Does Practice Match Training? Consultation Practices in Surgical Critical Care.

INTRODUCTION: Intensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation. METHODS: We surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried. RESULTS: 314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015). CONCLUSIONS: ICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents' scope of practice closely matched their training.

Observing pneumothoraces: The 35-millimeter rule is safe for both blunt and penetrating chest trauma.

BACKGROUND: As more pneumothoraxes (PTX) are being identified on chest computed tomography (CT), the empiric trigger for tube thoracostomy (TT) versus observation remains unclear. We hypothesized that PTX measuring 35 mm or less on chest CT can be safely observed in both penetrating and blunt trauma mechanisms. METHODS: A retrospective review was conducted of all patients diagnosed with PTX by chest CT between January 2011 and December 2016. Patients were excluded if they had an associated hemothorax, an immediate TT (TT placed before the initial chest CT), or if they were on mechanical ventilation. Size of PTX was quantified by measuring the radial distance between the parietal and visceral pleura/mediastinum in a line perpendicular to the chest wall on axial imaging of the largest air pocket. Based on previous work, a cutoff of 35 mm on the initial CT was used to dichotomize the groups. Failure of observation was defined as the need for a delayed TT during the first week. A univariate analysis was performed to identify predictors of failure in both groups, and multivariate analysis was constructed to assess the independent impact of PTX measurement on the failure of observation while controlling for demographics and chest injuries. RESULTS: Of the 1,767 chest trauma patients screened, 832 (47%) had PTX, and of those meeting inclusion criteria, 257 (89.0%) were successfully observed until discharge. Of those successfully observed, 247 (96%) patients had a measurement of 35 mm or less. The positive predictive value for 35 mm as a cutoff was 90.8% to predict successful observation. In the univariant analyses, rib fractures (p = 0.048), Glasgow Coma Scale (p = 0.012), and size of the PTX (≤35 mm or >35 mm) (P < 0.0001) were associated with failed observation. In multivariate analysis, PTX measuring 35 mm or less was an independent predictor of successful observation (odds ratio, 0.142; 95% confidence interval, 0.047-0.428)] for the combined blunt and penetrating trauma patients. CONCLUSION: A 35-mm cutoff is safe as a general guide with only 9% of stable patients failing initial observation regardless of mechanism. LEVEL OF EVIDENCE: Therapeutic, level III.

A pilot study to explore the safety of perioperative postpyloric enteral nutrition.

BACKGROUND: The practice of holding enteral nutrition (EN) 8 hours prior to surgery is common. We hypothesized that it was safe to continue postpyloric EN, and we developed an institutional practice pattern to investigate our hypothesis. METHODS: Our pilot study included intubated patients in the surgical intensive care unit at Froedtert Memorial Lutheran Hospital who received EN via a nasojejunal (NJ) feeding tube and underwent 1 or more surgical procedures. Demographic, illness, and injury information were collected as well as length of time to NJ placement, time to initiation of EN, EN interruptions, and complications. Additional hours of EN were calculated by totaling the number of hours a patient received EN past midnight on the day of surgery. RESULTS: A total of 14 patients with mean (SD) age 44.3 (19.9) were included. Patients had a mean (SD) Injury Severity Score (ISS) of 26.1 (9.2) on admission and underwent a total of 38 operations following placement of a feeding tube. The most frequent operation performed was an orthopedic procedure (n = 17; 46.1%). The mean (SD) length of EN interruptions for a single procedure was 222.4 (206.9) minutes. Patients received an additional 11.9 (4.7) hours of EN over the course of their hospitalization and an additional 1064.9 (490) kcal/d per operation. There were no adverse events. CONCLUSION: Perioperative continuation of postpyloric EN is feasible in some critically ill surgical patients and can result in additional calories provided. A multidisciplinary approach and an institutional policy can increase the likelihood of meeting nutrition goals in these patients.

Staged abdominal repairs reduce long-term quality of life.

INTRODUCTION: Damage control surgery increasingly requires serial operations and a staged abdominal repair (STAR) for ultimate abdominal closure. The effects of multiple operations on quality of life are unknown. We hypothesized that this population of patients had a lower quality of life than the general U.S. population. METHODS: Patients requiring STAR for general surgical and trauma diagnoses during a 5-year period from January 2002 to December 2006 were identified from the operative database of a single institution. Demographic, illness, and injury information were obtained from record review. Survivors were 3-7 years from their hospitalization for STAR when they were contacted and the SF-12v2 was administered by phone. The physical (PCS) and mental component (MCS) scores were calculated and compared to US population norms and a population of trauma patients. The non-STAR trauma population completed the SF-12v2 six months after injury. RESULTS: A total of 27 patients with a mean age of 46.5 years (SD = 15.9) participated in the survey. The participants were interviewed a median of 4.7 years after injury. The mechanism of injury included 8 (29.6%) general surgical causes including 4 perforated viscus, 3 intra-abdominal infections, and 1 wound dehiscence from a urological procedure. The remaining 19 (70.4%) were trauma-related, including 13 blunt and 6 penetrating injuries. Patients who had undergone a STAR procedure reported lower levels of physical quality of life [z = -15.42, p<0.001] and mental quality of life [z = -6.79, p<0.001] compared to population norms for healthy adults. Also, STAR patients reported lower physical [z = -2.22, p<0.05] and mental [z = -2.59, p<0.05] quality of life as the non-STAR trauma group. DISCUSSION: The number of patients undergoing STAR for a variety of reasons is increasing. Measurements of quality of life of STAR patients show that quality of life is reduced compared to a healthy U.S. adult population and to non-STAR trauma patients. CONCLUSIONS: The significant impact of severe abdominal injuries continues to affect the physical and mental health of patients years later. Injuries of this type are associated with lower quality of life than those observed in patients experiencing non-STAR trauma.