The Role of Dietary Intake in the Weight Loss Outcomes of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy: A Systematic Review and Meta-analysis.

The relationship between postoperative dietary intake and weight loss after bariatric surgery remains unclear. We performed a systematic review and meta-analysis of studies published between January 2000 and May 2023, reporting weight loss outcomes, and dietary intake before and after Roux-en-Y gastric bypass and sleeve gastrectomy. A total of 42 studies were included. There was no detectable difference in dietary intake between the two procedures. Roux-en-Y gastric bypass induced an average decrease in energy intake of 886 kcal/day at 12-month post-surgery; however, there was no correlation between daily energy intake and weight loss. These findings show a substantial reduction of energy intake in the first year after bariatric surgery but do not support a link between lower energy intake and greater weight loss.

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study.

BACKGROUND: High-grade liver injuries with extravasation (HGLI â€‹+ â€‹Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â€‹+ â€‹Extrav. Therefore, we evaluated the management of HGLI â€‹+ â€‹Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â€‹+ â€‹Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â€‹= â€‹0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â€‹> â€‹0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â€‹+ â€‹Extrav patients.

Prehospital ETCO2 is predictive of death in intubated and non-intubated patients.

BACKGROUND: Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO2) correlates with mortality in intubated patients. The predictive value of ETCO2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality. METHODS: This was a prospective, observational, multicenter study. ETCO2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs. RESULTS: Of 550 enrolled patients, 487 (88.5%) had ETCO2 measured through an NCC. Median age was 37 (27-52) years; 76.5% were male; median ISS was 13 (5-22). Mortality was 10.4%. Minimum prehospital ETCO2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69-0.84; Youden index â€‹= â€‹22 â€‹mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62-0.74, p â€‹= â€‹0.04) and shock index with an AUROC of 0.67 (CI 0.59-0.74, p â€‹= â€‹0.03). CONCLUSION: Prehospital ETCO2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients.

To observe or not to observe: Evaluation of the modified brain injury guideline management of small volume intracranial hemorrhage.

INTRODUCTION: Patients with small volume intracranial hemorrhage (ICH) are categorized as modified Brain Injury Guidelines (mBIG) 1 and are managed with a 6-h emergency department (ED) observation period. The current study aimed to describe the mBIG 1 patient population and determine the utility of the ED observation period. METHODS: A retrospective analysis was performed on trauma patients with small volume ICH. Exclusion criteria were Glasgow Coma Scale (GCS) < 13 and penetrating injuries. RESULTS: 359 patients were identified over the 8-year study period. The most common ICH was SDH (52.7%) followed by SAH (50.1%). Two patients (0.56%) had neurologic deterioration, but neither had radiographic progression. Overall, 14.3% of the cohort had radiographic progression; none required neurosurgical intervention. Four patients (1.1%) had readmission related to TBI from the index admission. CONCLUSION: There were no patients with small volume ICH that required neurosurgical intervention despite a small subset of patients having radiographic or clinical deterioration. Patients who meet the mBIG 1 criteria may be managed safely without an ED observation period.

Computer-Assisted Levothyroxine Dose Selection for the Treatment of Postoperative Hypothyroidism.

Background: Thyroid hormone replacement with levothyroxine (LT4) is a recommended treatment for patients undergoing thyroidectomy. The starting LT4 dose is frequently calculated based on the patient's weight. However, the weight-based LT4 dosing performs poorly in clinical practice, with only ∼30% of patients achieving target thyrotropin (TSH) levels at the first thyroid function testing after treatment initiation. A better way to calculate the LT4 dose for patients with postoperative hypothyroidism is needed. Methods: In this retrospective cohort study we used demographic, clinical, and laboratory data for 951 patients after thyroidectomy and several regression and classification machine learning methods to develop an LT4 dose calculator for treating postoperative hypothyroidism targeting the desired TSH level. We compared the accuracy with the current standard-of-care practice and other published algorithms and evaluated generalizability with fivefold cross-validation and out-of-sample testing. Results: The retrospective clinical chart review showed that only 285/951 (30%) patients met their postoperative TSH goal. Obese patients were overtreated with LT4. An ordinary least squares regression based on weight, height, age, sex, calcium supplementation, and height:sex interaction predicted prescribed LT4 dose in 43.5% of all patients and 45.3% of patients with normal postoperative TSH (0.45-4.5 mIU/L). The ordinal logistic regression, artificial neural networks regression/classification, and random forest methods achieved comparable performance. LT4 calculator recommended lower LT4 doses to obese patients. Conclusions: The standard-of-care LT4 dosing does not achieve the target TSH in most thyroidectomy patients. Computer-assisted LT4 dose calculation performs better by considering multiple relevant patient characteristics and providing personalized and equitable care to patients with postoperative hypothyroidism. Prospective validation of LT4 calculator performance in patients with various TSH goals is needed.

Global Diabetes Prevalence in COVID-19 Patients and Contribution to COVID-19- Related Severity and Mortality: A Systematic Review and Meta-analysis.

BACKGROUND: COVID-19 and diabetes both contribute to large global disease burdens. PURPOSE: To quantify the prevalence of diabetes in various COVID-19 disease stages and calculate the population attributable fraction (PAF) of diabetes to COVID-19-related severity and mortality. DATA SOURCES: Systematic review identified 729 studies with 29,874,938 COVID-19 patients. STUDY SELECTION: Studies detailed the prevalence of diabetes in subjects with known COVID-19 diagnosis and severity. DATA EXTRACTION: Study information, COVID-19 disease stages, and diabetes prevalence were extracted. DATA SYNTHESIS: The pooled prevalence of diabetes in stratified COVID-19 groups was 14.7% (95% CI 12.5-16.9) among confirmed cases, 10.4% (7.6-13.6) among nonhospitalized cases, 21.4% (20.4-22.5) among hospitalized cases, 11.9% (10.2-13.7) among nonsevere cases, 28.9% (27.0-30.8) among severe cases, and 34.6% (32.8-36.5) among deceased individuals, respectively. Multivariate metaregression analysis explained 53-83% heterogeneity of the pooled prevalence. Based on a modified version of the comparative risk assessment model, we estimated that the overall PAF of diabetes was 9.5% (7.3-11.7) for the presence of severe disease in COVID-19-infected individuals and 16.8% (14.8-18.8) for COVID-19-related deaths. Subgroup analyses demonstrated that countries with high income levels, high health care access and quality index, and low diabetes disease burden had lower PAF of diabetes contributing to COVID-19 severity and death. LIMITATIONS: Most studies had a high risk of bias. CONCLUSIONS: The prevalence of diabetes increases with COVID-19 severity, and diabetes accounts for 9.5% of severe COVID-19 cases and 16.8% of deaths, with disparities according to country income, health care access and quality index, and diabetes disease burden.

An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective.

INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

A comparison of medium-term heat acclimation by post-exercise hot water immersion or exercise in the heat: adaptations, overreaching, and thyroid hormones.

This research compared thermal and perceptual adaptations, endurance capacity, and overreaching markers in men after 3, 6, and 12 days of post-exercise hot water immersion (HWI) or exercise heat acclimation (EHA) with a temperate exercise control (CON), and examined thyroid hormones as a mechanism for the reduction in resting and exercising core temperature (Tre) after HWI. HWI involved a treadmill run at 65% V̇o2peak at 19°C followed by a 40°C bath. EHA and CON involved a work-matched treadmill run at 65% V̇o2peak at 33°C or 19°C, respectively. Compared with CON, resting mean body temperature (Tb), resting and end-exercise Tre, Tre at sweating onset, thermal sensation, and perceived exertion were lower and whole-body sweat rate (WBSR) was higher after 12 days of HWI (all P ≤ 0.049, resting Tb: CON -0.11 ± 0.15°C, HWI -0.41 ± 0.15°C). Moreover, resting Tb and Tre at sweating onset were lower after HWI than EHA (P ≤ 0.015, resting Tb: EHA -0.14 ± 0.14°C). No differences were identified between EHA and CON (P ≥ 0.157) except WBSR that was greater after EHA (P = 0.013). No differences were observed between interventions for endurance capacity or overreaching markers (mood, sleep, Stroop, P ≥ 0.190). Thermal adaptations observed after HWI were not related to changes in thyroid hormone concentrations (P ≥ 0.086). In conclusion, 12 days of post-exercise hot water immersion conferred more complete heat acclimation than exercise heat acclimation without increasing overreaching risk, and changes in thyroid hormones are not related to thermal adaptations after post-exercise hot water immersion.

Patient characteristics and diagnostic tests associated with syncopal falls: A Southwestern surgical congress multicenter study.

BACKGROUND: Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS: A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS: 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION: Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.

Disparate resource allocation during the COVID-19 pandemic among trauma centers: A Western Trauma Association national survey.

BACKGROUND: During the pandemic, hospitals implemented disaster plans to conserve resources while maintaining patient care. It was unclear how these plans impacted injury care and trauma surgeons. STUDY DESIGN: A 16 question survey assessing COVID-related hospital policy and resource allocation pre-COVID-19 peak (March), and a 19 question post-peak (June) survey was distributed to Trauma/Critical Care attending's via social media and the Western Trauma Association member email list. RESULTS: There were 120 pre- and 134 post-peak respondents. Most (95%) altered trauma PPE components, a nd 67% noted changes in their admission population pre-peak while 80% did so post-peak. Penetrating injury increased 56% at Level 1 centers and 27% at Level 2 centers. Altered ICU and transfusion criteria were noted with 25% relocating TBI patients, 17% revised rib fracture admission criteria, and 23% adjusted transfusion practices. Importantly, 12% changed their massive transfusion protocol, with 11% reducing the symptomatic transfusion threshold from 7 g/dL to 6 g/dL. Half (50%) disclosed impediments to patient care including PPE shortages and COVID test-related procedural delay (Fig. 2). While only 14% felt their institution was overwhelmed by COVID, the vast majority (81%) shared durable concerns about personal health and safety. CONCLUSIONS: Disparate approaches to COVID-19 preparedness and response characterize survey respondent facility actions. These disparities, especially between Level 1 and Level 2 centers, represent opportunities for the trauma community to coordinate best-practice planning and implementation in light of future consequence infection or pandemic care.

A multicenter validation of the modified brain injury guidelines: Are they safe and effective?

BACKGROUND: The modified Brain Injury Guidelines (mBIG) are an algorithm for treating patients with traumatic brain injury and intracranial hemorrhage by which selected patients do not require a repeat head computed tomography, a neurosurgery consult, or even an admission. The mBIG refined the original Brain Injury Guidelines (BIG) to improve safety and reproducibility. The purpose of this study is to assess safety and resource utilization with mBIG implementation. METHODS: The mBIG were implemented at three Level I trauma centers in August 2017. A multicenter retrospective review of prospectively collected data was performed on adult mBIG 1 and 2 patients. The post-mBIG implementation period (August 2017 to February 2021) was compared with a previous BIG retrospective evaluation (January 2014 to December 2016). RESULTS: There were 764 patients in the two study periods. No differences were identified in demographics, Injury Severity Score, or admission Glasgow Coma Scale score. Fewer computed tomography scans (2 [1,2] vs. 2 [2,3], p < 0.0001) and neurosurgery consults (61.9% vs. 95.9%, p < 0.0001) were obtained post-mBIG implementation. Hospital (2 [1,4] vs. 2 [2,4], p = 0.013) and intensive care unit (0 [0,1] vs. 1 [1,2], p < 0.0001) length of stay were shorter after mBIG implementation. No difference was seen in the rate of clinical or radiographic progression, neurosurgery operations, or mortality between the two groups.After mBIG implementation, eight patients (1.6%) worsened clinically. Six patients that clinically progressed were discharged with Glasgow Coma Scale score of 15 without needing neurosurgery intervention. One patient had clinical and radiographic decompensation and required craniotomy. Another patient worsened clinically and radiographically, but due to metastatic cancer, elected to pursue comfort measures and died. CONCLUSION: This prospective validation shows the mBIG are safe, pragmatic, and can dramatically improve resource utilization when implemented. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

MUlticenter STudy of tissue plasminogen activator (alteplase) use in COVID-19 severe respiratory failure (MUST COVID): A retrospective cohort study.

Background: Few therapies exist to treat severe COVID-19 respiratory failure once it develops. Given known diffuse pulmonary microthrombi on autopsy studies of COVID-19 patients, we hypothesized that tissue plasminogen activator (tPA) may improve pulmonary function in COVID-19 respiratory failure. Methods: A multicenter, retrospective, observational study of patients with confirmed COVID-19 and severe respiratory failure who received systemic tPA (alteplase) was performed. Seventy-nine adults from seven medical centers were included in the final analysis after institutional review boards' approval; 23 were excluded from analysis because tPA was administered for pulmonary macroembolism or deep venous thrombosis. The primary outcome was improvement in the PaO2/FiO2 ratio from baseline to 48 h after tPA. Linear mixed modeling was used for analysis. Results: tPA was associated with significant PaO2/FiO2 improvement at 48 h (estimated paired difference = 23.1 ± 6.7), which was sustained at 72 h (interaction term p < 0.00). tPA administration was also associated with improved National Early Warning Score 2 scores at 24, 48, and 72 h after receiving tPA (interaction term p = 0.00). D-dimer was significantly elevated immediately after tPA, consistent with lysis of formed clot. Patients with declining respiratory status preceding tPA administration had more marked improvement in PaO2/FiO2 ratios than those who had poor but stable (not declining) respiratory status. There was one intracranial hemorrhage, which occurred within 24 h following tPA administration. Conclusions: These data suggest tPA is associated with significant improvement in pulmonary function in severe COVID-19 respiratory failure, especially in patients whose pulmonary function is in decline, and has an acceptable safety profile in this patient population.

Social vulnerability is associated with increased morbidity following colorectal surgery.

INTRODUCTION: Neighborhood measures of social vulnerability encompassing multiple sociodemographic factors can be used to quantify disparities in outcomes. We hypothesize patients with high Social Vulnerability Index (SVI) are at increased risk of morbidity following colectomy. METHODS: We used local 2012-2017 National Surgical Quality Improvement Program (NSQIP) data to study colectomy patients, examining associations between SVI and postoperative outcomes. RESULTS: We included 976 patients from five hospitals. High SVI (>75th percentile) was associated with increased postoperative morbidity on unadjusted analysis (OR 1.84, 95% CI 1.35-2.52, p < 0.001); this association persisted after adjusting for demographics and comorbidities (OR 1.63, 95% CI 1.15-2.31, p = 0.005). The association with SVI was not significant after adjusting for perioperative risk modifiers such as emergent presentation (OR 1.37, 95% CI 0.95-1.98, p = 0.10). CONCLUSIONS: High social vulnerability is associated with increased postoperative complications. This effect appears mediated by perioperative risk factors, suggesting potential to improve outcomes by facilitating timely surgical intervention.

Development and validation of a prediction model for conversion of outpatient to inpatient surgery.

BACKGROUND: Unplanned hospital admission after intended outpatient surgery is an undesirable outcome. We aimed to develop a prediction model that estimates a patient's risk of conversion from outpatient surgery to inpatient hospitalization. METHODS: This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database, 2005 to 2018. Conversion from outpatient to inpatient surgery was defined as having outpatient surgery and >1 day hospital stay. The Surgical Risk Preoperative Assessment System was developed using multiple logistic regression on a training dataset (2005-2016) and compared to a model using the 26 relevant variables in the American College of Surgeons National Surgical Quality Improvement Program. The Surgical Risk Preoperative Assessment System was validated using a testing dataset (2017-2018). Performance statistics and Hosmer-Lemeshow plots were compared. Two high-risk definitions were compared: (1) the maximum Youden index, and (2) the cohort above the tenth decile of risk on the Hosmer-Lemeshow plot. The sensitivities, specificities, positive predictive values, negative predictive values, and accuracies were compared. RESULTS: In all, 2,822,379 patients were included; 3.6% of patients unexpectedly converted to inpatient. The 6-variable Surgical Risk Preoperative Assessment System model performed comparably to the 26-variable American College of Surgeons National Surgical Quality Improvement Program model (c-indices = 0.818 vs. 0.823; Brier scores = 0.0308 vs 0.0306, respectively). The Surgical Risk Preoperative Assessment System performed well on internal validation (c-index = 0.818, Brier score = 0.0341). The tenth decile of risk definition had higher specificity, positive predictive values, and accuracy than the maximum Youden index definition, while having lower sensitivity. CONCLUSION: The Surgical Risk Preoperative Assessment System accurately predicted a patient's risk of unplanned outpatient-to-inpatient conversion. Patients at higher risk should be considered for inpatient surgery, while lower risk patients could safely undergo operations at ambulatory surgery centers.

Development and Validation of a Multivariable Prediction Model for Postoperative Intensive Care Unit Stay in a Broad Surgical Population.

IMPORTANCE: Despite limited capacity and expensive cost, there are minimal objective data to guide postoperative allocation of intensive care unit (ICU) beds. The Surgical Risk Preoperative Assessment System (SURPAS) uses 8 preoperative variables to predict many common postoperative complications, but it has not yet been evaluated in predicting postoperative ICU admission. OBJECTIVE: To determine if the SURPAS model could accurately predict postoperative ICU admission in a broad surgical population. DESIGN, SETTING, AND PARTICIPANTS: This decision analytical model was a retrospective, observational analysis of prospectively collected patient data from the 2012 to 2018 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, which were merged with individual patients' electronic health record data to capture postoperative ICU use. Multivariable logistic regression modeling was used to determine how the 8 preoperative variables of the SURPAS model predicted ICU use compared with a model inputting all 28 preoperatively available NSQIP variables. Data included in the analysis were collected for the ACS NSQIP at 5 hospitals (1 tertiary academic center, 4 academic affiliated hospitals) within the University of Colorado Health System between January 1, 2012, and December 31, 2018. Included patients were those undergoing surgery in 9 surgical specialties during the 2012 to 2018 period. Data were analyzed from May 29 to July 30, 2021. EXPOSURE: Surgery in 9 surgical specialties, including general, gynecology, orthopedic, otolaryngology, plastic, thoracic, urology, vascular, and neurosurgery. MAIN OUTCOMES AND MEASURES: Use of ICU care up to 30 days after surgery. RESULTS: A total of 34 568 patients were included in the analytical data set: 32 032 (92.7%) in the cohort without postoperative ICU use and 2545 (7.4%) in the cohort with postoperative ICU use (no ICU use: mean [SD] age, 54.9 [16.6] years; 18 188 women [56.8%]; ICU use: mean [SD] age, 60.3 [15.3] years; 1333 men [52.4%]). For the internal chronologic validation of the 7-variable SURPAS model, data from 2012 to 2016 were used as the training data set (n = 24 250, 70.2% of the total sample size of 34 568) and data from 2017 to 2018 were used as the test data set (n = 10 318, 29.8% of the total sample size of 34 568). The C statistic improved in the test data set compared with the training data set (0.933; 95% CI, 0.924-0.941 vs 0.922; 95% CI, 0.917-0.928), whereas the Brier score was slightly worse in the test data set compared with the training data set (0.045; 95% CI, 0.042-0.048 vs 0.045; 95% CI, 0.043-0.047). The SURPAS model compared favorably with the model inputting all 28 NSQIP variables, with both having good calibration between observed and expected outcomes in the Hosmer-Lemeshow graphs and similar Brier scores (model inputting all variables, 0.044; 95% CI, 0.043-0.048; SURPAS model, 0.045; 95% CI, 0.042-0.046) and C statistics (model inputting all variables, 0.929; 95% CI, 0.925-0.934; SURPAS model, 0.925; 95% CI, 0.921-0.930). CONCLUSIONS AND RELEVANCE: Results of this decision analytical model study revealed that the SURPAS prediction model accurately predicted postoperative ICU use across a diverse surgical population. These results suggest that the SURPAS prediction model can be used to help with preoperative planning and resource allocation of limited ICU beds.

Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial.

BACKGROUND: Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS: This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS: A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION: Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE: Diagnostic test, level III.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

INTRODUCTION: Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians' perceptions of the impact of a multi-disciplinary debrief on OR culture. METHODS: A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated. RESULTS: Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture. CONCLUSIONS: Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.