Timing of Venous Thromboembolism Prophylaxis Initiation and Complications in Polytrauma Patients with High-Risk Bleeding Orthopedic Interventions: A Nationwide Analysis.

INTRODUCTION: There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide. METHODS: A retrospective cohort study of trauma patients ≥18 years who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons (ACS) verified trauma centers using the 2019-2020 ACS-TQIP databank. We excluded patients with a competing risk of non-orthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared to VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, DVT, and PE rates. RESULTS: The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (IQR 18, 44). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (aOR 2.02; 95% CI 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (HR 0.90; 95% CI 0.62-1.34). CONCLUSIONS: Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic re-intervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention. LEVEL OF EVIDENCE: Level III, Therapeutic.

Antibiotic use in acute mesenteric ischemia: a review of the evidence and call to action.

Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The standard practice after making the diagnosis includes aggressive resuscitation, anticoagulation, followed by revascularization and resection of necrotic bowel. The role of empiric antibiotics in the management of AMI is not well defined in the literature. This review article aims to examine our current understanding on this matter, based on bench research and clinical studies. It is demonstrated in animal study model that the ischemia/reperfusion (I/R) injury damages intestinal epithelium, and subsequently lead to barrier dysfunction, a condition that can support bacterial translocation through a complex interplay between the intestinal epithelium, the intestinal immune system and the intestine's endogenous bacterial population. Based on this mechanism, it is possible that the use of antibiotics may help mitigate the consequences of I/R injury, which is examined in few animal studies. In clinical practice, many guidelines support the use of prophylactic antibiotics, based on a meta-analysis of randomized control trials (RCTs) demonstrating the benefit of antibiotics in multi-organ dysfunction syndrome. However, there is no direct reference to AMI in this meta-analysis. Most clinical studies that focus on AMI and mentions the use of antibiotics are retrospective and single institution, and very few comments on the role of antibiotics in their discussions. We conclude that there is limited evidence in literature to support the use of prophylactic antibiotic in AMI to improve outcome. More clinical studies with high level of evidence and basic science research are needed to improve our understanding on this topic and ultimately help build a better clinical pathway for patients with AMI.

Surgical stabilization versus nonoperative treatment for flail and non-flail rib fracture patterns in patients with traumatic brain injury.

PURPOSE: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. METHODS: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. RESULTS: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034). CONCLUSION: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.

Emesis of an enteral bullet: A rare case of bullet embolism to the thoracic esophagus.

A case of migration of a foreign body from the stomach to the thoracic esophagus is described. The bullet was successfully retrieved endoscopically after exploratory laparotomy was performed to address the patient's injuries. Enteral migration of bullets is a rare phenomenon that should be considered when the location of retained ballistic fragments is inconsistent with gunshot wounds and expected trajectories.

High Mortality and Venous Thromboembolism Risk Following Major Penetrating Abdominal Venous Injuries.

BACKGROUND: Penetrating injuries to the inferior vena cava and/or iliac veins are a source of hemorrhage but may also predispose patients to venous thromboembolism (VTE). We sought to determine the relationship between iliocaval injury, VTE and mortality. METHODS: The National Trauma Data Bank was queried for penetrating abdominal trauma from 2015-2017. Univariate analyses compared baseline characteristics and outcomes based on presence of iliocaval injury. Multivariable analyses determined the effect of iliocaval injury on VTE and mortality. RESULTS: Of 9,974 patients with penetrating abdominal trauma, 329 had iliocaval injury (3.3%). Iliocaval injury patients were more likely to have a firearm mechanism (83% vs. 43%, P < 0.001), concurrent head (P = 0.036), spinal cord (P < 0.001), and pelvic injuries (P < 0.001), and higher total injury severity score (median 20 vs. 8.0, P < 0.001). They were more likely to undergo 24-hr hemorrhage control surgery (69% vs. 17%, P < 0.001), but less likely to receive VTE chemoprophylaxis during admission (64% vs. 68%, P = 0.04). Of patients undergoing iliocaval surgery, 64% underwent repair, 26% ligation, and 10% unknown. Iliocaval injury patients had higher rates of VTE (12% vs. 2%), 24-hr mortality (23% vs. 2.0%) and in-hospital mortality (33% vs. 3.4%) (P < 0.001 for all). VTE rates were similar following repair (14%) and ligation (17%). Iliocaval injury patients also had higher rates of cardiac complications (10.3% vs. 1.4%), acute kidney injury (8.2% vs. 1.3%), extremity compartment syndrome (4.0 vs. 0.2%), and unplanned return to OR (7.9% vs. 2.5%) (P < 0.001 for all). In multivariable analyses, iliocaval injury was independently associated with risk of VTE (OR 2.12; 95% CI, 1.29-3.48; P = 0.003), and in-hospital mortality (OR = 9.61; 95% CI, 4.96-18.64; P < 0.001). CONCLUSION: Iliocaval injuries occur in <5% of penetrating abdominal trauma but are associated with more severe injury patterns and high mortality rates. Regardless of repair type, survivors should be considered high risk for developing VTE.

The majority of major amputations after resuscitative endovascular balloon occlusion of the aorta are associated with preadmission trauma.

OBJECTIVE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving intervention. However, recent reports of associations with limb loss and mortality have called its safety into question. We aimed to evaluate patient and hospital characteristics associated with major amputation and in-hospital mortality among patients undergoing REBOA for trauma. METHODS: The National Trauma Data Bank (2015-2017) was queried for patients presenting to trauma centers and treated with REBOA. We included REBOA performed on hospital day 1 in patients who survived 6 or more hours from presentation. Univariable and multivariable analyses evaluated associations with major amputation and in-hospital mortality. RESULTS: A total of 316 patients underwent REBOA and survived in the acute period after presentation. Overall, mean age was 45 ± 20 years and the majority were male (73%) and White (56%). Most patients presented to level I trauma centers (72%) after blunt injuries (79%) with an average Injury Severity Score (ISS) of 31 ± 15, indicating major trauma. In 15 patients (5%), there were 18 major amputations-7 above knee and 11 below knee. A subgroup of 11 amputations were either traumatic amputations (73%) or mangled limbs requiring amputation within 24 hours (27%). Of the remaining amputations, 71% were associated with ipsilateral vascular or orthopedic lower extremity injuries of serious to severe Abbreviated Injury Scale severity. Comparing patients with amputations with those without amputations, there were no significant differences in patient demographics, comorbidities, or hospital characteristics. During hospitalization, patients requiring amputation more frequently received open peripheral vascular interventions (40% vs 10%; P = .002), underwent similar numbers of endovascular interventions (6.7% vs 4.7%; P = .5), and more often developed compartment syndrome (13% vs 2%; P = .04). Overall, there were 110 deaths (35%). The major amputation prevalence was similar between patients who died vs those who survived (3.6% vs 5.3%; P = .5). In multivariable analysis, prehospital cardiac arrest (odds ratio [OR], 8.47; 95% confidence interval [CI], 1.47-48.66; P = .02), penetrating vs blunt trauma (OR, 5.5; 95% CI, 1.05-28.82; P = .04), decreased Glasgow Coma Scale score (OR, 1.18; 95% CI, 1.05-1.32; P = .01), older age (OR, 1.06; 95% CI, 1.03-1.10; P < .001), and increased Injury Severity Score (OR, 1.05; 95% CI, 1.0-1.1; P = .03) were associated with higher mortality. CONCLUSIONS: The majority of major amputations in patients undergoing REBOA were secondary to the initial traumatic mechanism. Injury type and severity, as well as initial hemodynamic derangements, are associated with mortality after REBOA. Despite concerns about prohibitive limb complications of REBOA, baseline injuries seem to be the primary cause of limb loss, but further prospective analysis is needed.

Outcome after surgical stabilization of rib fractures versus nonoperative treatment in patients with multiple rib fractures and moderate to severe traumatic brain injury (CWIS-TBI).

BACKGROUND: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI. METHODS: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI. RESULTS: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034). CONCLUSION: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI. LEVEL OF EVIDENCE: Therapeutic, level IV.

The Boston Medical Center Coronavirus Disease 2019 (COVID-19) Procedure Team: Optimizing the surgeon's role in pandemic care at a safety-net hospital.

BACKGROUND: The coronavirus disease 2019 pandemic has claimed many lives and strained the US health care system. At Boston Medical Center, a regional safety-net hospital, the Department of Surgery created a dedicated coronavirus disease 2019 Procedure Team to ease the burden on other providers coping with the surge of infected patients. As restrictions on social distancing are lifted, health systems are bracing for additional surges in coronavirus disease 2019 cases. Our objective is to quantify the volume and types of procedures performed, review outcomes, and highlight lessons for other institutions that may need to establish similar teams. METHODS: Procedures were tracked prospectively along with patient demographics, immediate complications, and time from donning to doffing of the personal protective equipment. Retrospective chart review was conducted to obtain patient outcomes and delayed adverse events. We hypothesized that a dedicated surgeon-led team would perform invasive bedside procedures expeditiously and with few complications. RESULTS: From March 30, 2020 to April 30, 2020, there were 1,196 coronavirus disease 2019 admissions. The Procedure Team performed 272 procedures on 125 patients, including placement of 135 arterial catheters, 107 central venous catheters, 25 hemodialysis catheters, and 4 thoracostomy tubes. Specific to central venous access, the average procedural time was 47 minutes, and the rate of immediate complications was 1.5%, including 1 arterial cannulation and 1 pneumothorax. CONCLUSION: Procedural complication rate was less than rates reported in the literature. The team saved approximately 192 hours of work that could be redirected to other patient care needs. In times of crisis, redeployment of surgeons (who arguably have the most procedural experience) into procedural teams is a practical approach to optimize outcomes and preserve resources.

Implementation of a Novel Structured Social and Wellness Committee in a Surgical Residency Program: A Case Study.

This article provides a theoretical and practical rational for the implementation of an innovative and comprehensive social wellness program in a surgical residency program at a large safety net hospital on the East Coast of the United States. Using basic needs theory, we describe why it is particularly important for surgical residency programs to consider the residents sense of competence, autonomy, and belonging during residence. We describe how we have developed a comprehensive program to address our residents' (and residents' families) psychological needs for competence, autonomy, and belongingness.

Pulmonary artery adventitial fibroblasts cooperate with vasa vasorum endothelial cells to regulate vasa vasorum neovascularization: a process mediated by hypoxia and endothelin-1.

The precise cellular and molecular mechanisms regulating adventitial vasa vasorum neovascularization, which occurs in the pulmonary arterial circulation in response to hypoxia, remain unknown. Here, using a technique to isolate and culture adventitial fibroblasts (AdvFBs) and vasa vasorum endothelial cells (VVECs) from the adventitia of pulmonary arteries, we report that hypoxia-activated pulmonary artery AdvFBs exhibited pro-angiogenic properties and influenced the angiogenic phenotype of VVEC, in a process of cell-cell communication involving endothelin-1 (ET-1). We demonstrated that AdvFBs, either via co-culture or conditioned media, stimulated VVEC proliferation and augmented the self-assembly and integrity of cord-like networks that formed when VVECs where cultured on Matrigel. In addition, hypoxia-activated AdvFBs produced ET-1, suggesting a paracrine role for this pro-angiogenic molecule in these processes. When co-cultured on Matrigel, AdvFBs and VVECs self-assembled into heterotypic cord-like networks, a process augmented by hypoxia but attenuated by either selective endothelin receptor antagonists or oligonucleotides targeting prepro-ET-1 mRNA. From these observations, we propose that hypoxia-activated AdvFBs exhibit pro-angiogenic properties and, as such, communicate with VVECs, in a process involving ET-1, to regulate vasa vasorum neovascularization occurring in the adventitia of pulmonary arteries in response to chronic hypoxia.