Trauma Patients with an Open Abdomen Following Damage Control Laparotomy can be Extubated Prior to Abdominal Closure.

BACKGROUND: The open abdomen (OA) is commonly utilized as a technique during damage control laparotomy (DCL). We propose that a selected group of these OA patients can be extubated prior to abdominal closure to decrease ventilator days and risk of pneumonia. METHODS: A retrospective chart review was performed at a Level I trauma center on all adult trauma patients with an OA following DCL. Patients were stratified into two groups: extubated prior to (PRE) and extubated after (POST) abdominal closure. Successful extubation in the PRE group was measured by the absence of re-intubation. The two groups were compared using the Mann-Whitney U and Fisher's exact tests. Multivariate logistic regression identified independent predictors for successful extubation prior to abdominal closure. RESULTS: Thirty-one patients were in the PRE group, and 59 patients in the POST group. There were no differences between the groups with regard to age, gender, or hours from admission to completion of DCL. The PRE group had a significantly higher incidence of penetrating trauma (77 vs. 53%; p = 0.02), a significantly lower number of days from OA to extubation [0.6 (0.2-1.1) vs. 3.4 (2--8) days; p < 0.001], and a significant decrease in pneumonia (10 vs. 31%; p = 0.04). Two patients in each group required re-intubation [PRE (6%) vs. POST (3%); p = 0.61]. In a multivariate binominal logistic regression, penetrating trauma (p = 0.024), GCS on admission (p < 0.0001), and Injury Severity Score (p = 0.024) were identified as independent predictors for successful extubation. CONCLUSION: Presence of an OA following DCL does not require mechanical ventilation. Extubation of appropriate trauma patients prior to abdominal closure decreases pneumonia and hospital length of stay.

Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival?

OBJECTIVE: The diagnosis and management of intra-abdominal hypertension and abdominal compartment syndrome have changed significantly over the past decade with improved understanding of the pathophysiology and appropriate treatment of these disease processes. Serial intra-abdominal pressure measurements, nonoperative pressure-reducing interventions, and early abdominal decompression for refractory intra-abdominal hypertension or abdominal compartment syndrome are all key elements of this evolving strategy. DESIGN: Prospective, observational study. SETTING: Tertiary referral/level I trauma center. PATIENTS: Four hundred seventy-eight consecutive patients requiring an open abdomen for the management of intra-abdominal hypertension or abdominal compartment syndrome. INTERVENTIONS: Patients were managed by a defined group of surgical intensivists using established definitions and an evidence-based management algorithm. Both univariate and multivariate analyses were performed to identify patient and management factors associated with improved survival. MEASUREMENTS AND MAIN RESULTS: Whereas patient demographics and severity of illness remained unchanged over the 6-yr study period, the use of a continually revised intra-abdominal hypertension/abdominal compartment syndrome management algorithm significantly increased patient survival to hospital discharge from 50% to 72% (p = .015). Clinically significant decreases in resource utilization and an increase in same-admission primary fascial closure from 59% to 81% were recognized. Development of abdominal compartment syndrome, prophylactic use of an open abdomen to prevent development of intra-abdominal hypertension/abdominal compartment syndrome, and use of a multi-modality surgical/medical management algorithm were identified as independent predictors of survival. CONCLUSIONS: A comprehensive evidence-based management strategy that includes early use of an open abdomen in patients at risk significantly improves survival from intra-abdominal hypertension/abdominal compartment syndrome. This improvement is not achieved at the cost of increased resource utilization and is associated with an increased rate of primary fascial closure.

Injury characteristics of the Pulse Nightclub shooting: Lessons for mass casualty incident preparation.

BACKGROUND: On the morning of June 12, 2016, an armed assailant entered the Pulse Nightclub in Orlando, Florida, and initiated an assault that killed 49 people and injured 53. The regional Level I trauma center and two community hospitals responded to this mass casualty incident. A detailed analysis was performed to guide hospitals who strive to prepare for future similar events. METHODS: A retrospective review of all victim charts and/or autopsy reports was performed to identify victim presentation patterns, injuries sustained, and surgical resources required. Patients were stratified into three groups: survivors who received care at the regional Level I trauma center, survivors who received care at one of two local community hospitals, and decedents. RESULTS: Of the 102 victims, 40 died at the scene and 9 died upon arrival to the Level I trauma center. The remaining 53 victims received definitive medical care and survived. Twenty-nine victims were admitted to the trauma center and five victims to a community hospital. The remaining 19 victims were treated and discharged that day. Decedents sustained significantly more bullet impacts than survivors (4 ± 3 vs. 2 ± 1; p = 0.008) and body regions injured (3 ± 1 vs. 2 ± 1; p = 0.0002). Gunshots to the head, chest, and abdominal body regions were significantly more common among decedents than survivors (p < 0.0001). Eighty-two percent of admitted patients required surgery in the first 24 hours. Essential resources in the first 24 hours included trauma surgeons, emergency room physicians, orthopedic/hand surgeons, anesthesiologists, vascular surgeons, interventional radiologists, intensivists, and hospitalists. CONCLUSION: Mass shooting events are associated with high mortality. Survivors commonly sustain multiple, life-threatening ballistic injuries requiring emergent surgery and extensive hospital resources. Given the increasing frequency of mass shootings, all hospitals must have a coordinated plan to respond to a mass casualty event. LEVEL OF EVIDENCE: Epidemiological Study, level V.

Antiplatelet Agent Reversal Is Unnecessary in Blunt Traumatic Brain Injury Patients Not Requiring Immediate Craniotomy.

BACKGROUND: The need to reverse the coagulation impairment caused by chronic antiplatelet agents in traumatic brain injury (TBI) patients with acute traumatic intracerebral hemorrhage (TICH) remains controversial. We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy. METHODS: All adult blunt TICH patients (age ≥16 years) over a 4-year period were retrospectively reviewed. Patients with penetrating TBI, blunt TBI without TICH on admission computed tomography (CT), receiving warfarin, not on antiplatelet agents, or requiring immediate operative intervention were excluded. Patients were divided into 2 groups depending on whether they received a platelet transfusion: reversal group (RV) versus no reversal group (NR). Patient outcomes were analyzed using Mann-Whitney U and Fisher's exact tests. RESULTS: 169 blunt TBI patients on chronic antiplatelet therapy were studied (102 RV group, 67 NR group). The groups were well matched with regard to age, Injury Severity Score, Abbreviated Injury Scale-head, Glasgow Coma Score, mechanism of injury, need for intubation, time to initial CT scan, and hospital length of stay. Immediate platelet transfusion did not alter the occurrence of TICH extension on follow-up CT (26% vs 21%, P = .71), TBI-specific mortality (9% vs 13%, P = .45), need for ICP monitor (2% vs 3%, P = 1.0), burr hole (1% vs 3%, P = .56), or craniotomy (1% vs 3%, P = .56). DISCUSSION: Immediate platelet transfusion is unnecessary in blunt TBI patients on chronic antiplatelet therapy who do not require immediate craniotomy.

Mass shootings: Are children safer in the streets than in the home?

PURPOSE: Though the total fatality and injury count in mass shootings is known, the burden on the pediatric population remains undefined. We sought to define the impact of domestic vs. public mass shootings in the pediatric population. METHODS: Open-source databases, Everytown for Gun Violence, and Mother Jones were cross-referenced and used to review domestic and public mass shootings from 2009 to 2016. Mass shootings were defined as four or more fatalities and any injuries. Domestic mass shootings were defined as ones that occurred in the home where the assailant was either a family member or a past or present intimate partner of a family member. Public mass shootings occurred in a public space where the shooter was unknown to the victim. The number of incidents in each group, fatalities and injuries, and effect on children <18 years were analyzed along with perpetrator characteristics. Categorical data were analyzed using Fisher's Exact test. RESULTS: There were 71 Domestic and 31 Public mass shootings accounting for 331 vs. 281 fatalities and 28 vs. 217 injuries (p < 0.0001). Children <18 years accounted for 44% of Domestic and 10% of Public fatalities (p < 0.0001) and 46% vs. 2% of all injuries (p < 0.0001). The assailant was prohibited from owning or possessing a firearm in 32% of Domestic and 39% of Public mass shootings accounting for 54 vs. 25 fatalities. CONCLUSION: The pediatric fatality rate in mass shootings is alarming, especially among Domestic shooting events. This is a public health issue and requires vigilance to protect at-risk youth. TYPE OF STUDY: Epidemiology study, retrospective review. LEVEL OF EVIDENCE: Level IV.

Simulation-Based Testing of Pager Interruptions During Laparoscopic Cholecystectomy.

OBJECTIVE: To determine if pager interruptions affect operative time, safety, or complications and management of pager issues during a simulated laparoscopic cholecystectomy. DESIGN: Twelve surgery resident volunteers were tested on a Simbionix Lap Mentor II simulator. Each resident performed 6 randomized simulated laparoscopic cholecystectomies; 3 with pager interruptions (INT) and 3 without pager interruptions (NO-INT). The pager interruptions were sent in the form of standardized patient vignettes and timed to distract the resident during dissection of the critical view of safety and clipping of the cystic duct. The residents were graded on a pass/fail scale for eliciting appropriate patient history and management of the pager issue. Data was extracted from the simulator for the following endpoints: operative time, safety metrics, and incidence of operative complications. The Mann-Whitney U test and contingency table analysis were used to compare the 2 groups (INT vs. NO-INT). SETTING: Level I trauma center; Simulation laboratory. PARTICIPANTS: Twelve general surgery residents. RESULTS: There was no significant difference between the 2 groups in any of the operative endpoints as measured by the simulator. However, in the INT group, only 25% of the time did the surgery residents both adequately address the issue and provide effective patient management in response to the pager interruption. CONCLUSION: Pager interruptions did not affect operative time, safety, or complications during the simulated procedure. However, there were significant failures in the appropriate evaluations and management of pager issues. Consideration for diversion of patient care issues to fellow residents not operating to improve quality and safety of patient care outside the operating room requires further study.

Nonoperative management rather than endovascular repair may be safe for grade II blunt traumatic aortic injuries: An 11-year retrospective analysis.

BACKGROUND: The Society of Vascular Surgery (SVS) guidelines currently suggest thoracic endovascular aortic repair (TEVAR) for grade II-IV and nonoperative management (NOM) for grade I blunt traumatic aortic injury (BTAI). However, there is increasing evidence that grade II may also be observed safely. The purpose of this study was to compare the outcome of TEVAR and NOM for grade I-IV BTAI and determine if grade II can be safely observed with NOM. METHODS: The records of patients with BTAI from 2004 to 2015 at a Level I trauma center were retrospectively reviewed. Patients were separated into two groups: TEVAR versus NOM. All BTAIs were graded according to the SVS guidelines. Minimal aortic injury (MAI) was defined as BTAI grade I and II. Failure of NOM was defined as aortic rupture after admission or progression on subsequent computed tomography (CT) imaging requiring TEVAR or open thoracotomy repair (OTR). Statistical analysis was performed using Mann-Whitney U and χ tests. RESULTS: A total of 105 adult patients (≥16 years) with BTAI were identified over the 11-year period. Of these, 17 patients who died soon after arrival and 17 who underwent OTR were excluded. Of the remaining 71 patients, 30 had MAI (14 TEVAR vs. 16 NOM). There were no failures in either group. No patients with MAI in either group died from complications of aortic lesions. Follow-up CT imaging was performed on all MAI patients. Follow-up CT scans for all TEVAR patients showed stable stents with no leak. Follow-up CT in the NOM group showed progression in two patients neither required subsequent OTR or TEVAR. CONCLUSIONS: Although the SVS guidelines suggest TEVAR for grade II-IV and NOM for grade I BTAI, NOM may be safely used in grade II BTAI. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Analysis of Mortality in Traumatically Injured Patients Based on Body Mass Index and Mechanism Reveals Highest Mortality among the Underweight in Comparison with the Ideal Weight Patients.

The purpose of this study was to evaluate the effect of body mass index (BMI) on mortality after traumatic injury. The records of patients from 2012 to 2015 were retrospectively reviewed. The patients were stratified into the following groups based on admission BMI (kg/m2): underweight (UW) (BMI <19), ideal weight (IW) (BMI = 19-24.9), overweight (OW) (BMI = 25-29.9), obese (OB) (BMI = 30-39.9), and morbid obese (MO) (BMI >40). The groups were well matched with no significant differences in demographics and Injury Severity Score. Morality for the IW group was compared with the remaining BMI groups. A total of 6049 patients were identified. In comparison with IW group, the UW mortality was significantly higher (IW vs UW, 4.1% vs 8.8%, P = 0.001); however, the there was no significant difference with remaining groups. There was also no significant difference in mortality between IW and the remaining groups for patients that went directly to the operating room or for patients that had penetrating trauma (stab wounds and gunshot wounds). However, for blunt trauma, the mortality was significantly higher for UW (IW vs UW, 4.3% vs 9.4%, P = 0.001), no different for IW vs OW (4.3% vs 3.7%, P = 0.3), and significantly lower for IW vs OB (4.3% vs 2.8%, P = 0.04) and for IW vs MO (4.3% vs 1.0%, P = 0.03). After traumatic injuries, it is the underweight patients (BMI <19) and not the obese, that are at a significantly higher risk for overall mortality; this difference is especially evident after blunt trauma where obesity may actually confer a protective role.

Psychological Effect of a Mass Casualty Event on General Surgery Residents.

OBJECTIVE: To evaluate the psychological effect of a mass casualty shooting event on general surgery residents. DESIGN: Three and 7 months following the Pulse nightclub mass casualty shooting, the mental well-being of general surgery residents employed at the receiving institution was evaluated. A voluntary and anonymous screening questionnaire for posttraumatic stress disorder (PTSD) and major depression (MD) was administered. Responses were stratified into 2 groups; residents who worked (ON-CALL) and residents who did not work (OFF-CALL) the night of the event. Data were analyzed using Mann-Whitney U and Fisher's exact tests and are reported as median with interquartile range (IQR) or percentage. SETTING: Level I trauma center. PARTICIPANTS: Thirty-one general surgery residents. RESULTS: Twenty-four residents (77%) returned the 3-month questionnaire: 10 ON-CALL and 14 OFF-CALL. There was no difference in PTSD and MD between the 2 groups (30% vs. 14%; p = 0.61) and (30% vs. 7%; p = 0.27), respectively. Twenty-three of the 24 residents responded to the 7-month questionnaire. Over time, the incidence of PTSD did not resolve in the ON-CALL group, but did resolve in the OFF-CALL group (30% vs. 0%; p = 0.07). There was no significant change in the incidence of MD in either group (30% vs. 8%; p = 0.28). At 7 months postevent, more residents in both groups stated that they had sought counseling (30% vs. 44%; p = 0.65) and (0% vs. 15%; p = 0.22). CONCLUSIONS: The emotional toll associated with this mass casualty event had a substantial effect upon the general surgery residents involved. With the incidence of PTSD and MD identified, we believe that all residents should be provided with counseling following such events.

Laparoscopic Appendectomy Protocol Expedites Management of Uncomplicated Acute Appendicitis.

Bed availability remains a constant struggle for tertiary care centers resulting in the use of management protocols to streamline patient care and reduce length of stay (LOS). A standardized perioperative management protocol for uncomplicated acute appendicitis (UA) was implemented in April 2014 to decrease both CT scan usage and LOS. Patients who underwent laparoscopic appendectomy for UA from April 2012 to May 2013 (PRE group) and April 2014 to May 2015 (POST group) were compared retrospectively. There were no differences in patient demographics or clinical findings between the groups. All patients in the PRE group had a CT scan for the diagnosis of appendicitis, whereas there was a 14 per cent decrease in the POST group (P = 0.002). There was a significant decrease in median LOS between the groups [PRE 1.3 vs POST 0.9 days; (P < 0.001)]. There was no difference in subsequent emergency department visits for complications [3 (4%) vs 4 (4%); P = 1.0] or 30-day readmission rate [1 (1%) vs 5 (5%); P = 0.22] between the groups. A standardized perioperative management protocol for UA patients significantly decreased CT scan utilization and LOS without compromising patient care.

Pancreaticoduodenectomy in a community general surgery residency program.

The morbidity and mortality of pancreaticoduodenectomy (PD) has been well documented. A retrospective review was performed to determine the morbidity and mortality of PD performed within the general surgery residency program of a tertiary community hospital. Patients undergoing PD for benign or malignant disease over a 6-year period were analyzed to determine overall mortality, major complication rate, and length of stay (LOS). Of 50 consecutive patients undergoing PD, overall mortality was 6 per cent, with a major complication rate of 52 per cent. Mean operative time was 333 +/- 68 minutes with an estimated blood loss of 459 +/- 301 mL. Mean hospital LOS was 21 +/- 13 days. Eighty-four per cent of patients with malignant disease had negative margins of resection. General surgery residents within a community residency program, with attending faculty supervision, can perform PD with mortality, morbidity, and LOS comparable with that reported in the university setting.

Management of the Open Abdomen in Obese Trauma Patients.

Obesity incidence in the trauma population is increasing. Abdominal compartment syndrome has poor outcomes when left untreated. Surgeons may treat obese patients differently because of concern for increased morbidity and mortality. We studied the effects of body mass index (BMI) on resource utilization and outcome. An Institutional Review Board-approved retrospective review of trauma patients requiring temporary abdominal closure (TAC) was performed. Patients were stratified as follows: Group 1-BMI = 18.5 to 24.9 kg/m(2), Group 2-BMI = 25 to 29.9 kg/m(2), Group 3-BMI = 30 to 39.9 kg/m(2), Group 4-BMI ≥ 40 kg/m(2). Demographic data, illness severity as defined by Injury Severity Score, Acute Physiology and Chronic Health Evaluation Score Version II and Simplified Acute Physiology Score Version II scores, resource utilization, fascial closure rate, and survival were collected. About 380 patients required TAC. Median age of Group 1 was significantly lower than Groups 2 and 3 (P = 0.001). Severity of illness did not differ. Group 4 had a longer intensive care unit stay compared with Groups 1 and 2 (P = 0.005). Group 4 required mechanical ventilation longer than Group 1 (P = 0.027). Hospital stay, fascial closure, and survival were equivalent. Obese trauma patients with TAC have a longer intensive care unit stay and more ventilator days, but there is no difference in survival or type of closure. TAC can be used safely in trauma patients with a BMI ≥ 30 kg/m(2).

Effects of race and insurance on outcomes of the open abdomen.

Recent studies have suggested improved outcomes in surgical patients with healthcare insurance, whereas several others have noted disparities in access to health care, the care provided, and the aftercare of uninsured patients. Several different strategies exist in the management and prevention of the open abdomen secondary to abdominal compartment syndrome. To date, no study has evaluated the effects of race and insurance in patients with an open abdomen (OA). A retrospective review from our OA database was queried. All patients with an OA from January 2002 to December 2010 were included for analysis. Data analyzed included patients' demographics, race, insurance status, hospital charges, Injury Severity Scores, and outcomes. Insured patients were identified and compared with their uninsured counterparts. A total of 720 patients were treated for an OA during the study period. Of these, 273 (37.9%) died within their hospital stay. Patients who died were noted to be older and sicker with higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiologic Scores (27.6 vs. 18.2, P < 0.001 and 54.6 vs. 38.5, P < 0.001, respectively). Logistic regression analysis revealed that age, APACHE II, and Injury Severity Scores were independently associated with mortality. From our categorical variables, race was not associated with worse outcomes. In addition, being uninsured was significantly associated with increased mortality (odds ratio, 1.67; 95% confidence interval, 1.1 to 2.6; P = 0.05). "Self-pay" status was associated with increased mortality even after adjusting for severity of illness. Further studies incorporating baseline comorbidities need to be undertaken to further assess the reasons for these disparities.

Early intravenous ibuprofen decreases narcotic requirement and length of stay after traumatic rib fracture.

Pain control after traumatic rib fracture is essential to avoid respiratory complications and prolonged hospitalization. Narcotics are commonly used, but adjunctive medications such as nonsteroidal anti-inflammatory drugs may be beneficial. Twenty-one patients with traumatic rib fractures treated with both narcotics and intravenous ibuprofen (IVIb) (Treatment) were retrospectively compared with 21 age- and rib fracture-matched patients who received narcotics alone (Control). Pain medication requirements over the first 7 hospital days were evaluated. Mean daily IVIb dose was 2070 ± 880 mg. Daily intravenous morphine-equivalent requirement was 19 ± 16 vs 32 ± 24 mg (P < 0.0001). Daily narcotic requirement was significantly decreased in the Treatment group on Days 3 through 7 (P < 0.05). Total weekly narcotic requirement was significantly less among Treatment patients (P = 0.004). Highest and lowest daily pain scores were lower in the Treatment group (P < 0.05). Hospital length of stay was 4.4 ± 3.4 versus 5.4 ± 2.9 days (P = 0.32). There were no significant complications associated with IVIb therapy. Early IVIb therapy in patients with traumatic rib fractures significantly decreases narcotic requirement and results in clinically significant decreases in hospital length of stay. IVIb therapy should be initiated in patients with traumatic rib fractures to improve patient comfort and reduce narcotic requirement.

Intra-abdominal hypertension and abdominal compartment syndrome: the journey forward.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are recognized causes of significant morbidity and mortality among a wide variety of critically ill patient populations. Our understanding of IAH and ACS as causes of organ failure and patient death has increased significantly over the past two decades since their "rediscovery" as clinically important disease processes. The development of consensus definitions and recommendations for the diagnosis and management of IAH/ACS, patient care algorithms, an international clinical research working group, and other educational tools have advanced efforts to improve patient outcome. Nonoperative management strategies to reduce elevated intra-abdominal pressure (IAP) and early surgical intervention for refractory IAH/ACS have been demonstrated to significantly improve patient survival. It is only through such a comprehensive, goal-directed approach that patient outcome will continue to improve. Despite the significant advances that have been made, the journey toward conquering IAH/ACS as a cause of patient death after injury and/or illness has only just begun. It is remarkable to consider that two decades ago, IAH, the detrimental physiological effects of elevated IAP and ACS, the development of IAH-induced organ dysfunction and failure were essentially unrecognized as causes of morbidity and mortality among critically ill adult and pediatric patients. It is not because these disease processes have been recently discovered. The pathophysiological impact of elevated IAP on cardiac, pulmonary, and renal function was well defined over 150 years ago. It has only been within the past 15 years that physicians and nurses worldwide rediscovered this long-forgotten pathophysiological knowledge and began to actively reconsider these two disease processes in their patient's daily differential diagnosis. Originally considered diseases affecting solely the traumatically injured, IAH and ACS are now recognized to occur in both medical and surgical patients of any age and to result from a wide range of injuries and disease processes. Tremendous progress has been made in recent years with regard to our understanding of the diagnosis and management of IAH and ACS. Within this special supplement of The American Surgeon, you will find a series of "state-of-the-art" reviews authored by a number of the world's experts on IAH/ACS as well as abstracts of research that will be presented at the Fifth World Congress on the Abdominal Compartment Syndrome (Lake Buena Vista, Florida, August 10-13, 2011). This commentary will review where we were, where we are today, and where we are going with respect to the future of IAH and ACS.