Acute kidney injury in the acute care surgery patient: What you need to know.

ABSTRACT: Acute kidney injury is associated with poor outcomes in the trauma and emergency general surgery population, and recent consensus definitions have allowed for significant advances in defining the burden of disease. The current definitions rely on overall functional measures (i.e., serum creatinine and urine output), which can be confounded by a variety of clinical factors. Biomarkers are increasingly being investigated as more direct diagnostic assays for the diagnosis of acute kidney injury and may allow earlier detection and more timely therapeutic intervention. Etiologies fall into two general categories: disorders of renal perfusion and exposure to nephrotoxic agents. Therapy is largely supportive, and prevention offers the best chance to decrease clinical impact.

A decade of firearm injuries: Have we improved?

BACKGROUND: Firearm injuries are a growing public health issue, with marked increases coinciding with the coronavirus disease 2019 (COVID-19) pandemic. This study evaluates temporal trends over the past decade, hypothesizing that despite a growing number of injuries, mortality would be unaffected. In addition, the study characterizes the types of centers affected disproportionately by the reported firearm injury surge in 2020. METHODS: Patients 18 years and older with firearm injuries from 2011 to 2020 were identified retrospectively using the National Trauma Data Bank (NTDB®). Trauma centers not operating for the entirety of the study period were excluded to allow for temporal comparisons. Joinpoint regression and risk-standardized mortality ratios (SMR) were used to evaluate injury counts and adjusted mortality over time. Subgroup analysis was performed to describe centers with the largest increases in firearm injuries in 2020. RESULTS: A total of 238,674 patients, treated at 420 unique trauma centers, met inclusion criteria. Firearm injuries increased by 31.1% in 2020, compared to an annual percent change of 2.4% from 2011 to 2019 ( p = 0.01). Subset analysis of centers with the largest changes in firearm injuries in 2020 found that they were more often Level I centers, with higher historic trauma volumes and percentages of firearm injuries ( p < 0.001). Unadjusted mortality decreased by 0.9% from 2011 to 2020, but after controlling for demographics, injury characteristics and physiology, there was no difference in adjusted mortality over the same time period. However, among patients with injury severity scores ≥25, adjusted mortality improved compared with 2011 (SMR of 0.950 in 2020; 95% confidence interval, 0.916-0.986). CONCLUSION: Firearm injuries pose an increasing burden to trauma systems, with Level I and high-volume centers seeing the largest growth in 2020. Despite increasing numbers of firearm injuries, mortality has remained unchanged over the past decade. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Self-selection vs Randomized Assignment of Treatment for Appendicitis.

Importance: For adults with appendicitis, several randomized clinical trials have demonstrated that antibiotics are an effective alternative to appendectomy. However, it remains unknown how the characteristics of patients in such trials compare with those of patients who select their treatment and whether outcomes differ. Objective: To compare participants in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial (RCT) with a parallel cohort study of participants who declined randomization and self-selected treatment. Design, Setting, and Participants: The CODA trial was conducted in 25 US medical centers. Participants were enrolled between May 3, 2016, and February 5, 2020; all participants were eligible for at least 1 year of follow-up, with all follow-up ending in 2021. The randomized cohort included 1094 adults with appendicitis; the self-selection cohort included patients who declined participation in the randomized group, of whom 253 selected appendectomy and 257 selected antibiotics. In this secondary analysis, characteristics and outcomes in both self-selection and randomized cohorts are described with an exploratory analysis of cohort status and receipt of appendectomy. Interventions: Appendectomy vs antibiotics. Main Outcomes and Measures: Characteristics among participants randomized to either appendectomy or antibiotics were compared with those of participants who selected their own treatment. Results: Clinical characteristics were similar across the self-selection cohort (510 patients; mean age, 35.8 years [95% CI, 34.5-37.1]; 218 female [43%; 95% CI, 39%-47%]) and the randomized group (1094 patients; mean age, 38.2 years [95% CI, 37.4-39.0]; 386 female [35%; 95% CI, 33%-38%]). Compared with the randomized group, those in the self-selection cohort were less often Spanish speaking (n = 99 [19%; 95% CI, 16%-23%] vs n = 336 [31%; 95% CI, 28%-34%]), reported more formal education (some college or more, n = 355 [72%; 95% CI, 68%-76%] vs n = 674 [63%; 95% CI, 60%-65%]), and more often had commercial insurance (n = 259 [53%; 95% CI, 48%-57%] vs n = 486 [45%; 95% CI, 42%-48%]). Most outcomes were similar between the self-selection and randomized cohorts. The number of patients undergoing appendectomy by 30 days was 38 (15.3%; 95% CI, 10.7%-19.7%) among those selecting antibiotics and 155 (19.2%; 95% CI, 15.9%-22.5%) in those who were randomized to antibiotics (difference, 3.9%; 95% CI, -1.7% to 9.5%). Differences in the rate of appendectomy were primarily observed in the non-appendicolith subgroup. Conclusions and Relevance: This secondary analysis of the CODA RCT found substantially similar outcomes across the randomized and self-selection cohorts, suggesting that the randomized trial results are generalizable to the community at large. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Rotational thromboelastometry in patients with acute respiratory distress syndrome owing to coronavirus disease 2019: Is there a viscoelastic fingerprint and a role for predicting thrombosis?

OBJECTIVES: We evaluated rotational thromboelastometry tracings in 44 critically ill coronavirus disease 2019 patients, to determine whether there is a viscoelastic fingerprint and to test the hypothesis that the diagnosis and prediction of venous thromboembolism would be enhanced by the addition of rotational thromboelastometry testing. RESULTS: Rotational thromboelastometry values reflected an increase in clot strength for the EXTEM, INTEM, and FIBTEM assays beyond the reference range. No hyperfibrinolysis was noted. Fibrinolysis shutdown was present but did not correlate with thrombosis; 32% (14/44) of patients experienced a thrombotic episode. For every 1 mm increase of FIBTEM maximum clot formation, the odds of developing thrombosis increased 20% (95% confidence interval, 0-40%, P = .043), whereas for every 1,000 ng/mL increase in D-dimer, the odds of thrombosis increased by 70% (95% confidence interval, 20%-150%, P = .004), after adjustment for age and sex (AUC 0.96, 95% confidence interval, 0.90-1.00). There was a slight but significant improvement in model performance after adding FIBTEM maximum clot formation and EXTEM clot formation time to D-dimer in a multivariable model (P = .04). CONCLUSIONS: D-dimer concentrations were more predictive of thrombosis in our patient population than any other parameter. Rotational thromboelastometry confirmed the hypercoagulable state of coronavirus disease 2019 intensive care unit patients. FIBTEM maximum clot formation and EXTEM clot formation time increased the predictability for thrombosis compared with only using D-dimer. Rotational thromboelastometry analysis is most useful in augmenting the information provided by the D-dimer concentration for venous thromboembolism risk assessment when the D-dimer concentration is between 1,625 and 6,900 ng/dL, but the enhancement is modest. Fibrinolysis shutdown did not correlate with thrombosis.

Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis.

IMPORTANCE: Use of antibiotics for the treatment of appendicitis is safe and has been found to be noninferior to appendectomy based on self-reported health status at 30 days. Identifying patient characteristics associated with a greater likelihood of appendectomy within 30 days in those who initiate antibiotics could support more individualized decision-making. OBJECTIVE: To assess patient factors associated with undergoing appendectomy within 30 days of initiating antibiotics for appendicitis. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial, characteristics among patients who initiated antibiotics were compared between those who did and did not undergo appendectomy within 30 days. The study was conducted at 25 US medical centers; participants were enrolled between May 3, 2016, and February 5, 2020. A total of 1552 participants with acute appendicitis were randomized to antibiotics (776 participants) or appendectomy (776 participants). Data were analyzed from September 2020 to July 2021. EXPOSURES: Appendectomy vs antibiotics. MAIN OUTCOMES AND MEASURES: Conditional logistic regression models were fit to estimate associations between specific patient factors and the odds of undergoing appendectomy within 30 days after initiating antibiotics. A sensitivity analysis was performed excluding participants who underwent appendectomy within 30 days for nonclinical reasons. RESULTS: Of 776 participants initiating antibiotics (mean [SD] age, 38.3 [13.4] years; 286 [37%] women and 490 [63%] men), 735 participants had 30-day outcomes, including 154 participants (21%) who underwent appendectomy within 30 days. After adjustment for other factors, female sex (odds ratio [OR], 1.53; 95% CI, 1.01-2.31), radiographic finding of wider appendiceal diameter (OR per 1-mm increase, 1.09; 95% CI, 1.00-1.18), and presence of appendicolith (OR, 1.99; 95% CI, 1.28-3.10) were associated with increased odds of undergoing appendectomy within 30 days. Characteristics that are often associated with increased risk of complications (eg, advanced age, comorbid conditions) and those clinicians often use to describe appendicitis severity (eg, fever: OR, 1.28; 95% CI, 0.82-1.98) were not associated with odds of 30-day appendectomy. The sensitivity analysis limited to appendectomies performed for clinical reasons provided similar results regarding appendicolith (adjusted OR, 2.41; 95% CI, 1.49-3.91). CONCLUSIONS AND RELEVANCE: This cohort study found that presence of an appendicolith was associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics. Clinical characteristics often used to describe severity of appendicitis were not associated with odds of 30-day appendectomy. This information may help guide more individualized decision-making for people with appendicitis.

General Surgery Residents' Perception of Feedback: We Can Do Better.

BACKGROUND: Feedback (FB) regarding perioperative care is essential in general surgery residents' (GSRs) training. We hypothesized that FB would be distributed unevenly across preoperative (PrO), intraoperative (IO), and postoperative (PO) continuum of the perioperative period. We aimed to compare results between university- and community-hospital settings planning to institute structured, formalized FB in a large health care system operating multiple surgery residency programs in departments that are linked strategically. METHODS: Quantitative, cross-sectional, Likert scale anonymous surveys were distributed to all GSRs (categorical and preliminary; university: community 1:2). Twenty-five questions considered frequency and perceived quality of FB in PrO, IO, and PO settings. Data were tabulated using REDCap and analyzed in Microsoft Excel using the Mann-Whitney U test, with α = 0.05. Comparisons were made between university- and community-hospital settings, between junior (Post-Graduate Year (PGY) 1-3) and senior (PGY 4-5) GSRs, and by gender. RESULTS: Among 115 GSRs surveyed, 83 (72%) responded. Whereas 93% reported receiving some FB within the past year, 46% reported receiving FB ≤ 20% of the time. A majority (58%) found FB to be helpful ≥ 80% of the time. Among GSRs, 77%, 24%, and 64% reported receiving PrO, IO, or PO FB ≤ 20% of the time, respectively, but 52% also believed that FB was lacking in all 3 areas. Most GSRs wanted designated time for PrO planning FB (82%) and PO FB (87%), respectively. Thirty-six percent of GSRs reported that senior/chief (i.e., PGY-4/PGY-5 GSRs) took them through cases ≥40% of the time; notably,78% reported that FB from senior/chief GSRs was equally or more valuable than FB from attending surgeons. A majority (78%) reported that attending surgeons stated explicitly when they were providing FB only ≤20% of the time. GSRs at the community hospital campuses reported receiving a higher likelihood of "any" FB, IO FB, and PO FB (p < 0.05). Most GSRs surveyed preferred a structured format and designated times for debriefing and evaluation of performance. Subanalyses of gender and GSR level of training showed no differences. CONCLUSIONS: FB during GSR training varies across the perioperative continuum of care. Community programs seem to do better than University Programs. More work need to be done to elucidate why differences exist between the frequency of FB at University and Community programs. Further, data show particularly low FB outside of the operating room. Ideally, according to respondents, FB would be provided in a structured format and at designated times for debriefing and evaluation of performance, which poses a challenge considering the temporal dynamism of general surgery services.

World trauma education: hemorrhage control training for healthcare providers in India.

BACKGROUND: Hemorrhage remains a major cause of death around the world. Eighty percent of trauma patients in India do not receive medical care within the first hour. The etiology of these poor outcomes is multifactorial. We describe findings from the first Stop the Bleed (StB) course recently offered to a group of medical providers in southern India. METHODS: A cross-sectional survey of 101 participants who attended StB trainings in India was performed. Pre-training and post-training questionnaires were collected from each participant. In total, 88 healthcare providers' responses were analyzed. Three bleeding control skills were presented: wound compression, wound packing, and tourniquet application. RESULTS: Among participants, only 23.9% had received prior bleeding control training. Participants who reported feeling 'extremely confident' responding to an emergency medical situation rose from 68.2% prior to StB training to 94.3% post-training. Regarding hemorrhage control abilities, 37.5% felt extremely confident before the training, compared with 95.5% after the training. For wound packing and tourniquet application, 44.3% and 53.4%, respectively, felt extremely confident pre-training, followed by 97.7% for both skills post-training. Importantly, 90.9% of StB trainees felt comfortable teaching newly acquired hemorrhage control skills. A significant majority of participants said that confidence in their wound packing and tourniquet skills would improve with more realistic mannequins. CONCLUSION: To our knowledge, this is the first StB training in India. Disparities in access to care, long transport times, and insufficient numbers of prehospital personnel contribute to its significant trauma burden. Dissemination of these critical life-saving skills into this region and the resulting civilian interventions will increase the number of trauma patients who survive long enough to reach a trauma center. Additionally, considerations should be given to translating the course into local languages to increase program reach. LEVEL OF EVIDENCE: Level IV.

Association between intentional injury and long-term survival after trauma.

OBJECTIVE: To determine the risk-adjusted mortality of intentionally injured patients within 7 to 9 years postinjury, compared with unintentionally injured patients. BACKGROUND: Violent injury contributes significantly to trauma mortality in the United States. Homicide is the second leading killer of American youth, aged 15 to 24 years. Long-term survival among intentionally injured patients has not been well studied. It is also unknown whether intentionally injured patients have worse long-term survival compared with unintentionally or accidentally injured patients with equivalent injuries. METHODS: Adult trauma patients admitted for 24 hours or more and discharged alive from the Johns Hopkins Hospital from January 1, 1998, to December 31, 2000, were included. The primary outcome was mortality within 7 to 9 years postinjury. Long-term patient survival was determined using the National Death Index. The association between injury intentionality and mortality was investigated using a Cox proportional hazard regression model, adjusted for confounders such as injury severity and patient race, socioeconomic status, and comorbid conditions. Overall differences in survival between those with intentional versus unintentional injury were also determined by comparing adjusted Kaplan-Meier survival curves. RESULTS: A total of 2062 patients met inclusion criteria. Of these, 56.4% were intentionally injured and 43.6% were unintentionally injured. Compared with unintentionally injured patients, intentionally injured patients were younger and more often male and from a zip code with low median household income. Approximately 15% of all patients had died within 7 to 9 years of follow-up. Older age and presence of comorbidities were associated with this outcome; however, intentional injury was not found to be significantly associated with long-term mortality rates. There was also no significant difference in survival curves between groups; intentionally injured patients were much more likely to die of a subsequent injury, whereas those with unintentional injury commonly died of noninjury causes. CONCLUSIONS: There was no significant difference in mortality between intentionally injured and unintentionally injured patients within 7 to 9 years postinjury. These results confirm the long-term effectiveness of lifesaving trauma care for those with intentional injury. However, given that patients with intentional injuries were more likely to suffer a subsequent violent death, interventions focused on breaking the cycle of violence are needed.

Regional variations in cost of trauma care in the United States: who is paying more?

BACKGROUND: The study of regional variations in costs of care has been used to identify areas of savings for several diseases and conditions. This study investigates similar potential regional differences in the cost of adult trauma care using an all-payer, nationally representative sample. METHODS: Trauma patients aged 18 to 64 years in the 2006-2008 Nationwide Inpatient Sample were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes. Those with isolated diagnoses for five index conditions (ICs): blunt splenic injury, liver injury, tibia fracture, moderate traumatic brain injury, and pneumothorax/hemothorax were selected. Cost was estimated from charges using a cost-to-charge ratio. Generalized linear modeling was used to compare the mean cost for treating these ICs between US regions (Northeast, South, Midwest, and West), adjusting for hospital factors (size, teaching status, and location), patient demographics, injury severity, length of stay, Charlson comorbidity index, local wage index, and payer. Relative mean cost (RC) was calculated using Northeast as the reference, and sampling weights were applied to obtain regional estimates. Differences in adjusted mortality between regions were also assessed. RESULTS: Adjusted relative costs were estimated for 62,678 patients (South: 28,536; West: 12,975; Midwest: 11,450; and Northeast: 9,717). Mean costs for liver injury were 22%higher in the Midwest compared with the Northeast (RC: 1.22; 95%confidence interval [CI]: 1.10-1.35). Similarly higher costs were seen with other regions and ICs (RC for blunt splenic injury in the South: 1.18; 95% CI: 1.07-1.31; RC for pneumothorax/hemothorax in the West: 1.31; 95% CI: 1.22-1.41). No differences in adjusted mortality by region were noted overall. CONCLUSION: Even after controlling for factors known to influence medical care cost, as well as controlling for geographic differences in pricing, significant regional differences exist in the cost of trauma care. Exploring these variations may assist in identifying potential areas for cost savings.

Should the IDC-9 Trauma Mortality Prediction Model become the new paradigm for benchmarking trauma outcomes?

BACKGROUND: Optimum quantification of injury severity remains an imprecise science with a need for improvement. The accuracy of the criterion standard Injury Severity Score (ISS) worsens as a patient's injury severity increases, especially among patients with penetrating trauma. The objective of this study was to comprehensively compare the mortality prediction ability of three anatomic injury severity indices: the ISS, the New ISS (NISS), and the DRG International Classification of Diseases-9th Rev.-Trauma Mortality Prediction Model (TMPM-ICD-9), a recently developed contemporary injury assessment model. METHODS: Retrospective analysis of patients in the National Trauma Data Bank from 2007 to 2008. The TMPM-ICD-9 values were computed and compared with the ISS and NISS for each patient using in-hospital mortality after trauma as the outcome measure. Discrimination and calibration were compared using the area under the receiver operator characteristic curve. Subgroup analysis was performed to compare each score across varying ranges of injury severity and across different types of injury. RESULTS: A total of 533,898 patients were identified with a crude mortality rate of 4.7%. The ISS and NISS performed equally in the groups with minor (ISS, 1-8) and moderate (ISS, 9-15) injuries, regardless of the injury type. However, in the populations with severe (ISS, 16-24) and very severe (ISS, ≥ 25) injuries for all injury types, the NISS predicted mortality better than the ISS did. The TMPM-ICD-9 outperformed both the NISS and ISS almost consistently. CONCLUSION: The NISS and TMPM-ICD-9 are both superior predictors of mortality as compared with the ISS. The immediate adoption of NISS for evaluating trauma outcomes using trauma registry data is recommended. The TMPM-ICD-9 may be an even better measure of human injury, and its use in administrative or nonregistry data is suggested. Further research on its attributes is recommended because it has the potential to become the basis for benchmarking trauma outcomes. LEVEL OF EVIDENCE: Prognostic study, level III.

Mechanism of injury predicts case fatality and functional outcomes in pediatric trauma patients: the case for its use in trauma outcomes studies.

BACKGROUND/PURPOSE: The mechanism of injury (MOI) may serve as a useful adjunct to injury scoring systems in pediatric trauma outcomes research. The objective is to determine the independent effect of MOI on case fatality and functional outcomes in pediatric trauma patients. METHODS: Retrospective review of pediatric patients ages 2 to 18 years in the National Trauma Data Bank from 2002 through 2006 was done. Mechanism of injury was classified by the International Classification of Diseases, Ninth Revision, E codes. The main outcome measures were mortality, discharge disposition (home vs rehabilitation setting), and functional impairment at hospital discharge. Multiple logistic regression was used to adjust for injury severity (using the Injury Severity Score and the presence of shock upon admission in the emergency department), age, sex, and severe head or extremity injury. RESULTS: Thirty-five thousand ninety-seven pediatric patients in the National Trauma Data Bank met inclusion criteria. Each MOI had differences in the adjusted odds of death or functional disabilities as compared with the reference group (fall). The MOI with the greatest risk of death was gunshot wounds (odds ratio [OR], 3.52; 95% confidence interval [CI], 2.23-5.54 95). Pediatric pedestrians struck by a motor vehicle have the highest risk of locomotion (OR, 3.30; 95% CI, 2.89-3.77) and expression (OR, 1.65; 95% CI, 1.22-2.23) disabilities. CONCLUSION: Mechanism of injury is a significant predictor of clinical and functional outcomes at discharge for equivalently injured patients. These findings have implications for injury prevention, staging, and prognosis of traumatic injury and posttreatment planning.

Global surgical package reimbursement and the acute care surgeon: a threat to optimal care.

BACKGROUND: Emergency surgery patients risk greater mortality and morbidity than elective patients undergoing the same procedure. However, the differential effort required for the care of emergency surgical patients is poorly defined. This study sought to characterize costs and outcomes of elective versus emergent right hemicolectomy. METHODS: 2006 Nationwide Inpatient Sample data were used to compare mortality, total charges, and length of stay (LOS) in patients undergoing emergency versus elective right hemicolectomy (International Classification of Diseases-9th procedure code 45.73). Mann-Whitney tests examined total costs and LOS; multivariable regression modeled inhospital mortality controlling for age, gender, insurance status, and comorbidities. RESULTS: Among 8,074,825 inpatient admissions, 7,767 emergent and 10,399 elective right hemicolectomies were identified. Emergent patients were similar in age (66.9 years vs. 67.6 years; p=0.129), more likely women (43.7% vs. 42.3%; p=0.048) and had greater comorbidity (Charlson score 3.37 vs. 3.01; p<0.001) compared with elective patients. Emergent patient LOS was approximately double that of elective patients (13 days vs. 7 days; p<0.001). Mean total charges were $78,118 for emergent versus $39,265 elective patients (p<0.001). Emergent patients had greater odds of inhospital mortality (odds ratio, 5.86; 95% confidence intervals, 4.80-7.14). CONCLUSIONS: Emergent right hemicolectomy patients have greater comorbidity, experience longer stays, accrue twice the charges, and have higher mortality risk. This reflects a heightened effort required to care for emergent patients unrecognized by Global Surgical Package reimbursement. The concentration of emergency surgical patients in acute care surgery services necessitates accounting for the additional effort associated with these predictable risks to ensure optimal care.

Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs.

BACKGROUND: Pedestrian trauma is the most lethal blunt trauma mechanism, and the rate of mortality in African Americans and Hispanics is twice that compared with whites. Whether insurance status and differential survival contribute to this disparity is unknown. METHODS: This study is a review of vehicle-struck pedestrians in the National Trauma Data Bank, v7.0. Patients <16 years and > or =65 years, as well as patients with Injury Severity Score (ISS) <9, were excluded. Patients were categorized as white, African American, or Hispanic, and as privately insured, government insured, or uninsured. With white and privately insured patients as reference, logistic regression was used to evaluate mortality by race and insurance status after adjusting for patient and injury characteristics. RESULTS: In all, 26,404 patients met inclusion criteria. On logistic regression, African Americans had 22% greater odds of mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.06-1.41) and Hispanics had 33% greater odds of mortality (OR, 1.33; 95% CI, 1.14-1.54) compared with whites. Uninsured patients had 77% greater odds of mortality (OR, 1.77; 95% CI, 1.52-2.06) compared with privately insured patients. CONCLUSION: African American and Hispanic race, as well as uninsured status, increase the risk of mortality after pedestrian crashes. Given the greater incidence of pedestrian crashes in minorities, this compounded burden of injury mandates pedestrian trauma prevention efforts in inner cities to decrease health disparities.