Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Improving efficiency and reducing costs in robotic surgery: a Lean Six Sigma approach to optimize turnover time.

Operating room (OR) turnover time (TOT) is the time it takes to prepare an OR for the next surgery after the previous one has been completed. Reducing OR TOT can improve the efficiency of the OR, reduce costs, and improve surgeons' and patients' satisfaction. The objective of this study is to evaluate the effectiveness of an operating room (OR) turnover time (TOT) reduction initiative using the Lean Six Sigma methodology (DMAIC) in the bariatric and thoracic service lines. Performance improvement strategies consist of simplifying steps (surgical tray optimization) and concurrent steps (parallel task execution). We compared 2-month pre-implementation vs. post-implementation. A paired t-test was used to assess whether the difference in the measurements was statistically significant. The study found that TOT was reduced by 15.6% from an average of 35.6 ± 8.1 to minutes 30.09 ± 9.7 min (p < 0.05). Specifically, in the bariatric service line, TOT was reduced by 17.15% and in the thoracic service line, TOT was reduced by 9.6%. No adverse events related to the initiative were reported. The results of this study indicate that the TOT reduction initiative was effective in reducing TOT. The efficient use of operating rooms is crucial in hospital management, as it not only impacts finances but also affects the satisfaction of surgical teams and patients. This study shows the effectiveness of Lean Six Sigma methodology in reducing TOT and improving the efficiency in the OR.

Learning from terrorist mass casualty incidents: a global survey.

BACKGROUND: Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. METHODS: We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. RESULTS: Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). CONCLUSION: This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

Antiplatelet Agent Reversal Is Unnecessary in Blunt Traumatic Brain Injury Patients Not Requiring Immediate Craniotomy.

BACKGROUND: The need to reverse the coagulation impairment caused by chronic antiplatelet agents in traumatic brain injury (TBI) patients with acute traumatic intracerebral hemorrhage (TICH) remains controversial. We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy. METHODS: All adult blunt TICH patients (age ≥16 years) over a 4-year period were retrospectively reviewed. Patients with penetrating TBI, blunt TBI without TICH on admission computed tomography (CT), receiving warfarin, not on antiplatelet agents, or requiring immediate operative intervention were excluded. Patients were divided into 2 groups depending on whether they received a platelet transfusion: reversal group (RV) versus no reversal group (NR). Patient outcomes were analyzed using Mann-Whitney U and Fisher's exact tests. RESULTS: 169 blunt TBI patients on chronic antiplatelet therapy were studied (102 RV group, 67 NR group). The groups were well matched with regard to age, Injury Severity Score, Abbreviated Injury Scale-head, Glasgow Coma Score, mechanism of injury, need for intubation, time to initial CT scan, and hospital length of stay. Immediate platelet transfusion did not alter the occurrence of TICH extension on follow-up CT (26% vs 21%, P = .71), TBI-specific mortality (9% vs 13%, P = .45), need for ICP monitor (2% vs 3%, P = 1.0), burr hole (1% vs 3%, P = .56), or craniotomy (1% vs 3%, P = .56). DISCUSSION: Immediate platelet transfusion is unnecessary in blunt TBI patients on chronic antiplatelet therapy who do not require immediate craniotomy.

Injury characteristics of the Pulse Nightclub shooting: Lessons for mass casualty incident preparation.

BACKGROUND: On the morning of June 12, 2016, an armed assailant entered the Pulse Nightclub in Orlando, Florida, and initiated an assault that killed 49 people and injured 53. The regional Level I trauma center and two community hospitals responded to this mass casualty incident. A detailed analysis was performed to guide hospitals who strive to prepare for future similar events. METHODS: A retrospective review of all victim charts and/or autopsy reports was performed to identify victim presentation patterns, injuries sustained, and surgical resources required. Patients were stratified into three groups: survivors who received care at the regional Level I trauma center, survivors who received care at one of two local community hospitals, and decedents. RESULTS: Of the 102 victims, 40 died at the scene and 9 died upon arrival to the Level I trauma center. The remaining 53 victims received definitive medical care and survived. Twenty-nine victims were admitted to the trauma center and five victims to a community hospital. The remaining 19 victims were treated and discharged that day. Decedents sustained significantly more bullet impacts than survivors (4 ± 3 vs. 2 ± 1; p = 0.008) and body regions injured (3 ± 1 vs. 2 ± 1; p = 0.0002). Gunshots to the head, chest, and abdominal body regions were significantly more common among decedents than survivors (p < 0.0001). Eighty-two percent of admitted patients required surgery in the first 24 hours. Essential resources in the first 24 hours included trauma surgeons, emergency room physicians, orthopedic/hand surgeons, anesthesiologists, vascular surgeons, interventional radiologists, intensivists, and hospitalists. CONCLUSION: Mass shooting events are associated with high mortality. Survivors commonly sustain multiple, life-threatening ballistic injuries requiring emergent surgery and extensive hospital resources. Given the increasing frequency of mass shootings, all hospitals must have a coordinated plan to respond to a mass casualty event. LEVEL OF EVIDENCE: Epidemiological Study, level V.

Mass shootings: Are children safer in the streets than in the home?

PURPOSE: Though the total fatality and injury count in mass shootings is known, the burden on the pediatric population remains undefined. We sought to define the impact of domestic vs. public mass shootings in the pediatric population. METHODS: Open-source databases, Everytown for Gun Violence, and Mother Jones were cross-referenced and used to review domestic and public mass shootings from 2009 to 2016. Mass shootings were defined as four or more fatalities and any injuries. Domestic mass shootings were defined as ones that occurred in the home where the assailant was either a family member or a past or present intimate partner of a family member. Public mass shootings occurred in a public space where the shooter was unknown to the victim. The number of incidents in each group, fatalities and injuries, and effect on children <18 years were analyzed along with perpetrator characteristics. Categorical data were analyzed using Fisher's Exact test. RESULTS: There were 71 Domestic and 31 Public mass shootings accounting for 331 vs. 281 fatalities and 28 vs. 217 injuries (p < 0.0001). Children <18 years accounted for 44% of Domestic and 10% of Public fatalities (p < 0.0001) and 46% vs. 2% of all injuries (p < 0.0001). The assailant was prohibited from owning or possessing a firearm in 32% of Domestic and 39% of Public mass shootings accounting for 54 vs. 25 fatalities. CONCLUSION: The pediatric fatality rate in mass shootings is alarming, especially among Domestic shooting events. This is a public health issue and requires vigilance to protect at-risk youth. TYPE OF STUDY: Epidemiology study, retrospective review. LEVEL OF EVIDENCE: Level IV.

Mass casualty events: what to do as the dust settles?

Care during mass casualty events (MCE) has improved during the last 15 years. Military and civilian collaboration has led to partnerships which augment the response to MCE. Much has been written about strategies to deliver care during an MCE, but there is little about how to transition back to normal operations after an event. A panel discussion entitled The Day(s) After: Lessons Learned from Trauma Team Management in the Aftermath of an Unexpected Mass Casualty Event at the 76th Annual American Association for the Surgery of Trauma meeting on September 13, 2017 brought together a cadre of military and civilian surgeons with experience in MCEs. The events described were the First Battle of Mogadishu (1993), the Second Battle of Fallujah (2004), the Bagram Detention Center Rocket Attack (2014), the Boston Marathon Bombing (2013), the Asiana Flight 214 Plane Crash (2013), the Baltimore Riots (2015), and the Orlando Pulse Night Club Shooting (2016). This article focuses on the lessons learned from military and civilian surgeons in the days after MCEs.

Trauma Patients with an Open Abdomen Following Damage Control Laparotomy can be Extubated Prior to Abdominal Closure.

BACKGROUND: The open abdomen (OA) is commonly utilized as a technique during damage control laparotomy (DCL). We propose that a selected group of these OA patients can be extubated prior to abdominal closure to decrease ventilator days and risk of pneumonia. METHODS: A retrospective chart review was performed at a Level I trauma center on all adult trauma patients with an OA following DCL. Patients were stratified into two groups: extubated prior to (PRE) and extubated after (POST) abdominal closure. Successful extubation in the PRE group was measured by the absence of re-intubation. The two groups were compared using the Mann-Whitney U and Fisher's exact tests. Multivariate logistic regression identified independent predictors for successful extubation prior to abdominal closure. RESULTS: Thirty-one patients were in the PRE group, and 59 patients in the POST group. There were no differences between the groups with regard to age, gender, or hours from admission to completion of DCL. The PRE group had a significantly higher incidence of penetrating trauma (77 vs. 53%; p = 0.02), a significantly lower number of days from OA to extubation [0.6 (0.2-1.1) vs. 3.4 (2--8) days; p < 0.001], and a significant decrease in pneumonia (10 vs. 31%; p = 0.04). Two patients in each group required re-intubation [PRE (6%) vs. POST (3%); p = 0.61]. In a multivariate binominal logistic regression, penetrating trauma (p = 0.024), GCS on admission (p < 0.0001), and Injury Severity Score (p = 0.024) were identified as independent predictors for successful extubation. CONCLUSION: Presence of an OA following DCL does not require mechanical ventilation. Extubation of appropriate trauma patients prior to abdominal closure decreases pneumonia and hospital length of stay.

Nonoperative management rather than endovascular repair may be safe for grade II blunt traumatic aortic injuries: An 11-year retrospective analysis.

BACKGROUND: The Society of Vascular Surgery (SVS) guidelines currently suggest thoracic endovascular aortic repair (TEVAR) for grade II-IV and nonoperative management (NOM) for grade I blunt traumatic aortic injury (BTAI). However, there is increasing evidence that grade II may also be observed safely. The purpose of this study was to compare the outcome of TEVAR and NOM for grade I-IV BTAI and determine if grade II can be safely observed with NOM. METHODS: The records of patients with BTAI from 2004 to 2015 at a Level I trauma center were retrospectively reviewed. Patients were separated into two groups: TEVAR versus NOM. All BTAIs were graded according to the SVS guidelines. Minimal aortic injury (MAI) was defined as BTAI grade I and II. Failure of NOM was defined as aortic rupture after admission or progression on subsequent computed tomography (CT) imaging requiring TEVAR or open thoracotomy repair (OTR). Statistical analysis was performed using Mann-Whitney U and χ tests. RESULTS: A total of 105 adult patients (≥16 years) with BTAI were identified over the 11-year period. Of these, 17 patients who died soon after arrival and 17 who underwent OTR were excluded. Of the remaining 71 patients, 30 had MAI (14 TEVAR vs. 16 NOM). There were no failures in either group. No patients with MAI in either group died from complications of aortic lesions. Follow-up CT imaging was performed on all MAI patients. Follow-up CT scans for all TEVAR patients showed stable stents with no leak. Follow-up CT in the NOM group showed progression in two patients neither required subsequent OTR or TEVAR. CONCLUSIONS: Although the SVS guidelines suggest TEVAR for grade II-IV and NOM for grade I BTAI, NOM may be safely used in grade II BTAI. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Psychological Effect of a Mass Casualty Event on General Surgery Residents.

OBJECTIVE: To evaluate the psychological effect of a mass casualty shooting event on general surgery residents. DESIGN: Three and 7 months following the Pulse nightclub mass casualty shooting, the mental well-being of general surgery residents employed at the receiving institution was evaluated. A voluntary and anonymous screening questionnaire for posttraumatic stress disorder (PTSD) and major depression (MD) was administered. Responses were stratified into 2 groups; residents who worked (ON-CALL) and residents who did not work (OFF-CALL) the night of the event. Data were analyzed using Mann-Whitney U and Fisher's exact tests and are reported as median with interquartile range (IQR) or percentage. SETTING: Level I trauma center. PARTICIPANTS: Thirty-one general surgery residents. RESULTS: Twenty-four residents (77%) returned the 3-month questionnaire: 10 ON-CALL and 14 OFF-CALL. There was no difference in PTSD and MD between the 2 groups (30% vs. 14%; p = 0.61) and (30% vs. 7%; p = 0.27), respectively. Twenty-three of the 24 residents responded to the 7-month questionnaire. Over time, the incidence of PTSD did not resolve in the ON-CALL group, but did resolve in the OFF-CALL group (30% vs. 0%; p = 0.07). There was no significant change in the incidence of MD in either group (30% vs. 8%; p = 0.28). At 7 months postevent, more residents in both groups stated that they had sought counseling (30% vs. 44%; p = 0.65) and (0% vs. 15%; p = 0.22). CONCLUSIONS: The emotional toll associated with this mass casualty event had a substantial effect upon the general surgery residents involved. With the incidence of PTSD and MD identified, we believe that all residents should be provided with counseling following such events.

Laparoscopic Appendectomy Protocol Expedites Management of Uncomplicated Acute Appendicitis.

Bed availability remains a constant struggle for tertiary care centers resulting in the use of management protocols to streamline patient care and reduce length of stay (LOS). A standardized perioperative management protocol for uncomplicated acute appendicitis (UA) was implemented in April 2014 to decrease both CT scan usage and LOS. Patients who underwent laparoscopic appendectomy for UA from April 2012 to May 2013 (PRE group) and April 2014 to May 2015 (POST group) were compared retrospectively. There were no differences in patient demographics or clinical findings between the groups. All patients in the PRE group had a CT scan for the diagnosis of appendicitis, whereas there was a 14 per cent decrease in the POST group (P = 0.002). There was a significant decrease in median LOS between the groups [PRE 1.3 vs POST 0.9 days; (P < 0.001)]. There was no difference in subsequent emergency department visits for complications [3 (4%) vs 4 (4%); P = 1.0] or 30-day readmission rate [1 (1%) vs 5 (5%); P = 0.22] between the groups. A standardized perioperative management protocol for UA patients significantly decreased CT scan utilization and LOS without compromising patient care.

Management of the Open Abdomen in Obese Trauma Patients.

Obesity incidence in the trauma population is increasing. Abdominal compartment syndrome has poor outcomes when left untreated. Surgeons may treat obese patients differently because of concern for increased morbidity and mortality. We studied the effects of body mass index (BMI) on resource utilization and outcome. An Institutional Review Board-approved retrospective review of trauma patients requiring temporary abdominal closure (TAC) was performed. Patients were stratified as follows: Group 1-BMI = 18.5 to 24.9 kg/m(2), Group 2-BMI = 25 to 29.9 kg/m(2), Group 3-BMI = 30 to 39.9 kg/m(2), Group 4-BMI ≥ 40 kg/m(2). Demographic data, illness severity as defined by Injury Severity Score, Acute Physiology and Chronic Health Evaluation Score Version II and Simplified Acute Physiology Score Version II scores, resource utilization, fascial closure rate, and survival were collected. About 380 patients required TAC. Median age of Group 1 was significantly lower than Groups 2 and 3 (P = 0.001). Severity of illness did not differ. Group 4 had a longer intensive care unit stay compared with Groups 1 and 2 (P = 0.005). Group 4 required mechanical ventilation longer than Group 1 (P = 0.027). Hospital stay, fascial closure, and survival were equivalent. Obese trauma patients with TAC have a longer intensive care unit stay and more ventilator days, but there is no difference in survival or type of closure. TAC can be used safely in trauma patients with a BMI ≥ 30 kg/m(2).

Methodological background and strategy for the 2012-2013 updated consensus definitions and clinical practice guidelines from the abdominal compartment society.

The Abdominal Compartment Society (www.wsacs.org) previously created highly cited Consensus Definitions/Management Guidelines related to intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Implicit in this previous work, was a commitment to regularly reassess and update in relation to evolving research. Two years preceding the Fifth World Congress on Abdominal Compartment Syndrome, an International Guidelines committee began preparation. An oversight/steering committee formulated key clinical questions regarding IAH/ /ACS based on polling of the Executive to redundancy, structured according to the Patient, Intervention, Comparator, and Outcome (PICO) format. Scientific consultations were obtained from Methodological GRADE experts and a series of educational teleconferences were conducted to educate scientific review teams from among the wscacs. org membership. Each team conducted systematic or structured reviews to identify relevant studies and prepared evidence summaries and draft Grades of Recommendation Assessment, Development and Evaluation (GRADE) recommendations. The evidence and draft recommendations were presented and debated in person over four days. Updated consensus definitions and management statements were derived using a modified Delphi method. A writingcommittee subsequently compiled the results utilizing frequent Internet discussion and Delphi voting methods to compile a robust online Master Report and a concise peer-reviewed summarizing publication. A dedicated Paediatric Guidelines Subcommittee reviewed all recommendations and either accepted or revised them for appropriateness in children. Of the original 12 IAH/ACS definitions proposed in 2006, three (25%) were accepted unanimously, with four (33%) accepted by > 80%, and four (33%) accepted by > 50%, but required discussion to produce revised definitions. One (8%) was rejected by > 50%. In addition to previous 2006 definitions, the panel also defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, abdominal compliance, and suggested a refined open abdomen classification system. Recommendations were possible regarding intra-abdominal pressure (IAP) measurement, approach to sustained IAH, philosophy of protocolized IAP management and same-hospital-stay fascial closure, use of decompressive laparotomy, and negative pressure wound therapy. Consensus suggestions included use of non-invasive therapies for treating IAH/ACS, considering body position and IAP, damage control resuscitation, prophylactic open abdomen usage, and prudence in early biological mesh usage. No recommendations were made for the use of diuretics, albumin, renal replacement therapies, and utilizing abdominal perfusion pressure as a resuscitation-endpoint. Collaborating Methodological Guideline Development and Clinical Experts produced Consensus Definitions/Clinical Management statements encompassing the most contemporary evidence. Data summaries now exist for clinically relevant IAH/ACS questions, which will facilitate future scientific reanalysis.

Airway pressures as surrogate estimates of intra-abdominal pressure.

Intra-abdominal pressure (IAP) measurements are essential to the diagnosis and management of patients with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Peak inspiratory pressure (PIP), plateau pressure (Pplat), and mean airway pressure (Paw) are used by some surgeons as surrogate estimates of IAP during abdominal closure. Thirty mechanically ventilated surgical/trauma patients with risk factors for IAH/ACS underwent simultaneous triplicate measurements of PIP, Pplat, Paw, and IAP. PIP, Pplat, and Paw were compared with IAP using both coefficient of determination and Bland and Altman analysis. The coefficient of determination for each airway pressure in predicting change in IAP was: PIP 5 per cent (P = 0.24), Pplat 17 per cent (P = 0.02), and Paw 15 per cent (P = 0.03). Bland and Altman analysis identified that marked variability exists between airway pressure and IAP measurements: PIP 19.3 ± 18.7 mmHg, Pplat 11.1 ± 13.7 mmHg, and Paw 2.0 ± 9.8 mmHg. Airway pressures do not accurately reflect IAP and cannot be substituted for IAP measurements in patients at risk for IAH/ACS.

Perceptions of graduating general surgery chief residents: are they confident in their training?

BACKGROUND: Debate exists within the surgical education community about whether 5 years is sufficient time to train a general surgeon, whether graduating chief residents are confident in their skills, why residents choose to do fellowships, and the scope of general surgery practice today. STUDY DESIGN: In May 2013, a 16-question online survey was sent to every general surgery program director in the United States for dissemination to each graduating chief resident (CR). RESULTS: Of the 297 surveys returned, 76% of CRs trained at university programs, 81% trained at 5-year programs, and 28% were going directly into general surgery practice. The 77% of CRs who had done >950 cases were significantly more comfortable than those who had done less (p < 0.0001). Only a few CRs were uncomfortable performing a laparoscopic colectomy (7%) or a colonoscopy (6%), and 80% were comfortable being on call at a Level I trauma center. Compared with other procedures, CRs were most uncomfortable with open common bile duct explorations (27%), pancreaticoduodenectomies (38%), hepatic lobectomies (48%), and esophagectomies (60%) (p < 0.00001). Of those going into fellowships, 67% said they truly had an interest in that specialty and only 7% said it was because they were not confident in their surgical skills. CONCLUSIONS: Current graduates of general surgery residencies appear to be confident in their skills, including care of the trauma patient. Fellowships are being chosen primarily because of an interest in the subspecialty. General surgery residency no longer provides adequate training in esophageal or hepatopancreatobiliary surgery.

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.

Early intravenous ibuprofen decreases narcotic requirement and length of stay after traumatic rib fracture.

Pain control after traumatic rib fracture is essential to avoid respiratory complications and prolonged hospitalization. Narcotics are commonly used, but adjunctive medications such as nonsteroidal anti-inflammatory drugs may be beneficial. Twenty-one patients with traumatic rib fractures treated with both narcotics and intravenous ibuprofen (IVIb) (Treatment) were retrospectively compared with 21 age- and rib fracture-matched patients who received narcotics alone (Control). Pain medication requirements over the first 7 hospital days were evaluated. Mean daily IVIb dose was 2070 ± 880 mg. Daily intravenous morphine-equivalent requirement was 19 ± 16 vs 32 ± 24 mg (P < 0.0001). Daily narcotic requirement was significantly decreased in the Treatment group on Days 3 through 7 (P < 0.05). Total weekly narcotic requirement was significantly less among Treatment patients (P = 0.004). Highest and lowest daily pain scores were lower in the Treatment group (P < 0.05). Hospital length of stay was 4.4 ± 3.4 versus 5.4 ± 2.9 days (P = 0.32). There were no significant complications associated with IVIb therapy. Early IVIb therapy in patients with traumatic rib fractures significantly decreases narcotic requirement and results in clinically significant decreases in hospital length of stay. IVIb therapy should be initiated in patients with traumatic rib fractures to improve patient comfort and reduce narcotic requirement.