasis on early recognition and surgical intervention.