The Use and Impact of a Decision Support Tool for Appendicitis Treatment.

OBJECTIVE: Since introducing new and alternative treatment options may increase decisional conflict, we aimed to describe the use of the decision support tool (DST) and its impact on treatment preference and decisional conflict. BACKGROUND: For the treatment of appendicitis, antibiotics are an effective alternative to appendectomy, with both approaches associated with a different set of risks (eg, recurrence vs surgical complications) and benefits (eg, more rapid return to work vs decreased chance of readmission). Patients often have limited knowledge of these treatment options, and DSTs that include video-based educational materials and questions to elicit patient preferences about outcomes may be helpful. Concurrent with the Comparing Outcomes of Drugs and Appendectomy trials, our group developed a DST for appendicitis treatment ( www.appyornot.org ). METHODS: A retrospective cohort including people who self-reported current appendicitis and used the AppyOrNot DST between 2021 and 2023. Treatment preferences before and after the use of the DST, demographic information, and Ottawa Decisional Conflict Scale (DCS) were reported after completing the DST. RESULTS: A total of 8243 people from 66 countries and all 50 U.S. states accessed the DST. Before the DST, 14% had a strong preference for antibiotics and 31% for appendectomy, with 55% undecided. After using the DST, the proportion in the undecided category decreased to 49% ( P < 0.0001). Of those who completed the Ottawa Decisional Conflict Score (DCS; n = 356), 52% reported the lowest level of decisional conflict (<25) after using the DST; 43% had a DCS score of 25 to 50, 5.1% had a DCS score of >50 and 2.5% had and DCS score of >75. CONCLUSIONS: The publicly available DST appyornot.org reduced the proportion that was undecided about which treatment they favored and had a modest influence on those with strong treatment preferences. Decisional conflict was not common after use. The use of this DST is now a component of a nationwide implementation program aimed at improving the way surgeons share information about appendicitis treatment options. If its use can be successfully implemented, this may be a model for improving communication about treatment for patients experiencing emergency health conditions.

Transitional care programs for trauma patients: A scoping review.

BACKGROUND: Transitional care programs establish comprehensive outpatient care after hospitalization. This scoping review aimed to define participant characteristics and structure of transitional care programs for injured adults as well as associated readmission rates, cost of care, and follow-up adherence. METHODS: We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews standard. Information sources searched were Medline, the Cochrane Library, CINAHL, and Scopus Plus with Full Text. Eligibility criteria were systematic reviews, clinical trials, and observational studies of transitional care programs for injured adults in the United States, published in English since 2000. Two independent reviewers screened all full texts. A data charting process extracted patient characteristics, program structure, readmission rates, cost of care, and follow-up adherence for each study. RESULTS: A total of 10 studies described 9 transitional care programs. Most programs (60%) were nurse/social-worker-led post-discharge phone call programs that provided follow-up reminders and inquired regarding patient concerns. The remaining 40% of programs were comprehensive interdisciplinary case-coordination transitional care programs. Readmissions were reduced by 5% and emergency department visits by 13% among participants of both types of programs compared to historic data. Both programs improved follow-up adherence by 75% compared to historic data. CONCLUSION: Transitional care programs targeted at injured patients vary in structure and may reduce overall health care use.

Improving trauma tertiary survey performance and missed injury identification using an education-based quality improvement initiative.

BACKGROUND: Performance of a trauma tertiary survey (TTS) reduces rates of missed injuries, but performance has been inconsistent at trauma centers. The objectives of this study were to assess whether quality improvement (QI) efforts would increase the frequency of TTS documentation and determine if TTS documentation would increase identification of traumatic injuries. Our hypothesis was that QI efforts would improve documentation of the TTS. METHODS: Before-and-after analysis of QI interventions at a level 1 trauma center was performed. The interventions included an electronic template for TTS documentation, customized educational sessions, and emphasis from trauma leadership on TTS performance. The primary outcome was documentation of the TTS. Detection of additional injuries based on tertiary evaluation was a secondary outcome. Associations between outcomes and categorical patient and encounter characteristics were assessed using χ2 tests. RESULTS: Overall, 592 trauma encounters were reviewed (296 preimplementation and 296 postimplementation). Trauma tertiary survey documentation was significantly higher after implementation of the interventions (30.1% preimplementation vs. 85.1% postimplementation, p < 0.001). Preimplementation documentation of the TTS was less likely earlier in the academic year (14.3% first academic quarter vs. 46.5% last academic quarter, p < 0.001), but this temporal pattern was no longer evident postimplementation (88.5% first academic quarter vs. 77.9% last academic quarter, p = 0.126). Patients were more likely to have a missed traumatic injury diagnosed on TTS postimplementation (1.7% in preimplementation vs. 5.7% postimplementation, p = 0.009). CONCLUSION: Documentation of the TTS and missed injury detection rates were significantly increased following implementation of a bundle of QI interventions. The association between time of year and documentation of the TTS was also attenuated, likely through reduction of the resident learning curve. Targeted efforts to improve TTS performance may improve outcomes for trauma patients at teaching hospitals. LEVEL OF EVIDENCE: Care management, Level IV.

Frailty screening and a frailty pathway decrease length of stay, loss of independence, and 30-day readmission rates in frail geriatric trauma and emergency general surgery patients.

BACKGROUND: Frail geriatric trauma and emergency general surgery (TEGS) patients have longer lengths of stay (LOS), more readmissions, and higher rates of postdischarge institutionalization than their nonfrail counterparts. Despite calls to action by national trauma coalitions, there are few published reports of prospective interventions. The objective of this quality improvement project was to first develop a frailty screening program, and, then, if frail, implement a novel frailty pathway to reduce LOS, 30-day readmissions, and loss of independence. METHODS: This was a before-after study of a prospective cohort of all geriatric (≥65-years-old) patients admitted to the TEGS service from October 2016 to October 2017. All patients were screened for frailty for 3 months (preintervention) to obtain baseline outcomes. Subsequently, frail patients were entered into our frailty pathway (postintervention). Nonparametric statistical tests were used to assess significant differences in continuous variables; χ and Fisher exact tests were used for categorical variables, where appropriate. Both process and outcome measures were evaluated. RESULTS: Of 239 geriatric TEGS patients screened, 70 (29.3%) were frail. All TEGS geriatric patients were screened within 24 hours of admission. Following frailty pathway implementation, median LOS for frail patients decreased from 9 to 6 days (p = 0.4), readmissions decreased from 36.4% to 10.2% (p = 0.04), and loss of independence decreased by 40%, (100% vs 60%; p = 0.01). Outcomes for nonfrail geriatric patients did not differ between cohorts. CONCLUSIONS: Screening for frailty followed by implementing a frailty pathway decreased LOS, loss of independence, and 30-day readmission rates for frail geriatric TEGS patients at a single urban academic institution. The pathway required no additional resources; rather, we shifted focus toward frail patients without negatively affecting outcomes in nonfrail geriatric TEGS patients. Implementation of this pathway with larger patient cohorts and in varied settings is needed to confirm a causal relationship between our intervention and improved outcomes. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services.

IMPORTANCE: Time to definitive care following injury is important to the outcomes of trauma patients. Prehospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in prehospital care policies across trauma systems, potentially affecting patient outcomes. OBJECTIVE: To evaluate whether private vehicle prehospital transport confers a survival advantage vs ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle. MAIN OUTCOME AND MEASURE: In-hospital mortality. RESULTS: Of the 2 329 446 records assessed for eligibility, 103 029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR, 0.45; 95% CI, 0.36-0.56) and stab wound (OR, 0.32; 95% CI, 0.20-0.52) subgroups. CONCLUSIONS AND RELEVANCE: Private vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.

Assessment of Surgical and Trauma Capacity in Potosí, Bolivia.

BACKGROUND: Scaling up surgical and trauma care in low- and middle-income countries could prevent nearly 2 million annual deaths. Various survey instruments exist to measure surgical and trauma capacity, including Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT). OBJECTIVE: We sought to evaluate surgical and trauma capacity in the Bolivian department of Potosí using a combined PIPES and INTACT tool, with additional questions to further inform intervention targets. METHODS: In June and July 2014 a combined PIPES and INTACT survey was administered to 20 government facilities in Potosí with a minimum of 1 operating room: 2 third-level, 10 second-level, and 8 first-level facilities. A surgeon, head physician, director, or obstetrician-gynecologist completed the survey. Additional personnel responded to 4 short-answer questions. Survey items were divided into subsections, and PIPES and INTACT indices calculated. Medians were compared via Wilcoxon rank sum and Kruskal-Wallis tests. FINDINGS: Six of 20 facilities were located in the capital city and designated urban. Urban establishments had higher median PIPES (8.5 vs 6.7, P = .11) and INTACT (8.5 vs 6.9, P = .16) indices compared with rural. More than half of surgeons and anesthesiologists worked in urban hospitals. Urban facilities had higher median infrastructure and procedure scores compared with rural. Fifty-three individuals completed short-answer questions. Training was most desired in laparoscopic surgery and trauma management; less than half of establishments reported staff with trauma training. CONCLUSIONS: Surgical and trauma capacity in Potosí was most limited in personnel, infrastructure, and procedures at rural facilities, with greater personnel deficiencies than previously reported. Interventions should focus on increasing the number of surgical and anesthesia personnel in rural areas, with a particular focus on the reported desire for trauma management training. Results have been made available to key stakeholders in Potosí to inform targeted quality improvement interventions.

Surgical and trauma care in low- and middle-income countries: a review of capacity assessments.

BACKGROUND: Surgical and trauma capacity assessments help guide resource allocation and plan interventions to improve care for the injured in low- and middle-income countries (LMICs). To forge expert consensus on conducting these assessments, we undertook a systematic review of studies using five tools: (1) World Health Organization's (WHO) Guidelines for Essential Trauma Care, (2) WHO's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, (3) Personnel, Infrastructure, Procedures, Equipment, and Supplies tool, (4) Harvard Humanitarian Initiative tool, and (5) Emergency and Critical Care tool. MATERIALS AND METHODS: Publications describing utilization of survey instruments to assess surgical or trauma capacity in LMICs were reviewed. Included articles underwent thematic analysis to develop recommendations. A modified Delphi method was used to establish expert consensus. Experts rated recommendations on a Likert-type scale via online survey. Consensus was defined by Cronbach's α ≥ 0.80. Recommendations achieving agreement by ≥80% of experts were included. RESULTS: Two hundred and ninety-eight publications were identified and 41 included, describing evaluation of 1170 facilities across 36 LMICs. Nine recommendations were agreed upon by expert consensus: (1) inclusion of district hospitals, (2) inclusion of highest level public hospital, (3) inclusion of private facilities, (4) facility visits for on-site completion, (5) direct inspections, (6) checking surgical logs, (7) adaptation of survey instrument, (8) repeat assessments, and (9) need for increased collaboration. CONCLUSIONS: Expert recommendations developed in this review describe methodology to be employed when conducting assessments of surgical and trauma capacity in LMICs. Consensus has yet to be achieved for tool selection.

Police transport versus ground EMS: A trauma system-level evaluation of prehospital care policies and their effect on clinical outcomes.

BACKGROUND: Rapid transport to definitive care ("scoop and run") versus field stabilization in trauma remains a topic of debate and has resulted in variability in prehospital policy. We aimed to identify trauma systems frequently using a true "scoop and run" police transport approach and to compare mortality rates between police and ground emergency medical services (EMS) transport. METHODS: Using the National Trauma Databank (NTDB), we identified adult gunshot and stab wound patients presenting to Level 1 or 2 trauma centers from 2010 to 2012. Hospitals were grouped into their respective cities and regional trauma systems. Patients directly transported by police or ground EMS to trauma centers in the 100 most populous US trauma systems were included. Frequency of police transport was evaluated, identifying trauma systems with high utilization. Mortality rates and risk-adjusted odds ratio for mortality for police versus EMS transport were derived. RESULTS: Of 88,564 total patients, 86,097 (97.2%) were transported by EMS and 2,467 (2.8%) by police. Unadjusted mortality was 17.7% for police transport and 11.6% for ground EMS. After risk adjustment, patients transported by police were no more likely to die than those transported by EMS (OR = 1.00, 95% CI: 0.69-1.45). Among all police transports, 87.8% occurred in three locations (Philadelphia, Sacramento, and Detroit). Within these trauma systems, unadjusted mortality was 19.9% for police transport and 13.5% for ground EMS. Risk-adjusted mortality was no different (OR = 1.01, 95% CI: 0.68-1.50). CONCLUSIONS: Using trauma system-level analyses, patients with penetrating injuries in urban trauma systems were found to have similar mortality for police and EMS transport. The majority of prehospital police transport in penetrating trauma occurs in three trauma systems. These cities represent ideal sites for additional system-level evaluation of prehospital transport policies. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Nationwide Assessment of Trends in Choledocholithiasis Management in the United States From 1998 to 2013.

Importance: There are currently 2 widely accepted treatment strategies for patients presenting to the hospital with choledocholithiasis. However, the rate of use for each strategy in the United States has not been evaluated, and their trends over time have not been described. Furthermore, an optimal management strategy for choledocholithiasis has yet to be defined. Objective: To evaluate secular trends in the management of choledocholithiasis in the United States and to compare hospital length of stay between patients with choledocholithiasis treated with endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (ERCP+LC) vs laparoscopic common bile duct exploration with laparoscopic cholecystectomy (LCBDE+LC). Design, Setting, and Participants: In this cohort study, we studied patients with a primary diagnosis of choledocholithiasis that were included in the National Inpatient Sample between 1998 and 2013 from a representative sample of acute care hospitals in the United States. Patients with cholangitis or pancreatitis were excluded. Main Outcomes and Measures: Unadjusted and risk-adjusted median hospital length of stay. Results: Of the 37 207 patients included in our analysis, 36 048 (96.9%) were treated with ERCP+LC and 1159 (3.1%) were treated with LCBDE+LC. The mean (SD) age of patients treated with ERCP+LC was 50.7 (21.1) years and was 51.9 (20.9) years for those treated with LCBDE+LC; 25 788 (69.3%) were female. Analysis of the National Inpatient Sample data indicates that there are an average of 26 158 patients with choledocholithiasis admitted in the United States each year. The overall use of CBDE for patients with choledocholithiasis decreased from 39.8% of admissions in 1998 to 8.5% in 2013 (P < .001). A decrease was also seen for open CBDE (30.6% vs 5.5%; P < .001) and laparoscopic CBDE (9.2% vs 3.0%; P < .001) independently. Rates of management with LCBDE+LC decreased from 5.3% to 1.5% (P < .001), while rates of ERCP+LC increased from 52.8% to 85.7% (P < .001). The unadjusted median hospital length of stay was shorter for patients treated with LCBDE+LC than for those treated with ERCP+LC (3.0 vs 4.0 days; P < .001). After risk-adjustment, the median length of stay remained 0.5 days shorter for patients treated with LCBDE+LC than with ERCP+LC (3.5 vs 4.0 days; P < .001). Conclusions and Relevance: This study highlights the marked decline in the use of both open and laparoscopic CBDE in the United States as well as the benefit to the length of stay LCBDE+LC has over ERCP+LC. Despite a persistent need for CBDE and the potential benefits of LCBDE+LC over ERCP+LC for managing choledocholithiasis, if current trends continue, CBDE may be at risk of disappearing from the surgical armamentarium.

Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee.

BACKGROUND: Injury to the cervical spine (CS) is common after major trauma. The Eastern Association for the Surgery of Trauma first published its Practice Management Guidelines for the evaluation of CS injury in 1998. A subsequent revision was published in 2000. Since that time a large volume of literature has been published. As a result, the Practice Management Guidelines Committee set out to develop updated guidelines for the identification of CS injury. METHODS: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). The search retrieved English language articles regarding the identification of CS injury from 1998 to 2007. The questions posed were: who needs CS imaging; what imaging should be obtained; when should computed tomography, magnetic resonance imaging, or flexion/extension radiographs be used; and how is significant ligamentous injury excluded in the comatose patient? RESULTS: Seventy-eight articles were identified. From this group, 52 articles were selected to construct the guidelines. CONCLUSION: There have been significant changes in practice since the previous CS injury guidelines. Most significantly, computed tomography has supplanted plain radiography as the primary screening modality in those who require imaging. Clinical clearance remains the standard in awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion. Cervical collars should be removed as soon as feasible. Controversy persists regarding CS clearance in the obtunded patient without gross neurologic deficit.

Acute uncomplicated appendicitis: case time of day influences hospital length of stay.

BACKGROUND: Acute appendicitis is the most common surgical infection requiring operative intervention, and length of stay (LOS) typically is short. The timing of emergency appendectomies for acute appendicitis depends on many factors, including anesthesia and operating room availability, staffing, convenience, acuity of illness, and surgeon preference. Efforts to decrease LOS in surgery patients have focused largely on elective operations. We hypothesized that operative time of day would determine when patients were discharged after appendectomy. METHODS: Records of patients undergoing appendectomy between July, 2004 and June, 2005 were reviewed retrospectively. Operative date and time, hospital discharge date and time, operative findings, and postoperative complications were reviewed. Hospital LOS was calculated, and the Student t-test used to calculate significance. RESULTS: A total of 199 patients underwent appendectomy during the study period. Twenty-three "outliers," with complicated appendicitis or significant co-morbidities (LOS 4-21 days, 76% perforated), were excluded. Length of stay in uncomplicated appendicitis was influenced significantly by the time of day the operation was performed. Length of stay was shortest if surgery was performed between 0001 and 0400 h (mean LOS 20 h 40 min). In contrast, LOS was 50% greater if the operation was performed during the day (mean LOS 32 h 24 min for cases performed between 0700 and 1500 h). No patients were discharged between 2100 and 0700 h. Surgical site infections occurred in fewer than 5% of patients, and white blood cell count did not predict LOS. CONCLUSIONS: Operative time of day was a surprisingly important determinant of hospital LOS. Efforts to minimize LOS and optimize resource utilization should balance operating room availability, surgeon preferences, shift-dependent costs, nursing policies, and hospital systems.

Even ephemeral endotoxin exposure establishes endotoxin tolerance.

BACKGROUND: Macrophages previously exposed to bacterial lipopolysaccharide (LPS) develop a "tolerant" response with decreased extracellular signal-regulated kinase (ERK) activation in response to LPS rechallenge. Prior work using 21-hour LPS pretreatment showed that 100 ng/mL of LPS-inhibited tumor necrosis factor (TNF) release, whereas very low dose LPS (1 ng/mL) augmented TNF release. Endotoxin tolerance was also associated with alterations in activation of ERK and p38 kinase when cells were restimulated with LPS. We hypothesized that the interval after pretreatment, before LPS rechallenge, modulates macrophage response to LPS. METHODS: RAW 264.7 macrophage-like cells were pretreated for 4 hours in 0 ng/mL (none), 1 ng/mL, 10 ng/mL, or 100 ng/mL of Escherichia coli 0111:B4 LPS. After 4 hour pretreatment, medium was discarded. Cells were rechallenged immediately or 21 hours later with 0 ng/mL, 1 ng/mL, 10 ng/mL, or 100 ng/mL LPS. Supernatant TNF secretion at 3 hour was measured using enzyme-linked immunosorbent assay. Active phospho-ERK was examined by Western blot using specific monoclonal antibodies 30 minutes after LPS rechallenge. Statistical analysis by chi and student's t test. RESULTS: When macrophages were pretreated for 4 hour and incubated overnight (21-hour interval) 1 ng/mL of LPS augmented and 100 ng/mL inhibited TNF release with LPS rechallenge. In contrast, with immediate rechallenge, we saw additive effects with 100 ng/mL LPS and no difference with 1 ng/mL LPS versus no pretreatment. Western blot revealed that even with immediate rechallenge "tolerant" macrophages were unable to activate ERK. CONCLUSIONS: A short LPS exposure is sufficient to induce alterations in ERK activation in macrophages, but longer intervals are required to express altered cytokine release. In conjunction with other recent findings, these results suggest that both pretreatment dose and interval modulate macrophage responsiveness to LPS rechallenge.

Spinal fusion after revision surgery for pseudarthrosis in adult scoliosis.

STUDY DESIGN: A retrospective study. OBJECTIVE.: To decipher the incidence, characteristics, functional outcomes, and complications of spinal fusion after revision surgery for recurrent pseudarthrosis in adult patients with scoliosis. SUMMARY OF BACKGROUND DATA: While the rate of spinal fusion has been examined in the past, there have been no studies that have examined the incidence, characteristics, functional outcomes, and complications of spinal fusion after pseudarthrosis repair in adult patients with scoliosis. MATERIALS AND METHODS: A total of 132 patients with failed spinal fusion surgery for adult scoliosis and painful pseudarthroses were studied. Each patient had an average of 3.7 spinal surgeries before undergoing revision at our institution. In addition to clinical assessment and imaging studies, pseudarthrosis was confirmed intraoperatively in all patients. All patients underwent reinstrumentation and fusion along with adjunctive procedures as needed. Spinal fusion was assessed clinically and radiographically after surgery for a minimum of 40 months. Subjective functional outcomes and complications associated with the procedures were also studied. RESULTS: The overall incidence of spinal fusion after revision surgery for pseudarthrosis in adult scoliosis was 90%. There was a propensity for pseudarthrosis to recur at the thoracolumbar and lumbosacral junctions. Increasing thoracolumbar kyphosis and loss of sagittal balance were significant risk factors for recurrent pseudarthrosis after revision surgery (mean thoracolumbar kyphosis of 23 degrees and mean sagittal balance of 7.9 cm anteriorly associated with persistent pseudarthrosis). Additionally, patients with multiple preoperative sites of pseudarthroses were at a higher risk for continued pseudarthrosis after surgery. Cigarette smoking, age, and surgical approach did not have any significant correlation with pseudarthrosis. Seventy-two percent of patients were satisfied with the outcome and 80% would have chosen to undergo surgery again if necessary. Thirty-three percent of patients who underwent surgery had some complication related to the surgery. CONCLUSION: Revision surgery for pseudarthrosis repair in adult scoliosis is most successful at attaining fusion when thoracolumbar and overall sagittal alignment are restored as much as possible.

Open surgical treatment of osteoporotic fractures and deformity of the spine.

Osteoporotic fractures of the spine are an increasing major international health concern. The number of osteoporotic spinal fractures both in the United States and worldwide continue to increase. Early recognition is important in successful treatment.

Prone positioning does not affect cannula function during extracorporeal membrane oxygenation or continuous renal replacement therapy.

INTRODUCTION: Prone positioning in respiratory failure has been shown to be a useful adjunct in the treatment of severe hypoxia. However, the prone position can result in dislodgment or malfunction of tubes and cannulae. Certain patients receiving extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT) may also benefit from positional therapy. The impact of cannula-related complications in these patients is potentially disastrous. The safety and efficacy of prone positioning of these patients has not been previously reported. MATERIALS AND METHODS: A retrospective chart review evaluated ECMO or CRRT cannula location, and displacement or malfunction during positional change or while prone. The study was set in a General Surgery and Trauma Intensive Care Unit. The subjects were all patients at our institution who simultaneously underwent ECMO or CRRT and prone positioning from July 1996 to July 2001. There were no interventions. RESULTS: Ten patients underwent ECMO and 42 patients underwent CRRT during the study period. Seven patients underwent simultaneous prone positioning and either ECMO (4/10) or CRRT (4/42). A total of 68 turning events (prone to supine or supine to prone) were recorded, with each patient averaging 9.7 (range, 4-16) turning episodes. Turning was performed with sheets and extra nursing personnel; no special mechanical assist devices were used. No patients experienced inadvertent cannula removal during turning. Two patients had poor flow through their cannulae. In one patient, this occurred in the supine position and required repositioning of the cannula. In the second patient, cannulae were changed twice and flow was poor in both the supine and the prone positions. All ECMO and CRRT patients received venous cannulae. Cannula location (seven internal jugular and 11 femoral) did not the affect risk of malfunction. DISCUSSION AND CONCLUSIONS: Patients with venous cannulae for ECMO or CRRT can be safely placed in the prone position. Flow rates are maintained in this position. Potential cannula complications of ECMO and CRRT are not a contraindication to prone positioning in severely ill patients.

Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms.

BACKGROUND: Patients at risk for thoracolumbar junction (TLJ) and lumbar spine (LS) injury after blunt trauma are classically evaluated using conventional radiographs. Frequently, these patients also undergo abdominal and pelvic computed tomographic (CT) scanning to exclude the presence of associated intra-abdominal injuries. Standard abdominal and pelvic CT scan usually includes an anteroposterior (AP) scout film (scanogram) obtained before the cross-sectional imaging. The objective of this study was to determine whether a lateral CT scanogram and axial CT views would provide adequate imaging to allow for evaluation of the TLJ and LS and therefore eliminate the need for conventional screening computed lumbar spine radiographs (CLSRs). METHODS: Patients who sustained blunt injury and required both CLSRs as well as abdominal and pelvic CT scans were prospectively identified. The study protocol (CT + S) added lateral CT scanograms to all helical abdominal and pelvic CT scan studies. The AP and lateral CT scanograms were included with the axial images, and these views were reviewed together during final radiographic interpretation and diagnosis. The results of CT + S were compared with readings of the CLSRs (AP and lateral) in a blinded fashion by a trauma radiologist. RESULTS: Lateral scanograms were generated for 71 patients. All scanograms were technically adequate, with image quality equal or superior to computed plain radiographs. Ten patients were found to have 20 fractures, 19 acute and 1 chronic. All abnormalities identified by plain radiographs were seen using CT + S (sensitivity, 100%; specificity, 100%). Eight transverse process and two spinous process fractures not seen on CLSRs were identified using CT + S. CONCLUSION: Our CT + S protocol (axial CT images plus AP and lateral scanograms) outperformed screening CLSRs in the detection of fractures of the lower spine (TLJ + LS) after blunt trauma. In addition, scanogram imaging is less dependent on body habitus and adds no additional cost or time to abdominal and pelvic CT scanning. Further study is required to determine whether CT + S can routinely replace conventional radiographs of the lower spine after blunt trauma.

Hepatic angiography in patients undergoing damage control laparotomy.

OBJECTIVE: Patients undergoing damage control (DC) laparotomy require intensive and aggressive resuscitation, and may require additional maneuvers to control parenchymal bleeding. Those patients suffering significant liver injury are at high risk for arterial bleeding deep within the liver, and many require hepatic angiography in addition to hepatic packing. We reviewed our experience with hepatic angiography, and sought to determine its safety in the DC population of penetrating and blunt trauma patients. METHODS: A 3-year (June 1997-May 2000) retrospective review generated 37 DC patients. Patients sustaining hepatic trauma constituted the study group. Patients undergoing angiography in addition to DC laparotomy were compared with the group of patients not undergoing angiography. Data regarding mechanism of injury, patient demographics, extent of hepatic injury, and presence of associated injuries were collected. Physiologic parameters including vital signs at admission, lowest pH and base excess in the operating room, and lactate levels in the intensive care unit, as well as volumes of fluid resuscitation throughout all phases of DC were examined. Complications including death, intra-abdominal processes, acute respiratory distress syndrome and/or multiple organ dysfunction syndrome, and acute renal failure were reviewed. RESULTS: Nineteen patients (51%) had hepatic trauma and underwent perihepatic packing as a part of DC laparotomy. Eleven had sustained penetrating injury and 8 had blunt injury. There was 1 American Association for the Surgery of Trauma grade I, 5 grade II, 3 grade III, and 10 grade IV injuries. Nine patients in the study population underwent angiography, and eight of these were hepatic artery angiograms. One hepatic angiogram was obtained before operation and seven were obtained in the immediate postoperative period. Six underwent embolization of bleeding hepatic vessels, for a therapeutic liver angiography rate of 75%. There was no statistical difference in physiologic parameters or fluid requirements between the patients who underwent angiography and those who did not. There were no mishaps or complications from angiography or while in the angiography suite. CONCLUSION: Hepatic angiography is a safe adjunct to the principles of damage control. It has a high therapeutic ratio, with no significant untoward effect in this small study population.