Implementation of a Nurse-Driven Protocol for Catheter Removal to Decrease Catheter-Associated Urinary Tract Infection Rate in a Surgical Trauma ICU.

INTRODUCTION: Early removal of urinary catheters is an effective strategy for catheter-associated urinary tract infection (CAUTI) prevention. We hypothesized that a nurse-directed catheter removal protocol would result in decreased catheter utilization and CAUTI rates in a surgical trauma intensive care unit (STICU). METHODS: We performed a retrospective, cohort study following implementation of a multimodal CAUTI prevention bundle in the STICU of a large tertiary care center. Data from a 19-month historical control were compared to data from a 15-month intervention period. Pre- and postintervention indwelling catheter utilization and CAUTI rates were compared. RESULTS: Catheter utilization decreased significantly with implementation of the nurse-driven protocol from 0.78 in the preintervention period to 0.70 in the postintervention period (P < .05). As a result of the bundle, the CAUTI rate declined significantly, from 5.1 to 2.0 infections per 1000 catheter-days in the pre- vs postimplementation period (Incident Rate Ratio [IRR]: 0.38, 95% confidence interval: 0.21-0.65). CONCLUSIONS: Implementation of a nurse-driven protocol for early urinary catheter removal as part of a multimodal CAUTI intervention strategy can result in measurable decreases in both catheter utilization and CAUTI rates.

Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage.

OBJECTIVES: Mild traumatic brain injury (mTBI) is defined as Glasgow Coma Score (GCS) of 14 or 15. Despite good outcomes, patients are commonly transferred to trauma centers for observation and/or neurosurgical consultation. The aim of this study is to assess the value of redefining mTBI with novel radiographic criteria to determine the appropriateness of interhospital transfer for neurosurgical evaluation. METHODS: A retrospective study of patients with blunt head injury with GCS 13-15 and CT head from Jan 2014-Dec 2016 was performed. A novel criteria of head CT findings was created at our institution to classify mTBI. Outcomes included neurosurgical intervention and transfer cost. RESULTS: A total of 2120 patients were identified with 1442 (68.0%) meeting CT criteria for mTBI and 678 (32.0%) classified high risk. Two (0.14%) patients with mTBI required neurosurgical intervention compared with 143 (21.28%) high risk TBI (p < 0.0001). Mean age (55.8 years), and anticoagulation (2.6% vs 2.8%) or antiplatelet use (2.1% vs 3.0%) was similar between groups (p > 0.05). Of patients with mTBI, 689 were transferred without receiving neurosurgical intervention. Given an average EMS transfer cost of $700 for ground and $5800 for air, we estimate an unnecessary transfer cost of $733,600. CONCLUSION: Defining mTBI with the described novel criteria clearly identifies patients who can be safely managed without transfer for neurosurgical consultation. These unnecessary transfers represent a substantial financial and resource burden to the trauma system and inconvenience to patients.

Trauma Recidivism and Mortality Following Violent Injuries in Young Adults.

BACKGROUND: Trauma recidivism accounts for approximately 44% of emergency department admissions and remains a significant health burden with this patient cohort carrying higher rates of morbidity and mortality. METHODS: A level 1 trauma center registry was queried for patients aged 18-25 y presented between 2009 and 2015. Patients with nonaccidental gunshot wounds, stab wounds, or blunt assault-related injuries were categorized as violent injuries. Primary outcomes included mortality and recidivism, which were defined as patients with two unrelated traumas during the study period. Hospital records and the Social Security Death Index were used to aid in outcomes. RESULTS: A total of 6484 patients presented with 1215 (18.7%) sustaining violent injuries (87.4% male, median age 22.2 y). Mechanism of violent injuries included 64.4% gunshot wound, 21.1% stab, and 14.8% blunt assault. Compared with nonviolent injuries, violent injury patients had increased risk of mortality (9.3% versus 2.1%, P < 0.0001). Out-of-hospital mortality was 2.6% (versus 0.5% nonviolent, P < 0.0005), with an average time to death being 6.4 mo from initial injury. Recidivism was 24.9% with mean time to second violent injury at 31.9 ± 21.0 mo; 14.9% had two trauma readmissions, and 8.0% had ≥3. Ninety percent of subsequent injuries occurred within 5 y, with 19.1% in the first year. CONCLUSIONS: The burden of injury after violent trauma extends past discharge as patients have significantly higher mortality rates following hospital release. Over one-quarter present with a second unrelated trauma or death. Improved medical, psychological, and social collaborative treatment of these high-risk patients is needed to interrupt the cycle of violent injury.

Bowel Penetration by Inferior Vena Cava Filters: Feasibility and Safety of Percutaneous Retrieval.

OBJECTIVE. The purpose of this study was to evaluate the safety and technical feasibility of inferior vena cava filter (IVCF) removal when filter elements penetrate adjacent bowel. MATERIALS AND METHODS. A multicenter retrospective review of IVCF retrievals between 2008 and 2018 was performed. Adult patients with either CT or endoscopic evidence of filter elements penetrating bowel before retrieval were included. Technical success of IVCF retrieval was recorded. Patient records were assessed for immediate, 30-day, and 90-day complications after retrieval. RESULTS. Thirty-nine consecutive adult patients (11 men and 28 women; mean age, 51.2 years; age range, 18-81 years) qualified for inclusion. Filter dwell time was a median of 148 days (range, 32-5395 days). No IVCFs were known to have migrated or caused iliocaval thrombosis. Five IVCFs (12.8%) had more than 15° tilt relative to the inferior vena cava (IVC) before retrieval. Three IVCFs (7.7%) had fractured elements identified at the time of retrieval. Mean international normalized ratio (INR) was 1.24 ± 0.53 (SD), and mean platelet count was 262 ± 139 × 103/µL. Ten patients (25.6%) were on antibiotics at the time of retrieval. All 39 IVCFs were successfully retrieved (technical success = 100%). Two patients experienced minor complications in the immediate postprocedural period, which resulted in a minor complication rate of 5.1%. There were no complications (major or minor) identified in any patient at 30 or 90 days after retrieval. The overall major complication rate was 0%. CONCLUSION. Endovascular retrieval of IVCFs with CT evidence of filter elements that have penetrated adjacent bowel is both safe and technically feasible.

Carolinas Comfort Scale as a Measure of Hernia Repair Quality of Life: A Reappraisal Utilizing 3788 International Patients.

OBJECTIVE: The goal of the present study was to reaffirm the psychometric properties of the CCS using an expansive, multinational cohort. BACKGROUND: The Carolinas Comfort Scale (CCS) is a validated, disease-specific, quality of life (QOL) questionnaire developed for patients undergoing hernia repair. METHODS: The data were obtained from the International Hernia Mesh Registry, an American, European, and Australian prospective, hernia repair database designed to capture information delineating patient demographics, surgical findings, and QOL using the CCS at 1, 6, 12, and 24 months postoperatively. RESULTS: A total of 3788 patients performed 11,060 postoperative surveys. Patient response rates exceeded 80% at 1 year postoperatively. Acceptability was demonstrated by an average of less than 2 missing items per survey. The formal test of reliability revealed a global Cronbach's alpha exceeding 0.95 for all hernia types. Test-retest validity was supported by the correlation found between 2 different administrations of the CCS using the kappa coefficient. Principal component analysis identified 2 components with a good distribution of variance, with the first component explaining approximately 60% of the variance, regardless of hernia type. Discriminant validity was assessed by comparing survey responses and use of pain medication at 1 month postoperatively and analysis revealed that symptomatic patients demonstrated significantly higher odds of requiring pain medication in all activity domains and for all hernia types. CONCLUSIONS: The present study confirms that the CCS questionnaire is a validated, sensitive, and robust instrument for assessing QOL after hernia repair, which has become a predominant outcome measure in this discipline of surgery.

A prospective randomized double-blinded controlled trial evaluating indocyanine green fluorescence angiography on reducing wound complications in complex abdominal wall reconstruction.

BACKGROUND: The purpose of this prospective, randomized, double-blinded controlled trial was to investigate the utility of indocyanine green fluorescence angiography (ICG-FA) in reducing wound complications in complex abdominal wall reconstruction. MATERIALS AND METHODS: All consented patients underwent ICG-FA with SPY Elite after hernia repair and before flap closure. They were randomized into the control group, in which the surgical team was blinded to ICG-FA images and performed surgery as they normally would, or the experimental group, in which the surgery team viewed the images and could modify tissue flaps according to their findings. Patient variables and wound complications were compared with standard statistical methods. RESULTS: Among 95 patients, n = 49 control versus n = 46 experimental, preoperative characteristics were similar including age (58.3 versus 56.7 y; P = 0.4), body mass index (34.9 versus 33.6 kg/m(2); P = 0.8), tobacco use (8.2% versus 8.7%; P = 0.9), diabetes (30.6% versus 37.0%; P = 0.5), and previous hernia repair (71.4% versus 60.9%; P = 0.3). Operative characteristics were also similar, including rate of panniculectomy (69.4% versus 58.7%; P = 0.3) and component separation (73.5% versus 69.6%; P = 0.6). The experimental group more often had advancement flaps modified (37% versus 4.1%, P < 0.0001). There was no difference between groups in rates of skin necrosis (6.1% versus 2.2%; P = 0.3), fat necrosis (10.2% versus 13.0%, P = 0.7), reoperation (14.3% versus 26.1%, P = 0.7), wound infection (10.2% versus 21.7%; P = 0.12), or overall wound-related complications (32.7% versus 37.0%, P = 0.7). Skin/subcutaneous hypoperfusion on ICG-FA was associated with higher rates of wound infection (28% versus 9.4%, P < 0.02), but flap modification after viewing images did not prevent wound-related complications (15.6% versus 12.5%, P = 0.99). CONCLUSIONS: This is the first randomized, double-blinded, controlled trial to evaluate ICG-FA in abdominal wall reconstruction. Although ICG-FA guidance and intraoperative modification of flaps did not prevent wound-related complications or reoperation, it did identify at risk patients.

Analysis of the Final DENALI Trial Data: A Prospective, Multicenter Study of the Denali Inferior Vena Cava Filter.

PURPOSE: To report the final 2-year data on the efficacy and safety of a nitinol retrievable inferior vena cava (IVC) filter for protection against pulmonary embolism (PE). MATERIALS AND METHODS: This was a prospective multicenter trial of 200 patients with temporary indications for caval filtration who underwent implantation of the Denali IVC filter. After filter placement, all patients were followed for 2 years after placement or 30 days after filter retrieval. The primary endpoints were technical success of filter implantation in the intended location and clinical success of filter placement and retrieval. Secondary endpoints were incidence of clinically symptomatic recurrent PE, new or propagating deep vein thrombosis (DVT), and filter-related complications including migration, fracture, penetration, and tilt. RESULTS: Filter placement was technically successful in 199 patients (99.5%). Filters were clinically successful in 190 patients (95%). The rate of PE was 3% (n = 6), with 5 patients having a small subsegmental PE and 1 having a lobar PE. New or worsening DVT was noted in 26 patients (13%). Filter retrieval was attempted 125 times in 124 patients and was technically successful in 121 patients (97.6%). The mean filter dwell time at retrieval was 200.8 days (range, 5-736 d). There were no instances of filter fracture, migration, or tilt greater than 15° at the time of filter retrieval or during follow-up. CONCLUSIONS: The Denali IVC filter exhibited high success rates for filter placement and retrieval while maintaining a low complication rate in this clinical trial.

Do not waste your time: straight to magnetic resonance imaging for pediatric burners and stingers.

BACKGROUND: Permanent neurologic injury in pediatric patients with burner and stinger syndrome (BSS) is unlikely. This study aims to assess the feasibility of clinical observation without extensive radiologic workup in this selective population. METHODS: A retrospective study was conducted of patients aged younger than 18 years evaluated at a level I trauma center from 2012 to 2014. Patients were grouped according to positive deficit (PD) or negative deficit (ND) upon physical examination. Demographics, clinical findings, and outcomes were analyzed. RESULTS: Thirty patients (ND, n = 14; PD, n = 16) were evaluated for BSS, most often as a result of injurious football tackle. Age and length of stay were similar between groups. Injury Severity Score was lower in the ND group than the PD group (1.6 ± 1.2 vs 3.8 ± 3.1, respectively; P< .05). Cervical computed tomography was performed on 11 patients (78.6%) in the ND group and 15 patients (93.8%) in the PD group at considerable added cost, with only 1 positive result in the ND group and none in the PD group. Magnetic resonance imaging (MRI) revealed 2 positive findings in each group, and no surgical interventions were indicated. Ten ND (71.4%) and 12 PD (75%) patients reported complete resolution of symptoms at discharge (P> .05). CONCLUSIONS: Children presenting with BSS experience temporary symptoms that resolve without surgical intervention. Magnetic resonance imaging identified more injuries than computed tomographic imaging; therefore, we suggest that management for BSS should include observation, serial neurologic examinations, and MRI evaluation as appropriate.

Diagnostic Laparoscopy in the Intensive Care Unit.

Primary and acquired abdominal pathology accounts for a significant proportion of sepsis and SIRS in the ICU population. Abdominal processes often present a difficult diagnostic dilemma in the truly critically ill patient who, due to hemodynamic instability or severe acute respiratory distress syndrome (ARDS) requiring high-level ventilatory support, is at significant risk during transport to radiology department. Furthermore, the accuracy of radiologic studies in the ICU setting is often limited. Laparoscopy provides a "minimally invasive" definitive modality to diagnose intra-abdominal problems. It may quickly provide the necessary information to define further management. In selective circumstances, it may actually allow appropriate intervention. However, the overall mortality of patients who undergo diagnostic laparoscopy in the ICU is high regardless of diagnostic findingsduring this procedure. Although not a technically difficult procedure, diagnostic laparoscopy does require a certain skill level, especially when limited time and unfavorable patient physiology are taken into account. The use of diagnostic laparoscopy should be limited to patients in whom a therapeutic intervention is feasible.

Femur fractures should not be considered distracting injuries for cervical spine assessment.

INTRODUCTION: The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries. OBJECTIVES: We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging. METHODS: We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated. RESULTS: Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%). CONCLUSIONS: In our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.

The DENALI Trial: an interim analysis of a prospective, multicenter study of the Denali retrievable inferior vena cava filter.

PURPOSE: To assess safety and effectiveness of a nitinol retrievable inferior vena cava (IVC) filter in patients who require caval interruption to protect against pulmonary embolism (PE). MATERIALS AND METHODS: Two hundred patients with temporary indications for an IVC filter were enrolled in this prospective, multicenter clinical study. Patients undergoing filter implantation were to be followed for 2 years or for 30 days after filter retrieval. At the time of the present interim report, all 200 patients had been enrolled in the study, and 160 had undergone a retrieval attempt or been followed to 6 months with their filter in place. Primary study endpoints included technical and clinical success of filter placement and retrieval. Patients were also evaluated for recurrent PE, new or worsening deep vein thrombosis, and filter migration, fracture, penetration, and tilt. RESULTS: Clinical success of placement was achieved in 94.5% of patients (172 of 182), with a one-sided lower limit of the 95% confidence interval of 90.1%. Technical success rate of filter placement was 99.5%. Technical success rate of retrieval was 97.3%; 108 filters were retrieved in 111 attempts. In two cases, the filter apex could not be engaged with a snare, and one device was engaged but could not be removed. Filter retrievals occurred at a mean indwell time of 165 days (range, 5-632 d). There were no instances of filter fracture, migration, or tilt greater than 15° at the time of retrieval or 6-month follow-up. CONCLUSIONS: In this interim report, the nitinol retrievable IVC filter provided protection against pulmonary embolism, and the device could be retrieved with a low rate of complications.

Inferior vena cava filters: indications and management.

PURPOSE OF REVIEW: The purpose of this review was to examine recent studies concerning the use of inferior vena cava (IVC) filters. RECENT FINDINGS: In the past 18 months, the American College of Chest Physicians released the 9th edition of their guideline for the prevention and treatment of venous thromboembolism. There have also been a number of studies reviewing the use of IVC filters in select populations for the prophylactic prevention of pulmonary embolism. Trauma continues to be the leading indication for prophylactic filters in a number of series, but further studies have demonstrated some benefit of prophylactic filters in the bariatric and spine surgery populations. The IVC filter complication rate remains low; however, so does the retrieval rate for potentially removable filters. These retrieval rates are increased with use of dedicated patient tracking mechanisms. Finally, there have been a number of technology updates in the hardware itself, focusing on strut design. SUMMARY: Despite little change in the society guidelines, the use of vena cava filters (VCFs) continues to rise. Overall, the use of IVC filters, especially in prophylactic situations, will remain controversial until randomized, controlled trials are performed within each specific patient population.

The Association of the Affordable Care Act With Medicaid Enrollment Status and Costs of Care at a Level I Trauma Center in a Medicaid Non-expansion State.

INTRODUCTION: The intended purpose of the Patient Protection and Affordable Care Act (ACA) was to expand access to health care insurance for all Americans. In our study, we examine the association of Medicaid enrollment status, health care outcomes, and financial outcomes for trauma patients at a level I urban trauma center in a state that did not expand Medicaid coverage under the ACA. METHODS: We retrospectively reviewed trauma admissions from 2011 to 2016, via the trauma registry (n = 36,250). A subgroup of Medicaid patients (n = 8840) was identified and compared for changes in selected variables and demographics following ACA implementation. The association of Medicaid payor status, by 3 year average pre-ACA (n = 3516) and post-ACA (n = 3324), on patient outcomes, payments collected, and accrued costs of care were analyzed. RESULTS: Three-year Medicaid median actual payments decreased 7.5% following implementation of the ACA ($4072 vs. $3767, P < .01). In contrast, the Medicaid median total cost of care increased 23% ($3964 vs. $4882, P < .01). The rate of patients insured by Medicaid decreased (24.0% vs. 16.2%, P<.001). Patients were admitted longer (1 d vs. 2 d, P < .01), and more injured (ISS 5 vs. 6, P < .01). DISCUSSION: Medicaid payor status under the ACA was associated with a decrease in actual payments and an increase in total cost of care. Moreover, the divergence in actual payments collected with the increased total cost of care warrants examination to ascertain the root cause in efforts to reduce this widening gap.

Timing of venous thromboembolism chemoprophylaxis using objective hemoglobin criteria in blunt solid organ injury.

BACKGROUND: The purpose of this study was to evaluate the safety and efficacy of early venous thromboembolism (VTE) chemoprophylaxis following blunt solid organ injury. METHODS: A retrospective review of patients was performed for patients with blunt solid organ injury between 2009-2019. Enoxaparin was initiated when patients had <1g/dl Hemoglobin decline over a 24 h period. These patients were then categorized by initiation: ≤48 h and >48 h. RESULTS: There were 653 patients: 328 (50.2%) <48 h and 325 (49.8%) ≥48 h. Twenty-nine (4.4%) developed VTE. Patients in ≥48 h group suffered more frequent VTE events (6.5% vs 2.4%, p = 0.021). Non-operative failure occurred in 6 patients (1.9%) in ≥48 h group, and 5 patients (1.5%) < 48 h group. Blood transfusion following chemophrophylaxis initiation was required in 69 (21.3%) in ≥48 h group, and 46 (14.0%) in < 48 h group, occurring similarly between groups (p=0.021). CONCLUSION: Stable hemoglobin in the first 24 h is an efficacious, objective measure that allows early initiation of VTE chemoprophylaxis in solid organ injury. This practice is associated with earlier initiation of and fewer VTE events.

Emergency General Surgery Regionalization: Retrospective Cohort Study of Emergency General Surgery Patients at a Tertiary Care Center.

BACKGROUND: Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources. METHODS: We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients. RESULTS: Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different (P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts (P < .05). CONCLUSIONS: EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.

Atrial Cannulation During Resuscitative Clamshell Thoracotomy.

BACKGROUND: Resuscitative thoracotomy and clamshell thoracotomy are performed in the setting of traumatic arrest with the intent of controlling hemorrhage, relieving tamponade, and providing open chest cardiopulmonary resuscitation. Historically, return of spontaneous circulation rates for penetrating traumatic arrest as well as out of hospital survival have been reported as low as 40% and 10%. Vascular access can be challenging in patients who have undergone a traumatic arrest and can be a limiting step to effective resuscitation. Atrial cannulation is a well-established surgical technique in cardiac surgery. Herein, we present a case series detailing our application of this technique in the context of acute trauma resuscitation during clamshell thoracotomy for traumatic arrest in the emergency department. METHODS: A retrospective case series of atrial cannulation during traumatic arrest was conducted in Charlotte, NC at Carolinas Medical Center an urban level 1 trauma center. RESULTS: The mean rate of return of spontaneous circulation in our series, 60%, was greater than previously published upper limit of return of spontaneous circulation for penetrating causes of traumatic arrest. DISCUSSION: Intravenous access can be difficult to establish in the hypovolemic and exsanguinating patient. Traditional methods of vascular access may be insufficient in the setting of central vascular injury. Atrial appendage cannulation during atrial cannulation is a quick and reliable technique to achieve vascular access that employs common methods from cardiac surgery to improve resuscitation of traumatic arrest.

Unseen Burden of Injury: Post-Hospitalization Mortality in Geriatric Trauma Patients.

BACKGROUND/OBJECTIVES: Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. METHODS: Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. RESULTS: Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. CONCLUSION: Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.

Early warning: End-tidal carbon dioxide is associated with central venous oxygenation under continuous cardiorespiratory monitoring in a porcine model of hemorrhagic shock and resuscitation.

BACKGROUND: End-tidal carbon dioxide (ETCO2) has previously shown promise as a predictor of shock severity and mortality in trauma. ETCO2 monitoring is non-invasive, real-time, and readily available in prehospital settings, but the temporal relationship of ETCO2 to systemic oxygen transport has not been thoroughly investigated in the context of hemorrhagic shock. METHODS: A validated porcine model of hemorrhagic shock and resuscitation was used in male Yorkshire swine (N â€‹= â€‹7). Both ETCO2 and central venous oxygenation (SCVO2) were monitored and recorded continuously in addition to other traditional hemodynamic variables. RESULTS: Linear regression analysis showed that ETCO2 was associated with ScvO2 both throughout the experiment (ߠ​= â€‹1.783, 95% confidence interval (CI) [1.552-2.014], p â€‹< â€‹0.001) and during the period of most rapid hemorrhage (ߠ​= â€‹4.896, 95% CI [2.416-7.377], p â€‹< â€‹0.001) when there was a marked decrease in ETCO2. CONCLUSIONS: ETCO2 and ScvO2 were closely associated during rapid hemorrhage and continued to be temporally associated throughout shock and resuscitation.

Intercostal nerve cryoablation during surgical stabilization of rib fractures decreases post-operative opioid use, ventilation days, and intensive care days.

BACKGROUND: Intercostal nerve cryoablation is an adjunctive measure that has demonstrated pain control, decrease in opioid consumption, and decrease in hospital length of stay (LOS) in patients who undergo surgical stabilization of rib fractures (SSRF). METHODS: SSRF patients from January 2015 to September 2021 were retrospectively compared. All patients received multimodal pain regimens post-operatively and the independent variable was intraoperative cryoablation. RESULTS: 241 patients met inclusion criteria. 51 (21%) underwent intra-operative cryoablation during SSRF and 191 (79%) did not. Patients with standard treatment consumed 9.4 more daily MME (p = 0.035), consumed 73 percent more post-operative total MME (p = 0.001), spent 1.55 times as many days in the intensive care unit (p = 0.013), and spent 3.8 times as many days on the ventilator than patients treated with cryoablation, respectively. Overall hospital LOS, operative case time, pulmonary complications, MME at discharge, and numeric pain scores at discharge were no different (all p>0.05). CONCLUSION: Intercostal nerve cryoablation during SSRF is associated with fewer ventilator days, ICU LOS, total post-operative, and daily opioid use without increasing time in the operating room or perioperative pulmonary complications.

Prospective, long-term comparison of quality of life in laparoscopic versus open ventral hernia repair.

OBJECTIVES: To compare laparoscopic ventral hernia repair (LVHR) versus open ventral hernia repair (OVHR) for quality of life (QOL), complications, and recurrence in a large, prospective, multinational study. INTRODUCTION: As recurrence rates have decreased for LVHR and OVHR, QOL has become an extremely important differentiating outcomes measure. METHODS: A prospective, international database was queried from September 2007 to July 2011 for LVHR and OVHR. Carolinas Comfort Scale (CCS) was utilized to quantify QOL (pain, movement limitation, and mesh sensation) preoperatively and at 1, 6, and 12 months postoperatively. RESULTS: A total of 710 repairs included 402 OVHR and 308 LVHR. Demographics were mean age 57.1 ± 13.3 years, 49.6% male, 21.7% recurrent hernias, mean body mass index of 30.3 ± 6.6, and mean defect size of 89.4 ± 130.8. Preoperatively, 56.9% had pain, and 53.2% experienced movement limitation. At 1-month follow-up, 587 (82.7%) patients were provided CCS scores; more LVHR patients experienced pain (P < 0.001) and movement limitations (P < 0.001). At 6 and 12 months, there were no differences in QOL with 466 (65.6%) and 478 (67.3%) patients responding, respectively. After controlling for confounding variables, LVHR was independently associated with more frequent discomfort [odds ratio (OR) = 1.9, confidence interval (CI): 1.2-3.1], movement limitation (OR = 1.6, CI: 1.0-2.7), and overall symptoms (OR = 1.6, CI: 1.0-2.6) at 1 month. LVHR resulted in a shorter length of stay (LOS) (P < 0.001) and fewer infections (P = 0.004), but overall complication rates were equal. Recurrence rates were also equal (P = 0.66). CONCLUSION: In the largest, prospective QOL study comparing LVHR and OVHR, LVHR is associated with a decrease in QOL in the short term. LOS and infection rates are decreased in LVHR, but overall complication and recurrence rates are equal.