The Effect of Propofol on Peri-Induction Hemodynamics and Resuscitation in Operative Penetrating Trauma.

BACKGROUND: Hemorrhaging trauma patients may be disproportionately affected by choice of induction agent during rapid sequence intubation (RSI). Etomidate, ketamine, and propofol are safe in the trauma population-at-large but have not been assessed in patients with ongoing hemorrhage. We hypothesize that in hemorrhaging patients with penetrating injury, propofol deleteriously affects peri-induction hypotension compared to etomidate and ketamine. METHODS: Retrospective cohort study. Primary outcome was the effect of induction agent on peri-induction systolic blood pressure. Secondary outcomes were the incidence of peri-induction vasopressor use and quantity of peri-induction blood transfusion requirements. Linear multivariate regression modeling assessed the effect of induction agent on the variables of interest. RESULTS: 169 patients were included, 146 received propofol and 23 received etomidate or ketamine. Univariate analysis revealed no difference in peri-induction systolic blood pressure (P = .53), peri-induction vasopressor administration (P = .62), or transfusion requirements within the first hour after induction (PRBC P = .24, FFP P = .19, PLT P = .29). Choice of RSI agent did not independently predict peri-induction systolic blood pressure or blood product administration. Rather, only presenting shock index independently predicted peri-induction hypotension. CONCLUSIONS: This is the first study to directly assess the peri-induction effects of anesthetic induction agent choice in penetrating trauma patients undergoing emergent hemorrhage control surgery. Propofol does not appear to worsen peri-induction hypotension regardless of dose. Patient physiology is most predictive of peri-induction hypotension.

Characterization of fatal blunt injuries using postmortem computed tomography.

BACKGROUND: Rapid triage of blunt agonal trauma patients is necessary to maximize survival, but autopsy is uncommon, slow, and rarely informs resuscitation guidelines. Postmortem computed tomography (PMCT) can serve as an adjunct to autopsy in guiding blunt agonal trauma resuscitation. METHODS: Retrospective cohort review of trauma decedents who died at or within 1 hour of arrival following blunt trauma and underwent noncontrasted PMCT. Primary outcome was the prevalence of mortal injury defined as potential exsanguination (e.g., cavitary injury, long bone and pelvic fractures), traumatic brain injury, and cervical spine injury. Secondary outcomes were potentially mortal injuries (e.g., pneumothorax) and misplacement airway devices. Patients were grouped by whether arrest occurred prehospital/in-hospital. Univariate analysis was used to identify differences in injury patterns including multiple-trauma injury patterns. RESULTS: Over a 9-year period, 80 decedents were included. Average age was 48.9 ± 21.7 years, 68% male, and an average ISS of 42.3 ± 16.3. The most common mechanism was motor vehicle accidents (67.5%) followed by pedestrian struck (15%). Of all decedents, 62 (77.5%) had traumatic arrest prehospital while 18 (22.5%) arrived with pulse. Between groups there were no significant differences in demographics including ISS. The most common mortal injuries were traumatic brain injury (40%), long bone fractures (25%), moderate/large hemoperitoneum (22.5%), and cervical spine injury (25%). Secondary outcomes included moderate/large pneumothorax (18.8%) and esophageal intubation rate of 5%. There were no significant differences in mortal or potentially mortal injuries, and no differences in multiple-trauma injury patterns. CONCLUSION: Fatal blunt injury patterns do not vary between prehospital and in-hospital arrest decedents. High rates of pneumothorax and endotracheal tube misplacement should prompt mandatory chest decompression and confirmation of tube placement in all blunt arrest patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; 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.

Sleep Deprivation, Burnout, and Acute Care Surgery.

Purpose of Review: To define what sleep deprivation is, how it relates to the growing problem of burnout within surgeons, and what can be done to mitigate its effects. Recent Findings: There is a growing awareness that sleep deprivation, in both its acute and chronic manifestations, plays an immense role in burnout. The physical and mental manifestations of sleep deprivation are manifold, effecting nearly every physiologic system. Studies evaluating strategies at mitigating the effects of sleep deprivation are promising, including work done with napping, stimulant use, and service restructuring, but are fundamentally limited by generalizability, scale, and scope. Summary: The overwhelming majority of data published on sleep deprivation is limited by size, scope, and generalizability. Within acute care surgery, there is a dearth of studies that adequately define and describe sleep deprivation as it pertains to high-performance professions. Given the growing issue of burnout amongst surgeons paired with a growing patient population that is older and more complex, strategies to combat sleep deprivation are paramount for surgeon retention and wellbeing.

Post-mortem computed tomography assessment of medical support device position following fatal trauma: a single-center experience.

PURPOSE: To evaluate the percentage of misplaced medical support lines and tubes in deceased trauma patients using post-mortem computed tomography (PMCT). METHODS: Over a 9-year period, trauma patients who died at or soon after arrival in the emergency department were candidates for inclusion. Whole body CT was performed without contrast with support medical devices left in place. Injury severity score (ISS) was calculated by the trauma registrar based on the injuries identified on PMCT. The location of support medical devices was documented in the finalized radiology reports. RESULTS: A total of 87 decedents underwent PMCT, of which 69% (n = 60) were male. For ten decedents, the age was unknown. For the remaining 77 decedents, the average age was 48.4 years (range 18-96). The average ISS for the cohort was 43.4. Each decedent had an average of 3.3 support devices (2.9-3.6, 95% CI), of which an average of 1 (31.3%, 0.8-1.2, 95% CI) was malpositioned. A total of 60 (69.0%) had at least one malpositioned medical support device. The most commonly malpositioned devices were decompressive needle thoracostomies (n = 25/32, 78.1%). The least malpositioned devices were intraosseous catheters (n = 7/69, 10.1%). Nearly one quarter (n = 19/82, 23.2%) of mechanical airways were malpositioned, including 4.9% with esophageal intubation. CONCLUSION: Malpositioned supportive medical devices are commonly identified on post-mortem computed tomography trauma decedents, seen in 69.0% of the cohort, including nearly one quarter with malpositioned mechanical airways. Post-mortem CT can serve as a useful adjunct in the quality improvement process by providing data for education of trauma and emergency physicians and first responders.

Age Does Not Predict Failure to Rescue Following Resuscitative Thoracotomy in Penetrating Trauma.

BACKGROUND: The limitations of resuscitative thoracotomy (RT) after penetrating trauma have been well documented, but there is a paucity of data on the effect age has on mortality. This begs the question as to the utility of RT in an aging patient population. We investigate the significance of age as a predictor for failure to rescue after RT in penetrating trauma. OBJECTIVE: We sought to identify whether chronologic age has a measurable effect on rates of failure to rescue after RT. METHODS: We performed a retrospective cohort analysis using the Trauma Quality Improvement Program from 2011 to 2015 including all pulseless patients undergoing RT after penetrating injury. Our primary outcome was failure to rescue defined as death in the emergency department after RT. Multivariate analyses were performed to identify the relationship between age and morality controlling for injury severity. RESULTS: One thousand one hundred twelve RTs were performed during the study period with an overall failure to rescue rate of 61.8% (n = 687) within the emergency department and an in-hospital mortality rate of 96.9%, which is in line with national data. On univariate analysis, there was no significant association between age and mortality (p = 0.44). On multivariate analysis examining the interaction between age and mortality adjusting for injury severity, we found that chronologic age was not an independent predictor of death after RT. CONCLUSIONS: Age does not appear to be an independent predictor of failure to rescue after RT in penetrating trauma and should not be a sole determinant in procedural decision making.

Rheumatic disease among Oklahoma tribal populations: a cross-sectional study.

OBJECTIVE: Rheumatic diseases cause significant morbidity within American Indian populations. Clinical disease presentations, as well as historically associated autoantibodies, are not always useful in making a rapid diagnosis or assessing prognosis. The purpose of our study was to identify autoantibody associations among Oklahoma tribal populations with rheumatic disease. METHODS: Oklahoma tribal members (110 patients with rheumatic disease and 110 controls) were enrolled at tribal-based clinics. Patients with rheumatic disease (suspected or confirmed diagnosis) were assessed by a rheumatologist for clinical features, disease criteria, and activity measures. Blood samples were collected and tested for common rheumatic disease autoantibodies [antinuclear antibody (ANA), anti-cyclic citrullinated peptide antibodies (anti-CCP), rheumatoid factor (RF), anti-Ro, anti-La, anti-Sm, anti-nRNP, anti-ribosomal P, anti-dsDNA, and anticardiolipins]. RESULTS: In patients with suspected systemic rheumatic diseases, 72% satisfied American College of Rheumatology classification criteria: 40 (36%) had rheumatoid arthritis (RA), 16 (15%) systemic lupus erythematosus, 8 (7%) scleroderma, 8 (7%) osteoarthritis, 4 (4%) fibromyalgia, 2 (2%) seronegative spondyloarthropathy, 1 Sjögren's syndrome, and 1 sarcoidosis. Compared to controls, RA patient sera were more likely to contain anti-CCP (55% vs 2%; p < 0.001) or RF IgM antibodies (57% vs 10%; p < 0.001); however, the difference was greater for anti-CCP. Anti-CCP positivity conferred higher disease activity scores (DAS28 5.6 vs 4.45; p = 0.021) while RF positivity did not (DAS28 5.36 vs 4.64; p = 0.15). Anticardiolipin antibodies (25% of rheumatic disease patients vs 10% of controls; p = 0.0022) and ANA (63% vs 21%; p < 0.0001) were more common in rheumatic disease patients. CONCLUSION: Anti-CCP may serve as a more specific RA biomarker in American Indian patients, while the clinical significance of increased frequency of anticardiolipin antibodies needs further evaluation.

Prosthetic valve endocarditis caused by Candida lusitaniae, an uncommon pathogen: a case report.

INTRODUCTION: Candida lusitaniae was originally described as a human pathogen in 1979 and typically affects immunocompromised patients. CASE PRESENTATION: We describe a case of prosthetic valve endocarditis with Candida lusitaniae in an immunocompetent 62-year-old woman following aortic valve replacement. In vitro testing demonstrated that our isolate was sensitive to amphotericin B, caspofungin and fluconazole. CONCLUSION: The infection was lethal despite aggressive medical and surgical management and sterilization of blood cultures. The outcome of our case illustrates the need to recognize Candida lusitaniae fungemia as a life-threatening infection in a patient with a prosthetic aortic valve.