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.

Optimizing discharge opioid prescribing in trauma patients: A quasi-experimental study.

BACKGROUND: Patients prescribed higher opioid dosages are at increased risk of overdose and death without added pain reduction. Increases in opioid prescribing continue to fuel the epidemic. We hypothesized a comprehensive guideline to standardize opioid prescribing would decrease postdischarge dosages for patients experiencing trauma without requiring additional refills. METHODS: This quasiexperimental study compared opioid prescribing by trauma providers before and after the implementation of a departmental guideline on April 1, 2019, aimed at aligning opioid prescription patterns with Centers for Disease Control and Prevention recommendations. Patients prescribed opioids before implementation were the control group, whereas patients prescribed opioids after were the intervention group. The primary outcome was the proportion of patients receiving ≥50 morphine milligram equivalents per day. RESULTS: We identified 293 and 280 patients experiencing trauma in the control and intervention groups, respectively. There were no differences between the groups' Injury Severity Score (P = .69) or the frequency of having a procedure performed (P = .80). Total morphine milligram equivalents and maximum morphine milligram equivalents per day were 16% and 25% lower, respectively, in the intervention group compared with the control group (P < .001). The proportion of trauma patients prescribed ≥50 morphine milligram equivalents per day at discharge decreased from 57% to 18% after implementation (P < .001). The proportion of trauma patients prescribed ≥90 morphine milligram equivalents per day also decreased, from 37% to 14% (P < .001). There was no significant increase in the frequency of refill requests (P = .105) or refill prescriptions (P = .099) after discharge. CONCLUSION: A departmental guideline aimed at optimizing opioid prescription patterns successfully lowers the amount of morphine milligram equivalents prescribed to trauma patients and improves compliance with Centers for Disease Control and Prevention recommendations.

The 35-mm rule to guide pneumothorax management: Increases appropriate observation and decreases unnecessary chest tubes.

INTRODUCTION: Axial imaging has allowed for more precise measurement and, in-turn, more objective guidelines related to the management of traumatic pneumothoraces (PTXs). In 2017, our trauma center used a guideline to observe any PTX ≤35 mm in stable patients. We hypothesize that this guideline would decrease unnecessary chest tubes without affecting failure rates. METHODS: This is a single-center retrospective review of all adult trauma patients who had a PTX diagnosed on computed tomography before (2015-2016) and after (2018-2019) guideline implementation. We excluded patients with chest tubes inserted before computed tomography, concurrent hemothoraces, mechanical ventilation, or mortality in the first 24 hours. Descriptive statistical analyses, χ2 test, and Mann-Whitney U test were performed as appropriate. RESULTS: A total of 266 patients met our inclusion criteria. Ninety-nine (37.2%) and 167 patients (62.7%) were admitted before and after 2017, respectively. Overall, there were no differences in demographics or severity of injuries between both groups. After guideline implementation, there was a significant increase in observation rates and compliance rate. Tube thoracostomies decreased from 28.3% to 18% (p = 0.04). There were no statistically significant changes in observation failure rates, hospital or intensive care unit length of stay, complications, or mortality. CONCLUSION: The implementation of the 35 mm guideline is an effective tool to decrease unnecessary tube thoracostomy in hemodynamically normal patients without evidence of hemothorax. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Trauma surgeon-performed peripheral arterial repairs are associated with equivalent outcomes when compared with vascular surgeons.

BACKGROUND: Civilian extremity trauma with vascular injury carries a significant risk of morbidity, limb loss, and mortality. We aim to describe the trends in extremity vascular injury repair and compare outcomes between trauma and vascular surgeons. METHODS: We performed a single-center retrospective review of patients 18 years or older with extremity vascular injury requiring surgical intervention between January 2009 and December 2019. Demographics, injury characteristics, operative course, and hospital course were analyzed. Descriptive statistics were used to examine management trends, and outcomes were compared for arterial repairs. Multivariate regression was used to evaluate surgeon specialty as a predictor of complications, readmission, vascular outcomes, and mortality. RESULTS: A total of 231 patients met our inclusion criteria; 80% were male with a median age of 29 years. The femoral vessels were most commonly injured (39.4%), followed by the popliteal vessels (26.8%). Trauma surgeons performed the majority of femoral artery repairs (82%), while vascular surgeons repaired the majority of popliteal artery injuries (84%). Both had a similar share of brachial artery repairs (36% vs. 39%, respectively). There were no differences in complications, readmission, vascular outcomes, and mortality. Median time from arrival to operating room was significantly shorter for trauma surgeons. There was a significant downward trend between 2009 and 2017 in the proportion of total and femoral vascular procedures performed by trauma surgeons. On multivariate regression, surgical specialty was not a significant predictor of need for vascular reintervention, prophylactic or delayed fasciotomies, postoperative complications, or readmissions. CONCLUSION: Traumas surgeons arrived quicker to the operating and had no difference in short-term clinical outcomes of brachial and femoral artery repairs compared with patients treated by vascular surgeons. Over the last decade, there has been a significant decline in the number of open vascular repairs done by trauma surgeons. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Reduction of surgical site infections after laparoscopic gastric bypass with circular stapled gastrojejunostomy.

BACKGROUND: Circular stapled gastrojejunostomy (GJ) is favored by many surgeons during laparoscopic Roux-en-Y gastric bypass (LRYGB). However, it has been associated with higher rates of surgical site infection (SSI). OBJECTIVES: To study the impact of introducing standard technical modifications (intervention) on the incidence of SSI after LRYGB with circular stapled GJ. SETTING: Tertiary academic medical center. METHODS: Consecutive patients who underwent primary LRYGB between May 2010 and September 2014 were separated into preintervention and postintervention cohorts. The intervention consisted of the use of a stapler cover, wound irrigation, antibiotic application to the wound, and primary wound closure. Predictor variables studied included patient demographic characteristics, the intervention, and other operative and perioperative factors. The primary outcome studied was SSI. Univariate and multivariate analyses were used to determine factors independently associated with SSI. RESULTS: Three hundred thirty patients underwent LRYGB (preintervention n = 200, postintervention n = 130). Patients' characteristics were similar in both groups. A 21-mm stapler and chlorhexidine-based skin preparation were more frequently used in the postintervention group. SSI rate decreased from 15% to 3.8% (P<.01) after the intervention. On multivariate analysis, the intervention (OR .28, 95% CI .09-0.86, P = .026), use of chlorhexidine-based prep (OR .37, 95%CI .15-.93, P = .034), and maintenance of patient temperature (OR .47 95%CI .26-0.85, P = .012) were independently associated with reduced SSI rates. CONCLUSION: Use of a stapler cover, wound irrigation, wound antibiotic application, and primary wound closure were associated with a significantly lower wound infection rate after LRYGB with the circular stapled GJ. The observed SSI rates after our intervention are similar to those reported after hand-sewn and linear stapled techniques. In addition, other factors associated with decreasing the likelihood of developing SSI were use of chlorhexidine-based prep and maintaining intraoperative normothermia.