Diagnosis and Management of Blunt Cardiac Injury: What You Need to Know.

ABSTRACT: Blunt cardiac injury (BCI) encompasses a wide spectrum, from occult and inconsequential contusion to rapidly fatal cardiac rupture. A small percentage of patients present with abnormal electrocardiogram (ECG) or shock, but most are initially asymptomatic. The potential for sudden dysrhythmia or cardiac pump failure mandates consideration of the presence of BCI, including appropriate monitoring and management. In this review we will present what you need to know to diagnose and manage BCI.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for management of acute respiratory distress syndrome and severe hypoxemia.

LEVEL OF EVIDENCE: Therapeutic/Care Management: Level V.

Delayed fascial closure in nontrauma abdominal emergencies: A nationwide analysis.

BACKGROUND: Initially used in trauma management, delayed abdominal closure endeavors to decrease operative time during the index operation while still being lifesaving. Its use in emergency general surgery is increasing, but the data evaluating its outcome are sparse. We aimed to study the association between delayed abdominal closure, mortality, morbidity, and length of stay in an emergency surgery cohort. METHODS: The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program database was examined for patients undergoing emergency laparotomy. The patients were classified by the timing of abdominal wall closure: delayed fascial closure versus immediate fascial closure. Propensity score matching was performed based on preoperative covariates, wound classification, and performance of bowel resection. The outcomes were then compared by univariable analysis. RESULTS: After matching, both the delayed fascial closure and immediate fascial closure groups consisted of 3,354 patients each. Median age was 65 years, and 52.6% were female. The delayed fascial closure group had a higher in-hospital mortality (35.3% vs 25.0%, P < .001), a higher 30-day mortality (38.6% vs 29.0%, P < .001), a higher proportion of acute kidney injury (9.5% vs 6.6%, P < .001), a lower proportion of postoperative sepsis (11.8% vs 15.6%, P < .001), and a lower proportion of surgical site infection (3.4% vs 7.0%, P < .001). CONCLUSION: Compared with immediate fascial closure, delayed fascial closure is associated with an increased mortality in the patients matched based on comorbidities and surgical site contamination. In emergency general surgery, delaying abdominal closure may not have the presumed overarching benefits, and its indications must be further defined in this population.

Modified Frailty Index-5 Score and Post-Operative Infectious Complications in Patients Undergoing Surgery for Intestinal-Cutaneous Fistula: A Nationwide Retrospective Cohort Analysis.

Background: Post-operative infectious complications after repair of intestinal-cutaneous fistulas (ICF) represent a substantial burden and these outcomes vary widely in the literature. We aimed to evaluate the use of the modified frailty index-5 (mFI-5) to account for physiologic reserve to predict infectious complications in patients with ICF undergoing operative repair. Methods: We used the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) 2006-2017 dataset to include patients who underwent ICF repair. The main outcome measure was 30-day infectious complications (surgical site infection [SSI], sepsis, pneumonia, and urinary tract infection [UTI]). The risk of 30-day post-operative infectious complications was assessed based on mFI-5 score. We performed multivariable logistic regression analyses to evaluate the association between infectious complications and mFI-5. Results: We identified 4,197 patients who underwent an ICF repair. The median age (interquartile range [IQR]) was 57 (46, 67) years, and the majority of patients were female (2,260; 53.9%); white (3,348; 79.8%); and 1,586 (38.3%) were obese. After adjustment for relevant confounders such as baseline patient characteristics, and operative details, mFI-5 was independently associated with infectious complications (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.25-3.21), particularly SSI (OR, 2.16; 95% CI, 1.28-3.63) and pneumonia (OR, 5.31; 95% CI, 2.29-12.35), but not UTI or sepsis. Conclusions: We showed that the mFI-5 is a strong predictor of infectious complications after ICF repair. It can be utilized to account for physiologic reserve, therefore reducing the variability of outcomes reported for ICF repair.

Development of a field artificial intelligence triage tool: Confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds.

BACKGROUND: In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury. METHODS: Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables. RESULTS: A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery. CONCLUSION: Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings. LEVEL OF EVIDENCE: Prognostic, Level III.

Bowel Ischemia in COVID-19 Infection: One-Year Surgical Experience.

BACKGROUND: COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution's surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period. METHODS: All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed. RESULTS: Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation. CONCLUSION: Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.

The risk of midgut volvulus in patients with abdominal wall defects: A multi-institutional study.

BACKGROUND: The management of malrotation in patients with congenital abdominal wall defects has varied among surgeons. We were interested in investigating the risk of midgut volvulus in patients with gastroschisis and omphalocele to help determine if these patients may benefit from undergoing a Ladd procedure. METHODS: A retrospective chart review was performed for all patients managed at three institutions born between 1/1/2000 and 12/31/2008 with a diagnosis of gastroschisis or omphalocele. Patient charts were reviewed through 12/31/2012 for occurrence of midgut volvulus or need for second laparotomy. RESULTS: Of the 414 patients identified with abdominal wall defects, 299 patients (72%) had gastroschisis, and 115 patients (28%) had omphalocele. The mean gestational age at birth was 36.1±2.3weeks, and the mean birth weight was 2.57±0.7kg. There were a total of 8 (1.9%) cases of midgut volvulus: 3 (1.0%) patients with gastroschisis compared to 5 patients (4.4%) with omphalocele (p=0.04). CONCLUSIONS: Patients with omphalocele have a greater risk of developing midgut volvulus, and a Ladd procedure should be considered during definitive repair to mitigate these risks. LEVEL OF EVIDENCE: III; retrospective comparative study.

Central Venous Access in the Pediatric Population With Emphasis on Complications and Prevention Strategies.

Central venous catheters are often necessary in the pediatric population. Access may be challenging, and each vessel presents its own unique set of risks and complications. Central venous catheterization is useful for hemodynamic monitoring, rapid fluid infusion, and administration of hyperosmolar medications, including vasopressors, antibiotics, chemotherapy, and parenteral nutrition. Recent advances have improved the catheters used as well as techniques for insertion. A serious complication of central access is infection, which is associated with morbidity, mortality, and significant financial costs. Reduction of catheter-related bloodstream infections is realized with use of ethanol locks, single lumens when appropriate, and prudent adherence to insertion and maintenance bundles. Ultrasound guidance used for central venous catheter placement improves accuracy of placement, reducing time and unsuccessful insertion and complication rates. Patients with central venous catheters are best served by multidisciplinary team involvement.

Can omphalocele ratio predict postnatal outcomes?

BACKGROUND: The clinical course of patients with omphalocele is challenging to predict. There is no standard method to characterize omphalocele size. Previous studies suggest that the ratio of abdominal circumference to omphalocele defect in-utero is indicative of postnatal outcomes. We hypothesize that omphalocele ratio correlates with outcomes of primary closure versus staged closure. METHODS: A retrospective chart review of all neonates diagnosed with omphalocele from 2002 to 2013 with prenatal ultrasounds available (n=30) was conducted. Omphalocele ratio was defined as omphalocele diameter/abdominal circumference (OD/AC). Data collected included primary versus staged closure, time to full feeds, duration of mechanical ventilation, and length of stay (LOS). Long-term outcomes and quality of life were also reported. RESULTS: ROC curve analysis generated optimal OD/AC ratio of 0.26. Twenty of 30 patients had a ratio less than this cutoff. Sixty percent (12/20) in the low-ratio group achieved primary closure versus zero (0/10) in the high-ratio group (p=0.001). Time on mechanical ventilation was 15.8 days (low-ratio) versus 79 days (high-ratio) (p=0.05). LOS was 33.8 days (low-ratio) versus 85.6 days (high-ratio) (p=0.119). PedsQL™ mean score was 85.5 ± 11.0 (n=20) at long-term follow-up. Readmission rates yielded no difference. CONCLUSIONS: The omphalocele ratio is a promising predictor of postnatal outcomes.