Traumatic Brain Injuries After Falls From Height vs Falls at the US-Mexico Border Wall.

This cohort study examines the incidence, severity, and mortality of fall-related injuries among migrants at the US-Mexico border in San Diego, California.

Ethics in disaster, mass casualty care, and critical care.

The primary ethical principle guiding general medical practice is autonomy. However, in mass casualty (MASCAL) or disaster scenarios, the principles of beneficence and justice become of foremost concern. Despite multiple reviews, publications, and training courses available to prepare for a MASCAL incident, a minority of physicians and healthcare providers are abreast of these. In this review, we describe several MASCAL scenarios and their associated ethical, moral, and medicolegal quandaries in attempts to curb potential future misadventures.

A border health crisis at the United States-Mexico border: an urgent call to action.

In this Viewpoint, we provide an overview of the worsening trend of traumatic injuries across the United States-Mexico border after its recent fortification and height extension to 30-feet. We further characterize the international factors driving migration and the current U.S. policies and political climate that will allow this public health crisis to progress. Finally, we provide recommendations involving prevention efforts, effective resource allocation, and advocacy that will start addressing the humanitarian and economic consequences of current U.S. border policies and infrastructure.

Percutaneous auricular neuromodulation (nerve stimulation) for the treatment of pain following cholecystectomy and hernia repair: a randomized, double-masked, sham-controlled pilot study.

BACKGROUND: Percutaneous auricular nerve stimulation (neuromodulation) involves implanting electrodes around the ear and administering an electric current. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial; and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following two ambulatory surgical procedures. METHODS: Within the recovery room following cholecystectomy or hernia repair, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied. Participants were randomized to 5 days of either electrical stimulation or sham in a double-blinded fashion. RESULTS: In the first 5 days, the median (IQR) pain level for active stimulation (n=15) was 0.6 (0.3-2.4) vs 2.6 (1.1-3.7) for the sham group (n=15) (p=0.041). Concurrently, the median oxycodone use for the active stimulation group was 0 mg (0-1), compared with 0 mg (0-3) for the sham group (p=0.524). Regarding the highest pain level experienced over the entire 8-day study period, only one participant (7%) who received active stimulation experienced severe pain, versus seven (47%) in those given sham (p=0.031). CONCLUSIONS: Percutaneous auricular neuromodulation reduced pain scores but not opioid requirements during the initial week after cholecystectomy and hernia repair. Given the ease of application as well as a lack of systemic side effects and reported complications, a definitive clinical trial appears warranted. TRIAL REGISTRATION NUMBER: NCT05521516.

Disaster planning for a surgical surge: when mass trauma threatens to overwhelm your operating rooms.

Mass casualty events particularly those requiring multiple simultaneous operating rooms are of increasing concern. Existing literature predominantly focuses on mass casualty care in the emergency department. Hospital disaster plans should include a component focused on preparing for multiple simultaneous operations. When developing this plan, representatives from all segments of the perioperative team should be included. The plan needs to address activation, communication, physical space, staffing, equipment, blood and medications, disposition offloading, special populations, and rehearsal.

INTRACOLON COOLING INCREASES SURVIVAL RATE IN THE RAT MODEL OF LETHAL HEMORRHAGE.

ABSTRACT: Background: The objective of this study was to investigate whether transrectal intracolon (TRIC) cooling can prolong the survival duration in a rat hemorrhagic shock (HS) model. Methods: A lethal HS was induced by bleeding 47% of the total blood volume. A TRIC device was placed into the colon to maintain the intracolon temperature either at 37°C (TRIC37) or at 10°C (TRIC10) post-HS. In the surface cooling (SC) rats, the body temperatures were maintained at the same level as the esophageal temperature of the TRIC10 rats. A separated group of TRIC10 rats were resuscitated (Res) at 90 min post-HS. A total of six groups were as follows: (i) Sham TRIC37 (n = 5), (ii) Sham TRIC10 (n = 5), (iii) HS TRIC37 (n = 5), (iv) HS TRIC10 (n = 6), (v) HS SC (n = 6), and (vi) HS TRIC10 + Res (n = 6). Results: An average post-HS survival time was 18.4 ± 9.4 min in HS TRIC37 and 82 ± 27.82 min in the HS SC group. In striking contrast, the HS TRIC10 group exhibited an average survival time of 150.2 ± 66.43 min. The post-HS blood potassium level rose significantly in the HS TRIC37 and HS SC, whereas it remained unchanged in the TRIC10 groups. Post-HS intestinal damage occurred in HS TRIC37 and HS SC groups but virtually absent in HS TRIC10 groups. After resuscitation at 90 min post-HS, all HS TRIC10 rats were fully recovered from the lethal HS. Conclusions: TRIC10 reversed the high blood potassium level, prevented the intestinal damage, and prolonged the survival duration by sixfold relative to normothermia and by twofold compared with SC post-HS. All TRIC10 rats were successfully resuscitated at 90 min post-HS.

Sigh Ventilation in Patients With Trauma: The SiVent Randomized Clinical Trial.

Importance: Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown. Objective: To determine whether adding sigh breaths improves clinical outcomes. Design, Setting, and Participants: A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours. Interventions: Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished. Main Outcomes and Measures: The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality. Results: Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]). Conclusions and Relevance: In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT02582957.

Are trauma surgeons prepared? A survey of trauma surgeons' disaster preparedness before and during the COVID-19 pandemic.

Objective: US trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However, trauma surgeons may lack formal MCI training. The recent COVID-19 pandemic drove multiple patient surges, overloaded Emergency Medical Services (EMS) agencies, and stressed TCs. This survey assessed trauma surgeons' MCI training, experience, and system and personal preparedness before the pandemic compared with the pandemic's third year. Methods: Survey invitations were emailed to all 1544 members of the American Association for the Surgery of Trauma in 2019, and then resent in 2022 to 1575 members with additional questions regarding the pandemic. Questions assessed practice type, TC characteristics, training, experience, beliefs about personal and hospital preparedness, likelihood of MCI scenarios, interventions desired from membership organizations, and pandemic experiences. Results: The response rate was 16.7% in 2019 and 12% in 2022. In 2022, surgeons felt better prepared than their hospitals for pandemic care, mass shootings, and active shooters, but remained feeling less well prepared for cyberattack and hazardous material events, compared with 2019. Only 35% of the respondents had unintentional MCI response experience in 2019 or 2022, and even fewer had experience with intentional MCI. 78% had completed a Stop the Bleed (STB) course and 63% own an STB kit. 57% had engaged in family preparedness activities; less than 40% had a family action plan if they could not come home during an MCI. 100% of the respondents witnessed pandemic-related adverse events, including colleague and coworker illness, patient surges, and resource limitations, and 17% faced colleague or coworker death. Conclusions: Trauma surgeons thought that they became better at pandemic care and rated themselves as better prepared than their hospitals for MCI care, which is an opportunity for them to take greater leadership roles. Opportunities remain to improve surgeons' family and personal MCI preparedness. Surgeons' most desired professional organization interventions include advocacy, national standards for TC preparedness, and online training. Level of evidence: VII, survey of expert opinion.

Novel Association of Blunt Cerebrovascular Injuries with the San Diego-Mexico Border Wall Height Extension.

BACKGROUND: The San Diego-Mexico border wall height extension is associated with increased traumatic injuries and related costs after wall falls. We report previous trends and a neurological injury type not previously associated with border falls: blunt cerebrovascular injuries (BCVIs). METHODS: In this retrospective cohort study, patients who presented to the UC San Diego Health Trauma Center for injuries from border wall falls from 2016 to 2021 were considered. Patients were included if they were admitted before (January 2016 to May 2018) or after (January 2020 to December 2021) the height extension period. Patient demographics, clinical data, and hospital stay data were compared. RESULTS: We identified 383 patients, 51 (68.6% male; mean age, 33.5 years) in the pre-height extension cohort and 332 (77.1% male; mean age, 31.5 years) in the post-height extension cohort. There were 0 and 5 BCVIs in the pre- and post-height extension groups, respectively. BCVIs were associated with increased injury severity scores (9.16 vs. 31.33; P < 0.001), longer intensive care unit lengths of stay (median, 0 days; [interquartile range (IQR), 0-3 days]; vs. median, 5 days [IQR, 2-21 days]; P = 0.022), and increased total hospital charges (median, $163,490 [IQR, $86,578-$282,036]; vs. median, $835,260 [IQR, $171,049-$1,933,996]; P = 0.048). Poisson modeling found BCVI admissions were 0.21 (95% confidence interval, 0.07-0.41; P = 0.042) per month higher after the height extension. CONCLUSIONS: We review the injuries correlating with the border wall extension and reveal an association with rare, potentially devastating BCVIs that were not seen before the border wall modifications. These BCVIs and associated morbidity shed light on the trauma increasingly found at the southern U.S. border, which could be informative for future infrastructure policy decisions.

Falling from new heights: Traumatic fracture burden and resource utilization after border wall height increase.

BACKGROUND: San Diego County hospitals commonly care for patients injured by falls from the United States-Mexico border. From 2018 to 2019, the height of >400 miles of an existing border wall was raised. Prior work has demonstrated a 5-fold increase in traumatic border wall fall injuries after barrier expansion. We aimed to examine the impact of a barrier height increase on fracture burden and resource use. METHODS: We performed a retrospective review of patients admitted to a level 1 trauma center from 2016 to 2021 with lower extremity or pelvic fractures sustained from a border wall fall. We defined the pre-wall group as patients admitted from 2016 to 2018 and the post-wall group as those admitted from 2019 to 2021. We collected demographic and treatment data, hospital charges, weight-bearing status at discharge, and follow-up. RESULTS: A total of 320 patients (pre-wall: 45; post-wall: 275) were admitted with 951 lower extremity fractures (pre-wall: 101; post-wall: 850) due to border wall fall. Hospital resources were utilized to a greater extent post-wall: a 537% increase in hospital days, a 776% increase in intensive care unit days, and a 468% increase in operative procedures. Overall, 86% of patients were non-weight-bearing on at least 1 lower extremity at discharge; 82% were lost to follow-up. CONCLUSION: Traumatic lower extremity fractures sustained from border wall fall rapidly rose after the wall height increase. Hospital resources were used to a greater extent. Patients were frequently discharged with weight-bearing limitations and rarely received scheduled follow-up care. Policymakers should consider the costs of caring for border fall patients, and access to follow-up should be expanded.

Inhalation Injury: Which Providers Can Assess the Need for Intubation?

Previous studies have suggested that many burn patients undergo unnecessary intubation due to concern for inhalation injury. We hypothesized that burn surgeons would intubate burn patients at a lower rate than non-burn acute care surgeons (ACSs). We performed a retrospective cohort study of all patients admitted to an American Burn Association-verified burn center who presented emergently following burn injury from June 2015 to December 2021. Patients excluded include polytrauma patients, isolated friction burns, and patients intubated prior to hospital arrival. Our primary outcome was intubation rates between burn and non-burn ACSs. 388 patients met inclusion criteria. 240 (62%) patients were evaluated by a burn provider and 148 (38%) were evaluated by a non-burn provider; the groups were well-matched. In total, 73 (19%) of patients underwent intubation. There was no difference in the rate of emergent intubation, diagnosis of inhalation injury on bronchoscopy, time to extubation, or incidence of extubation within 48 hours between burn and non-burn ACSs. We found no difference between burn and non-burn ACSs in the airway evaluation and management of burn patients. Surgical providers with acute care surgery backgrounds and Advanced Trauma Life Support training are well-equipped for initial airway management in burn patients. Further studies should seek to compare other types of provider groups to identify opportunities for intervention and education in preventing unnecessary intubations.

Cross-Border Antibiotic Resistance Patterns in Burn Patients.

Background: Antimicrobial resistance (AMR) is a growing problem worldwide, with differences in regional resistance patterns partially driven by local variance in antibiotic stewardship. Trauma patients transferring from Mexico have more AMR than those injured in the United States; we hypothesized a similar pattern would be present for burn patients. Patients and Methods: The registry of an American Burn Association (ABA)-verified burn center was queried for all admissions for burn injury January 2015 through December 2019 with hospital length-of-stay (LOS) longer than seven days. Patients were divided into two groups based upon burn location: United States (USA) or Mexico (MEX). All bacterial infections were analyzed. Results: A total of 73 MEX and 826 USA patients were included. Patients had a similar mean age (40.4 years MEX vs. 42.2 USA) and gender distribution (69.6% male vs. 64.4%). The MEX patients had larger median percent total body surface area burned (%TBSA; 11.1% vs. 4.3%; p ≤ 0.001) and longer hospital LOS (18.0 vs. 13.0 days; p = 0.028). The MEX patients more often had respiratory infections (16.4% vs. 7.4%; p = 0.046), whereas rates of other infections were similar. The MEX patients had higher rates of any resistant organism (47.2% of organisms MEX vs. 28.1% USA; p = 0.013), and were more likely to have resistant infections on univariable analysis; however, on multivariable analysis country of burn was no longer significant. Conclusions: Antimicrobial resistance is more common in burn patients initially burned in Mexico than those burned in the United States, but location was not a predictor of resistance compared to other traditional burn-related factors. Continuing to monitor for AMR regardless of country of burn remains critical.

Reducing Systemic Risks in a Traumatic Panfacial Injury Patient.

Panfacial trauma refers to injuries caused by high-energy mechanisms to two or more regions of the craniofacial skeleton, including the frontal bone, the midface, and the occlusal unit. As with any trauma, Advanced Trauma Life Support protocols should be followed in unstable patients. For the patient with panfacial traumatic injury, advanced perioperative care or critical care is frequently required. This article describes surgical critical care for panfacial injuries, a component of the acute-care surgery model, to reduce systemic risks, improve the patient's condition, and enable a successful surgical outcome.

Up and over: Consequences of raising the United States-Mexico border wall height.

OBJECTIVES: San Diego County's geographic location lends a unique demographic of migrant patients injured by falls at the United States-Mexico border. To prevent migrant crossings, a 2017 Executive Order allocated funds to increase the southern California border wall height from 10 ft to 30 ft, which was completed in December 2019. We hypothesized that the elevated border wall height is associated with increased major trauma, resource utilization, and health care costs. METHODS: Retrospective trauma registry review of border wall falls was performed by the two Level I trauma centers that admit border fall patients from the southern California border from January 2016 to June 2022. Patients were assigned to either "pre-2020" or "post-2020" subgroups based upon timing of completion of the heightened border wall. Total number of admissions, operating room utilization, hospital charges, and hospital costs were compared. RESULTS: Injuries from border wall falls grew 967% from 2016 to 2021 (39 vs. 377 admissions); this percentage is expected to be supplanted in 2022. When comparing the two subgroups, operating room utilization (175 vs. 734 total operations) and median hospital charges per patient ($95,229 vs. $168,795) have risen dramatically over the same time period. Hospital costs increased 636% in the post-2020 subgroup ($11,351,216 versus $72,172,123). The majority (97%) of these patients are uninsured at admission, with costs largely subsidized by federal government entities (57%) or through state Medicaid enrollment postadmission (31%). CONCLUSION: The increased height of the United States-Mexico border wall has resulted in record numbers of injured migrant patients, placing novel financial and resource burdens on already stressed trauma systems. To address this public health crisis, legislators and health care providers must conduct collaborative, apolitical discussions regarding the border wall's efficacy as a means of deterrence and its impact on traumatic injury and disability. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Characterizing the frequency, morbidity, and types of traumatic brain injuries after the Mexico-San Diego border wall extension: a retrospective cohort review.

OBJECTIVE: The aim of this study was to investigate the impact of the US-Mexico border wall height extension on traumatic brain injuries (TBIs) and related costs. METHODS: In this retrospective cohort study, patients who presented to the UC San Diego Health Trauma Center for injuries from falling at the border wall between 2016 and 2021 were considered. Patients in the pre-height extension period (January 2016-May 2018) were compared with those in the post-height extension period (January 2020-December 2021). Demographic characteristics, clinical data, and hospital charges were analyzed. RESULTS: A total of 383 patients were identified: 51 (0 TBIs, 68.6% male) in the pre-height extension cohort and 332 (14 TBIs, 77.1% male) in the post-height extension cohort, with mean ages of 33.5 and 31.5 years, respectively. There was an increase in the average number of TBIs per month (0.0 to 0.34) and operative TBIs per month (0.0 to 0.12). TBIs were associated with increased Injury Severity Score (8.8 vs 24.2, p < 0.001), median (IQR) hospital length of stay (5.0 [2-11] vs 8.5 [4-45] days, p = 0.03), and median (IQR) hospital charges ($163,490 [$86,369-$277,918] vs $243,658 [$136,769-$1,127,920], p = 0.04). TBIs were normalized for changing migration rates on the basis of Customs and Border Protection apprehensions. CONCLUSIONS: This heightened risk of intracranial injury among vulnerable immigrant populations poses ethical and economic concerns to be addressed regarding border wall infrastructure.

Post-traumatic Liver Pseudoaneurysms: Rare but Serious Sequela.

INTRODUCTION: The liver is the most commonly injured organ after blunt abdominal trauma. Nonoperative management is the standard of care in stable individuals. Liver injuries, particularly high-grade injuries, can develop pseudoaneurysms (PSAs), which can rupture and cause life-threatening bleeding, even after hospital discharge. There is no consensus on whether patients should receive predischarge contrast computed tomography (CT) screening, or at what time interval after injury, nor which patients are at the highest risk for PSA. The purpose of this study was to identify the rates of PSA in our population and potential risk factors for their formation. METHODS: The trauma registry at our Level 1 urban trauma center was queried for patients admitted with liver injuries between 2015 and 2021. Demographic information was collected from the registry. Individual charts were then reviewed for timing of CT scans, CT findings, interventions, and complications. Liver injury grade was assessed using radiology reports or operative findings. The frequency of PSAs was then analyzed using descriptive statistics using Microsoft Excel and SPSS for odds ratio. RESULTS: A total of 172 patients were admitted with liver injuries during the study period. 130 patients received a CT scan diagnosing liver injury, 42 were diagnosed with liver injury intraoperatively. Of the 130 patients (59.9%) which received follow-up CT scans, six (6.5%) developed PSA, four of which being from penetrating injuries (odds ratio, 6.95). CONCLUSIONS: This study demonstrated a low incidence of PSA consistent with the known literature. We found the majority of the PSA developed following penetrating injury. This may represent a significant indication for follow-up imaging regardless of grade. A larger study will be necessary to identify those most at risk for PSA formation and determine the best PSA screening algorithm.

Who is informed of trauma informed care? Patients' primary language and comprehensiveness of initial trauma assessment.

BACKGROUND: For patients with limited English proficiency, language poses a unique challenge in patient-provider communication. Using certified medical interpretation (CMI) can be difficult in time- and resource-limited settings including trauma. We hypothesized that there would be limited use of CMI during major trauma resuscitations, less comprehensive assessments, and less empathetic communication for Spanish-speaking patients (SSPs) with limited English proficiency compared with English-speaking patients (ESPs). METHODS: We analyzed video-recorded encounters of trauma initial assessments at a Level 1 trauma center. Each encounter was evaluated from patient arrival until completion of the secondary survey per Advanced Trauma Life Support protocol. A standard checklist of provider actions was used to assess comprehensiveness of the primary and secondary surveys and communication events such as provider introduction, reassurances, and communicating next steps to patients. We compared the SSP and ESP cohorts for significant differences in completion of checklist items. RESULTS: Fifty patients with Glasgow Coma Scale scores of 14 and 15 were included (25 SSPs, 25 ESPs). The median age was 34 years (interquartile range, 25-65 years) for SSPs and 40 years (interquartile range, 29-54 years) for ESPs. In SSPs, 72% were male; in ESPs, 60% were male. Spanish-speaking patients received less comprehensive motor (48% complete SSPs vs. 96% ESPs, p < 0.001) and sensory (4% complete SSPs vs. 68% ESPs, p < 0.001) examinations, and less often had providers explain next steps (32% SSPs vs. 96% ESPs, p < 0.001) or reassure them (44% SSPs vs. 88% ESPs, p = 0.001). No patients were asked their primary language. Two SSP encounters (8%) used CMI; most (80%) used ad hoc interpretation, and 12% used English. CONCLUSION: We found significant differences in the initial care provided to trauma patients based on primary language. Inclusion of an interpreter as part of the trauma team may improve the quality of care provided to trauma patients with limited English proficiency. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Wearable, noninvasive, pulsed shortwave (radiofrequency) therapy for analgesia and opioid sparing following outpatient surgery: A proof-of-concept case series.

BACKGROUND: It is often difficult to concurrently provide adequate analgesia while minimizing opioid requirements following ambulatory surgery. Nonthermal, pulsed shortwave (radiofrequency) fields are a noninvasive treatment used as an adjunct analgesic and wound healing therapy. The devices may be placed by nursing staff in less than a minute, are relatively inexpensive and readily available, theoretically provide analgesia for nearly any anatomic location, and have no systemic side effects-patients cannot detect any sensations from the devices-or significant risks. Here we present a case series to demonstrate the use of pulsed, electromagnetic field devices for outpatient herniorrhaphy and breast surgery. CASE REPORT: Following moderately painful ambulatory umbilical (n = 3) and inguinal (n = 2) hernia repair as well as bilateral breast surgery (n = 2), patients had taped over their surgical incision(s) 1 or 2 noninvasive, wearable, disposable, pulsed shortwave therapy devices (RecoveryRx, BioElectronics Corporation, Frederick, Maryland) which functioned continuously for 30 days. Average resting pain scores measured on the 0-10 numeric rating scale were a median of 0 during the entire treatment period. Six patients avoided opioid use entirely, while the remaining individual required only 5 mg of oxycodone during the first postoperative day. CONCLUSIONS: These cases demonstrate that the ambulatory use of pulsed shortwave devices is feasible and may be an effective analgesic, possibly obviating opioid requirements following outpatient herniorrhaphy and breast surgery. Considering the lack of any side effects, adverse events, and misuse/dependence/diversion potential, further study with a randomized, controlled trial appears warranted.

One size does not fit all: Sex bias in pharmacologic venous thromboembolism prophylaxis.

BACKGROUND: The optimal enoxaparin dosing strategy to achieve venous thromboembolism (VTE) prophylaxis in trauma patients remains unclear. Current dosing guidelines often include weight, age, and renal function but still fail to achieve appropriate prophylactic anti-Xa levels in many patients. We hypothesized that additional patient factors influence anti-Xa response to enoxaparin in trauma patients. METHODS: This is a retrospective review of patients admitted to a Level 1 trauma center for ≥4 days from July 2015 to September 2020, who received enoxaparin VTE prophylaxis per protocol (50-59 kg, 30 mg/dose; 60-99 kg, 40 mg/dose; ≥100 kg, 50 mg/dose; all doses every 12 hours) and had an appropriately timed peak anti-Xa level. Multivariate regression was performed to identify independent predictors of prophylactic anti-Xa levels (0.2-0.4 IU/mL) upon first measurement. RESULTS: The cohort (N = 1,435) was 76.4% male, with a mean ± SD age of 49.9 ± 20.0 years and a mean ± SD weight of 82.5 ± 20.2 kg (males, 85.2 kg; females, 73.7 kg; p <0.001). Overall, 68.6% of patients (n = 984) had a prophylactic anti-Xa level on first assessment (69.6% of males, 65.1% of females). Males were more likely to have a subprophylactic level than females (22.1% vs. 8.0%, p <0.001), whereas females were more likely to have supraprophylactic levels than males (26.9% vs. 8.3%, p < 0.001). When controlling for creatinine clearance, anti-Xa level was independently associated with dose-to-weight ratio (odds ratio, 0.191 for 0.5 mg/kg; p < 0.001; confidence interval, 0.151-0.230) and female sex (odds ratio, 0.060; p < 0.001; confidence interval, 0.047-0.072). Weight and age were not significant when controlling for the other factors. CONCLUSION: Male patients have a decreased anti-Xa response to enoxaparin when compared with female patients, leading to a greater incidence of subprophylactic anti-Xa levels in male patients at all dose-to-weight ratios. To improve the accuracy of VTE chemoprophylaxis, sex should be considered as a variable in enoxaparin dosing models. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality.

BACKGROUND: Surgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach. METHODS: The American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses. RESULTS: There were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001). CONCLUSION: SPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a "step-up" approach. Larger, prospective studies to compare indications and outcomes for "step up" versus open SPN are warranted.