Beyond the Do-not-resuscitate Order: An Expanded Approach to Decision-making Regarding Cardiopulmonary Resuscitation in Older Surgical Patients.

American Society of Anesthesiologists guidelines recommend that anesthesiologists revisit do-not-resuscitate orders preoperatively and revise them if necessary based on patient preferences. In patients without do-not-resuscitate orders or other directives limiting treatment however, "full code" is the default option irrespective of clinical circumstances and patient preferences. It is time to revisit this approach based on (1) increasing understanding of the power of default options in healthcare settings, (2) changing demographics and growing evidence suggesting that an expanding subset of patients is vulnerable to poor outcomes after perioperative cardiopulmonary resuscitation (CPR), and (3) recommendations from multiple societies promoting risk assessment and goal-concordant care in older surgical patients. The authors reconsider current guidelines in the context of these developments and advocate for an expanded approach to decision-making regarding CPR, which involves identifying high-risk elderly patients and eliciting their preferences regarding CPR irrespective of existing or presumed code status.

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk.

BACKGROUND: Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. MATERIALS AND METHODS: We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. RESULTS: 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. CONCLUSIONS: Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

Impact of catastrophic brain injury guidelines on organ donation rates: Results of an EAST multicenter trial.

BACKGROUND: One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without. METHODS: This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation. RESULTS: A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation. CONCLUSION: There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients. LEVEL OF EVIDENCE: Prognostic; Level III.

The Ethics of Discharge Planning After Violent Injury.

INTRODUCTION: Victims of violence (VoV) are at disproportionate risk for future violence, making consideration of patient safety by Emergency Medicine (EM) physicians and Trauma Surgeons (TS) essential when discharge planning (DP) for VoV. Practice patterns and ethical perspectives in DP for VoV, and their respective scenario- and specialty-specific variations, are unknown. METHODS: We surveyed 118 EM and 37 TS physicians at a level 1 trauma center. Three clinical scenarios were presented (intimate partner violence, elder abuse, gun violence), each followed by four questions assessing practices and ethical dilemmas in DP. Responses were compared using Chi-Square testing. RESULTS: Response rate was 51.6%. EM physicians more frequently supported patient autonomy to proceed with a potentially unsafe discharge plan after an episode of Intimate Partner Violence (P = .013) and believed that admission could facilitate change in the victim's social situation after an episode of Elder Abuse (P = .026). TS physicians were more likely to offer social admission, providing additional time to navigate safe discharge planning (P = .003), less likely to see social admission as an inappropriate use of limited resources (P = .030) and less likely to support patient autonomy to proceed with a potentially unsafe discharge (P = .003) after gun-related violence. CONCLUSION: There appears to exist scenario- and specialty-specific variability in the practice patterns and ethical perspectives of EM and TS physicians when discharge planning for victims of violence. These findings highlight the need for further evaluation of specific factors underlying variability by situation and specialty, and their implications for patient-centered outcomes.

The choices we make: Ethical challenges in trauma surgery.

BACKGROUND: Ethical issues in trauma surgery are commonplace but scarcely studied. We aim to characterize the ethical dilemmas trauma surgeons encounter in clinical practice and describe perceptions about the ability to manage these dilemmas and strategies they use to address them. METHODS: Members of a U.S. trauma society were electronically surveyed on handling ethically challenging scenarios. The survey instrument was developed using published ethics literature and iterative cognitive interviews. Domains included perceived frequency of encountering and self-efficacy of managing ethical situations in trauma surgery. Common situations were defined as those encountered monthly or weekly. Ethical problems were categorized within 7 larger categories: general ethics, autonomy, communication, justice, end-of-life, conflict, and other. Descriptive analyses were performed; group comparisons were analyzed using analysis of variance. RESULTS: Of 1,748 surveyed, 548 responded (30.6%) and 154 (28%) were female. Most were White, under 55 years age, had completed fellowship training, and were practicing at a level I or II trauma center. The most encountered ethical categories were generic ethics and communication (79%). Issues involving conflict were least frequent (21%). Respondents felt most uncomfortable with autonomy topics. Respondents with high self-efficacy in handling ethical situations were older, in practice ≥15 years, served on an ethics committee, and/or frequently experienced ethical challenges. CONCLUSION: Most trauma surgeons regularly encounter ethical challenges, especially those related to communication. Trauma surgeons encounter ethical issues involving conflict least often, and lowest self-efficacy scores with issues involving autonomy. Experienced trauma surgeons reported higher self-efficacy scores in managing ethical issues. Future work should examine how self-efficacy translates to observed behavior, and how trauma surgeons build and enhance their ethical skillsets in the care of the injured patient.

Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery.

BACKGROUND: Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. METHODS: This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90 days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. RESULTS: Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90 days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). CONCLUSIONS: Among Veterans, recent antibiotic exposure within 90 days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.

Regional ethics of surgeon resuscitation for organ transplantation after lethal injury.

BACKGROUND: Trauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of deciding whether, when, and how to resuscitate a patient who will not directly benefit from it. As there are no established guidelines to follow, we aimed to describe resuscitation practices for organ transplantation; we hypothesized that resuscitation practices vary regionally. METHOD: Over a 3-month period, we surveyed trauma surgeons practicing in Levels I and II trauma centers within a single state using an instrument to measure resuscitation attitudes and practices for organ preservation. Descriptive statistics were calculated for practice patterns. RESULTS: The survey response rate was 51% (31/60). Many (81%) had experience with resuscitations where the primary goal was to preserve potential for organ transplantation. Many (90%) said they encountered this dilemma at least monthly. All respondents were willing to intubate; most were willing to start vasopressors (94%) and to transfuse blood (84%) (range, 1 unit to >10 units). Of respondents, 29% would resuscitate for ≥24 hours, and 6% would perform a resuscitative thoracotomy. Respect for patients' dying process and future organ quality were the factors most frequently considered very important or important when deciding to stop or forgo resuscitation, followed closely by concerns about excessive resource use. CONCLUSION: Trauma surgeons' regional resuscitation practices vary widely for this patient population. This variation implies a lack of professional consensus regarding initiation and extent of resuscitations in this setting. These data suggest this is a common clinical challenge, which would benefit from further study to determine national variability, areas of equipoise, and features amenable to practice guidelines.

How Should Complex Communication Responsibilities Be Distributed in Surgical Education Settings?

Part of any trauma surgeon's job is communicating effectively in difficult, often time-limited, situations. The ability to effectively discuss topics like goals of care in these settings has a direct effect on patient care. Many factors contribute to the complexity of these conversations, including patient, physician, surrogate, and system-specific factors. In responding to the case of Mr. D and Dr. J, we attempt to outline and analyze some of the moral challenges and ethical questions that this professional responsibility poses to trauma surgeons and trainees.

Gun Violence Research and the Profession of Trauma Surgery.

The effects of violence are clearly a central component of any trauma surgeon's job. The role trauma surgeons should play in its prevention and advocacy, however, is not clearly defined. In this article, we discuss the statistics and lack of research on gun violence and survey some of the moral frameworks that define a trauma surgeon's professional responsibilities in violence prevention at a practice and a policy level.

Artificial intelligence can predict daily trauma volume and average acuity.

BACKGROUND: The goal of this study was to integrate temporal and weather data in order to create an artificial neural network (ANN) to predict trauma volume, the number of emergent operative cases, and average daily acuity at a Level I trauma center. METHODS: Trauma admission data from Trauma Registry of the American College of Surgeons and weather data from the National Oceanic and Atmospheric Administration was collected for all adult trauma patients from July 2013-June 2016. The ANN was constructed using temporal (time, day of week), and weather factors (daily high, active precipitation) to predict four points of daily trauma activity: number of traumas, number of penetrating traumas, average Injury Severity Score (ISS), and number of immediate operative cases per day. We trained a two-layer feed-forward network with 10 sigmoid hidden neurons via the Levenberg-Marquardt back propagation algorithm, and performed k-fold cross validation and accuracy calculations on 100 randomly generated partitions. RESULTS: Ten thousand six hundred twelve patients over 1,096 days were identified. The ANN accurately predicted the daily trauma distribution in terms of number of traumas, number of penetrating traumas, number of OR cases, and average daily ISS (combined training correlation coefficient r = 0.9018 ± 0.002; validation r = 0.8899 ± 0.005; testing r = 0.8940 ± 0.006). CONCLUSION: We were able to successfully predict trauma and emergent operative volume, and acuity using an ANN by integrating local weather and trauma admission data from a Level I center. As an example, for June 30, 2016, it predicted 9.93 traumas (actual: 10), and a mean ISS of 15.99 (actual: 13.12). This may prove useful for predicting trauma needs across the system and hospital administration when allocating limited resources. LEVEL OF EVIDENCE: Prognostic/epidemiological, level III.

Evidence-Based Care of Geriatric Trauma Patients.

The doubling of the geriatric population over the next 20 years will challenge the existing health care system. Optimal care of geriatric trauma patients will be of paramount importance to the health care discussion in America. These patients warrant special consideration because of altered anatomy, physiology, and the resultant decreased ability to tolerate the stresses imposed by traumatic insult. Despite increased risk for worsened outcomes, nearly half of all geriatric trauma patients will be cared for at nondesignated trauma centers. Effective communication is crucial in determining goals of care and arriving at what patients would consider a meaningful outcome.

Functional status, age, and long-term survival after trauma.

BACKGROUND: The association between functional status in trauma survivors and long-term outcomes is unknown. METHODS: We performed an observational cohort study on adult trauma patients (≥18 years), who required admission to the intensive care unit and who survived hospitalization between 1997 and 2011. The exposure of interest was a functional status defined as bed mobility, transfers, and gait level assessed at the time of hospital discharge. Adjusted odds ratios were estimated by multivariable logistic regression models. The primary outcome was all-cause, postdischarge mortality. RESULTS: We analyzed 3,565 patients with a mean (standard deviation) age of 55 (12.4) years; 60% were male, and 78% were white. The 720-day postdischarge mortality was 22.8%. In a logistic regression model, the lowest functional status category at hospital discharge was associated with 4-fold increased odds of 720-day postdischarge mortality (adjusted odds ratio 4.06 (95% confidence interval, 2.65-6.20, P < .001) compared with patients with independent functional status. We compared the odds of 720-day postdischarge mortality in patients with independent functional status and in patients in the lowest functional status category at hospital discharge. The odds of 720-day postdischarge mortality were stronger in older adults (≥65 years: adjusted odds ratio 3.34 [95% confidence interval, 1.72-6.50, P < .001]) than in younger adults (<65 years: adjusted odds ratio 2.53 [95% confidence interval, 1.39-4.60, P = .002]). Finally, improvement of functional status prior to discharge was associated with a 52% decrease in the odds of 720-day postdischarge mortality (adjusted odds ratio 0.48; 95% confidence interval, 0.30-0.75; P < .001) compared with patients without a change in functional status prior to discharge. CONCLUSION: In trauma intensive care unit survivors, functional status at hospital discharge is predictive of long-term mortality.

Comparing Readmissions and Infectious Complications of Blunt Splenic Injuries Using a Statewide Database.

BACKGROUND: Although non-operative management of blunt splenic injury (BSI) is increasingly common, the long-term infectious complications after adjunct splenic artery embolization (SAE) are not well described. METHODS: Patients aged 18-64 y with BSI were identified in the California State Inpatient Database (2007-2011) and categorized as receiving either non-operative management (NOM) without SAE, NOM with SAE, or operative management (OM). The cumulative incidence of infections (surgical site infections [SSI], pneumonia, urinary tract infections, and sepsis) requiring readmission at different times up to one y after injury were calculated. Patient and treatment factors associated with infectious readmissions were determined using multivariable logistic regression models. RESULTS: Of the 4,360 patients with BSI, 61.6% had NOM without SAE, 5.8% had NOM with SAE, and 32.6% had OM. The cumulative incidences of infectious complications after each of the management modes were 1.27%, 1.59%, and 1.76%, respectively, during admission (p = 0.446); 2.16%, 5.18%, and 4.85%, respectively, at 30 d after injury (p < 0.001); and 4.69%, 9.16%, and 8.85%, respectively, at one y after injury (p < 0.001). Risk factors for infection-associated readmissions within one y after injury were Charlson score ≥2 (adjusted odds ratio [AOR] 3.9; 95% confidence interval [CI] 2.61-6.02), length of stay >seven d (AOR 2.47; 95% CI 1.58-3.85), NOM with SAE (AOR 2.00; 95% CI 1.19-3.34), and OM (AOR 1.47; 95% CI 1.05-2.07). CONCLUSIONS: The long-term risk of infectious complications in patients with BSI who have NOM with SAE is similar to that in patients who are treated with OM, indicating the need for pro-active strategies to reduce long-term infectious complications after SAE.

The excess morbidity and mortality of emergency general surgery.

BACKGROUND: Emergency general surgery (EGS) carries a disproportionate burden of risk from medical errors, complications, and death compared with non-EGS (NEGS). Previous studies have been limited by patient and procedure heterogeneity but suggest worse outcome in EGS patients because of preoperative risk factors. The aim of this study was to quantify the excess burden of morbidity and mortality associated with EGS by controlling for patient-specific factors. We hypothesized that EGS is an independent risk factor for morbidity and mortality. METHODS: We retrospectively analyzed data from the American College of Surgeons-National Surgical Quality Improvement Program. Fourteen procedures common to both EGS and NEGS from 2008 through 2012 were included. Patients were stratified based on emergency status. The primary outcome was death within 30 days of operation. Secondary outcomes were postoperative complications. Variables from the American College of Surgeons-National Surgical Quality Improvement Program preoperative risk assessment were analyzed. χ and Wilcoxon signed-rank tests were used to compare variables. Multivariate logistic regression was used to identify independent risk factors for mortality and complications. RESULTS: Of 66,665 patients, 24,068 were EGS and 42,597 were NEGS. Mortality was 12.50% for EGS patients and 2.66% for NEGS patients (p < 0.0001). Major complications occurred in 32.80% of EGS patients and 12.74% of NEGS patients (p < 0.0001). When preoperative variables and procedure type were controlled, EGS was independently associated with death (odds ratio, 1.39; p = 0.029) and major complications (odds ratio, 1.31; p = 0.001). CONCLUSION: EGS is an independent risk factor for death and postoperative complications. The excess morbidity and mortality of EGS are not fully explained by preoperative risk factors, making EGS an excellent target for quality improvement projects. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.