Prospective Evaluation of a Dynamic Acuity Score for Regularly Assessing a Critically Ill Patient's Risk of Mortality.

OBJECTIVE: Predictive models developed for use in ICUs have been based on retrospectively collected data, which does not take into account the challenges associated with live, clinical data. This study sought to determine if a previously constructed predictive model of ICU mortality (ViSIG) is robust when using data collected prospectively in near real-time. DESIGN: Prospectively collected data were aggregated and transformed to evaluate a previously developed rolling predictor of ICU mortality. SETTING: Five adult ICUs at Robert Wood Johnson-Barnabas University Hospital and one adult ICU at Stamford Hospital. PATIENTS: One thousand eight hundred and ten admissions from August to December 2020. MEASUREMENTS AND MAIN RESULTS: The ViSIG Score, comprised of severity weights for heart rate, respiratory rate, oxygen saturation, mean arterial pressure, mechanical ventilation, and values for OBS Medical's Visensia Index. This information was collected prospectively, whereas data on discharge disposition was collected retrospectively to measure the ViSIG Score's accuracy. The distribution of patients' maximum ViSIG Score was compared with ICU mortality rate, and cut points determined where changes in mortality probability were greatest. The ViSIG Score was validated on new admissions. The ViSIG Score was able to stratify patients into three groups: 0-37 (low risk), 38-58 (moderate risk), and 59-100 (high risk), with mortality of 1.7%, 12.0%, and 39.8%, respectively ( p < 0.001). The sensitivity and specificity of the model to predict mortality for the high-risk group were 51% and 91%. Performance on the validation dataset remained high. There were similar increases across risk groups for length of stay, estimated costs, and readmission. CONCLUSIONS: Using prospectively collected data, the ViSIG Score produced risk groups for mortality with good sensitivity and excellent specificity. A future study will evaluate making the ViSIG Score visible to clinicians to determine whether this metric can influence clinician behavior to reduce adverse outcomes.

Improving elementary students' knowledge and behavior to prevent traumatic injury: the impact of a behavioral skills training model delivered by aspirational role models.

Trauma is the leading cause of childhood morbidity and mortality annually in the USA, accounting for 11% of deaths, most commonly due to car crashes, suffocation, drowning, and falls. Prevention is paramount for reducing the incidence of these injuries. As an adult level 1 and pediatric level 2 trauma center, there is a commitment to injury prevention through outreach and education. The Safety Ambassadors Program (SAP) was developed as part of this aim. Safety Ambassadors (SA) are high schoolers who teach elementary school students about safety/injury prevention. The curriculum addresses prevalent areas of injury risk: car/pedestrian safety, wheeled sports/helmets, and fall prevention. The study group hypothesized that participation in SAP leads to improved safety knowledge and behaviors and ultimately reduces childhood preventable injuries. Educational material was delivered by high school students (ages 16-18 years old). First and second-grade participants (ages 6-8 years old) completed pre- and post-course exams to assess knowledge (12 questions) and behavior (4 questions). Results were retrospectively reviewed, and pre/post training mean scores were calculated. Scores were calculated based on number of correct answers on pre/post exam. Comparisons were made using the Student t-test. All tests were 2-tailed with significance set at 0.05. Pre- and post-training results were assessed for 2016-2019. Twenty-eight high schools and 37 elementary schools were enrolled in the program with 8832 student participants in SAP. First graders demonstrated significant improvement in safety knowledge (pre 9 (95% CI 8.9-9.2) vs post 9.8 (95%CI 9.6-9.9), (p < 0.01)) and behavior modification (pre 3.2 (95%CI 3.1-3.2) vs post 3.6 (95% CI 3.5-3.6), (p < 0.01)). Similar findings were seen in 2nd graders: safety knowledge (pre 9.6 (95% CI 9.4-9.9) vs post 10.1 (95% CI 9.9-10.2), (p < 0.01)) and behavior (pre 3.3 (95% CI 3.1-3.4) vs post 3.5 (95%CI 3.4-3.6), (p < 0.01)).    Conclusion: SAP is a novel evidence-based educational program delivered to elementary school students by aspirational role models. This model is impactful, relatable, and engaging when provided by participants' older peer mentors. On a local level, it has demonstrated improved safety knowledge and behavior in elementary school students. As trauma is the leading cause of pediatric death and disability, enhanced education may lead to life-saving injury prevention in this vulnerable population. What is Known: • Preventable trauma is the leading cause of pediatric death in the USA and education has contributed to improvements in both safety knowledge and behavior. • The ideal delivery method for injury prevention education in children continues to be under investigation. What is New: • Our data suggest that a peer-based injury prevention model is both an effective education delivery method and easily instituted within existing school systems. • This study supports implementation of peer-based injury prevention programs to improve safety knowledge and practices. • With more widespread institution and research, we hope to ultimately reduce preventable childhood injury.

Traumatic Popliteal Artery Occlusion Following Lower Extremity Crush Injury Presenting With Isolated Patellar Dislocation.

While traumatic popliteal artery injury historically has a low incidence, failure to acutely recognize the vascular insult poses a significant risk of limb loss and functional impairment. A 71-year-old male presented with left lower extremity pain in setting of a crush injury working underneath a vehicle resulting in an isolated lateral dislocation of his patella and complete occlusion of the distal popliteal artery. He was taken to the operating room for an in-situ bypass and four-compartment fasciotomy. His hospital stay included three staged washouts/debridements with eventual closure. He was discharged after 38 days to a rehabilitation facility with ability to self-ambulate with assistance within one month. This patient's presentation is unique for his isolated patellar dislocation without associated injuries characteristically associated with a traumatic vascular injury of the popliteal artery and serves to remind the importance of complete examination in the setting of blunt trauma.

Developing a National Trauma Research Action Plan: Results from the postadmission critical care research gap Delphi survey.

INTRODUCTION: The 2016 National Academies of Science, Engineering and Medicine report included a proposal to establish a National Trauma Research Action Plan. In response, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care from prehospital care to rehabilitation as part of an overall strategy to achieve zero preventable deaths and disability after injury. The Postadmission Critical Care Research panel was 1 of 11 panels constituted to develop this research agenda. METHODS: We recruited interdisciplinary experts in surgical critical care and recruited them to identify current gaps in clinical critical care research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. The first of four survey rounds asked participants to generate key research questions. On subsequent rounds, we asked survey participants to rank the priority of each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category. RESULTS: Twenty-five subject matter experts generated 595 questions. By Round 3, 249 questions reached ≥60% consensus. Of these, 22 questions were high, 185 were medium, and 42 were low priority. The clinical states of hypovolemic shock and delirium were most represented in the high-priority questions. Traumatic brain injury was the only specific injury pattern with a high-priority question. CONCLUSION: The National Trauma Research Action Plan critical care research panel identified 22 high-priority research questions, which, if answered, would reduce preventable death and disability after injury. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

Age is But a Number: Damage Control Surgery Outcomes in Geriatric Emergency General Surgery.

BACKGROUND: Damage control surgery (DCS) with temporary abdominal closure (TAC) is increasingly utilized in emergency general surgery (EGS). As the population ages, more geriatric patients (GP) are undergoing EGS operations. Concern exists for GP's ability to tolerate DCS. We hypothesize that DCS in GP does not increase morbidity or mortality and has similar rates of primary closure compared to non-geriatric patients (NGP). METHODS: A retrospective chart review from 2014-2020 was conducted on all non-trauma EGS patients who underwent DCS with TAC. Demographics, admission lab values, fluid amounts, length of stay (LOS), timing of closure, post-operative complications and mortality were collected. GP were compared to NGP and results were analyzed using Chi square and Wilcox signed rank test. RESULTS: Ninety-eight patients (n = 50, <65 y; n = 48, ≥65 y) met inclusion criteria. There was no significant difference in median number of operations (3 versus 2), time to primary closure (2.5 versus 3 d), hospital LOS (19 versus 17.5 d), ICU LOS (11 versus 8 d), rate of primary closure (66% versus 56%), post op ileus (44% versus 48%), abscess (14% versus 10%), need for surgery after closure (32% versus 19%), anastomotic dehiscence (16% versus 6%), or mortality (34% versus 42%). Average time until take back after index procedure did not vary significantly between young and elderly group (45.8 versus 38.5 h; P = 0.89). GP were more likely to have hypertension (83% versus 50%; P ≤ 0.05), atrial fibrillation (25% versus 4%; P ≤ 0.05) and lower median heart rate compared to NGP (90 versus 103; P ≤ 0.05). CONCLUSIONS: DCS with TAC in geriatric EGS patients achieves similar outcomes and mortality to younger patients. Indication, not age, should factor into the decision to perform DCS.

External validation of urinary C-C motif chemokine ligand 14 (CCL14) for prediction of persistent acute kidney injury.

BACKGROUND: Persistent acute kidney injury (AKI) portends worse clinical outcomes and remains a therapeutic challenge for clinicians. A recent study found that urinary C-C motif chemokine ligand 14 (CCL14) can predict the development of persistent AKI. We aimed to externally validate urinary CCL14 for the prediction of persistent AKI in critically ill patients. METHODS: This was a secondary analysis of the prospective multi-center SAPPHIRE study. We evaluated critically ill patients with cardiac and/or respiratory dysfunction who developed Kidney Disease: Improving Global Outcomes (KDIGO) stage 2-3 AKI within one week of enrollment. The main exposure was the urinary concentration of CCL14 measured at the onset of AKI stage 2-3. The primary endpoint was the development of persistent severe AKI, defined as ≥ 72 h of KDIGO stage 3 AKI or death or renal-replacement therapy (RRT) prior to 72 h. The secondary endpoint was a composite of RRT and/or death by 90 days. We used receiver operating characteristic (ROC) curve analysis to assess discriminative ability of urinary CCL14 for the development of persistent severe AKI and multivariate analysis to compare tertiles of urinary CCL14 and outcomes. RESULTS: We included 195 patients who developed KDIGO stage 2-3 AKI. Of these, 28 (14%) developed persistent severe AKI, of whom 15 had AKI ≥ 72 h, 12 received RRT and 1 died prior to ≥ 72 h of KDIGO stage 3 AKI. Persistent severe AKI was associated with chronic kidney disease, diabetes mellitus, higher non-renal APACHE III score, greater fluid balance, vasopressor use, and greater change in baseline serum creatinine. The AUC for urinary CCL14 to predict persistent severe AKI was 0.81 (95% CI, 0.72-0.89). The risk of persistent severe AKI increased with higher values of urinary CCL14. RRT and/or death at 90 days increased within tertiles of urinary CCL14 concentration. CONCLUSIONS: This secondary analysis externally validates urinary CCL14 to predict persistent severe AKI in critically ill patients.

Fever in the ICU: A Predictor of Mortality in Mechanically Ventilated COVID-19 Patients.

PURPOSE: While fever may be a presenting symptom of COVID-19, fever at hospital admission has not been identified as a predictor of mortality. However, hyperthermia during critical illness among ventilated COVID-19 patients in the ICU has not yet been studied. We sought to determine mortality predictors among ventilated COVID-19 ICU patients and we hypothesized that fever in the ICU is predictive of mortality. MATERIALS AND METHODS: We conducted a retrospective cohort study of 103 ventilated COVID-19 patients admitted to the ICU between March 14 and May 27, 2020. Final follow-up was June 5, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. RESULTS: 103 patients were included, 40 survived and 63(61.1%) died. Deceased patients were older {66 years[IQR18] vs 62.5[IQR10], (p = 0.0237)}, more often male {48(68%) vs 22(55%), (p = 0.0247)}, had lower initial oxygen saturation {86.0%[IQR18] vs 91.5%[IQR11.5], (p = 0.0060)}, and had lower pH nadir than survivors {7.10[IQR0.2] vs 7.30[IQR0.2] (p < 0.0001)}. Patients had higher peak temperatures during ICU stay as compared to hospital presentation {103.3°F[IQR1.7] vs 100.0°F[IQR3.5], (p < 0.0001)}. Deceased patients had higher peak ICU temperatures than survivors {103.6°F[IQR2.0] vs 102.9°F[IQR1.4], (p = 0.0008)}. Increasing peak temperatures were linearly associated with mortality. Febrile patients who underwent targeted temperature management to achieve normothermia did not have different outcomes than those not actively cooled. Multivariable analysis revealed 60% and 75% higher risk of mortality with peak temperature greater than 103°F and 104°F respectively; it also confirmed hyperthermia, age, male sex, and acidosis to be predictors of mortality. CONCLUSIONS: This is one of the first studies to identify ICU hyperthermia as predictive of mortality in ventilated COVID-19 patients. Additional predictors included male sex, age, and acidosis. With COVID-19 cases increasing, identification of ICU mortality predictors is crucial to improve risk stratification, resource management, and patient outcomes.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey.

BACKGROUND: A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings. METHODS: Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact. RESULTS: Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment. CONCLUSION: This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Nutrition Education on the Wards: A Self-Study Module for Improving Medical Student Knowledge of Nutrition Assessment and Interventions.

Introduction: Nutrition plays a key role in the prevention and treatment of disease. Hospitalized patients are often malnourished, which is a major contributor to medical complications, decreased quality of life, lengthened medical stay, increased health care costs, and mortality. However, medical students continue to have inadequate education in nutrition and report feeling poorly trained in nutrition. We proposed an online module that could be used by medical students as a self-study activity to learn about key signs for the diagnosis of malnutrition and the nutrition interventions available in the hospital setting. Methods: Third- and fourth-year medical students at Rutgers Robert Wood Johnson Medical School in medicine, surgery, and critical care clerkships were given access to an online nutrition education module discussing the signs of malnutrition in hospitalized patients and the interventions available in the inpatient setting. A premodule and postmodule survey was given via email at the beginning and at the end of the clerkship. A one-sample t test was used to assess the relationship between the mean scores of the pre- and postmodule surveys. Results: One hundred nine out of 255 students responded to the premodule survey. Thirty-two students completed the module and postmodule survey. There was a significant difference in mean scores between students who completed the module and postmodule survey compared to the overall student population prior to having access to the module. Discussion: Medical students have limited training in nutrition education, and our findings show that a self-study online module can improve students' knowledge.

Trauma Service Utilization Increases Cost But Does Not Add Value for Minimally Injured Patients.

OBJECTIVE: Trauma care provides value to the critically injured. Our aim was to assess whether trauma team involvement adds value to the care of minimally injured patients and to define its costs. METHODS: Minimally injured patients admitted to a trauma center were propensity matched and compared by involvement versus no involvement of the trauma service (TS). Demographics, injury severity, complications, length of emergency department stay, mortality, and hospital costs and charges were studied. RESULTS: A total of 1253 patients were enrolled, with 308 propensity matched to the following groups: TS (n = 102) and no TS (n = 206). TS demonstrated a 30% increase in total charges and costs with no difference in complications. TS did demonstrate decreased time in the emergency department but had an increased delay to operation. Findings were similar when stratified for only lower extremity injuries. CONCLUSIONS: TS involvement for minimally injured patients does not increase value. Reducing TS involvement while avoiding trauma undertriage may reduce costs to the healthcare system without affecting outcomes.

Identification and validation of biomarkers of persistent acute kidney injury: the RUBY study.

PURPOSE: The aim of the RUBY study was to evaluate novel candidate biomarkers to enable prediction of persistence of renal dysfunction as well as further understand potential mechanisms of kidney tissue damage and repair in acute kidney injury (AKI). METHODS: The RUBY study was a multi-center international prospective observational study to identify biomarkers of the persistence of stage 3 AKI as defined by the KDIGO criteria. Patients in the intensive care unit (ICU) with moderate or severe AKI (KDIGO stage 2 or 3) were enrolled. Patients were to be enrolled within 36 h of meeting KDIGO stage 2 criteria. The primary study endpoint was the development of persistent severe AKI (KDIGO stage 3) lasting for 72 h or more (NCT01868724). RESULTS: 364 patients were enrolled of whom 331 (91%) were available for the primary analysis. One hundred ten (33%) of the analysis cohort met the primary endpoint of persistent stage 3 AKI. Of the biomarkers tested in this study, urinary C-C motif chemokine ligand 14 (CCL14) was the most predictive of persistent stage 3 AKI with an area under the receiver operating characteristic curve (AUC) (95% CI) of 0.83 (0.78-0.87). This AUC was significantly greater than values for other biomarkers associated with AKI including urinary KIM-1, plasma cystatin C, and urinary NGAL, none of which achieved an AUC > 0.75. CONCLUSION: Elevated urinary CCL14 predicts persistent AKI in a large heterogeneous cohort of critically ill patients with severe AKI. The discovery of CCL14 as a predictor of persistent AKI and thus, renal non-recovery, is novel and could help identify new therapeutic approaches to AKI.

Surgeons in surge - the versatility of the acute care surgeon: outcomes of COVID-19 ICU patients in a community hospital where all ICU patients are managed by surgical intensivists.

BACKGROUND: Reported characteristics and outcomes of critically ill patients with COVID-19 admitted to the intensive care unit (ICU) are widely disparate with varying mortality rates. No literature describes outcomes in ICU patients with COVID-19 managed by an acute care surgery (ACS) division. Our ACS division manages all ICU patients at a community hospital in New Jersey. When that hospital was overwhelmed and in crisis secondary to COVID-19, we sought to describe outcomes for all patients with COVID-19 admitted to our closed ICU managed by the ACS division. METHODS: This was a prospective case series of the first 120 consecutive patients with COVID-19 admitted on March 14 to May 10, 2020. Final follow-up was May 27, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. RESULTS: One hundred and twenty patients were included (median age 64 years (range 25-89), 66.7% men). The most common comorbidities were hypertension (75; 62.5%), obesity (61; 50.8%), and diabetes (50; 41.7%). One hundred and thirteen (94%) developed acute respiratory distress syndrome, 89 (74.2%) had shock, and 76 (63.3%) experienced acute kidney injury. One hundred (83.3%) required invasive mechanical ventilation (IMV). Median ICU length of stay (LOS) was 8.5 days (IQR 9), hospital LOS was 14.5 days (IQR 13). Mortality for all ICU patients with COVID-19 was 53.3% and 62% for IMV patients. CONCLUSIONS: This is the first report of patients with COVID-19 admitted to a community hospital ICU managed by an ACS division who also provided all surge care. Mortality of critically ill patients with COVID-19 admitted to an overwhelmed hospital in crisis may not be as high as initially thought based on prior reports. While COVID-19 is a non-surgical disease, ACS divisions have the capability of successfully caring for both surgical and medical critically ill patients, thus providing versatility in times of crisis. LEVEL OF EVIDENCE: Level V.

Failure to rescue in the surgical patient: a review.

PURPOSE OF REVIEW: Evaluating patient outcomes is essential in a healthcare environment focused on quality. Mortality after surgery has been considered a useful quality metric. More important than mortality rate, failure to rescue (FTR) has emerged as a metric that is important and may be improveable. The purpose of this review is to define FTR, describe patient and hospital level factors that lead to FTR, and highlight possible solutions to this problem. RECENT FINDINGS: FTR is defined as a death following a complication. Depending on the patient population, FTR rates vary from less than 1% to over 40%. Numerous patient factors including frailty, congestive heart failure (CHF), renal failure, serum albumin <3.5, COPD, cirrhosis, and higher ASA class may predispose patients to FTR. Hospital factors including technology, teaching status, increased nurse-to-patient ratios, and closed ICUs may help reduce FTR. More difficult to measure variables, such as hospital culture and teamwork may also influence FTR rates. Early warning systems may allow earlier identification of the deteriorating patient. SUMMARY: FTR is a major clinical concern and efforts aimed at optimizing patient and hospital factors, culture and communication, as well as early identification of the deteriorating patient may improve FTR rate.

A review of early warning systems for prompt detection of patients at risk for clinical decline.

Early Warning Scores (EWS) are a composite evaluation of a patient's basic physiology, changes of which are the first indicators of clinical decline and are used to prompt further patient assessment and when indicated intervention. These are sometimes referred to as "track and triggers systems" with tracking meant to denote periodic observation of physiology and trigger being a predetermined response criteria. This review article examines the most widely used EWS, with special attention paid to those used in military and trauma populations.The earliest EWS is the Modified Early Earning Score (MEWS). In MEWS, points are allocated to vital signs based on their degree of abnormality, and summed to yield an aggregate score. A score above a threshold would elicit a clinical response such as a rapid response team. Modified Early Earning Score was subsequently followed up with the United Kingdom's National Early Warning Score, the electronic cardiac arrest triage score, and the 10 Signs of Vitality score, among others.Severity of illness indicators have been in military and civilian trauma populations, such as the Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity. The sequential organ failure assessment score and its attenuated version quick sequential organ failure assessment were developed to aggressively identify patients near septic shock.Effective EWS have certain characteristics. First, they should accurately capture vital signs information. Second, almost all data should be derived electronically rather than manually. Third, the measurements should take into consideration multiple organ systems. Finally, information that goes into an EWS must be captured in a timely manner. Future trends include the use of machine learning to detect subtle changes in physiology and the inclusion of data from biomarkers. As EWS improve, they will be more broadly used in both military and civilian environments. LEVEL OF EVIDENCE: Review article, level I.

AAST Critical Care Committee clinical consensus: ECMO, nutrition.

The American Association for the Surgery of Trauma Critical Care Committee has developed clinical consensus guides to help with practical answers based on the best evidence available. These are focused in areas in which the levels of evidence may not be that strong and are based on a combination of expert consensus and research. Overall, quality of the research is mixed, with many studies suffering from small numbers and issues with bias. The first two of these focus on the use of extracorporeal membrane oxygenation in trauma patients and nutrition for the critically ill surgical/trauma patient.

Increased Healthcare-Associated Infections in a Surgical Intensive Care Unit Related to Boarding Non-Surgical Patients.

Background: Hospital over-capacity often forces boarding patients outside of their designated intensive care unit (ICU). Anecdotal evidence suggested medical intensive care unit (MICU) patients boarding in the surgical intensive care unit (SICU) were responsible for increases in healthcare-associated infection (HAI) rates. We studied the effect of ICU boarding on rates of SICU HAIs. Methods: This single-center, retrospective two-year database study compared primary SICU patients (Home) to MICU patients boarding in the SICU (Boarders). Variables studied included age, gender, Acute Physiology and Chronic Health Evaluation III (APACHE III) scores, and comorbidities. Healthcare-associated infections included Clostridium difficile infection, catheter-associated urinary tract infections, central line-associated blood stream infection, and ventilator-associated pneumonia. Student t-test, Fisher exact testing, and a multivariable regression model were used to determine the significance of associations. Results: A total of 2,562 patients were included in the study; 328 (12.8%) were Boarders and 2,234 (87.2%) were Home. Univariable analysis demonstrated that Boarders were older (64.0 ± 16.9 vs. 60.2 ± 17.4), more severely ill (APACHE III score 70.5 ± 31.1 vs. 53.4 ± 21.9), more likely to have cirrhosis, coronary artery disease, and asthma/chronic obstructive pulmonary disease, but less likely to have hypertension. On univariable analysis boarding was associated with an increase HAI rate (19 HAI/1,000 patient days vs. 6.2, p < 0.001). Multivariable regression modeling demonstrated boarding status remained independently associated with HAI (odds ratio [OR] 1.83 95% confidence interval [CI] 1.02-3.27). Cost estimates demonstrated an additional cost of $83,303 per 1,000 patient days. Conclusion: The practice of hospital boarding is associated with development of HAI and increased hospital costs. Efforts at determining the cause of this increase and then reducing HAIs will improve patient care and help hospital budgets.

Multimodality Monitoring in Neurocritical Care: Decision-Making Utilizing Direct And Indirect Surrogate Markers.

Substantial progress has been made to create innovative technology that can monitor the different physiological characteristics that precede the onset of secondary brain injury, with the ultimate goal of intervening prior to the onset of irreversible neurological damage. One of the goals of neurocritical care is to recognize and preemptively manage secondary neurological injury by analyzing physiologic markers of ischemia and brain injury prior to the development of irreversible damage. This is helpful in a multitude of neurological conditions, whereby secondary neurological injury could present including but not limited to traumatic intracranial hemorrhage and, specifically, subarachnoid hemorrhage, which has the potential of progressing to delayed cerebral ischemia and monitoring postneurosurgical interventions. In this study, we examine the utilization of direct and indirect surrogate physiologic markers of ongoing neurologic injury, including intracranial pressure, cerebral blood flow, and brain metabolism.

Surgical management of pancreatic necrosis: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. METHODS: A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. RESULTS: Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. CONCLUSION: Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. LEVEL OF EVIDENCE: Systematic review/guideline, level III.

Case report of EUS-guided endoscopic transduodenal necrosectomy in a patient with sleeve gastrectomy.

BACKGROUND: After an acute attack of pancreatitis, walled-off pancreatic fluid collections (PFC) occur in approximately 10 % of cases. Drainage of the cavity is recommended when specific indications are met. Endoscopic drainage has been adopted as the main intervention for symptomatic walled-off PFC. Altered gastric anatomy in these patients poses an interesting challenge. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN). CASE PRESENTATION: Forty year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 was found to have symptomatic gallstone disease complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging significant for 10.8 × 7.6 cm fluid collection with necrotic debris in the body and tail of the pancreas and endoscopic necrosectomy was attempted. EGD showed tubular gastric body and antrum, with extrinsic compression in the antrum and duodenal bulb from the pancreatic cyst. Duodenal bulb was selected as the preferred fistula site due to sleeve gastrectomy. Patient underwent successful TDN in two sessions. Patient had symptomatic improvement at follow-up with resolution of WOPN. CONCLUSION: To our knowledge, this is the first reported case of EUS-guided endoscopic necrosectomy in a patient with sleeve gastrectomy. The duodenal approach was used in our patient due to history of sleeve gastrectomy.

TIMP2•IGFBP7 biomarker panel accurately predicts acute kidney injury in high-risk surgical patients.

BACKGROUND: Acute kidney injury (AKI) is an important complication in surgical patients. Existing biomarkers and clinical prediction models underestimate the risk for developing AKI. We recently reported data from two trials of 728 and 408 critically ill adult patients in whom urinary TIMP2•IGFBP7 (NephroCheck, Astute Medical) was used to identify patients at risk of developing AKI. Here we report a preplanned analysis of surgical patients from both trials to assess whether urinary tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) accurately identify surgical patients at risk of developing AKI. STUDY DESIGN: We enrolled adult surgical patients at risk for AKI who were admitted to one of 39 intensive care units across Europe and North America. The primary end point was moderate-severe AKI (equivalent to KDIGO [Kidney Disease Improving Global Outcomes] stages 2-3) within 12 hours of enrollment. Biomarker performance was assessed using the area under the receiver operating characteristic curve, integrated discrimination improvement, and category-free net reclassification improvement. RESULTS: A total of 375 patients were included in the final analysis of whom 35 (9%) developed moderate-severe AKI within 12 hours. The area under the receiver operating characteristic curve for [TIMP-2]•[IGFBP7] alone was 0.84 (95% confidence interval, 0.76-0.90; p < 0.0001). Biomarker performance was robust in sensitivity analysis across predefined subgroups (urgency and type of surgery). CONCLUSION: For postoperative surgical intensive care unit patients, a single urinary TIMP2•IGFBP7 test accurately identified patients at risk for developing AKI within the ensuing 12 hours and its inclusion in clinical risk prediction models significantly enhances their performance. LEVEL OF EVIDENCE: Prognostic study, level I.