Social Determinants of Health and Limitation of Life-Sustaining Therapy in Neurocritical Care: A CHoRUS Pilot Project.

BACKGROUND: Social determinants of health (SDOH) have been linked to neurocritical care outcomes. We sought to examine the extent to which SDOH explain differences in decisions regarding life-sustaining therapy, a key outcome determinant. We specifically investigated the association of a patient's home geography, individual-level SDOH, and neighborhood-level SDOH with subsequent early limitation of life-sustaining therapy (eLLST) and early withdrawal of life-sustaining therapy (eWLST), adjusting for admission severity. METHODS: We developed unique methods within the Bridge to Artificial Intelligence for Clinical Care (Bridge2AI for Clinical Care) Collaborative Hospital Repository Uniting Standards for Equitable Artificial Intelligence (CHoRUS) program to extract individual-level SDOH from electronic health records and neighborhood-level SDOH from privacy-preserving geomapping. We piloted these methods to a 7 years retrospective cohort of consecutive neuroscience intensive care unit admissions (2016-2022) at two large academic medical centers within an eastern Massachusetts health care system, examining associations between home census tract and subsequent occurrence of eLLST and eWLST. We matched contextual neighborhood-level SDOH information to each census tract using public data sets, quantifying Social Vulnerability Index overall scores and subscores. We examined the association of individual-level SDOH and neighborhood-level SDOH with subsequent eLLST and eWLST through geographic, logistic, and machine learning models, adjusting for admission severity using admission Glasgow Coma Scale scores and disorders of consciousness grades. RESULTS: Among 20,660 neuroscience intensive care unit admissions (18,780 unique patients), eLLST and eWLST varied geographically and were independently associated with individual-level SDOH and neighborhood-level SDOH across diagnoses. Individual-level SDOH factors (age, marital status, and race) were strongly associated with eLLST, predicting eLLST more strongly than admission severity. Individual-level SDOH were more strongly predictive of eLLST than neighborhood-level SDOH. CONCLUSIONS: Across diagnoses, eLLST varied by home geography and was predicted by individual-level SDOH and neighborhood-level SDOH more so than by admission severity. Structured shared decision-making tools may therefore represent tools for health equity. Additionally, these findings provide a major warning: prognostic and artificial intelligence models seeking to predict outcomes such as mortality or emergence from disorders of consciousness may be encoded with self-fulfilling biases of geography and demographics.

Evaluation of Frailty Assessment Compliance in Acute Care Surgery: Changing Trends, Lessons Learned.

BACKGROUND: Routine frailty assessment has emerged recently in the surgical literature and is an important prognostication and risk stratification tool. The aim of our study was to review our 7-y experience with two frailty assessment tools and changing trends in their use. METHODS: We performed a 7-y (2011-2017) analysis of our prospectively maintained frailty database. Frail patients were identified using the emergency general surgery and trauma specific frailty indices. Outcome measures were rates of compliance with frailty assessment, overall complications, discharge to skilled nursing facility (SNF)/rehab, and mortality over the study period. Multivariate logistic regression and Cochran-Armitage trend analyses were performed. RESULTS: We evaluated a total of 1045 geriatric patients (Trauma: 587, EGS: 458). Mean age was 74.5 ± 7.9 y, 74% were males, and 81% were white. Overall, 34% of the patients were frail. Compared to non-frail patients, frail patients had higher adjusted rates of complications (OR 2.4 [1.9-2.9]), mortality (OR 1.8 [1.4-2.3]), and rehab/SNF disposition (OR 3.7 [3.1-4.3]). The compliance rate of measuring frailty increased from 12% in 2011 to 78% in 2017, P < 0.001 (Figure). The complication rate decreased (33% versus 21%, P < 0.001), while the rate of discharge disposition to SNF/Rehab increased (41% versus 58%, P < 0.001). There was no difference in mortality (11% versus 9.8%, P = 0.48) over the study period. CONCLUSIONS: Adherence to frailty measurement increased over the study period. This was accompanied by a significant decline in overall in-hospital complications. Frailty indices can be utilized to identify high-risk patients and develop post-operative strategies to improve outcomes in acute care surgery.

Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank.

INTRODUCTION: Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level. METHODS: We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis. RESULTS: We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers. CONCLUSION: Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.

Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma.

BACKGROUND: Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS: The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS: MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE: Level III Prognostic.

Open Versus Laparoscopic Repair of Traumatic Diaphragmatic Injury: A Nationwide Propensity-Matched Analysis.

INTRODUCTION: Minimally invasive surgical techniques have become routinely applied in the evaluation and treatment of patients with isolated traumatic diaphragmatic injuries (TDI). However, there remains a paucity of data that compares the laparoscopic repair to the open repair approach. The aim of our study is to examine patient outcomes between TDI patients managed laparoscopically versus those managed using open repair. METHODS: Adult (age ≥18 years) trauma patients presenting with TDI that required surgical repair were identified in the Trauma Quality Improvement Program database 2017. Patients were excluded if they underwent any other surgical procedure of the abdomen or chest. Patients were then stratified into 2 groups based on the surgical approach: laparoscopic repair of the diaphragm versus open repair. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were in-hospital major complications and length of stay (LOS). Secondary outcome measure was in-hospital mortality. RESULTS: A total of 177 adult trauma patients who had a laparoscopic repair of their isolated diaphragmatic injury were matched to 354 patients who had an open repair. Mean age was 35 ± 16 years, 78% were male, and mean BMI was 27 ± 7 kg/m2. 67 percent of the patients had penetrating injuries, and the median ISS was 17 [9-21]. CT imaging was done in 67% of the patients, with 71% presenting with left-sided injury and 21% having visceral herniation. Conversion from laparoscopic to open was reported in 7.3% of the cases. Patients with a laparoscopic repair had significantly lower rates of major complications (5.6 versus 14.4%; P<0.001), shorter hospital LOS (6 [3-9] versus 9 [5-13] days; P<0.001) and ICU LOS (3 [2-7] versus 5 [2-10] days; P<0.001). No difference was found in rates of in-hospital mortality (0.6 versuss 2.0%; P = 0.129) between the 2 groups. CONCLUSION: Laparoscopic repair of traumatic diaphragmatic injury was associated with decreased morbidity and a shorter hospital course, with a low conversion rate to open repair. Future studies remain necessary to further explore the long-term outcomes of patients with such injury. LEVEL OF EVIDENCE: Level III STUDY TYPE: Therapeutic.

Racial and Ethnic Disparities in Frail Geriatric Trauma Patients.

BACKGROUND: Frailty in geriatric trauma patients is commonly associated with adverse outcomes. Racial disparities in geriatric trauma patients are previously described in the literature. We aimed to assess whether race and ethnicity influence outcomes in frail geriatric trauma patients. METHODS: We performed a 1-year (2017) analysis of TQIP including all geriatric (age ≥ 65 years) trauma patients. The frailty index was calculated using 11-variables and a cutoff limit of 0.27 was defined for frail status. Multivariate regression analysis was performed to control for demographics, insurance status, injury parameters, vital signs, and ICU and hospital length of stay. RESULTS: We included 41,111 frail geriatric trauma patients. In terms of race, among frail geriatric trauma patients, 35,376 were Whites and 2916 were African Americans; in terms of ethnicity, 37,122 were Non-Hispanics and 2184 were Hispanics. On regression analysis, the White race was associated with higher odds of mortality (OR, 1.5; 95% CI, 1.2-2.0; p < 0.01) and in-hospital complications (OR, 1.4; 95% CI, 1.1-1.9; p < 0.01). White patients were more likely to be discharged to SNF (OR, 1.2; 95% CI, 1.1-1.4; p = 0.03) and less likely to be discharged home (p = 0.04) compared to African Americans. Non-Hispanics were more likely to be discharged to SNF (OR, 1.3; 95% CI, 1.1-1.5; p < 0.01) and less likely to be discharged home (p < 0.01) as compared to Hispanics. No significant difference in in-hospital mortality was seen between Hispanics and Non-Hispanics. CONCLUSION: Race and ethnicity influence outcomes in frail geriatric trauma patients. These disparities exist regardless of age, gender, injury severity, and insurance status. Further studies are needed to highlight disparities by race and ethnicity and to identify potentially modifiable risk factors in the geriatric trauma population.

Transfer of acute care surgery patients in a rural state: a concerning trend.

BACKGROUND: Regionalized care of complex patients to larger hospitals is an increasingly common practice as the population ages and the physician shortage evolves. The Acute Care Surgery model is new, and there are limited data on the patients being transferred through this system. We hypothesized transfer patients would be older, more complex, and require additional resources. MATERIALS AND METHODS: Retrospective chart review of Acute Care Surgery patients admitted to a single tertiary facility. Patient demographics, clinical presentation, and outcomes were obtained. RESULTS: We found that our 161 transferred patients (TPs) were older (61.2 versus 54.7 y [P < 0.001]), had more comorbidities (Charlson Comorbidity Index 4 versus 3.1 [P < 0.001]), and required more resources than 611 local patients (LP; length of stay 8.2 versus 3.4 [P < 0.001], intensive care unit admission 24% versus 6% of patients [P < 0.001]). Admission diagnosis was similar, with pancreaticobiliary (TP 29% versus LP 30%) and small bowel (TP 25% versus LP 23%) complaints most common. Most common intervention was laparoscopic cholecystectomy for both (29% versus 25%). Subspecialty interventions were similar (IR, advanced endoscopy) at TP 10% and LP 8%. TPs were more likely to not require a procedure (31% versus 23%). Insurance provider differed between groups, particularly for Medicare (55% versus 34%) and privately insured (26% versus 45%). CONCLUSIONS: Although this study confirms transfer patients need the resources for which they were referred to a tertiary center, we unexpectedly found nearly half of transfer patients undergo basic surgical procedures or do not require intervention. This points to a concerning lack of general surgery resources in the community.

Interpretation and Use of Applied/Operational Machine Learning and Artificial Intelligence in Surgery.

Applications for artificial intelligence (AI) and machine learning in surgery include image interpretation, data summarization, automated narrative construction, trajectory and risk prediction, and operative navigation and robotics. The pace of development has been exponential, and some AI applications are working well. However, demonstrations of clinical utility, validity, and equity have lagged algorithm development and limited widespread adoption of AI into clinical practice. Outdated computing infrastructure and regulatory challenges which promote data silos are key barriers. Multidisciplinary teams will be needed to address these challenges and to build AI systems that are relevant, equitable, and dynamic.

Early COVID-19 respiratory risk stratification using machine learning.

Background: COVID-19 has strained healthcare systems globally. In this and future pandemics, providers with limited critical care experience must distinguish between moderately ill patients and those who will require aggressive care, particularly endotracheal intubation. We sought to develop a machine learning-informed Early COVID-19 Respiratory Risk Stratification (ECoRRS) score to assist in triage, by providing a prediction of intubation within the next 48 hours based on objective clinical parameters. Methods: Electronic health record data from 3447 COVID-19 hospitalizations, 20.7% including intubation, were extracted. 80% of these records were used as the derivation cohort. The validation cohort consisted of 20% of the total 3447 records. Multiple randomizations of the training and testing split were used to calculate confidence intervals. Data were binned into 4-hour blocks and labeled as cases of intubation or no intubation within the specified time frame. A LASSO (least absolute shrinkage and selection operator) regression model was tuned for sensitivity and sparsity. Results: Six highly predictive parameters were identified, the most significant being fraction of inspired oxygen. The model achieved an area under the receiver operating characteristic curve of 0.789 (95% CI 0.785 to 0.812). At 90% sensitivity, the negative predictive value was 0.997. Discussion: The ECoRRS score enables non-specialists to identify patients with COVID-19 at risk of intubation within 48 hours with minimal undertriage and enables health systems to forecast new COVID-19 ventilator needs up to 48 hours in advance. Level of evidence: IV.

Fibrinogen supplementation for the trauma patient: Should you choose fibrinogen concentrate over cryoprecipitate?

BACKGROUND: Trauma-induced coagulopathy is frequently associated with hypofibrinogenemia. Cryoprecipitate (Cryo), and fibrinogen concentrate (FC) are both potential means of fibrinogen supplementation. The aim of this study was to compare the outcomes of traumatic hemorrhagic patients who received fibrinogen supplementation using FC versus Cryo. METHODS: We performed a 2-year (2016-2017) retrospective cohort analysis of the American College of Surgeons Trauma Quality Improvement Program database. All adult trauma patients (≥18 years) who received FC or Cryo as an adjunct to resuscitation were included. Patients with bleeding disorders, chronic liver disease, and those on preinjury anticoagulants were excluded. Patients were stratified into those who received FC, and those who received Cryo. Propensity score matching (1:2) was performed. Outcome measures were transfusion requirements, major complications, hospital, and intensive care unit lengths of stay, and mortality. RESULTS: A matched cohort of 255 patients who received fibrinogen supplementation (85 in FC, 170 in Cryo) was analyzed. Overall, the mean age was 41 ± 19 years, 74% were male, 74% were white and median Injury Severity Score was 26 (22-30). Compared with the Cryo group, the FC group required less units of packed red blood cells, fresh frozen plasma, and platelets, and had shorter in-hospital and intensive care unit length of stay. There were no significant differences between the two groups in terms of major in-hospital complications and mortality. CONCLUSION: Fibrinogen supplementation in the form of FC for the traumatic hemorrhagic patient is associated with improved outcomes and reduced transfusion requirements as compared with Cryo. Further studies are required to evaluate the optimal method of fibrinogen supplementation in the resuscitation of trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

After 9,000 laparotomies for blunt trauma, resuscitation is becoming more balanced and time to intervention shorter: Evidence in action.

BACKGROUND: Several advancements in hemorrhage control have been advocated for in the past decade, including balanced transfusions and earlier times to intervention. The aim of this study was to examine the effect of these advancements on outcomes of blunt trauma patients undergoing emergency laparotomy. METHODS: This is a 5-year (2013-2017) analysis of the Trauma Quality Improvement Program. Adult (18 years or older) blunt trauma patients with early (≤4 hours) packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions and an emergency (≤4 hours) laparotomy for hemorrhage control were identified. Time-trend analysis of 24-hour mortality, PRBC/FFP ratio, and time to laparotomy was performed over the study period. The association between mortality and PRBC/FFP ratio, patient demographics, injury characteristics, transfusion volumes, and American College of Surgeons verification level was examined by hierarchical regression analysis adjusting for interyear variability. RESULTS: A total of 9,773 blunt trauma patients with emergency laparotomy were identified. The mean ± SD age was 44 ± 18 years, 67.5% were male, and median Injury Severity Score was 34 (range, 24-43). The mean ± SD systolic blood pressure at presentation was 73 ± 28 mm Hg, and the median transfusion requirements were PRBC 9 (range, 5-17) and FFP 6 (range, 3-12). During the 5-year analysis, time to laparotomy decreased from 1.87 hours to 1.37 hours ( p < 0.001), PRBC/FFP ratio at 4 hours decreased from 1.93 to 1.71 ( p < 0.001), and 24-hour mortality decreased from 23.0% to 19.3% ( p = 0.014). On multivariate analysis, decreased PRBC/FFP ratio was independently associated with decreased 24-hour mortality (odds ratio, 0.88; p < 0.001) and in-hospital mortality (odds ratio, 0.89; p < 0.001). CONCLUSION: Resuscitation is becoming more balanced and time to emergency laparotomy shorter in blunt trauma patients, with a significant improvement in mortality. Future efforts should be directed toward incorporating transfusion practices and timely surgical interventions as markers of trauma center quality. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Ethical, legal, and communication challenges in managing goals-of-care discussions in chronically critically ill patients.

Clinicians should expect controversial goals of care discussions in the surgical intensive care from time to time. Differing opinions about the likelihood of meaningful recovery in patients with chronic critical illness often exist between intensive care unit providers of different disciplines. Outcome predictions presented by health-care providers are often reflections of their own point of view that is influenced by provider experience, profession, and personal values, rather than the consequence of reliable scientific evaluation. In addition, family members of intensive care unit patients often develop acute cognitive, psychologic, and physical challenges. Providers in the surgical intensive care unit should approach goals-of-care discussions in a structured and interprofessional manner. This best practice paper highlights medical, legal and ethical implications of changing goals of care from prioritizing cure to prioritizing comfort and provides tools that help physicians become effective leaders in the multi-disciplinary management of patients with challenging prognostication.

Traumatic brain injury induced temperature dysregulation: What is the role of ß blockers?

BACKGROUND: Traumatic brain injury (TBI) is associated with sympathetic discharge that leads to posttraumatic hyperthermia (PTH). Beta blockers (ßß) are known to counteract overactive sympathetic discharge. The aim of our study was to evaluate the effect of ßß on PTH in critically-ill TBI patients. METHODS: We performed retrospective cohort analysis of the Medical Information Mart for Intensive Care database. We included all critically ill TBI patients with head Abbreviated Injury Scale (AIS) score of 3 or greater and other body region AIS score less than 2 who developed PTH (at least one febrile episode [T > 38.3°C] with negative microbiological cultures (blood, urine, and bronchoalveolar lavage). Patients on preinjury ßß were excluded. Patients were stratified into (ßß+) and (ßß-) groups. Propensity score matching was performed (1:1 ratio) controlling for patient demographics, injury parameters and other medications that influence temperature. Outcomes were the number of febrile episodes, maximum temperature, and the time interval between febrile episodes. Multivariate linear regression was performed. RESULTS: We analyzed 4,286 critically ill TBI patients. A matched cohort of 1,544 patients was obtained: 772 ßß + (metoprolol, 60%; propranolol, 25%; and atenolol, 15%) and 772 ßß-. Mean age was 63.4 ± 15.4 years, median head AIS score of 3 (3-4), and median Injury Severity Score of 10 (9-16). Patients in the ßß+ group had a lower number of febrile episodes (8 episodes vs. 12 episodes; p = 0.003), lower median maximum temperature (38.0°C vs. 38.5°C; p = 0.025), and a longer median time between febrile episodes (3 hours vs. 1 hour; p = 0.013). On linear regression, propranolol was found to be superior in terms of reducing the number of febrile episodes and the maximum temperature. However, there was no significant difference between the three ßß in terms of reducing the time interval between febrile episodes (p = 0.582). CONCLUSION: Beta blockers attenuate PTH by decreasing the frequency of febrile episodes, increasing the time interval between febrile episodes, and reducing the maximum rise in temperature. ßß may be a potential therapeutic modality in PTH. LEVEL OF EVIDENCE: Therapeutic, level IV.

Whole blood hemostatic resuscitation in pediatric trauma: A nationwide propensity-matched analysis.

BACKGROUND: Whole blood (WB) has shown promise in pediatric trauma resuscitation following its prominent role in the resuscitation of adult trauma patients. Although WB in children has been shown to be feasible, its effectiveness has yet to be explored. The aim of this study was to examine the outcomes of WB transfusion as an adjunct to component therapy (CT) compared with CT only as early resuscitation for pediatric trauma patients. METHODS: Children aged 1 to 17 years, who were transfused within 4 hours of presentation, were identified in the Trauma Quality Improvement Program 2017 database. Patients were stratified into those receiving WB-CT versus CT alone. Propensity score matching in a 1:2 ratio was performed based on patient demographics, injury characteristics, hemorrhage control interventions, and trauma center level. The primary outcome measure was patient transfusion requirement. Secondary outcome measures were mortality, hospital length of stay, ventilation days, and major complications. RESULTS: A total of 135 children receiving WB-CT were matched to 270 patients receiving CT only. Mean (SD) age was 12 (5) years, 66% were male, and the median Injury Severity Score was 32 (range, 20-43). A total of 51% of patients were in shock, 34% had penetrating injuries, and 41% required surgical intervention for hemorrhage control. Total blood products transfused were significantly decreased in children receiving WB, both at 4 hours (35 [22-73] vs. 48 [33-95] mL/kg; p = 0.013) and 24 hours (39 [24-97] vs. 53 [36-119] mL/kg; p < 0.001). Mortality rate at 24 hours (19.3% vs. 21.9%; p = 0.546) and in-hospital mortality (31.1% vs. 34.4%; p = 0.502) were not different. Similarly, no difference in hospital length of stay and rates of major complications was found. Patients in the WB group required significantly less ventilation days (2 [2-6] vs. 3 [2-8] days; p = 0.021). CONCLUSION: Using WB as an adjunct to CT was associated with decreased transfusion requirements and ventilation days in pediatric trauma patients. LEVEL OF EVIDENCE: Therapeutic, level III.

Four-factor prothrombin complex concentrate in adjunct to whole blood in trauma-related hemorrhage: Does whole blood replace the need for factors?

BACKGROUND: The use of whole blood (WB) for the treatment of hemorrhagic shock and coagulopathy is increasing in civilian trauma patients. Four-factor prothrombin complex concentrate (4-PCC) in adjunct to component therapy showed improved outcomes in trauma patients. Our study aims to evaluate the outcomes of trauma patients who received 4-PCC and WB (4-PCC-WB) compared with WB alone. METHODS: We performed a 3-year (2015-2017) analysis of the American College of Surgeons-Trauma Quality Improvement Program database. All adult (age, ≥18 years) trauma patients who received WB were included. We excluded patients who were on preinjury anticoagulants. Patients were stratified into two groups, 4-PCC-WB versus WB alone, and matched in a 1:2 ratio using propensity score matching. Outcome measures were packed red blood cells, plasma, platelets, and cryoprecipitate transfused, in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS) among survivors, and mortality. RESULTS: A total of 252 patients (4-PCC-WB, 84; WB alone, 168) were matched. The mean ± SD age was 47 ± 21 years, 63% were males, median Injury Severity Score was 30 (21-40), and 87% had blunt injuries. Patients who received 4-PCC-WB had decreased requirement for packed red blood cell (8 U vs. 10 U, p = 0.04) and fresh frozen plasma (6 U vs. 8 U, p = 0.01) transfusion, lower rates of acute kidney injury (p = 0.03), and ICU LOS (5 days vs. 8 days, p = 0.01) compared with WB alone. There was no difference in the platelet transfusion (p = 0.19), cryoprecipitate transfusion (p = 0.37), hospital LOS (p = 0.72), and in-hospital mortality (p = 0.72) between the two groups. CONCLUSION: Our study demonstrates that the use of 4-PCC as an adjunct to WB is associated with a reduction in transfusion requirements and ICU LOS compared with WB alone in the resuscitation of trauma patients. Further studies are required to evaluate the role of PCC with WB in the resuscitation of trauma patients. LEVEL OF EVIDENCE: Therapeutic, level III.

Regionalization of trauma care by operative experience: Does the volume of emergent laparotomy matter?

INTRODUCTION: The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients. METHODS: We performed a (2017) analysis of the Trauma Quality Improvement Program database. We included adult (age, ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: high volume (HV), ≥25 cases per year; medium volume (MV), 13 to 24 cases per year; and low volume (LV), ≤12 cases per year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality. RESULTS: A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean ± SD age was 40 ± 17 years, abdomen Abbreviated Injury Scale was 3 (2-4), and Injury Severity Score was 26 (17-35). For American College of Surgeons (ACS) level I centers, 50% were HV; 29%, MV; and 21%, LV. For ACS level II centers, 7% were HV; 23%, MV; and 70%, LV. For ACS level III centers, 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. High-volume blunt centers had a significantly lower time to laparotomy (72 [41-144] minutes) versus MV (81 [49-145] minutes) and LV (94 [56-158] minutes) centers (p < 0.001). The same trend was observed for HV penetrating trauma centers (35 [24-52] minutes) versus MV (46 [33-63] minutes) and LV (51 [38-69] minutes) centers (p < 0.001). CONCLUSION: Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience. LEVEL OF EVIDENCE: Prognostic, Level III; Therapeutic/Care management, Level IV.

Managing acute uncomplicated appendicitis in frail geriatric patients: A second hit may be too much.

INTRODUCTION: Studies have proposed the use of antibiotics only in cases of acute uncomplicated appendicitis (AUA). However, there remains a paucity of data evaluating this nonoperative approach in the vulnerable frail geriatric population. The aim of this study was to examine long-term outcomes of frail geriatric patients with AUA treated with appendectomy compared with initial nonoperative management (NOP). METHODS: We conducted a 1-year (2017) analysis of the Nationwide Readmissions Database and included all frail geriatric patients(age, ≥65 years) with a diagnosis of AUA. Frailty was assessed using the five-factor modified frailty index. Patients were stratified into those undergoing appendectomy at index admission (operative management) versus those receiving antibiotics only without operative intervention (NOP). Propensity score matching in a 1:1 ratio was performed adjusting for patient- and hospital-related factors. RESULTS: A total of 5,562 frail geriatric patients with AUA were identified from which a matched cohort of 1,320 patients in each group was obtained. Patients in the NOP and operative management were comparable in terms of age (75.5 ± 7.7 vs. 75.5 ± 7.4 years; p = 0.882) and modified frailty index (0.4 [0.4-0.6] vs. 0.4 [0.4-0.6]; p = 0.526). Failure of NOP management was reported in 18% of patients, 95% of which eventually underwent appendectomy. Over the 6-month follow-up period, patients in the NOP group had significantly higher rates of Clostridium difficile enterocolitis (3% vs. 1%; p < 0.001), greater number of overall hospitalized days (5 [3-9] vs. 4 [2-7] days; p < 0.001), and higher overall costs (US $16,000 [12,000-25,000] vs. US $11,000 [8,000-19,000]; p < 0.001). Patients undergoing appendectomy after failed NOP had significantly higher rates of complications (20% vs. 11%; p < 0.001), mortality (4% vs. 2%; p = 0.019), and appendiceal neoplasm (3% vs. 1%; p = 0.027). CONCLUSION: One in six patients failed NOP within 6 months and required appendectomy with subsequent more complications and higher mortality. Appendectomy may offer better outcomes in managing AUA in the frail geriatric population. LEVEL OF EVIDENCE: Therapeutic, level IV.

Never-frozen liquid plasma transfusion in civilian trauma: a nationwide propensity-matched analysis.

BACKGROUND: Never-frozen liquid plasma (LQP) was found to reduce component waste, decrease health care expenses, and have a superior hemostatic profile compared with fresh frozen plasma (FFP). Although transfusing LQP in hemorrhaging patients has become more common, its clinical effectiveness remains to be explored. This study aims to examine outcomes of trauma patients transfused with LQP compared with thawed FFP. METHODS: Adult (≥18 years) trauma patients receiving early (≤4 hours) plasma transfusions were identified in the Trauma Quality Improvement Program 2017. Patients were stratified into those receiving LQP versus FFP. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were mortality and time to first plasma unit transfusion. Secondary outcome measures were major complications and hospital length of stay. RESULTS: A total of 107 adult trauma patients receiving LQP were matched to 214 patients receiving FFP. Mean age was 48 ± 19 years, 73% were male, and median Injury Severity Score was 27 [23-41]. A total of 42% of patients were in shock, 22% had penetrating injuries, and 31% required surgical intervention for hemorrhage control. Patients received a median of 4 [2-6] units of PRBC, 2 [1,3] units of LQP or FFP, and 1 [0-1] unit of platelets. The median time to the first LQP unit transfused was significantly shorter compared with the first FFP unit transfused (54 [28-79] minutes vs. 98 [59-133] minutes; p < 0.001). Rates of 24-hour mortality (2.8% vs. 3.7%; p = 0.664) and in-hospital mortality (16.8% vs. 20.1%; p = 0.481) were not different between the LQP and FFP groups. Similarly, there was no difference in major complications (15.9% vs. 21.5%; p = 0.233) and hospital length of stay (12 [6-21] vs. 12 [6-23] days; p = 0.826). CONCLUSION: Never-frozen liquid plasma is safe and effective in resuscitating trauma patients. Never-frozen liquid plasma has the potential to expand our transfusion armamentarium given its longer storage time and immediate availability. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Resuscitative Endovascular Balloon Occlusion of the Aorta vs Pre-Peritoneal Packing in Patients with Pelvic Fracture.

BACKGROUND: Pelvic hemorrhage is potentially lethal despite homeostatic interventions such as pre-peritoneal packing (PP), resuscitative endovascular balloon occlusion of the aorta (REBOA), surgery, and/or angioembolization. REBOA may be used as an alternative/adjunct to PP for temporizing bleeding in patients with pelvic fractures. Our study aimed to compare the outcomes of REBOA and/or PP, as temporizing measures, in blunt pelvic fracture patients. We hypothesized that REBOA is associated with worsened outcomes. STUDY DESIGN: We performed a 2017 review of the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) and identified trauma patients with blunt pelvic fractures who underwent REBOA placement and/or PP before laparotomy and/or angioembolization. Propensity score matching was performed, adjusting for demographics, vitals, mechanism of injury, ISS, each body region-AIS, and pelvic fracture type. Outcomes were complication rates and mortality. RESULTS: A total of 156 patients (PP: 52; REBOA: 52; REBOA+PP: 52) were matched and included. Mean age was 43 ± 18 years, Injury Severity Score (ISS) was 28 (range 17-32), and 74% were males. Overall mortality was 42%. The 24-hour mortality (25% vs 14% vs 35%; p = 0.042), in-hospital mortality (44% vs 29% vs 54%; p = 0.034), and 4-hour pRBC units transfused (15 [9-23] vs 10 [4-19] vs 16 [9-27]; p = 0.017) were lower in the REBOA group. The REBOA group had faster times to both laparotomy (p = 0.040) and/or angioembolization (p = 0.012). There was no difference between the groups in acute kidney injury, lower limb amputations, or hospital and ICU length of stay among survivors. CONCLUSIONS: REBOA is a less invasive procedure compared with PP and is associated with improved outcomes. Further clinical trials are needed to define the optimal patient who will benefit from REBOA.

Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma.

INTRODUCTION: Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients. METHODS: We analyzed the (2015-2016) Trauma Quality Improvement Program. We included adult (age, ≥18 years) trauma patients presenting with hemorrhagic shock and requiring at least 1 U of packed red blood cells (pRBCs) within 4 hours. Patients were stratified into WB-CT versus CT only. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were hospital length of stay and major complications. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 8,494 patients were identified, of which 280 received WB-CT (WB, 1 [1-1]; pRBC, 16 [10-23]; FFP, 9 [6-16]; platelets, 3 [2-5]) and 8,214 received CT only (pRBC, 15 [10-24]; FFP, 10 [6-16]; platelets, 2 [1-4]). Mean ± SD age was 34 ± 16 years, 79% were male, Injury Severity Score was 33 (24-43), and 63% had penetrating injuries. Patients who received WB-CT had a lower 24-hour mortality (17% vs. 25%; p = 0.002), in-hospital mortality (29% vs. 40%; p < 0.001), major complications (29% vs. 41%; p < 0.001), and a shorter length of stay (9 [7-12] vs. 15 [10-21]; p = 0.011). On regression analysis, WB was independently associated with reduced 24-hour mortality (odds ratio [OR], 0.78 [0.59-0.89]; p = 0.006), in-hospital mortality (OR, 0.88 [0.81-0.90]; p = 0.011), and major complications (OR, 0.92 [0.87-0.96]; p = 0.013). CONCLUSION: The use of WB as an adjunct to CT is associated with improved outcomes in resuscitation of severely injured civilian trauma patients. Further studies are required to evaluate the role of adding WB to massive transfusion protocols. LEVEL OF EVIDENCE: Therapeutic, level IV.