"Sutton's Law in Surgery: 'That's Where the Money is'".

Many students, residents, and learners have heard of the infamous bank robber, who when arrested was asked "Why do you rob banks?" He supposedly replied "Because that's where the money is." Except it did not happen that way. He did rob close to a hundred banks and jewelry stores and stole an estimated $2,000,000.1 A well-known maxim in medicine and surgery, few know the details of the unrelated men behind "Sutton's Law."

Does "Sludge" Require Cholecystectomy?

Biliary sludge is a subjective, ill-defined term. Surgery is often consulted for laparoscopic cholecystectomy, regarded as a low risk procedure.After IRB approval, a word search was used to identify "sludge" in all ultrasounds performed in 2016. The number of patients undergoing cholecystectomy, complications, pathologic findings, and risk factors were identified. Non-operative patients were evaluated for subsequent symptoms and studies or procedures related to biliary pathology.2769 patients underwent RUQ US; 253 patients were found to have sludge. Of 48 (19%) cholecystectomy patients, 9 had cholelithiasis. No deaths occurred in the cholecystectomy group. Two surgical complications occurred. Fifty (24.4%) of the 205 non-operative patients underwent subsequent US imaging: 44% residual sludge, 28% normal, 18% stones, and 10% other.Sludge may resolve 28% of the time. Repeat ultrasound is prudent before proceeding with cholecystectomy. If an abnormality is seen on repeat imaging and risk factors persist, cholecystectomy may be reasonable.

Post-Mortem CT Delivers Fast and Accurate Injury Identification in Trauma Patients.

BACKGROUND: Accurate and timely injury identification is critical but difficult to achieve in trauma patients who die shortly after arrival to the hospital. Autopsy has historically been used to detect injuries, but few undergo formal autopsy. This study investigates the utility of post-mortem computed tomography (PMCT) for injury identification in a diverse trauma population. METHODS: Cross-sectional study of adult trauma patients who died within 24 hours of arrival to a Level I trauma center were included. Among patients with PMCT, injury severity score (ISS) and number of injuries (NOI) were calculated either from physical exam alone (pre-PMCT) or exam and imaging (post-PMCT). ISS and NOI before and after PMCT were compared. A cause of death analysis was performed for patients who underwent comprehensive (ie, head, neck, and torso) PMCT. Non-parametric repeated measures tests were used, as appropriate. RESULTS: 7.3% (N = 28) of patients received PMCT. Compared to pre-PMCT, median ISS (21 vs 3.5) and NOI (5 vs 2) were greater post-PMCT (P < .001, respectively). Autopsy rate was 13.2% overall; 82.5% of autopsies were due to a penetrating mechanism, and median time to autopsy reporting was 38.5 days. Among 17 patients who received comprehensive PMCT, 64.7% had a single cause of death identified, and the remaining were classified as either multiple potential contributors or unknown. DISCUSSION: PMCT is a readily available method to identify injuries in trauma patients who expire shortly upon presentation. Given the low autopsy rate for blunt trauma and delay in reporting, PMCT is an important adjunct for trauma providers.

Time to stroke: A Western Trauma Association multicenter study of blunt cerebrovascular injuries.

BACKGROUND: Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury. METHODS: Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed. RESULTS: During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred. CONCLUSIONS: The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level III.

Performance of a dose-defining insulin infusion protocol among trauma service intensive care unit admissions.

BACKGROUND: Among critically ill patients, glycemic control reduces mortality and morbidities, but the use of intravenous insulin infusion is complicated by hypoglycemia. Having a standardized algorithm increases the likelihood of effective and safe utilization of intravenous insulin therapy. A tabular dose-defining protocol for intravenous insulin infusion is described, containing design elements intended to minimize risk for hypoglycemia while seeking control in a narrow target range, and performance is evaluated among critically ill trauma service patients. METHODS: The protocol assigns insulin infusion rate (IR) for ranges of blood glucose (BG). The columns are arranged in order of increasing maintenance rate (MR) for insulin infusion. Patient column assignment is determined according to rate of change of BG. During stable column assignment, the IR is a function of column MR and BG. Within-column, the protocol formula provides that (a) for BG between 70 mg/dL and target BG, the IR increases exponentially to the column MR; and (b) for BG above upper target BG range, the IR increases linearly as an adaptation of the rule of 1800, with slope determined by the column MR. Values for IR calculated by formula are rounded to correspond to BG ranges of the table. Performance was assessed in 27 sequential runs among 24 trauma service patients admitted to a surgical intensive care unit (2004-2005). RESULTS: Using point-of-care measurements, mean preinfusion BG was 230.0 +/- 67.9 mg/dL. BG < 140 mg/dL was reached during all 27 runs (median time 5.0 h), and target BG was < 110 mg/dL during 25 runs (median time 11.0 h). For the group of runs attaining target before interruption of insulin infusion, the average +/- SD of the principal measure of glycemic control, the within-run mean BG, was 113.7 +/- 14.8 mg/dL (coefficient of variation 13%, n = 25 runs). After attaining target, the average within-run SD for BG was 22.9 mg/dL. The within-run frequency of hypoglycemic measurements (BG < 70 mg/dL) as a percentage of BG determinations was 2.4%. In this series, no instance of BG <50 mg/dL was seen. CONCLUSIONS: This report describes a nurse-implemented tabular protocol for intravenous insulin infusion having the advantages of efficacy, safety, and simplicity of use. Wide variability of IR in the neighborhood of BG 110 mg/dL is associated with stable BG response, and protection against hypoglycemia is achieved by rapid decline of IR at BGs in or below the target range.

The incidence and significance of free air after percutaneous endoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) is well established as a safe and effective means of providing enteral feeding access in patients unable to tolerate oral feeding. There is some question, however, as to the true incidence of free air after PEG and the clinical significance of free air in these patients. We report our experience with 119 patients over 4 years who underwent placement of a percutaneous gastrostomy tube. This study is a retrospective review of percutaneous endoscopic gastrostomies performed by the Critical Care Service for Surgery (CCSS). A database of percutaneous endoscopic gastrostomies performed by the CCSS was maintained from September 1997 through December 2001. Complications of percutaneous gastrostomies were added to the database when noted. The electronic medical record of all patients was reviewed for the results of radiographic studies. Prior abdominal operations were noted as well as gastrostomy tube complications and outcome. A total of 115 intensive care unit patients underwent PEG placement by the CCSS. This total includes 18 patients who had undergone prior upper abdominal surgery, Three additional patients who underwent placement of a gastrostomy tube by vascular interventional radiology and one patient who underwent PEG placement by the ear, nose, and throat service were brought to the attention of CCSS secondary to complications for a total of 119 patients. Only four patients (3.4%) were found to have free air on subsequent chest radiograph. Six patients (5.2%) were found to have free air on abdominal CT scans. Two patients with free air on CT underwent exploratory celiotomy as a result of additional signs of peritonitis. Both were negative explorations. The incidence of free air after PEG in our experience is significantly less than the incidence in previous studies. In patients with free air after PEG placement exploratory celiotomy is not indicated in the absence of other clinical findings of peritonitis. Additionally it was noted that PEG placement could safely be performed in patients with prior upper abdominal surgery with a low incidence of complications.

Timing of pulmonary emboli after trauma: implications for retrievable vena cava filters.

BACKGROUND: Four recent reports of the retrieval of optional vena cava filters (VCF) in trauma patients had average implant durations of 10, 19, and 19 days (one not specified). Two patients in these studies had pulmonary emboli after VCF removal. No evidence-based guidelines exist on the appropriate time to remove optional VCF. The purpose of this study was to examine the timing of pulmonary emboli (PE) and determine the optimal time to remove optional VCFs. METHODS: A multicenter retrospective chart review of trauma patients who had a postinjury PE between January 2001 and December 2004 was performed. We examined the demographics, prophylaxis at the time of PE (pharmacologic [unfractionated or low molecular weight heparin] or sequential compression devices [SCD]), diagnostic test used, timing of PE from the date of injury, and survival outcome. RESULTS: In all, 146 patients were identified, mean age 45.1 (+/- 21.1 SD); Injury Severity Score 18.0 (+/- 12.1 SD). Diagnosis was obtained by spiral computed tomography (N = 93), pulmonary arteriogram (N = 18), V/Q (N = 26), autopsy (N = 6), clinical (N = 6), and unknown (N = 3). Overall mortality was 17.8% (N = 26). Pulmonary embolism was felt to contribute to or was the cause of death in 85% (N = 22) of these patients. Two late PE deaths occurred (days 21 and 43). Sixty (37%) patients had pharmacologic prophylaxis at the time of PE and 83 (50.9%) had SCDs. Average time from injury to PE was 7.9 days (+/- 8.1 SD), the longest being 43 days postinjury. Eleven percent of PE occurred after 21 days, including fatal PE. CONCLUSIONS: Clinical criteria defining the time to remove optional VCFs without exposing patients to the risk of PE by removing a filter too soon should be determined.

Optimal dose of enoxaparin in critically ill trauma and surgical patients.

BACKGROUND: Low-molecular-weight heparin is effective for prevention of venous thromboembolism. The efficacy of daily dosing in critically ill patients is unknown. METHODS: Seventeen critically ill patients on 40 mg of enoxaparin subcutaneously daily were studied. Anti-Xa activity was measured 4 hours after the third dose and before the fourth dose. Adverse events were recorded. RESULTS: Mean peak anti-Xa activity was 0.19 +/- 0.09 International Units/mL and mean trough was 0.044 +/- 0.04 International Units/mL. The recommended target range is 0.1 to 0.2 International Units/mL. The trough was below therapeutic levels in all but two patients. One thrombosis occurred in a patient despite a therapeutic trough. CONCLUSION: Daily dosing of enoxaparin is inadequate for critically ill patients and should be abandoned. Further studies using twice daily dosing are needed. Patients with renal insufficiency may require an increased interval of administration (daily dosing). Anti-Xa levels may not correlate with the risk of thromboembolic complications. Patients with renal insufficiency and morbid obesity may require alternative dosing and monitoring of anti-Xa levels.

Multidisciplinary approach to abdominal wall reconstruction after decompressive laparotomy for abdominal compartment syndrome.

INTRODUCTION: Decompressive laparotomy for abdominal compartment syndrome has been shown to reduce mortality in critically ill patients, but little is known about the outcome of abdominal wall reconstruction. This study investigates the role of plastic surgeons in the management and reconstruction of these abdominal wall defects. METHODS: We performed a retrospective review of 82 consecutive critically ill patients who underwent decompressive laparotomy for abdominal compartment syndrome, at a university level 1 trauma center, from April 2000 to May 2004. Patients reconstructed by trauma surgeons alone (n = 15) were compared with patients reconstructed jointly with plastic surgeons (n = 12), using Student t test and chi analysis. RESULTS: Eighty-two patients underwent decompressive laparotomy for abdominal compartment syndrome, yielding 50 survivors (61%). Of the 27 patients who underwent abdominal wall reconstruction, 6 had early primary fascial repair, and 21 had staged reconstruction with primary fascial closure (n = 4), components separation alone (n = 3), components separation with mesh (n = 10), or permanent mesh only (n = 4). Compared with patients whose reconstruction was performed by trauma surgeons, patients who underwent a combined approach with plastic surgeons were older (50.5 versus 31.7 years, P < 0.05), had more comorbidities (P < 0.001), were less likely to have a traumatic etiology (P < 0.001), had a longer delay to reconstruction (407 versus 119 days, P < 0.05), and were more likely to undergo components separation (P < 0.05). Mean follow-up of 11.5 months revealed 2 recurrent hernias in the combined reconstruction group, both of which were successfully repaired. CONCLUSIONS: A multidisciplinary approach is essential to the successful management of abdominal wall defects after decompressive laparotomy for abdominal compartment syndrome. Although carefully selected patients can undergo early primary fascial repair, most of reconstructed patients had staged closure of the abdominal wall via components separation, with a low rate of recurrent hernia. High-risk patients with large defects and comorbidities appear to benefit from the involvement of a plastic surgeon.

Blood transfusion is an independent predictor of increased mortality in nonoperatively managed blunt hepatic and splenic injuries.

BACKGROUND: Management strategies for blunt solid viscus injuries often include blood transfusion. However, transfusion has previously been identified as an independent predictor of mortality in unselected trauma admissions. We hypothesized that transfusion would adversely affect mortality and outcome in patients presenting with blunt hepatic and splenic injuries after controlling for injury severity and degree of shock. METHODS: We retrospectively reviewed records from all adults with blunt hepatic and/or splenic injuries admitted to a Level I trauma center over a 4-year period. Demographics, physiologic variables, injury severity, and amount of blood transfused were analyzed. Univariate and multivariate analysis with logistic and linear regression were used to identify predictors of mortality and outcome. RESULTS: One hundred forty-three (45%) of 316 patients presenting with blunt hepatic and/or splenic injuries received blood transfusion within the first 24 hours. Two hundred thirty patients (72.8%) were selected for nonoperative management, of whom 75 (33%) required transfusion in the first 24 hours. Transfusion was an independent predictor of mortality in all patients (odds ratio [OR], 4.75; 95% confidence interval [CI], 1.37-16.4; p = 0.014) and in those managed nonoperatively (OR, 8.45; 95% CI, 1.95-36.53; p = 0.0043) after controlling for indices of shock and injury severity. The risk of death increased with each unit of packed red blood cells transfused (OR per unit, 1.16; 95% CI, 1.10-1.24; p < 0.0001). Blood transfusion was also an independent predictor of increased hospital length of stay (coefficient, 5.45; 95% CI, 1.64-9.25; p = 0.005). CONCLUSION: Blood transfusion is a strong independent predictor of mortality and hospital length of stay in patients with blunt liver and spleen injuries after controlling for indices of shock and injury severity. Transfusion-associated mortality risk was highest in the subset of patients managed nonoperatively. Prospective examination of transfusion practices in treatment algorithms of blunt hepatic and splenic injuries is warranted.

Intrapleural tissue plasminogen activator for complicated pleural effusions.

BACKGROUND: This study is aimed at evaluating the safety and efficacy of intrapleural tissue plasminogen activator (TPA) for complicated pleural effusions, including posttraumatic hemothorax. METHODS: Data were retrospectively collected from hospitalized patients over a 4-year period (1999-2003) who were treated with intrapleural TPA after failing drainage by tube thoracostomy. Pre- and post-TPA imaging studies were reviewed and scored by a blinded radiologist. RESULTS: Forty-one consecutive patients with 42 effusions were identified with the following indications: 6 traumatic hemothoraces (14%), 22 loculated pleural effusions (52%), 2 line-associated hemothoraces (5%), and 12 empyemas (29%). Nine patients (22%) required operative drainage including two with posttraumatic hemothoraces. All patients managed nonoperatively demonstrated radiographic improvement after TPA administration. One patient (2.4%) developed hematuria, requiring transfusion. No trauma patient required TPA-related blood transfusion and no deaths were attributable to TPA therapy. CONCLUSION: Intrapleural TPA administration appears safe for use in complicated pleural effusions and may decrease the need for operative intervention.