Post-Operative Euglycemic Diabetic Ketoacidosis in a Patient With SGLT-2 Inhibitor Use and Recent Sleeve Gastrectomy.

A 51-year-old woman with type 2 diabetes mellitus developed euglycemic diabetic ketoacidosis (euDKA) in the post-operative setting after robotic-assisted sleeve gastrectomy. She developed tachycardia on post-operative day (POD) 1 before developing altered mental status and tachypnea on POD 2. The diagnosis was ultimately made by discovering ketonuria in the setting of anion gap metabolic acidosis despite repeatedly normal blood glucose levels. Pre-operatively, her blood glucose levels were managed with sodium-glucose co-transporter-2 (SGLT-2) inhibitor-containing combination pill, Invokamet®, as well as basal-bolus insulin regimen consisting of aspart (NovoLog®) and glargine-lixisenatide (Soliqua®). SLGT-2 inhibitors have been associated with an increased risk of euDKA, particularly in the context of severe bodily stressors such as surgery. EuDKA is a difficult diagnosis to make because of the lack of characteristic severe hyperglycemia that is typical of DKA. Clinicians should be mindful of euDKA in the post-operative setting of diabetic patients, particularly for those on SGLT-2 inhibitors.

Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis: Port Placement and Dissection Techniques.

BACKGROUND Situs inversus is a rare congenital condition. Since 1991, more than 60 cases of laparoscopic cholecystectomy have been reported in patients with situs inversus. There are many different port placement techniques depending on the surgeon's preference. The fact that some of the critical dissection is easier performed by the left hand poses technical difficulty for right-handed surgeons. CASE REPORT A 56-year-old woman with known situs inversus totalis and extensive past surgical history presented with acute cholecystitis. A Veress needle was used to enter the abdomen at Palmer's point. Visiport was used to place the first 5-mm port at the left mid-clavicular line. The dissection was performed in a mirror image to the usual dissection through the epigastric port. CONCLUSIONS There have been several techniques described in the literature to facilitate the dissection in laparoscopic cholecystectomy in patients with situs inversus totalis. We argue that the first port should be placed at the mid-clavicular line with Visiport. The other ports should be placed in mirror image of the normally placed ports, including a 12-mm epigastric port, 5-mm or 11-mm paraumbilical port, and 5-mm port at the left anterior axillary line. For dissection, we argue that it is preferable to have 2 assistants with 1 retracting the gallbladder and the other holding the camera. This allows the primary surgeon to use the dominant hand during critical dissection in this unfamiliar anatomy.

Laparoscopic placement of the LINX® system in management of severe reflux after sleeve gastrectomy.

BACKGROUND: Management of severe reflux after sleeve gastrectomy (SG) is often done by conversion to Roux-en-Y gastric bypass (RYGB). The LINX® system could be an alternative treatment. METHOD: Between 2015 and 2017, 13 patients had LINX® system placed to manage their reflux after SG. Pre-operative evaluation included a barium swallow, endoscopy with pH monitor and esophageal motility. RESULTS: Ten females and three males with mean age of 49 ±â€¯13 years were evaluated. Their mean weight before placing the LINX® system was 193 ±â€¯45 lbs. and mean BMI of 33 ±â€¯6 kg/m2. The mean time between SG and placing the LINX® system was 43 ±â€¯19 months. The mean Bravo score was 46 ±â€¯26 (normal 14.7). One patient developed severe dysphagia post-operatively requiring removal of the LINX® after 18 days and one patient was lost to follow up. The mean follow-up in the remaining 11 patients was 26 ±â€¯12 months. The mean GERD-HRQL score dropped significantly from 47/75 ±â€¯17/75 to 12/75 ±â€¯14/75 (p = .0003). CONCLUSION: The LINX® system may be used as an alternative to RYGB conversion in managing refractory post-SG reflux.

Comparing Outcomes Between "Pull" Versus "Push" Percutaneous Endoscopic Gastrostomy in Acute Care Surgery: Under-Reported Pull Percutaneous Endoscopic Gastrostomy Incidence of Tube Dislodgement.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) complications are often under-reported in the literature, especially regarding the incidence of tube dislodgement (TD). TD can cause significant morbidity depending on its timing. We compared outcomes between "push" and "pull" PEGs. We hypothesized that push PEGs, because of its T-fasteners and balloon tip, would have a lower incidence of TD and complications compared with pull PEGs. METHODS: We performed a chart review of our prospectively maintained acute care surgery database for patients who underwent PEG tube placement from July 1, 2009 through June 30, 2013. Data regarding age, gender, body mass index, indications (trauma versus nontrauma), and complications (including TD) were extracted. Procedure-related complications were classified as either major if patients required an operative intervention or minor if they did not. We compared outcomes between pull PEG and push PEG. Multiple regression analysis was performed to identify risk factors associated with major complications. RESULTS: During the 4-y study period, 264 patients underwent pull PEGs and 59 underwent push PEGs. Age, gender, body mass index, and indications were similar between the two groups. The overall complications (major and minor) were similar (20% pull versus 22% push, P = 0.61). The incidence of TD was also similar (12% pull versus 9% push, P = 0.49). However, TD associated with major complications was higher in pull PEGs but was not statistically significant (6% pull versus 2% push, P = 0.21). Multiple regression analysis showed that dislodged pull PEG was associated with major complications (odds ratio 29.5; 95% confidence interval, 11.3-76.9; P < 0.001). CONCLUSIONS: The incidence of pull PEG TD associated with major complications is under-recognized. Specific measures should be undertaken to help prevent pull PEG TD. LEVEL OF EVIDENCE: IV, therapeutic.

Prospective validation of the brain injury guidelines: managing traumatic brain injury without neurosurgical consultation.

BACKGROUND: To optimize neurosurgical resources, guidelines were developed at our institution, allowing the acute care surgeons to independently manage traumatic intracranial hemorrhage less than or equal to 4 mm. The aim of our study was to evaluate our established Brain Injury Guidelines (BIG 1 category) for managing patients with traumatic brain injury (TBI) without neurosurgical consultation. METHODS: We formulated the BIG based on a 4-year retrospective chart review of all TBI patients presenting at our Level 1 trauma center. We then prospectively implemented our BIG 1 category to identify TBI patients that were to be managed without neurosurgical consultation (No-NC). Propensity scoring matched patients with No-NC to a similar cohort of patients managed with NC before the implementation of our BIG in a 1:1 ratio for demographics, severity of injury, and type and size of intracranial hemorrhage. Primary outcome measure was need for neurosurgical intervention and 30-day readmission rates. RESULTS: A total of 254 TBI patients (127 of NC and 127 of No-NC patients) were included in the analysis. The mean (SD) age was 40.8 (22.7) years, 63.4% (n = 161) were male, median Glasgow Coma Scale (GCS) score was 15 (range, 13-15), and median head Abbreviated Injury Scale (AIS) score was 2 (range, 2-3). There was no neurosurgical intervention or 30-day readmission in both the groups. In the No-NC group, 3.9% of the patients had postdischarge emergency department visits compared with 4.7% of the NC group (p = 0.5). All patients were discharged home from the emergency department. CONCLUSION: We validated our BIG and demonstrated that acute care surgeons can effectively care for minimally injured TBI patients with good outcomes. A national multi-institutional prospective evaluation is warranted. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

A three-year prospective study of repeat head computed tomography in patients with traumatic brain injury.

BACKGROUND: A definitive consensus on the standardization of practice of a routine repeat head CT (RHCT) scan in patients with traumatic intracranial hemorrhage is lacking. We hypothesized that in examinable patients without neurologic deterioration, RHCT scan does not lead to neurosurgical intervention (craniotomy/craniectomy). STUDY DESIGN: This was a 3-year prospective cohort analysis of patients aged 18 years and older, without antiplatelet or anticoagulation therapy, presenting to our level 1 trauma center with intracranial hemorrhage on initial head CT and a follow-up RHCT. Neurosurgical intervention was defined by craniotomy/craniectomy. Neurologic deterioration was defined as altered mental status, focal neurologic deficits, and/or pupillary changes. RESULTS: A total of 1,129 patients were included. Routine RHCT was performed in 1,099 patients. The progression rate was 19.7% (216 of 1,099), with subsequent neurosurgical intervention in 4 patients. Four patients had an abnormal neurologic examination, with a Glasgow Coma Scale (GCS) of ≤8 requiring intubation. Thirty patients had an RHCT secondary to neurologic deterioration; 53% (16 of 30) had progression on RHCT, of which 75% (12 of 16) required neurosurgical intervention. There was an association between deterioration in neurologic examination and need for neurosurgical intervention (odds ratio 3.98; 95% CI 1.7 to 9.1). The negative predictive value of a deteriorating neurologic examination in predicting the need for neurosurgical intervention was 100% in patients with GCS > 8. CONCLUSIONS: Routine repeat head CT scan is not warranted in patients with normal neurologic examination. Routine repeat head CT scan does not supplement the need for neurologic examination for determining management in patients with traumatic brain injury.

Levothyroxine therapy before brain death declaration increases the number of solid organ donations.

BACKGROUND: Protocols call for the start of hormonal therapy with levothyroxine after the declaration of brain death. As the hormonal perturbations occur during the process of brain death, the role of the early initiation of levothyroxine therapy (LT) to salvage organs is not well defined. The aim of this study was to evaluate the impact of early LT (before the declaration of brain death) on the number of solid organs procured per donor. METHODS: We performed an 8-year retrospective analysis of all trauma patients who progressed to brain death. Patients who consented for organ donation, received LT, and donated solid organs were included. Patients were dichotomized into two groups: early LT group, patients who received LT before the declaration of brain death, and late LT group, those who received LT after brain death. The two groups were compared for differences in demographics, clinical characteristics, need for vasopressor, and number of solid organ donation. RESULTS: A total of 100 solid organ donors were identified of which, 41% (n=77) donors who received LT therapy were included. LT before the declaration of brain death was initiated in 37 patients compared with 40 patients who had it started after the declaration of brain death. There was no difference in demographics between the two groups except that patients in the early LT group were more likely to be hypotensive on presentation (54% vs. 25%, p = 0.001). Early LT therapy was associated with an increase in solid organ procurement rate (odds ratio, 1.9; 95% confidence interval, 1.4-2.7; p = 0.01). Sixty-seven patients donated a total of 291 solid organs. CONCLUSION: The early use of LT and aggressive blood product resuscitation was associated with a significantly higher number of solid organs donated per donor. Earlier use of LT before the declaration of brain death may be considered in potential organ donors. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons.

BACKGROUND: It is becoming a standard practice that any "positive" identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines-based on each patient's history, physical examination, and initial head CT findings-regarding which patients require a period of observation, RHCT, or neurosurgical consultation. METHODS: In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. RESULTS: A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients worsened clinically or radiographically or required any intervention. BIG 2 category had radiographic worsening in 2.6% of the patients. All patients who required neurosurgical intervention (13%) were in BIG 3. There was excellent agreement between assigned BIG and verified BIG. κ statistic is equal to 0.98. CONCLUSION: We have proposed BIG based on patient's history, neurologic examination, and findings of initial head CT scan. These guidelines must be used as supplement to good clinical examination while managing patients with traumatic brain injury. Prospective validation of the BIG is warranted before its widespread implementation. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Repeat head computed tomography in anticoagulated traumatic brain injury patients: still warranted.

Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neurosurgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ(2) and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older (P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission (P < 0.001), were more likely to present with an abnormal neurologic examination (P = 0.004), and had higher hospital and intensive care unit lengths of stay (P < 0.005). Eighty-four per cent of patients were on antiplatelet therapy and 27 per cent were on warfarin. The CAP patients have a threefold increase in the rate of worsening repeat head CT (26 vs 9%, P < 0.05). Prehospital CAP therapy is high risk for progression of bleeding on repeat head CT. Routine repeat head CT remains an important component in this patient population and can provide useful information.

Fatal gunshot wound to the head: the impact of aggressive management.

BACKGROUND: Patients with fatal gunshot wounds (GSWs) to the head often have poor outcomes but are ideal candidates for organ donation. The purpose of this study was to evaluate the effects of aggressive management on organ donation in patient with fatal GSWs to the head. METHODS: A 5-year review of all patients at a trauma center with GSWs to the head was performed. The primary outcome was organ donation after fatal GSW to the head. RESULTS: A total of 98 patients with fatal GSWs to the head were identified. The rate of potential organ donation was 70%, of whom 49% eventually donated 72 solid organs. Twenty-five percent of patients were not considered eligible for donation as a result of disseminated intravascular coagulopathy. The T4 protocol lead to significant organ procurement rates (odds ratio, 3.6; 95% confidence interval, 1.3 to 9.6; P = .01). Failures to organ donation in eligible patients were due to lack of family consent and cardiac arrest. CONCLUSIONS: Organ donation after fatal GSW to the head is a legitimate goal. Management goals should focus on early aggressive resuscitation and correction of coagulopathy.

Predicting hospital discharge disposition in geriatric trauma patients: is frailty the answer?

BACKGROUND: The frailty index (FI) has been shown to predict outcomes in geriatric patients. However, FI has never been applied as a prognostic measure after trauma. The aim of our study was to identify hospital admission factors predicting discharge disposition in geriatric trauma patients. METHODS: We performed a 1-year prospective study at our Level 1 trauma center. All trauma patients 65 years or older were enrolled. FI was calculated using 50 preadmission variables. Patient's discharge disposition was dichotomized as favorable outcome (discharge home, rehabilitation) or unfavorable outcomes (discharge to skilled nursing facility, death). Multivariate logistic regression was performed to identify factors that predict unfavorable outcome. RESULTS: A total of 100 patients were enrolled, with a mean (SD) age of 76.51 (8.5) years, 59% being males, median Injury Severity Score (ISS) of 14 (range, 9-18), median head Abbreviated Injury Scale (h-AIS) score of 2 (2-3), and median Glasgow Coma Scale (GCS) score of 13 (12-15). Of the patients, 69% had favorable outcome, and 31% had unfavorable outcome. On univariate analysis, FI was found to be a significant predictor for unfavorable outcome (odds ratio, 1.8; 95% confidence interval, 1.2-2.3). After adjusting for age, ISS, and GCS score in a multivariate regression model, FI remained a strong predictor for unfavorable discharge disposition (odds ratio, 1.3; 95% confidence interval, 1.1-1.8). CONCLUSION: The concept of frailty can be implemented in geriatric trauma patients with similar results as those of nontrauma and nonsurgical patients. FI is a significant predictor of unfavorable discharge disposition and should be an integral part of the assessment tools to determine discharge disposition for geriatric trauma patients. LEVEL OF EVIDENCE: Prognostic study, level II.

A prospective evaluation of platelet function in patients on antiplatelet therapy with traumatic intracranial hemorrhage.

BACKGROUND: Platelet transfusion is increasingly used in patients with traumatic intracranial hemorrhage (ICH) on aspirin therapy to minimize the progression of ICH. We hypothesized (null) that platelet transfusion in this cohort of patients does not improve platelet function. METHODS: We performed a prospective interventional trail on patients with traumatic ICH on daily high-dose (325 mg) aspirin therapy. All patients received one pack of apheresis platelets. Blood samples were collected before and 1 hour after platelet transfusion. Platelet function was assessed using Verify Now Platelet Function Assay, and a cutoff of greater than 550 aspirin reaction units was used to define functioning platelets (FP). RESULTS: Twenty-eight patients were enrolled in the study. On presentation, 79% (22 of 28) of the patients had nonfunctioning platelets (NFPs), and transfusion of platelets did not improve platelet function as 81% (18 of 22) still had NFP. Of the 22 patients, 4 converted from NFP to FP after transfusion. There was no difference in the progression of ICH (37.5% vs. 30%, p = 0.7) or neurosurgical intervention (12.5% vs. 15%, p = 0.86) between patients with FP and NFP after platelet transfusion. CONCLUSION: Administration of one pack of apheresis platelet did not improve platelet function. In our study, progression of ICH and the need for neurosurgical intervention were independent of platelet function. Further randomized clinical trials are required to assess both the dose dependence effect and role of platelet transfusion in patients on antiplatelet therapy with traumatic ICH. LEVEL OF EVIDENCE: Therapeutic study, level III.

The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation.

BACKGROUND: Neurosurgical services are a limited resource and effective use of them would improve the health care system. Acute care surgeons (ACS) are accustomed to treating mild traumatic brain injury (TBI) including those with minor radiographic intracranial injuries. We hypothesized that ACS safely manage mild TBI with intracranial hemorrhage (ICH) on head computed tomographic (CT) scan without neurosurgical consultation (NC). METHODS: We performed a retrospective analysis on all TBI patients with positive findings on head CT scan managed without NC during a 2-year period. Propensity scoring matched NC to no-NC patients on a 1:2 ratio for Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (h-AIS) score, neurological examination, age, Injury Severity Score (ISS), findings of initial head CT scan including type and size of ICH. RESULTS: A total of 270 patients with mild TBI and positive CT scan findings were included (90 with NC and 180 without NC). Sixty-three percent were male, and mean (SD) age was 39 (25) years. The median GCS was 15 (13-15), and the h-AIS score was 2 (1-3). In both groups, there was no neurosurgical intervention, in-hospital mortality, or 30-day readmission. In the no-NC group, 8% of the patients had postdischarge emergency department (ED) visits compared with 4% of the NC group (p = 0.5). All patients with postdischarge ED visits in both groups were discharged home from the ED. CONCLUSION: ACS can manage mild TBI with ICH without obtaining an inpatient NC. Further guidelines should be established to help identify which patients meet criteria to be safely managed without NC. LEVEL OF EVIDENCE: Care management/therapeutic study, level IV.

Video consultation for trauma and emergency surgical patients.

The saying goes that a picture is worth a thousand words, but what then is the value of video? For the care of trauma and emergency surgical patients, the use of video consultation between medical providers may be worth its weight in gold. Telemedicine has become an important tool in reducing the disparity among the haves and the have not's, in this case facilities with a trauma service and those without. This article presents the use of live video for trauma consultations between the only level 1 trauma center in Southern Arizona and several smaller rural hospitals. We also expand on what we believe the future and direction of telesurgery in the fields of critical care and trauma surgery.

Post-traumatic intra-cocoon mesenteric tear: a case report.

Sclerosing peritonitis, more commonly called abdominal cocoon, is a rare intra-peritoneal disease that is characterized by complete or partial encapsulation of the small intestine by a thick collagenous membrane. This disease mostly presents in the form of small bowel obstruction, however in our case the patient presented with intra-cocoon bleeding following a motor vehicle accident.