The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial.

BACKGROUND: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(ß -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE: IV.

Improving elementary students' knowledge and behavior to prevent traumatic injury: the impact of a behavioral skills training model delivered by aspirational role models.

Trauma is the leading cause of childhood morbidity and mortality annually in the USA, accounting for 11% of deaths, most commonly due to car crashes, suffocation, drowning, and falls. Prevention is paramount for reducing the incidence of these injuries. As an adult level 1 and pediatric level 2 trauma center, there is a commitment to injury prevention through outreach and education. The Safety Ambassadors Program (SAP) was developed as part of this aim. Safety Ambassadors (SA) are high schoolers who teach elementary school students about safety/injury prevention. The curriculum addresses prevalent areas of injury risk: car/pedestrian safety, wheeled sports/helmets, and fall prevention. The study group hypothesized that participation in SAP leads to improved safety knowledge and behaviors and ultimately reduces childhood preventable injuries. Educational material was delivered by high school students (ages 16-18 years old). First and second-grade participants (ages 6-8 years old) completed pre- and post-course exams to assess knowledge (12 questions) and behavior (4 questions). Results were retrospectively reviewed, and pre/post training mean scores were calculated. Scores were calculated based on number of correct answers on pre/post exam. Comparisons were made using the Student t-test. All tests were 2-tailed with significance set at 0.05. Pre- and post-training results were assessed for 2016-2019. Twenty-eight high schools and 37 elementary schools were enrolled in the program with 8832 student participants in SAP. First graders demonstrated significant improvement in safety knowledge (pre 9 (95% CI 8.9-9.2) vs post 9.8 (95%CI 9.6-9.9), (p < 0.01)) and behavior modification (pre 3.2 (95%CI 3.1-3.2) vs post 3.6 (95% CI 3.5-3.6), (p < 0.01)). Similar findings were seen in 2nd graders: safety knowledge (pre 9.6 (95% CI 9.4-9.9) vs post 10.1 (95% CI 9.9-10.2), (p < 0.01)) and behavior (pre 3.3 (95% CI 3.1-3.4) vs post 3.5 (95%CI 3.4-3.6), (p < 0.01)).    Conclusion: SAP is a novel evidence-based educational program delivered to elementary school students by aspirational role models. This model is impactful, relatable, and engaging when provided by participants' older peer mentors. On a local level, it has demonstrated improved safety knowledge and behavior in elementary school students. As trauma is the leading cause of pediatric death and disability, enhanced education may lead to life-saving injury prevention in this vulnerable population. What is Known: • Preventable trauma is the leading cause of pediatric death in the USA and education has contributed to improvements in both safety knowledge and behavior. • The ideal delivery method for injury prevention education in children continues to be under investigation. What is New: • Our data suggest that a peer-based injury prevention model is both an effective education delivery method and easily instituted within existing school systems. • This study supports implementation of peer-based injury prevention programs to improve safety knowledge and practices. • With more widespread institution and research, we hope to ultimately reduce preventable childhood injury.

Utility of computed tomography reconstructed thoracolumbar spinal imaging in blunt trauma.

OBJECTIVES: Fractures of the thoracolumbar (TL) spine are common and may cause neurologic damage, pain, and reduced quality of life. Computed tomography (CT) TL reconstructions from CT chest, abdomen, and pelvis (CAP) are used to identify TL fractures; however, their benefit over CAP imaging is unclear. We hypothesized that reformatted TL images do not identify additional clinically significant injuries or change outcomes. METHODS: Retrospective data were collected 2016 to 2021 from trauma patients at a level 1 trauma center. All patients 18 years or older with TL fractures on CT CAP with/without CT TL reformats were included. Clinically significant TL fractures were defined as requiring operative fixation, brace, or spinal rehabilitation. A binary classification model was created to assess the diagnostic utility of CTCAP compared with CTTL in predicting clinically significant fractures in patients who underwent CT CAP/TL. RESULTS: There were 828 patients with TL fractures, 634 had both CT CAP/CT TL (CAPTL) and 194 CTCAP only (CAP). There were 134 clinically significant TL fractures (16%) (14 [7.2%] CT CAP vs. 120 [18.9%] CT CAPTL, p < 0.001). There were no differences among unstable fractures, fractures on magnetic resonance imaging (MRI) only, mortality, or neurologic deficits on discharge between CAPTL and CAP ( p > 0.05). Among clinically significant fractures, CAPTL was not associated with increased MRI utilization, surgery, spinal brace, or spinal cord rehabilitation ( p > 0.05). Among clinically insignificant fractures, CAPTL was associated with increased MRIs, length of stay (LOS), and intensive care unit LOS ( p < 0.05). CAPTL was also an independent predictor of increased MRIs (odds ratio, 5.79; 95% confidence interval, 2.29-14.65; p < 0.01) and spine consultation (odds ratio, 2.39; 95% confidence interval, 1.64-3.67; p < 0.01). More CT CAP/TL were performed in those with clinically significant fractures; however, CTCAP was equivalent to CTTL for detection of fractures ( p > 0.05). CONCLUSION: CTCAP alone is sufficient to identify clinically significant TL fractures. While the addition of TL reformatted imaging minimizes missed injuries, it is associated with increased hospital LOS and MRI resource utilization. Therefore, careful consideration is needed for appropriate CT TL patient selection. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Screening and intervention for intimate partner violence at trauma centers and emergency departments: an evidence-based systematic review from the Eastern Association for the Surgery of Trauma.

Background: Intimate partner violence (IPV) is a serious public health issue with a substantial burden on society. Screening and intervention practices vary widely and there are no standard guidelines. Our objective was to review research on current practices for IPV prevention in emergency departments and trauma centers in the USA and provide evidenced-based recommendations. Methods: An evidence-based systematic review of the literature was conducted to address screening and intervention for IPV in adult trauma and emergency department patients. The Grading of Recommendations, Assessment, Development and Evaluations methodology was used to determine the quality of evidence. Studies were included if they addressed our prespecified population, intervention, control, and outcomes questions. Case reports, editorials, and abstracts were excluded from review. Results: Seven studies met inclusion criteria. All seven were centered around screening for IPV; none addressed interventions when abuse was identified. Screening instruments varied across studies. Although it is unclear if one tool is more accurate than others, significantly more victims were identified when screening protocols were implemented compared with non-standardized approaches to identifying IPV victims. Conclusion: Overall, there were very limited data addressing the topic of IPV screening and intervention in emergency medical settings, and the quality of the evidence was low. With likely low risk and a significant potential benefit, we conditionally recommend implementation of a screening protocol to identify victims of IPV in adults treated in the emergency department and trauma centers. Although the purpose of screening would ultimately be to provide resources for victims, no studies that assessed distinct interventions met our inclusion criteria. Therefore, we cannot make specific recommendations related to IPV interventions. PROSPERO registration number: CRD42020219517.

The Impact of Surgical Boot Camp on Medical Student Confidence and Imposter Syndrome.

INTRODUCTION: Transitioning from medical student to surgical intern is accompanied by increased responsibility, stress, and clinical burden. This environment lends itself to imposter syndrome (IS), a psychological condition grounded in self-doubt causing fear of being discovered as fraud despite adequate abilities. We hypothesized a 2-week surgical boot camp for fourth year medical students would improve confidence in technical skills/knowledge and IS. METHODS: Thirty medical students matching into surgical specialties completed the boot-camp in February 2020. Presurveys/postsurveys assessed confidence levels using a 1-5 Likert scale regarding 32 technical skills and knowledge points. The Clance Impostor Phenomenon Scale (CIPS) assessed IS, where increasing scores correlate to greater IS. RESULTS: Median (interquartile range [IQR]) subject age was 27 y (26, 28), 20 (66.7%) were male, and 21 (70%) were Caucasian. Of the 30 students, 23 (76.7%) had a break in training with a median [IQR] of 2 [1, 3] y outside of medicine. Confidence scores were significantly improved in all five assessment categories (P < 0.05); however, there was no change in CIPS in median [IQR] presurveys versus postsurveys (65.5 [52, 75] versus 64 [52, 75], P = 0.70). Females had higher mean (standard deviation) pre-CIPS than males (68.4 [15.2] versus 61.6 [14.9], P = 0.02). There was no strong correlation between age and CIPS in the presurvey (Spearman Rank Correlation Coefficient [SRCC]: 0.29, P = 0.19) or postsurvey (SRCC: 0.31, P = 0.10). While subjects who worked outside of medicine had a stronger relationship with IS (SRCC: 0.37, P = 0.05), multivariable regression analysis did not reveal any significant differences. CONCLUSIONS: We advocate for surgical boot-camp training courses to improve trainee skill and confidence. As IS is not improved by boot camp, additional research is needed to identify opportunities to improve IS among surgical trainees.

Subcutaneous Emphysema, Pneumothorax, Pneumomediastinum, and Pneumoperitoneum Following Synthetic Cannabinoid Toxicity in an Incarcerated Man.

BACKGROUND: Synthetic cannabinoids are a recreational drug that can cause toxicity with significant side effects. CASE: We report a 21-year-old incarcerated male with a delayed presentation of pneumothorax, pneumomediastinum, and pneumoperitoneum following synthetic cannabinoid use with altered mental status. DISCUSSION: This case not only highlights the need to consider pneumothorax when evaluating synthetic cannabinoid toxicity but it also emphasizes a vulnerable population (incarcerated individuals at risk for trauma, substance use disorders, and mental illness) who are at risk for delayed medical care and poor follow-up.

Review of Traumatic Duodenal Injuries: Etiology, Diagnosis, and Management.

Traumatic duodenal injuries are rare and often challenging to diagnose and treat. Management of these injuries remains controversial and continues to evolve. Here, we performed a review of the literature and guidelines for the diagnosis and management of traumatic duodenal injuries.A common recommendation in more recent literature is primary, tension-free repair of duodenal injuries when possible if surgical repair is necessary. Conversely, if duodenal injuries are unamenable to primary repair, more complex procedures such as Roux-en-Y duodenojejunostomy or pancreaticoduodenectomy may be necessary. Regardless of injury grade or type of surgical repair, the literature continues to support wide extraluminal drainage. Over time, the management of complex duodenal injuries has evolved to favor simple primary repair whenever possible. According to recent studies, more complex procedures are associated with higher rates of post-operative complications and should be reserved for severe injuries when primary repair is not possible.

Evaluation of Procalcitonin's Utility to Predict Concomitant Bacterial Pneumonia in Critically Ill COVID-19 Patients.

Background: Historically, procalcitonin(PCT) has been used as a predictor of bacterial infection and to guide antibiotic therapy in hospitalized patients. The purpose of this study was to determine PCT's diagnostic utility in predicting secondary bacterial pneumonia in critically ill patients with severe COVID-19 pneumonia. Methods: A retrospective cohort study was conducted in COVID-19 adults admitted to the ICU between March 2020, and March 2021. All included patients had a PCT level within 72 h of presentation and serum creatinine of <1.5mg/dL. A PCT threshold of 0.5ng/mL was used to compare patients with high( ≥ 0.5ng/mL) versus low(< 0.5ng/mL) PCT. Bacterial pneumonia was defined by positive respiratory culture. A receiver operating characteristics (ROC) curve was utilized to evaluate PCT as a diagnostic test for bacterial pneumonia, with an area under the curve(AUC) threshold of 0.7 to signify an accurate diagnostic test. A multivariable model was constructed to identify variables associated with in-hospital mortality. Results: There were 165 patients included: 127 low PCT versus 38 high PCT. There was no significant difference in baseline characteristics, vital signs, severity of disease, or outcomes among low versus high PCT groups (all p > 0.05). While there was no difference in bacterial pneumonia in low versus high groups (34(26.8%) versus 12(31.6%), p = 0.562), more patients in the high PCT group had bacteremia (19(15%) versus 11(28.9%), p = 0.050). Sensitivity was 26.1% and specificity was 78.2% for PCT to predict bacterial pneumonia coinfection in ICU patients with COVID-19 pneumonia. ROC yielded an AUC 0.54 (p = 0.415). After adjusting for LDH>350U/L and creatinine in multivariable regression, PCT did not enhance performance of the regression model. Conclusions: PCT offers little to no predictive utility in diagnosing concomitant bacterial pneumonia in critically ill patients with COVID-19 nor in predicting increased severity of disease or worse outcomes including mortality.

The Utility of Lower Extremity Screening Duplex for the Detection of Deep Vein Thrombosis in Trauma.

BACKGROUND: Trauma patients are high-risk for venous thromboembolism (VTE). Lower extremity screening duplex ultrasonography (LESDUS) is controversial and not standardized for early VTE diagnosis. By implementing risk stratification and selective screening, we aim to optimize resource utilization. MATERIALS AND METHODS: A retrospective review were conducted at a Level-1 Trauma Center, January 2015-October 2019. LESDUS was performed within 72-h of presentation, then weekly. Demographics, VTE data, and outcomes were collected from the trauma registry. Risk assessment profile (RAP) score was calculated based on collected data. RESULTS: Of 5,645 patients included, 2,813 (49.8%) were screened for lower extremity deep vein thrombosis (LEDVT). Of 187 patients with LEDVT, 154 were diagnosed on LESDUS, 18 after negative LESDUS, and 15 in unscreened patients. Patients with VTE were older (61y versus 55, P < 0.01), more often male (70.9% versus 29.1%, P = 0.03), had higher ISS (16 versus 10, P < 0.01), longer hospital length of stay (LOS) (11.5 d versus 3, P < 0.01), longer ICU LOS (4.5 d versus 1, P < 0.01), and increased mortality (9.1% versus 4.3%, P = 0.01). RAP was higher in VTE patients versus those without (nine versus three, P < 0.01). RAP ≥8 was 62.5% sensitive and 70.4% specific for VTE. Chemoprophylaxis delay also correlated with increased VTE (OR = 1.48, 95% CI = 1.03-2.12). CONCLUSIONS: VTE remains a significant complication in trauma patients. Despite a universal LESDUS protocol, only 50% of patients underwent screening and 20% of all LE DVTs were not identified on LESDUS. To optimize resource utilization and protocol adherence, LESDUS should only be performed if RAP ≥8 or if unable to administer timely chemoprophylaxis.

Fever in the ICU: A Predictor of Mortality in Mechanically Ventilated COVID-19 Patients.

PURPOSE: While fever may be a presenting symptom of COVID-19, fever at hospital admission has not been identified as a predictor of mortality. However, hyperthermia during critical illness among ventilated COVID-19 patients in the ICU has not yet been studied. We sought to determine mortality predictors among ventilated COVID-19 ICU patients and we hypothesized that fever in the ICU is predictive of mortality. MATERIALS AND METHODS: We conducted a retrospective cohort study of 103 ventilated COVID-19 patients admitted to the ICU between March 14 and May 27, 2020. Final follow-up was June 5, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. RESULTS: 103 patients were included, 40 survived and 63(61.1%) died. Deceased patients were older {66 years[IQR18] vs 62.5[IQR10], (p = 0.0237)}, more often male {48(68%) vs 22(55%), (p = 0.0247)}, had lower initial oxygen saturation {86.0%[IQR18] vs 91.5%[IQR11.5], (p = 0.0060)}, and had lower pH nadir than survivors {7.10[IQR0.2] vs 7.30[IQR0.2] (p < 0.0001)}. Patients had higher peak temperatures during ICU stay as compared to hospital presentation {103.3°F[IQR1.7] vs 100.0°F[IQR3.5], (p < 0.0001)}. Deceased patients had higher peak ICU temperatures than survivors {103.6°F[IQR2.0] vs 102.9°F[IQR1.4], (p = 0.0008)}. Increasing peak temperatures were linearly associated with mortality. Febrile patients who underwent targeted temperature management to achieve normothermia did not have different outcomes than those not actively cooled. Multivariable analysis revealed 60% and 75% higher risk of mortality with peak temperature greater than 103°F and 104°F respectively; it also confirmed hyperthermia, age, male sex, and acidosis to be predictors of mortality. CONCLUSIONS: This is one of the first studies to identify ICU hyperthermia as predictive of mortality in ventilated COVID-19 patients. Additional predictors included male sex, age, and acidosis. With COVID-19 cases increasing, identification of ICU mortality predictors is crucial to improve risk stratification, resource management, and patient outcomes.

Prolonged operating room time in emergency general surgery is associated with venous thromboembolic complications.

BACKGROUND: We evaluated the association between operating room time and developing a deep vein thrombosis (DVT) or pulmonary embolus (PE) after emergency general surgery (EGS). METHODS: We reviewed six common EGS procedures in the 2013-2015 NSQIP dataset. After tabulating their incidence of postoperative VTE events, we calculated predictors of developing a VTE using adjusted multivariate logistic regressions. RESULTS: Of 108,954 EGS patients, 1,366 patients (1.3%) developed a VTE postoperatively. The median time to diagnosis was 9 days [5-16] for DVTs and 8 days [5-16] for PEs. Operating room time of 100 min or more was associated with increased risk of developing a DVT (OR 1.30 [1.12-2.21]) and PE (OR:1.25 [1.11-2.43]) with a 7% and 5% respective increase for every 10 min increase after the 100 min. Other independent predictors of VTE complications were older age, and history of cancer, and emergent colectomies on procedure-level analysis. CONCLUSION: Prolonged operating room time is independently associated with increased risk of developing VTE complications after an EGS procedure. Most of the VTE complications were delayed in presentation.

Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies.

BACKGROUND: Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children. METHODS: An American College of Surgeons-verified Level 1 trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann-Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications. RESULTS: Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11-17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17-42), pediatric trauma score 5 (6; 2-8), penetrating abdominal trauma index score [PATI] 29 (32; 12-44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14-18) vs. 16 (7; 10-17)) and were more severely injured (ISS, 33 [25; 17-42] vs. 16 [16; 9-25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5-16.5] vs. 1 (0; [0-1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8-25] vs. 7 [4; 4-8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18-41] vs. nonsurvivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18-39] days) requiring 3 (2; 2-4) laparotomies during 4 (6; 2-8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15-18 years) and period (1996-2006 vs. 2007-2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 - 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93-0.99], p = 0.0254) predicted mortality after severe injury. CONCLUSION: DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Kaolin-based hemostatic dressing improves hemorrhage control from a penetrating inferior vena cava injury in coagulopathic swine.

BACKGROUND: Retrohepatic inferior vena cava (RIVC) injuries are often lethal due to challenges in obtaining hemorrhage control. We hypothesized that packing with a new kaolin-based hemostatic dressing (Control+; Z-Medica, Wallingford, CT) would improve hemorrhage control from a penetrating RIVC injury compared with packing with standard laparotomy sponges alone. METHODS: Twelve male Yorkshire pigs received a 25% exchange transfusion of blood for refrigerated normal saline to induce a hypothermic coagulopathy. A laparotomy was performed and a standardized 1.5 cm injury to the RIVC was created which was followed by temporary abdominal closure and a period of uncontrolled hemorrhage. When the mean arterial pressure reached 70% of baseline, demonstrating hemorrhagic shock, the abdomen was re-entered, and the injury was treated with perihepatic packing using standard laparotomy sponges (L; n = 6) or a new kaolin-based hemostatic dressing (K; n = 6). Animals were then resuscitated for 6 hours with crystalloid solution. The two groups were compared using the Wilcoxon rank sum test and Fisher exact test. A p value of 0.05 or less was considered statistically significant. RESULTS: There was no difference in the animal's temperature, heart rate, mean arterial pressure, cardiac output, and blood loss at baseline or before packing was performed (all p > 0.05). In the laparotomy sponge group, five of six pigs survived the entire study period, whereas all six pigs treated with kaolin-based D2 hemostatic dressings survived. Importantly, there was significantly less blood loss after packing with the new hemostatic kaolin-based dressing compared with packing with laparotomy sponge (651 ± 180 mL vs. 1073 ± 342 mL; p ≤ 0.05). CONCLUSION: These results demonstrate that the use of this new hemostatic kaolin-based dressing improved hemorrhage control and significantly decreased blood loss in this penetrating RIVC model. LEVEL OF EVIDENCE: This is basic science research based on a large animal model, level V.

Intra-abdominal packing with laparotomy pads and QuikClot™ during damage control laparotomy: A safety analysis.

BACKGROUND: Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage control in critically injured patients. Combat Gauze™ and Trauma Pads™ ([QC] Z-Medica QuikClot®) are kaolin impregnated hemostatic agents, that in addition to LP, may improve hemorrhage control. While QC packing has been effective in a swine liver injury model, QC remains unstudied for human intra-abdominal use. We hypothesized QC packing during damage control laparotomy (DCL) better controls hemorrhage than standard packing and is safe for intracorporeal use. METHODS: A retrospective review (2011-2014) at a Level-I Trauma Center reviewed all patients who underwent DCL with intentionally retained packing. Clinical characteristics, intraoperative and postoperative parameters, and outcomes were compared with respect to packing (LP vs. LP+QC). All complications occurring within the patients' hospital stays were reviewed. A p≤0.05 was considered significant. RESULTS: 68 patients underwent DCL with packing; (LP n=40; LP+QC n=28). No difference in age, BMI, injury mechanism, ISS, or GCS was detected (Table 1, all p>0.05). LP+QC patients had a lower systolic blood pressure upon ED presentation and greater blood loss during index laparotomy than LP patients. LP+QC patients received more packed red blood cell and fresh frozen plasma resuscitation during index laparotomy (both p<0.05). Despite greater physiologic derangement in the LP+QC group, there was no difference in total blood products required after index laparotomy until abdominal closure (LP vs LP+QC; p>0.05). After a median of 2days until abdominal closure in both groups, no difference in complications rates attributable to intra-abdominal packing (LP vs LP+QC) was detected. CONCLUSION: While the addition of QC to LP packing did not confer additional benefit to standard packing, there was no additional morbidity identified with its use. The surgeons at our institution now select augmented packing with QC for sicker patients, as we believe this may have additional advantage over standard LP packing. A randomized controlled trial is warranted to further evaluate the intra-abdominal use of advanced hemostatic agents, like QC, for both hemostasis and associated morbidity.

Fibroblast growth factor and vascular endothelial growth factor play a critical role in endotheliogenesis from human adipose-derived stem cells.

OBJECTIVE: Adipose-derived stem cells (ASCs) are a potential adult mesenchymal stem cell source for restoring endothelial function in patients with critical limb ischemia. Fibroblast growth factor 2 (FGF2) and vascular endothelial growth factor (VEGF) play a major role in angiogenesis and wound healing. This study evaluated the effects of FGF and VEGF on the proliferation, migration, and potential endothelial differentiation of human ASCs with regards to their use as endothelial cell substitutes. METHODS: ASCs were isolated from clinical lipoaspirates and cultured in M199 medium with fetal bovine serum (10%), FGF2 (10 ng/mL), VEGF (50 ng/mL), or combinations of FGF2 and VEGF. Cell proliferation rates, viability, and migration were measured by growth curves, MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide), and scratch assays. For cell attachment determinations, ASCs were seeded onto a scaffold of small intestinal submucosa for 5 days. Endothelial differentiation capabilities of ASCs were confirmed by expression of endothelial cell-specific markers using quantitative polymerase chain reaction, immunofluorescence staining, and cord formation on Matrigel (BD Biosciences, San Jose, Calif). PD173074, a selective inhibitor of FGF receptor, was used to confirm the importance of FGF signaling. RESULTS: ASCs treated with FGF or combinations of FGF and VEGF showed increased proliferation rates and consistent differentiation toward an endothelial cell lineage increase in platelet endothelial cell adhesion molecule (CD31), von Willebrand factor, endothelial nitric oxide synthase, and vascular endothelial cadherin message, and in protein and cord formation on Matrigel. FGF and VEGF stimulated ASC migration and increased the attachment and retention after seeding onto a matrix graft of small intestinal submucosa. Blockade of FGF signaling with PD173074 abrogated ASC endothelial cell differentiation potential. CONCLUSIONS: These results indicate that FGF and VEGF are ASC promoters for proliferation, migration, attachment, and endothelial differentiation. FGF and VEGF have a costimulatory effect on ASC endotheliogenesis. These results further suggest that ASCs with enhanced FGF signaling may potentially be used for tissue engineering and cell-based therapies in patients with critical limb ischemia.