Trends in Surgical Critical Care Training Among General Surgery Residents: Pursuing an Ideal Curriculum.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) provides no specific guidelines for surgical critical care (SCC) training during general surgery residency. Growing emphasis is placed on this experience with increasing case requirements and dedicated SCC content on board certification exams. METHODS: A digital survey was distributed to ACGME-accredited general surgery residencies via email. Respondents reported number and setting of critical care months during residency and rated comfort level within 5 critical care principles and overall satisfaction with their SCC experience. Study cohorts were formed to compare experiences and competencies between respondents based on setting, months, postgraduate year (PGY) level, and formal surgical intensive care unit (SICU) experience. Differences between cohorts were compared using the Mantel-Haenszel test (P < .05). RESULTS: Seventy-three residents responded with 45% training at academic centers versus 46% in community hospitals. Approximately 50% completed a formal SICU rotation, while 9% reported no dedicated critical care rotation during residency. Overall, 78% felt satisfied with their SCC experience. Residents training at academic centers were more satisfied overall and felt more comfortable with ventilator management. Those who completed 5 or more months of critical care training reported greater confidence with intravenous sedation and ventilator management, while residents having a formal SICU rotation felt more confident with vasopressor and ventilator management. DISCUSSION: Variability remains within SCC training among general surgery residents with perceived benefits seen in training at academic centers and completing a formal SICU rotation. Although limited, these findings offer a foundation for developing an effective SCC curriculum.

Utility of 4-Factor Prothrombin Complex Concentrate in Trauma and Acute-Care Surgical Patients.

CONTEXT: Since 2013, prothrombin complex concentrate (PCCs) have been approved in the United States for the reversal of anticoagulation induced by vitamin K antagonists. However, there has been limited investigation into their use in trauma and acute-care surgery (ACS). OBJECTIVE: To investigate the role that 4-factor PCC may have in reversing anticoagulation in the setting of trauma and ACS. METHODS: All trauma and ACS patients who presented between March 14, 2014, and August 1, 2015, were included in this retrospective descriptive analysis. Patients receiving 4-factor PCC were compared with patients receiving fresh frozen plasma (FFP) alone. The following data were collected from medical records: age, sex, race, international normalized ratio (INR) at admission (baseline) and after reversal, blood products given, dosing of medication, injury severity score, length of stay, thromboembolic event, death during admission, and death within 90 days after admission. RESULTS: There were 188 trauma and ACS patients who required reversal of anticoagulation. Of these, 98 patients received FFP and 90 received PCC. Patients who received PCC were at increased risk for death during admission (20% vs 9.2% for FFP group) or within 90 days (39% vs 15%, respectively). Patients in the PCC group had a higher median baseline INR (2.9 vs 2.5 in the FFP group) and a lower postintervention INR (1.4 vs 1.8); consequently, the decrease in INR was greater in the PCC group than in the FFP group (1.5 vs 0.7, respectively). The number of total units of packed red blood cells transfused was significantly higher in patients receiving PCC. CONCLUSION: Patients receiving PCC had worse outcomes than those who received FFP. Given that these differences may have resulted from baseline differences between groups, these results mandate further prospective analysis of the use of PCC in trauma and ACS patients.