Trauma bay virtual reality-A game changer for ATLS instruction and assessment.

BACKGROUND: Medical educational research highlights the need for high-fidelity, multidisciplinary simulation training to teach complex decision-making skills, such as those taught in Advanced Trauma Life Support (ATLS). This approach is, however, expensive and time-intensive. Virtual reality (VR) education simulation may improve skill acquisition in a cost-effective and time-sensitive manner. We developed a novel trauma VR simulator (TVRSim) for providers to apply ATLS principles. We hypothesized in this pilot study that TVRSim could differentiate practitioner competency with increasing experience and would be well accepted. METHODS: Providers at a Level I trauma center (acute care surgeons, novice (MS4 & PGY1), junior (PGY2 & 3), senior (PGY4-6) residents) ran a blunt, polytrauma VR code. Ten critical decision points were assessed: intubation, cricothyroidotomy, chest tube, intravenous access, focused abdominal sonography for trauma examination, pelvic binder, activation of massive transfusion protocol, administration of hypertonic saline, hyperventilation and decision to go to the operating room (OR). Learner assessment was based on frequency and time to correct decisions. Participant satisfaction was measured using validated surveys. RESULTS: All 31 providers intubated and obtained intravenous access. Novices and juniors frequently failed at hypertonic saline and hyperventilation decisions. Juniors often failed at cricothyroidotomy (60%) and OR (100%) decisions. Mean time to all decisions except going to the OR was longer for all groups compared to acute care surgeons. Mean number of decisions/min was significantly higher for surgeons and seniors compared to juniors and novices. Mortality was 92.3% for novices, 80% for juniors, 25% for seniors and 0% for the attendings. Participants found TVRSim comfortable, easy to use/interact with/performance enhancing, and helped develop skills and learning. CONCLUSIONS: In this pilot study using a sample of convenience, TVRSim was able to discern decision-making abilities among trainees with increasing experience. All trainees felt that the platform enhanced their performance and facilitated skill acquisition and learning. TVRSim could be a useful adjunct to teach and assess ATLS skills. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level IV.

Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists.

BACKGROUND: Malignant small bowel obstructions (MSBOs) are one of the most challenging problems surgeons encounter, and evidence-based treatment recommendations are lacking. We hypothesized that current opinions on MSBO management differ between acute care surgeons (ACSs) and surgical oncologists (SOs). METHODS: We developed three case scenarios describing patients with previously treated cancer who developed an MSBO. Each case had five to six alternate scenarios, intended to capture the heterogeneity of MSBO presentations. Members of the Society of Surgical Oncology, the American Society of Peritoneal Surface Malignancies, and the Eastern Association for the Surgery of Trauma were asked how likely they would be to offer surgical treatment in each scenario. Responses were analyzed for factors associated with the likelihood surgeons would offer surgical management. RESULTS: 316 surgeons completed the survey: 119 (37.7%) SOs and 197 (62.3%) ACSs. Overall, SOs were nearly twice as likely as ACSs to recommend surgical management. The largest differences between provider groups were seen in patients with an increased metastatic burden. In a patient with MSBO with metastatic colon cancer, both SOs (95.8%) and ACSs (94.4%) were likely or very likely to offer an operation (p=0.587); however, this fell to 91.6% and 77.7%, respectively, when this patient had multiple hepatic metastases (p=0.001). All surgeons were less likely to offer surgery to patients with multiple sites of obstruction, recurrent MSBO, and shorter disease-free intervals. DISCUSSION: Opinions on MSBO management differ based on surgeon training and experience. Multidisciplinary management of patients with MSBO should be offered when available and increased emphasis placed on determining optimal management guidelines across specialties. LEVEL OF EVIDENCE: Level IV Epidemiologic.

Reducing the pain: A cost-effectiveness analysis of transversus abdominis plane block using liposomal bupivacaine for outpatient laparoscopic ventral hernia repair.

BACKGROUND: Transversus abdominis plane block with liposomal bupivacaine has been studied as an effective method of reducing the need for postoperative opioids and increasing same-day discharge rates. However, less is known about the cost-effectiveness of this strategy relative to opioids alone for hernia repair. We performed an economic evaluation of these strategies using a computer simulation model. METHODS: A decision tree was constructed to determine cost-effectiveness as measured by incremental cost-effectiveness ratios per quality-adjusted life-year. Base-case costs, quality-adjusted life-year values, and probabilities were derived from published studies and Medicare fee schedules. For input parameters for which we could not find values in the published literature, we used expert opinion. A 1-month time horizon was selected to focus on the immediate postoperative period. Finally, we performed 1-way, 2-way, and probabilistic sensitivity analyses. RESULTS: The liposomal bupivacaine transversus abdominis plane block was a dominant strategy yielding a $456.75 decrease in cost and an 0.1 increase in quality-adjusted life-years relative to opioids alone. In 1-way sensitivity analysis of cost incremental cost-effectiveness ratio, values were most sensitive to variations in the amount saved by same-day discharge and the cost of bupivacaine. In probabilistic sensitivity analyses, transversus abdominis plane strategy was cost-effective at a willingness-to-pay threshold of $50,000/quality-adjusted life-year in 94.5% of iterations and at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in 97.1% of iterations. CONCLUSION: The use of liposomal bupivacaine transversus abdominis plane block resulted in cost savings and improved quality-adjusted life-years in base-case analyses and was cost-effective at conventional willingness-to-pay thresholds in the majority of iterations in probabilistic sensitivity analyses.

Telephone Follow-Up for Emergency General Surgery Procedures: Safety and Implication for Health Resource Use.

BACKGROUND: It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk core emergency general surgery (cEGS) procedures is safe. We measured the efficacy of telephone follow-up to determine if it could safely reduce the need for routine postoperative clinic visits in this population. STUDY DESIGN: Low-risk nonelective laparoscopic appendectomy, laparoscopic cholecystectomy, umbilical hernia, and inguinal hernia repair patients received telephone follow-up for symptoms concerning for surgical complication within 10 days of discharge. Clinic appointments were made if critical thresholds were reached. Outcomes of interest included rates of completed telephone screens, clinic visits avoided, and missed complications at 30 days postoperatively. RESULTS: Of 402 patients screened, 62 (15.4%) were scheduled for a clinic visit due to threshold responses and 27 (6.7%) were scheduled per patient request, while 275 (68.4%) patients screened negative and did not attend a clinic visit. One hundred sixty-three (59.3%) of the negative screen cohort were contacted after 30 days. Nine (5.5%) patients in this cohort were diagnosed with low-grade complications; no high-grade (Clavien-Dindo ≥ 3) complications were missed by telephone screening. Twenty surgery-related complications were identified in the full patient population; early telephone screening successfully identified the single high-grade complication. CONCLUSIONS: Post-discharge telephone follow-up in cEGS patients reduced the need for clinic follow-up visits by 68%. Missed complications were infrequent and low grade; telephone screening identified the single high-grade complication. Telephone follow-up for low-risk EGS patients is safe and increases efficiency of postoperative resource use.

Stop flailing: The impact of bicortically displaced rib fractures on pulmonary outcomes in patients with chest trauma - an American Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Current evaluation of rib fractures focuses almost exclusively on flail chest with little attention on bicortically displaced fractures. Chest trauma that is severe enough to cause fractures leads to worse outcomes. An association between bicortically displaced rib fractures and pulmonary outcomes would potentially change patient care in the setting of trauma. We tested the hypothesis that bicortically displaced fractures were an important clinical marker for pulmonary outcomes in patients with nonflail rib fractures. METHODS: This nine-center American Association for the Surgery of Trauma multi-institutional study analyzed adults with two or more rib fractures. Admission computerized tomography scans were independently reviewed. The location, degree of rib fractures, and pulmonary contusions were categorized. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of pneumonia, acute respiratory distress syndrome (ARDS), and tracheostomy. Analyses were performed in nonflail patients and also while controlling for flail chest to determine if bicortically displaced fractures were independently associated with outcomes. RESULTS: Of the 1,110 patients, 103 (9.3%) developed pneumonia, 78 (7.0%) required tracheostomy, and 30 (2.7%) developed ARDS. Bicortically displaced fractures were present in 277 (25%) of patients and in 206 (20.3%) of patients without flail chest. After adjusting for patient demographics, injury, and admission physiology, negative pulmonary outcomes occurred over twice as frequently in those with bicortically displaced fractures without flail chest (n = 206) when compared with those without bicortically displaced fractures-pneumonia (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.6), ARDS (OR, 2.6; 95% CI, 1.0-6.8), and tracheostomy (OR, 2.7; 95% CI, 1.4-5.2). When adjusting for the presence of flail chest, bicortically displaced fractures remained an independent predictor of pneumonia, tracheostomy, and ARDS. CONCLUSION: Patients with bicortically displaced rib fractures are more likely to develop pneumonia, ARDS, and need for tracheostomy even when controlling for flail chest. Future studies should investigate the utility of flail chest management algorithms in patients with bicortically displaced fractures. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level III.

Cholecystostomy: Are we using it correctly?

BACKGROUND: Percutaneous Cholecystostomy Tubes (PCT) have become an accepted and common modality of treating acute cholecystitis in patients that are not appropriate surgical candidates. As percutaneous gallbladder drainage has rapidly increased newer research suggests that the technique may be overused, and patients may be burdened with them for extended periods. We examined our experience with PCT placement to identify independent predictors of interval cholecystectomy versus destination PCT. METHODS: All patients with cholecystitis initially treated with PCT from 2014 to 2017 were stratified by whether they underwent subsequent interval cholecystectomy. Demographic data, initial laboratory values, Tokyo Grade, Charlson Comorbidity Index, ASA Class, complications related to PCT, complications related to cholecystectomy, and mortality data were retrospectively collected. Descriptive statistics, univariable, and multivariable Poisson regression were performed. RESULTS: 165 patients received an initial cholecystostomy tube to treat cholecystitis. 61 (37%) patients went on to have an interval cholecystectomy. There were 4 complications reported after cholecystectomy. A total of 46 (27.9%) deaths were reported, only one of which was in the cholecystectomy group. Age, Tokyo Grade, liver function tests, ASA Class, and Charlson Comorbidity Index were significantly different between the interval cholecystectomy and no-cholecystectomy groups. Univariable regression was performed and variables with p < 0.2 were included in the multivariable model. Multivariable Poisson regression showed that increasing Tokyo Grade (IRR 0.454, p = 0.042, 95% CI 0.194-0.969); and increasing Charlson Comorbidity Score (IRR 0.890, p = 0.026, 95% CI 0.803-0.986) were associated with no-cholecystectomy. Higher Albumin (IRR 1.580, p = 0.011, 95% CI 1.111-2.244) was associated with having an interval cholecystectomy. CONCLUSION: Patients in the no-cholecystectomy group were older, had more comorbidities, higher Tokyo Grade, ASA Class, and initial liver function test values than those that had interval cholecystectomy. Since interval cholecystectomy was performed with a low rate of complications, we may be too conservative in performing cholecystectomy after drainage and condemning many patients to destination tubes.

An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

INTRODUCTION: Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS: We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS: We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION: CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. LEVEL OF EVIDENCE: Epidemiologic/Diagnostic study, level III.

Nonoperative management of adhesive small bowel obstruction: what is the break point?

BACKGROUND: The current management paradigm for recurrent adhesive small bowel obstruction (SBO) is nonoperative. Rates of recurrence differ based on time interval between and number of previous occurrences. Optimal time to intervene has not been determined. METHODS: We constructed a Markov model to evaluate costs and quality of life on a hypothetical cohort of 40-year-old patients after their first episode of medical management for postoperative SBO. We estimated a relative risk reduction of .55 with surgical intervention and a relative risk increase of 2.1, 2.9, and 5.7 after the medical management of the 2nd, 3rd, and 4th SBO. RESULTS: Surgery performed after earlier episodes of SBO was more costly but also more effective. The cost difference between surgery after the 1st SBO recurrence vs the 2nd SBO recurrence was $1,643, with an increase of .135 quality-adjusted life years (QALYs), the incremental cost-effectiveness ratio was $12,170 per QALY. CONCLUSIONS: Surgery after the first episode of SBO provides a small increase in QALY at a small cost since surgical intervention lowers the risk of recurrence.

An innovative approach to predict the development of adult respiratory distress syndrome in patients with blunt trauma.

BACKGROUND: Pulmonary contusion (PC) is a common injury associated with blunt chest trauma. Complications such as pneumonia and adult respiratory distress syndrome (ARDS) occur in up to 50% of patients with PC. The ability to predict which PC patients are at increased risk of developing complications would be of tremendous clinical utility. In this study, we test the hypothesis that a novel method that objectively measures percent PC can be used to identify patients at risk to develop ARDS after injury. METHODS: Patients with unilateral or bilateral PC with an admission chest computed tomographic angiogram were identified from the trauma registry. Demographic, infectious, and outcome data were collected. Percent PC was determined on admission chest computed tomography using our novel semiautomated, attenuation-defined computer-based algorithm, in which the lung was segmented with minimal manual editing. Factors contributing to the development of ARDS were identified by both univariate and multivariable logistic regression analyses. ARDS was defined as PaO2/FiO2 ratio of less than 200 with diffuse bilateral infiltrates on chest radiograph with no evidence of congestive heart failure. RESULTS: Quantifying percent PC from our objective computer-based approach proved successful. We found that a contusion size of 24% of total lung volume or greater was most significant at predicting ARDS, which occurred in 78% of these patients. Such patients also had a significantly higher incidence of pneumonia when compared with those with contusions less than 24%. The specificity of contusion size of 24% or greater was 94%, although sensitivity was 37%; positive predictive value was 78%, and negative predictive value was 72%. CONCLUSION: We developed and describe a software-based methodology to accurately measure the size of lung contusion in patients of blunt trauma. In our analyses, contusions of 24% or greater most significantly predict the development of ARDS. Such an objective approach can identify patients with PC who are at increased risk for developing respiratory complications before they happen. Further research is needed to use this novel methodology as a means to prevent posttraumatic lung injury in patients with blunt trauma. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; diagnostic study, level IV.