Surgical Emergencies in the ICU.

Surgical emergencies are common in the critical care setting and require prompt diagnosis and management. Here, we discuss some of the surgical emergencies involving the gastrointestinal, hepatobiliary, and genitourinary sites. In addition, foreign body aspiration and necrotizing soft-tissue infections have been elaborated. Clinicians should be aware of the risk factors, keys examination findings, diagnostic modalities, and medical as well as surgical treatment options for these potentially fatal illnesses.

A team approach to effectively discharge trauma patients.

BACKGROUND: Trauma patients represent a high-volume and high-acuity population. This makes discharge planning difficult. Discharged by noon is a metric shown to correlate with hospital throughput. Improvements in efficiency will be needed to improve resource utilization and increase discharge by noon rate. This study aimed to evaluate the impact of a standardized discharge team on length of stay and discharge by noon. MATERIALS AND METHODS: A university level I trauma center implemented a discharge team composed of a trauma attending and an advanced practice provider. This team is tasked with evaluating patients on the discharge list daily. This allowed patients ready for discharge to be evaluated and discharged before noon. A retrospective review was performed to analyze discharge by noon rates before and after implementation of the discharge team. RESULTS: A total of 3053 patients were discharged before the implementation of the discharge team and 3801 after. Discharges by noon increased from 25.5% to 51.2% in the post. For patients with an injury severity score >15, this same improvement was seen, 22.5% to 51.9%. Similar improvements were seen when controlling for final discharge disposition and primary payer status. CONCLUSIONS: By establishing a separate discharge team, large improvements can be seen in the discharge by noon rate. These improvements were maintained when controlling for injury severity score, final discharge disposition, and insurance status. Significant savings are possible in both charges to the patient and direct costs to the facility. The utilization of a discharge team should be considered at similar facilities.

Secondary overtriage in a statewide rural trauma system.

BACKGROUND: Rural hospitals have variable degrees of involvement within the nationwide trauma system because of differences in resources and operational goals. "Secondary overtriage" refers to the patient who is discharged home shortly after being transferred from another hospital. An analysis of these occurrences is useful to determine the efficiency of the trauma system as a whole. MATERIALS AND METHODS: Data were extracted from a statewide trauma registry from 2007-2012 to include those who were (1) discharged home within 48 h of arrival and (2) did not undergo a surgical procedure. We then identified those who arrived as a transfer before being discharged (secondary overtriage) from those who arrived from the scene. Factors associated with transfers were analyzed using a logistic regression. Injuries were classified based on the need of a specific consultant. Time of arrival to the emergency department was analyzed using 8-h blocks, with the 7 AM-3 PM block as reference. RESULTS: A total of 19,319 patients fit our inclusion criteria of which 1897 (9.8%) arrived as transfers. Descriptive analysis showed a number of differences between transfers and nontransfers because of our large sample size. Thus, we examined variables that had more clinical significance using logistic regression controlling for age, injury severity score, the type of injury, blood products given, the time of arrival to initial emergency room, and whether a computed tomography scan was obtained initially. Factors associated with being transferred were injury severity score >15, transfusion of packed-red-blood-cells, graveyard-shift arrivals, and neurosurgical, spine, and facial injuries. Patients having a computed tomography scan were less likely to be transferred. CONCLUSIONS: Secondary overtriage may result from the hospital's limited resources. Some of these limitations are the availability of surgical specialists, blood products, and overall coverage during the "graveyard-shift." However, some of these transfers may be appropriate even though patients are ultimately discharged shortly after transfer.

Diagnostic and therapeutic considerations in cases of civilian intravascular ballistic embolism: a review of case reports.

Background: Ballistic embolism (BE) is a rare complication of firearm injuries notoriously associated with a vexing clinical picture in the trauma bay. Unless considered early, the associated confusion can lead to needless delay in the management of the patient with a gunshot wound. Despite this known entity, there is a relative paucity of high-grade evidence regarding complications, management, and follow-up in these patients. Methods: An electronic database literature search was conducted to identify cases of acute intravascular BE in pediatric and adult civilians occurring during index hospitalization, filtered to publications during the past 10 years. Exclusion criteria included non-vascular embolization, injuries occurring in the military setting, and delayed migration defined as occurring after discharge from the index hospitalization. Results: A total of 136 cases were analyzed. Nearly all cases of BE occurred within 48 hours of presentation. Compared with venous emboli, arterial emboli were significantly more likely to be symptomatic (71% vs. 7%, p<0.001), and 43% of patients developed symptoms attributable to BE in the trauma bay. In addition, arterial emboli were significantly less likely to be managed non-invasively (19% vs. 49%, p<0.001). Open retrieval was significantly more likely to be successful compared with endovascular attempts (91% vs. 29%, p<0.001). Patients with arterial emboli were more likely to receive follow-up (52% vs. 39%) and any attempt at retrieval during the hospitalization was significantly associated with outpatient follow-up (p=0.034). All but one patient remained stable or had clinically improved symptoms after discharge. Conclusion: Consideration for BE is reasonable in any patient with new or persistent unexplained signs or symptoms, especially during the first 48 hours after a penetrating firearm injury. Although venous BE can often be safely observed, arterial BE generally necessitates urgent retrieval. Patients who are managed non-invasively may benefit from follow-up in the first year after injury.

Futility in acute care surgery: first do no harm.

The consequences of the delivery of futile or potentially ineffective medical care and interventions are devastating on the healthcare system, our patients and their families, and healthcare providers. In emergency situations in particular, determining if escalating invasive interventions will benefit a frail and/or severely critically ill patient can be exceedingly difficult. In this review, our objective is to define the problem of potentially ineffective care within the specialty of acute care surgery and describe strategies for improving the care of our patients in these difficult situations.

A Comprehensive Spinal Cord Injury Treatment Protocol Improves Outcomes and Decreases Complications.

BACKGROUND: Spinal cord injury (SCI) is a devastating event with a complicated recovery. Through the use of an interdisciplinary team a comprehensive care plan was developed, utilizing all available best practices, to prevent secondary complications. Previous work has shown the benefit of single system protocols or interventions. This study aimed to assess changes in outcomes after implementation of a comprehensive protocol. MATERIAL AND METHODS: This was a retrospective cohort study performed at an ACS Level I trauma center. It was based on data abstract from the institutions trauma registry over a 10 year period. Patients with quadriplegia after a traumatic injury were included. Data on hospital outcomes and complications was collected and compared before and after the use of the Spinal cord injury protocol. RESULTS: 58 patients were evaluated. Overall, there was a reduction in complications after the implementation, with significant reductions in pneumonia (47% vs 16%; P = .02) and decubitus ulcers (47% to 11%; P = .005). ICU length of stay decreased by 7 days and hospital length of stay decreased 13 days. There was no difference in mortality. Hospital costs also decreased a mean of $42,000. CONCLUSIONS: A comprehensive SCI protocol can reduce secondary complications in quadriplegic patients. This study found significant decreases in pneumonia and decubitus ulcer rates after implementation of the protocol. Lengths of stay and cost were also significantly reduced. Future research using comprehensive SCI protocols is needed to further assess its effects on outcomes for this specific patient population. Similar centers should consider adoption of comprehensive SCI protocols.

Mastering the Match: Recruiting a Successful Surgery Resident.

PURPOSE OF REVIEW: The objective of general surgery residency is to produce competent surgeons. At a minimum this requires being procedurally and clinically capable and able to pass the board exams. Recruitment is designed to select those residents who can successfully do so. But there is more to being a successful resident than that. In this review, we attempt to define a "successful resident" and how to attract them to your program. RECENT FINDINGS: Resident applicants are still most concerned with matching to a program that will prepare them for a surgery career. Though there is variation of importance for different applicants, resident life, comradery, and relationships with faculty or mentors do factor into residency ranking. The program website remains the most utilized resource for applicants. However, social media (SM) has an increasing role in applicants' evaluation of a program. SM and the preinterview gathering seem to expose the subjective aspects of a program most effectively. Additional assessments evaluating personality, grit or career goals may assist in screening applicants for good "fit." SUMMARY: In order to recruit successful residents, it is necessary to determine which applicant attributes are important to the program. Additionally, a program must maintain an updated website with clearly delineated resident expectations and program strengths. The screening and interview process must be maximized to target residents with career goals complimentary to available program opportunities. If SM is utilized, post should be frequent with relevant information pertaining to both resident life and educational or clinical opportunities.

High value care education in general surgery residency programs: A multi-institutional needs assessment.

BACKGROUND: The ACGME mandates that residency programs provide training related to high value care (HVC). The purpose of this study was to explore HVC education in general surgery residency programs. METHODS: An electronic survey was distributed to general surgery residents in geographically diverse programs. RESULTS: The response rate was 29% (181/619). Residents reported various HVC components in their curricula. Less than half felt HVC is very important for their future practice (44%) and only 15% felt confident they could lead a QI initiative in practice. Only 20% of residents reported participating in a root cause analysis and less than one-third of residents (30%) were frequently exposed to cost considerations. CONCLUSION: Few residents feel prepared to lead quality improvement initiatives, have participated in patient safety processes, or are aware of patients' costs of care. This underscores the need for improved scope and quality of HVC education and establishment of formal curricula.

Bouveret syndrome: a case report.

Bouveret syndrome is characterized by the migration of a gallstone through a cholecystenteric fistula into the proximal duodenum resulting in gastric outlet obstruction. Bouveret syndrome is a rare phenomenon that most commonly occurs in females and the elderly. A 79-year-old female presented with symptoms of gastric outlet obstruction and was diagnosed with Bouveret syndrome. This report describes the symptoms, diagnosis, and management of Bouveret syndrome, as well as its prevalence and differentiation from gallstone ileus. Patients with Bouveret syndrome present with varied, non-specific symptoms that may include emesis, abdominal pain, anorexia, and abdominal distention. Computed tomography remains the diagnostic modality of choice. Although different techniques are reported, surgical intervention is almost always required in the treatment of Bouveret syndrome.

Traumatic spinal cord injury in West Virginia: Disparities by insurance and discharge disposition from an acute care hospital.

Context: Medicaid has been linked to worse outcomes in a variety of diagnoses such as lung cancer, uterine cancer, and cardiac valve procedures. It has furthermore been linked to the reduced health-related quality of life outcomes after traumatic injuries when compared to other insurance groups. In spinal cord injury (SCI), the care provided in the subacute setting may vary based upon payor status, which may have implications on outcomes and cost of care.Design: A retrospective review utilizing the institutional trauma databank was performed for all adult patients with spinal cord injury since 2009. Pediatric patients were excluded. Insurance type, race, length of stay, discharge status (alive/dead), discharge disposition, injury severity score (ISS), and hospital charges billed were recorded.Results: Two hundred patients were identified. Overall 27.5% of patients with SCI during the period of our review were Medicaid beneficiaries. ISS was similar between Medicaid and non-Medicaid patients, but the Medicaid beneficiaries were younger (37 vs 50 years of age; P < .001). Medicaid beneficiaries had a significantly longer length of stay (20.9 days; P < .001) when compared to all other patients. They furthermore were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center. Inpatient charges billed for Medicaid beneficiaries were significantly higher than those of non-Medicaid patients (203,264 USD vs 140,114 USD; P = .015), likely reflecting the increased length of stay while awaiting appropriate disposition.Conclusion: Medicaid patients with SCI in West Virginia had a longer hospital stay, higher charges billed, and were more likely to be discharged home or to a skilled nursing facility rather than an acute rehabilitation center, when compared to non-Medicaid patients. The lack of availability of rehabilitation facilities for Medicaid beneficiaries likely explains this difference.

Enhancing the Educational Value and Faculty Attendance of a Morbidity and Mortality Conference.

OBJECTIVE: There exists significant variation in the approach to and execution of morbidity and mortality conference (M&MC). Faculty attendance remains a working challenge. We sought to change our department's M&MC and hypothesized improved educational value and attendance. DESIGN: Complications were submitted in Clavien-Dindo format. A designated M&MC moderator facilitated discussion. A teaching point (TP) was assigned to each complication intended to be the focus of discussion. Presentations followed a structured 6-slide PowerPoint template. A web-based tool using Google Forms was developed and distributed as an "App" for tracking of attendance. An anonymous online survey was distributed to participants to elucidate perception of M&MC following the intervention. SETTING: Academic medical center. PARTICIPANTS: Postgraduate year-1 to 5 surgery residents and faculty at West Virginia University, Morgantown. RESULTS: Forty-eight of sixty-three surveys were returned (response rate 76%). Twenty-five faculty (70%) and 23 residents (82%) responded. A predetermined TP was viewed as the most favorable change made by both faculty and residents. 65% of faculty and residents acknowledged improved educational value, 58% found a single moderator to help streamline Morbidity and Mortality (M&M) presentations and 71% felt that a standard PowerPoint template improved quality of presentations. Both residents (96%) and faculty (68%) believed a predetermined TP improved the educational value of the conference and medical knowledge during preparation. More residents (43%) than faculty (16%) believed that changes to the department's M&MC format allowed better identification of quality improvement issues. Furthermore, the majority of residents (83%) believed that changes to the department's M&M format allowed better identification of system factors compared to faculty (32%), p = 0.003. Faculty participation increased from 60% to 80% after changes (p = 0.03). CONCLUSIONS: The educational value of M&MC and attendance can be improved with simple changes, but faculty and residents may have different expectations and perceptions.

Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy (ATT) and endovascular stents. METHODS: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. RESULTS: A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol versus no screening protocol (odds ratio [OR], 4.74; 95% confidence interval [CI], 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR, 12.7; 95% CI, 6.24-25.62; p = 0.003). The use of ATT versus no ATT resulted in a decreased risk of stroke (OR, 0.20; 95% CI, 0.06-0.65; p < 0.0001) and mortality (OR, 0.17; 95% CI, 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to ATT versus ATT alone (OR, 1.63; 95% CI, 0.2-12.14; p = 0.63). CONCLUSION: We recommend using a screening protocol to detect BCVI in blunt polytrauma patients. Among patients with high-risk cervical spine injuries, we recommend screening computed tomography angiography to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a computed tomography angiography to detect BCVI. We recommend the use of ATT in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to ATT in patients with Grade II or III BCVIs. LEVEL OF EVIDENCE: Guidelines, Level III.

Monitoring modalities and assessment of fluid status: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Fluid administration in critically ill surgical patients must be closely monitored to avoid complications. Resuscitation guided by invasive methods are not consistently associated with improved outcomes. As such, there has been increased use of focused ultrasound and Arterial Pulse Waveform Analysis (APWA) to monitor and aid resuscitation. An assessment of these methods using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework is presented. METHODS: A subsection of the Surgical Critical Care Task Force of the Practice Management Guideline Committee of EAST conducted two systematic reviews to address the use of focused ultrasound and APWA in surgical patients being evaluated for shock. Six population, intervention, comparator, and outcome (PICO) questions were generated. Critical outcomes were prediction of fluid responsiveness, reductions in organ failures or complications and mortality. Forest plots were generated for summary data and GRADE methodology was used to assess for quality of the evidence. Reviews are registered in PROSPERO, the International Prospective Register of Systematic Reviews (42015032402 and 42015032530). RESULTS: Twelve focused ultrasound studies and 20 APWA investigations met inclusion criteria. The appropriateness of focused ultrasound or APWA-based protocols to predict fluid responsiveness varied widely by study groups. Results were mixed in the one focused ultrasound study and 9 APWA studies addressing reductions in organ failures or complications. There was no mortality advantage of either modality versus standard care. Quality of the evidence was considered very low to low across all PICO questions. CONCLUSION: Focused ultrasound and APWA compare favorably to standard methods of evaluation but only in specific clinical settings. Therefore, conditional recommendations are made for the use of these modalities in surgical patients being evaluated for shock. LEVEL OF EVIDENCE: Systematic Review, level II.

Small Bowel Obstruction Due to Suprapubic Catheter Placement.

Suprapubic catheter placement has associated complications such as bowel injury, bladder injury, or bleeding. This case describes the management of an elderly patient who had suprapubic catheter placement complicated by small bowel obstruction. The catheter had continued production of urine. Further patient treatment required abdominal exploration and bowel resection.