Hospital Academic Status and the Volume-Outcome Association in Postoperative Patients Requiring Intensive Care: Results of a Nationwide Analysis of Intensive Care Units in the United States.

Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 - -0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.

Abdominal Wall Thickness Predicts Surgical Site Infection in Emergency Colon Operations.

BACKGROUND: Body mass index (BMI) does not reliably predict Surgical site infections (SSI). We hypothesize that abdominal wall thickness (AWT) would serve as a better predictor of SSI for patients undergoing emergency colon operations. METHODS: We retrospectively evaluated our Emergency Surgery Database (2007-2018). Emergency colon operations for any indication were included. AWT was measured by pre-operative CT scans at 5 locations. Only superficial and deep SSIs were considered as SSI in the analysis. Univariate then multivariable analyses were used to determine predictors of SSI. RESULTS: 236 patients met inclusion criteria. The incidence of post-operative SSI was 25.8% and the median BMI was 25.8kg/m2 [22.5-30.1]. The median AWT between patients with and without SSI was significantly different (2.1cm [1.4, 2.8] and 1.8cm [1.2, 2.5], respectively). A higher BMI trended toward increased rates of SSI, but this was not statistically significant. In overweight (BMI 25-29.9kg/m2) and obese (BMI ≥30kg/m2) patients, SSI versus no SSI rates were (50.0% versus 41.9% and 47.4% versus 36.4%, P = 0.365 and 0.230) respectively. The incidence of SSI in patients with an average AWT < 1.8cm was 20% and 30% for patients with average AWT ≥1.8cm. On multivariable analysis, AWT ≥1.8cm at 2cm inferior to umbilicus was an independent predictor of SSI (OR 2.98, 95%CI 1.34-6.63, P = 0.007). CONCLUSIONS: AWT is a better predictor of SSI than BMI. Preoperative imaging of AWT may direct intraoperative decisions regarding wound management. Future clinical outcomes research in emergency surgery should include abdominal wall thickness as an important patient variable.

The Obesity Paradox in Elderly Patients Undergoing Emergency Surgery: A Nationwide Analysis.

BACKGROUND: Obesity has long been considered a risk factor for postoperative adverse events in surgery. We sought to study the impact of body mass index (BMI) on the clinical outcomes of the high-risk emergency general surgery (EGS) elderly patients. METHODS: All EGS ≥65 years old patients in the 2007-2016 ACS-NSQIP database, identified using the variables 'emergency' and 'surgspec,' were included. Patients were classified into five groups: normal weight: BMI <25 kg/m2, overweight: BMI ≥25 kg/m2 and <30 kg/m2, Class I: BMI ≥30 kg/m2 and <35 kg/m2, Class II: BMI ≥35 kg/m2 and <40 kg/m2, and Class III: BMI ≥40 kg/m2. Patients with BMI<18.5 kg/m2 were excluded. Multivariable logistic regression models were built to assess the relationship between obesity and 30-day postoperative mortality, overall morbidity, and individual postoperative complications after adjusting for demographics (e.g., age, gender), comorbidities (e.g., diabetes mellitus, heart failure), laboratory tests (e.g., white blood cell count, albumin), and operative complexity (e.g., ASA classification). RESULTS: A total of 78,704 patients were included, of which 26,011 were overweight (33.1%), 13,897 (17.6%) had Class I obesity, 5904 (7.5%) had Class II obesity, and 4490 (5.7%) had Class III obesity. On multivariable analyses, compared to the nonobese, patients who are overweight or with Class I-III obesity paradoxically had a lower risk of mortality, bleeding requiring transfusion, pneumonia, stroke and myocardial infarction (MI). Additionally, the incidence of MI and stroke decreased in a stepwise fashion as BMI progressed from overweight to severely obese (MI: OR: 0.84 [0.73-0.95], OR: 0.73 [0.62-0.86], OR: 0.66 [0.52-0.83], OR: 0.51 [0.38-0.68]; stroke: OR: 0.80 [0.65-0.99], OR: 0.79 [0.62-1.02], OR: 0.71 [0.50-1.00], OR: 0.43 [0.28-0.68]). CONCLUSION: In our study of elderly EGS patients, overweight and obese patients had a lower risk of mortality, bleeding requiring transfusion, pneumonia, reintubation, stroke, and MI. Further studies are needed to confirm and investigate the obesity paradox in this patient population.

Validation of the Artificial Intelligence-Based Predictive Optimal Trees in Emergency Surgery Risk (POTTER) Calculator in Emergency General Surgery and Emergency Laparotomy Patients.

BACKGROUND: The Predictive Optimal Trees in Emergency Surgery Risk (POTTER) tool is an artificial intelligence-based calculator for the prediction of 30-day outcomes in patients undergoing emergency operations. In this study, we sought to assess the performance of POTTER in the emergency general surgery (EGS) population in particular. METHODS: All patients who underwent EGS in the 2017 American College of Surgeons NSQIP database were included. The performance of POTTER in predicting 30-day postoperative mortality, morbidity, and 18 specific complications was assessed using the c-statistic metric. As a subgroup analysis, the performance of POTTER in predicting the outcomes of patients undergoing emergency laparotomy was assessed. RESULTS: A total of 59,955 patients were included. Median age was 50 years and 51.3% were women. POTTER predicted mortality (c-statistic = 0.93) and morbidity (c-statistic = 0.83) extremely well. Among individual complications, POTTER had the highest performance in predicting septic shock (c-statistic = 0.93), respiratory failure requiring mechanical ventilation for 48 hours or longer (c-statistic = 0.92), and acute renal failure (c-statistic = 0.92). Among patients undergoing emergency laparotomy, the c-statistic performances of POTTER in predicting mortality and morbidity were 0.86 and 0.77, respectively. CONCLUSIONS: POTTER is an interpretable, accurate, and user-friendly predictor of 30-day outcomes in patients undergoing EGS. POTTER could prove useful for bedside counseling of patients and their families and for benchmarking of EGS care.

Appraising the Quality of Reporting of American College of Surgeons NSQIP Emergency General Surgery Studies.

BACKGROUND: The quality of emergency general surgery (EGS) studies that use the American College of Surgeons-National Quality Improvement Program (ACS-NSQIP) database is variable. We aimed to critically appraise the methodologic reporting of EGS ACS-NSQIP studies. STUDY DESIGN: We searched the PubMed ACS-NSQIP bibliography for EGS studies published from 2004 to 2019. The quality of reporting of each study was assessed according to the number of criteria fulfilled with respect to the 13-item RECORD statement and the 10-item JAMA Surgery checklist. Three criteria in each checklist were not applicable and were therefore excluded. An analysis was conducted comparing studies published in high and low impact factor (IF) journals. RESULTS: We identified a total of 99 eligible studies. Twenty-six percent of studies were published in high IF journals, and 73% of the journals had a policy requiring adherence to reporting statements. The median number of criteria fulfilled for the RECORD statement (out of 10 items) and the JAMA Surgery checklist (out of 7 items) were both equal to 4 (interquartile range [IQR] 3, 5). Sixty-three percent of studies did not explain the methodology for data cleaning, 81% of studies did not describe the population selection process, and 55% did not discuss the implications of missing variables. There were no differences in overall scores between studies published in high and low IF journals. CONCLUSIONS: The methodologic reporting of EGS studies using ACS-NSQIP remains suboptimal. Future efforts should focus on improving adherence to the policies to mitigate potential sources of bias and improve the credibility of large database studies.

Unplanned readmission after emergency laparotomy: A post hoc analysis of an EAST multicenter study.

BACKGROUND: Hospital readmission is an important quality-of-care indicator. We sought to examine the rates and predictors of unplanned readmission for the high-risk non-trauma emergency laparotomy patient. METHODS: This is a post hoc analysis of a multicenter prospective observational study. Between April 2018 and June 2019, a total of 19 centers enrolled all adult patients undergoing emergency laparotomies and systematically collected preoperative, operative, and 30-day postoperative variables. For the purpose of this study, we defined unplanned readmission as a readmission occurring within 30 days from discharge and one that was immediately preceded by an emergency department visit. Patients were excluded if they died during the index admission, were discharged to hospice, or were transferred to other hospitals. Predictors of unplanned readmission were evaluated using a multivariable logistic regression model, adjusting for patient demographics, comorbidities, laboratory variables, and preoperative acuity of disease variables. RESULTS: A total of 1,347 patients were included, of which 234 (17.4%) had an unplanned readmission. The median patient age was 60 y, 49.4% were male, and 71.4% were white. The most common diagnoses were hollow viscus perforation (28.1%) and small bowel obstruction (24.5%). Predictors of unplanned readmission included patient factors (eg, disseminated cancer [odds ratio: 2.22, confidence interval: 1.35-3.64, P = .002], weight loss >10% in the past 6 months [odds ratio: 1.65, confidence interval: 1.07-2.54, P = .023], dyspnea at baseline [odds ratio: 1.62, confidence interval: 1.06-2.48, P = .026], wound complications [odds ratio: 2.23, confidence interval: 1.55-3.19, P < .001], and discharge to nursing homes [odds ratio: 1.68, confidence interval: 1.02-2.80, P = .044]). CONCLUSION: Unplanned readmission after emergency laparotomies are common, especially for patients with wound complications or requiring nursing homes. These system factors are potential quality improvement targets to reduce readmissions.

Leveraging interpretable machine learning algorithms to predict postoperative patient outcomes on mobile devices.

Setting patient and family expectations for postoperative outcomes is an important aspect of care, a cornerstone of which is accurate, personalized, and explainable risk estimation. Modern machine learning offers a plethora of models that can effectively capture the complex, nonlinear contributions of preoperative risk factors to the surgical patient's overall risk. However, most of these models produce risk estimates that are not interpretable, which compromises trust in these systems, renders them unaccountable, and limits their widespread adoption. Recent developments in machine learning have been successful at creating risk calculators that address this gap, producing explainable risk estimates without compromising accuracy. In this work, we describe how the state of the art in postoperative risk estimation addresses the shortcomings of older methods, and how they have been applied in a clinical setting. We conclude with a discussion of the potential of machine learning models to be systematically integrated in health care more broadly and future prospects beyond passive risk prediction.

Direct Oral Anticoagulants Are a Potential Alternative to Low-Molecular-Weight Heparin for Thromboprophylaxis in Trauma Patients Sustaining Lower Extremity Fractures.

BACKGROUND: Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Use of direct oral anticoagusants (DOACs) for VTE prophylaxis is effective in elective orthopedic surgery, but currently not approved for trauma patients. The primary objective of this study was to compare the effectiveness and safety of thromboprophylaxis of DOACs with low-molecular-weight heparin (LMWH) in trauma patients sustaining LEF. MATERIALS AND METHODS: We included adult trauma patients admitted to trauma quality improvement program participating trauma centers (between 2013 and 2016), who sustained LEF and were started on DOACs or LMWH for thromboprophylaxis after admission. Propensity score matching was performed to compare symptomatic VTE and bleeding control interventions between the groups. RESULTS: Of 1,009,922 patients in trauma quality improvement program, 167,640 met inclusion criteria (165,009 received LMWH and 2631 received DOACs). After propensity score matching, 2280 predominantly elderly (median age: 67 y) isolated femur fracture patients (median ISS: 10) were included in each group (4560 patients in total). Symptomatic VTE occurred in 1.4% of patients in both matched groups (P = 0.992). Bleeding control interventions occurred less often in the DOAC group, albeit statistically insignificant (5.8% versus 6.0%, P = 0.772). CONCLUSIONS: This study found similar rates of VTE and bleeding control measures for thromboprophylaxis with DOACs or LMWH in matched trauma patients with LEF. Further prospective research is warranted to consolidate the safety of DOAC thromboprophylaxis in trauma patients with LEF. Favorable oral administration and likely increased adherence could benefit this high-risk population.

The Geriatric Nutritional Risk Index is a powerful predictor of adverse outcome in the elderly emergency surgery patient.

BACKGROUND: The degree to which malnutrition impacts perioperative outcomes in the elderly emergency surgery (ES) patient remains unknown. We aimed to study the relationship between malnutrition, as measured by the Geriatric Nutritional Risk Index (GNRI), and postoperative outcomes in elderly patients undergoing ES. METHODS: Using the 2007 to 2016 American College of Surgeons National Surgical Quality Improvement Program database, all patients 65 years or older undergoing ES were included in our study. The GNRI, defined as (1.489 × albumin [g/L]) + (41.7 × [weight/ideal weight]) was calculated for each patient in the database. Patients with missing height, weight, or preoperative albumin data were excluded. Patients were divided into four malnutrition groups: very severe (GNRI < 73), severe (GNRI, 73-82), moderate (GNRI, 82-92), and mild (GNRI, 92-98). Geriatric Nutritional Risk Index greater than 98 constituted the normal nutrition group. Risk-adjusted multivariable logistic regressions were performed to study the relationship between malnutrition-measured using either GNRI, albumin level, or body mass index less than 18.5 kg/m-and the following postoperative outcomes: 30-day mortality, 30-day morbidity (including infectious and noninfectious complications), and hospital length of stay. The relationship between GNRI score and 30-day mortality for six common ES procedures was then assessed. RESULTS: A total of 82,725 patients were included in the final analyses. Of these, 55,214 were malnourished with GNRI less than 98 (66.74%). Risk-adjusted multivariable analyses showed that, as malnutrition worsened from mild to very severe, the risk of mortality, morbidity, and the hospital length of stay progressively increased (all p < 0.05). Patients with very severe malnutrition had at least a twofold increased likelihood of mortality (odds ratio [OR], 2.79; 95% confidence interval [CI], 2.57-3.03), deep vein thrombosis (OR, 2.07; 95% CI, 1.77-2.42), and respiratory failure (OR, 1.95; 95% CI, 1.81-2.11). Geriatric Nutritional Risk Index predicted mortality better than albumin or body mass index alone for ES. CONCLUSION: Malnutrition, measured using GNRI, is a strong independent predictor of adverse outcomes in the elderly ES patient and could be used to assess the nutrition status and counsel patients (and families) preoperatively. LEVEL OF EVIDENCE: Prognostic study, Level IV.

Opioids After Surgery in the United States Versus the Rest of the World: The International Patterns of Opioid Prescribing (iPOP) Multicenter Study.

OBJECTIVE: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world. SUMMARY OF BACKGROUND DATA: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic. METHODS: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients. RESULTS: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ±â€Š13.9 in US and 183.5 ±â€Š133.7 mg versus 0.8 ±â€Š3.9 and 4.6 ±â€Š27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001). CONCLUSIONS: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility.

BACKGROUND: Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS: Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS: Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS: The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

Isolated rib cage fractures in the elderly: Do all patients belong to the intensive care unit? A retrospective nationwide analysis.

BACKGROUND: Western Trauma Association guidelines recommend admitting patients 65 years or older with two or more rib fractures diagnosed by chest radiograph to the intensive care unit (ICU). Increased use of computed tomography has led to identification of less severe, "occult" rib fractures. We aimed to evaluate current national trends in disposition of older patients with isolated rib cage fractures and to identify characteristics of patients initially admitted to the ward who failed ward management. METHODS: A retrospective cohort study of patients 65 years or older with isolated two or more blunt rib cage fractures using the 2010 to 2016 American College of Surgeons Trauma Quality Improvement Program database was performed. Ward failure was defined as patients initially admitted to the ward with subsequent need for unplanned ICU admission or intubation. Multivariable analyses were derived to study the independent predictors of failure of ward management. Propensity score matching sub-analysis was used to assess outcomes in patients admitted to the ward versus ICU. RESULTS: There were 5,021 patients included in the analysis. Of these patients, 1,406 (28.0%) were admitted to the ICU. On multivariable analysis, age was an independent predictor of ICU admission. Of the 3,577 patients admitted directly to the ward, 38 (1.1%) patients required unplanned intubation or ICU admission. Independent predictors of failure of ward management included chronic renal failure (odds ratio [OR], 7.20; p ≤ 0.001; 95% confidence interval [CI], 2.50-20.76), traumatic pneumothorax (OR, 8.70; p = 0.008; 95% CI, 1.76-42.93), concurrent sternal fracture (OR, 6.52; p ≤ 0.001; 95% CI, 2.53-16.80), drug use disorder (OR, 6.58; p = 0.032; 95% CI, 1.17-36.96), and emergency department oxygen requirement or oxygen saturation less than 95% (OR, 2.38; p = 0.018; 95% CI, 1.16-4.86). Mortality was higher in patients with delayed ICU care versus patients with successful ward disposition (21.1% vs. 0.8%; p < 0.001). CONCLUSION: Our results suggest that the majority of isolated rib cage fractures in older patients are safely managed on the ward with exceedingly low ward failure rates (1.1%). Patients with failure of ward management have significantly higher mortality, and we have identified predictors of failing the ward. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV; Prognostic III.

A multidisciplinary approach to decreasing length of stay in acute care surgery patients.

AIM: To decrease hospital length of stay in acute care surgery patients. DESIGN: An observational cohort quality improvement project at a single tertiary referral centre. METHODS: A multidisciplinary team of physicians, nurses, case managers, and physical and occupational therapists was created to identify patients at risk for prolonged length of stay and implement weekly multidisciplinary rounding, with a systematic method of tracking progress in real time. The main outcome measure was hospital length of stay. The observed/expected ratios for length of stay 2 years before (2012-2014) and after (2014-2016) the intervention were compared. RESULTS: A total of 6,120 patients was analysed. Early identification and action on barriers to discharge created a significant decrease in risk-adjusted acute care surgery patient days per year (96 days) with limited added cost (1-2 hr per week). Patients discharged to home with or without services benefited most. CONCLUSION: Decreasing length of stay in acute care surgery patients is possible without adding a significant burden to healthcare providers. IMPACT: We describe a comprehensive, multidisciplinary initiative to decrease the length of stay of acute care surgery patients. Institutions can use existing resources in a sustainable manner to create a significant decrease in patient days per year with limited added cost. REGISTRATION: https://osf.io/zfc3t.

Mild traumatic brain injuries with minor intracranial hemorrhage: Can they Be safely managed in the community? - A cohort study.

BACKGROUND: Patients with mild traumatic brain injury (mTBI) are frequently transferred to level 1 trauma centers (L1TC) if they have minor findings on a computerized tomographic scan of the head due to the absence of continuous neurosurgical coverage in community hospitals (CH). We hypothesized that such patients can be safely managed at community hospitals with a qualified Trauma team. METHODS: This is a multicentered Retrospective Cohort Study. Patients with mild Traumatic Brain Injury (defined as Glasgow Coma Scale [GCS] 13-15 at presentation) and with minor findings on head Computerized Tomography (CT) presenting at a L1TC or 4 Community Hospitals between March 1st, 2012 and February 28th, 2014 were included. All these community hospitals are Level III Trauma center with a well-organized trauma team. Minor CT findings were defined as 1) epidural hematoma<2 mm; 2) subarachnoid hemorrhage<2 mm; 3) subdural hematoma<4 mm; 4) intraparenchymal hemorrhage<5 mm; 5) minor pneumocephalus; or 6) linear or minimally depressed skull fracture. Our primary end point was the need for TBI specific interventions in 3 groups of patients: 1) direct admission to the L1TC (L1TC group), 2) those admitted at one of the 4 CH (CH group), and 3) those transferred from CH to L1TC (TRANSFER group). TBI-specific interventions were defined as intracranial pressure monitor (ICP) placement, hyperosmolar therapy, or neurosurgical operation. Our secondary aim was to demonstrate that these patients can be safely managed in Community Hospitals with qualified Trauma teams. We also sought to identify the clinical outcomes in these three groups of patients - in terms of mortality and complications. RESULTS: A total of 191 patients were included - 39 CH, 64 L1TC and 88 TRANSFER. There was no difference among the groups in terms of TBI-specific interventions: one TRANSFER, four L1TC, and no CH patients required hyperosmolar therapy (p = 0.277). None of the patients required placement of an intracranial pressure monitoring device (ICP) or a neurosurgical operation and complications and mortality rates were similar among the groups. CONCLUSIONS: Patients with mild TBI and minor findings on head CT can be safely managed at CH with qualified Trauma Teams. LEVEL OF EVIDENCE: Therapeutic/Care Management Study, Level IVhbv.

The Effect of Immunosuppression on Emergency Colectomy Outcomes: A Nationwide Retrospective Analysis.

BACKGROUND: The impact of immunosuppression on the outcomes of emergent surgery remains poorly described. We aimed to quantify the impact of chronic immunosuppression on outcomes of patients undergoing emergent colectomy (EC). METHODS: The Colectomy-Targeted ACS-NSQIP database 2012-2016 was queried for patients who underwent colectomy for an emergent indication. As per NSQIP, chronic immunosuppression was defined as the use of corticosteroid or immunosuppressant medication within the prior 30 days. Patients undergoing EC for any indication were divided into two groups: immunosuppressant use (IMS) and no immunosuppressant use (NIS). Patients were propensity-score-matched on demographics, comorbidities, preoperative laboratory values, and operative variables in a 1:1 ratio to control for confounding factors. The primary outcome was 30-day mortality. Secondary outcomes included overall 30-day morbidity, individual postoperative complications (e.g., wound dehiscence, anastomotic leak, and sepsis), and hospital length of stay. RESULTS: Out of a total of 130,963 patients, 17,707 patients underwent an EC, of which 15,422 were NIS and 2285 were IMS. Totally, 2882 patients were matched (1441 NIS; 1441 IMS). The median age was 66 [IQR 56-76]; 56.8% were female; patients more frequently underwent a diversion procedure rather than primary anastomosis (68.4% vs 31.6%). Overall, as compared to NIS, IMS patients had higher 30-day mortality (21.4% vs 18.5%, p = 0.045) and overall morbidity (79.7% vs 75.7%, p = 0.011). Particularly, IMS patients had increased rates of unplanned intubations (11.5% vs 7.9%, p = 0.001), wound dehiscence (5.7% vs 3.5%, p = 0.006), progressive renal insufficiency 2.2% vs 1.2%, p = 0.042), pneumonia (12.6% vs 10.0%, p = 0.029), and longer median hospital length of stay [12.0 (8.0-21.0) vs 11.0 (7.0-19.0), p < 0.001] as compared to NIS patients. CONCLUSIONS: Chronic immunosuppression is independently associated with a significant and quantifiable increase in 30-day mortality and complications for patients undergoing EC. Our results provide the emergency surgeon with quantifiable risk estimates that can help guide better patient counseling while setting reasonable expectations.

Contemporary management of penetrating renal trauma - A national analysis.

INTRODUCTION: Indications for nonoperative management (NOM) after penetrating renal injury remain ill-defined. Using a national database, we sought to describe the experience of operative and nonoperative management in the United States and retrospectively examine risk factors for failure of NOM. MATERIALS AND METHODS: The TQIP database 2010-2016 was used to identify patients with penetrating renal trauma. Outcomes of patients treated with an immediate operation (IO) and NOM are described. Failure of NOM was defined as the need for a renal operation after 4 h from arrival. Univariate then multivariable regression analyses were performed to identify predictors of NOM failure. RESULTS: Out of 8139 patients with kidney trauma, 1,842 had a penetrating mechanism of injury and were included. Of those, 89% were male, median age was 28 years, and 330 (18%) were offered NOM. Compared to IO, NOM patients were less likely to have gunshot wound (59% vs 89% p < 0.001) or high-grade renal injuries [AAST 4-5] (48% vs 76%, p < 0.001). Lower rates of in-hospital complications and shorter ICU and hospital stays were observed in the NOM group. NOM failed in 26 patients (8%). Independent predictors of NOM failure included a concomitant abdominal injury (OR = 3.99, 95% CI 1.03-23.23, p = 0.044), and every point increase in AAST grade (OR = 2.43, 95% CI 1.27-5.21, p = 0.005). CONCLUSIONS: NOM is highly successful in selected patients. Concomitant abdominal injuries and higher grade AAST injuries predict NOM failure and should be considered when selecting patients for IO or NOM.

Fresh Frozen Plasma-to-Packed Red Blood Cell Ratio and Mortality in Traumatic Hemorrhage: Nationwide Analysis of 4,427 Patients.

BACKGROUND: Despite the presence of highly reliable data, studies on packed red blood cells (pRBC):fresh frozen plasma (FFP) ratio suffer from limited sample size and the presence of survivor bias. We sought to study the association between FFP:pRBC and early mortality in the hemorrhaging trauma patient. STUDY DESIGN: This was a retrospective nationwide cohort that included all TQIP participating hospitals (2013 to 2016). We included all trauma patients who were transfused ≥10 pRBCs and ≥1 FFP within 24 hours. We excluded transferred patients and those who died in the emergency department or had missing/inaccurate transfusion data. Patients were assigned to 7 FFP:pRBC cohorts (range 1:1 to 1:6, and 1:6+) only if the ratio was similar at 4 and 24 hours and, to avoid survival bias, were excluded otherwise. Multivariable analyses correcting for all available confounders (age, demographics, comorbidities, vital signs, Injury Severity Score [ISS] and mechanism, procedures performed) were derived to study the independent relationship between FFP:pRBC and 24-hour mortality. RESULTS: Of 1,002,595 patients, 4,427 patients were included. Mean age was 41 years, 79% were males, 61% had blunt trauma, and median ISS was 29. Most patients were transfused in a 1:1, 1:2, or 1:3 ratio (31%, 41%, and 11%, respectively); mortality ranged between 28% for 1:1 and 62% for 1:4. In multivariable analyses, the odds of mortality independently and incrementally increased to 1.23 (95% CI 1.02 to 1.48) for a 1:2 ratio, 2.11 (95% CI 1.42 to 3.13) for 1:4, and as high as 4.11 (95% CI 2.31 to 7.31) for 1:5 (all p < 0.05). CONCLUSIONS: A 1:1 FFP:pRBC ratio is associated with the lowest mortality in the hemorrhaging trauma patient, and mortality increases with decreasing ratios.