Do we have the guts to go? The abdominal compartment, intra-abdominal hypertension, the human microbiome and exploration class space missions.

Humans are destined to explore space, yet critical illness and injury may be catastrophically limiting for extraterrestrial travel. Humans are superorganisms living in symbiosis with their microbiomes, whose genetic diversity dwarfs that of humans. Symbiosis is critical and imbalances are associated with disease, occurring within hours of serious illness and injury. There are many characteristics of space flight that negatively influence the microbiome, especially deep space itself, with its increased radiation and absence of gravity. Prolonged weightlessness causes many physiologic changes that are detrimental; some resemble aging and will adversely affect the ability to tolerate critical illness or injury and subsequent treatment. Critical illness-induced intra-abdominal hypertension (IAH) may induce malperfusion of both the viscera and microbiome, with potentially catastrophic effects. Evidence from animal models confirms profound IAH effects on the gut, namely ischemia and disruption of barrier function, mechanistically linking IAH to resultant organ dysfunction. Therefore, a pathologic dysbiome, space-induced immune dysfunction and a diminished cardiorespiratory reserve with exacerbated susceptibility to IAH, imply that a space-deconditioned astronaut will be vulnerable to IAH-induced gut malperfusion. This sets the stage for severe gut ischemia and massive biomediator generation in an astronaut with reduced cardiorespiratory/immunological capacity. Fortunately, experiments in weightless analogue environments suggest that IAH may be ameliorated by conformational abdominal wall changes and a resetting of thoracoabdominal mechanics. Thus, review of the interactions of physiologic changes with prolonged weightlessness and IAH is required to identify appropriate questions for planning exploration class space surgical care.

L'humanité est à l'aube d'une nouvelle ère d'exploration spatiale, mais le risque de maladies et blessures graves pourrait restreindre de manière catastrophique le potentiel des voyages dans l'espace. L'être humain est un superorganisme vivant en symbiose avec son microbiote, dont la diversité génétique éclipse celle de l'hôte. Cette symbiose est essentielle : tout déséquilibre est associé à une dégradation de l'état de santé dans les heures suivant l'occurrence d'une blessure ou d'une maladie grave. Bon nombre de caractéristiques propres au vol spatial ont des répercussions négatives sur le microbiote; l'espace lointain présente des dangers particuliers en raison de l'exposition accrue au rayonnement et de l'absence de gravité. L'exposition prolongée à l'apesanteur cause une myriade de changements physiologiques nuisant à la santé. Certains ressemblent à des processus de vieillissement et réduiront la capacité à tolérer une blessure ou une maladie grave et son traitement. L'hypertension intra-abdominale (HIA) causée par une maladie grave peut réduire la perfusion des viscères et du microbiote, ce qui peut avoir des conséquences catastrophiques. Des études sur modèle animal ont confirmé les effets profondément délétères de l'HIA sur les intestins par l'apparition d'une ischémie et une altération de la barrière intestinale; cette découverte permettrait d'établir un lien mécanistique entre l'HIA et la défaillance d'organes résultante. Par conséquent, une dysbiose pathologique, associée à un dysfonctionnement immunitaire en apesanteur et à une réduction de la réserve cardiorespiratoire accompagnée d'une exacerbation de la susceptibilité à l'HIA, pourrait signifier qu'un astronaute exposé à l'effet déconditionnant de l'apesanteur serait vulnérable aux problèmes de perfusion de l'intestin découlant de l'HIA. Ce problème pourrait à son tour mener à une ischémie intestinale grave et à une production massive de biomédiateurs chez un astronaute présentant déjà une capacité cardiorespiratoire et immunitaire réduite. Heureusement, des expériences dans des environnements simulant l'apesanteur semblent indiquer que les effets de l'HIA pourraient être contrés par des changements conformationnels de la paroi abdominale et un rétablissement de la mécanique thoracoabdominale. Par conséquent, un examen des interactions des changements physiologiques associés à un état d'apesanteur prolongé et à l'HIA est requis pour déterminer les questions à poser afin de planifier adéquatement les soins chirurgicaux en contexte d'exploration spatiale.

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage in a Perfused Human Cadaver Model.

BACKGROUND: Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate. OBJECTIVES: We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT). METHODS: Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded. RESULTS: There was no significant difference between the fluid loss/no movement (p > 0.450) and fluid loss/movement (p > 0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p > 0.000) and movement (p > 0.000). The iTClamp was also significantly faster to apply than the Foley (p > 0.000). CONCLUSIONS: The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

Transoceanic Telementoring of Tube Thoracostomy Insertion: A Randomized Controlled Trial of Telementored Versus Unmentored Insertion of Tube Thoracostomy by Military Medical Technicians.

Background:Tension pneumothorax is a frequent cause of potentially preventable death. Tube thoracostomy (TT) can obviate death but is invasive and fraught with complications even in experienced hands. We assessed the utility of a remote international virtual network (RIVN) of specialized mentors to remotely guide military medical technicians (medics) using wireless informatics.Methods:Medics were randomized to insert TT in training mannequins (TraumaMan; Abacus ALS, Meadowbrook, Australia) supervised by RIVN or not. The RIVN consisted of trauma surgeons in Canada and Australia and a senior medic in Ohio. Medics wore a helmet-mounted wireless camera with laser pointer to confirm anatomy and two-way voice communication using commercial software (Skype®). Performance was measured through objective task completion (pass/fail) regarding safety during the procedure, proper location, and secure anchoring of the tube, in addition to remote mentor opinion and subjective debrief.Results:Fourteen medics attempted TT, seven mentored and seven not. The RIVN was functional and surgeons on either side of the globe had real-time communication with the mentees. TT placement was considered safe, successful, and secure in 100% of mentored (n = 7) procedures, although two (29%) received corrective remote guidance. All (100%) of the unmentored attempted and adequately secured the TT and were safe. However, only 71% (n = 5) completed the task successfully (p = 0.46). Participating medics subjectively felt remote telementoring (RTM) increased self-confidence (strong agreement mean 5/5 ± 0); confidence to perform field TT (agreement (4/5 ± 1); and decreased anxiety (strong agreement 5/5 ± 1). Subjectively, the remote mentors felt in 100% of the mentored procedures that "yes" they were able to assist the medics (1.86 ± 0.38), and in 71% (n = 5) felt "yes" they made TT safer (2.29 ± 0.49).Conclusions:RTM descriptively increased the success of TT placement and allowed for real-time troubleshooting from thousands of kilometers with a redundant capability. RTM was subjectively associated with high levels of satisfaction and self-reported self-confidence. Continued controlled and critical evaluation and refinement of telemedical techniques should continue. Trial Registration: ID ISRCTN/77929274.

Feasibility of continuous sedation monitoring in critically ill intensive care unit patients using the NeuroSENSE WAVCNS index.

Sedation in the intensive care unit (ICU) is challenging, as both over- and under-sedation are detrimental. Current methods of assessment, such as the Richmond Agitation Sedation Scale (RASS), are measured intermittently and rely on patients' behavioral response to stimulation, which may interrupt sleep/rest. A non-stimulating method for continuous sedation monitoring may be beneficial and allow more frequent assessment. Processed electroencephalography (EEG) monitors have not been routinely adopted in the ICU. The aim of this observational study was to assess the feasibility of using the NeuroSENSE™ monitor for EEG-based continuous sedation assessment. With ethical approval, ICU patients on continuous propofol sedation were recruited. Depth-of-hypnosis index (WAVCNS) values were obtained from the NeuroSENSE. Bedside nurses, blinded to the NeuroSENSE, performed regular RASS assessments and maintained the sedation regimen as per standard of care. Participants were monitored throughout the duration of their propofol infusion, up to 24 h. Fifteen patients, with median [interquartile range] age of 57 [52-62.5] years were each monitored for a duration of 9.0 [5.7-20.1] h. Valid WAVCNS values were obtained for 89% [66-99] of monitoring time and were widely distributed within and between individuals, with 6% [1-31] spent < 40 (very deep), and 3% [1-15] spent > 90 (awake). Significant EEG suppression was detected in 3/15 (20%) participants. Observed RASS matched RASS goals in 36/89 (40%) assessments. The WAVCNS variability, and incidence of EEG suppression, highlight the limitations of using RASS as a standalone sedation measure, and suggests potential benefit of adjunct continuous brain monitoring.

One thousand consecutive in-hospital deaths following severe injury: Has the etiology of traumatic inpatient death changed in Canada?

SUMMARY: A wide range of factors have traditionally led to early in-hospital death following severe injury. The primary goal of this commentary was to evaluate the causes of early posttraumatic inpatient deaths over an extended period. Although early posttraumatic in-hospital death remains multifactorial, severe traumatic brain injuries are the dominant cause and have increased in proportion over time. Other traditional causes of death have also decreased owing to improved clinical care.

Active Negative Pressure Peritoneal Therapy After Abbreviated Laparotomy: The Intraperitoneal Vacuum Randomized Controlled Trial.

OBJECTIVE: To determine whether active negative pressure peritoneal therapy with the ABThera temporary abdominal closure device reduces systemic inflammation after abbreviated laparotomy. BACKGROUND: Excessive systemic inflammation after abdominal injury or intra-abdominal sepsis is associated with poor outcomes. METHODS: We conducted a single-center, randomized controlled trial. Forty-five adults with abdominal injury (46.7%) or intra-abdominal sepsis (52.3%) were randomly allocated to the ABThera (n = 23) or Barker's vacuum pack (n = 22). On study days 1, 2, 3, 7, and 28, blood and peritoneal fluid were collected. The primary endpoint was the difference in the plasma concentration of interleukin-6 (IL-6) 24 and 48 hours after temporary abdominal closure application. RESULTS: There was a significantly lower peritoneal fluid drainage from the ABThera at 48 hours after randomization. Despite this, there was no difference in plasma concentration of IL-6 at baseline versus 24 (P = 0.52) or 48 hours (P = 0.82) between the groups. There was also no significant intergroup difference in the plasma concentrations of IL-1ß, -8, -10, or -12 p70 or tumor necrosis factor α between these time points. The cumulative incidence of primary fascial closure at 90 days was similar between groups (hazard ratio, 1.6; 95% confidence interval, 0.82-3.0; P = 0.17). However, 90-day mortality was improved in the ABThera group (hazard ratio, 0.32; 95% confidence interval, 0.11-0.93; P = 0.04). CONCLUSIONS: This trial observed a survival difference between patients randomized to the ABThera versus Barker's vacuum pack that did not seem to be mediated by an improvement in peritoneal fluid drainage, fascial closure rates, or markers of systemic inflammation. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01355094.

The "weekend warrior": fact or fiction for major trauma?

BACKGROUND: The "weekend warrior" engages in demanding recreational sporting activities on weekends despite minimal physical activity during the week. We sought to identify the incidence and injury patterns of major trauma from recreational sporting activities on weekends versus weekdays. METHODS: We performed a retrospective cohort study using the Alberta Trauma Registry comparing all adults who were severely injured (injury severity score [ISS] ≥ 12) while engaging in physical activity on weekends versus weekdays between 1995 and 2009. RESULTS: Among the 351 identified patients (median ISS 18; median hospital stay 6 d; mortality 6.6%), significantly more were injured on the weekend than during the week (54.8% v. 45.2%, p = 0.016). Common mechanisms were motocross (23.6%), hiking or mountain/rock climbing (15.4%), skateboarding or rollerblading (12.3%), hockey/ice-skating (10.3%) and aircraft- (9.9%) and water-related (7.7%) activities. This distribution was similar regardless of the day of the week. Most patients were injured as a result of a ground-level (21.9%) or higher fall while hiking, mountain climbing or rock climbing (25.9%); motocross-related incidents (24.2%); or collision with a tree, person, man-made object or moving vehicle (14.0%). Injury patterns were similar across both groups (all p > 0.05): head (55.8%), spine (35.1%), chest (35.0%), extremities (31.1%), face (17.4%), abdomen (13.1%). Surgical intervention was required in 41% of patients: 15.1% required open reduction and internal fixation, 8.3% spinal fixation, 7.4% craniotomy, 5.1% facial repair and 4.3% laparotomy. CONCLUSION: The weekend warrior concept may be a validated entity for major trauma.

CONTEXTE: Le « guerrier du dimanche ¼ s'adonne à des activités sportives récréatives la fin de semaine, malgré un degré minime d'activité physique durant la semaine. Nous avons voulu mesurer l'incidence des blessures et les types de traumatismes majeurs consécutifs à des activités sportives pratiquées la fin de semaine plutôt que les jours de semaine. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective à partir du registre de traumatologie de l'Alberta pour comparer tous les adultes victimes d'une blessure grave (score de gravité des traumatismes ≥ 12) lors de la pratique d'activités physiques la fin de semaine plutôt que les jours de semaine, entre 1995 et 2009. RÉSULTATS: Parmi les 351 patients recensés (score médian 18, séjour hospitalier médian 6 j, mortalité 6,6 %), un nombre significativement plus grand se sont blessés la fin de semaine plutôt qu'un jour de semaine (54,8 % c. 45,2 %, p = 0,016). Les activités les plus souvent en cause étaient : motocross (23,6 %), randonnée/ alpinisme/ escalade (15,4 %), planche à roulettes ou patins à roues alignées (12,3 %), hockey/patin sur glace (10,3 %) et activités pratiqués dans les airs (9,9 %) et sur l'eau (7,7 %). Cette distribution est demeurée similaire, indépendamment du jour de la semaine. La plupart des patients ont subi leurs blessures par suite d'une chute au niveau du sol (21,9 %) ou de plus haut lors de randonnées, d'alpinisme ou d'escalade (25,9 %), d'un accident de motocross (24,2 %) ou d'une collision avec un arbre, une personne, un obstacle artificiel ou un véhicule en mouvement (14,0 %). Les types de traumatismes étaient similaires dans tous les groupes (tous, p > 0,05) : tête (55,8 %), colonne vertébrale (35,1 %), thorax (35,0 %), membres (31,1 %), visage (17,4 %), abdomen (13,1 %). Chez 41 % des patients, il a fallu intervenir chirurgicalement : 15,1 % réduction ouverte avec fixation interne, 8,3 % fixation vertébrale, 7,4 % craniotomie, 5,1 % intervention au visage et 4,3 % laparotomie. CONCLUSION: Le concept de « guerrier du dimanche ¼ pourrait être une entité valide associée à des traumatismes majeurs.

Thrombotic triad in microgravity.

Thrombotic disease may be an underdiagnosed condition of prolonged exposure to microgravity and yet the underlying factors remain poorly defined. Recently, an internal jugular vein thrombosis was diagnosed in a low-risk female astronaut after an approximately 7-week space mission. Six of the additional 10 crew members demonstrated jugular venous flow risk factors, such as suspicious stagnation or retroversion. Fortunately, all were asymptomatic. Observations in space as well as clinical and in vitro microgravity studies on Earth, where experiments are designed to recapitulate the conditions of space, suggest effects on blood flow stasis, coagulation, and vascular function. In this article, the related literature on thrombotic disease in space is reviewed, with consideration of these elements of Virchow's triad.

Enabling the mission through trans-atlantic remote mentored musculoskeletal ultrasound: case report of a portable hand-carried tele-ultrasound system for medical relief missions.

Modern medical practice has become extremely dependent upon diagnostic imaging technologies to confirm the results of clinical examination and to guide the response to therapies. Of the various diagnostic imaging techniques, ultrasound is the most portable modality and one that is repeatable, dynamic, relatively cheap, and safe as long as the imaging provided is accurately interpreted. It is, however, the most user-dependent, a characteristic that has prompted the development of remote guidance techniques, wherein remote experts guide distant users through the use of information technologies. Medical mission work often brings specialist physicians to less developed locations, where they wish to provide the highest levels of care but are often bereft of diagnostic imaging resources on which they depend. Furthermore, if these personnel become ill or injured, their own care received may not be to the standard they have left at home. We herein report the utilization of a compact hand-carried remote tele-ultrasound system that allowed real-time diagnosis and follow-up of an acutely torn adductor muscle by a team of ultrasonographers, surgeons, and physicians. The patient was one of the mission surgeons who was guided to self-image. The virtual network of supporting experts was located across North America, whereas the patient was in Lome, Togo, West Africa. The system consisted of a hand-carried ultrasound, the output of which was digitized and streamed to the experts within standard voice-over-Internet-protocol software with an embedded simultaneous videocamera image of the ultrasonographer's hands using a customized graphical user interface. The practical concept of a virtual tele-ultrasound support network was illustrated through the clinical guidance of multiple physicians, including National Aeronautics and Space Administration Medical Operations remote guiders, Olympic team-associated surgeons, and ultrasound-focused emergentologists.

Just-in-time cost-effective off-the-shelf remote telementoring of paramedical personnel in bedside lung sonography-a technical case study.

PURPOSE: Remote telementored ultrasound (RTMUS) is a new discipline that allows a remote expert to guide variably experienced clinical responders through focused ultrasound examinations. We used the examination of the pleural spaces after tube thoracostomy (TT) removal by a nurse with no prior ultrasound experience as an illustrative but highly accurate example of the technique using a simple cost-effective system. MATERIALS AND METHODS: The image outputs of a handheld ultrasound machine and a head-mounted Web camera were input into a customized graphical user interface and streamed over a freely available voice over Internet protocol system that allowed two-way audio and visual communication between the novice examiner and the remote expert. The bedside nurse was then guided to examine the anterior chest of a patient who had recently had bilateral TTs removed. The team sought to determine the presence or absence of any recurrent pneumothoraces using the standard criteria for the ultrasound diagnosis of post-removal pneumothorax (PTXs). An upright chest radiograph (CXR) was obtained immediately after the RTMUS examination. RESULTS: The RTMUS system enabled the novice user to learn how to hold the ultrasound probe, where to place it on the chest, and thereafter to diagnose a subtle unilateral PTX characterized as "tiny" on the subsequent formal CXR report. CONCLUSIONS: As ultrasound has almost limitless clinical utility, using simple but advanced informatics and communication technologies has potential to improve worldwide healthcare delivery. RTMUS could be used both to enhance the information content as well as to digitally document important physiologic findings in any clinical encounter wherever a portable ultrasound and Internet connectivity are available.

Simple, almost anywhere, with almost anyone: remote low-cost telementored resuscitative lung ultrasound.

BACKGROUND: Apnea (APN) and pneumothorax (PTX) are common immediately life-threatening conditions. Ultrasound is a portable tool that captures anatomy and physiology as digital information allowing it to be readily transferred by electronic means. Both APN and PTX are simply ruled out by visualizing respiratory motion at the visceral-parietal pleural interface known as lung sliding (LS), corroborated by either the M-mode or color-power Doppler depiction of LS. We thus assessed how economically and practically this information could be obtained remotely over a cellular network. METHODS: Ultrasound images were obtained on handheld ultrasound machines streamed to a standard free internet service (Skype) using an iPhone. Remote expert sonographers directed remote providers (with variable to no ultrasound experience) to obtain images by viewing the transmitted ultrasound signal and by viewing the remote examiner over a head-mounted webcam. Examinations were conducted between a series of remote sites and a base station. Remote sites included two remote on-mountain sites, a small airplane in flight, and a Calgary household, with base sites located in Pisa, Rome, Philadelphia, and Calgary. RESULTS: In all lung fields (20/20) on all occasions, LS could easily and quickly be seen. LS was easily corroborated and documented through capture of color-power Doppler and M-mode images. Other ultrasound applications such as the Focused Assessment with Sonography for Trauma examination, vascular anatomy, and a fetal wellness assessment were also demonstrated. CONCLUSION: The emergent exclusion of APN-PTX can be immediately accomplished by a remote expert economically linked to almost any responder over cellular networks. Further work should explore the range of other physiologic functions and anatomy that could be so remotely assessed.

Hypothetical Case of Pancreatitis During a Long Duration Lunar Mission.

INTRODUCTION: This peer-reviewed hypothetical case was written to help the readership understand the challenges of dealing with quite common yet very debilitating diseases during space missions. This scenario is based on a real case of an astronaut who had previously flown in space and developed acute pancreatitis after being dehydrated from wilderness survival training. Many astronauts experience life threatening illness and injury before and after flight and, as space missions become longer and more remote, it is only a matter of time before these events occur during a mission. Future exploration space mission planners need to anticipate that these common catastrophic medical events will occur.CASE REPORT: You are a flight surgeon working on console at Mission Control during a long duration lunar mission. You have completed extensive space, military, and civilian aerospace medical training to address almost any anticipated medical event and can summon advice from medical experts located around the world. One crewmember is a 37-yr-old man who just completed an 8-h moonwalk and now describes a constant 7/10 dull epigastric pain with radiation around the left flank to his back. His pain is getting progressively worse and he is presently sitting with his trunk flexed and knees drawn up in extreme distress. Working with the flight director, you must decide in the next 12 h whether to recommend the multibillion-dollar mission be aborted and have the crew return to Earth immediately to save your patient.Hamilton DR, McBeth PB, Greene MR, Kirkpatrick AW, Ball CG. Hypothetical case of pancreatitis during a long duration lunar mission. Aerosp Med Hum Perform. 2019; 90(6):570-578.

Validation and experience with a simple continuous intra-abdominal pressure measurement technique in a multidisciplinary medical/surgical critical care unit.

BACKGROUND: Raised intra-abdominal pressure (IAP) or intra-abdominal hypertension (IAH) may induce many adverse effects including the abdominal compartment syndrome. We evaluated a new technique for continuous monitoring of intra-abdominal pressure (CIAP) using a standard three-way bladder catheter in a diverse group of intensive care unit patients. METHODS: CIAP measured using a standard three-way bladder catheter was compared with five standard intermittent IAP (IIAP) measurements in 79 patients. RESULTS: Mean (standard deviation) CIAP was identical (15.4 mm Hg [5.8]) for CIAP and IIAP one minute after saline injection. Mean differences between methods were less than 1 mm Hg, and similar whether IIAP was measured at 1 minute, 2 minutes, 3 minutes, 4 minutes, or 5 minutes. Bland-Altman analysis comparing CIAP and IIAP (1 minute) revealed a mean difference (95% confidence interval) of -0.06 mm Hg (-0.51, 0.39). Limits of agreement were -4.12 mm Hg to 4.00 mm Hg. Considering gradations of IAH defined by the World Society of the Abdominal Compartment Syndrome, CIAP was sensitive for detecting slightly elevated IAP (>11 mm Hg) but is less sensitive for distinguishing between higher grades of IAH (e.g., pressures >20 mm Hg or 25 mm Hg). Limits of agreement were best for patients with IAP less than 20 mm Hg, surgical or traumatic diagnoses and for patients with BMI less than 26. CONCLUSIONS: Overall, CIAP is an accurate and simple means of measuring IAP when compared with the current standardized method. Elevated CIAP measurements should be confirmed with IIAP measurements if accurate grading is required until further validation and experience is obtained.

Management of haemothoraces in blunt thoracic trauma: study protocol for a randomised controlled trial.

INTRODUCTION: Haemothorax following blunt thoracic trauma is a common source of morbidity and mortality. The optimal management of moderate to large haemothoraces has yet to be defined. Observational data have suggested that expectant management may be an appropriate strategy in stable patients. This study aims to compare the outcomes of patients with haemothoraces following blunt thoracic trauma treated with either chest drainage or expectant management. METHODS AND ANALYSIS: This is a single-centre, dual-arm randomised controlled trial. Patients presenting with a moderate to large sized haemothorax following blunt thoracic trauma will be assessed for eligibility. Eligible patients will then undergo an informed consent process followed by randomisation to either (1) chest drainage (tube thoracostomy) or (2) expectant management. These groups will be compared for the rate of additional thoracic interventions, major thoracic complications, length of stay and mortality. ETHICS AND DISSEMINATION: This study has been approved by the institution's research ethics board and registered with ClinicalTrials.gov. All eligible participants will provide informed consent prior to randomisation. The results of this study may provide guidance in an area where there remains significant variation between clinicians. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT03050502.

Getting the invite list right: a discussion of sepsis severity scoring systems in severe complicated intra-abdominal sepsis and randomized trial inclusion criteria.

Background: Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database. Methods: All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality. Results: Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality). Conclusions: No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission. Trial registration: https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.

Closed Or Open after Source Control Laparotomy for Severe Complicated Intra-Abdominal Sepsis (the COOL trial): study protocol for a randomized controlled trial.

Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise. Methods: The Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score ≥ 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score ≥ 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources. Discussion: Although facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only. Trial registration: ClinicalTrials.gov, NCT03163095.

The Damage Control Surgery in Austere Environments Research Group (DCSAERG): A dynamic program to facilitate real-time telementoring/telediagnosis to address exsanguination in extreme and austere environments.

Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.

Abbreviated closure for remote damage control laparotomy in extreme environments: A randomized trial of sutures versus wound clamps comparing terrestrial and weightless conditions.

INTRODUCTION: Far-Forward Damage Control Laparotomies (DCLs) might provide direct-compression of visceral hemorrhage, however, suturing is a limiting factor, especially for non-physicians. We thus compared abbreviated skin closures comparing skin-suture (SS) versus wound-clamp (WC), on-board a research aircraft in weightlessness (0g) and normal gravity (1g). METHODS: Surgeons conducted DCLs on a surgical-simulator; onboard the hangered-aircraft (1g), or during parabolic flight (0g), randomized to either WC or SS. RESULTS: Ten surgeons participated. Two (40%) surgeons randomized to suture in 0g were incapacitated with motion-sickness, and none were able to close in either 1 or 0g. With WC, two completely closed in 1g as did three in 0g, despite having longer incisions (p = 0.016). Overall skin-closure with WC was significantly greater in both 1g (p = 0.016) and 0g (p = 0.008). CONCLUSIONS: WC was more effective in 1g and particularly 0g. Future studies should address the utility of abbreviated WC abdominal closure to facilitate potential Far-Forward DCL. TRIAL REGISTRATION: ID ISRCTN/77929274.