Patient Outcomes in Laparoscopic Appendectomy With Acute Surgical Care Model Compared to Traditional Call.

INTRODUCTION: Shift-based models for acute surgical care (ACS), where surgical emergencies are treated by a dedicated team of surgeons working shifts, without a concurrent elective practice, are becoming more common nationwide. We compared the outcomes for appendectomy, one of the most common emergency surgical procedures, between the traditional (TRAD) call and ACS model at the same institution during the same time frame. METHODS: A retrospective review of patients who underwent laparoscopic appendectomy for acute appendicitis during 2017-2018. ACS and TRAD-patient demographics, clinical presentation, operative details, and outcomes were compared using independent sample t-tests, Wilcoxon rank-sum tests and Fisher's exact or χ2 tests. Multiple exploratory regression models were constructed to examine the effects of confounding variables. RESULTS: Demographics, clinical presentation, and complication rates were similar between groups except for a longer duration of symptoms prior to arrival in the TRAD group (Δ = 0.5 d, P = 0.006). Time from admission to operating room (Δ = -1.85 h, P = 0.003), length of hospital stay (Δ = -2.0 d, P < 0.001), and total cost (Δ = $ -2477.02, P < 0.001) were significantly lower in the ACS group compared to the TRAD group. Furthermore, perforation rates were lower in ACS (8.3% versus 28.6%, P = 0.003). Differences for the outcomes remained significant even after controlling for duration of symptoms prior to arrival (P < 0.05). CONCLUSIONS: Acute appendicitis managed using the ACS shift-based model seems to be associated with reduced time to operation, hospital stay, and overall cost, with equivalent success rates, compared to TRAD.

Pneumopericardium Resulting From Blunt Thoracic Trauma.

Pneumopericardium is a rare clinical condition defined by the presence of air in the pericardial sac. While this initially does not pose much danger, the accumulation of a sufficient amount of air can convert the pneumopericardium to a tension pathology. This may present with the classic signs, symptoms, and lethal dangers of cardiac tamponade. As with cardiac tamponade, treatment involves decompression of the pericardial sac through pericardiocentesis. This may be followed by insertion of a pericardial tube for continued drainage. While cardiac tamponade is well recognized by its classic findings, the rarer pneumopericardium may be more easily missed. This is further complicated by the backdrop of concurrent traumatic injuries in which it typically presents, as well as the absence of the defining accumulated pericardial effusion. We present a case of a 38-year old male who developed pneumopericardium and worsening hemodynamic status as a complication to blunt trauma, a rare etiology for this condition. CT of the chest demonstrated air in the pericardium and a coexisting pneumothorax. A bedside chest tube was placed. Upon resolution of the pneumothorax, his hemodynamic status improved. Repeat bedside ultrasound demonstrated complete resolution of his pneumopericardium. This case emphasizes the importance of early recognition and diagnosis of this rare yet easily missed condition.

Rectus Sheath Hematoma: A Rare Surgical Emergency.

A rectus sheath hematoma (RSH) is a rare medical condition that consists of blood accumulating in the rectus abdominis muscle sheath. RSH is most frequently due to a hemorrhage from the superior or inferior epigastric artery. RSH has many specific risk factors, such as anticoagulant use. As the use of anticoagulants increases, the incidence of RSH has also increased. This condition can present with the infrequent complication of abdominal compartment syndrome (ACS), which can require surgical decompression of the abdomen to avoid high morbidity and mortality. We present the case of a 79-year-old male who, after receiving anticoagulants, developed a right-sided RSH which progressed to ACS. The patient was transferred to our care for community-acquired pneumonia, pneumothorax, and increasing respiratory support. He was admitted to the medical intensive care unit (MICU), was placed on a nasal cannula, and given vancomycin and Zosyn for pneumonia. After two days, the patient was switched to enoxaparin for anticoagulation. After three days, the patient's pneumothorax had resolved. At this time, the patient reported swelling in his right lower quadrant (RLQ) with mild pain, nausea, vomiting, and difficulty voiding completely. The physical examination confirmed RLQ swelling, and a kidney, ureter, and bladder (KUB) x-ray and ultrasound were ordered. A CT with and without contrast was also obtained which showed a large right rectus sheath hematoma extension into preperitoneal space and a small amount of intraperitoneal fluid along the right paracolic gutter. Soon after, the patient became lightheaded and fell after using the restroom. Vitals at the time were a blood pressure of 79/56, heart rate (HR) of 127, and oxygen saturation of 88% with his hemoglobin dropping from 11.4 g/dL earlier that morning to 8.4 g/dL. The patient's care was transferred to our surgical team in the surgical intensive care unit (SICU). He received an arterial line, two doses of protamine, 1-liter of crystalloids, and two units of packed red blood cells (PRBC). The patient's vitals normalized. Interventional radiology (IR) was consulted but they requested the coagulopathy be corrected before any intervention. Reversal of his Lovenox® was thromboelastographic (TEG)-guided and included platelets, cryoprecipitate, and prothrombin complex concentrate/fresh frozen plasma (PCC/FFP), in addition to more PRBCs. During these interventions, the patient acutely decompensated with hypotension, difficulty breathing, and expansion of his hematoma. A bladder pressure in the 30s was obtained, causing him to be sent to the operating room (OR) for decompression, extraperitoneal packing, and the wound was temporarily closed. The patient returned and IR was able to embolize the right inferior epigastric artery. The patient was taken to the OR again for exploration, removal of packing, and closure. RSH is a rare complication that can occur due to trauma, coagulopathy, obesity, and muscle strains during a pregnancy. Larger hematomas tend to occur below the arcuate line because there is an absence of the posterior rectus sheath which enables the hematomas to spread. An RSH can be treated with conservative measures, but for patients who continue to bleed, more aggressive measures should be taken to avoid life-threatening complications, such as ACS.

A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wound Healing.

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. The short and long-term consequences of living with a chronically open abdominal compartment include pulmonary, musculoskeletal, gastrointestinal, and emotional disability. The closure of catastrophic open abdomens presents a challenge to the surgeon. We present a technique utilizing a mechanical abdominal closure device in conjunction with biologic xenograft in closing complex open abdomens. This technique offers another option for definitive fascial closure and accelerated wound healing in this difficult patient population. The dynamic tissue system (DTS) is installed after control of original intraabdominal pathology. A porcine urinary bladder matrix (PUBM) is then placed in the subcutaneous space once fascial closure is achieved. Overall, primary myofascial closure was achieved in 100% of patients at a mean of 9.36 days.

Determining suicide risk in trauma patients using a universal screening program.

BACKGROUND: Trauma patients may be at elevated risk for subsequent suicide; however, it is unclear whether patients at risk can be identified during their initial presentation following injury. The objectives of this study were to evaluate the use of a standardized clinical decision support system for suicide risk screening developed by our hospital system and to determine the incidence of positive suicide screenings in our trauma population. METHODS: Adult trauma patient screenings were performed by nursing staff during the triage process using the Columbia Suicide Severity Rating Scale, Clinical Practice Screener, Recent (C-SSRS). Adult trauma patients who had a suicide risk screening completed from February 2015 to November 2015 were evaluated retrospectively. Patients were divided into cohorts consisting of those with positive and negative screening assessments. Significance was set at α = 0.05. Statistical analysis was performed using Student t test and a χ test where appropriate. RESULTS: Overall, 3,623 of 3,712 patients (98%) completed a suicide risk screening during the study period. Those who went unscreened were not evaluated due to altered mental status/intubation/emergent surgery (97%), death (1%), or an unwillingness to cooperate (2%). The suicide risk screening result was positive in 161 of 3,623 patients (4%) in the study cohort. On univariate analysis, patients with a positive suicide risk screen result were more likely to be white (43% vs 32%; p = 0.01), identify English as their primary language (91% vs 73%; p < 0.01), have insurance coverage (48% vs 28%; p < 0.01), and were more likely to initiate a low-level trauma activation (27% vs 16%; p <0.01) than those who had a negative screening result. A positive suicide risk assessment result was moderately associated with patients of white race (odds ratio, 1.83; 95% confidence interval, 1.27-2.65) on multivariable logistic regression. CONCLUSION: Our universal suicide screening process identifies an at-risk subpopulation of trauma patients. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic, level IV.