Extracorporeal membrane oxygenation in severe traumatic brain injury: Is it safe?

BACKGROUND: Patients with severe traumatic brain injury (TBI) are at an increased risk of respiratory failure refractory to traditional therapies. The safety of extracorporeal membrane oxygenation (ECMO) in this population remains unclear. We aimed to examine outcomes following ECMO compared with traditional management in severe TBI patients. METHODS: We performed a retrospective cohort study using the Trauma Quality Improvement Program (2017-2020). We identified patients 18 years or older with severe TBI (Abbreviated Injury Score head, ≥3) who underwent ECMO or had either in-hospital cardiac or acute respiratory distress syndrome during their hospitalization. The study excluded pPatients who arrived without signs of life, had a prehospital cardiac arrest, had an unsurvivable injury, were transferred out within 48 hours of arrival, or were received as a transfer and died within 12 hours of arrival Patients with missing information regarding in-hospital mortality were also excluded. Outcomes included mortality, in-hospital complications, and intensive care unit length of stay. To account for patient and injury characteristics, we used 1:1 propensity matching. We performed a subgroup analysis among ECMO patients, comparing patients who received anticoagulants with those who did not. RESULTS: We identified 10,065 patients, of whom 221 (2.2%) underwent ECMO. In the propensity-matched sample of 134 pairs, there was no difference in mortality. Extracorporeal membrane oxygenation was associated with a higher incidence of cerebrovascular accidents (9% vs. 1%, p = 0.006) and a lower incidence of ventilator-associated pneumonia. In the subgroup analysis of 64 matched pairs, patients receiving anticoagulation had lower mortality, higher unplanned return to the operating room, and longer duration of ventilation and intensive care unit length of stay. CONCLUSION: Extracorporeal membrane oxygenation use in severe TBI patients was not associated with higher mortality and should be considered a potential intervention in this patient population. Systemic anticoagulation showed mortality benefit, but further work is required to elucidate the impact on neurological outcomes, and the appropriate dosing and timing of anticoagulation. LEVEL OF EVIDENCE: Therapeutic; Level IV.

Outcomes of severe isolated blunt chest trauma in young and geriatric patients.

PURPOSE: Our understanding of the growing geriatric population's risk factors for outcomes after traumatic injury remains incomplete. This study aims to compare outcomes of severe isolated blunt chest trauma between young and geriatric patients and assess predictors of mortality. METHODS: The ACS-TQIP 2017-2020 database was used to identify patients with severe isolated blunt chest trauma. Patients having extra-thoracic injuries, no signs of life upon presentation to the emergency department (ED), prehospital cardiac arrest, or who were transferred to or from other hospitals were excluded. The primary outcome was in-hospital mortality. Univariate and multivariable regression analyses were performed to assess independent predictors of mortality. RESULTS: A total of 189,660 patients were included in the study, with a median age of 58 years; 37.5% were aged 65 or older, and 1.9% died by discharge. Patients aged 65 and older had significantly higher mortality (3.4% vs. 1.0%, p < 0.001) and overall complications (7.0% vs. 4.7%, p < 0.001) compared to younger patients. Age ≥ 65 was independently associated with mortality (OR: 5.45, 95%CI: 4.96-5.98, p < 0.001), prolonged hospitalization, and complications. In the geriatric group, age > 75 was an independent predictor of mortality compared to ages 65-75 (OR: 2.62, 95%CI: 2.37-2.89, p < 0.001). Geriatric patients with an MVC, presenting with a GCS ≤ 8, and having an SBP < 90 had the highest mortality of 56.9%. CONCLUSION: The geriatric trauma patient with isolated severe blunt chest injury has significantly higher mortality and morbidity compared to younger patients and warrants special consideration of multiple factors that affect outcomes. Individual predictors of mortality carry a greater impact on mortality in geriatric patients.

The impact of frailty on long-term functional outcomes in severely injured geriatric patients.

BACKGROUND: The incidence of severe injury in the geriatric population is increasing. However, the impact of frailty on long-term outcomes after injury in this population remains understudied. Therefore, we aimed to understand the impact of frailty on long-term functional outcomes of severely injured geriatric patients. METHODS: We conducted a retrospective cohort study, including patients ≥65 years old with an Injury Severity Score ≥15, who were admitted between December 2015 and April 2022 at one of 3 level 1 trauma centers in our region. Patients were contacted between 6 and 12 months postinjury and administered a trauma quality of life survey, which assessed for the presence of new functional limitations in their activities of daily living. We defined frailty using the mFI-5 validated frailty tool: patients with a score ≥2 out of 5 were considered frail. The impact of frailty on long-term functional outcomes was assessed using 1:1 propensity matching adjusting for patient characteristics, injury characteristics, and hospital site. RESULTS: We included 580 patients, of whom 146 (25.2%) were frail. In a propensity-matched sample of 125 pairs, frail patients reported significantly higher functional limitations than nonfrail patients (69.6% vs 47.2%; P < .001). This difference was most prominent in the following activities: climbing stairs, walking on flat surfaces, going to the bathroom, bathing, and cooking meals. In a subgroup analysis, frail patients with traumatic brain injuries experienced significantly higher long-term functional limitations. CONCLUSION: Frail geriatric patients with severe injury are more likely to have new long-term functional outcomes and may benefit from screening and postdischarge monitoring and rehabilitation services.

First do no harm: Predicting futility of intervention in geriatric emergency general surgery.

BACKGROUND: Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care. METHODS: We queried NSQIP 2015-2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors. RESULTS: Of 41,029 patients, 5589 (13.6 â€‹%) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 â€‹% CI,3.5-26.8, p â€‹< â€‹0.001), septic shock (aOR 4.9, 95 â€‹% CI,4.5-5.4, p â€‹< â€‹0.001), and dialysis (aOR 2.1, 95 â€‹% CI,1.8-2.4, p â€‹< â€‹0.001). Without risk factors, mortality rates were 11.9 â€‹% after colectomy and 10.2 â€‹% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 â€‹% and 100 â€‹% following colectomy and small bowel resection, respectively. CONCLUSIONS: In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making.

Discharge to Skilled Nursing Facility Is a Risk Factor for Readmission: A Nationwide Propensity-Matched Study.

INTRODUCTION: General surgery procedures place stress on geriatric patients, and postdischarge care options should be evaluated. We compared the association of discharge to a skilled nursing facility (SNF) versus home on patient readmission. METHODS: We retrospectively reviewed the Nationwide Readmission Database (2016-2019) and included patients ≥65 y who underwent a general surgery procedure between January and September. Our primary outcome was 30-d readmissions. Our secondary outcome was predictors of readmission after discharge to an SNF. We performed a 1:1 propensity-matched analysis adjusting for patient demographics and hospital course to compare patients discharged to an SNF with patients discharged home. We performed a sensitivity analysis on patients undergoing emergency procedures and a stepwise regression to identify predictors of readmission. RESULTS: Among 140,056 included patients, 33,916 (24.2%) were discharged to an SNF. In the matched population of 19,763 pairs, 30-d readmission was higher in patients discharged to an SNF. The most common diagnosis at readmission was sepsis, and a greater proportion of patients discharged to an SNF were readmitted for sepsis. In the sensitivity analysis, emergency surgery patients discharged to an SNF had higher 30-d readmission. Higher illness severity during the index admission and living in a small or fringe county of a large metropolitan area were among the predictors of readmission in patients discharged to an SNF, while high household income was protective. CONCLUSIONS: Discharge to an SNF compared to patients discharged home was associated with a higher readmission. Future studies need to identify the patient and facility factors responsible for this disparity.

Emergency general surgery in older adult patients: Factors associated with fragmented care.

BACKGROUND: Care fragmentation has been shown to lead to increased morbidity and mortality. We aimed to explore the factors related to care fragmentation after hospital discharge in geriatric emergency general surgery patients, as well as examine the association between care fragmentation and mortality. METHODS: We designed a retrospective study of the Nationwide Readmissions Database 2019. We included patients ≥65 years old admitted with an emergency general surgery diagnosis who were discharged alive from the index admission. The primary outcome was 90-day care fragmentation, defined as an unplanned readmission to a non-index hospital. Multivariable logistic regression was performed, adjusting for patient and hospital characteristics. RESULTS: A total of 447,027 older adult emergency general surgery patients were included; the main diagnostic category was colorectal (22.6%), and 78.2% of patients underwent non-operative management during the index hospitalization. By 90 days post-discharge, 189,622 (24.3%) patients had an unplanned readmission. Of those readmitted, 20.8% had care fragmentation. The median age of patients with care fragmentation was 76 years, and 53.2% were of female sex. Predictors of care fragmentation were living in rural counties (odds ratio 1.76, 95% confidence interval: 1.57-1.97), living in a low-income ZIP Code, discharge to intermediate care facility (odds ratio 1.28, 95% confidence interval: 1.22-1.33), initial non-operative management (odds ratio 1.17, 95% confidence interval: 1.12-1.23), leaving against medical advice (odds ratio 2.60, 95% confidence interval: 2.29-2.96), and discharge from private investor-owned hospitals (odds ratio 1.18, 95% confidence interval: 1.10-1.27). Care fragmentation was significantly associated with higher mortality. CONCLUSION: The burden of unplanned readmissions in older adult patients who survive an emergency general surgery admission is underestimated, and these patients frequently experience care fragmentation. Future directions should prioritize evaluating the impact of initiatives aimed at alleviating the incidence and complications of care fragmentation in geriatric emergency general surgery patients.

The Open Abdomen After Intra-Abdominal Contamination in Emergency General Surgery.

INTRODUCTION: Delayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. METHODS: This retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. RESULTS: We identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). CONCLUSIONS: In the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

Debunking the "Obesity Paradox": Obesity Is Associated With Adverse Outcomes in Emergency General Surgery.

INTRODUCTION: Obesity is increasingly prevalent both nationwide and in the emergency general surgery (EGS) population. While previous studies have shown that obesity may be protective against mortality following EGS procedures, the association between body mass index (BMI) and postoperative outcomes, as well as intraoperative decision-making, remains understudied. METHODS: The National Surgical Quality Improvement Program 2015-2019 database was used to identify all adult patients undergoing an open abdominal or abdominal wall procedure for EGS conditions. Our outcomes included 30-d postoperative mortality, composite 30-d morbidity, delayed fascial closure, reoperation, operative time, and hospital length of stay (LOS). Multivariable logistic regression models were used to explore the association between BMI and each outcome of interest while adjusting for patient demographics, comorbidities, laboratory tests, preoperative and intraoperative variables. RESULTS: We identified 78,578 patients, of which 3121 (4%) were categorized as underweight, 23,661 (30.1%) as normal weight, 22,072 (28.1%) as overweight, 14,287 (18.2%) with class I obesity, 7370 (9.4%) with class II obesity, and 8067 (10.3%) with class III obesity. Class III obesity was identified as a risk factor for 30-d postoperative morbidity (adjusted odds ratio 1.14, 95% CI, 1.03-1.26, P < 0.01). An increase in obesity class was also associated with a stepwise increase in the risk of undergoing delayed fascial closure, experiencing a prolonged operative time, and having an extended LOS. CONCLUSIONS: Obesity class was associated with an increase in delayed fascial closure, longer operative time, higher reoperation rates, and extended hospital LOS. Further studies are needed to explore how a patient's BMI impacts intraoperative factors, influences surgical decision-making, and contributes to hospital costs.

The management of complicated colorectal cancer in older patients in a global perspective after COVID-19: the CO-OLDER WSES project.

BACKGROUND: Colorectal (CRC) cancer is becoming a disease of the elderly. Ageing is the most significant risk factor for presenting CRC. Early diagnosis of CRC and management is the best way in achieving good outcomes and longer survival but patients aged ≥75 years are usually not screened for CRC. This group of patients is often required to be managed when they are symptomatic in the emergency setting with high morbidity and mortality rates. Our main aim is to provide clinical data about the management of elderly patients presenting complicated colorectal cancer who required emergency surgical management to improve their care. METHODS: The management of complicated COlorectal cancer in OLDER patients (CO-OLDER; ClinicalTrials.gov ID: NCT05788224; evaluated by the local ethical committee CPP EST III-France with the national number 2023-A01094-41) in the emergency setting project provides carrying out an observational multicenter international cohort study aimed to collect data about patients aged ≥75 years to assess modifiable risk factors for negative outcomes and mortality correlated to the emergency surgical management of this group of patients at risk admitted with a complicated (obstructed and perforated) CRC. The CO-OLDER protocol was approved by Institutional Review Board and released. Each CO-OLDER collaborator is asked to enroll ≥25 patients over a study period from 1st January 2018 to 30th October 2023. Data will be analyzed comparing two periods of study: before and after the COVID-19 pandemic. A sample size of 240 prospectively enrolled patients with obstructed colorectal cancer in a 5-month period was calculated. The secured database for entering anonymized data will be available for the period necessary to achieve the highest possible participation. RESULTS: One hundred eighty hospitals asked to be a CO-OLDER collaborator, with 36 potentially involved countries over the world. CONCLUSIONS: The CO-OLDER project aims to improve the management of elderly people presenting with a complicated colorectal cancer in the emergency setting. Our observational global study can provide valuable data on the effectiveness of different management strategies in improving primary assessment, management and outcomes for elderly patients with obstructed or perforated colorectal cancer in the emergency setting, guiding clinical decision-making. This information can help healthcare providers make informed decisions about the best course of action for these patients.

The overlooked factor: The impact of disability on postoperative complications after emergency general surgery procedures.

BACKGROUND: Despite more than 61 million people in the United States living with a disability, studies on the impact of disability on health care disparities in surgical patients remain limited. Therefore, we aimed to understand the impact of disability on postoperative outcomes. METHODS: We performed a retrospective cohort study using the Nationwide Readmission Database (2019). We compared patients ≥18 years undergoing emergency general surgery procedures with a disability condition with those without a disability. In accordance with the Centers for Disease Control and Prevention, disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. The primary outcome was 30-day readmission rates. Secondary outcomes included hospital length of stay and 30-day complications and mortality. Patients were 1:1 propensity-matched using patient, procedure, and hospital characteristics. RESULTS: Among our population of 378,733 patients, 5,877 (1.6%) patients had at least 1 disability condition. A higher proportion of patients with a disability had low household income, $1 to $45,999, and an Elixhauser Comorbidity score ≥3. Among 5,768 matched pairs, patients with a disability had a significantly higher incidence of 30-day readmission (17.2% vs 12.7%; P < .001), infectious complications (29.8% vs 19.5%; P < .001), and a longer length of stay (8 vs 6 days; P < .001). Motor impairment, the most common disability, was associated with the greatest increase in patient readmission, morbidity, and length of stay. CONCLUSION: Severe intellectual, hearing, visual, or motor impairments were associated with higher readmission, morbidity, and longer length of stay. Further research is needed to understand the mechanisms responsible for these disparities and to develop interventions to ameliorate them.

A novel preoperative score to predict severe acute cholecystitis.

BACKGROUND: In a large multicenter trial, The Parkland Grading Scale (PGS) for acute cholecystitis outperformed other grading scales and has a positive correlation with complications but is limited in its inability to preoperatively predict high-grade cholecystitis. We sought to identify preoperative variables predictive of high-grade cholecystitis (PGS 4 or 5). METHODS: In a six-month period, patients undergoing cholecystectomy at a single institution with prospectively graded PGS were analyzed. Stepwise logistic regression models were constructed to predict high-grade cholecystitis. The relative weight of the variables was used to derive a novel score, the Severe Acute Cholecystitis Score (SACS). This score was compared with the Emergency Surgery Acuity Score(ESS), American Association for the Surgery of Trauma (AAST) preoperative score and Tokyo Guidelines (TG) for their ability to predict high-grade cholecystitis. Severe Acute Cholecystitis Score was then validated using the database from the AAST multicenter validation of the grading scale for acute cholecystitis. RESULTS: Of the 575 patients that underwent cholecystectomy, 172 (29.9%) were classified as high-grade. The stepwise logistic regression modeling identified seven independent predictors of high-grade cholecystitis. From these variables, the SACS was derived. Scores ranged from 0 to 9 points with a C statistic of 0.76, outperforming the ESS ( C statistic of 0.60), AAST (0.53), and TG (0.70) ( p < 0.001). Using a cutoff of 4 or more on the SACS correctly identifies 76.2% of cases with a specificity of 91.3% and a sensitivity of 40.7%. In the multicenter database, there were 464 patients with a prospectively collected PGS. The C statistic for SACS was 0.74. Using the same cutoff of 4, SACS correctly identifies 71.6% of cases with a specificity of 83.8% and a sensitivity of 52.2%. CONCLUSION: The Severe Acute Cholecystitis Score can preoperatively predict high-grade cholecystitis and may be useful for counseling patients and assisting in surgical decision making. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

Traumatic lower extremity amputation as a risk factor for venous thromboembolism.

BACKGROUND: This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism. METHODS: All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT). RESULTS: A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p â€‹< â€‹0.001) and DVT (6.5% vs. 3.4%, p â€‹< â€‹0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p â€‹= â€‹0.015) and DVT (4.7% vs. 2.6%, p â€‹< â€‹0.001). CONCLUSIONS: In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.

The association of disability conditions with access to minimally invasive general surgery.

BACKGROUND: Despite the high prevalence of disability conditions in the US, their association with access to minimally invasive surgery (MIS) remains under-characterized. OBJECTIVE: To understand the association of disability conditions with rates of MIS and describe nationwide temporal trends in MIS in patients with disability conditions. METHODS: We conducted a retrospective cohort study using the Nationwide Readmission Database (2016-2019). We included patients ≥18 years undergoing general surgery procedures. Our primary outcome was the impact of disability conditions on the rate of MIS. We performed 1:1 propensity matching, comparing patients with disability conditions with those without and adjusting for patient, procedure, and hospital characteristics. We performed a subgroup analysis among patients<65 years and with patients with each type of disability. We evaluated temporal trends of MIS in patients with disabilities. We identified predictors of undergoing MIS using mixed effects regression analysis. RESULTS: In the propensity-matched comparison, a lower proportion of patients with disabilities had MIS. In the sub-group analyses, the rate of MIS was significantly lower in patients below 65 years with disabilities and among patients with motor and intellectual impairments. There was an increasing trend in the proportion of patients with disabilities undergoing MIS (p < 0.005). The regression analysis confirmed that the presence of a disability was associated with decreased odds of undergoing MIS. CONCLUSIONS: This study characterizes the negative association of disability conditions with access to MIS. As the healthcare landscape evolves, considerations on how to equitably share new treatment modalities with a wide range of patient populations are necessary.

Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION: Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population. METHODS: Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes. RESULTS: Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012). CONCLUSIONS: Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus.

BACKGROUND: Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS: 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS: 842 patients were included, of which 409 (48.6 â€‹%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 â€‹% vs 0.0 â€‹%, p â€‹= â€‹0.045), reduced ostomy rate (38.3 â€‹% vs 29.4 â€‹%, p â€‹= â€‹0.013), an increased overall length of stay (12 days vs 8 days, p â€‹< â€‹0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p â€‹< â€‹0.001). CONCLUSION: In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.

Are we ready for "green surgery" to promote environmental sustainability in the operating room? Results from the WSES STAR investigation.

BACKGROUND: The importance of environmental sustainability is acknowledged in all sectors, including healthcare. To meet the United Nations Sustainable Development Goals 2030 Agenda, healthcare will need a paradigm shift toward more environmentally sustainable practices that will also impact clinical decision-making. The study investigates trauma and emergency surgeons' perception, acceptance, and employment of environmentally friendly habits. METHODS: An online survey based on the most recent literature regarding environmental sustainability in healthcare and surgery was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to the 917 WSES members through the society's website and Twitter/X profile. RESULTS: 450 surgeons from 55 countries participated in the survey. Results underline both a generally positive attitude toward environmental sustainability but also a lack of knowledge about several concepts and practices, especially concerning the potential contribution to patient care. DISCUSSION: The topic of environmental sustainability in healthcare and surgery is still in its infancy. There is a clear lack of salient guidance and knowledge, and there is a critical need for governments, institutions, health agencies, and scientific societies to promote, disseminate, and report environmentally friendly initiatives and their potential impacts while employing an interdisciplinary approach.

Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity matched study.

BACKGROUND: Surgical site infections (SSI) are a common complication of laparotomy incisions. The role of Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis. We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an emergency laparotomy procedure. METHODS: We conducted a retrospective cohort study using the National Surgery Quality Initiative Program (NSQIP) database from 2013 to 2020. We included patients ≥18 years undergoing an emergency laparotomy. We performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions, ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intraoperative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) laparotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition. RESULTS: We included 65,803 patients with completely closed incisions of whom 387 patients received NPWT. There was no significant difference in the rate of total SSIs (13.4 â€‹% vs. 11.9 â€‹%; p â€‹= â€‹0.52) in the matched population of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received NPWT. There was no significant difference in the rate of total SSIs (3.6 â€‹% vs. 4.4 â€‹%; p â€‹= â€‹0.51) in the matched population of 477 pairs. Secondary outcomes did not differ significantly in either group. CONCLUSION: The rate of SSIs was not significantly different when prophylactic NPWT was used compared to standard dressings for patients with a closed or partially closed laparotomy incision.

Optimal dose of cryoprecipitate in massive transfusion following trauma.

BACKGROUND: While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients. METHODS: Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables. RESULTS: The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality. CONCLUSION: One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

From admission to vaccination: COVID-19 vaccination patterns and their relationship with hospitalization in trauma patients.

BACKGROUND: COVID-19 vaccination rates in the hospitalized trauma population are not fully characterized and may lag behind the general population. This study aimed to outline COVID-19 vaccination trends in hospitalized trauma patients and examine how hospitalization influences COVID-19 vaccination rates. METHODS: We conducted a retrospective institutional study using our trauma registry paired with the COVID-19 vaccination ENCLAVE registry. We included patients ≥18 years admitted between April 21, 2021 and November 30, 2022. Our primary outcome was the change in vaccination posthospitalization, and secondary analyzed outcomes included temporal trends of vaccination in trauma patients and predictors of non-vaccination. We compared pre and posthospitalization weekly vaccination rates. We performed joinpoint regression to depict temporal trends and multivariate regression for predictors of nonvaccination. RESULTS: The rate of administration of the first vaccine dose increased in the week after hospitalization (P = .018); however, this increase was not sustained in the following weeks. The percentage of unvaccinated patients declined faster in the general population in Massachusetts compared to the hospitalized trauma population. By the conclusion of the study, 27.1% of the trauma population was unvaccinated, whereas <5% of the Massachusetts population was unvaccinated. Urban residence, having multiple hospitalizations, and experiencing moderate to severe frailty were associated with vaccination. Conversely, being in the age groups 18 to 45 years and 46 to 64 years, as well as having Medicaid or self-pay insurance, were linked to being unvaccinated. CONCLUSION: Hospitalization initially increased the rate of administration of the first vaccine dose in trauma patients, but the effect was not sustained. By the conclusion of the study period, a greater percentage of trauma patients were unvaccinated compared to the general population of Massachusetts. Strategies for sustained health care integration need to be developed to address this ongoing challenge in the high-risk trauma population.