Variability in antemortem and postmortem blood alcohol concentration levels among fatally injured adults.

Background: Excessive alcohol use is a risk factor for injury-related deaths. Postmortem blood samples are commonly used to approximate antemortem blood alcohol concentration (BAC) levels.Objectives: To assess differences between antemortem and postmortem BACs among fatally injured adults admitted to one shock trauma center (STC).Method: Fifty-two adult decedents (45 male, 7 female) admitted to a STC in Baltimore, Maryland during 2006-2016 were included. STC records were matched with records from Maryland's Office of the Chief Medical Examiner (OCME). The antemortem and postmortem BAC distributions were compared. After stratifying by antemortem BACs <0.10 versus ≥0.10 g/dL, differences in postmortem and antemortem BACs were plotted as a function of length of hospital stay.Results: Among the 52 decedents, 22 died from transportation-related injuries, 20 died by homicide or intentional assault, and 10 died from other injuries. The median BAC antemortem was 0.10 g/dL and postmortem was 0.06 g/dL. Thirty-one (59.6%) decedents had antemortem BACs ≥0.08 g/dL versus 22 (42.3%) decedents using postmortem BACs. Postmortem BACs were lower than the antemortem BACs for 42 decedents, by an average of 0.07 g/dL. Postmortem BACs were higher than the antemortem BACs for 10 decedents, by an average of 0.06 g/dL.Conclusion: Postmortem BACs were generally lower than antemortem BACs for the fatally injured decedents in this study, though not consistently. More routine antemortem BAC testing, when possible, would improve the surveillance of alcohol involvement in injuries. The findings emphasize the usefulness of routine testing and recording of BACs in acute care facilities.

Percentage of Mortal Encounters Transferred in Emergency General Surgery.

BACKGROUND: Despite the frequent occurrence of interhospital transfers in emergency general surgery (EGS), rates of transfer of complications are undescribed. Improved understanding of hospital transfer patterns has a multitude of implications, including quality measurement. The objective of this study was to describe individual hospital transfer rates of mortal encounters. MATERIALS AND METHODS: A retrospective review was undertaken from 2013 to 2015 of the Maryland Health Services Cost Review Commission database. Two groups of EGS encounters were identified: encounters with death following transfer and encounters with death without transfer. The percentage of mortal encounters transferred was defined as the percentage of EGS hospital encounters with mortality initially presenting to a hospital transferred to another hospital before death at the receiving hospital. RESULTS: Overall, 370,242 total EGS encounters were included, with 17,003 (4.6%) of the total EGS encounters with mortality. Encounters with death without transfer encompassed 15,604 (91.8%) of mortal EGS encounters and encounters with death following transfer 1399 (8.2%). EGS disease categories of esophageal varices or perforation, necrotizing fasciitis, enterocutaneous fistula, and pancreatitis had over 10% of these total mortal encounters with death following transfer. For individual hospitals, percentage of mortal encounters transferred ranged from 0.8% to 35.2%. The percentage of mortal encounters transferred was inversely correlated with annual EGS hospital volume for all state hospitals (P < 0.001, r = -0.57). CONCLUSIONS: Broad variability in individual hospital practices exists for mortality transferred to other institutions. Application of this knowledge of percentage of mortal encounters transferred includes consideration in hospital quality metrics.

Multicompartment management of patients with severe traumatic brain injury.

PURPOSE OF REVIEW: Intracranial pressure (ICP) control is a mainstay of traumatic brain injury (TBI) management. However, development of intracranial hypertension (ICH) may be affected by factors outside of the cranial vault in addition to the local effects of the TBI. This review will examine the pathophysiology of multiple compartment syndrome (MCS) and current treatment considerations for patients with TBI given the effects of MCS. RECENT FINDINGS: Elevated intra-abdominal pressure (IAP) is associated with ICP elevation, and decompressive laparotomy in patients with concurrent elevations in IAP and ICP can reduce ICP. Elevated intrathoracic pressure may be similarly associated with ICP elevation, although the ideal ventilator management strategy for TBI patients when considering MCS is unclear. SUMMARY: In MCS, intracranial, intrathoracic and intra-abdominal compartment pressures are interrelated. TBI patient care should include ICP control as well as minimization of intrathoracic and intra-abdominal pressure as clinically possible.

Early Pharmacologic Therapy in Patients With Blunt Cerebrovascular Injury and TBI: Is it Safe and Effective? An EAST Multicenter Study.

BACKGROUND: Blunt cerebrovascular injury (BCVI) with concurrent traumatic brain injury (TBI) presents increased risk of both ischemic stroke and bleeding. This study investigated the safety and survival benefit of BCVI treatment (antithrombotic and/or anticoagulant therapy) in this population. We hypothesized that treatment would be associated with fewer and later strokes in patients with BCVI and TBI without increasing bleeding complications. METHODS: Patients with head AIS >0 were selected from a database of BCVI patients previously obtained for an observational trial. A Kaplan-Meier analysis compared stroke survival in patients who received BCVI treatment to those who did not. Logistic regression was used to evaluate for confounding variables. RESULTS: Of 488 patients, 347 (71.1%) received BCVI treatment and 141 (28.9%) did not. BCVI treatment was given at a median of 31 h post-admission. BCVI treatment was associated with lower stroke rate (4.9% vs 24.1%, P < .001 and longer stroke-free survival (P < .001), but also less severe systemic injury. Logistic regression identified motor GCS and BCVI treatment as the only predictors of stroke. No patients experienced worsening TBI because of treatment. DISCUSSION: Patients with BCVI and TBI who did not receive BCVI treatment had an increased rate of stroke early in their hospital stay, though this effect may be confounded by worse motor deficits and systemic injuries. BCVI treatment within 2-3 days of admission may be safe for patients with mean head AIS of 2.6. Future prospective trials are needed to confirm these findings and determine optimal timing of BCVI treatment in TBI patients with BCVI.

Does treatment delay for blunt cerebrovascular injury affect stroke rate?: An EAST multicenter study.

BACKGROUND: The purpose of this study was to analyze injury characteristics and stroke rates between blunt cerebrovascular injury (BCVI) with delayed vs non-delayed medical therapy. We hypothesized there would be increased stroke formation with delayed medical therapy. METHODS: This is a sub-analysis of a 16 center, prospective, observational trial on BCVI. Delayed medial therapy was defined as initiation >24 hours after admission. BCVI which did not receive medical therapy were excluded. Subgroups for injury presence were created using Abbreviated Injury Scale (AIS) score >0 for AIS categories. RESULTS: 636 BCVI were included. Median time to first medical therapy was 62 hours in the delayed group and 11 hours in the non-delayed group (p < 0.001). The injury severity score (ISS) was greater in the delayed group (24.0 vs the non-delayed group 22.0, p <  0.001) as was the median AIS head score (2.0 vs 1.0, p <  0.001). The overall stroke rate was not different between the delayed vs non-delayed groups respectively (9.7% vs 9.5%, p = 1.00). Further evaluation of carotid vs vertebral artery injury showed no difference in stroke rate, 13.6% and 13.2%, p = 1.00 vs 7.3% and 6.5%, p = 0.84. Additionally, within all AIS categories there was no difference in stroke rate between delayed and non-delayed medical therapy (all N.S.), with AIS head >0 13.8% vs 9.2%, p = 0.20 and AIS spine >0 11.0% vs 9.3%, p = 0.63 respectively. CONCLUSIONS: Modern BCVI therapy is administered early. BCVI with delayed therapy were more severely injured. However, a higher stroke rate was not seen with delayed therapy, even for BCVI with head or spine injuries. This data suggests with competing injuries or other clinical concerns there is not an increased stroke rate with necessary delays of medical treatment for BCVI.

Factors associated with stroke formation in blunt cerebrovascular injury: An EAST multicenter study.

BACKGROUND: Stroke risk factors after blunt cerebrovascular injury (BCVI) are ill-defined. We hypothesized that factors associated with stroke for BCVI would include medical therapy (i.e., Aspirin), radiographic features, and protocolization of care. METHODS: An Eastern Association for the Surgery of Trauma-sponsored, 16-center, prospective, observational trial was undertaken. Stroke risk factors were analyzed individually for vertebral artery (VA) and internal carotid artery (ICA) BCVI. Blunt cerebrovascular injuries were graded on the standard 1 to 5 scale. Data were from the initial hospitalization only. RESULTS: Seven hundred seventy-seven BCVIs were included. Stroke rate was 8.9% for all BCVIs, with an 11.7% rate of stroke for ICA BCVI and a 6.7% rate for VA BCVI. Use of a management protocol (p = 0.01), management by the trauma service (p = 0.04), antiplatelet therapy over the hospital stay (p < 0.001), and Aspirin therapy specifically over the hospital stay (p < 0.001) were more common in ICA BCVI without stroke compared with those with stroke. Antiplatelet therapy over the hospital stay (p < 0.001) and Aspirin therapy over the hospital stay (p < 0.001) were more common in VA BCVI without stroke than with stroke. Percentage luminal stenosis was higher in both ICA BCVI (p = 0.002) and VA BCVI (p < 0.001) with stroke. Decrease in percentage luminal stenosis (p < 0.001), resolution of intraluminal thrombus (p = 0.003), and new intraluminal thrombus (p = 0.001) were more common in ICA BCVI with stroke than without, while resolution of intraluminal thrombus (p = 0.03) and new intraluminal thrombus (p = 0.01) were more common in VA BCVI with stroke than without. CONCLUSION: Protocol-driven management by the trauma service, antiplatelet therapy (specifically Aspirin), and lower percentage luminal stenosis were associated with lower stroke rates, while resolution and development of intraluminal thrombus were associated with higher stroke rates. Further research will be needed to incorporate these risk factors into lesion specific BCVI management. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, Level IV.

Angioembolization significantly improves vascular injuries in blunt splenic trauma.

PURPOSE: Non-operative management (NOM) of blunt splenic injury (BSI) uses angioembolization (AE) or observation (OBS). AE improves the success of NOM. However, how AE improves BSI is unknown. We hypothesized AE would decrease rate of pseudoaneurysm (PSA) presence, PSA size, PSA number, and rate of active extravasation. METHODS: We performed a retrospective review of computerized tomography (CT)-diagnosed BSI over a 2-year period. Patients undergoing NOM with an initial and repeat CT were included. Patients were excluded if they underwent primary splenectomy after BSI diagnosis or did not have repeat CT imaging. RESULTS: One hundred and fifteen patients with BSI had repeat CT imaging; 55/115 (47.8%) had AE; and 60/115 (52.2%) had OBS. On the initial CT, AE patients had more frequent PSA presence (52.7% vs. 6.7%, p < 0.001), higher median number of PSA (1.0 vs. 0, p < 0.001), higher median PSA size (1.15 mm vs. 0 mm, p < 0.001), and more frequent rates of active extravasation (10.9% vs. 0%, p = 0.01) compared with OBS patients. On repeat CT compared to the initial CT, AE patients had significant decrease in rate of PSA presence (21.8% vs. 52.7%, p < 0.001), median PSA size (0 mm vs. 1.15 mm, p < 0.001), median PSA number (p < 0.001), and rate of active extravasation (0% vs. 10.9%, p = 0.03). On repeat CT compared to the initial CT, OBS patients had an increase in rate of PSA presence (18.3% vs. 6.7%, p = 0.04). CONCLUSIONS: AE significantly decreases PSA presence, number, and size as well as rates of active extravasation. AE should be standard practice in vascular injuries undergoing NOM to maximize splenic salvage.

Surgical Intensivist-Led Training in Critical Care Ultrasound Improves Performance.

BACKGROUND: Critical care ultrasound (CCUS) is essential in modern practice, with CCUS including cardiac and noncardiac ultrasound. The most effective CCUS training is unknown, with a diverse skill set and knowledge needed for competence. The objective of this project was to evaluate the effect of a surgical intensivist-led training program on CCUS competence in critical care fellows. METHODS: This was a single institution retrospective review from 2016 to 2018 at the R Adams Cowley Shock Trauma Center. Our yearlong surgical intensivist (SI)-led CCUS training program for critical care fellows includes a daylong CCUS training class, CCUS lectures, a CCUS rotation, and bedside CCUS instruction during rotations. Fellows take a knowledge test and skills test before (pretest) and after (posttest) this program. Critical care ultrasound skill was graded on a scale from 1-5, with 4 (minimal help) or 5 (no help) considered competent. Emergency medicine, surgery, and medicine-trained critical care fellows were included. RESULTS: Forty-two critical care fellows were included. Mean posttest scores increased significantly for 21/22 (96%) of skills tested and for 14/30 (47%) of knowledge questions compared to pretest scores. The mean composite skill score increased from 3.25 to 4.82 from pretest to posttest (P < .001). The mean composite knowledge score increased from 60% to 80% from pretest to posttest (P < .001). CONCLUSION: SI-led training improves CCUS competence and knowledge despite the breadth of CCUS.

Fatal Necrotizing Soft-Tissue Infection Caused by Clostridium tetani in an Injecting Drug User: A Case Report.

The aim of this brief report is to raise awareness of necrotizing soft-tissue infections caused by Clostridium tetani in intravenous drug users, highlight the potentially unique dangers of this infection in this specific patient population, and outline the course of treatment currently considered the standard of care.

Influence of luminal stenosis in aneurysmal and non-aneurysmal blunt cerebrovascular injury.

BACKGROUND: Current blunt cerebrovascular injury (BCVI) grading grossly differentiates injury characteristics such as luminal stenosis (LS) and aneurysmal disease. The effect of increasing degree of LS beyond the current BCVI grading scale on stroke formation is unknown. STUDY DESIGN: BCVI over a 3-year period were retrospectively reviewed. To investigate influence of LS beyond the BCVI grading scale within aneurysmal and non-aneurysmal BCVI, grade 2 BCVI were subdivided into BCVI with ≥ 25% and ≤ 50% LS and BCVI with > 50% and ≤ 99% LS. Grade 3 BCVI were subdivided into BCVI with pseudoaneurysm (PSA) without LS and BCVI with PSA and LS. We hypothesized increased LS beyond the current BCVI grade distinctions would be associated with higher rates of stroke formation. RESULTS: 312 BCVI were included, of which 140 were carotid BCVI and 172 vertebral BCVI. Sixteen carotid BCVI underwent endovascular intervention (EI) and 19 suffered a stroke. In carotid BCVI stroke rates increased sequentially with BCVI grade except in grade 3. There was a stroke rate of 12% in grade 1 carotid BCVI, 18% in grade 2, 6% in grade 3, and 31% in grade 4. In subgroup analysis for grade 2 carotid BCVI, BCVI with > 50% and ≤ 99% LS had higher rates of stroke (22% vs. 15%, p = 0.44) than BCVI with ≥ 25% and ≤ 50% LS. In subgroup analysis of grade 3 carotid BCVI, BCVI with PSA and LS had higher rates of stroke (9% vs. 4%, p = 0.48) than BCVI with PSA without LS. Higher rates of EI in grade 2 carotid BCVI with > 50% and ≤ 99% LS (22% vs. 5%, p = 0.14) and grade 3 carotid BCVI with PSA and LS (35% vs. 4%, p = 0.01) were noted in subgroup analysis. CONCLUSION: Higher percentage LS beyond the currently used BCVI grading scale has a non-significantly increased rate of stroke in both aneurysmal and non-aneurysmal BCVI. Grade 3 BCVI with PSA and LS seems to be a high-risk subgroup. Use of EI confounds modern measurement of stroke risk in higher LS BCVI.

Comparison of individual and composite radiographic markers of frailty in trauma.

BACKGROUND: Clinical frailty scores usually involve questionnaires or physical testing. Many trauma patients are not able to participate in these. Radiographic measurement of frailty may be a viable alternative. Individual radiographic markers of frailty have been investigated, such as sarcopenia or osteopenia. The ideal radiographic variable (or variables) to measure frailty in trauma is unknown. STUDY DESIGN: A retrospective review was performed of restrained drivers ages 40 and greater at a single institution from 2010-2015. Multiple markers of radiographic frailty were measured including: sarcopenia, osteopenia, vascular calcifications, sarcopenic obesity, emphysema, renal volume, cervical spine degeneration, and cerebral atrophy. Frailty was defined as the worst quartile for each radiographic variable, and these values were summed to create a composite marker of frailty. The primary outcome was discharge disposition. We hypothesized that a composite frailty score would be associated with discharge disposition while individual markers would not be associated with discharge disposition. RESULTS: Overall 489 patients were included in this study. Cerebral atrophy (p = 0.05), renal volume (p = 0.004), sarcopenia (p = 0.05), vascular calcifications (p = 0.02) and sarcopenic obesity (p = 0.01) were associated with discharge disposition. Pearson's correlation coefficients between radiographic frailty markers were all less than 0.4. Youden's Index was 0.26 (p < 0.001) at a composite score of 3. In multivariable analysis, the composite score of 3 or greater was associated with poor discharge disposition (OR 2.39, 95% CI 1.10-5.18, p = 0.03). CONCLUSIONS: Individual radiographic frailty markers are inadequate markers of frailty, as they may miss patients who are frail. This study also suggests that a composite radiographic frailty score may better predict patient outcome than individual radiographic markers of frailty.

Interhospital Transfers with Wide Variability in Emergency General Surgery.

Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume (P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume (P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.

Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections.

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique (P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.

Graduating Surgical Residents Lack Competence in Critical Care Ultrasound.

OBJECTIVE: Ultrasound provides accessible imaging for bedside diagnostics and procedural guidance, but may lead to misdiagnosis in untrained users. The main objective of this study was to determine observed and self-perceived competence with critical care ultrasound in graduated general surgery residents. DESIGN: The design of this study was a retrospective review. Ultrasound training program records were reviewed for number of prior ultrasound examinations performed, self-perceived competence, observed competence on faculty examinations, and intended future use of individual critical care ultrasound examinations. SETTING: This study was undertaken at the R Adams Cowley Shock Trauma Center, which is a tertiary care center in Baltimore, MD. PARTICIPANTS: Graduated general surgery residents were identified at the beginning of their surgical critical care fellowship at our institution, and were included if they participated in our critical care ultrasound education program. Fifteen graduated general surgery residents were included. RESULTS: Prior ultrasound experience ranged from 100% for focused assessment of sonography for trauma (FAST) to 13.3% for advanced cardiac assessment. Self-perceived competence ranged from 46.7% with FAST to 0% for advanced cardiac assessment. Observed competence ranged from 20.0% for FAST examinations to 0% for basic cardiac assessment, advanced cardiac assessment, and inferior vena cava (IVC) assessment. All participants intended to use ultrasound in the future for FAST, pneumothorax detection and basic cardiac assessment, and 86.7% for IVC assessment and advanced cardiac assessment. Of participants with self-perceived competence, 28.6% had observed competence with FAST, 0% with IVC assessment, and 100% with pneumothorax detection. CONCLUSIONS: Graduated general surgery residents are not competent in multiple critical care ultrasound examinations despite universally planning to use critical care ultrasound in future practice. Current exposure to ultrasound in residency may give a false sense of competency with ultrasound use. A standardized ultrasound curriculum is an urgent need for general surgery training.

Physiology, not modern operative approach, predicts mortality in extremity necrotizing soft tissue infections at a high-volume center.

BACKGROUND: Multiple factors are associated with mortality in necrotizing soft tissue infection, such as organ dysfunction and underlying medical comorbidities, but are not often modifiable. Operative interventions are an attractive modifiable variable in modern management of extremity necrotizing soft tissue infection, but the influence of amputation and advanced wound management techniques on mortality is unknown. METHODS: A single-institution review was performed of extremity necrotizing soft tissue infection . Admission demographics, organ dysfunction, and operative interventions were investigated. The primary outcome was mortality. Advanced wound management techniques were considered flap creation or use of a dermal matrix substitute for coverage of neurovascular structures, tendon, or bone. RESULTS: Overall, 124 patients with extremity necrotizing soft tissue infection were included, with 112 of 124 (90.3%) patients living and 12 of 124 (9.7%) patients dying. Patients who lived had a lower Sequential Organ Failure Assessment score (1.00 [interquartile range, 5] vs 10.50 [interquartile range, 11], P < .001), but no difference in use of amputation (11.6% vs 25.0%, P = .19) or advanced wound management techniques (12.5% vs 0%, P = 0.36), respectively. Indications for amputation in the 16 patients who underwent amputation included nonsalvageable limb in 13 of 16 (81.3%), medical comorbidity in 2 of 16 (12.5%), and a nonsalvageable limb and medical comorbidity in 1 of 16 (6.3%) patients. In multivariate analysis, only the Sequential Organ Failure Assessment score remained associated with mortality (odds ratio 1.315, 95% confidence interval 1.146-1.509, P < .001) CONCLUSION: Use of amputation or advanced wound management techniques was not associated with mortality in patients with extremity necrotizing soft tissue infection. At centers able to provide the critical care support, aggressive use of limb salvage may not affect mortality.

BRAF and KRAS gene mutations in intraductal papillary mucinous neoplasm/carcinoma (IPMN/IPMC) of the pancreas.

The Raf/MEK/ERK (MAPK) signal transduction is an important mediator of a number of cellular fates including growth, proliferation, and survival. The BRAF gene is activated by oncogenic RAS, leading to cooperative effects in cells responding to growth factor signals. Our study was performed to elucidate a possible role of BRAF in the development of IPMN (Intraductal Papillary Mucinous Neoplasm) and IPMC (Intraductal Papillary Mucinous Carcinoma) of the pancreas. Mutations of BRAF and KRAS were evaluated in 36 IPMN/IPMC samples and two mucinous cystadenomas by direct genomic sequencing. Exons 1 for KRAS, and 5, 11, and 15 for BRAF were examined. Totally we identified 17 (47%) KRAS mutations in exon 1, codon 12 and one missense mutation (2.7%) within exon 15 of BRAF. The mutations appear to be somatic since the same alterations were not detected in the corresponding normal tissues. Our data provide evidence that oncogenic properties of BRAF contribute to the tumorigenesis of IPMN/IPMC, but at a lower frequency than KRAS.

Perioperative use of nonsteroidal anti-inflammatory drugs and the risk of anastomotic failure in emergency general surgery.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesic and anti-inflammatory adjuncts. Nonsteroidal anti-inflammatory drug administration may potentially increase the risk of postoperative gastrointestinal anastomotic failure (AF). We aim to determine if perioperative NSAID utilization influences gastrointestinal AF in emergency general surgery (EGS) patients undergoing gastrointestinal resection and anastomosis. METHODS: Post hoc analysis of a multi-institutional prospectively collected database was performed. Anastomotic failure was defined as the occurrence of a dehiscence/leak, fistula, or abscess. Patients using NSAIDs were compared with those without. Summary, univariate, and multivariable analyses were performed. RESULTS: Five hundred thirty-three patients met inclusion criteria with a mean (±SD) age of 60 ± 17.5 years, 53% men. Forty-six percent (n = 244) of the patients were using perioperative NSAIDs. Gastrointestinal AF rate between NSAID and no NSAID was 13.9% versus 10.7% (p = 0.26). No differences existed between groups with respect to perioperative steroid use (16.8% vs. 13.8%; p = 0.34) or mortality (7.39% vs. 6.92%, p = 0.84). Multivariable analysis demonstrated that perioperative corticosteroid (odds ratio, 2.28; 95% confidence interval, 1.04-4.81) use and the presence of a colocolonic or colorectal anastomoses were independently associated with AF. A subset analysis of the NSAIDs cohort demonstrated an increased AF rate in colocolonic or colorectal anastomosis compared with enteroenteric or enterocolonic anastomoses (30.0% vs. 13.0%; p = 0.03). CONCLUSION: Perioperative NSAID utilization appears to be safe in EGS patients undergoing small-bowel resection and anastomosis. Nonsteroidal anti-inflammatory drug administration should be used cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF. LEVEL OF EVIDENCE: Therapeutic study, level III.

Delayed interventions and mortality in trauma damage control laparotomy.

BACKGROUND: In damage control laparotomy, operative principles include hemorrhage and contamination control. However, required components of initial damage control laparotomy are unknown, and nonemergency injury repair is sometimes delayed for resuscitation, angiography, or nonabdominal operations. The frequency and effects of delayed interventions are unknown. METHODS: A retrospective review of patients undergoing damage control laparotomy at a single, urban trauma center was performed. Interventions initially performed at the second laparotomy were considered delayed interventions. RESULTS: In the study, 330 damage control laparotomy patients survived to reoperation. Of all interventions, 13.9% were first performed at the second laparotomy, including 11.9% of visceral interventions and 27.2% of vascular interventions. Overall, 29.7% of patients underwent an unplanned re-exploration, and 21.8% of patients underwent re-exploration for hemorrhage control. There was no significant increase in mortality (33.3% vs 23.9%, P = .09), intra-abdominal infection (37.9% vs 28.0%; P = .10), anastomotic leak (8.0% vs 5.8%, P = .45), or enterocutaneous fistula formation (9.2% vs 9.1%, P = 1.00) with delayed interventions overall. However, mortality was increased in patients undergoing delayed vascular interventions (59.1% vs 22.8%, P = .003), unplanned re-exploration (45.9% vs 18.1%, P < .001) and re-exploration for hemorrhage control (50.0% vs 19.8%, P < .001). CONCLUSION: Delayed interventions are common in damage control laparotomy, with abdominal interventions often spread over multiple explorations. Mortality is increased in patients undergoing emergent re-exploration and with delayed repair of major vascular injuries. Ideal treatment of damage control laparotomy patients may include addressing injuries more completely at the first laparotomy instead of deferring care for other priorities.

Acute care surgery and emergency general surgery: Addition by subtraction.

INTRODUCTION: The formation of Acute Care Surgery services leads to decreased time to treatment and improved outcomes for emergency general surgery (EGS) patients. However, minimal work has focused on the ideal care delivery system and team structure. We hypothesize that the implementation of a dedicated EGS team (separate from trauma and surgical critical care), with EGS-specific protocols and dedicated operating room (OR) time, will increase productivity and improve mortality. METHODS: This is a retrospective review of financial and EGS registry data from fiscal year (FY) 12 to FY15. Data are from an academic, university-based EGS team composed of two acute care surgery attending surgeons, advanced practitioners (APs), residents, and a fellow. In FY12, processes were implemented to standardize paging of consults, patient sign-out with attending surgeons' and APs' participation, clinical/billing protocols, OR availability, and quality improvement. Outcomes included relative value units (RVUs), surgical case volume, charges/payments, and number of patient encounters. The secondary outcome was mortality. The χ test was used to compare mortality, and p < 0.05 was considered significant. RESULTS: Total patient encounters increased from 6,723 in FY 12 to 9,238 in FY 15 (+37%). Relative value units increased from 18,422 in FY 12 to 25,314 in FY 15 (+37%). Charges increased by 76% and payments increased by 60% from FY 12 to FY 15. Charges per encounter increased from $461 in FY 12 to $591 in FY 15 (+28%) Additionally, both inpatient and surgical case loads increased. Mortality remained stable throughout the study period (FY 12, 4.5%; FY 13, 5.2%; FY 14, 5.3%; FY 15, 3.2%: p = 0.177). CONCLUSIONS: Implementation of dedicated OR time, defined EGS team structure, practice protocols, and active attending surgeons'/APs' participation was temporally related to increased case volume, patients seen, and revenue, while mortality remained unchanged. Further study is necessary to establish the translatability of these data to other systems. LEVEL OF EVIDENCE: Economic/decision, level III.

Evolution of Fascial Closure Optimization in Damage Control Laparotomy.

Management of patients undergoing damage control laparotomy (DCL) involves many surgical, medical, and logistical factors. Ideal patient management optimizing fascial closure with regard to timing and closure techniques remains unclear. A retrospective review of patients undergoing DCL from 2000 to 2012 at an urban Level I trauma center was undertaken. Mortality of DCL decreased over the study period from 62.5 to 34.6 per cent, whereas enterocutaneous fistula rate decreased from 12.5 to 3.8 per cent. Delayed primary fascial closure rate improved from 22.2 to 88.2 per cent. Time to closure (P < 0.001), time to first attempted closure (P < 0.001), and number of explorations (P < 0.001) were associated with ability to achieve delayed primary fascial closure. In subgroup analysis, achievement of delayed primary fascial closure was decreased with time to closure after one week (91.7% vs 52.0%, P = 0.002) and time to first attempted closure after two days (86.5% vs 70.0%, P = 0.042). In multivariate analysis, time to closure (odds ratio: 0.13, 95% confidence interval: 0.04-0.39; P < 0.001) and time to first attempted closure (odds ratio: 0.61, 95% confidence interval: 0.37-0.99; P = 0.046) were the only factors associated with achieving delayed primary fascial closure. Timing of attempted closure plays a significant role in attaining delayed primary fascial closure, highlighting the importance of early re-exploration.