Whole Blood and Blood Component Resuscitation in Trauma: Interaction and Association with Mortality.

OBJECTIVE: Evaluate the interaction between whole blood (WB) and blood component resuscitation in relation to mortality following trauma. SUMMARY BACKGROUND DATA: WB is increasingly available in civilian trauma resuscitation, and it is typically transfused concomitantly with blood components. The interaction between WB and blood component transfusions is unclear. METHODS: Adult trauma patients with a shock index >1 who received ≥4 combined units of red blood cells (RBC) or WB within 4 hours across 501 United States trauma centers were included using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database. The associations between 1)WB resuscitation and mortality, 2)WB to total transfusion volume ratio (WB:TTV) and mortality, 3)balanced blood component transfusion in the setting of combined WB and component resuscitation and mortality were evaluated with multivariable analysis. RESULTS: A total of 12,275 patients were included (WB: 2,884 vs. component-only: 9,391). WB resuscitation was associated with lower odds of 4-hour (adjusted odds ratio [aOR]: 0.81 [0.68-0.97]), 24-hour, and 30-day mortality compared to component-only. Higher WB:TTV ratios were significantly associated with lower 4-hour, 24-hour, and 30-day mortality, with a 13% decrease in odds of 4-hour mortality for each 10% increase in the WB:TTV ratio (0.87 [95%CI:0.80 - 0.94]). Balanced blood component transfusion was associated with significantly lower odds of 4-hour (aOR: 0.45 [95%CI: 0.29 - 0.68]), 24-hour, and 30-day mortality in the setting of combined WB and blood component resuscitation. CONCLUSIONS: WB resuscitation, higher WB:TTV ratios, and balanced blood component transfusion in conjunction with WB were associated with lower mortality in trauma patients presenting in shock requiring 4 units of RBC and/or WB transfusion within 4 hours of arrival.

Multiphysics and multiscale modeling of microthrombosis in COVID-19.

Emerging clinical evidence suggests that thrombosis in the microvasculature of patients with Coronavirus disease 2019 (COVID-19) plays an essential role in dictating the disease progression. Because of the infectious nature of SARS-CoV-2, patients' fresh blood samples are limited to access for in vitro experimental investigations. Herein, we employ a novel multiscale and multiphysics computational framework to perform predictive modeling of the pathological thrombus formation in the microvasculature using data from patients with COVID-19. This framework seamlessly integrates the key components in the process of blood clotting, including hemodynamics, transport of coagulation factors and coagulation kinetics, blood cell mechanics and adhesive dynamics, and thus allows us to quantify the contributions of many prothrombotic factors reported in the literature, such as stasis, the derangement in blood coagulation factor levels and activities, inflammatory responses of endothelial cells and leukocytes to the microthrombus formation in COVID-19. Our simulation results show that among the coagulation factors considered, antithrombin and factor V play more prominent roles in promoting thrombosis. Our simulations also suggest that recruitment of WBCs to the endothelial cells exacerbates thrombogenesis and contributes to the blockage of the blood flow. Additionally, we show that the recent identification of flowing blood cell clusters could be a result of detachment of WBCs from thrombogenic sites, which may serve as a nidus for new clot formation. These findings point to potential targets that should be further evaluated, and prioritized in the anti-thrombotic treatment of patients with COVID-19. Altogether, our computational framework provides a powerful tool for quantitative understanding of the mechanism of pathological thrombus formation and offers insights into new therapeutic approaches for treating COVID-19 associated thrombosis.

Association of Comorbidities and Functional Level With Mortality in Geriatric Bowel Perforation.

INTRODUCTION: Spontaneous bowel perforation is associated with high morbidity and mortality. This entity remains understudied in the geriatric patient. We sought to use a national surgical sample to uncover independent predictors of mortality in elderly patients undergoing emergent operation for perforated bowel. METHODS: Using the American College of Surgeons National Surgical Quality Improvement database, years 2007 to 2017, all geriatric patients (age ≥65 y) who underwent emergency surgery and who had a postoperative diagnosis of bowel perforation were included. Univariate and multivariable analyses were used to identify independent predictors of 30-d mortality. RESULTS: A total of 8981 patients were included. The median (interquartile range) age was 75 y (69, 82), and 59.0% were female. Twenty-one percent of patients were partially or totally dependent, and 25.2% were admitted from sources other than home. Overall, 30-d mortality rate was 22.1%. Independent predictors of mortality included the following: age 70-79 y (odds ratio [OR]: 1.59, P < 0.001), age ≥80 y (OR: 3.23, P < 0.001), American Society of Anesthesiologists ≥3 (OR: 4.74, P < 0.001), admission from chronic care facility (OR: 1.61, P < 0.001), being partially or totally dependent (OR: 1.50, P < 0.001), chronic steroid use (OR: 1.36, P < 0.001), and preoperative septic shock (OR: 3.74, P < 0.001). Having immediate fascial closure was protective against mortality (immediate fascial closure only, OR: 0.55, P < 0.001; -immediate closure of all surgical site layers, OR: 0.44, P < 0.001). CONCLUSIONS: In geriatric patients, functional status and chronic steroid therapy play an important role in determining survival following surgery for bowel perforation. These factors should be considered during preoperative counseling and decision-making.

Angioembolization in Severe Pelvic Trauma is Associated with Venous Thromboembolism.

INTRODUCTION: Management of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE). METHODS: All adults (age >16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups. RESULTS: Of 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03). CONCLUSIONS: Pelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.

Predictors of Mortality in Extracorporeal Membrane Oxygenation Support Patients Following Major Trauma.

INTRODUCTION: The usage of extracorporeal membrane oxygenation (ECMO) in trauma patients has increased significantly within the past decade. Despite increased research on ECMO application in trauma patients, there remains limited data on factors predicting morbidity and mortality outcome. Therefore, the primary objective of this study is to describe patient characteristics that are independently associated with mortality in ECMO therapy in trauma patients, to further guide future research. METHODS: This retrospective study was conducted using the Trauma Quality Improvement Program database from 2010 to 2019. All adult (age ≥ 16 y) trauma patients that utilized ECMO were included. A Significant differences (P < 0.05) in demographic and clinical characteristics between groups were calculated using an independent t-test for normal distributed continuous values, a Mann-Whitney U test for non-normal distributed values, and a Pearson chi-square test for categorical values. A multivariable regression model was used to identify independent predictors for mortality. A survival flow chart was constructed by using the strongest predictive value for mortality and using the optimal cut-off point calculated by the Youden index. RESULTS: Five hundred forty-two patients were included of whom 205 died. Multivariable analysis demonstrated that the female gender, ECMO within 4 h after presentation, a decreased Glasgow Coma Scale, increased age, units of blood in the first 4 h, and abbreviated injury score for external injuries were independently associated with mortality in ECMO trauma patients. It was found that an external abbreviated injury score of ≥3 had the strongest predictive value for mortality, as patients with this criterion had an overall 29.5% increased risk of death. CONCLUSIONS: There is an ongoing increasing trend in the usage of ECMO in trauma patients. This study has identified multiple factors that are individually associated with mortality. However, more research must be done on the association between mortality and noninjury characteristics like Pao2/Fio2 ratio, acute respiratory distress syndrome classification, etc. that reflect the internal state of the patient.

Sex Related Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury.

OBJECTIVE: Current literature suggests that thoracic endovascular aortic repair (TEVAR) in older patients with aortic aneurysms results in higher peri-operative mortality and lower long term survival in females compared with males. However, sex related outcomes in younger patients with blunt thoracic aortic injury (BTAI) undergoing TEVAR remain unknown. This study examined the association between sex and outcomes after TEVAR for BTAI. METHODS: A retrospective cohort study was performed of all patients who underwent TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) between 2016 and 2019. The primary outcome was in hospital death. Secondary outcomes were peri-operative complications. Multivariable logistic regression was used to adjust for demographics, comorbidities, injury severity score, and aortic injury grade. RESULTS: Two thousand and twenty-two patients were included; 26% were female. Compared with males, females were older (46 [IQR 30, 62] vs. 39 [IQR 28, 56] years; p < .001), more often obese (41% vs. 33%; p = .005), had lower rates of alcohol use disorder (4.1% vs. 8.9%; p < .001) and a higher prevalence of hypertension (29% vs. 22%; p = .001). The injury severity was comparable between females and males (Injury Severity Score ≥ 25; 84% vs. 80%; p = .11) and there was no difference in aortic injury grades when comparing females with males (grade 1, 33% vs. 33%; grade 2, 24% vs. 25%; grade 3, 43% vs. 40%; grade 4, 0.8% vs. 1.3%; p = .53). Multivariable logistic regression demonstrated no difference for in hospital mortality between females and males (OR 1.02; 95% CI 0.67 - 1.53, p = .93). Compared with males, females were at lower risk of acute kidney injury (AKI) (OR 0.33; 95% CI 0.17 - 0.64; p = .001) and ventilator associated pneumonia (VAP) (OR 0.50; 95% CI 0.28 - 0.91; p = .023). CONCLUSION: This study did not demonstrate a sex related in hospital mortality difference following TEVAR for BTAI. However, female sex was associated with a lower risk of AKI and VAP. Future studies should evaluate sex differences and long term outcomes following TEVAR in patients with BTAI.

Intraoperative Deaths: Who, Why, and Can We Prevent Them?

INTRODUCTION: Intraoperative deaths (IODs) are rare but catastrophic. We systematically analyzed IODs to identify clinical and patient safety patterns. METHODS: IODs in a large academic center between 2015 and 2019 were included. Perioperative details were systematically reviewed, focusing on (1) identifying phenotypes of IOD, (2) describing emerging themes immediately preceding cardiac arrest, and (3) suggesting interventions to mitigate IOD in each phenotype. RESULTS: Forty-one patients were included. Three IOD phenotypes were identified: trauma (T), nontrauma emergency (NT), and elective (EL) surgery patients, each with 2 sub-phenotypes (e.g., ELm and ELv for elective surgery with medical arrests or vascular injury and bleeding, respectively). In phenotype T, cardiopulmonary resuscitation was initiated before incision in 42%, resuscitative thoracotomy was performed in 33%, and transient return of spontaneous circulation was achieved in 30% of patients. In phenotype NT, ruptured aortic aneurysms accounted for half the cases, and median blood product utilization was 2,694 mL. In phenotype ELm, preoperative evaluation did not include electrocardiogram in 12%, cardiac consultation in 62%, stress test in 87%, and chest x-ray in 37% of patients. In phenotype ELv, 83% had a single peripheral intravenous line, and vascular injury was almost always followed by escalation in monitoring (e.g., central/arterial line), alert to the blood bank, and call for surgical backup. CONCLUSIONS: We have created a framework for IOD that can help with intraoperative safety and quality analysis. Focusing on interventions that address appropriateness versus futility in care in phenotypes T and NT, and on prevention and mitigation of intraoperative vessel injury (e.g., intraoperative rescue team) or preoperative optimization in phenotype EL may help prevent IODs.

Hospital Academic Status and the Volume-Outcome Association in Postoperative Patients Requiring Intensive Care: Results of a Nationwide Analysis of Intensive Care Units in the United States.

Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 - -0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.

Risk factors for ischemic gastrointestinal complications in patients undergoing open cardiac surgical procedures: A single-center retrospective experience.

BACKGROUND: Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery. METHODS: All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC. RESULTS: Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre- or intraoperative utilization of intra-aortic balloon pump or catheter-based assist devices (OR = 4.54), intraoperative transfusion requirement of >4 RBC units(OR = 2.47), and cardiopulmonary bypass > 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC. CONCLUSIONS: We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above-identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team.

Exercise capacity following ventricular assist device implantation via thoracotomy with outflow cannula anastomosis to the descending aorta.

Left ventricular assist device (LVAD) implantation via left lateral thoracotomy with outflow cannula anastomosis to the descending aorta is an alternative technique that avoids anterior mediastinal planes and requires a single incision. This study compares changes in exercise capacity following LVAD implantation with outflow cannula anastomosis to the descending aorta versus ascending aorta. Adult patients who received a continuous flow centrifugal LVAD implantation and completed both pre- and postimplantation cardiopulmonary exercise tests (CPETs) and or 6-minute walk tests (6MWT) were included. Change in CPET parameters (maximum oxygen intake: vO2 max, oxygen uptake efficiency ratio: OUES, ventilatory efficiency ratio: vE/vCO2 Slope) and 6MWT distance were compared between ascending and descending aorta anastomosis groups. Ascending and descending aorta anastomosis cohorts included 59 and 14 patients, respectively. Pre- and postimplantation CPETs were performed 63 ± 12 days before and 216 ± 17 days following implantation. The improvement in CPET parameters (vO2 max, OUES, vE/vCO2 Slope) or 6MWT distance was not significantly different between the ascending and descending aorta anastomosis groups. This study found no significant difference in the improvement of CPET parameters or 6MWT distance between LVAD implantation via thoracotomy with outflow cannula anastomosis to descending aorta and standard implantation via sternotomy with outflow cannula anastomosis to ascending aorta.

Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter.

BACKGROUND: The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic. STUDY DESIGN: Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs. RESULTS: Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs. CONCLUSIONS: Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.

Optimal dose of cryoprecipitate in massive transfusion following trauma.

BACKGROUND: While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients. METHODS: Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables. RESULTS: The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality. CONCLUSION: One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Safety of the injectable expanding biopolymer foam for non-compressible truncal bleeding in swine.

BACKGROUND: A novel hydrophobically modified chitosan (hm-chitosan) polymer has been previously shown to improve survival in a non-compressible intra-abdominal bleeding model in swine. We performed a 28-day survival study to evaluate the safety of the hm-chitosan polymer in swine. METHODS: Female Yorkshire swine (40-50 kg) were used. A mild, non-compressible, closed-cavity bleeding model was created with splenic transection. The hm-chitosan polymer was applied intra-abdominally through an umbilical nozzle in the same composition and dose previously shown to improve survival. Animals were monitored intraoperatively and followed 28 days postoperatively for survival, signs of pain, and end-organ function. Gross pathological and microscopic evaluations were performed at the conclusion of the experiment. RESULTS: A total of 10 animals were included (hm-chitosan = 8; control = 2). The 2 control animals survived through 28 days, and 7 of the 8 animals from the hm-chitosan group survived without any adverse events. One animal from the hm-chitosan group required early termination of the study for signs of pain, and superficial colonic ulcers were found on autopsy. Laboratory tests showed no signs of end-organ dysfunction after exposure to hm-chitosan after 28 days. On gross pathological examination, small (<0.5 cm) peritoneal nodules were noticed in the hm-chitosan group, which were consistent with giant-cell foreign body reaction in microscopy, presumably related to polymer remnants. Microscopically, no signs of systemic polymer embolization or thrombosis were noticed. CONCLUSION: Prolonged intraperitoneal exposure to the hm-chitosan polymer was tolerated without any adverse event in the majority of animals. In the single animal that required early termination, the material did not appear to be associated with end-organ dysfunction in swine. Superficial colonic ulcers that would require surgical repair were identified in 1 out of 8 animals exposed to hm-chitosan.

Outcomes of Combined Opioids and Benzodiazepines Consumption in Elderly Trauma: A Retrospective Cohort Study.

BACKGROUND: Acute substance intoxication is associated with traumatic injury and worse hospital outcomes. The objective of this study was to evaluate the association between simultaneous opioids and benzodiazepines (OB) use and hospital outcomes in elderly trauma patients. METHODS: We performed a retrospective analysis using the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) 2017 database. We included trauma patients (age ≥ 65 years) examined by urine toxicology within 24 hours of presentation. The primary outcome was in-hospital mortality. Secondary outcomes included hospital and ICU lengths of stay (HLOS AND ICULOS), in-hospital complications (eg, ventilator-associated pneumonia), unplanned intubation, and duration of mechanical ventilation. Patients were stratified being both positive for opioids and benzodiazepines (OB+) or not (OB-) based on having positive or negative drug screen for both drugs, respectively. A 1:1 propensity score matching was performed controlling for demographics (eg, age and sex), comorbidities (eg, alcoholism), and injury characteristics. RESULTS: Of 77,311 tested patients, 849 OB+ were matched to OB- patients. Compared to OB- group, OB+ patients were more likely to have unplanned intubation (26 [3.1%] vs 8 [0.9%], P = 0.002) and had prolonged HLOS (≥2 days: 683 [84.0%] vs 625 [77.8%], P = 0.002). There were no differences in all other outcomes (P > 0.05). CONCLUSIONS: The OB intake is associated with higher incidence of unplanned intubation and longer HLOS in elderly trauma patients. Early identification of elderly trauma patient with OB+ can help provide necessary pharmacologic and behavioral interventions to treat their substance use and potentially improve outcomes.

A Surgical Perspective of Gastrointestinal Manifestations and Complications of COVID-19 Infection.

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, has quickly spread over the world since December 2019. COVID-19 is a systemic disease that can affect various organs throughout the body. Gastrointestinal (GI) symptoms have been reported in 16% to 33% of all patients with COVID-19 and in 75% of critically ill patients. This chapter reviews the GI manifestations of COVID-19 as well as their diagnostic and treatment modalities.

Surgical Implications of Coronavirus Disease-19.

As the coronavirus disease-19 (COVID-19) pandemic continues to evolve in 2022 with the surge of novel viral variants, it is important for physicians to understand and appreciate the surgical implications of the pandemic. This review provides an overview of the implications of the ongoing COVID-19 pandemic on surgical care and provides recommendations for perioperative management. Most observational studies suggest a higher risk for patients undergoing surgery with COVID-19 compared with risk-adjusted non-COVID-19 patients.

Using the Field Artificial Intelligence Triage (FAIT) tool to predict hospital critical care resource utilization in patients with truncal gunshot wounds.

BACKGROUND: Tiered trauma triage systems have resulted in a significant mortality reduction, but models have remained unchanged. The aim of this study was to develop and test an artificial intelligence algorithm to predict critical care resource utilization. METHODS: We queried the ACS-TQIP 2017-18 database for truncal gunshot wounds(GSW). An information-aware deep neural network (DNN-IAD) model was trained to predict ICU admission and need for mechanical ventilation (MV). Input variables included demographics, comorbidities, vital signs, and external injuries. The model's performance was assessed using the area under receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). RESULTS: For the ICU admission analysis, we included 39,916 patients. For the MV need analysis, 39,591 patients were included. Median (IQR) age was 27 (22,36). AUROC and AUPRC for predicting ICU need were 84.8 ± 0.5 and 75.4 ± 0.5, and the AUROC and AUPRC for MV need were 86.8 ± 0.5 and 72.5 ± 0.6. CONCLUSIONS: Our model predicts hospital utilization outcomes in patients with truncal GSW with high accuracy, allowing early resource mobilization and rapid triage decisions in hospitals with capacity issues and austere environments.

Revisiting abdominal closure in mesenteric ischemia: is there an association with outcome?

PURPOSE: Current guidelines advocate liberal use of delayed abdominal closure in patients with acute mesenteric ischemia (AMI) undergoing laparotomy. Few studies have systematically examined this practice. The goal of this study was to evaluate the effect of delayed abdominal closure on postoperative morbidity and mortality in patients with AMI. METHODS: We performed a retrospective cohort study of the ACS-NSQIP 2013-2017 registry. We included patients with a diagnosis of AMI undergoing emergency laparotomy. Patients were divided into two groups based on the type of abdominal closure: (1) delayed fascial closure (DFC) when no layers of the abdominal wall were closed and (2) immediate fascial closure (IFC) if deep layers or all layers of the abdominal wall were closed. Propensity score matching was performed based on comorbidities, pre-operative, and operative characteristics. Univariable analysis was performed on the matched sample. RESULTS: The propensity-matched cohort consisted of 1520 patients equally divided into the DFC and IFC groups. The median (IQR) age was 68 (59-77), and 836 (55.0%) were female. Compared to IFC, the DFC group showed increased in-hospital mortality (38.9% vs. 31.6%, p = 0.002), 30-day mortality (42.4% vs. 36.3%, p = 0.012), and increased risk of respiratory failure (59.5% vs. 31.2%, p < 0.001). CONCLUSIONS: The delayed fascial closure technique was associated with increased mortality compared to immediate fascial closure. These findings do not support the blanket incorporation of delayed closure in mesenteric ischemia care or its previously advocated liberal use.

Development of a Machine Learning-Based Prescriptive Tool to Address Racial Disparities in Access to Care After Penetrating Trauma.

Importance: The use of artificial intelligence (AI) in clinical medicine risks perpetuating existing bias in care, such as disparities in access to postinjury rehabilitation services. Objective: To leverage a novel, interpretable AI-based technology to uncover racial disparities in access to postinjury rehabilitation care and create an AI-based prescriptive tool to address these disparities. Design, Setting, and Participants: This cohort study used data from the 2010-2016 American College of Surgeons Trauma Quality Improvement Program database for Black and White patients with a penetrating mechanism of injury. An interpretable AI methodology called optimal classification trees (OCTs) was applied in an 80:20 derivation/validation split to predict discharge disposition (home vs postacute care [PAC]). The interpretable nature of OCTs allowed for examination of the AI logic to identify racial disparities. A prescriptive mixed-integer optimization model using age, injury, and gender data was allowed to "fairness-flip" the recommended discharge destination for a subset of patients while minimizing the ratio of imbalance between Black and White patients. Three OCTs were developed to predict discharge disposition: the first 2 trees used unadjusted data (one without and one with the race variable), and the third tree used fairness-adjusted data. Main Outcomes and Measures: Disparities and the discriminative performance (C statistic) were compared among fairness-adjusted and unadjusted OCTs. Results: A total of 52 468 patients were included; the median (IQR) age was 29 (22-40) years, 46 189 patients (88.0%) were male, 31 470 (60.0%) were Black, and 20 998 (40.0%) were White. A total of 3800 Black patients (12.1%) were discharged to PAC, compared with 4504 White patients (21.5%; P < .001). Examining the AI logic uncovered significant disparities in PAC discharge destination access, with race playing the second most important role. The prescriptive fairness adjustment recommended flipping the discharge destination of 4.5% of the patients, with the performance of the adjusted model increasing from a C statistic of 0.79 to 0.87. After fairness adjustment, disparities disappeared, and a similar percentage of Black and White patients (15.8% vs 15.8%; P = .87) had a recommended discharge to PAC. Conclusions and Relevance: In this study, we developed an accurate, machine learning-based, fairness-adjusted model that can identify barriers to discharge to postacute care. Instead of accidentally encoding bias, interpretable AI methodologies are powerful tools to diagnose and remedy system-related bias in care, such as disparities in access to postinjury rehabilitation care.