Incidence of Endoscopic Retrograde Cholangiography after Subtotal Fenestrating and Reconstituting Cholecystectomy.

BACKGROUND: Laparoscopic subtotal cholecystectomy (SC) is used for the difficult cholecystectomy, but published experience with resource utilization for SC is limited. We hypothesized that the need for advanced resources are common after SC. STUDY DESIGN: Retrospective review of laparoscopic cholecystectomies between 2017 and 2021 at a large center. SC cases were identified using a medical record tool. Baseline characteristics were assessed with student's t-test and chi-squared. Primary outcome was ERC within 60-days. Secondary outcomes were reconstituted SC on post-op ERC and length of stay (LOS). Uni- and multivariable logistic regression were used for binary outcomes. Multiple linear regression was used for LOS. Covariates included age, sex, BMI, ASA class. RESULTS: A total of 1222 laparoscopic cholecystectomies were performed between 2017 and 2021. Of these, 87 (7%) were SC. Male (p<0.001) and older (p<0.001) patients were more likely to undergo SC. Odds of post-op ERC were higher in the SC group (OR 9.79 95% CI 5.90, 16.23 p<0.001). There was no difference in pre-op ERC (17% vs 21% p=0.38). Reconstituting SC had lower odds of post-op ERC (OR 0.12, 0.023-0.58, p=0.009). LOS was 1.81 times higher in the SC group(p=<0.001). Post-op ERC was not associated with LOS (p=.24). CONCLUSIONS: We present one of the largest single-center series of SC. SC patients are more likely to be male, older, have higher ASA class, and have increased LOS. SC should be performed when access to ERC and interventional radiology is available. Absent these adjuncts, reconstituting SC decreases the need for early ERC, but long-term outcomes are unknown.

Vascular imaging immediately after tourniquet removal does not increase vasospasm risk.

BACKGROUND: Prehospital tourniquet use is now standard in trauma patients with diagnosed or suspected extremity vascular injuries. Tourniquet-related vasospasm is an understudied phenomenon that may confound management by causing erroneous arterial pressure indices (APIs) and abnormalities on computed tomography angiography (CTA) that do not reflect true arterial injuries. We hypothesized that shorter intervals between tourniquet removal and CTA imaging and longer total tourniquet times would be correlated with a higher likelihood of false positive CTA. MATERIALS AND METHODS: We performed a single-institution retrospective cohort study of patients presenting to a busy, urban Level 1 Trauma Center with prehospital tourniquets from 2019 to 2021. Patients who presented with a tourniquet disengaged upon arrival or who died prior to admission to the Trauma Unit were excluded. Tourniquet duration, time between tourniquet removal and CTA imaging (CTA interval), CTA findings, and management of extremity arterial injuries were extracted. The proportion of false positive injuries on CTA was assessed for correlation with increasing time interval from tourniquet removal to CTA imaging and correlation with increasing total tourniquet time using multivariable logistic regression. RESULTS: 251 patients were identified with prehospital tourniquets. 127 underwent CTA of the affected extremity, 96 patients had an abnormal CTA finding, and 57 (45% of total CTA patients) had false positive arterial injuries on imaging. Using multivariable logistic regression, neither the CTA interval nor the tourniquet duration was associated with false positive CTA injuries. Female sex was associated with false positive injuries on CTA (OR 2.91, 95% CI: 1.01 - 8.39). Vasospasm was cited as a possible explanation by radiologists in 40% of false positive CTA reports. CONCLUSIONS: Arterial vasospasm is a frequent finding on CTA after tourniquet use for extremity trauma, but concerns regarding tourniquet-related vasospasm should not alter trauma patient management. Neither the duration of tourniquet application nor the time interval since removal is associated with decreased CTA accuracy, and any delay in imaging does not appear to reduce the likelihood of vasospasm. These findings are important for supporting expedited care of trauma patients with severe extremity injuries.

Comparison of phenobarbital monotherapy to a benzodiazepine-based regimen for management of alcohol withdrawal syndrome in trauma patients.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is associated with increased morbidity and mortality in the trauma population. Benzodiazepines (BZDs) are standard of care for AWS; however, given the risk of delirium with BZDs and reports of BZD-refractory withdrawal, phenobarbital (PHB) has emerged as an alternative therapy for AWS. Safety and efficacy studies of PHB for AWS in trauma patients are lacking. Our aim was to compare a BZD versus PHB protocol in the management of AWS in trauma patients. METHODS: We performed a retrospective cohort study at a level 1 trauma center of patients at risk for AWS managed with either a BZD or a low-dose oral PHB regimen. Patients were excluded if they were taking BZDs or barbiturates before admission, received propofol or dexmedetomidine before initiation of the study drug, presented with delirium tremens or seizures, or died or discharged within 24 hours of presentation. The primary outcome was complicated AWS (seizures or alcohol withdrawal delirium/delirium tremens). Secondary outcomes included uncomplicated AWS; therapy escalation; oversedation; delirium-, intensive care unit-, and ventilator-free days; and length of stay. RESULTS: A total of 411 patients were identified; 118 received BZD, and 293 received PHB. The odds of developing complicated AWS with PHB versus BZD-based therapy were not statistically significant (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.21-1.39); however, patients receiving PHB were less likely to develop uncomplicated AWS (OR, 0.08; 95% CI, 0.04-0.14) and less likely to require escalation of therapy (OR, 0.45; 95% CI, 0.24-0.84). The PHB group had a length of stay 3.1 days shorter than the BZD group ( p = 0.002). There was no difference in intensive care unit-, ventilator-, or delirium-free days. CONCLUSION: A PHB-based protocol for the management of AWS is a safe and effective alternative to BZD-based regimens in trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury.

BACKGROUND: Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium. OBJECTIVE: To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies. METHODS: A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score. RESULTS: Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns. CONCLUSION: Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.

Analysis of Need for Intervention in Low-Grade Traumatic Splenic Injury.

BACKGROUND: Blunt splenic injuries are common traumatic injuries. Severe injuries may require blood transfusion, procedural, or operative intervention. Conversely, patients with low-grade injuries and normal vital signs frequently do not require intervention. The level and duration of monitoring required to safely manage these patients are unclear. We hypothesize that low-grade splenic trauma has a low rate of intervention and may not require acute hospitalization. METHODS: This retrospective descriptive analysis included patients admitted to a level I trauma center with low injury burden (injury severity score <15) and The American Association for the Surgery of Trauma (AAST) grade 1 (G1) and 2 (G2) splenic injuries between January 2017 and December 2019 using the Trauma Registry of the American College of Surgeons (TRACS). The primary outcome was the need for any intervention. Secondary outcomes included time to intervention and length of stay. RESULTS: 107 patients met inclusion criteria. 87.9% required no intervention . 9.4% required blood products, with a median time to transfusion of 7.4 hours from arrival. All patients receiving blood products had extenuating circumstances such as bleeding from other injuries, anticoagulant use, or medical comorbidities. 2 patients required splenic artery embolization, one presenting with return precautions 9 days post-injury and 1 with significant comorbidities. One patient with concomitant bowel injury required splenectomy. CONCLUSIONS: Low-grade blunt splenic trauma has a low rate of intervention, which typically occurs within the first 12 hours of presentation. This suggests that outpatient management with return precautions may be appropriate for select patients after a short interval of observation.

Multiyear experience with mobile online platform for documentation of acute care surgery fellows supervision.

BACKGROUND: There is currently no standard for documenting supervision of acute care surgery (ACS) fellows. To accomplish this goal, we developed a web-based survey that is accessible via mobile platform. We hypothesize that our mobile access survey is an effective, reproducible tool for assessing fellow clinical performance. METHODS: A retrospective review from 2016 to 2022 of all data captured in an encrypted database on all ACS fellows at our institution was performed. Supervision was defined as: Type 1 direct face-to-face, Type 2a immediately available in-house, Type 2b available after notification via phone with remote electronic medical record access, and Type 3 retrospective review. Data were collected by supervising faculty using a web-based clinical performance survey created by fellowship program leadership. Survey data collected included clinical summary, trainee, proctoring faculty, clinical service, operative/nonoperative, supervision type, Zwisch autonomy scale, time to input data, and graduate medical education milestone performance. Data were analyzed using descriptive statistics. RESULTS: A total of 883 proctoring events were identified, including the majority as Type 1 (97.4%). Trauma comprised 64% of evaluations. Fifty-two percent of the proctoring events were surgical cases. Complexity was graded as average (77%), hardest (16%), basic (7%). Guidance included supervision only, 491 of 666 (74%), with 26% requiring faculty intervention. Fellow performance was graded as average (66%), above average (31%), and below average/critical deficiency (3%). Graduate medical education performance was available for 247 of 883 interactions identifying 31 events with potential for improvement. Average evaluation completion time: 2 minutes (n = 134). CONCLUSION: A mobile web-based survey is a convenient and reliable tool for documenting ACS fellow clinical activity and was effectively used by all ACS faculty to record supervision. A combination of clinical and objective data is useful to determine ACS fellows' performance and to provide targeted education and remediation. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Assessment of safety and effectiveness of non-neurosurgical management for minimal traumatic brain injury (TBI).

BACKGROUND: Patients with mild traumatic brain injury (TBI) and intracranial hemorrhage often receive neurosurgical consultation. However, only a small proportion of patients require intervention. Our hypothesis is that low-risk minimal TBI patients managed without immediate neurosurgical consultation will have a reasonable safety and effectiveness outcome profile. METHODS: A non-neurosurgical management protocol for adult minimal TBI was implemented at a level I trauma center as an interdisciplinary quality-improvement initiative in November 2018. Minimal TBI was defined as Glasgow Coma Scale (GCS) of 15 secondary to blunt mechanism, without anticoagulant or antiplatelet therapy, and isolated pneumocephalus and/or traumatic subarachnoid hemorrhage on head CT imaging. Safety was assessed by in-hospital mortality, neurosurgical interventions, and ED revisits within two weeks of discharge. Effectiveness was assessed by neurosurgical consult rate and length of stay. Outcomes were compared 8-months pre- and post-protocol implementation. RESULTS: A total of 97 patients were included, of which 49 were pre-protocol and 48 were post-protocol There was no difference in rates of in-hospital mortality [0 (0%) vs 0 (0%)], neurosurgical procedure [1 (2.1%) vs 0 (0%)], operations [0 (0%) vs 0 (0%)], and ED revisits [1 (2.0%) vs 2 (4.2%), p = 0.985] between the periods. There was a significant reduction in neurosurgical consults post-protocol implementation (92% vs 29%, p<0.001). CONCLUSION: A protocol for minimal TBI patients effectively reduced neurosurgical consultation without changes in safety profile. Such an interdisciplinary management protocol for low-risk neurotrauma can effectively utilize the neurosurgery consult services by stratifying neurologically stable TBI patient.

Decision Support Tool to Judiciously Assign High-Frequency Neurologic Examinations in Traumatic Brain Injury.

INTRODUCTION: Traumatic brain injury (TBI) management includes serial neurologic examinations to assess for changes dictating neurosurgical interventions. We hypothesized hourly examinations are overassigned. We conducted a decision tree analysis to determine an algorithm to judiciously assign hourly examinations. METHODS: A retrospective cohort study of 1022 patients with TBI admitted to a Level 1 trauma center from January 1, 2019, to December 31, 2019, was conducted. Patients with penetrating TBI or immediate or planned interventions and those with nonsurvivable injuries were excluded. Patients were stratified by whether they underwent an unplanned intervention (e.g., craniotomy or invasive intracranial monitoring). Univariate analysis identified factors for inclusion in chi-square automatic interaction detection technique, classifying those at risk for unplanned procedures. RESULTS: A total of 830 patients were included, 287 (35%) were assigned hourly (Q1) examinations, and 17 (2%) had unplanned procedures, with 16 of 17 (94%) on Q1 examinations. Patients requiring unplanned procedures were more likely to have mixed intracranial hemorrhage pattern (82% versus 39%; P = 0.001), midline shift (35% versus 14%; P = 0.023), an initial poor neurologic examination (Glasgow Comas Scale ≤8, 77% versus 14%; P < 0.001), and be intubated (88% versus 17%; P < 0.001). Using chi-square automatic interaction detection, the decision tree demonstrated low-risk (2% misclassification) and excellent discrimination (area under the curve = 0.915, 95% confidence interval 0.844-0.986; P < 0.001) of patients at risk of an unplanned procedure. By following the algorithm, 167 fewer patients could have been assigned Q1 examinations, resulting in an estimated 6012 fewer examinations. CONCLUSIONS: Using a 4-factor algorithm can optimize the assignment of neuro examinations and substantially reduce neuro examination burden without sacrificing patient safety.

Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery.

BACKGROUND: Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. METHODS: This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90 days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. RESULTS: Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90 days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). CONCLUSIONS: Among Veterans, recent antibiotic exposure within 90 days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.

Expectant Management of Blunt Grade III Renal Injuries: Early Discharge Outcomes From a Level I Trauma Center.

OBJECTIVES: To determine whether patients with American Association for the Surgery of Trauma (AAST) grade III blunt renal injuries discharged within 48 hours of admission have increased rates of readmission for renal-related complications compared to patients observed for over 48 hours. METHODS: Renal trauma patients from 2005 through 2020 were identified from our institutional trauma registry. Patients with AAST III blunt renal injuries who survived beyond 48 hours of admission were included. Univariable analysis was used to identify variables associated with discharge within 48 hours. Reasons for readmission were compared between patients discharged before and after 48 hours of admission. RESULTS: Of the 1751 renal trauma patients, 377 (21.5%) met inclusion criteria. Sixty-five of 377 (17.2%) AAST III injuries were discharged within 48 hours of admission. Forty (10.6%) patients required readmission, 3 in the early discharge group and 37 in the standard discharge group. No patient required readmission for renal-related complications. CONCLUSION: Patients with AAST grade III blunt renal injuries are not at increased risk for early renal-related complications if discharged within 48 hours of admission and should be considered for early discharge. The very low rate of renal-related complications for AAST III blunt renal injuries supports their categorization as "low-grade" renal trauma.

COVID-19 Vaccination Gap in Admitted Trauma Patients: A Critical Opportunity.

BACKGROUND: Coronavirus disease 2019 (COVID-19) vaccination is the core strategy for pandemic management. We hypothesized that a vaccination gap might exist between emergency department (ED) patients admitted for trauma and other ED patients. STUDY DESIGN: This was an observational quality improvement study using electronic health record data at an academic level-1 trauma center. Participants were all patients presenting to the adult ED with a Tennessee home address between January 1 and June 1, 2021. We measured the proportional difference in vaccination between admitted trauma patients and other ED patients over time (by week) and association via Spearman's rank correlation coefficient. Binary logistic regression facilitated covariate analysis to account for age, sex, race, home county, and ethnicity without and then with interaction between trauma admission and time. Geographic visual analysis compared county-level vaccination rates with odds of trauma admission by home county using a bivariate chloropleth map. RESULTS: The proportional difference in vaccination between trauma-admitted and other ED patients increased over time (Spearman's = 0.699). Adjusting for age, sex, race, home county, and ethnicity, there was a statistically significant vaccination difference between trauma-admitted and other ED patients (odds ratio = 0.53, 95% CI 0.43-0.65, p < 0.0001). Geographic analysis revealed increased trauma admission odds and lower vaccination rates in surrounding counties compared with Davidson County. CONCLUSIONS: We observed a widening COVID-19 vaccination gap between trauma-admitted and other ED patients. Vaccine outreach during trauma admission may provide a valuable point of contact for unvaccinated patients.

Balanced Crystalloid versus Saline in Adults with Traumatic Brain Injury: Secondary Analysis of a Clinical Trial.

Balanced crystalloids may improve outcomes compared with saline for some critically ill adults. Lower tonicity of balanced crystalloids could worsen cerebral edema in patients with intracranial pathology. The effect of balanced crystalloids versus saline on clinical outcomes in patients with traumatic brain injury (TBI) requires further study. We planned an a priori subgroup analysis of TBI patients enrolled in the pragmatic, cluster-randomized, multiple-crossover Isotonic Solutions and Major Adverse Renal Events Trial (SMART) (ClinicalTrials.gov: NCT02444988, NCT02547779). Primary outcome was 30-day in-hospital mortality. Secondary outcomes included hospital discharge disposition (home, facility, death). Regression models adjusted for pre-specified baseline covariates compared outcomes. TBI patients assigned to balanced crystalloids (n = 588) and saline (n = 569) had similar baseline characteristics including Injury Severity Score 19 (10); mean maximum head/neck Abbreviated Injury Score, 3.4 (1.0). Isotonic crystalloid volume administered between intensive care unit admission and first of hospital discharge or 30 days was 2037 (3470) mL and 1723 (2923) mL in the balanced crystalloids and saline groups, respectively (p = 0.18). During the study period, 94 (16%) and 82 (14%) patients (16%) died in the balanced crystalloid and saline groups, respectively (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.60 to 1.75; p = 0.913). Patients in the balanced crystalloid group were more likely to die or be discharged to another medical facility (aOR 1.38 [1.02-1.86]; p = 0.04). Overall, balanced crystalloids were associated with worse discharge disposition in critically injured patients with TBI compared with saline. The confidence intervals cannot exclude a clinically relevant increase in mortality when balanced crystalloids are used for patients with TBI.

Predicting Mortality in Elderly Spine Trauma Patients.

STUDY DESIGN: Retrospective analysis on prospectively collected data. OBJECTIVE: The aim of this study was to construct a clinical prediction model for 90-day mortality in elderly patients with traumatic spine injuries. SUMMARY OF BACKGROUND DATA: Spine trauma in the elderly population is increasing. Comparing elderly spine trauma patients to younger patients with similar injuries proves challenging due to the extensive comorbidities and frailty found in the elderly. There is a paucity of evidence to predict survival of elderly patients following traumatic spinal injuries. METHODS: All patients 65+ with spine trauma presenting to a level I trauma center from 2010 to 2019 were reviewed from a prospectively maintained trauma registry. Retrospective chart review was performed to record injury, frailty scores, comorbidities, presence of spinal cord injury, imaging evidence of sarcopenia and osteopenia, mortality, and complications. We preselected 13 variables for our multivariable logistic regression model: hypotension on admission, gender, marital status, age, max Abbreviated Injury Scale, Modified Frailty Index, surgical treatment, hematocrit, white blood count, spinal cord injury, closed head injury, injury level and presence of high energy mechanism. The performance of the prediction model was evaluated using a concordance index and calibration plot. The model was internally validated via bootstrap approach. RESULTS: Over the 9-year period, 1746 patients met inclusion criteria; 359 (20.6%) patients died within 90 days after presenting with spine trauma. The most important predictors for 90-day mortality were age, hypotension, closed head injury, max Abbreviated Injury Scale and hematocrit. There was an optimism-corrected C-index of 0.77. A calculator was created to predict a personalized mortality risk. CONCLUSION: The incidence of spine trauma in elderly patients continues to increase. Previous publications described preexisting conditions that imply increased mortality, but ours is the first to develop a predictive calculator. Prospective research is planned to externally validate this model to better determine its predictive value and utility in the clinical setting.

The choices we make: Ethical challenges in trauma surgery.

BACKGROUND: Ethical issues in trauma surgery are commonplace but scarcely studied. We aim to characterize the ethical dilemmas trauma surgeons encounter in clinical practice and describe perceptions about the ability to manage these dilemmas and strategies they use to address them. METHODS: Members of a U.S. trauma society were electronically surveyed on handling ethically challenging scenarios. The survey instrument was developed using published ethics literature and iterative cognitive interviews. Domains included perceived frequency of encountering and self-efficacy of managing ethical situations in trauma surgery. Common situations were defined as those encountered monthly or weekly. Ethical problems were categorized within 7 larger categories: general ethics, autonomy, communication, justice, end-of-life, conflict, and other. Descriptive analyses were performed; group comparisons were analyzed using analysis of variance. RESULTS: Of 1,748 surveyed, 548 responded (30.6%) and 154 (28%) were female. Most were White, under 55 years age, had completed fellowship training, and were practicing at a level I or II trauma center. The most encountered ethical categories were generic ethics and communication (79%). Issues involving conflict were least frequent (21%). Respondents felt most uncomfortable with autonomy topics. Respondents with high self-efficacy in handling ethical situations were older, in practice ≥15 years, served on an ethics committee, and/or frequently experienced ethical challenges. CONCLUSION: Most trauma surgeons regularly encounter ethical challenges, especially those related to communication. Trauma surgeons encounter ethical issues involving conflict least often, and lowest self-efficacy scores with issues involving autonomy. Experienced trauma surgeons reported higher self-efficacy scores in managing ethical issues. Future work should examine how self-efficacy translates to observed behavior, and how trauma surgeons build and enhance their ethical skillsets in the care of the injured patient.

Professionalism of Admitting and Consulting Services and Trauma Patient Outcomes.

OBJECTIVE: To determine whether trauma patients managed by an admitting or consulting service with a high proportion of physicians exhibiting patterns of unprofessional behaviors are at greater risk of complications or death. SUMMARY BACKGROUND DATA: Trauma care requires high-functioning interdisciplinary teams where professionalism, particularly modeling respect and communicating effectively, is essential. METHODS: This retrospective cohort study used data from 9 level I trauma centers that participated in a national trauma registry linked with data from a national database of unsolicited patient complaints. The cohort included trauma patients admitted January 1, 2012 through December 31, 2017. The exposure of interest was care by 1 or more high-risk services, defined as teams with a greater proportion of physicians with high numbers of patient complaints. The study outcome was death or complications within 30 days. RESULTS: Among the 71,046 patients in the cohort, 9553 (13.4%) experienced the primary outcome of complications or death, including 1875 of 16,107 patients (11.6%) with 0 high-risk services, 3788 of 28,085 patients (13.5%) with 1 high-risk service, and 3890 of 26,854 patients (14.5%) with 2+ highrisk services (P < 0.001). In logistic regression models adjusting for relevant patient, injury, and site characteristics, patients who received care from 1 or more high-risk services were at 24.1% (95% confidence interval 17.2% to 31.3%; P < 0.001) greater risk of experiencing the primary study outcome. CONCLUSIONS: Trauma patients who received care from at least 1 service with a high proportion of physicians modeling unprofessional behavior were at an increased risk of death or complications.

The Efficacy and Safety of Methylnaltrexone for the Treatment of Postoperative Ileus.

BACKGROUND: Postoperative ileus (POI) is a surgical complication resulting in increased morbidity and length of stay (LOS). Usual care for POI includes bowel rest and gastric decompression. It has been questioned if methylnaltrexone (MNTX), a peripheral opioid antagonist, could be used as treatment for POI. The purpose of this study was to determine if MNTX is effective and safe for POI treatment. METHODS: This single-center, retrospective cohort study included patients ⩾ 18 years with a POI. Patients with acute colonic pseudo-obstruction, small bowel obstruction, and gastrointestinal malignancy were excluded. The intervention was MNTX administration. The primary outcome was time to ileus resolution. Secondary outcomes included LOS, duration of nasogastric tube, total parenteral nutrition requirement, and incidence of gastrointestinal perforations. RESULTS: 110 patients were included in the analysis; 28 received MNTX. Time to ileus resolution was 9.9 days for the MNTX group and 11.4 days for the control group (P = .38). Duration of gastric decompression was 4.6 days for the MNTX group and 4.2 days for the control group (P = .71). Length of stay was 19.9 days for the MNTX group and 19.7 days for the control group (P = .96). The percentage of TPN requirement was 17.9% in the MNTX group and 22.0% in the control group (P = .65). No gastrointestinal perforations were observed in either group. CONCLUSION: For the treatment of POI, MNTX did not significantly reduce time to resolution of ileus, LOS, duration of gastric decompression, or TPN requirements. However, no gastrointestinal perforations were seen, indicating that MNTX may be safely used in these patients.

Surgical outcomes and complications of bedside tracheostomy in the ICU for patients on ECMO.

OBJECTIVE: Extracorporeal membrane oxygenation (ECMO) is increasingly employed in the management of patients with severe cardiac and pulmonary dysfunction. Patients commonly require tracheostomy for ventilator liberation. Though bedside percutaneous tracheostomy is commonly performed, it has the potential for increased complications, both surgical and with the ECMO circuit. We examined surgical outcomes of bedside percutaneous tracheostomy in the ECMO population. METHODS: Patients were identified from an institutional database for bedside procedures. Demographics and data on complications were recorded. Descriptive statistics were calculated. RESULTS: 37 patients on ECMO at the time of tracheostomy were identified. Median age and BMI were 43.2 and 28.0, respectively. 33 patients (89%) were on VV ECMO, and 4 (11%) were on VA ECMO. All were on anticoagulation prior to tracheostomy, which was held for 4 h before and after the procedure in all cases. There were no procedure-related deaths or airway losses. No patients experienced periprocedural clotting events of their ECMO circuit or oxygenator within 24 h. 3 patients (8%) required reintervention (re-exploration or bronchoscopy) for bleeding. Four other patients (10%) had minor bleeding controlled with packing. One patient had pneumomediastinum which resolved without intervention, and one had an occlusion of their tracheostomy which was treated with tracheostomy exchange. CONCLUSIONS: Bedside percutaneous tracheostomy is feasible for patients on ECMO. Further study is needed to determine specific risk factors for complications and means to mitigate these. Bedside percutaneous tracheostomy may be considered as part of the management of patients on ECMO to help facilitate liberation from mechanical support.

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial.

PURPOSE: To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression. RESULTS: A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively. CONCLUSIONS: Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry).

PURPOSE: Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. RESULTS: In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). CONCLUSION: Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL. LEVEL OF EVIDENCE: 2B.