Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Admitting service influences the outcomes of patients with small bowel obstruction.

BACKGROUND: Small bowel obstruction (SBO) is a common problem that often requires operation. We tested the hypotheses that patients admitted to a surgical service have improved outcomes and that these outcomes are related to early operation. METHODS: Retrospective review of 281 patients with 336 episodes of SBO between 1992 and 1998 was performed. Parametric and nonparametric analysis was used as appropriate. RESULTS: There were 222 admissions to a surgical service and 114 admissions to a medical service. Patient characteristics were similar between groups. Eighty-seven percent of patients had a previous abdominal or pelvic operation. There were 211 patients (217 admissions) who required operation. Operated patients admitted to the surgical service had a shorter preoperative (2.7 vs 6.3 days, P <.01) and overall length of stay (LOS) (17.9 vs 22.8 days, P <.0001). There was no difference in time to resumption of diet between groups. The number of previous admissions or operations did not affect the need for operative intervention. Unoperated patients admitted to a medical service had a shorter time to resumption of diet (3.1 vs 4.3 days) and LOS (4.8 vs 7.2 days, both P <.05) than the surgical service group. Operative mortality was 3.4%. The likelihood of developing a complication was related to the occurrence of an enterotomy (n = 21, odds ratio = 2.69; 95% confidence interval [CI]: 1.1-6.7, P =.014) or the need for bowel resection (odds ratio = 1.97; 95% CI: 1.2-3.5, P =.02). The occurrence of a complication resulted in a 46% increase in LOS (P <.0001). Patients operated on within 24 hours of admission had a decreased LOS (P <.05) and mortality, with no difference in the occurrence of postoperative complications. CONCLUSIONS: Patients with SBO who require operation benefit from a shorter time to operation and reduced LOS when admitted to a surgical service. Early operation is associated with a reduction in mortality, and avoidance of enterotomy decreases the risk of complications.

Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy.

BACKGROUND: Mandatory celiotomy has been proposed for all patients with unexplained free fluid on abdominal computed tomography (CT) scanning after blunt abdominal injury. This recommendation has been based upon retrospective data and concerns over the potential morbidity from the late diagnosis of blunt intestinal injury. This study examined the rate of intestinal injury in patients with free fluid on abdominal CT after blunt abdominal trauma. METHODS: This study was a multicenter prospective series of all patients with blunt abdominal trauma admitted to four level I trauma centers over 22 months. Data were collected concurrently at the time of patient enrollment and included demographics, injury severity score, findings on CT scan, and presence or absence of blunt intestinal injury. This database was specifically queried for those patients who had free fluid without solid organ injury. RESULTS: In all, 2,299 patients were evaluated. Free fluid was present in 265. Of these, 90 patients had isolated free fluid with only 7 having a blunt intestinal injury. Conversely, 91% of patients with free fluid did not. All patients with free fluid were observed for a mean of 8 days (95% confidence interval 6.1 to 10.4, range 1 to 131). There were no missed injuries. CONCLUSIONS: Free fluid on abdominal CT scan does not mandate celiotomy. Serial observation with the possible use of other adjunctive tests is recommended.

Prospective randomized trials affect the outcomes of intraabdominal infection.

OBJECTIVE: To compare the characteristics and outcomes of patients with intraabdominal infections enrolled in prospective randomized trials (PRTs) with those of a cohort of patients not enrolled in a trial. SUMMARY BACKGROUND DATA: Prospective randomized trials are the gold standard for the evaluation of new treatments. Patients are screened using rigorous eligibility criteria and sometimes are excluded from PRTs because of associated medical conditions or more severe illness. However, the effect that the exclusion of these patients has on the applicability of clinical trial outcomes has not been defined. METHODS: One hundred sixty-eight adults with intraabdominal infection were treated at a single institution during 7 years. Fifty-three patients were enrolled in four PRTs comparing various antibiotic regimens for treatment; 115 were not enrolled. Patient characteristics and outcomes of these two groups were compared. RESULTS: Patients with infections from appendicitis (n = 68) had a low severity of illness and similar outcomes in both groups. These patients and those for whom a concurrent PRT was unavailable were excluded from subsequent analysis. Eighty-eight patients (42 PRT, 46 not enrolled) with serious infection remained for analysis. Patients enrolled in PRTs were younger, had less severe illness, had a decreased length of stay, a lower incidence of antibiotic resistance, and less frequent extraabdominal infections than those not enrolled in a trial. Patients enrolled in PRTs were more likely to be cured and were less likely to die. Logistic regression analysis demonstrated that cure was associated with a lower initial severity of illness, absence of antibiotic resistance, and participation in a PRT. CONCLUSIONS: Patients with intraabdominal infection enrolled in PRTs have an increased likelihood of cure and survival. This is due in part to a lower incidence of antibiotic resistance, which may reflect improved drug selection. Patients not enrolled in PRTs are at greater risk for treatment failure and death because of concomitant illness. Outcomes from PRTs may not be applicable to all patients with intraabdominal infections.

Geriatric trauma hospitalization in the United States: a population-based study.

The objective of this study was to characterize elderly trauma hospitalizations nationwide. Elderly Medicare beneficiaries hospitalized in 1989, with trauma as a primary or secondary diagnosis, were studied cross-sectionally. Descriptive analyses and primary mortality rates among different levels of trauma center designation were provided. Estimated relative risks, chi-square tests of association, and multivariate logistic regression were performed. There were 577,193 geriatric trauma patients admitted to 5227 short-stay U.S. hospitals. Level one trauma centers constituted less than 4% of hospitals, but admitted 7.5% of patients, including disproportionate numbers of blacks, males, and patients with more severe primary injury diagnoses. Risk of inpatient death increased with age, male gender, black race, and severity of injury. Level one trauma center patients displayed a 1.49 greater risk for inpatient death even after controlling for confounding variables in a multivariate model. This population-based study provides a detailed national picture of the elderly trauma hospitalization experience, contrasting profiles and outcomes between hospitals with and without designated trauma centers. Although demonstrating higher inpatient mortality rates, Level one trauma centers admit a decidedly different patient population than other hospitals, which is disproportionately younger, black and male and includes the most severely injured geriatric patients. Additional confounding factors should be explored.

The "Airmedical F.A.S.T." for trauma patients--the initial report of a novel application for sonography.

BACKGROUND: While established as an initial screening tool for the evaluation of injured patients at the trauma center, sonographic evaluation of the patient in the prehospital setting remains untested. The purpose of this study was to determine the feasibility of this procedure during prehospital helicopter transport. METHODS: Two qualified flight surgeons performed all imaging studies. Confirmatory endpoints were documented for all images obtained in flight. RESULTS: For this preliminary study, 100 patients are presented; 84 studies were analyzed; 16 were excluded due to patient weight (8), hemodynamic instability (6), or problems with machine calibration (2). Sensitivity was 81.3%; specificity was 100%. The positive predictive value was 100%; the negative predictive value was 95.7%. The accuracy was 96.4%. CONCLUSION: Sonographic studies obtained during air-medical transport are of similar quality and consistency as those obtained in the emergency department. The ability to detect hemoperitoneum in the field may challenge traditional algorithms for prehospital care as a result.

Necrotizing soft tissue infections: are we making any progress?

BACKGROUND: Necrotizing soft tissue infections are a group of diseases with significant associated mortality. A wide spectrum of bacteria can be involved, and diagnosis can be difficult. METHODS: Review of pertinent literature of the diagnosis and therapy of necrotizing soft-tissue infection. RESULTS: Mortality and other adverse outcomes are directly related to advanced age, the presence of organ system failure, lactic acidemia, the percentage of body surface area involved with infection, and delays in operative management. Patients usually die early from the consequences of septic shock, whereas late mortality is related to multiple organ failure. CONCLUSION: Early recognition and treatment can lower mortality from necrotizing soft tissue infection. Prompt operative debridement, broad-spectrum antimicrobials, and physiologic support are important components of treatment.

Comparison of methods of measurements of oxygen consumption in mechanically ventilated patients with multiple trauma: the Fick method versus indirect calorimetry.

OBJECTIVE: The purpose of this study was to compare the measurements of whole body oxygen consumption determined by the Fick method and by indirect calorimetry in mechanically ventilated patients with multiple trauma. DESIGN: A prospective, correlational, within-subjects design. SETTING: Surgical intensive care unit of a Level I trauma center. PATIENTS: Thirty-eight mechanically ventilated adults with multiple injuries who received a pulmonary artery catheter within 24 hrs of admission to the surgical intensive care unit. MEASUREMENTS AND MAIN RESULTS: After the initial resuscitation, simultaneous measurements of oxygen consumption (V(O2) by the reverse Fick equation and by indirect calorimetry were performed every 6 hrs for 24 hrs in normothermic patients who were at rest for at least 30 mins. At each measurement period, the mean V(O2) values determined by indirect calorimetry were significantly greater than the mean V(O2) values determined by the Fick method (time 1: 172+/-38 vs. 125+/-47 mL/min/m2, p < .0001; time 2: 170+/-31 vs. 130+/-48 mL/min/m2, p < .0001; time 3: 170+/-32 vs. 132+/-53 mL/min/m2, p < .0001; time 4: 169+/-29 vs. 130+/-60 mL/min/m2, p < .0002). By using the Bland and Altman technique, the mean bias was 41+/-3.95 mL/min/m2. Correlation coefficients of VO2 values between methods of measurements were statistically significant (r2 = .32, p = .0001; r2 = .32, p = .0001; r2 = .33, p = .0001; r2 = .18, p = .0001). CONCLUSIONS: Indirect calorimetry should be the preferred standard for measurement of oxygen consumption in severely injured patients.

Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury.

OBJECTIVE: To determine the negative predictive value of cranial computed tomography (CT) scanning in a prospective series of patients and whether hospital admission for observation is mandatory after a negative diagnostic evaluation after minimal head injury (MHI). SUMMARY BACKGROUND DATA: Hospital admission for observation is a current standard of practice for patients who have sustained MHI, despite having undergone diagnostic studies that exclude the presence of an intracranial injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that admission will allow prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. METHODS: In a prospective, multiinstitutional study during a 22-month period at four level I trauma centers, all patients with MHI were evaluated using the following protocol: a standardized physical and neurologic examination in the emergency department, cranial CT scanning, and then admission for observation. MHI was defined as either a documented loss of consciousness or evidence of posttraumatic amnesia and an emergency department Glasgow Coma Scale score of 14 or 15. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, need for craniotomy, and death. RESULTS: Two thousand one hundred fifty-two consecutive patients fulfilled the study protocol. The CT was interpreted as negative for intracranial injury in 1,788, positive in 217, and equivocal in 119. Five patients with CT scans initially interpreted as negative required intervention. There was one craniotomy in a patient whose CT scan was initially interpreted as negative. This patient had facial fractures that required surgical intervention and elevation of depressed intracranial fracture fragments. The negative predictive power of a cranial CT scan based on the preliminary reading of the CT scan and defined by the subsequent need for neurosurgical intervention in the population fully satisfying the protocol was 99.70%. CONCLUSIONS: Patients with a cranial CT scan, obtained on a helical CT scanner, that shows no intracerebral injury and who do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either inpatient or outpatient observation. Implementation of this practice could result in a potential decrease of more than 500,000 hospital admissions annually.

Single versus combination antimicrobial therapy for ventilator-associated pneumonia.

The appropriate selection of definitive antimicrobial therapy is a necessary component of the overall treatment for ventilator-associated pneumonia. When possible, single-agent therapy is preferable. A combination of antibiotics is necessary to treat multiple organisms not susceptible to a single appropriate antibiotic and when antibiotic-resistant gram-negative bacteria are present. Treatment failure is more commonly the result of persistent pneumonia and the development of antibiotic resistance than to recurrence after successful antimicrobial therapy. The duration of treatment will vary depending on the severity of the underlying illness and the pneumonic process.

Improved outcome after early fixation of acetabular fractures.

This study was done in order to evaluate the effect of the timing of fixation for acetabular and pelvic ring fractures on patient outcome. Demographic, clinical and outcome data for 5821 trauma patients admitted from January 1993 through January 1996 were retrospectively reviewed. Pelvic fractures were classified according to Young and Burgess. Patients who had fixation within 24 h of admission were compared with those who had later operation. Main outcome measures were Multiple Organ Dysfunction Score according to Moore, hospital and intensive care unit length of stay and discharge disposition. Out of 416 patients with pelvic fractures, one hundred patients had fracture fixation [90 open reduction and internal fixation, 10 external fixation]. There were 59 acetabular fractures and 41 pelvic ring fractures. The overall mortality was 4%. Early fixation of acetabular fractures was associated with lower MODS (p < 0.006) and decreased total length of stay (p < 0.026). Length of hospital stay was also less with early fixation of pelvic ring fractures (p < 0.04). Functional outcome was improved in early fixation of acetabular fractures with a greater proportion of patients being discharged home rather than to rehabilitation or skilled care (p = 0.05). Patients who underwent early repair of acetabular and pelvic ring fractures had a shorter length of hospital stay compared to those with late fixation. Patients with early repair of acetabular fractures had significantly less organ dysfunction and exhibited improved functional outcome.

Evaluation and management of tertiary peritonitis.

Tertiary or recurrent peritonitis can occur after any operation for secondary bacterial peritonitis. The major risk factors for the development of tertiary peritonitis include malnutrition, a high Acute Physiology and Chronic Health Evaluation II score, the presence of organisms resistant to antimicrobial therapy, and organ system failure. Most patients with tertiary peritonitis will have fever and leukocytosis, even though other signs of infection may be absent. The management of tertiary peritonitis should include the provision of appropriate physiologic support, the administration of antimicrobial therapy, and operation or intervention to control the source of contamination and to decrease the bacterial load. Antibiotic-resistant organisms and bacteremia are present more commonly and mortality is greater in patients with tertiary peritonitis. Early recognition and effective intervention are critical to achieving a successful outcome.

Oxygen consumption in the early postinjury period: use of continuous, on-line indirect calorimetry.

OBJECTIVE: To determine the patterns of oxygen consumption (Vo2) using indirect calorimetry (IC) for the first 24 hrs after serious blunt traumatic injury. DESIGN: Prospective, observational study. SETTING: Surgical intensive care unit of a Level 1 trauma center. PATIENTS: Sixty-six mechanically ventilated patients with blunt traumatic injury and Injury Severity Score >15. INTERVENTIONS: IC for 24 hrs postinjury. Patients were resuscitated to standard parameters of perfusion. MEASUREMENTS AND MAIN RESULTS: Mean patient age was 50.1+/-18.7 yrs with a mean Injury Severity Score 30.7+/-11.3). Mean Vo2 for all patients for the 24-hr study period was 168.5+/-29.5 mL/min/m2. The level of Vo2 was not related to Injury Severity Score, the number or combination of organ systems injured, or to the use of vasoactive agents. Patients >65 yrs of age had significantly lower Vo2 (P = .0038) compared with patients < or =50 yrs. Vo2 did not change over time after resuscitation to normal parameters of perfusion. Mean Vo2 was 156.5+/-63.2 mL/min/m2 in patients who developed multiple organ dysfunction, and 172.4+/-33.3 mL/min/m2 in those who did not develop multiple organ dysfunction (p = .16). CONCLUSIONS: Seriously injured patients are hypermetabolic in the early postinjury period. The level of Vo2 is unrelated to injury severity or number of organ systems involved. Elderly patients can be expected to have lower levels of Vo2. Vo2 does not change significantly in response to resuscitation to normal parameters of perfusion. Vo2 measured by IC did not predict the development of multiple organ dysfunction.

Optimizing the management of blunt splenic injury in adults and children.

BACKGROUND: The treatment for splenic injury is evolving to an increased use of nonoperative management. We studied patients with blunt injury to the spleen to determine the overall success with splenic salvage and the reason that adults and children have different outcomes. METHODS: Patient records were reviewed retrospectively for information and parameters that may influence outcome. Patients were categorized by age and type of management. RESULTS: Two hundred sixty-seven patients (222 adults; 45 children < 16 years old) with blunt splenic trauma were treated over a 7.5-year period. Adults had a significantly higher injury severity score (ISS; 27.2 +/- 0.9 vs 19.9 +/- 2.0; P < .05), splenic injury score (SIS; 2.8 +/- 0.1 vs 2.3 +/- 0.1; P < .01), and mortality rate (11.7% vs 2.2%; P < .05) compared with children. Eighty-six adults and 3 children had emergent operation; 23 patients had splenorrhaphy. Nonoperative management was selected initially in 178 patients; 83% (105 adults and 42 children) were treated successfully. The ISS and SIS of patients in whom nonoperative management failed were different from those patients in whom treatment was successful (ISS, 27.5 +/- 2.1 vs 20.6 +/- 1.0; SIS, 3.6 +/- 0.2 vs 2.1 +/- 0.1; P < .05) but were similar to those patients who needed initial emergent operation. Adults and children who had successful nonoperative management had similar ISSs (21.4 +/- 1.1 vs 18.4 +/- 2.0) and SISs (2.0 +/- 0.1 vs 2.3 +/- 0.1). Overall splenic salvage was achieved in 64% of patients (57% of adults and 96 % of children). Salvage increased from 50% to 85% during the study period. CONCLUSIONS: Splenic preservation is possible in most adults and children with blunt injury with the appropriate use of both operative salvage and nonoperative treatment. The higher salvage rate and decreased need for operation in children is due to their lower severity of overall injury and splenic injury. Operative salvage has become less common in adults because more patients are selected for nonoperative management.

Effectiveness of a 2-specialty, 2-tiered triage and trauma team activation protocol.

STUDY OBJECTIVE: To determine the effectiveness, safety, and resource allocation of a 2-specialty, 2-tiered triage and trauma team activation protocol. METHODS: We conducted a 6-month retrospective analysis of a 2-specialty, 2-tiered trauma team activation system at an urban Level I trauma center. Based on prehospital data, patients with a high likelihood of serious injury were assigned to triage category 1 and patients with a low likelihood of serious injury were assigned to category 2. Category 1 patients were immediately evaluated by both emergency medicine and trauma services. Category 2 patients were evaluated initially by emergency medicine staff with a mandatory trauma service consultation. Main outcomes measured included mortality, need for emergency procedures, need for emergency surgery, complications, and discharge disposition. Potential physician-hours saved were calculated for category 2 cases. RESULTS: Five hundred sixty-one patients were assigned a triage classification (272 to category 1 and 289 to category 2). Category 1 patients had a higher mortality rate (95% confidence interval [CI] for difference of 15.9%, 11.1% to 20.7%, P < .0001), need for emergency surgery (10.7% versus 1.4%, 95% CI for difference of 9.3%, 5.2% to 13.4%; P < .0001), need for emergency procedures (89% of total procedures, 95% CI 83% to 95%; P < .0001), and discharges to rehabilitation facilities (95% CI for difference of 15.1%, 9.3% to 21.0%; P < .0001). The 2-tiered response system saved an estimated 578 physician-hours of time for the trauma service over the study period. CONCLUSION: This evaluation tool effectively predicts likelihood of serious injury, mortality, need for emergency surgery, and need for rehabilitation. Patients with a low likelihood of serious injury may be initially evaluated by the emergency medicine service effectively and safely, thus allowing more efficient use of surgical personnel.

Oxygen delivery is an important predictor of outcome in patients with ruptured abdominal aortic aneurysms.

OBJECTIVE: The purpose of this study was to evaluate the relation of oxygen delivery (DO2) to the occurrence of multiple organ dysfunction (MOD) in patients with ruptured abdominal aortic aneurysms (AAA). SUMMARY BACKGROUND DATA: Patients with ruptured AAA are at high risk for the development of MOD and death. Previous reports of high-risk general surgical patients have shown improved survival when higher levels of DO2 are achieved. METHODS: Hemodynamic data were collected at 4-hour intervals on 57 consecutive patients (mean age, 70.5 years) who survived 24 hours after repair of infrarenal ruptured AAA. Patients were resuscitated to standard parameters of perfusion (pulse, blood pressure, urine output, normal base deficit). MOD was determined based on six organ systems. Standard parametric (analysis of variance, t tests) and nonparametric (chi square, Wilcoxon) tests were used to compare hemodynamic data, red blood cell requirements, colon ischemia, and organ failure for patients with and without MOD. RESULTS: Patients who developed MOD had a significantly lower cardiac index and DO2 for the first 12 hours; the difference was most significant at 8 hours. Logistic regression analysis demonstrated that the strongest predictors of MOD were DO2, early onset of renal failure, and total number of red blood cells transfused. CONCLUSIONS: DO2 is an earlier and better predictor of MOD after ruptured AAA than previously identified risk factors. Failure to achieve a normal DO2 in the first 8 hours after repair is strongly associated with the development of MOD and a high mortality. Strategies to restore normal DO2 may be useful to improve outcome in these high-risk patients.