Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Burden of unintentional pediatric firearm injury: An examination of the Nationwide Readmission Database.

BACKGROUND: Significant increases in firearm-related mortality in the US pediatric population drive an urgent need to study these injuries to drive prevention policies. The purpose of this study was (1) to characterize those with and without readmissions, (2) to identify risk factors for 90-day unplanned readmission, and (3) to examine reasons for hospital readmission. METHODS: The 2016-2019 Nationwide Readmission Database of the Healthcare Cost and Utilization Project was used to identify hospital admissions with unintentional firearm injury in patients younger than 18 years. Ninety-day unplanned readmission characteristics were assessed and detailed. Multivariable regression analysis was used to assess factors associated with unplanned 90-day readmission. RESULTS: Over 4 years, 1,264 unintentional firearm injury admissions resulted in 113 subsequent readmissions (8.9%). There were no significant differences in age or payor, but more women (14.7% vs. 23%) and older children (13-17 years [80.5%]) had readmissions. The mortality rate during primary hospitalization was 5.1%. Survivors of initial firearm injury were more frequently readmitted if they had a mental health diagnosis (22.1% vs. 13.8%; p = 0.017). Readmission diagnosis included complications (15%), mental health or drug/alcohol (9.7%), trauma (33.6%), a combination of the prior three (28.3%), and chronic disease (13.3%). More than a third (38.9%) of the trauma readmissions were for new traumatic injury. Female children, those with longer lengths of stay, and those with more severe injuries were more likely to have unplanned 90-day readmissions. Mental health and drug/alcohol abuse diagnoses were not an independent predictor for readmission. CONCLUSION: This study provides insight into the characteristics of and risk factors for unplanned readmission in the pediatric unintentional firearm injury population. In addition to using prevention strategies, the utilization of trauma-informed care must be integrated into all aspects of care for this population to help minimize the long-term psychological impact of surviving firearm injury. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Palliative Care Utilization in Burn Patients.

Background: Burn injuries are a common cause for hospitalization, and severe burns have an increased risk of death in patients with advanced age, inhalational injury, comorbid conditions. Very little is known about the utilization of palliative care consultation in burn patients. Objective: The aim of this study was to evaluate the factors influencing the utilization of inpatient palliative care consultation for patients with severe burn injuries. Methods: This was a retrospective chart review study at a single burn center. Results: Seventeen out of 191 patients (8.9%) received a palliative care consultation with the average time for consultation of 10.3 days. Factors that appear to impact consultation were age, presence of inhalational injury, and multiple comorbid conditions. Conclusion: Inpatient palliative care consultation was underutilized in patients with severe burn injurie. Further research into the outcomes of palliative care consultation could help further support the utility of early involvement in burn patients.

Revision Surgery Following Severe Frostbite Injury Compared to Similar Hand and Foot Burns.

Severe frostbite is associated with loss of digits or limbs and high levels of morbidity. The current practice is to salvage as much of the limb/digit as possible with the use of thrombolytic and adjuvant therapies. Sequelae from amputation can include severe nerve pain and poor wound healing requiring revision surgery. The aim of this study was to examine the rate of revision surgery after primary amputation and compare this to revision surgery in isolated hand/foot burns. Frostbite and burn patients from 2014 to 2019 were identified in the prospectively maintained database at a single urban burn and trauma center. Patients with primary amputations related to isolated hand/foot burns or frostbite were included in the study. Descriptive statistics included Student's t-test and Fisher's exact test. A total of 63 patients, 54 frostbite injuries and 9 isolated hand or foot burns, met inclusion criteria for the study. The rate of revision surgery was similar following frostbite and burn injury (24% vs 33%, P = .681). There were no significant differences in age, sex, or length of stay on the primary hospitalization between those that required revision surgery and those that did not. Neither the impacted limb nor the presence of infection or cellulitis on primary amputation was associated with future need for revision surgery. Of the 16 patients requiring revision surgery, 5 (31%) required additional debridement alone, 6 (38%) required reamputation alone, and 5 required both. A total of 6 patients (38%) had cellulitis or infection at the time of revision surgery. Time from primary surgery to revision ranged from 4 days to 3 years. Planned, delayed primary amputation is a mainstay of frostbite management. To our knowledge, this is the first assessment of revision surgery in the setting of severe frostbite injury. Our observed rate of revision surgery following frostbite injury did not differ significantly from revision surgery in the setting of isolated hand or foot burns. This study brings up important questions of timing and surgical planning in these complex patients that will require a multicenter collaborative study.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Firearm trauma: Race and insurance influence mortality and discharge disposition.

BACKGROUND: Health insurance and race impact mortality and discharge outcomes in the general trauma population. It remains unclear if disparities exist by race and/or insurance in outcomes following firearm injuries. The purpose of this study was to assess differences in mortality and discharge based on race and insurance status following firearm injuries. METHODS: The National Trauma Data Bank (2007-2016) was queried for firearm injuries by International Classification of Diseases, Ninth/Tenth Revision, Ecodes. Patients with known discharge disposition, age (18-64 years), race, and insurance were included in analysis (N = 120,005). To minimize bias due to missing data, we used multiple imputation for variables associated with outcomes following traumatic injury: Injury Severity Score, Glasgow Coma Scale score, respiratory rate, systolic blood pressure, and sex. Multivariable regression analysis was additionally adjusted for age, sex, Injury Severity Score, intent, Glasgow Coma Scale score, systolic blood pressure, heart rate, respiratory rate, year, and clustered by facility to assess differences in mortality and discharge disposition. RESULTS: The average age was 31 years, 88.6% were male, and 50% non-Hispanic Blacks. Overall mortality was 11.5%. Self-pay insurance was associated with a significant increase in mortality rates in all racial groups compared with non-Hispanic Whites with commercial insurance. Hispanic commercial, Medicaid, and self-pay patients were significantly less likely to discharge with posthospital care compared with commercially insured non-Hispanic Whites. When examining racial differences in mortality and discharge by individual insurance types, commercially insured non-Hispanic Black and other race patients were significantly less likely to die compared with similarly insured non-Hispanic White patients. Regardless of race, no significant differences in mortality were observed in Medicaid or self-pay patients compared with non-Hispanic White patients. CONCLUSION: Victims of firearm injuries with a self-pay insurance status have a significantly higher rate of mortality. Hispanic patients regardless of insurance status were significantly less likely to discharge with posthospital care compared with non-Hispanic Whites with commercial insurance. Continued efforts are needed to understand and address the relationship between insurance status, race, and outcomes following firearm violence. LEVEL OF EVIDENCE: Prognostic and epidemiologic, Level IV.

An Institutional Protocol for the Treatment of Severe Frostbite Injury-A 6-Year Retrospective Analysis.

The treatment of severe frostbite injury has undergone rapid development in the past 30 years with many different diagnostic and treatment options now available. However, there is currently no consensus on the best method for management of this disease process. At our institution, we have designed a protocol for severe frostbite injury that includes diagnosis, medical treatment, wound cares, therapy, and surgery. This study assess the efficacy of our treatment since its implementation six years ago. During this time, all patients with severe frostbite injury were included in prospective observational trial of the protocol. We found that this protocol results in significant tissue salvage with over 80.7% of previously ischemic tissue becoming viable and not requiring amputation. We also were able to improve our center's efficiency over the course of six years and now our current average time from rapid rewarming to delivery of thrombolytics is under six hours.

Stop flailing: The impact of bicortically displaced rib fractures on pulmonary outcomes in patients with chest trauma - an American Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Current evaluation of rib fractures focuses almost exclusively on flail chest with little attention on bicortically displaced fractures. Chest trauma that is severe enough to cause fractures leads to worse outcomes. An association between bicortically displaced rib fractures and pulmonary outcomes would potentially change patient care in the setting of trauma. We tested the hypothesis that bicortically displaced fractures were an important clinical marker for pulmonary outcomes in patients with nonflail rib fractures. METHODS: This nine-center American Association for the Surgery of Trauma multi-institutional study analyzed adults with two or more rib fractures. Admission computerized tomography scans were independently reviewed. The location, degree of rib fractures, and pulmonary contusions were categorized. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of pneumonia, acute respiratory distress syndrome (ARDS), and tracheostomy. Analyses were performed in nonflail patients and also while controlling for flail chest to determine if bicortically displaced fractures were independently associated with outcomes. RESULTS: Of the 1,110 patients, 103 (9.3%) developed pneumonia, 78 (7.0%) required tracheostomy, and 30 (2.7%) developed ARDS. Bicortically displaced fractures were present in 277 (25%) of patients and in 206 (20.3%) of patients without flail chest. After adjusting for patient demographics, injury, and admission physiology, negative pulmonary outcomes occurred over twice as frequently in those with bicortically displaced fractures without flail chest (n = 206) when compared with those without bicortically displaced fractures-pneumonia (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.6), ARDS (OR, 2.6; 95% CI, 1.0-6.8), and tracheostomy (OR, 2.7; 95% CI, 1.4-5.2). When adjusting for the presence of flail chest, bicortically displaced fractures remained an independent predictor of pneumonia, tracheostomy, and ARDS. CONCLUSION: Patients with bicortically displaced rib fractures are more likely to develop pneumonia, ARDS, and need for tracheostomy even when controlling for flail chest. Future studies should investigate the utility of flail chest management algorithms in patients with bicortically displaced fractures. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Graft survival of fourth-time renal transplant recipients is similar to third-time recipients: A SRTR database analysis.

BACKGROUND: Candidates for repeat kidney transplant (KT) have increased. While graft and patient survival are inferior to primary KT, second and third KTs improve patient survival over dialysis. Little is known about the outcomes after fourth KTs. METHODS: We retrospectively compared characteristics of third and fourth KTs in the SRTR. Factors associated with graft survival in third vs fourth KT and patient survival of fourth KT vs patients waitlisted for a 4th KT were assessed by Cox regression and multivariable linear regression analysis. RESULTS: There were 3055 third- and fourth-time KTs performed in the United States. Fourth-time graft survival was not significantly different from third-time transplants (HR 1.06, P = .653). Patients who received a fourth KT have a significant survival advantage compared with patients who remained on the waitlist for a fourth KT (HR = 0.53, P = .006). CONCLUSIONS: Graft and patient survival of fourth KTs are comparable to third KTs, but inferior to first and second KTs in terms of graft and patient survival. Recipients of fourth KT have had an increased life expectancy compared with patients waitlisted for a fourth KT.

Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS: A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS: In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION: Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE: Therapeutic, level IV.

Use of Chest Computed Tomography for Blunt Pediatric Chest Trauma: Does It Change Clinical Course?

INTRODUCTION: Given the concern for radiation-induced malignancy in children and the fact that risk of severe chest injury in children is low, the risk/benefit ratio must be considered in each child when ordering a computed tomography (CT) scan after blunt chest trauma. METHODS: The study included pediatric blunt trauma patients (age, <15 years) with chest radiograph (CR) before chest CT on admission to our adult and pediatric level I trauma center. Surgeons were asked to view the blinded images and reads and indicate if they felt CT was warranted based on CR findings, if their clinical management change based on additional findings on chest CT, and how they might change management. RESULTS: Of the 127 patients identified, 64.6% had no discrepancy between their initial CR and chest CT and 35.4% of the children's imaging contained a discrepancy. The majority of the pediatric and general trauma surgeons felt CT was indicated in 6 of 45 patients based on CR. In 87% of patients with a discrepancy in findings on CR and CT, the majority of surgeons agreed that their management would not change based on the additional information. In the 6 patients in which the CT was considered indicated, 4 of the 6 would have triggered a management change. CONCLUSIONS: Our study suggests that chest CT scans frequently serve as confirmatory diagnostic tools and in the pediatric blunt chest trauma patient and can be withheld in many cases without hindering the management of an injured child.

Marijuana use should not preclude consideration for kidney transplantation.

Transplant eligibility for tobacco and/or marijuana using candidates varies among transplant centers. This study compared the impact of marijuana use and tobacco use on kidney transplant recipient outcomes. Kidney transplant recipients at a single center from 2001 to 2015 were reviewed for outcomes of all-cause graft loss, infection, biopsy-proven acute rejection, and estimated glomerular filtration rate between four groups: marijuana-only users, marijuana and tobacco users, tobacco-only users, and nonusers. The cohort (N = 919) included 48 (5.2%) marijuana users, 45 (4.8%) marijuana and tobacco users, 136 (14.7%) tobacco users, and 75% nonusers. Smoking status was not significantly associated with acute rejection, estimated glomerular filtration rate or pneumonia within one-year post-transplant in an adjusted model. Compared to nonuse, marijuana and tobacco use and tobacco-only use was significantly associated with increased risk of graft loss (aHR 1.68, P = .034 and 1.52, P = .006, respectively). Patients with isolated marijuana use had similar overall graft survival compared to nonusers (aHR 1.00, P = .994). Marijuana use should not be an absolute contraindication to kidney transplant.

Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy.

PURPOSE: Blunt aortic injuries (BAI) have historically been considered an indication for emergent surgical intervention. Nevertheless, the observation that the outcome of the concomitant traumatic injuries has a major impact on prognosis and the rise of thoracic endovascular aortic repair (TEVAR) as an effective therapy for BAI have significantly changed in recent years the treatment algorithm of this condition. Our objective was to identify findings associated with the aortic injury which would be the best predictor of prognosis, with the objective of guiding the decision-making process for selecting the optimal timing of aortic repair. METHODS: We reviewed blunt aortic injuries from 3 Level I Trauma Centers from July 2008 to December 2016. We analyzed overall and BAI-related 30-day mortality in relation to: hemodynamics, timing of treatment, TEVAR vs open repair, and aortic injury grade as defined by the Society for Vascular Surgery. Based on computed tomographic angiography (CT scan) imaging, we selected the radiologic aortic findings most indicative of high mortality risk, which we defined as "Radiographic Severe Injury" (RSI): (1) total/partial aortic transection, (2) active contrast extravasation, or (3) the association of 2 of more of the following: contained contrast extravasation > 10 mm, periaortic hematoma, and/or mediastinal hematoma with thickness > 10 mm, or significant left pleural effusion. RESULTS: Of a total of 76 consecutive patients, 50 (66%) underwent immediate repair, 24 (31%) delayed aortic repair, and 2 (3%) died prior to repair. 58 patients (76%) had TEVAR, while 16 (24%) had open repair. Overall mortality was 18% and BAI-related mortality was 13%. In BAI-related mortalities, 70% of patients had RSI. Patients with high risk of overall mortality had hypotension and tachycardia (SBP < 100, HR ≥ 100), high ISS, and required vasopressors. Factors only associated with BAI-related mortality included RSI. CONCLUSION: CT scan findings suggestive of RSI are predictive of mortality associated with BAI. Radiologic assessment of the severity of the aortic injury with characterization for the presence of RSI may represent the key factors to determine the optimal timing of treatment of the aortic injury and guide the overall treatment strategy. LEVEL OF EVIDENCE: IV.

Impostor Phenomenon and Burnout in General Surgeons and General Surgery Residents.

OBJECTIVE: Impostor phenomenon (IP) characterizes feelings of self-doubt coupled with feelings that achievements were based on luck and a fear of being discovered as an intellectual fraud. Recently, studies have focused on IP in medical trainees and its association with burnout; however, this research has not yet been conducted on surgeons. This study addresses that gap by investigating the prevalence of IP and burnout in general surgeons and surgery residents. DESIGN: Participants completed two unlinked, blinded surveys. The first survey included demographics and scholarly activity, while the second included the Clance Impostor Phenomenon Scale (CIPS) and a validated, single-item burnout score. SETTING: Hennepin County Medical Center and University of Minnesota, Minneapolis, MN. PARTICIPANTS: General surgeons and general surgery residents at two teaching hospitals, one community-based (N = 46) and one university-based (N = 42). RESULTS: The majority of both surgeons and residents were male, Caucasian, and married. Residents scored significantly higher compared to faculty in nearly half of CIPS questions. The overall CIPS score was significantly higher in trainees as well (61 vs 51, p = 0.017). Burnout did not differ significantly between trainees (30%) and faculty (41%) (p = 0.545). We found no significant differences in gender or years of practice in those with clinical IP (CIPS >62), and logistic regression analysis showed burnout as the only significant association for clinical IP symptoms (OR 3.95, p = 0.017). CONCLUSIONS: Contrary to studies in other medical fields, female general surgery faculty and trainees were no more likely than males to display characteristics of IP. Residents did; however, score higher than faculty on overall CIPS score. While we cannot determine how burnout and IP directly impact each other, our study shows that both faculty and trainees experiencing burnout are more likely to report symptoms of IP.

Occupational exposure during emergency department thoracotomy: A prospective, multi-institution study.

BACKGROUND: Occupational exposure is an important consideration during emergency department thoracotomy (EDT). While human immunodeficiency virus/hepatitis prevalence in trauma patients (0-16.8%) and occupational exposure rates during operative trauma procedures (1.9-18.0%) have been reported, exposure risk during EDT is unknown. We hypothesized that occupational exposure risk during EDT would be greater than other operative trauma procedures. METHODS: A prospective, observational study at 16 US trauma centers was performed (2015-2016). All bedside EDT resuscitation providers were surveyed with a standardized data collection tool and risk factors analyzed with respect to the primary end point, EDT occupational exposure (percutaneous injury, mucous membrane, open wound, or eye splash). Provider and patient variables and outcomes were evaluated with single and multivariable logistic regression analyses. RESULTS: One thousand three hundred sixty participants (23% attending, 59% trainee, 11% nurse, 7% other) were surveyed after 305 EDTs (gunshot wound, 68%; prehospital cardiopulmonary resuscitation, 57%; emergency department signs of life, 37%), of which 15 patients survived (13 neurologically intact) their hospitalization. Overall, 22 occupational exposures were documented, resulting in an exposure rate of 7.2% (95% confidence interval [CI], 4.7-10.5%) per EDT and 1.6% (95% CI, 1.0-2.4%) per participant. No differences in trauma center level, number of participants, or hours worked were identified. Providers with exposures were primarily trainees (68%) with percutaneous injuries (86%) during the thoracotomy (73%). Full precautions were utilized in only 46% of exposed providers, while multiple variable logistic regression determined that each personal protective equipment item utilized during EDT correlated with a 34% decreased risk of occupational exposure (odds ratio, 0.66; 95% CI, 0.48-0.91; p = 0.010). CONCLUSIONS: Our results suggest that the risk of occupational exposure should not deter providers from performing EDT. Despite the small risk of viral transmission, our data revealed practices that may place health care providers at unnecessary risk of occupational exposure. Regardless of the lifesaving nature of the procedure, improved universal precaution compliance with personal protective equipment is paramount and would further minimize occupational exposure risks during EDT. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Multicenter study of crystalloid boluses and transfusion in pediatric trauma-When to go to blood?

BACKGROUND: The 9th edition of Advanced Trauma Life Support recommends up to three crystalloid boluses in pediatric trauma patients with consideration of transfusion after the second bolus; however, this approach is debated. We aimed to determine if requirement of more than one fluid bolus predicts the need for transfusion. METHODS: The 2010 to 2016 highest tier activation patients younger than 15 years from two ACS Level I pediatric trauma centers were identified from prospectively maintained trauma databases. Those with a shock index (heart rate/systolic blood pressure) greater than 0.9 were included. Crystalloid boluses (20 ± 10 mL/kg) and transfusions administered prehospital and within 12 hours of hospital arrival were determined. Univariate and multivariable analyses were conducted to determine association between crystalloid volume and transfusion. RESULTS: Among 208 patients, the mean age was 5 ± 4 years (60% male), 91% sustained blunt injuries, and median (interquartile range) Injury Severity Score was 11 (6,25). Twenty-nine percent received one bolus, 17% received two, and 10% received at least three. Transfusion of any blood product occurred in 50 (24%) patients; mean (range) red blood cells was 23 (0-89) mL/kg, plasma 8 (0-69), and platelets 1 (0-18). The likelihood of transfusion increased logarithmically from 11% to 43% for those requiring 2 or more boluses (Fig. 1). This relationship persisted on multivariable analysis that adjusted for institution, age, and shock index with good discrimination (Area under the Receiver Operating Characteristic, 0.84). Shock index was also strongly associated with transfusion. CONCLUSION: Almost half of pediatric trauma patients with elevated shock index require transfusion following two crystalloid boluses and the odds of requiring a transfusion plateau at this point in resuscitation. This supports consideration of blood with the second bolus in conjunction with shock index though prospective studies are needed to confirm this and its impact on outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Circulation first - the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial.

Background: The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence. Methods: This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes. Results: From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death. Conclusion: The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted. Trial registration: IRB approval number: HM20006627. Retrospective trial not registered.

General Surgery Resident Case Logs: Do They Accurately Reflect Resident Experience?

INTRODUCTION: Operative experience during residency lays the foundation for independent practice and additional specialty training following general surgery residency. The aim of this study was to examine operative experience of general surgery residents and detail the results of an intervention aimed at improving resident record keeping in the Accreditation Council for Graduate Medical Education (ACGME) case log system to better reflect their experience. METHODS: Residents were asked to characterize variances in recorded operative experience identified through an audit of operative logs. Based on the results of the audit, an intervention was designed to prompt timely record keeping by residents. The intervention included education and discussion of survey audit results, weekly presentation of graphs detailing operative experience, and possible missed cases in the ACGME logs and addition of a first assistant column in morbidity and mortality (M&M) logs. RESULTS: The audit of case logs identified discrepancies in 24.2% of the 636 cases examined. Chief residents were significantly more accurate (95.9%) in recording operative experience in ACGME case logs, whereas 50.3% of junior resident case logs contained variances. Residents characterized discrepancies as "forgot to log" (9.6%), "staff did the case" (5.2%), "another resident did more of the case" (3.6%), "other" (3.6%), a "more advanced resident was present for the case" (1.6%), "not present for case" (0.6%), and "left for consult" (0.3%). Over the 4-week intervention period, residents logged between 72.7% and 94.0% of cases. A month following the intervention period, we observed a 13.3% increase in recorded cases compared with the intervention period. Review of first assistant case logging following inclusion of a "first assistant" column in M&M logs demonstrated a 70.5% increase in first assistant cases logged into the ACGME system compared with the same time period a year ago. CONCLUSIONS: Based on our results, we found that weekly displays of cases improved resident record keeping in the ACGME case log system, especially by junior residents. We believe that the addition of first assistant column on M&M lists, periodic audits reviewed at conferences, and semiannual evaluations will help junior residents more accurately report their experience during training.

The ligation of the intersphincteric fistula tract procedure for anal fistula: a mixed bag of results.

BACKGROUND: The ligation of the intersphincteric fistula tract procedure, a sphincter-preserving technique, aims to obtain complete, durable healing, while preserving fecal continence in the treatment of transsphincteric anal fistulas. OBJECTIVE: This was a systematic review to evaluate the outcomes of the originally described (classic) ligation of the intersphincteric fistula tract procedure and the identified technical variations of the procedure. DATA SOURCES: PubMed, Web of Science, and the archive of Diseases of the Colon & Rectum were searched with the terms "ligation of intersphincteric fistula" and "ligation of intersphincteric fistula tract." STUDY SELECTION: Original, English-language studies reporting the primary healing rate for each technical variation of the ligation of the intersphincteric fistula tract procedure were included. Studies were excluded when the technique used was unclear or when primary healing rate was reported in a pooled manner including outcomes from multiple technical variations of the ligation of the intersphincteric fistula tract procedure. INTERVENTION: Outcomes associated with all of the technical variations of the ligation of the intersphincteric fistula tract procedure were investigated. MAIN OUTCOME MEASURES: The main outcome measured was primary healing rate. Secondary outcome measures included time to healing, changes in continence, and risk factors for failure. RESULTS: In all, 26 studies met criteria for review, including 1 randomized controlled trial and 25 cohort/case series. Seven technical variations of the ligation of the intersphincteric fistula tract procedure were identified and classified according to the surgical technique. Primary healing rates ranged from 47% to 95%. LIMITATIONS: The levels of evidence available in the published works are relatively low, as indicated by the Oxford Center for Evidence-Based Medicine evidence levels. CONCLUSIONS: The ligation of the intersphincteric fistula tract procedure is a promising treatment option for transsphincteric fistulas, with reasonable success rates and minimal impact on continence. The true efficacy of the procedure is unknown because of the number of technical variations and the pooled results reported in the literature.