Perioperative Tissue Oximetry-driven Fluid Resuscitation Improves Flap Perfusion in Autologous Free Tissue Breast Reconstruction.

Introduction: The use of tissue oximetry for monitoring following free tissue transfer has become a common practice to facilitate early detection of poor flap perfusion. We hypothesized that T stat readings may guide fluid administration in the postoperative period and improve perfusion in patients undergoing autologous breast reconstruction. Methods: Patients undergoing free flap breast reconstruction from 2015 to 2018 were reviewed. Mean percutaneous oximetry readings of the first four postoperative days were recorded. The mean change at 24 hours from the original reading was calculated (∆TO). The study population was divided in two groups based on whether administration of intravenous fluids (IVFs) was increased/maintained (group 1) or decreased (group 2) after postoperative day 1. Results: A total of 120 patients were identified. The mean age was 53, and mean BMI was 33. Overall, patients for whom fluid administration was decreased experienced an increase in their tissue perfusion, while patient who received a bolus or maintained the same rate of IVF experienced a decrease. Patients who had a negative ∆TO experienced a statistically significant difference between groups 1 and 2 at 24 and 72 hours (-4 versus +3 and -11 versus +13, respectively). For patients with a positive ∆TO, although decreasing fluids resulted in higher readings, it did not reach statistical significance at 24 or 72 hours (0 versus +2 and +4 versus +6, respectively). Conclusions: In patients undergoing free tissue breast reconstruction, tissue oximetry readings may be used as a novel guide for postoperative fluid management.

Palmar Venous Malformation: A Case Report of a Rare Occurrence and a Treatment Algorithm.

Palmar venous malformations are not well described in the surgical literature and are a therapeutic challenge due to the intricate anatomy of the hand. We present the case of a 19-year-old right-handed female patient from Mexico who was referred to us with a right palmar lesion present since birth, previously diagnosed as a venous malformation. The patient reported that she had undergone sclerotherapy 10 years before in addition to a prior aborted attempt at excision. Venous palmar malformations are rare occurrences. Although an individualized approach is important, the development of an algorithm may assist in the standardization of the treatment of this pathology to preserve the hand's functional status.

Full versus Baby Dose Aspirin for Antithrombotic Prophylaxis in Free Tissue Transfer: Does Size Matter?

The postoperative prophylactic use of aspirin is a common practice among plastic surgeons after free tissue transfer. The use of baby aspirin (81 mg) has become more popular due to previously published literature in other fields. We hypothesized that a full dose daily aspirin is nonsuperior to a baby dose daily aspirin in preventing arterial thrombosis in free tissue transfer. Methods: All patients undergoing free tissue transfer of the extremities from 2008 to 2020 were retrospectively reviewed. They were divided into two groups based on the postoperative dose of aspirin administered (full versus baby dose). The decision to administer full or baby dose was based on the surgeon's preference. Primary outcome was revision of the arterial anastomosis. Secondary outcomes included flap complications. Results: A total of 183 patients were identified. Out of those, 78 patients received full dose aspirin postoperatively, whereas 105 received a baby dose of aspirin. Patients who received baby aspirin did not have a higher incidence of returning to the operating room for revision of their arterial anastomosis [7.6% versus 7.7%; adjusted odds ratio, 0.93 (95% confidence interval, 0.28-3.11); adjusted P, 0.906]. No differences were found between the two groups in complete and partial flap loss, wound dehiscence, or infection. None of the patients experienced any aspirin-related gastrointestinal complications. Conclusions: In patients undergoing free tissue transfer, thrombosis of the arterial anastomosis is rare. Administration of a full dose of aspirin postoperatively was not superior to a baby dose of aspirin in preventing arterial-related complications.

Not all flaps are created equal: Assessing the impact of active smoking in muscle-only versus perforator flaps for patients undergoing nonelective extremity-free tissue transfer-A case control study.

INTRODUCTION: Active smoking is known to impair wound healing following free tissue transfer for reconstruction due to its vasoconstrictive effect on the microcirculation. The aim of this study was to evaluate the impact of flap selection on flap loss, in nonelective, traumatic extremity-free soft tissue transfer in active smokers. METHODS: All patients undergoing a free tissue transfer for acute trauma of the extremity at a level I trauma center from 2011 to 2017 were identified. Breast reconstruction and osseous/osseocutaneous flaps were excluded. The study population was divided in two groups based on the type of flap used (muscle versus perforator flap). Factors known to be associated with impaired wound healing were extracted from the database. Primary outcome was major smoking related complications (complete/partial flap loss). Secondary outcomes included minor flap-related complications (infection, dehiscence) and donor site complications. The impact of smoking was assessed for the different type of flaps using multivariate analyses. RESULTS: A total of 118 flaps were identified during the study period. Out of those, 52 were perforator-based fasciocutaneous flaps, while 66 were muscle flaps. Active smoking status resulted in a statistically significant increase in the incidence of major and minor complications in the perforator flap group (36% vs. 4%, adjusted odds ratio, AOR [95%CI]: 2.31[1.48,19.30], adj-p = 0.021 and 32% vs. 17%, AOR [95% CI]: 1.23[1.11,14.31], adj-p = 0.034) but had no impact in the muscle group. CONCLUSIONS: The present study suggests a higher incidence of flap related complications in smokers when a perforator flap was selected but no impact when a muscle flap was utilized.

Flow-through Anterolateral Thigh Flaps: Report of 3 Consecutive Cases and Review of its Utility.

In the field of plastic and reconstructive surgery, soft tissue reconstruction of Gustilo 3B with peripheral vascular disease or 3C fractures is a complex treatment algorithm. The concomitant issue of soft tissue coverage with vascular reconstruction is the main challenge when opting for free tissue transfer. The flow-through flap offers the surgeon the ability to treat a vascular injury or high-grade stenosis to maintain distal perfusion, while also providing soft tissue coverage. In this study, we present a case series of 3 patients who underwent flow-through anterolateral thigh free flap for lower extremity soft tissue coverage. Each patient had a history of trauma and either single vessel runoff or a dominant branch with diminutive secondary blood flow to the foot. All patients successfully underwent free flap reconstruction of lower extremity wounds while concomitantly reconstructing diseased arterial supply. Only 1 patient suffered partial flap loss postoperatively that was treated with debridement and split thickness skin grafting. Flow-through free tissue transfer is a valuable treatment option not only in Gustilo 3C fractures requiring soft tissue coverage, but also in patients with Gustilo 3B fractures with peripheral vascular disease.

Impact of Blood Transfusion in Free Flap Breast Reconstruction Using Propensity Score Matching.

BACKGROUND: Microvascular thrombosis has been associated with cytokine release and inflammatory syndromes which can occur as a result of blood transfusions. This phenomenon could potentially lead to complications in breast free flap reconstruction. The aim of this study was to evaluate the impact of perioperative blood transfusion in free flap breast reconstruction using large population analysis. METHODS: The American College of Surgeons National Quality Improvement Program database was queried for delayed free flap breast reconstructions performed in 2016. The study population was divided based on perioperative blood transfusion within 24 hours of the start of the operation. Propensity score matching analysis was used to ensure homogeneity between the two study groups. Primary outcome was unplanned return to the operating room (OR) within 30 days. Secondary outcomes were readmission and complications. RESULTS: A total of 1,256 patients were identified. Out of those, 91 patients received a perioperative blood transfusion. All the patients received only one unit of PRBC within the first 24 hours. Those patients were matched with similar patients who did not receive a transfusion on a ratio of 1:3 (273 patients). Patients who received a transfusion had a significantly higher incidence of reoperation (42 vs. 10%, p < 0.001). Patients who received a transfusion were more likely to return to the OR after 48 hours from the initial operation (13 vs. 5%, p = 0.001). All returns to the OR were due to flap-related complications. Perioperative blood transfusion increased the incidence of wound dehiscence (9 vs. 2%, p = 0.041) but had no protective effect on the development of other postoperative complications. CONCLUSION: Perioperative blood transfusion in free flap breast reconstruction is associated with an increased probability of flap-related complications and subsequent return to the OR without decreasing the probability of developing other systemic postoperative complications.

Development and Validation of Scoring System to Predict Secondary Amputations in Free Flap Reconstruction.

Need for amputation is a potential complication when limb salvage is attempted. The present study aimed to develop a risk assessment tool to predict the risk of future amputation when counseling patients about their reconstructive options. METHODS: All patients undergoing a free flap lower extremity soft tissue reconstruction by the senior author from 2005 to 2019 were retrospectively identified. Patient's demographics, comorbidities, and technical aspects of the operation were extracted. Logistic regressions were used to create a predictive scoring system for future amputation. RESULTS: A total of 277 patients were identified. Of these patients, two-thirds (183) were used to derive the scoring system and one-third (94) were used to validate the score. In total, 25 of 183 patients (14%) underwent an amputation. A stepwise forward logistic regression identified age > 55 years, smoking, acute wound, aggressive fluid resuscitation intra-operatively, inability to use a superficial vein for drainage, and inability to use the posterior tibialis artery for anastomosis as independent predictors of need for future amputations. The beta co-efficients were used to create the scoring system, and the patients were categorized into mild, moderate, and severe risk based on their cumulative score. The validity of the scoring system was verified by using the one-third validation cohort. CONCLUSIONS: In patients undergoing free flap reconstruction of the lower extremity, the need for future amputation is 14%. The use of a scoring system can guide the surgeon's and patient's decision regarding limb salvage.

Perioperative Fluid Resuscitation in Free Flap Breast Reconstruction: When Is Enough Enough?

Perioperative liberal fluid resuscitation (LFR) can result in interstitial edema and venous congestion and may be associated with compromised perfusion of free flaps and higher incidence of wound complications. We hypothesized that restrictive intraoperative fluid resuscitation improves flap perfusion and lowers the wound complication rate in free flap breast reconstruction. METHODS: Patients undergoing free flap reconstruction of the breast from 2010 to 2018 were retrospectively reviewed. The study population was divided into 2 groups, LFR (≥7 ml/kg/h) and restrictive fluid resuscitation (RFR) (<7 ml/kg/h). Mean percutaneous oximetry readings of the flap over the first 24 hours were recorded. Primary outcome was development of any wound complication. Secondary outcomes were mean percutaneous oximetry readings within the first 24 hours, length of stay, and development of acute kidney injury. RESULTS: One hundred twenty-six patients were identified, with 41 patients undergoing LFR. The mean fluid received for the RFR group was 5.5 versus 10.2 ml/kg/h for the LFR group (P < 0.001). LFR resulted in a significantly higher incidence of wound complications (76% versus 15%, P < 0.001). The mean oximetry readings within 24 hours were significantly lower for the LFR group (41% versus 56%, P < 0.001). Urine output intraoperatively and within the first 24 hours was similar between the 2 groups. No patients developed acute kidney injury. CONCLUSION: RFR in free flap breast reconstruction is associated with increased flap perfusion and lower incidence of wound-related complications and should be considered whenever possible.

Tissue Oximetry Readings Accurately Predict Late Complications in Patients Undergoing Free Flap Breast Reconstruction: Exploring the Optimal Cut Point Value.

BACKGROUND: The use of tissue oximetry for monitoring following free tissue transfer has become a common practice across the United States to facilitate early detection of poor flap perfusion in the postoperative setting. There is no consensus on the optimal value, below which there is a higher chance of wound complications in patients undergoing free flap breast reconstruction. METHODS: Patients undergoing free flap breast reconstruction from 2015 to 2018 were retrospectively reviewed. Patients who returned to the operating room for a revision of the anastomosis were excluded from analysis. Patients were divided in two groups based on the development of late complications. Those were defined as fat necrosis, wound dehiscence, or distal flap ischemia/necrosis that developed after discharge from the hospital. Mean percutaneous oximetry readings of the first 24 hours were recorded and the mean change from the initial reading was calculated. The correlation between tissue oximetry change and development of complications was explored. RESULTS: A total of 120 patients were identified. The mean age was 53, while the mean body mass index was 33. A total of 38 patients developed late wound complication. History of smoking, diabetes mellitus, neoadjuvant radiation therapy, and the mean change of the tissue oximetry reading were identified as independent predictors of wound complications. The absolute number of the tissue oximetry reading did not predict late complications. A multivariate analysis revealed that patients who experienced a mean decrease < 15% from the initial reading during the first 24 hours were significantly more likely to develop late flap-related wound complications. CONCLUSION: In patients undergoing free tissue breast reconstruction, tissue oximetry readings do not predict late wound complications. However, the mean change at 24 hours from the initial reading does. A decrease of <15% in tissue perfusion was associated with a significant increase in the probability of developing flap-related wound complications.

Challenging the Surgical Axiom: Albumin Level Does Not Reliably Predict Development of Wound Complications in Patients Undergoing Body Contouring.

INTRODUCTION: Hypoalbuminemia has traditionally been associated with a poor nutritional status and subsequent high incidence of postoperative wound complications in surgical patients. Recent evidence, however, suggests that traditional nutritional markers are inadequate in predicting postoperative morbidity. OBJECTIVE: To test the hypothesis that preoperative albumin levels are not associated with adverse outcomes in patients undergoing body contouring. METHODS: All patients undergoing body contouring from 2015 to 2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Demographics, comorbidities, and wound classification were extracted from the database. The independent predictors of developing wound complications were identified. Logistic regressions were used to identify the impact of albumin on outcomes. RESULTS: During the study period, 4496 patients were identified. Wound complications developed in 202 patients (4.5%). Increasing body mass index, history of diabetes mellitus, American Society of Anesthesiologists classification, history of prior open wound, and tobacco use were independently associated with the development of postoperative complications. Albumin levels were not associated with the development of wound complications. Similarly, albumin levels were not associated with the need for a repeated operation, with readmission, or with the total hospital length of stay. CONCLUSION: Albumin values were not associated with wound complications or need for reoperation in patients undergoing body contouring. Further research is warranted.

Gender Bias in the Integrated Plastic Surgery Residency: A Snapshot of Current Trends.

According to the American Society of Plastic Surgeons, the male to female ratio of plastic surgeons is approximately 5:1. As more surgical specialties are recruiting female residents, there has been an increase in the amount of females. We set out to examine the current trends in residency recruitment and whether a quantifiable gender bias exists. METHODS: A review of all the integrated plastic surgery programs within the United States was conducted. Data were collected regarding department or division status, the gender of the chairman and the program directors, the number of residents per year and gender of residents per year. The ratio of male to female residents was calculated. RESULTS: A total of 62 residency programs were identified. The vast majority had a male program director with only 8 female program directors identified. The mean ratio of female/male (F/M) residents overall was 1/1.2. Female program directors selected residents in the same ratio as their male counterparts [F/M ratio: 1/1.26 versus 1/1.18, p:0.813]. A linear logistic regression failed to identify the geographic location, department status, gender of the department chairman or the number of residents selected per year as predictors of higher F/M ratio. CONCLUSIONS: There are still fewer female program directors and residents in plastic surgery overall. However, neither was more likely to select a resident of their own gender. This analysis does not rule out the possible self-selection factor.

Clostridium difficile Infection in the Plastic Surgery Population: Lessons from the ACS NSQIP Database.

Clostridium difficile-associated infections (CDI) have a significant impact on morbidity and mortality of hospitalized medical and surgical patients. There is a paucity of data regarding the incidence, impact, and modifiable risk factors in the plastic surgery population. METHODS: The ACS NSQIP database was retrospectively queried for all cases performed by plastic surgeons during 2016. All plastic surgery cases, combined cases, demographics, and baseline clinical characteristics were extracted from the database. The study population was divided into 2 groups based on the development of CDI. Independent variables for development of CDI were identified. RESULTS: During the study period, a total of 29,256 patients underwent a procedure by plastic surgery, with the most commonly performed procedures involving the breast (58%) and trunk (14%). Only 44 patients developed post-operative CDI (0.1%). Factors independently associated with development of CDI were wound classification at the end of the surgery, COPD, procedures involving the trunk, and surgery for reconstruction of pressure ulcers. Outpatient surgery was associated with decreased odds of developing CDI [AOR (95% CI):0.2 (0.1, 0.4), adj P < 0.001]. Staying overnight did not increase the odds of developing CDI; however, staying for >1 day in the hospital was associated with an increased risk of CDI development [AOR (95% CI): 1.03 (1.01, 1.13), adj P = 0.001]. Combined cases, ASA, body mass index, diabetes, and active smoking were not associated with CDI. CONCLUSIONS: CDI are rare in the plastic surgery population and are most associated with trunk/decubitus ulcer reconstructions, inpatient hospital stay, and contaminated wounds. The patients that usually fit in these categories have acutely or chronically infected wounds, which are often treated with systemic antibiotics. For patient with decubitus ulcers and other trunk reconstruction, the guidelines for pre and post-operative systemic antibiotic usage is not well defined. For patients who have had trunk reconstruction, development of evidence-based antibiotic stewardship guidelines may help these patients by limiting antibiotic usage and thereby reducing the incidence of CDI.

Rib fractures in the elderly: physiology trumps anatomy.

INTRODUCTION: Rib fractures in elderly patients are associated with increased morbidity and mortality. Predicting which patients are at risk for complications is an area of debate. Current models use anatomic, physiologic or laboratory parameters in isolation to answer this question. The 'RibScore' is an anatomic model that assesses fracture severity. Given that frailty is a major driver of adverse outcomes in the elderly, we hypothesize that the combined analysis of fracture severity, physiologic reserve and current pulmonary function are better predictors of respiratory compromise in this population. METHODS: This is a retrospective chart review of 263 trauma patients age ≥55 from January 2014 to June 2017. Criteria included blunt mechanism and ≥ 1 rib fracture identified by CT. Variables indicating adverse pulmonary outcomes were defined by: pneumonia, respiratory failure and tracheostomy. Three models were assessed: (1) RibScore, (2) Modified Frailty Index (mFI) and (3) initial partial pressure of carbondioxide (PaCO2). RESULTS: A total of 263 patients met inclusion criteria. 13% developed pulmonary complications. Increased RibScore, mFI and PaCO2 were each statistically associated with risk of complications. Receiver operating characteristics area under the curve analysis of individual models predicted complications with the following concordance statistic (CS): anatomic (RibScore) yielded a CS of 0.79 (95% CI 0.69 to 0.89); physiologic (mFI) yielded a CS of 0.83 (95% CI 0.75 to 0.91) and laboratory (PaCO2) yielded a CS of 0.88 (95% CI 0.80 to 0.95). The PaCO2 had the highest discriminative ability of the three individual models. Combining all three models yielded the best performance with a CS of 0.90 (95% CI 0.81 to 0.97). DISCUSSION: The RibScore maintains discriminative ability in the elderly. However, models based on mFI and PaCO2 individually outperform the RibScore. A combination of all three models yields the highest discriminative ability. This combined approach is best for assessing the severity of rib fractures and prediction of complications in the elderly. LEVEL OF EVIDENCE: Prognostic Study, Level III.

Men present with higher clinical class of chronic venous disease before endovenous catheter ablation.

BACKGROUND: Risk factors for chronic venous disease (CVD) have been widely reported in population health management. However, predisposing factors associated with patients treated for advanced stages of CVD have yet to be established. We examined the demographics and risk factors associated with advanced clinical presentation of CVD for patients referred for vein ablation. METHODS: Retrospective analysis of our institutional Vascular Quality Initiative Varicose Vein Registry included endovenous laser treatment and radiofrequency ablation procedures at our tertiary institution, community hospital, and outpatient vein clinic between January 2015 and December 2016. All incompetent truncal veins were divided into two groups based on the Clinical, Etiology, Anatomy, and Pathophysiology clinical class of CVD: mild-moderate (C1-C3) and severe (C4-C6). The two groups were compared in terms of their demographics and medical comorbidities using univariate and multivariate analysis. Data analysis was conducted on SPSS 22.0 (IBM Corp, Armonk, NY). RESULTS: During the study period, a total of 650 incompetent truncal veins were ablated. The mean age of patients was 58 years, and 73% were female. Severe CVD composed 21% of the cohort. Male sex was a risk for advanced CVD (odds ratio, 2.6; P < .001). Older age was also associated with severe CVD; the average age was 63 years for patients with advanced stage CVD vs 56 years for mild to moderate CVD (P < .001). Race, diabetes, body mass index, number of pregnancies, congestive heart failure, history of venous thromboembolism, current anticoagulation, and history of smoking or current smoking status did not affect the severity of CVD. CONCLUSIONS: Among patients treated with vein ablation for superficial venous insufficiency, older age and male sex were associated with increased severity of advanced CVD. Despite the higher incidence of varicose veins among women, men are more likely to have clinically advanced CVD when they present for truncal vein ablation.

Nerve Transfer Surgery for Penetrating Upper Extremity Injuries.

CONTEXT: Nerve transfer surgery is an option for repair of penetrating injuries of the upper extremity. In the right setting, it has advantages over tendon transfers and nerve grafting. OBJECTIVE: To review our experience since 2006 of nerve transfer surgery in the upper extremities. DESIGN: We included cases performed to repair penetrating trauma within three months of injury with at least three years' follow-up. MAIN OUTCOME MEASURES: Preoperative and postoperative muscle strength of the affected extremity. RESULTS: All 16 patients were males aged 16 to 43 years. Six patients underwent nerve transfer surgery because of elbow flexion; 5, finger extension; 3, finger flexion; and 2, wrist pronation. Nine patients (56%) had associated vascular injury, and 4 (25%) had fractures. Average follow-up was 6 years. No perioperative complications occurred. Patients had a mean of 3.7 operations after the initial trauma. All patients received physical therapy. All patients improved from 0 of 5 muscle strength preoperatively to a mean of 3.8 (range = 2/5 to 5/5) within 1 year after surgery. In all cases, strength was maintained, and 8 (50%) had continued improvement after Year 1. Ten (63%) returned to their previous employment level. Mean Disabilities of the Arm, Shoulder and Hand score improved from 68 to 83 postoperatively. CONCLUSION: Nerve transfer is a safe, effective technique for correcting penetrating trauma-related nerve injury. In appropriate patients it offers advantages over other techniques. Outcomes can be maintained long term, and many patients can return to their previous level of function.

Use of Epidural Analgesia as an Adjunct in Elective Abdominal Wall Reconstruction: A Review of 4983 Cases.

CONTEXT: Use of epidural analgesia in patients undergoing elective abdominal wall reconstruction is common. OBJECTIVE: To assess the impact of epidural analgesia in patients undergoing abdominal wall reconstruction. DESIGN: All patients who underwent elective ventral hernia repair from 2005 to 2014 were retrospectively identified. Patients were divided into two groups by the postoperative use of epidural analgesics as an adjunct analgesic method. Preoperative comorbidities, American Society of Anesthesiologists status, operative findings, postoperative pain management, and venothromboembolic prophylaxis were extracted from the database. Logistic regressions were performed to assess the impact of epidural use. MAIN OUTCOME MEASURES: Severity of pain on postoperative days 1 and 2. RESULTS: During the study period, 4983 patients were identified. Of those, 237 patients (4.8%) had an epidural analgesic placed. After adjustment for differences between groups, use of epidural analgesia was associated with significantly lower rates of 30-day presentation to the Emergency Department (adjusted odds ratio [AOR] = 0.53, 95% confidence interval [CI] = 0.32-0.87, adjusted p = 0.01). Use of epidural analgesia resulted in higher odds of abscess development (AOR = 5.89, CI = 2.00-17.34, adjusted p < 0.01) and transfusion requirement (AOR = 2.92, CI = 1.34-6.40, adjusted p < 0.01). Use of epidural analgesia resulted in a significantly lower pain score on postoperative day 1 (3 vs 4, adjusted p < 0.01). CONCLUSION: Use of epidural analgesia in patients undergoing abdominal wall reconstruction may result in longer hospital stay and higher incidence of complications while having no measurable positive clinical impact on pain control.

The Relationship between Age, Common Bile Duct Diameter and Diagnostic Probability in Suspected Choledocholithiasis.

BACKGROUND: Aging has been associated with increasing common bile duct (CBD) diameter and reported as independently predictive of the likelihood of choledocolithiasis. These associations are controversial with uncertain diagnostic utility in patients presenting with symptomatic disease. The current study examined the relationship between age, CBD size, and the diagnostic probability of choledocolithiasis. METHODS: Symptomatic patients undergoing evaluation for suspected choledocolithiasis from January 2008 to February 2011 were reviewed. In the cohort without choledocolithiasis, the relationship between aging and CBD size was examined as a continuous variable and by comparing mean CBD size across stratified age groups. Multivariate analysis examined the relationship between increasing age and diagnostic probability of choledocolithiasis in all patients. RESULTS: Choledocolithasis was diagnosed by MR cholangiopancreatography (MRCP) or endoscopic retrograde (ERCP) in 496 of 1,000 patients reviewed. Mean CBD was 6.0 mm (±2.8 mm) in the 504 of 1,000 patients without choledocolithiasis on ERCP/MRCP. Increasing age had no correlation with CBD size as a continuous variable (r2 = 0.011, p = 0.811). No difference occurred across age groups (Kruskal-Wallis, p = 0.157). Age had no association with diagnostic likelihood of choledocolithiasis (AOR [95% CI] 0.99 [0.98-1.01], adjusted-p = 0.335). CONCLUSION: In a large population undergoing investigation for biliary disease, increasing age was neither associated with increasing CBD diameter nor predictive of the likelihood of choledocolithiasis.

Clinical relevance of the routine daily chest X-Ray in the surgical intensive care unit.

INTRODUCTION: A daily Chest X-ray (CXR) is obtained in many surgical intensive care units (SICU). This study implemented a selective CXR protocol in a high volume, academic SICU and evaluated its impact on clinical outcomes. METHODS: All SICU patients admitted in 2/2010 were compared with patients admitted in 2/2012. Between the time periods, a protocol eliminating the routine daily CXRs was instituted. RESULTS: In 02/2010 and 02/2012, 107 and 90 patients were admitted to the SICU, respectively, for a total of 1384 patient days. CXRs decreased from 365 (57.1% of patient-days) in 2010 to 299 (40.9% of patient days; p < 0.001) in 2012. A greater proportion of Physician Directed CXRs (PDCXRs) had new findings (80.8%) compared to Automatic Daily CXRs (ADCXRs) (23.5%, p < 0.001). There was no difference in overall or SICU length of stay, ventilator-free days, morbidity or mortality. CONCLUSION: Eliminating ADCXRs decreased the number of CXRs performed, without affecting LOS, mechanical ventilation, morbidity or mortality. Physician-directed ordering of CXRs increased the diagnostic value of the CXR and decreased the number of clinically irrelevant CXRs performed.