2024 Focused Update: Guidelines on Use of Corticosteroids in Sepsis, Acute Respiratory Distress Syndrome, and Community-Acquired Pneumonia.

RATIONALE: New evidence is available examining the use of corticosteroids in sepsis, acute respiratory distress syndrome (ARDS) and community-acquired pneumonia (CAP), warranting a focused update of the 2017 guideline on critical illness-related corticosteroid insufficiency. OBJECTIVES: To develop evidence-based recommendations for use of corticosteroids in hospitalized adults and children with sepsis, ARDS, and CAP. PANEL DESIGN: The 22-member panel included diverse representation from medicine, including adult and pediatric intensivists, pulmonologists, endocrinologists, nurses, pharmacists, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. We followed Society of Critical Care Medicine conflict of interest policies in all phases of the guideline development, including task force selection and voting. METHODS: After development of five focused Population, Intervention, Control, and Outcomes (PICO) questions, we conducted systematic reviews to identify the best available evidence addressing each question. We evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach and formulated recommendations using the evidence-to-decision framework. RESULTS: In response to the five PICOs, the panel issued four recommendations addressing the use of corticosteroids in patients with sepsis, ARDS, and CAP. These included a conditional recommendation to administer corticosteroids for patients with septic shock and critically ill patients with ARDS and a strong recommendation for use in hospitalized patients with severe CAP. The panel also recommended against high dose/short duration administration of corticosteroids for septic shock. In response to the final PICO regarding type of corticosteroid molecule in ARDS, the panel was unable to provide specific recommendations addressing corticosteroid molecule, dose, and duration of therapy, based on currently available evidence. CONCLUSIONS: The panel provided updated recommendations based on current evidence to inform clinicians, patients, and other stakeholders on the use of corticosteroids for sepsis, ARDS, and CAP.

And Miles to Go Before We Sleep: EAST Diversity and Inclusivity Progress and Remaining Challenges.

OBJECTIVE: The aim of this study was to examine the diversity, equity, and inclusion landscape in academic trauma surgery and the EAST organization. SUMMARY BACKGROUND DATA: In 2019, the Eastern Association for the Surgery of Trauma (EAST) surveyed its members on equity and inclusion in the #EAST4ALL survey and assessed leadership representation. We hypothesized that women and surgeons of color (SOC) are underrepresented as EAST members and leaders. METHODS: Survey responses were analyzed post-hoc for representation of females and SOC in academic appointments and leadership, EAST committees, and the EAST board, and compared to the overall respondent cohort. EAST membership and board demographics were compared to demographic data from the Association of American Medical Colleges. RESULTS: Of 306 respondents, 37.4% identified as female and 23.5% as SOC. There were no significant differences in female and SOC representation in academic appointments and EAST committees compared to their male and white counterparts. In academic leadership, females were underrepresented ( P < 0.0001), whereas SOC were not ( P = 0.08). Both females and SOC were underrepresented in EAST board membership ( P = 0.002 and P = 0.043, respectively). Of EAST's 33 presidents, 3 have been white women (9%), 2 have been Black, non-African American men (6%), and 28 (85%) have been white men. When compared to 2017 AAMC data, women are well-represented in EAST's 2020 membership ( P < 0.0001) and proportionally represented on EAST's 2019-2020 board ( P > 0.05). CONCLUSIONS: The #EAST4ALL survey suggests that women and SOC may be underrepresented as leaders in academic trauma surgery. However, lack of high-quality demographic data makes evaluating representation of structurally marginalized groups challenging. National trauma organizations should elicit data from their members to re-assess and promote the diversity landscape in trauma surgery.

Patient Outcomes in Laparoscopic Appendectomy With Acute Surgical Care Model Compared to Traditional Call.

INTRODUCTION: Shift-based models for acute surgical care (ACS), where surgical emergencies are treated by a dedicated team of surgeons working shifts, without a concurrent elective practice, are becoming more common nationwide. We compared the outcomes for appendectomy, one of the most common emergency surgical procedures, between the traditional (TRAD) call and ACS model at the same institution during the same time frame. METHODS: A retrospective review of patients who underwent laparoscopic appendectomy for acute appendicitis during 2017-2018. ACS and TRAD-patient demographics, clinical presentation, operative details, and outcomes were compared using independent sample t-tests, Wilcoxon rank-sum tests and Fisher's exact or χ2 tests. Multiple exploratory regression models were constructed to examine the effects of confounding variables. RESULTS: Demographics, clinical presentation, and complication rates were similar between groups except for a longer duration of symptoms prior to arrival in the TRAD group (Δ = 0.5 d, P = 0.006). Time from admission to operating room (Δ = -1.85 h, P = 0.003), length of hospital stay (Δ = -2.0 d, P < 0.001), and total cost (Δ = $ -2477.02, P < 0.001) were significantly lower in the ACS group compared to the TRAD group. Furthermore, perforation rates were lower in ACS (8.3% versus 28.6%, P = 0.003). Differences for the outcomes remained significant even after controlling for duration of symptoms prior to arrival (P < 0.05). CONCLUSIONS: Acute appendicitis managed using the ACS shift-based model seems to be associated with reduced time to operation, hospital stay, and overall cost, with equivalent success rates, compared to TRAD.

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study.

BACKGROUND: This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. METHODS: A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS: In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. CONCLUSION: When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Laparoscopic management of combined cholecystogastric and cholecystocolonic fistulae.

Cholecystogastric and cholecystocolonic fistulae are rare sequelae of longstanding cholelithiasis and can complicate surgical management. Our case involves a male patient in his early 40s with a history of chronic cholelithiasis who presented to the emergency department with severe abdominal pain. Findings on imaging were consistent with acute calculous cholecystitis. During laparoscopic cholecystectomy, the presence of both cholecystogastric and cholecystocolonic fistulae was discovered. Fistula resection with cholecystectomy in a one-step approach using indocyanine green (ICG) angiography was performed. The patient improved and was discharged 3 days later. Laparoscopic management complemented by ICG angiography is a viable surgical approach in patients with cholecystogastric and cholecystocolonic fistulae.

Improved Outcomes in Treating Acute Biliary Disorders With a Shift-Based Acute Care Surgery Model.

BACKGROUND: As Acute Care Surgery and shift-based models increase in popularity, there is evidence of better outcomes for many types of emergency general surgery patients. We explored the difference in outcomes for patients with acute biliary disorders, treated by either Acute Care Surgery (ACS) model or traditional call model (TRAD) during the same period. METHODS: Retrospective review of patients undergoing laparoscopic cholecystectomy for acute biliary disease 2017-2018. Demographics, clinical presentation, operative details, and outcomes were compared. RESULTS: Demographics, clinical presentation, and complication rates were similar between groups. Time from surgical consult to operating room (Δ = -15.34 hours [-24.57, -6.12], P = .001), length of stay (Δ = -1.4 days [-2.45, -.35], P = .009), and total charges were significantly decreased in ACS group compared to TRAD (Δ$2797.76 [-4883.12, -712.41], P = .009). CONCLUSIONS: Acute biliary disease can be managed successfully in an ACS shift-based model with reduced overall hospital charges and equivalent outcomes.

Impact of COVID-19 pandemic at a level 1 trauma center.

Introduction: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic commonly called COVID-19 brought new changes to healthcare delivery in the US. The purpose of this study is to identify the impact of COVID-19 on the delivery of acute surgical care for patients at a Level 1 trauma center during the lockdown period of the pandemic from March 13-May 1 2020. Methods: All trauma admission to the University Medical Center Level 1 Trauma Center from March 13 to May 13, 2020, were retrospectively abstracted and compared to the same period during 2019. Analysis focused on the lockdown period of March 13-May 1, 2020, and compared to the same dates in 2019. Abstracted data included demographics, care timeframes, length of stay, and mortality. The data were analyzed using Chi-Square, Fisher Exact, and the Mann-Whitney U test. Results: A total of 305 (2019) vs. 220 (2020) procedures were analyzed. No significant differences were seen in mean BMI, Injury Severity Score, American Society of Anesthesia Score, and Charlson Comorbidity Index between the two groups. Diagnosis time, interval to surgery, anesthesia time, surgical preparation time, operation time, transit time, mean hospital stay, and mortality were similar. Conclusion: The results of this study demonstrate that the lockdown period of the COVID-19 pandemic did not significantly affect the trauma surgery service line, aside from case volume, at a Level 1 trauma center in West Texas during the lockdown period. Despite changes to healthcare delivery during the pandemic, care of surgical patients was conserved as timely and of high quality.

Creation of standardized tools to evaluate reporting in health research: Population Reporting Of Gender, Race, Ethnicity & Sex (PROGRES).

Despite increasing diversity in research recruitment, research finding reporting by gender, race, ethnicity, and sex has remained up to the discretion of authors. This study developped and piloted tools to standardize the inclusive reporting of gender, race, ethnicity, and sex in health research. A modified Delphi approach was used to develop standardized tools for the inclusive reporting of gender, race, ethnicity, and sex in health research. Health research, social epidemiology, sociology, and medical anthropology experts from 11 different universities participated in the Delphi process. The tools were pilot tested on 85 health research manuscripts in top health research journals to determine inter-rater reliability of the tools. The tools each spanned five dimensions for both sex and gender as well as race and ethnicity: Author inclusiveness, Participant inclusiveness, Nomenclature reporting, Descriptive reporting, and Outcomes reporting for each subpopulation. The sex and gender tool had a median score of 6 and a range of 1-15 out of 16 possible points. The percent agreement between reviewers piloting the sex and gender tool was 82%. The interrater reliability or average Cohen's Kappa was 0.54 with a standard deviation of 0.33 demonstrating moderate agreement. The race and ethnicity tool had a median score of 1 and a range of 0-15 out of 16 possible points. Race and ethnicity were both reported in only 25.8% of studies evaluated. Most studies that reported race reported only the largest subgroups; White, Black, and Latinx. The percent agreement between reviewers piloting the race and ethnicity tool was 84 and average Cohen's Kappa was 0.61 with a standard deviation of 0.38 demonstrating substantial agreement. While the overall dimension scores were low (indicating low inclusivity), the interrater reliability measures indicated moderate to substantial agreement for the respective tools. Efforts in recruitment alone will not provide more inclusive literature without improving reporting.

Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study.

OBJECTIVE: Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service. DESIGN: A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. SETTING: Ten American College of Surgeons-verified Level 1 adult trauma centers. PARTICIPANTS: All general surgery residents and trauma/acute/surgical critical care fellows were surveyed. RESULTS: The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions. CONCLUSIONS: Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial.

OBJECTIVE: This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients. METHODS: A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R). RESULTS: Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge. CONCLUSION: Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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

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

Alternative management of delayed spontaneous oesophageal perforation by endoscopic stenting.

Boerhaave's syndrome or spontaneous perforation of the oesophagus is a life-threatening condition that carries high mortality. Delayed diagnosis has a mortality rate of 20%-50%. While surgical intervention has been the mainstay of treatment, advancements in endoscopy and oesophageal stenting have allowed for alternative management. Our case involves a 33-year-old man with self-induced emesis and DKA. After 10 days in the ICU, he developed a large right pleural effusion, which was treated with chest tube placement. Upper GI study confirmed delayed Boerhaave's syndrome. A self-expanding stent was inserted followed by percutaneous endoscopic gastrostomy (PEG) for decompression and jejunal extension for nutrition. He developed empyema and underwent right thoracotomy for washout and lung decortication. Stent was exchanged once due to recurrent leak following migration and removed after 40 days. Endoscopic stent placement with PEG with jejunal extension followed by thoracotomy is a viable alternative to primary repair of delayed oesophageal perforation.

Optimization of donor management goals yields increased organ use.

Multiple strategies have been used in an effort to increase the pool of organs for transplantation. Standardizing donor management has produced promising results. Donor management goals (DMGs) are now being used as end points of intensive care unit care during the prerecovery phase but no prospective results have been reported. Data from the United Network for Organ Sharing Region 11 were collected for successful achievement of eight common donor management goals (mean airway pressure [MAP], central venous pressure [CVP], pH, PaO2, sodium, glucose, single pressor use, and urine output) before organ recovery. Two time periods were studied with different panels of DMGs. The analysis identified the success rate of transplantation. Goals were stratified by their statistical correlation with the number of organs transplanted per donor (OTPD) in an effort to identify the most important parameter(s). Eight hundred five organ donors were studied with 2685 organs transplanted. DMGs were assessed through two phases of the study. Achieving DMGs rose from 18 to 66 per cent associated with significant improvement in OTPD (range, 2.96 to 3.45). The success of transplantation was primarily associated with limitations in vasopressor use and PaO2. Tight glucose control did affect the rate of pancreatic transplants. Thoracic organs were the most sensitive to DMGs with a 10- to 15-fold increase in lung transplantation when PaO2 rose above 100 mmHg. MAP, CVP, pH, sodium, and urine output had little effect on transplantation. Standardization of end points of donor management was associated with increased rates of transplantation. Surprisingly, not all standard goals are necessary for optimal organ use. The most significant parameters were the low use of vasopressor agents and oxygenation. Donor management strategies should strive to optimize these goals.

An analysis of risk-taking behavior among adolescent blunt trauma patients.

INTRODUCTION: The impact of risk-taking behavior among adolescent blunt trauma patients is not fully appreciated. This study examined the relationship between adolescent risk-taking behaviors, the resultant injury severity, and outcome for blunt trauma. METHODS: Between January 2000 and December 2005, data were collected on adolescent blunt trauma patients (12-18 years) admitted to either a Level I adult trauma center or large urban pediatric hospital. Five groups of risk-taking behavior were examined: ATV riders, drug and alcohol users, unhelmeted motorcyclists, unhelmeted extreme sports participants and unrestrained motor vehicle occupants. Demographic data, mechanism of injury, injury severity, hospital course and outcomes were evaluated for each group. RESULTS: A total of 2030 adolescents were admitted following blunt trauma; 723 adolescents (36%) were engaged in risk-taking behavior at the time of their injury. Most patients were male (68%). Unrestrained MVA occupants were the most frequently encountered risk takers (37%); among this subset, most were unrestrained passengers (74%). Head injuries were frequent (22%) among risk takers. When compared to non-risk-takers, there were no significant age, race, gender, or ISS differences. However, a significantly higher number of positive head CT scans were found among risk-taking adolescents (22%, p < 0.05). Mortality was low (3%). CONCLUSIONS: Risk-taking behavior is prevalent among adolescent blunt trauma patients. Improved injury prevention strategies are needed to discourage these behaviors during adolescence.

Apixaban-induced haematoma causing small bowel intussusception.

Apixaban (Eliquis) is a direct acting oral anticoagulant (DOAC) indicated for treatment of deep vein thrombosis, non-valvular atrial fibrillation, pulmonary embolism and postoperative venous thromboprophylaxis following hip or knee replacement. Complications are minimal and include, but are not limited to, bleeding and intracranial haemorrhage, and haematoma formation. Our patient is a 73-year-old woman who presented with clinical and radiographic findings of small bowel obstruction. She was found to be taking apixaban for atrial fibrillation. CT scan showed small bowel intussusception. She underwent an exploratory laparotomy and resection of the small bowel intussusception with primary side-to-side anastomosis. Histopathological examination showed that the intussusception was caused by an intramural haematoma. This case presents a rare instance of adult intussusception caused by a DOAC. To our knowledge, no case of intussusception caused by apixaban has yet been found in literature.

Protocol driven management of suspected common duct stones: A Southwestern Surgical Congress multi-centered trial.

BACKGROUND: Several options exist for the diagnosis and management of suspected common duct stones. We hypothesized that a protocol-directed approach would shorten length of stay in this patient population. METHODS: Patients from four participating institutions with a peak bilirubin <4 mg/dL underwent surgery as the initial procedure, whereas patients with a bilirubin ≥4 mg/dL underwent endoscopy. The primary endpoint was length of stay. Analysis involved chi square and Wilcoxon-Mann-Whitney test with significance at p < 0.05. RESULTS: 214 patients were managed under the protocol during six-month study period. 111 patients (52%) required endoscopy and surgery. Length of stay and the number of MRCPs performed pre-operatively significantly decreased following protocol implementation (p < 0.05). CONCLUSIONS: "Surgery first" approach in patients with bilirubin <4 ml/dL resulted in low morbidity and mortality, reduced MRCP, and length of stay.

Laparoscopic removal of migrated intrauterine device.

Intrauterine device (IUD) is a popular long-acting reversible contraceptive device with an estimated rate of use of about 5.3%. It is highly effective but not without complications, one of which is uterine perforation. The patient was a 32-year-old female who presented with nausea, vomiting and right upper quadrant abdominal pain that was tender on palpation. CT scan was performed and they found signs of acute calculous cholecystitis with incidental finding of a migrated IUD in the left lateral mid-abdomen within the peritoneal cavity. She underwent a laparoscopic cholecystectomy followed by a successful IUD retrieval. Most uterine perforations occur at the time of insertion; however, partial perforation with subsequent delayed complete perforation may also occur. This case emphasises the importance of a full workup for a missing IUD and that, if incidentally found, IUDs can be removed safely laparoscopically in conjunction with another procedure.