Outcomes after emergency general surgery and trauma care in incarcerated individuals: An EAST multicenter study.

BACKGROUND: The US incarcerates more individuals than any other country. Prisoners are the only population guaranteed health care by the US constitution, but little is known about their surgical needs. This multicenter study aimed to describe the acute care surgery (ACS) needs of incarcerated individuals. METHODS: Twelve centers prospectively identified incarcerated patients evaluated in their emergency department by the ACS service. Centers collected diagnosis, treatment, and complications from chart review. Patients were classified as either emergency general surgery (EGS) patients or trauma patients and their characteristics and outcomes were investigated. Poisson regression accounting for clustering by center was used to calculate the relative risk (RR) of readmission, representation within 90 days, and failure to follow-up as an outpatient within 90 days for each cohort. RESULTS: More than 12 months, ACS services evaluated 943 patients, 726 (80.3%) from jail, 156 (17.3%) from prison, and 22 (2.4%) from other facilities. Most were men (89.7%) with a median age of 35 years (interquartile range, 27-47). Trauma patients comprised 54.4% (n = 513) of the cohort. Admission rates were similar for trauma (61.5%) and EGS patients (60.2%). Head injuries and facial fractures were the most common injuries, while infections were the most common EGS diagnosis. Self-harm resulted in 102 trauma evaluations (19.9%). Self-inflicted injuries were associated with increased risk of readmission (RR, 4.3; 95% confidence interval, 3.02-6.13) and reevaluation within 90 days (RR, 4.96; 95% confidence interval, 3.07-8.01). CONCLUSION: Incarcerated patients who present with a range of trauma and EGS conditions frequently require admission, and follow-up after hospitalization was low at the treating center. Poor follow-up coupled with high rates of assault, self-harm, mental health, and substance use disorders highlight the vulnerability of this population. Hospital and correctional facility interventions are needed to decrease self-inflicted injuries and assaults while incarcerated. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry).

PURPOSE: Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. RESULTS: In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). CONCLUSION: Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL. LEVEL OF EVIDENCE: 2B.

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial.

PURPOSE: To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression. RESULTS: A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively. CONCLUSIONS: Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial).

BACKGROUND: Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population. METHODS: We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head. RESULTS: Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001). CONCLUSION: Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Lumbar and sacral brucellosis due to queso fresco ingestion.

Brucellosis is rare in the USA, with 100-200 cases reported annually. In this case we illustrate the complex management of spinal brucellosis. A 22-year-old male presented with 3 months of low back pain. Imaging revealed osteomyelitis/diskitis of L5/S1 and abscesses involving the pre-vertebral, epidural and pelvic recesses. Initial biopsies were inconclusive, but the patient later endorsed eating unpasteurized cheese (queso fresco) from Mexico; therefore, Brucella serology was sent and was positive. Despite aggressive antibiotic therapy there was disease progression. The patient underwent debridement of the involved vertebrae and drainage. Multiple cultures failed to grow the organisms, but Brucella polymerase chain reaction was positive. A month later he underwent a second vertebral debridement as well as placement of tobramycin impregnated beads in the vertebral space. He has since recovered. Surgery should be considered if there is a poor response to medical management and patients may need repeated debridement.

Effectiveness of a 1-Hour Extended Focused Assessment With Sonography in Trauma Session in the Medical Student Surgery Clerkship.

OBJECTIVE: To demonstrate the effectiveness of incorporating 1 hour of ultrasound training on the extended focused assessment with sonography in trauma (eFAST) into the year-3 medical student surgical clerkship. DESIGN: A prospective cohort study where participants served as self-controls. One hour of instruction in the eFAST examination, along with 3 required observed examinations, was incorporated into the year-3 surgery clerkship. Effectiveness of the training was evaluated by a preliminary and posttraining assessment. An online survey was used assessing comfort based on a 5-point Likert scale. An online quiz was used assessing knowledge, and a 2-part objective structured clinical examination (OSCE) was used assessing skill and speed. Participants also logged 3 eFAST examinations during the 10-week clerkship where they reported their comfort in performing and interpreting the eFAST on a 5-point Likert scale. Postassessment was held during the last week of the clerkship and included the same online quiz, survey, and 2-part OSCE. SETTING: The study was performed at Loma Linda University and affiliated hospitals where surgical clerkship students rotate. PARTICIPANTS: A total of 148 year-3 medical students completed the study. RESULTS: All testing modalities showed improvement. The mean average of the OSCE improved from 46% ± 27% to 81% ± 18%. The percentage of participants able to perform the examination in less than 6 minutes increased from 18% ± 27% to 84% ± 36%. Participants' comfort level in recognizing eFAST pathology increased from a mean of 2.40 ± 0.94 to 3.55 ± 0.87 out of 5. Comfort in performing the eFAST examination improved from 2.81 ± 0.79 to 3.77 ± 0.68. Comfort in interpreting the eFAST examination improved from 2.88 ± 0.87 to 3.65 ± 0.72. CONCLUSIONS: This study demonstrates that incorporating 1 hour of eFAST training into the general surgery clerkship is feasible and may lead to improved competency in performing and interpreting the eFAST examination.