Implementation of the 300-mL Rule for the Management of Traumatic Hemothorax.

BACKGROUND: Traumatic hemothorax (HTX) is often managed with tube thoracostomy (TT); however, TT carries a high complication rate. In 2017, a guideline was implemented at our Level I trauma center to observe traumatic HTX ≤300mL in hemodynamically stable patients. We hypothesized that this guideline would decrease TT placement without increasing observation failure rates. METHODS: This was a single-center retrospective review of all adult patients admitted with a HTX on computed tomography (CT) before (2015-2016) and after (2018-2019) the guideline implementation. Exclusion criteria were TT placement prior to CT scan, absence of CT scan, death within 5 days of admission, and a concurrent pneumothorax (PTX) >20mm. HTX volume was calculated using CT scan images and Mergo's formula: V=d 2xL (V: volume; d: depth; L: length). The primary outcome was observation failure, defined as the need for TT, video-assisted thoracoscopic surgery, thoracotomy after repeat imaging or worsening of symptoms and pulmonary morbidity. RESULTS: A total of 357 patients met inclusion criteria, of whom 210 were admitted after guideline implementation. There were no significant differences in baseline demographics, comorbidities, or injury characteristics across both cohorts. The post-implementation cohort had a significant increase in observation rate (75% vs 59%) and a decrease in TT placement (42% vs 57%). Moreover, the post-implementation group had a statistically significant shorter hospital (6 vs 8 days) and ICU (2 vs 3 days) LOS. No significant differences in observation failure, pulmonary complications, 30-day readmission, or 30-day mortality were observed across both cohorts. CONCLUSION: The implementation of the 300mL guideline led to a decrease in TT placement without increasing observation failure or complication rates. LEVEL OF EVIDENCE: Level III, Therapeutic/Care Management.

Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study.

Background: Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA. Methods: The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury. Results: 14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%. Conclusion: The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage. Level of evidence: 2.

Thoracic irrigation for prevention of secondary intervention after thoracostomy tube drainage for hemothorax: A Western Trauma Association multi-center study.

BACKGROUND: Retained hemothorax (rHTX) requiring intervention occurs in up to 20% of patients who undergo chest tube (TT) placement for a hemothorax (HTX). Thoracic irrigation at the time of TT placement decreases the need for secondary intervention in this patient group but those findings are limited because of the single center design. A multi-center study was conducted to evaluate the effectiveness of thoracic irrigation. METHODS: A multi-center, prospective, observational study was conducted between June 2018 and July 2023. Eleven sites contributed patients. Patients were included if they had a TT placed for a HTX and were excluded if: age < 18 years, TT for pneumothorax, thoracotomy or VATS performed within 6 hours of TT, TT >24 hours after injury, TT removed <24 hours, or death within 48 hours. Thoracic irrigation was performed at the discretion of the attending. Each hemithorax was considered separately if bilateral HTX. The primary outcome was secondary intervention for HTX-related complications (rHTX, effusion, or empyema). Secondary intervention was defined as: TT placement, instillation of thrombolytics, VATS, or thoracotomy. Irrigated and non-irrigated hemithoraces were compared using a propensity weighted analysis with age, sex, mechanism of injury, Abbreviated Injury Scale (AIS) chest and TT size as predictors. RESULTS: 493 patients with 462 treated hemothoraces were included, 123 (25%) had thoracic irrigation at TT placement. There were no significant demographic differences between the cohorts. Fifty-seven secondary interventions were performed, 10 (8%) and 47 (13%) in the irrigated and non-irrigated groups, respectively (p = 0.015). Propensity weighted analysis demonstrated a reduction in secondary interventions in the irrigated cohort (Odds Ratio 0.56 (0.34-0.85); p = 0.005). CONCLUSION: This Western Trauma Association multi-center study demonstrates a benefit of thoracic irrigation at the time of TT placement for a HTX. Thoracic irrigation reduces the odds of a secondary intervention for rHTX-related complications by 44%. LEVEL OF EVIDENCE: Therapeutic Study, Level II.

Cardiac Magnetic Resonance Imaging Used to Determine a Rare Etiology of a Layered Left Ventricular Apical Thrombus.

Eosinophilic myocarditis (EM) is a rare disease, often associated with hypereosinophilic syndrome (HES). Historically, the diagnostic gold standard was endomyocardial biopsy (EMB). We present a unique case of a 58-year-old female who presents after a syncopal episode and was found to have a layered left ventricular (LV) thrombus. Using laboratory studies and cardiac magnetic resonance imaging (MRI), we were able to delineate the etiology, avoiding any invasive testing.

Thoracic Cavity Irrigation Prevents Retained Hemothorax and Decreases Surgical Intervention in Trauma Patients.

INTRODUCTION: Retained hemothorax (HTX) is a common complication following thoracic trauma. Small studies demonstrate the benefit of thoracic cavity irrigation at the time of tube thoracostomy for the prevention of retained HTX. We sought to assess the effectiveness of chest irrigation in preventing retained HTX leading to a secondary surgical intervention. METHODS: We performed a single-center retrospective study from 2017-2021 at a Level I trauma center comparing bedside thoracic cavity irrigation via tube thoracostomy (TT) versus no irrigation. Using the trauma registry, patients with traumatic HTX were identified. Exclusion criteria were TT placement at an outside hospital, no TT within 24 hours of admission, thoracotomy or video-assisted thoracoscopic surgery (VATS) prior to or within 6 hours after TT placement, VATS as part of rib fixation or diaphragmatic repair, and death within 96 hours of admission. Bivariate and multivariable analyses were conducted. RESULTS: A total of 370 patients met the inclusion criteria, of whom 225 (61%) were irrigated. Patients who were irrigated were more likely to suffer a penetrating injury (41% vs 30%, p = 0.03) and less likely to have a flail chest (10% vs 21%, p = 0.01) (Table 1). On bivariate analysis, irrigation was associated with lower rates of VATS (6% vs 19%, p < 0.001) and retained HTX (10% vs 21%, p < 0.001) (Figure 1). The irrigated cohort had a shorter TT duration (4 vs 6 days, p < 0.001) and hospital length of stay (LOS) (7 vs 9 days, p = 0.04). On multivariable analysis, thoracic cavity irrigation had lower odds of VATS (aOR: 0.37, 95%CI: 0.30-0.54), retained HTX (aOR: 0.42, 95%CI: 0.25-0.74), and a shorter TT duration (ß: -1.58, 95%CI: -2.52, -0.75). CONCLUSION: Our 5-year experience with thoracic irrigation confirms findings from smaller studies that irrigation prevents retained HTX and decreases the need for surgical intervention. LEVEL OF EVIDENCE: Level III, Therapeutic/Care Management.

A Collaborative Multidisciplinary Trauma Program Improvement Team Improves VTE Chemoprophylaxis Guideline Compliance In Non-Operative Stable TBI.

BACKGROUND: Delays in initiating venous thromboembolism (VTE) prophylaxis in patients suffering from traumatic brain injury (TBI) persist despite guidelines recommending early initiation. We hypothesized that the expansion of a Trauma Program Performance Improvement (PI) team will improve compliance of early (24-48 hour) initiation of VTE prophylaxis and will decrease VTE events in TBI patients. METHODS: We performed a single-center retrospective review of all TBI patients admitted to a Level I trauma center before (2015-2016,) and after (2019-2020,) the expansion of the Trauma Performance Improvement and Patient Safety (PIPS) team and the creation of trauma process and outcome dashboards. Exclusion criteria included discharge or death within 48 hours of admission, expanding intracranial hemorrhage on CT scan, and a neurosurgical intervention (craniotomy, pressure monitor, or drains) prior to chemoprophylaxis initiation. RESULTS: A total of 1,112 patients met the inclusion criteria, of which 54% (n = 604) were admitted after Trauma PIPS expansion. Following the addition of a dedicated PIPS nurse in the trauma program and creation of process dashboards, the time from stable CT to VTE prophylaxis initiation decreased (52 hours to 35 hours; p < 0.001) and more patients received chemoprophylaxis at 24-48 hours (59% from 36%, p < 0.001) after stable head CT. There was no significant difference in time from first head CT to stable CT (9 vs 9 hours; p = 0.15). The Contemporary group had a lower rate of VTE events (1% vs 4%; p < 0.001) with no increase in bleeding events (2% vs 2%; p = 0.97). On multivariable analysis, being in the Early cohort was an independent predictor of VTE events (aOR: 3.74; 95%CI: 1.45-6.16). CONCLUSION: A collaborative multidisciplinary Trauma PIPS team improves guideline compliance. Initiation of VTE chemoprophylaxis within 24-48 hours of stable head CT is safe and effective. LEVEL OF EVIDENCE: Level III, Therapeutic/Care Management.

Early venous thromboembolism chemoprophylaxis in traumatic brain injury requiring neurosurgical intervention: Safe and effective.

BACKGROUND: Traumatic brain injury patients who require neurosurgical intervention are at the highest risk of worsening intracranial hemorrhage. This subgroup of patients has frequently been excluded from prior research regarding the timing of venous thromboembolism chemoprophylaxis. This study aims to assess the efficacy and safety of early venous thromboembolism chemoprophylaxis in patients with traumatic brain injuries requiring neurosurgical interventions. METHODS: This is a single-center retrospective review (2016-2020) of traumatic brain injury patients requiring neurosurgical intervention admitted to a level I trauma center. Interventions included intracranial pressure monitoring, subdural drain, external ventricular drain, craniotomy, and craniectomy. Exclusion criteria included neurosurgical intervention after chemoprophylaxis initiation, death within 5 days of admission, and absence of chemoprophylaxis. The total population was stratified into Early (≤72 hours of intervention) versus Late (>72 hours after intervention) chemoprophylaxis initiation. RESULTS: A total of 351 patients met the inclusion criteria, of whom 204 (58%) had early chemoprophylaxis initiation. Overall, there were no significant differences in baseline and admission characteristics between cohorts. The Early chemoprophylaxis cohort had a statistically significant lower venous thromboembolism rate (5% vs 13%, P < .001) with no increased risk of worsening intracranial hemorrhage (10% vs 13%, P = .44) or neurosurgical reintervention (8% vs 10%, P = .7). On subgroup analysis, a total of 169 patients required either a craniotomy or a craniectomy before chemoprophylaxis. The Early chemoprophylaxis cohort had statistically significant lower venous thromboembolism rates (2% vs 11%, P < .001) with no increase in intracranial hemorrhage (8% vs 11%, P = .6) or repeat neurosurgical intervention (8% vs 10%, P = .77). CONCLUSION: Venous thromboembolism prophylaxis initiation within 72 hours of neurosurgical intervention is safe and effective. Further prospective research is warranted to validate the results of this study.

Artificial intelligence-powered discovery of small molecules inhibiting CTLA-4 in cancer.

BACKGROUND/OBJECTIVES: Checkpoint inhibitors, which generate durable responses in many cancer patients, have revolutionized cancer immunotherapy. However, their therapeutic efficacy is limited, and immune-related adverse events are severe, especially for monoclonal antibody treatment directed against cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), which plays a pivotal role in preventing autoimmunity and fostering anticancer immunity by interacting with the B7 proteins CD80 and CD86. Small molecules impairing the CTLA-4/CD80 interaction have been developed; however, they directly target CD80, not CTLA-4. SUBJECTS/METHODS: In this study, we performed artificial intelligence (AI)-powered virtual screening of approximately ten million compounds to identify those targeting CTLA-4. We validated the hits molecules with biochemical, biophysical, immunological, and experimental animal assays. RESULTS: The primary hits obtained from the virtual screening were successfully validated in vitro and in vivo. We then optimized lead compounds and obtained inhibitors (inhibitory concentration, 1 micromole) that disrupted the CTLA-4/CD80 interaction without degrading CTLA-4. CONCLUSIONS: Several compounds inhibited tumor development prophylactically and therapeutically in syngeneic and CTLA-4-humanized mice. Our findings support using AI-based frameworks to design small molecules targeting immune checkpoints for cancer therapy.

Open versus endovascular repair of penetrating non-aortic arterial injuries: A systematic review and meta analysis.

BACKGROUND: Non-aortic arterial injuries are common and are associated with high morbidity and mortality. Historically, open surgical repair (OSR) was the conventional method of repair. With recent advancements in minimally invasive techniques, endovascular repair (ER) has gained popularity. We sought to compare outcomes in patients undergoing endovascular and open repairs of traumatic non-aortic penetrating arterial injuries. METHODS: A systematic review and meta-analysis was conducted using MEDLINE (OVID), Web of Science, Cochrane Library, and Scopus Database from January 1st, 1990, to March 20th, 2023. Titles and abstracts were screened, followed by full text review. Articles assessing clinically important outcomes between OSR and ER in penetrating arterial injuries were included. Exclusion criteria included blunt injuries, aortic injuries, pediatric populations, review articles, and non-English articles. Odds ratios (OR) and Cohen's d ratios were used to quantify differences in morbidity and mortality. RESULTS: A total of 3770 articles were identified, of which 8 met inclusion criteria and were included in the review. The articles comprised a total of 8369 patients of whom 90 % were male with a median age of 28 years. 85 % of patients were treated with OSR while 15 % underwent ER. With regards to injury characteristics, those who underwent ER were less likely to present with concurrent venous injuries (OR: 0.41; 95 %CI: 0.18, 0.94; p = 0.03). Regarding hospital outcomes, patients who underwent ER had a lower likelihood of in-hospital or 30-day mortality (OR: 0.72; 95 %CI: 0.55, 0.95; p = 0.02) and compartment syndrome (OR: 0.29, 95 %CI: 0.12, 0.71; p = 0.007). The overall risk of bias was moderate. CONCLUSION: Endovascular repair of non-aortic penetrating arterial injuries is increasingly common, however open repair remains the most common approach. Compared to ER, OSR was associated with higher odds of compartment syndrome and mortality. Further prospective research is warranted to determine the patient populations and injury patterns that most significantly benefit from an endovascular approach. LEVEL OF EVIDENCE: Level III, Systematic Reviews & Meta-Analyses.

TK1 expression influences pathogenicity by cell cycle progression, cellular migration, and cellular survival in HCC 1806 breast cancer cells.

Breast cancer is the most common cancer diagnosis worldwide accounting for 1 out of every 8 cancer diagnoses. The elevated expression of Thymidine Kinase 1 (TK1) is associated with more aggressive tumor grades, including breast cancer. Recent studies indicate that TK1 may be involved in cancer pathogenesis; however, its direct involvement in breast cancer has not been identified. Here, we evaluate potential pathogenic effects of elevated TK1 expression by comparing HCC 1806 to HCC 1806 TK1-knockdown cancer cells (L133). Transcriptomic profiles of HCC 1806 and L133 cells showed cell cycle progression, apoptosis, and invasion as potential pathogenic pathways affected by TK1 expression. Subsequent in-vitro studies confirmed differences between HCC 1806 and L133 cells in cell cycle phase progression, cell survival, and cell migration. Expression comparison of several factors involved in these pathogenic pathways between HCC 1806 and L133 cells identified p21 and AKT3 transcripts were significantly affected by TK1 expression. Creation of a protein-protein interaction map of TK1 and the pathogenic factors we evaluated predict that the majority of factors evaluated either directly or indirectly interact with TK1. Our findings argue that TK1 elevation directly increases HCC 1806 cell pathogenicity and is likely occurring by p21- and AKT3-mediated mechanisms to promote cell cycle arrest, cellular migration, and cellular survival.

Early career acute care surgeons' priorities and perspectives: A mixed-methods analysis to better understand full-time employment.

BACKGROUND: Understanding the expectations of early career acute care surgeons will help clarify the practice and employment models that will attract and retain high-quality surgeons, thereby sustaining our workforce. This study aimed to outline the clinical and academic preferences and priorities of early career acute care surgeons and to better define full-time employment. METHODS: A survey on clinical responsibilities, employment preferences, work priorities, and compensation was distributed to early career acute care surgeons in the first 5 years of practice. A subset of agreeable respondents underwent virtual semistructured interviews. Both quantitative and thematic analysis were used to describe current responsibilities, expectations, and perspectives. RESULTS: Of 471 surgeons, 167 responded (35%), the majority of whom were assistant professors within the first 3 years of practice (80%). The median desired clinical volume was 24 clinical weeks and 48 call shifts per year, 4 weeks less than their median current clinical volume. Most respondents (61%) preferred a service-based model. The top priorities cited in choosing a job were geography, work schedule, and compensation. Qualitative interviews identified themes related to defining full-time employment, first job expectations and realities, and the often-misaligned system and surgeon. CONCLUSION: Understanding the perspectives of early career surgeons entering the workforce is important particularly in the field of acute care surgery where no standard workload or practice model exists. The wide variety of expectations, practice models, and schedule preferences may lead to a mismatch between surgeon desires and employment expectation. Consistent employment standards across our specialty would provide a framework for sustainability. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Undertriage of Severely Injured Trauma Patients.

INTRODUCTION: The American College of Surgeons (ACS) delineates trauma team activation (TTA) criteria to identify seriously injured trauma patients in the field. Patients are deemed to be severely undertriaged (SU), placing them at risk for adverse outcomes, when they do not meet TTA criteria but nonetheless sustain significant injuries (Injury Severity Score [ISS] ≥25). OBJECTIVES: Delineate patient demographics, injuries, and outcomes after SU. PARTICIPANTS: Trauma patients presenting to our ACS-verified Level 1 trauma center with ISS ≥25 were included (11/2015-03/2022). Transfers and private vehicle transports were excluded. Patients were dichotomized and compared by trauma arrival level: TTA (Appropriately Triaged, AT) vs routine consults (SU). RESULTS: Study criteria were satisfied by 1653 patients: 1375 (83%) AT and 278 (17%) SU. Severely undertriaged patients were older than AT patients (47 vs 36 years, P < .001). Severely undertriaged occurred almost exclusively following blunt trauma (96% vs 71%, P < .001). Injury Severity Score was lower following SU than AT (29 vs 32, P < .001). The most common severe injuries (Abbreviated Injury Scale score [AIS] ≥3) among the SU group were in the Chest (n = 179, 64%). Severely undertriaged patients necessitated emergent intubation (n = 34, 12%), surgery (n = 59, 21%), and angioembolization (n = 22, 8%) at high rates. Severely undertriaged mortality was n = 40, 14%. CONCLUSION: Severely undertriaged occurred among a substantial proportion of ISS ≥25 patients, predominately following blunt trauma. Severe chest injuries were most likely to evade capture. Rates of intubation, emergent intervention, and in-hospital mortality were high after SU. Efforts should be made to identify such patients in the field as they may benefit from TTA.

The Variation of Withdrawal of Life Sustaining Therapy in Older Adults With Traumatic Brain Injury.

INTRODUCTION: The decision to withdraw life sustaining treatment (WDLST) in older adults with traumatic brain injury is subject to wide variability leading to nonbeneficial interventions and unnecessary use of hospital resources. We hypothesized that patient and hospital factors are associated with WDLST and WDLST timing. METHODS: All traumatic brain injury patients ≥65 with Glasgow coma scores (GCS) of 4-11 from 2018 to 2019 at level I and II centers were selected from the National Trauma Data Bank. Patients with head abbreviated injury scores 5-6 or death within 24 h were excluded. Bayesian additive regression tree analysis was performed to identify the cumulative incidence function (CIF) and the relative risks (RR) over time for withdrawal of care, discharge to hospice (DH), and death. Death alone (no WDLST or DH) served as the comparator group for all analyses. A subanalysis of the composite outcome WDLST/DH (defined as end-of-life-care), with death (no WDLST or DH) as a comparator cohort was performed. RESULTS: We included 2126 patients, of whom 1957 (57%) underwent WDLST, 402 (19%) died, and 469 (22%) were DH. 60% of patients were male, and the mean age was 80 y. The majority of patients were injured by fall (76%, n = 1644). Patients who were DH were more often female (51% DH versus 39% WDLST), had a past medical history of dementia (45% DH versus 18% WDLST), and had lower admission injury severity score (14 DH versus 18.6 WDLST) (P < 0.001). Compared to those who DH, those who underwent WDLST had a lower GCS (9.8 versus 8.4, P < 0.001). CIF of WDSLT and DH increased with age, stabilizing by day 3. At day 3, patients ≥90 y had an increased RR of DH compared to WDLST (RR 2.5 versus 1.4). As GCS increased, CIF and RR of WDLST decreased, while CIF and RR of DH increased (RR on day 3 for GCS 12: WDLST 0.42 versus DH 1.31).Patients at nonprofit institutions were more likely to undergo WDLST (RR 1.15) compared to DH (0.68). Compared to patients of White race, patients of Black race had a lower RR of WDLST at all timepoints. CONCLUSIONS: Patient and hospital factors influence the practice of end-of-life-care (WDLST, DH, and death), highlighting the need to better understand variability to target palliative care interventions and standardize care across populations and trauma centers.

Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations.

Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.

The efficacy of various Enoxaparin dosing regimens in general surgery patients: A systematic review.

BACKGROUND: Patients undergoing surgical procedures are at an increased risk of venous thromboembolism events. A fixed Enoxaparin dosing regimen is the standard of care for chemoprophylaxis in most institutions; however, breakthrough venous thromboembolism events are still reported. We aimed to systematically review the literature to determine the ability of various Enoxaparin dosing regimens to achieve adequate prophylactic anti-Xa levels for venous thromboembolism prevention in hospitalized general surgery patients. Additionally, we aimed to assess the correlation between subprophylactic anti-Xa levels and the development of clinically significant venous thromboembolism events. METHODS: A systematic review was conducted using major databases from January 1, 1993, to February 17, 2023. Two independent researchers screened titles and abstracts, followed by a full-text review. Articles were included if Enoxaparin dosing regimens were evaluated by anti-Xa levels. Exclusion criteria included systematic reviews, pediatric population, nongeneral surgery (defined as trauma, orthopedics, plastics, and neurosurgery), and non-Enoxaparin chemoprophylaxis. The primary outcome was peak Anti-Xa level measured at steady state concentration. The risk of bias was assessed using the Risk of Bias in Nonrandomized studies-of Intervention tool. RESULTS: A total of 6,760 articles were extracted, of which 19 were included in the scoping review. Nine studies included bariatric patients, whereas 5 studies explored abdominal surgical oncology patients. Three studies assessed thoracic surgery patients, and 2 studies included patients undergoing "general surgery" procedures. A total of 1,502 patients were included. The mean age was 47 years, and 38% were males. The percentages of patients reaching adequate prophylactic anti-Xa levels were 39%, 61%, 15%, 50%, and 78% across the 40 mg daily, 40 mg twice daily, 30 mg twice daily, and weight-tiered, and body mass index-based groups, respectively. The overall risk of bias was low to moderate. CONCLUSION: Fixed Enoxaparin dosing regimens are not correlated with adequate anti-Xa levels in general surgery patients. Additional research is warranted to assess the efficacy of dosing regimens based on novel physiologic parameters (such as estimated blood volume).

Anti-Factor Xa Monitoring of Enoxaparin Thromboembolism Prophylaxis in Emergency General Surgery Patients.

BACKGROUND: Rates of venous thromboembolism (VTE) remain high in emergency general surgery (EGS) patients despite chemical VTE prophylaxis. Emerging literature supports anti-factor Xa (AFXa) monitoring for patients on enoxaparin (LMWH), although a significant knowledge gap remains regarding the optimal dosing and monitoring in EGS patients. We hypothesize that standard dose VTE prophylaxis regimens provide inadequate VTE prophylaxis in EGS patients. STUDY DESIGN: A prospective cohort study of all adult EGS patients at a single institution between August 2021 and February 2022 receiving standard dose LMWH for VTE prophylaxis was performed. AFXa levels were obtained 4 hours after the third dose of enoxaparin with a target range of 0.3 to 0.5 IU/mL. Adjustment to dosing and repeat AFXa measurement after the adjusted third dose was obtained. RESULTS: A total of 81 patients underwent AFXa monitoring, the majority (75%) of whom were started on 40 mg LMWH daily. Initial peak AFXa measurement was low in 87.7% of patients (mean 0.16 IU/mL). Of patients who had an initial low AFXa, remained admitted, and underwent dosing adjustment and AFXa reassessment (27%), the majority were adjusted to either 30 or 40 mg of LMWH twice daily (23.7% and 55%, respectively), with 82% of patients remaining low. There were no significant differences in demographics or BMI between those with low vs adequate AFXa levels at either initial or subsequent measurement. CONCLUSIONS: Standard LMWH dosing provides inadequate AFXa inhibition for adequate VTE prophylaxis. These findings highlight the importance of ongoing AFXa monitoring and the need to establish clinical protocols to improve VTE prophylaxis in EGS patients.

Factors Associated With Triage Decisions in Older Adult Trauma Patients: Impact on Mortality and Morbidity.

INTRODUCTION: As medical advances have significantly increased the life expectancy among older adults, the number of older patients requiring trauma care has risen proportionately. Nevertheless, it is unclear among this growing population which sociodemographic and economic factors are associated with decisions to triage and transfer to level I/II centers. This study aims to assess for any association between patient sociodemographic characteristics, triage decisions, and outcomes during acute trauma care presentations. METHODS: The National Trauma Data Bank was queried for patients aged 65 and older with an injury severity score > 15 between the years 2007 to 2017. Factors associated with subsequent levels of triage on presentation were assessed using multivariate logistic regression, and associations of levels of triage with outcomes of mortality, morbidity, and hospital length of stay are examined using logistic and linear regression models. RESULTS: Triage of 210,310 older adult trauma patients showed significant findings. American Indian patients had higher odds of being transferred to level I/II centers, while Asian, Black, and Native Hawaiian patients had lower odds of being transferred to level I/II centers when compared to Caucasian patients (P < 0.001). Regarding insurance, self-pay (uninsured) patients were less likely to be transferred to a higher level of care; however, this was also demonstrated in private insurance holders (P < 0.001). Caucasian patients had significantly higher odds of mortality, with Black patients (odds ratio [OR] 0.80 [0.75, 0.85]) and American Indian patients (OR 0.87 [0.72, 1.04]) having significantly lower odds (P < 0.001). Compared to government insurance, private insurance holders (OR 0.82 [0.80, 0.85]) also had significantly lower odds of mortality, while higher odds among self-pay were observed (OR 1.75 [1.62, 1.90]), (P < 0.001). CONCLUSIONS: Access to insurance is associated with triage decisions involving older adults sustaining trauma, with lower access increasing mortality risk. Factors such as race and gender were less likely to be associated with triage decisions. However, due to this study's retrospective design, further prospective analysis is necessary to fully assess the decisions that influence trauma triage decisions in this patient population.

Quantifying the impact of reduced opioid use in patients after emergency laparotomy.

BACKGROUND: Emergency laparotomies have high rates of morbidity and mortality. The evaluation and management of pain are crucial, as poorly managed pain may contribute to postoperative complications and increase the risk of mortality. This study aims to describe the relationship between opioid use and opioid-related adverse effects and identify what constitutes appropriate dose reductions to elicit clinically relevant benefits. METHODS: This was a retrospective, observational study of patients presenting for emergency laparotomy due to trauma from 2014 to 2018. The primary objective was to define clinical outcomes that may be significantly affected by changes in milligrams of morphine equivalent during the first 72 hours postoperatively; additionally, we sought to quantify the approximate differences in morphine equivalent that correlate with clinically meaningful outcomes such as hospital length of stay, pain scores, and time to first bowel movement. For descriptive summaries, patients were categorized into low, moderate, and high groups based on morphine equivalent requirements of 0 to 25, 25 to 50, and >50, respectively. RESULTS: A total of 102 (35%), 84 (29%), and 105 (36%) patients were stratified into the low, moderate, and high groups, respectively. Mean pain scores for postoperative days 0 to 3 (P = .034), time to first bowel movement (P = .002), and nasogastric tube duration (P = .003) were the clinical outcomes found to be significantly associated with morphine equivalent. Estimated clinically significant reductions in morphine equivalent for these outcomes ranged from 194 to 464. CONCLUSION: Clinical outcomes, such as pain scores, and opioid-related adverse effects, such as time to first bowel movement and nasogastric tube duration, may be linked with the amount of opioids used.

Optimizing discharge opioid prescribing in trauma patients: A quasi-experimental study.

BACKGROUND: Patients prescribed higher opioid dosages are at increased risk of overdose and death without added pain reduction. Increases in opioid prescribing continue to fuel the epidemic. We hypothesized a comprehensive guideline to standardize opioid prescribing would decrease postdischarge dosages for patients experiencing trauma without requiring additional refills. METHODS: This quasiexperimental study compared opioid prescribing by trauma providers before and after the implementation of a departmental guideline on April 1, 2019, aimed at aligning opioid prescription patterns with Centers for Disease Control and Prevention recommendations. Patients prescribed opioids before implementation were the control group, whereas patients prescribed opioids after were the intervention group. The primary outcome was the proportion of patients receiving ≥50 morphine milligram equivalents per day. RESULTS: We identified 293 and 280 patients experiencing trauma in the control and intervention groups, respectively. There were no differences between the groups' Injury Severity Score (P = .69) or the frequency of having a procedure performed (P = .80). Total morphine milligram equivalents and maximum morphine milligram equivalents per day were 16% and 25% lower, respectively, in the intervention group compared with the control group (P < .001). The proportion of trauma patients prescribed ≥50 morphine milligram equivalents per day at discharge decreased from 57% to 18% after implementation (P < .001). The proportion of trauma patients prescribed ≥90 morphine milligram equivalents per day also decreased, from 37% to 14% (P < .001). There was no significant increase in the frequency of refill requests (P = .105) or refill prescriptions (P = .099) after discharge. CONCLUSION: A departmental guideline aimed at optimizing opioid prescription patterns successfully lowers the amount of morphine milligram equivalents prescribed to trauma patients and improves compliance with Centers for Disease Control and Prevention recommendations.