Heterotopic Ossification of the Abdomen: A Rare Sequela Following Trauma and Damage Control Laparotomy.

Heterotopic ossification (HO) of the abdomen is a rare yet highly morbid complication following blunt and penetrating trauma requiring damage control laparotomy. We present the case of a 22-year-old man, 20 months after life-threatening motor vehicle crash with major vascular injury requiring multiple abdominal surgeries. The patient was initially treated at a community hospital and subsequently developed a chronic left lower quadrant enterocutaneous fistula, accompanied by a gradually worsening diffuse abdominal pain. He was referred to our tertiary care center with extensive skin breakdown and an inability to control the fistula despite numerous wound care consultations. He also had severe abdominal deformities due to HO in the abdominal wall, peritoneum, paraspinal muscles, and parapelvic regions. As HO is largely underreported, it is crucial to refer those patients, once medically stabilized, to tertiary care centers for surveillance and possible treatment when symptomatic.

Open Versus Laparoscopic Appendectomy: A Post Hoc Analysis of the EAST Appendicitis MUSTANG Study.

Background: We sought to understand which factors are associated with open appendectomy as final operative approach. We hypothesize that higher American Association for the Surgery of Trauma (AAST) Emergency General Surgery (EGS) grade is associated with open appendectomy. Patients and Methods: Post hoc analysis of the Eastern Association for the Surgery of Trauma (EAST) Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated and Gangrenous (MUSTANG) prospective appendicitis database was performed. All adults (age >18) undergoing appendectomy were stratified by final operative approach: laparoscopic or open appendectomy (including conversion from laparoscopic). Univariable analysis was performed to compare group characteristics and outcomes, and multivariable logistic regression was performed to identify demographic, clinical, or radiologic factors associated with open appendectomy. Results: A total of 3,019 cases were analyzed. One hundred seventy-five (5.8%) patients underwent open appendectomy, including 127 converted from laparoscopic to open. The median age was 37 (25) years and 53% were male. Compared with the laparoscopic group, open appendectomy patients had more comorbidities, higher proportion of symptoms greater than 96 hours, and higher AAST EGS grade. Moreover, on intraoperative findings, the open appendectomy group had a higher incidence of perforated and gangrenous appendicitis with purulent contamination, abscess/phlegmon, and purulent abdominal/pelvic fluid. On multivariable analysis controlling for comorbidities, clinical and imaging AAST grade, duration of symptoms, and intra-operative findings, only AAST Clinical Grade 5 appendicitis was independently associated with open appendectomy (odds ratio [OR], 5.63; 95% confidence interval [CI], 1.24-25.55; p = 0.025). Conclusions: In the setting of appendicitis, generalized peritonitis (AAST Clinical Grade 5) is independently associated with greater odds of open appendectomy.

Small Intestinal Perforation Secondary to Necrotizing Enteritis-An Under-Recognized Complication of Crohn's Disease.

Small bowel perforation is an uncommon but severe event in the natural history of Crohn's disease with fewer than 100 cases reported. We review Crohn's disease cases with necrotizing enteritis and share a case of a 26-year-old female who presented with a recurrent episode of small intestinal perforation. A PubMed literature review of case reports and series was conducted using keywords and combinations of "Crohn's disease," "small intestine perforation," "small bowel perforation," "free perforation," "regional enteritis," and "necrotizing enteritis." Data extracted included demographic data, pre- or postoperative steroid administration, medical or surgical management, and case fatality. Nineteen reports from 1935 to 2021 qualified for inclusion. There were 43 patients: 20 males and 23 females with a mean age of 36 ± 15 years old. 75 total perforations were described: 56 ileal (74.6%), 15 jejunal (20.0%), 2 cecal (2.7%), and 1 small intestine non-specified (2.7%). 38 of 43 patients were managed surgically by primary repair (11), ostomy creation (21), or an anastomosis (11). Of 11 case fatalities, medical management alone was associated with higher mortality (5/5; 100% mortality) compared to those treated surgically (6/38; 15.8% mortality; P < .001). Patient sex, disease history, acute abdomen, and pre- or postoperative steroid use did not significantly correlate with mortality. Jejunal perforation was significantly (P = .028) associated with event mortality while ileal was not (P = .45). Although uncommon, necrotizing enteritis should be considered in Crohn's patients who present with small intestinal perforation. These cases often require urgent surgical intervention and may progress to fulminant sepsis and fatality if not adequately treated.

Severe Short Bowel Syndrome: Prognosis for Nutritional Independence Through Management by a Multidisciplinary Nutrition Service and Surgery.

INTRODUCTION: Short bowel syndrome (SBS) is a debilitating condition associated with significant morbidity and mortality. Historically, SBS patients require indefinite parenteral nutrition (PN) and endure lifelong nutritional challenges. The purpose of this study was to review the outcomes, specifically nutritional independence, of a multidisciplinary nutrition service. METHODS: A retrospective analysis of SBS patients followed by our surgical nutrition service was performed. Patients without 1-year follow-up were excluded. Demographics and nutritional parameters were collected at 4 intervals: initial presentation, 1-year, 2-year, and 5-year follow-up. Short bowel syndrome anatomical subtypes identified through operative reports were characterized as end jejunostomy, jejunocolonic, or jejuno-ileocolonic with ileo-cecal valve intact. Intestinal failure was defined by the requirement of PN, while intestinal insufficiency was defined by enteral support requirement. Clinical outcomes examined included mortality, fistula closure, and nutritional independence. RESULTS: The study cohort comprised 89 patients, 50 of whom had ≤ 100 cm intestinal length. Mean age was 57 ± 17y, 55 (62%) were female, and median initial intestinal length was 77 [60-120] cm. Short bowel syndrome was complicated by fistulas in 47 (53%) of patients. Overall mortality was 13%, and 67 (75%) were liberated from PN. A total of 58 (65%) underwent operative intervention and fistula closure was achieved in 37 of 47 (79%) patients. CONCLUSIONS: Short bowel syndrome patients can experience significant benefit under treatment by a multidisciplinary nutrition service. By incorporating surgical intervention, the majority of patients previously relegated to lifelong PN have the opportunity to become nutritionally independent within 5 years.

Teduglutide for the treatment of low-output enterocutaneous fistula - A pilot randomized controlled study.

BACKGROUND & AIMS: Enterocutaneous fistula (ECF) is a complication of surgery or inflammatory bowel disease associated with disproportionately high healthcare costs, morbidity, and mortality. We performed this proof-of-concept, feasibility, open-label, pilot randomized, crossover study to assess the efficacy and safety of the use of teduglutide (TED) to treat ECF. METHODS: Adults (age >18) with low-output (<200 mL/d) ECF were randomized to 2 months of continuing standard-of-care (SOC) followed by crossover to 2 months of SOC + TED or the reverse order. The primary efficacy endpoint was decrease in fistula volume by 20% of baseline 3-day average. Secondary efficacy endpoints were: fistula resolution and health-related quality of life questionnaire scores. RESULTS: Six out of 10 planned subjects were randomized and completed the study, which was terminated early due to slow enrollment during the Covid-19 pandemic. Overall subject compliance with daily TED injections was high (98%). Five of six enrolled subjects met the definition for the primary efficacy endpoint; these clinical responses were not observed during the SOC arm in these subjects. One subject experienced complete fistula closure during TED treatment. Adverse events during treatment were uncommon, minor, and usually resolved despite ongoing treatment. Quality of life survey responses were highly variable and did not correlate with fistula changes. CONCLUSIONS: Two months of teduglutide treatment was feasible, well-tolerated, and resulted in observable decreases in ECF drainage in the majority of subjects, including spontaneous closure in one subject. This therapy shows promise, but larger, multicenter confirmatory trials are required. CLINICALTRIALS: GOV: (NCT02889393).

Early hypermetabolism is uncommon in trauma intensive care unit patients.

BACKGROUND: Classic experiments demonstrating hypermetabolism after major trauma were performed in a different era of critical care. We aim to describe the modern posttraumatic metabolic response in the trauma intensive care unit (TICU). METHODS: This prospective observational study enrolled TICU mechanically ventilated adults (aged ≥18) from 3/2018-2/2019. Multiple, daily resting energy expenditure (REE) measurements were recorded. Basal energy expenditure (BEE) was calculated by the Harris-Benedict equation. Hypometabolism was defined as average daily REE < 0.85*BEE and hypermetabolism defined as average daily REE > 1.15*BEE. Demographics, interventions, and clinical outcomes were abstracted. Descriptive statistics and multivariable logistical regression models evaluating demographics with the outcome variable of hypermetabolism for the first 3 days ("sustained hypermetabolism") were performed, along with group-based trajectory modeling (GBTM). RESULTS: Fifty-five patients were analyzed: median age was 38 (28-56) years; 38 (69%) were male; body mass index (kg/m2 ) was 28 (26-32); and Injury Severity Score was 27 (19-34), with (38 [71%] blunt, 8 [15%] penetrating, 7 [13%] burn) injury mechanism. Overall, 19 (35%) had hypermetabolism on day 1 ("immediate hypermetabolism"), and 11 (21%) had sustained hypermetabolism for the first 3 days. Logistic regression analysis identified penetrating mechanism (adjusted odds ratio [AOR], 16.4; 95% CI, 1.9-199.6; p = .015), burn mechanism (AOR, 11.1; 95% CI, 1.3-116.8; p =.029), and maximum temperature (AOR, 4.2; 95% CI, 1.3-20.3; p= .041) as independent predictors of sustained hypermetabolism. GBTM identified 4 nutrition phenotypes, with 2 hyperconsumptive phenotypes associated with increased risk of malnutrition at discharge. CONCLUSION: Only a minority of injured patients is hypermetabolic in the first week after injury. Elevated temperature, penetrating mechanism, and burn mechanism are independently associated with sustained hypermetabolism. Hyperconsumptive phenotype patients are more likely to develop malnutrition during hospitalization.

Rapid Diagnosis of Altered Mental Status in Home Parenteral Nutrition Patient.

This report describes the application of a routine lab test to confirm a diagnosis of hypernatremia suspected to be secondary to an error in parenteral nutrition compounding. The novel aspect of this case is the use of the "urine electrolytes" laboratory test to verify that the electrolyte concentration of the mixture is consistent with what was printed on the bag label.

Alcohol/Illicit Substance Use in Fatal Motorcycle Crashes.

BACKGROUND: The objective of the current study is to determine how alcohol and illicit substance use contributes to motorcycle crash fatalities by examining the relationship between toxicology levels found postmortem and the behavior of riders and passengers in fatal motorcycle crashes. MATERIALS AND METHODS: All motorcycle fatalities in Miami-Dade County, FL, from 2009 to 2014 were reviewed using the Miami-Dade County Medical Examiner's toxicology reports and the corresponding crash reports. RESULTS: Positive alcohol/illicit substance detection was found in 44% of our population of 227 fatalities. When compared with those with a negative alcohol/illicit substance detection, those with a positive alcohol/illicit substance detection were more likely to be found at fault of the crash (77% versus 50%, P < 0.001), more likely to be in a single-vehicle crash (47% versus 21%, P < 0.001) and less likely to wear a helmet (44% versus 64%, P = 0.002). However, there was no significant relationship between speeding and alcohol/illicit substance detection (29% versus 33%, P = 0.748). In addition, a regression analysis demonstrated that there was less helmet use and more single-vehicle crashes with higher blood alcohol concentration. CONCLUSIONS: In fatal motorcycle crashes, alcohol and illicit substance use had a significantly negative impact on the risk aversion of motorcycle fatalities in regard to fault, helmet use, and single-vehicle crashes.

Redefining Preventable Death-Potentially Survivable Motorcycle Scene Fatalities as a New Frontier.

BACKGROUND: The National Academies of Science, Engineering, and Medicine defined a roadmap to achieve zero preventable trauma deaths. In the United States, there are over 5000 motorcycle fatalities annually. Florida leads the nation in annual motorcycle crash (MCC) deaths and injuries. It is unknown how many are potentially preventable. We hypothesize that certain patterns of injuries in on-scene fatalities that are potentially survivable and aim to make recommendations to achieve the National Academies of Science, Engineering, and Medicine objective. MATERIALS AND METHODS: Miami-Dade County medical examiner reports of MCC deaths pronounced on scene, and emergency medical service or law enforcement reports from 2010 to 2012 were reviewed by board-certified trauma surgeons. Causes of death were categorized into exsanguination, traumatic brain injury or decapitation, crushed chest, or airway complications. Determination of potentially survivable versus nonsurvivable injuries was based upon whether the riders had potentially survivable injuries and had they been transported immediately to a trauma center. Traumatic brain injury cases were reviewed by a board-certified neurosurgeon. RESULTS: Sixty MCC scene deaths were analyzed. Ninety-five percent were men, 55% were helmeted, and 42% had positive toxicology. The median Injury Severity Score was 41 (Range 14-75, IQR 31-75). Nineteen (32%) deaths were potentially survivable, with death due to airway in 14 (23%) and exsanguination in 4 (7%) patients. CONCLUSIONS: One-third of on-scene urban motorcycle deaths are potentially survivable in a young patient population. ISS score comparison demonstrates the lower injury burden in those deemed potentially survivable. Automatic alert systems in motorcycles and first responder training to police are recommended to improve trauma system efficacy in reducing preventable deaths from MCCs.

Use of Predictive Equations for Energy Prescription Results in Inaccurate Estimation in Trauma Patients.

BACKGROUND: Overfeeding and underfeeding are associated with poor clinical outcomes. In the absence of indirect calorimetry (IC), the Society of Critical Care Medicine/ASPEN recommend prescribing 25-30 kcal/kg. The Harris-Benedict equation (HBE) multiplied by a stress factor is commonly applied in critically ill patients. We describe the difference between estimated and actual energy needs in critically injured patients. METHODS: From March to November 2018, we collected demographics and energy needs determined by continuous IC (started within 4 days) in intubated adults. Ideal or adjusted body weight was used for 25-30 kcal/kg, and HBE was multiplied by a 1.3 stress factor (1.3HBE). Daily requirements up to 14 days, extubation, or death were calculated using all 3 methods and compared with IC. RESULTS: Fifty-five subjects were included. Median age was 38 [27-58] years, 38 (69%) were male, body mass index was 28 [25-33] kg/m2 , and Acute Physiology and Chronic Health Evaluation II score was 17 [14-24] Mechanism of injury was blunt (38, 69%), penetrating (9, 16%), and burn (8, 15%). By day 14, compared with measured energy requirements by IC, the other methods could result in a cumulative 1827-kcal (+7%) surplus (1.3HBE), a 1313-kcal (-5%) deficit (25 kcal/kg), or a 3950-kcal (+14%) surplus (30 kcal/kg) per patient over a median 9 days. CONCLUSION: In critically injured patients, predictive equations for energy needs do not account for dynamic metabolic changes over time and could result in underfeeding or overfeeding. Adjusting daily prescription based on continuous IC may result in better individualized treatment.

Fatal gastrointestinal bleeding in a case report of Coat's plus syndrome.

INTRODUCTION: Coat's plus syndrome is an extremely rare genetic syndrome that leads to a variety of symptoms. We are reporting a case of Coat's plus syndrome that had persistent GI bleeding and review of current literature. PRESENTATION OF CASE: The patient is a female in her 40 s with a history of coat's disease and end stage renal failure on dialysis. The etiology of renal failure was not discovered, and the patient was being worked up for a kidney transplant. The patient required admission after deterioration of nutritional status with a BMI of 14.3. During admission the patient initially had intermittent GI bleeding requiring weekly blood transfusions. On work up of the GI bleed, no etiology was identified either. As a result persistent negative GI bleed work up, we pursued alternative diagnoses. The history of Coat's disease prompted us to work up the patient for Coat's plus syndrome. A genetic test confirmed the presence of CTC-1 gene mutation, which results in Coat's plus syndrome. With no treatment available as of yet, the patient continued to deteriorate into multi-organ failure. DISCUSSION: We present an example of GI bleeding in Coat's plus syndrome, only identified thru genetic testing, that is very rare and complex in nature. Despite numerous workups, no specific etiology was identified for the GI bleeding. CONCLUSION: Previous reports have not investigated cause of GI bleeding, since it is extremely rare in the literature. Further investigation is warranted to understand cause and effects of GI bleeding in this rare genetic disease.

Continuous Indirect Calorimetry in Critically Injured Patients Reveals Significant Daily Variability and Delayed, Sustained Hypermetabolism.

BACKGROUND: Previous studies have used using Indirect Calorimetry (IC) with solitary or sparse measurements of resting energy expenditure (REE). This "snapshot" may not capture the dynamic nature of metabolic requirements. Using continuous IC, we describe the variation of REE during the first days in the intensive care unit. METHODS: Injured adults (≥18 years) requiring mechanical ventilation from March 2018 to September 2018 were enrolled. IC was initiated within 4 days of admission and continuous REE recorded until 14 days, extubation, or death. Multiple 10-minute periods collected during steady state were used to calculate daily REE maximum, minimum, average, and variability [(REEmax - REEmin/2)/average REE]. RESULTS: We included 55 patients. Median age was 38 [27-58] years, 38 (69%) were male, body mass index was 28 [25-33] kg/m2 , and Acute Physiology and Chronic Health Evaluation II was 17 [14-24]. Mechanism of injury was: blunt (n = 38, 69%), penetrating (n = 9, 16%), and burn (n = 8, 15%). Average REE increased gradually from 1,663 kcal [1,435-2,143] to a maximum of 2,080 [1,701-2,336] on day 7, a relative 25% increase, which was sustained through day 14. REE variability ranged 8%-13% and was not reliably predicted by fever, tachycardia, elevated intracranial pressures, hypertension, or hypotension. CONCLUSION: In critically injured patients, steady-state REE measurements display fluctuations over a 24-hour period and demonstrate a gradual rise over the first few days after injury. Continuous REE, if available, is recommended for more precise matching of energy delivery to metabolic requirements.

A Weaning Protocol for Venovenous Extracorporeal Membrane Oxygenation With a Review of the Literature.

Several articles have discussed the weaning process for venoarterial extracorporeal membrane oxygenation; however, there is no published report to outline a standardized approach for weaning a patient from venovenous extracorporeal membrane oxygenation (ECMO). This complex process requires an organized approach and a thorough understanding of ventilator management and ECMO physiology. The purpose of this article is to describe the venovenous ECMO weaning protocol used at our institution as well as provide a review of the literature.

Identification of methicillin-susceptible or methicillin-resistant Staphylococcus aureus carrier status preoperatively using polymerase chain reaction in patients undergoing elective surgery with hardware implantation.

We compared bedside polymerase chain reaction to culture for identifying Staphylococcus aureus in patients about to undergo surgery with hardware implantation. Patients were screened for S. aureus carrier status at the preoperative clinic and on the day of surgery. The sensitivity, specificity, positive and negative predictive values, and accuracy were calculated.

Simple acute appendicitis versus non-perforated gangrenous appendicitis: is there a difference in the rate of post-operative infectious complications?

BACKGROUND: According to the 2002 Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-abdominal Infections, antimicrobial therapy is not recommended beyond 24 hours for the treatment of postoperative acute or gangrenous appendicitis without perforation. However, clinicians commonly consider gangrenous appendicitis to pose a greater risk of post-operative infectious complications, such as surgical site infections and intra-abdominal abscesses. This study examines the relative risk of post-operative infection between patients with simple and gangrenous appendicitis. METHODS: A retrospective review of patients with either non-perforated gangrenous or simple appendicitis from 2010 to 2012 was performed at a large urban teaching hospital. RESULTS: The rate of post-operative intra-abdominal abscess formation, which was diagnosed on patient readmission to the hospital, was significantly greater in patients with non-perforated gangrenous appendicitis in comparison to those with simple non-perforated appendicitis. Also, patients with non-perforated gangrenous appendicitis received extended courses of post-operative antibiotics, despite SIS recommendations. CONCLUSIONS: The role of peri-operative antibiotics for non-perforated gangrenous appendicitis merits further study.

Comparison of mortality of ESRD patients with lupus by initial dialysis modality.

BACKGROUND AND OBJECTIVES: Little is known regarding whether mortality among ESRD patients with SLE differs between those initiating with peritoneal dialysis (PD) versus hemodialysis (HD). This study compared the mortality risk of ESRD patients with SLE initiating with PD versus HD after matching their baseline sociodemographic and clinical factors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Of 11,023 ESRD patients with SLE initiating dialysis with PD or HD between 1995 and 2006 with complete records in the US Renal Data System, 1352 pairs were matched on 13 predictors utilizing a predicted probability of group membership into the PD group using propensity score matching. The primary outcome was overall mortality. Secondary outcomes were cardiovascular-related and infection-related mortality. Outcomes were compared between groups with survival statistics. The period of observation ended on December 31, 2009. The median follow-up was 3 years. RESULTS: Matched pairs were predominantly women (86%) with a median age of 39 years. Matched pairs had a balance (P ≥ 0.05) of all baseline factors. Matched pairs had a similar risk of overall mortality (hazard ratio, 0.96 [95% confidence interval, 0.82 to 1.13]; mortality, 21.4% [290 to 1352] versus 22.5% [304 to 1352] for PD versus HD) within the first 3 years of observation. Matched pairs also had similar cardiovascular-related mortality (10.5% versus 9.5% for PD versus HD) and infection-related mortality (3% versus 4.4% for PD versus HD). CONCLUSIONS: In ESRD patients with SLE, the mortality was similar among those initiating with PD versus HD after predictors were matched between groups.

Mandated self-reporting of ventilator-associated pneumonia bundle and catheter-related bloodstream infection bundle compliance and infection rates.

IMPORTANCE: As quality measures increasingly become tied to payment, evaluating the most effective ways to provide high-quality care becomes more important. OBJECTIVES: To determine whether mandated reporting for ventilator and catheter bundle compliance is correlated with decreased infection rates, and to determine whether labor-intensive audits are correlated with compliance. DESIGN, SETTING, AND PARTICIPANTS: Multiyear retrospective review of aggregated data from all patients admitted to 15 intensive care units in a Veterans Affairs hospital setting (the Veterans Integrated Service Network 16) from 2009 to 2011. EXPOSURES: Ventilator-associated pneumonia and catheter-related bloodstream infections. MAIN OUTCOMES AND MEASURES: Mean rates of ventilator-associated pneumonia and catheter-related bloodstream infection were analyzed by year. Relationships between infection rates, self-reported compliance, and audits were analyzed by Pearson correlation. RESULTS: During the study period, ventilator-associated pneumonia decreased from 2.50 to 1.60 infections per 1000 ventilator days (P = .07). The rate of pneumonia was not correlated with self-reported compliance overall (R = 0.19) or by individual year (2009, R = 0.30; 2010, R = 0.24; 2011, R = 0.46); there was a correlation in cardiac intensive care units (R = -0.70) but not other types of intensive care units (mixed, R = -0.18; medical, R = 0.42; surgical, R = 0.34). Catheter-related bloodstream infections decreased from 2.38 to 0.73 infections per 1000 catheter days (P = .04). The rate of catheter infection was not correlated with self-reported compliance overall (R = -0.18), by individual year (2009, R = -0.39; 2010, R = -0.42; 2011, R = 0.37), or by intensive care unit type (mixed, R = -0.19; cardiac, R = 0.55; medical, R = 0.17; surgical, R = -0.44). CONCLUSIONS AND RELEVANCE: Current mandated self-reported compliance and audit measures are poorly correlated with decreased ventilator-associated pneumonia or catheter-related bloodstream infection.

Multicenter review of diaphragm pacing in spinal cord injury: successful not only in weaning from ventilators but also in bridging to independent respiration.

BACKGROUND: Ventilator-dependent spinal cord-injured (SCI) patients require significant resources related to ventilator dependence. Diaphragm pacing (DP) has been shown to successfully replace mechanical ventilators for chronic ventilator-dependent tetraplegics. Early use of DP following SCI has not been described. Here, we report our multicenter review experience with the use of DP in the initial hospitalization after SCI. METHODS: Under institutional review board approval for humanitarian use device, we retrospectively reviewed our multicenter nonrandomized interventional protocol of laparoscopic diaphragm motor point mapping with electrode implantation and subsequent diaphragm conditioning and ventilator weaning. RESULTS: Twenty-nine patients with an average age of 31 years (range, 17-65 years) with only two females were identified. Mechanism of injury included motor vehicle collision (7), diving (6), gunshot wounds (4), falls (4), athletic injuries (3), bicycle collision (2), heavy object falling on spine (2), and motorcycle collision (1). Elapsed time from injury to surgery was 40 days (range, 3-112 days). Seven (24%) of the 29 patients who were evaluated for the DP placement had nonstimulatable diaphragms from either phrenic nerve damage or infarction of the involved phrenic motor neurons and were not implanted. Of the stimulatable patients undergoing DP, 72% (16 of 22) were completely free of ventilator support in an average of 10.2 days. For the remaining six DP patients, two had delayed weans of 180 days, three had partial weans using DP at times during the day, and one patient successfully implanted went to a long-term acute care hospital and subsequently had life-prolonging measures withdrawn. Eight patients (36%) had complete recovery of respiration, and DP wires were removed. CONCLUSION: Early laparoscopic diaphragm mapping and DP implantation can successfully wean traumatic cervical SCI patients from ventilator support. Early laparoscopic mapping is also diagnostic in that a nonstimulatable diaphragm is a convincing evidence of an inability to wean from ventilator support, and long-term ventilator management can be immediately instituted. LEVEL OF EVIDENCE: Therapeutic study, level V.