Can We Actually Predict Long-Term Patient Satisfaction After Traumatic Brain Injury?

INTRODUCTION: The Traumatic Brain Injury - Patient Reported Outcome (TBI-PRO) model was previously derived to predict long-term patient satisfaction as assessed by the Quality of Life After Brain Injury (QOLIBRI) score. The aim of this study is to externally and prospectively validate the TBI-PRO model to predict long-term patient-reported outcomes and to derive a new model using a larger dataset of older adults with TBI. METHODS: Patients admitted to a Level I trauma center with TBI were prospectively followed for 1 y after injury. Outcomes predicted by the TBI-PRO model based on admission findings were compared to actual QOLIBRI scores reported by patients at 3,6, and 12 mo. When deriving a new model, Collaborative European NeuroTrauma Effectiveness Research in TBI and the Transforming Research and Clinical Knowledge in Traumatic Brain Injury databases were used to identify older adults (≥50 y) with TBI from 2014 to 2018. Bayesian additive regression trees were used to identify predictive admission covariates. The coefficient of determination was used to identify the fitness of the model. RESULTS: For prospective validation, a total of 140 patients were assessed at 3 mo, with follow-up from 69 patients at 6 mo and 13 patients at 12 mo postinjury. The area under receiver operating curve of the TBI-PRO model for predicting favorable outcomes at 3, 6, and 12 mo were 0.65, 0.57, and 0.62, respectively. When attempting to derive a novel predictive model, a total of 1521 patients (80%) was used in the derivation dataset while 384 (20%) were used in the validation dataset. A past medical history of heart conditions, initial hospital length of stay, admission systolic blood pressure, age, number of reactive pupils on admission, and the need for craniectomy were most predictive of long-term QOLIBRI-Overall Scale. The coefficient of determination for the validation model including only the most predictive variables were 0.28, 0.19, and 0.27 at 3, 6, and 12 mo, respectively. CONCLUSIONS: In the present study, the prospective validation of a previously derived TBI-PRO model failed to accurately predict a long-term patient reported outcome measures in TBI. Additionally, the derivation of a novel model in older adults using a larger database showed poor accuracy in predicting long-term health-related quality of life. This study demonstrates limitations to current targeted approaches in TBI care. This study provides a framework for future studies and more targeted datasets looking to assess long-term quality of life based upon early hospital variables and can serve as a starting point for future predictive analysis.

Evaluation of an Association Between Enoxaparin Dose per Estimated Blood Volume and Clinically Relevant Bleeding in Low-Weight Trauma Patients.

BACKGROUND: The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier. OBJECTIVE: To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients. METHODS: This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints. RESULTS: A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models. CONCLUSION AND RELEVANCE: No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg.

Sigh Ventilation in Patients With Trauma: The SiVent Randomized Clinical Trial.

Importance: Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown. Objective: To determine whether adding sigh breaths improves clinical outcomes. Design, Setting, and Participants: A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours. Interventions: Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished. Main Outcomes and Measures: The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality. Results: Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]). Conclusions and Relevance: In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT02582957.

Acute clavicle fixation after blunt chest trauma: effect on pulmonary outcomes and patient disposition.

PURPOSE: Clavicle fractures are common in patients who sustain blunt chest trauma (BCT). Recently, surgical fixation of rib fractures in patients with BCT has been shown to improve pulmonary and clinical outcomes. Therefore, the purpose of this study is to assess the role of early clavicle fixation (ECF) versus non-operative (NO) treatment for midshaft clavicle fractures in this same population. METHODS: A retrospective chart review was performed in patients with midshaft clavicle fractures and BCT at a Level I Trauma Center between 2007 and 2017. Patients with pre-existing pulmonary conditions and head injuries necessitating mechanical ventilation were excluded. Demographic data, injury mechanisms, and Thoracic Trauma Severity Scores (TTS) were analyzed. Inpatient pulmonary outcomes were assessed with serial vital capacity (VC) measurements, intubation, mechanical ventilation, and pulmonary complications data. In addition, intensive care unit (ICU) and hospital length of stay (LOS), mortality, discharge location, and incidence of postoperative complications in the ECF group were also measured. RESULTS: Thirty-six patients underwent ECF, and 24 underwent NO treatment. The ECF cohort was statistically younger and had a greater incidence of clavicle fracture shortening than the NO group. There was no difference in pulmonary outcomes, ICU or hospital LOS, or mortality between groups. There were no complications associated with ECF. Patients who underwent ECF were more likely to discharge to home. There were no postoperative complications associated with ECF. CONCLUSION: ECF of midshaft clavicle fractures does not improve pulmonary outcomes in patients with BCT. However, despite the lack of pulmonary benefit, there appears to be no added risk of harm. Therefore, ECF is a reasonable consideration in this patient population who otherwise meet clavicle fracture operative indications.

Multi-frame, ultrafast, x-ray microscope for imaging shockwave dynamics.

Inertial confinement fusion (ICF) holds increasing promise as a potential source of abundant, clean energy, but has been impeded by defects such as micro-voids in the ablator layer of the fuel capsules. It is critical to understand how these micro-voids interact with the laser-driven shock waves that compress the fuel pellet. At the Matter in Extreme Conditions (MEC) instrument at the Linac Coherent Light Source (LCLS), we utilized an x-ray pulse train with ns separation, an x-ray microscope, and an ultrafast x-ray imaging (UXI) detector to image shock wave interactions with micro-voids. To minimize the high- and low-frequency variations of the captured images, we incorporated principal component analysis (PCA) and image alignment for flat-field correction. After applying these techniques we generated phase and attenuation maps from a 2D hydrodynamic radiation code (xRAGE), which were used to simulate XPCI images that we qualitatively compare with experimental images, providing a one-to-one comparison for benchmarking material performance. Moreover, we implement a transport-of-intensity (TIE) based method to obtain the average projected mass density (areal density) of our experimental images, yielding insight into how defect-bearing ablator materials alter microstructural feature evolution, material compression, and shock wave propagation on ICF-relevant time scales.

Lost in Follow-Up: Predictors of Patient No-Shows to Clinic Follow-Up After Abdominal Injury.

BACKGROUND: The aim of this study is to evaluate risk factors for non-attendance to post-discharge, hospital follow-up appointments for traumatically injured patients who underwent exploratory laparotomy. METHODS: This is a retrospective chart review of patients who underwent exploratory laparotomy for traumatic abdominal injury at an urban, Midwestern, level I trauma center with clinic follow-up scheduled after discharge. Clinically, relevant demographic characteristics, patients' distance from hospital, and the presence of staples, sutures, and drains requiring removal were collected. Descriptive statistics of categorical variables were calculated as totals and percentages and compared with a chi-squared test or Fisher's exact when appropriate. RESULTS: The sample included 183 patients who were largely assaultive trauma survivors (68%), male (80%), and black (53%) with a mean age of 35.4 ± 14.9 years. Overall, 18.5% no-showed for their follow-up appointment. On multivariate analysis for clinic no-show; length of stay (odds ratio = 0.92 [0.84-0.99], P = 0.04) and the need for suture, staple, or drain removal were protective for clinic attendance (odds ratio = 5.59 [1.07-7.01], P = 0.04). Overall, 12 patients (6.4%) were readmitted. Forty patients (18.3%) had their follow-up in the emergency department (ED). On multivariate regression of risk factors for ED visits, the only statistically significant factors (P < 0.05) were clinic appointment no-show (OR = 2.81) and self-pay insurance (OR = 4.78). CONCLUSIONS: Abdominal trauma patients are at high risk of no-show for follow-up appointments and no-show visits are associated with ED visits. Future work is needed evaluating interventions to improve follow-up.

Neither Skin Sutures nor Foam Dressing Use Affect Tracheostomy Complication Rates.

BACKGROUND: Tracheostomy is commonly used for managing the airway of trauma patients. Complications are common and result in increased length of stays and treatment cost. The aim of this study is to evaluate whether the utilization of skin sutures or foam barrier dressings affect tracheostomy complication rates. MATERIALS AND METHODS: This is a single-center retrospective review of patients who underwent a tracheostomy by the trauma service between January 2014 and December 2017. Collected variables included demographics, patient history, treatment variables, complications, and outcomes. Univariate and multivariate analyses were constructed to identify significant predictors for the development of complications. RESULTS: A total of 268 patients were included. The median age was 43.5 y, 221 (82.5%) patients were men, and the median BMI was 28 (IQR 24.6, 32.2). Most (87.3%) of the procedures were performed in the operating room and 82.5% were open. Skin sutures were used in 46.3% and 53.4% had a foam barrier dressing placed. Current smoking [OR 8.1 (95% CI 1.5, 43.6)] and BMI [OR 1.1 (95% CI 1.03, 1.2)] significantly increased the risk of developing pressure necrosis. Use of sutures or foam dressings was not associated with pressure necrosis, bleeding, or surgical site infection. There were no unexpected tracheostomy decannulations regardless of the use of skin sutures. CONCLUSIONS: Suturing the tracheostomy or applying a foam barrier dressing was not associated with overall complications or decannulation rates. Based on our data, we suggest that skin sutures may be safely abandoned.

Antibiotic Duration and Outcome Complications for Surgical Site Infection Prevention in Traumatic Mandible Fracture.

BACKGROUND: The appropriate duration of antibiotic therapy for surgical site infection (SSI) prevention in traumatic mandibular fracture repair is unknown, and practices vary significantly. The objective of this study was to characterize antibiotic duration and outcomes after surgical repair of traumatic mandibular fracture. METHODS: A single-center, retrospective analysis of all adult patients who underwent surgical fixation of a mandible fracture between January 2014 and December 2016 was performed. Operative service was categorized between otolaryngology (ear, nose, and throat surgery), plastic and reconstructive surgery, and oral and maxillofacial services. Primary outcomes were SSI and operative complications (including osteomyelitis, nonunion, malocclusion, and hardware infections). Differences in antibiotic prescription pattern were analyzed using analysis of variance test and Pearson chi-squared test. RESULTS: A total of 75 patients were included in the study with 33 (44.0%), 26 (34.7%), and 16 (21.3%) managed by plastic and reconstructive surgery, ear, nose, and throat surgery, and oral and maxillofacial services, respectively. Median age was 30.0 y. Median injury severity score was 4.0. There was no significant difference in hospital length of stay (P = 0.44), intensive care unit length of stay (P = 0.53), or postoperative complications (P = 0.15). None of our patients developed an SSI or postantibiotics complications. Although the total inpatient duration of antibiotics was not significantly different among services (P = 0.37), there were significant differences in outpatient duration of antibiotics (P = 0.007) and total duration of antibiotics (P = 0.003). CONCLUSIONS: Duration of antibiotics is not associated with postoperative SSI or antibiotics-related complications. The wide variation in prescribing practices and lack of any clear benefit for prolonged antibiotics provides an opportunity to explore the benefits of a standardized short course of antibiotics. LEVEL OF EVIDENCE: Therapeutic study, III.

Superficial Surgical Infections in Operative Abdominal Trauma Patients: A Trauma Quality Improvement Database Analysis.

BACKGROUND: Surgical site infections (SSIs) have a substantial impact on economic and health indices for patients and health-care institutions. The aim of this study was to identify risk factors for superficial SSIs (sSSIs) in operative abdominal trauma patients using a national cohort. METHODS: A retrospective analysis of adult trauma patients treated within the Trauma Quality Improvement Database who underwent an exploratory laparotomy from 2010 to 2015 was performed. Risk factors for infection were evaluated using χ2, Wilcoxon rank-sum, and multivariate logistic regression. RESULTS: In total, 41,034 patients underwent an exploratory laparotomy for trauma. There were 18,538 (45.6%) penetrating injuries. Additionally, 10,938 (26.7%) patients suffered a hollow viscus injury with one (8484; 20.7%), two (2188; 5.3%), or three or more (266; 0.7%) hollow viscus organs injured, respectively. The sSSI rate was 4.3%. On multivariate analysis, colonic injuries conferred the greatest single organ independent risk for sSSIs (odds ratio [OR] 2.88 [2.41-3.44]), followed by duodenal injuries (OR 1.99 [1.24-3.17]), small bowel injuries (OR 1.54 [1.28-1.84]), gastric injuries (OR 1.41 [1.06-1.89]), body mass index >30 (1.32 [1.14-1.54]), severe Injury Severity Score (16-25) (OR 1.43 [1.19-1.74]), profound Injury Severity Score (>25) (OR 1.76 [1.44-2.15]), and increasing number of hollow viscus injuries with one (OR 2.75 [2.33-3.26]), two (OR 3.82 [2.98-4.89]), or three (OR 6.85 [4.20-11.17]) organs injured, respectively. CONCLUSIONS: The incidence of sSSI in operative abdominal trauma patients increases with increased body mass index, increased age, location of injury, blood transfusion need, and increasing number hollow viscus injuries. Consideration should be given to avoiding primary skin closure in patients with these risk factors as a way to mitigate SSIs in this patient population.

A Call to Follow-Up: Results Regarding Trauma Clinic Follow-Up Patterns.

The objective of this study was to assess the current practice pattern regarding posthospitalization follow-up of trauma patients among the members of the Eastern Association for the Surgery of Trauma (EAST). An anonymous online multiple-choice survey of EAST members in 2016 was conducted. Ten questions relating to the follow-up care of injured patients were presented to the Active, Senior, and Associate members of EAST. Data were screened for quantitative concerns prior to analysis. Of the 1,610 members surveyed, 289 responded (18%). Approximately 52% of respondents stated that their institution has a dedicated trauma follow-up clinic where most injured patients are seen after discharge. Less than 20% reported that nontrauma multidisciplinary providers are present in clinics. Most (89.5%) reported that follow-up is a single visit, unless a patient has long-standing issues. Only 3 respondents stated that patients are regularly seen 3+ months out from injury, and a significant minority (17.7%) acknowledged no set follow-up timeline. Only 3.6% of participants indicated that they have a psychologist embedded in the trauma team, and 11.5% reported that no system is currently in place to manage mental health. Despite more than 20 years of literature highlighting the long-term physical and mental health sequelae after trauma, these survey results demonstrate that there is a lack of standardized and multidisciplinary follow-up. Given the improvement in outcomes with the identification and treatment of these sequelae, greater attention should be paid to functional recovery, social and psychological well-being, and chronic pain.

Negative pressure therapy is effective in abdominal incision closure.

BACKGROUND: CDC wound classification demonstrates surgical site infection (SSI) occurs in 15%-30% of contaminated (class III) and >30% of dirty-infected (class IV) wounds. Several techniques have been used to decrease SSI rates in midline laparotomy incisions; however, no technique has shown superiority. Evidence suggests incisional negative pressure wound therapy (INPWT) can decrease wound complications, but no literature exists regarding INPWT for high-risk laparotomy incisions. We sought to analyze the efficacy of INPWT in the management of high-risk midline laparotomy incisions. METHODS: Retrospective review of adult patients who underwent laparotomy between January 2013 and June 2014 with midline closure using INPWT. Only class III or IV wounds were included. Laparotomy incisions were loosely closed. INPWT set at 125 mm Hg is placed over oil emulsion impregnated gauze. INPWT is removed after 5 d and the wound left open to air. Records were reviewed for immediate and/or delayed surgical site complications. Primary end point was 30-d incisional SSI. Secondary end points included other surgical site complications. RESULTS: One class III and 12 class IV wounds were treated with INPWT for a median of 5 d. The class III wound developed a small skin dehiscence with no evidence of superficial or deep SSI. Among class IV wounds, the rate of superficial and deep incisional SSI was 25% and 0%, respectively. The overall surgical site complication rate was 41.7%. CONCLUSIONS: INPWT in closure of high-risk midline laparotomy incisions is a safe, effective method of wound closure with equivalent SSI rates to previously described methods.

Thoracic irrigation prevents retained hemothorax: a pilot study.

BACKGROUND: Upward of 20% of patients undergoing thoracostomy tube (TT) placement develop retained hemothorax (HTx) requiring secondary intervention. The aim of this study was to define the rate of secondary intervention in patients undergoing prophylactic thoracic irrigation. METHODS: A prospective observational trial of 20 patients who underwent thoracic irrigation at the time of TT placement was conducted. Patients with HTx identified on chest x-ray were included. After standard placement of a 36-French TT, the HTx was evacuated using a sterile suction catheter advanced within the TT. Warmed sterile saline was instilled into the chest through the TT followed by suction catheter evacuation. The TT was connected to the sterile drainage atrium and suction applied. TTs were managed in accordance with our standard division protocol. RESULTS: The population was predominantly (70%) male at median age 35 years, median ISS 13, with 55% suffering penetrating trauma. Thirteen (65%) patients underwent TT placement within 6 h of trauma with the remainder within 24 h. Nineteen patients received the full 1000-mL irrigation. The majority demonstrated significant improvement on postprocedure chest x-ray. The secondary intervention rate was 5%. A single patient required VATS on post-trauma day zero for retained HTx. Median TT duration was 5 d with median length of stay of 7 d. No adverse events related to the pleural lavage were noted. CONCLUSIONS: Thoracic irrigation at the time of TT placement for traumatic HTx may decrease the rate of retained HTx.

Thoracostomy tube function not trajectory dictates reintervention.

BACKGROUND: Hemothorax and/or pneumothorax can be managed successfully managed with tube thoracostomy (TT) in the majority of cases. Improperly placed tubes are common with rates near 30%. This study aimed to determine whether TT trajectory affects the rate of secondary intervention. METHODS: A retrospective review of all adult trauma patients undergoing TT placement over a 4-y period was performed. TT trajectory was classified as ideal, nonideal, or kinked-based on anterior-posterior chest x-ray. TTs with sentinel port outside the thoracic cavity were excluded. The primary outcome was any secondary intervention. RESULTS: Four-hundred eighty-six patients and a total of 547 hemithoraces underwent placement and met inclusion criteria. The majority of patients were male (76%), with a median age of 41 y, and majority suffered blunt trauma ideal trajectory was identified in 429 (78.4%). Kinked TTs were noted in 33 (6%) hemothoraces with a 45.5% replacement rate. Review with staff demonstrates inherent bias to replace kinked TTs. The overall secondary intervention rate was 27.8%. Kinked TTs were removed from final analysis due to treatment bias. Subsequent analysis demonstrated no significant difference between ideal and nonideal trajectories (25.1% versus 34.1%, P = 0.09). CONCLUSIONS: Intrathoracic trajectory of nonkinked TTs with the sentinel port within the thoracic cavity does not affect secondary intervention rates, including the rate of surgical intervention.

A dual-stage approach to contaminated, high-risk ventral hernia repairs.

BACKGROUND: The Modified Hernia Grading System (MHGS) was developed to risk stratify complex ventral hernia repairs (VHRs). MHGS grade 3 patients have mesh infections, dirty or contaminated fields, and/or violation of the alimentary tract. Reported surgical site infection (SSI) rates are over 40% after single-stage VHR in contaminated fields. In an attempt to decrease the SSI rate in MHGS grade 3 patients, we developed a dual-stage VHR (DSVHR) approach. METHODS: We reviewed adult general surgery patients undergoing DSVHR between January 2010 and June 2014. All patients were MHGS grade 3. Primary end point was 30-d superficial and deep SSI. Secondary end points included other surgical site occurrences, 6-mo recurrence, and mesh excision rates. RESULTS: Fifteen patients underwent DSVHR. Mean age was 56 y, and median body mass index was 38.3 kg/m(2). Operative indication included enterocutaneous fistulas (ECF; n = 6), ECF with infected mesh (n = 2), infected mesh (n = 2), and VHR requiring bowel resection (n = 5). Thirty-one operative procedures were performed with median of 2.5 d between procedures. Fascial closure was re-established in 12 patients; five patients had underlay biologic mesh placement; seven underwent component separation with retrorectus mesh placement (synthetic [n = 2], biologic [n = 5]). The remaining patients underwent bridging repair with biologic mesh. One patient developed a recurrence after 6 mo, whereas a single patient had a recurrence of their ECF. Four (27%) patients developed a SSI, with an additional four (27%) experiencing a surgical site occurrence. There were no postoperative mesh infections. CONCLUSIONS: DSVHR in MHGS grade 3 patients is associated with a lower SSI rate than previously reported for those undergoing single-stage repairs.

Risk factors for fracture-related infections after low-velocity gunshot fractures to the pelvis.

BACKGROUND: Although treatments have improved dramatically in recent years, mortality following gunshot wounds (GSW) to the pelvis continue to range between 3 and 20 %. This project was designed to determine the incidence and risk factors associated with pelvic fracture-related infection (FRI) following GSWs to the pelvis given the paucity of evidence regarding this complication. METHODS: A retrospective review of 13 years (1/2010-12/2022) of patients with GSW to the pelvis was performed. Patients meeting inclusion criteria underwent chart review for the development of pelvic FRI and the following additional data elements were extracted: demographics, presence and type of bowel injury, operations performed, complications, use of postoperative antibiotics (≤24 h vs. >24 h), surgical osseous debridement, presence of retained bullet fragments, and bullet trajectory. Discrete variables were analyzed using Wilcoxon rank-sum test, chi-square, and Fischer's exact test. Pearson correlation coefficients were calculated for continuous variables. RESULTS: 242 patients were included in the study. Concomitant bowel injury was present in 108 patients (45 %). Eleven patients (4.5 %) developed FRI, all of whom had a concomitant bowel injury (p < 0.001). Neither the presence of retained bullet fragments nor the bullet trajectory (through bowel before the bone) was associated with FRI. Antibiotic duration >24 h was not associated with a lower rate of pelvic FRI. CONCLUSION: Development of FRI after a GSW to the pelvis occurs in 4.5 % of patients and is significantly associated with concomitant bowel injury, specifically colonic injury. These findings can be used to help guide further studies on the role of prophylactic antibiotics or other strategies to prevent pelvic FRI.

Timing of ultra-portable ultrasound (UPUS) Examinations in detecting clinically concerning recurrent pneumothorax.

BACKGROUND: Recurrent pneumothorax (rPTX) is a common complication following thoracostomy tube (TT) removal in chest trauma patients. While chest X-ray (CXR) is most commonly used to detect a rPTX, bedside ultraportable ultrasound (UPUS) is a feasible, low cost, and radiation free alternative. No consensus exists with regards to the optimal timing of diagnostic imaging to assess for rPTX post-TT removal. Accordingly, we sought to identify an ideal UPUS timing to detect a rPTX METHODS: We conducted a single center prospective study of adult (≥18years) patients admitted with a chest trauma. UPUS examinations were performed using the Butterfly iQ+™ ultrasound. Three intercostal spaces (ICS) were evaluated (2nd through 4th). Post-TT UPUS examinations were performed at different timepoints following tube removal (1-6 h). A rPTX on UPUS was defined as the absence of lung-sliding in one or more intercostal spaces, and was considered a clinically concerning rPTX if lung-sliding was absent in ≥2 ICS. UPUS findings were compared to CXR. RESULTS: Ninety-two patients (97 hemi-thoraces) were included in the analysis. A total of 58 patients had a post-TT removal rPTX of which 11 were either clinically concerning or expanding. Comparing UPUS findings to CXR, the 3-hour post-TT removal ultrasound examinations were associated with the highest sensitivity. By hour 4, no rPTX showed expansion in size. Three patients required an intervention for a clinically concerning rPTX, all of whom were detected on UPUS 3-hour post-TT removal. CONCLUSION: Bedside UPUS performed at 3-hour post-TT removal has the highest sensitivity in detecting clinically concerning rPTX. Size of rPTX appears to stabilize by hour 4. In the absence of clinical symptoms, repeat imaging or observation of non-significant rPTX beyond 4 h may not provide added clinical benefit. LEVEL OF EVIDENCE: Level II, Diagnostic Tests or Criteria.

Fever and infections in surgical intensive care: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document.

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.

Early venous thromboembolism chemoprophylaxis in traumatic brain injury requiring neurosurgical intervention: Safe and effective.

BACKGROUND: Traumatic brain injury patients who require neurosurgical intervention are at the highest risk of worsening intracranial hemorrhage. This subgroup of patients has frequently been excluded from prior research regarding the timing of venous thromboembolism chemoprophylaxis. This study aims to assess the efficacy and safety of early venous thromboembolism chemoprophylaxis in patients with traumatic brain injuries requiring neurosurgical interventions. METHODS: This is a single-center retrospective review (2016-2020) of traumatic brain injury patients requiring neurosurgical intervention admitted to a level I trauma center. Interventions included intracranial pressure monitoring, subdural drain, external ventricular drain, craniotomy, and craniectomy. Exclusion criteria included neurosurgical intervention after chemoprophylaxis initiation, death within 5 days of admission, and absence of chemoprophylaxis. The total population was stratified into Early (≤72 hours of intervention) versus Late (>72 hours after intervention) chemoprophylaxis initiation. RESULTS: A total of 351 patients met the inclusion criteria, of whom 204 (58%) had early chemoprophylaxis initiation. Overall, there were no significant differences in baseline and admission characteristics between cohorts. The Early chemoprophylaxis cohort had a statistically significant lower venous thromboembolism rate (5% vs 13%, P < .001) with no increased risk of worsening intracranial hemorrhage (10% vs 13%, P = .44) or neurosurgical reintervention (8% vs 10%, P = .7). On subgroup analysis, a total of 169 patients required either a craniotomy or a craniectomy before chemoprophylaxis. The Early chemoprophylaxis cohort had statistically significant lower venous thromboembolism rates (2% vs 11%, P < .001) with no increase in intracranial hemorrhage (8% vs 11%, P = .6) or repeat neurosurgical intervention (8% vs 10%, P = .77). CONCLUSION: Venous thromboembolism prophylaxis initiation within 72 hours of neurosurgical intervention is safe and effective. Further prospective research is warranted to validate the results of this study.

Thoracic cavity irrigation prevents retained hemothorax and decreases surgical intervention in trauma patients.

INTRODUCTION: Retained hemothorax (HTX) is a common complication following thoracic trauma. Small studies demonstrate the benefit of thoracic cavity irrigation at the time of tube thoracostomy (TT) for the prevention of retained HTX. We sought to assess the effectiveness of chest irrigation in preventing retained HTX leading to a secondary surgical intervention. METHODS: We performed a single-center retrospective study from 2017 to 2021 at a Level I trauma center, comparing bedside thoracic cavity irrigation via TT versus no irrigation. Using the trauma registry, patients with traumatic HTX were identified. Exclusion criteria were TT placement at an outside hospital, no TT within 24 hours of admission, thoracotomy or video-assisted thoracoscopic surgery (VATS) prior to or within 6 hours after TT placement, VATS as part of rib fixation or diaphragmatic repair, and death within 96 hours of admission. Bivariate and multivariable analyses were conducted. RESULTS: A total of 370 patients met the inclusion criteria, of whom 225 (61%) were irrigated. Patients who were irrigated were more likely to suffer a penetrating injury (41% vs. 30%, p = 0.03) and less likely to have a flail chest (10% vs. 21%, p = 0.01). On bivariate analysis, irrigation was associated with lower rates of VATS (6% vs. 19%, p < 0.001) and retained HTX (10% vs. 21%, p < 0.001). The irrigated cohort had a shorter TT duration (4 vs. 6 days, p < 0.001) and hospital length of stay (7 vs. 9 days, p = 0.04). On multivariable analysis, thoracic cavity irrigation had lower odds of VATS (adjusted odds ratio, 0.37; 95% confidence interval [CI], 0.30-0.54), retained HTX (adjusted odds ratio, 0.42; 95% CI, 0.25-0.74), and a shorter TT duration ( ß = -1.58; 95% CI, -2.52 to -0.75). CONCLUSION: Our 5-year experience with thoracic irrigation confirms findings from smaller studies that irrigation prevents retained HTX and decreases the need for surgical intervention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Physiologic parameters and radiologic findings can predict pulmonary complications and guide management in traumatic rib fractures.

BACKGROUND: Traumatic rib fracture is associated with a high morbidity rate and identifying patients at risk of developing pulmonary complications (PC) can guide management and potentially decrease unnecessary intensive care admissions. Therefore, we sought to assess and compare the utility of a physiologic parameter, vital capacity (VC), with the admission radiologic findings (RibScore) in predicting PC in patients with rib fractures. METHODS: This is a single-center retrospective review (2015-2018) of all adult (≥18 years) patients admitted to a Level I trauma center with traumatic rib fracture. Exclusion criteria included no CT scan and absence of VC within 48 h of admission. The cohort was stratified into two groups based on presence or absence of PC (pneumonia, unplanned intubation, unplanned transfer to the intensive care unit for a respiratory concern, or the need for a tracheostomy). Multivariable logistic regression models were constructed to identify predictors of PC. RESULTS: A total of 654 patients met the inclusion criteria of whom 70 % were males. The median age was 51 years and fall (48 %) was the most common type of injury. A total of 36 patients (5.5 %) developed a pulmonary complication. These patients were more likely to be older, had a higher ISS, and were more likely to require a tube thoracostomy placement. On multivariable logistic regression, first VC ≤30 % (AOR: 4.29), day 1 VC ≤30 % (AOR: 3.61), day 2 VC ≤30 % (AOR: 5.54), Δ(Day2-Day1 VC) (AOR: 0.96), and RibScore ≥2 (AOR: 3.19) were significantly associated with PC. On discrimination analysis, day 2 VC had the highest area under the receiver operating characteristic curve (AuROC), 0.81, and was superior to first VC and day 1 VC in predicting PC. There was no statistically significant difference in predicting PC between day 2 VC and RibScore. On multivariable analysis, first VC ≤30 %, day 1 VC ≤30 %, day 2 VC ≤30 %, and admission RibScore ≥2 were associated with prolonged hospital and ICU LOS. CONCLUSION: VC and RibScore emerged as independent predictors of PC. However, VC was not found to be superior to RibScore in predicting PC. Further prospective research is warranted to validate the findings of this study.