Laparoscopic common bile duct exploration is an effective, safe, and less-costly method of treating choledocholithiasis.

BACKGROUND: Advancements in laparoscopic techniques led to the adoption of laparoscopic common bile duct exploration (LCBDE) as an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for management of choledocholithiasis (CD). The goal of this study was to describe the initial experience at a safety net hospital with acute care surgeons performing LCBDE for suspected CD. We hypothesized LCBDE would reduce length of stay and hospital costs compared to laparoscopic cholecystectomy (LC) and ERCP performed in the same hospital admission. METHODS: This was a retrospective case-control study from 2019 to 2023 comparing LCBDE to LC/ERCP among patients diagnosed with CD. Statistical analyses were performed using Mann-Whitney U tests for continuous variables and Chi-square tests for categorical variables. Data reported as median [interquartile range] or research subjects with condition (percentage). RESULTS: A total of 110 LCBDE were performed, while 121 subjects underwent LC and ERCP. Patients in the LCBDE group were more likely to be female with a total of 87 female subjects (77.6%) compared to 76 male subjects (62.8%) (95% CI 1.14-3.74). Initial WBC was lower in the LCBDE group at 8.4 [6.9-11.8] compared to the LC/ERCP group at 10.9 [7.9-13.5] (p = 0.0013). Remaining demographics and lab values were similar between the two groups. Patients who underwent LCBDE had a significantly shorter length of stay at 2 days [1-3] compared to those in the LC/ERCP group at 4 days [3-6] (p < 0.001). Hospital charges for the LCBDE group were $46,685 [$38,687-$56,703] compared to $60,537 [$47,527-$71,739] for the LC/ERCP group (p < 0.001). CONCLUSION: LCBDE is associated with significantly lower hospital costs and shorter length of stay with similar post-operative complication and 30-day readmission rates. Our results show that LCBDE is safe and should be considered as a first-line approach in the management of CD.

Surgical stabilization of rib fractures in anticoagulated patients: Proceed with caution?

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is increasingly performed, however the outcome of patients undergoing SSRF while on pre-injury antithrombotic therapy remains unknown. We compared surgical variables and outcomes of patients who were and were not on antithrombotic therapy. We hypothesize pre-injury anticoagulation is associated with delay in SSRF and worse outcomes. METHODS: For this retrospective cohort study, we queried the Chest Injury International Database, for patients undergoing SSRF between 08/2018 and 03/2022. Antithrombotic therapy was categorized into antiplatelet and anticoagulant use. Primary outcome was time from admission to SSRF. Secondary outcomes included SSRF duration and complications. Numerical data were presented as median (IQR), categorical data as number (%). Inverse probability weighting was used to control for confounding. RESULTS: Two hundred and eighteen SSRF patients were included, 25 (11 %) were on antithrombotic therapy. These patients were older (72 years, (65-80) versus 57 years, (43-66); p < 0.001) with lower ISS (14, (10-20) versus 21, (14-30); p = 0.002). Time from admission to SSRF was comparable (2 days, (1-4) versus 2 days, (1-4); p = 0.37) as was operative time (154 mins, (120.0-212.0) versus 177 mins, (143.0-210.0); p = 0.34). Patients using antithrombotics had fewer ICU-free days (24 (22-26) versus 28 (23-28); p = 0.003) but more ventilator free days (28, (28-28) versus 27 (27-28); p < 0.008). After adjusting for confounding, pre-injury anticoagulation was not significantly associated with delayed SSRF (Relative Risk, RR=1.37, 95 % CI 0.30-6.24), operative time (RR=1.07, 95 % CI0.88-1.31), IFD <=28 (RR=2.05, 95 %CI:0.33-12.67), VFD<=27 (RR=0.71, 95 %CI:0.15-3.48) or complications (RR=0.55, 95 % CI0.06-5.01). CONCLUSION: Pre-injury antithrombotic drug use neither delayed SSRF nor impacted operative time in patients requiring SSRF and was not associated with increased risk of complications. Our data suggest SSRF can be safely performed without delay in patients who use anticoagulation pre-injury. LEVEL OF EVIDENCE: IV. STUDY TYPE: Therapeutic/care management.

Increasing the Threshold to Perform Preperitoneal Pelvic Packing Decreases Morbidity Without Affecting Mortality.

OBJECTIVES: To determine the effectiveness of an updated protocol that increased the transfusion threshold to perform preperitoneal pelvic packing in patients with pelvic ring injuries and hemodynamic instability (HDI). DESIGN: Retrospective review. SETTING: Urban level 1 trauma center. PATIENTS SELECTION CRITERIA: Severely injured (injury severity score > 15) patients with pelvic ring injuries treated before and after increasing the threshold to perform preperitoneal pelvic packing from 2 to 4 units of red blood cells (RBCs). HDI was defined as a systolic blood pressure <90 mm Hg. OUTCOME MEASURES AND COMPARISONS: Mortality from hemorrhage, anterior pelvic space infections, and venous thromboembolisms before and after increasing preperitoneal pelvic packing threshold. RESULTS: One hundred sixty-six patients were included: 93 treated under the historical protocol and 73 treated under the updated protocol. HDI was present in 46.2% (n = 43) of the historical protocol group and 49.3% (n = 36) of the updated protocol group (P = 0.69). The median age of patients with HDI was 35.0 years (interquartile range 26.0-52.0), 74.7% (n = 59) were men, and the median injury severity score was 41.0 (interquartile range 29.0-50.0). Patients with HDI in the updated protocol group had a lower heart rate on presentation (105.0 vs. 120.0; P = 0.004), required less units of RBCs over the first 24 hours (6.0 vs. 8.0, P = 0.03), and did not differ in age, injury severity score, systolic blood pressure on arrival, base deficit or lactate on arrival, resuscitative endovascular balloon occlusion of the aorta, resuscitative thoracotomy, angioembolization, or anterior pelvis open reduction internal fixation (P > 0.05). The number of PPPs performed decreased under the new protocol (8.3% vs. 65.1%, P < 0.0001), and there were fewer anterior pelvic infections (0.0% vs. 13.9%, P = 0.02), fewer VTEs (8.3% vs. 30.2%; P = 0.02), and no difference in deaths from acute hemorrhagic shock (5.6% vs. 7.0%, P = 1.00). CONCLUSIONS: Increasing the transfusion threshold from 2 to 4 units of red blood cells to perform pelvic packing in severely injured patients with pelvic ring injuries decreased anterior pelvic space infections and venous thromboembolisms without affecting deaths from acute hemorrhage. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Neutrophil-mediated Inflammatory Plasminogen Degradation, Rather Than High Plasminogen-Activator Inhibitor-1, May Underly Failures and Inefficiencies of Intrapleural Fibrinolysis.

BACKGROUND: Complex pleural space infections often require treatment with multiple doses of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease, with treatment failure frequently necessitating surgery. Pleural infections are rich in neutrophils, and neutrophil elastase degrades plasminogen, the target substrate of tPA, that is required to generate fibrinolysis. We hypothesized that pleural fluid from patients with pleural space infection would show high elastase activity, evidence of inflammatory plasminogen degradation, and low fibrinolytic potential in response to tPA that could be rescued with plasminogen supplementation. RESEARCH QUESTION: Does neutrophil elastase degradation of plasminogen contribute to intrapleural fibrinolytic failure? STUDY DESIGN AND METHODS: We obtained infected pleural fluid and circulating plasma from hospitalized adults (n = 10) with institutional review board approval from a randomized trial evaluating intrapleural fibrinolytics vs surgery for initial management of pleural space infection. Samples were collected before the intervention and on days 1, 2, and 3 after the intervention. Activity assays, enzyme-linked immunosorbent assays, and Western blot analysis were performed, and turbidimetric measurements of fibrinolysis were obtained from pleural fluid with and without exogenous plasminogen supplementation. Results are reported as median (interquartile range) or number (percentage) as appropriate, with an α value of .05. RESULTS: Pleural fluid elastase activity was more than fourfold higher (P = .02) and plasminogen antigen levels were more than threefold lower (P = .04) than their corresponding plasma values. Pleural fluid Western blot analysis demonstrated abundant plasminogen degradation fragments consistent with elastase degradation patterns. We found that plasminogen activator inhibitor 1 (PAI-1), the native tPA inhibitor, showed high antigen levels before the intervention, but the overwhelming majority of this PAI-1 (82%) was not active (P = .003), and all PAI-1 activity was lost by day 2 after the intervention in patients receiving intrapleural tPA and deoxyribonuclease. Finally, using turbidity clot lysis assays, we found that the pleural fluid of 9 of 10 patients was unable to generate a significant fibrinolytic response when challenged with tPA and that plasminogen supplementation rescued fibrinolysis in all patients. INTERPRETATION: Our findings suggest that inflammatory plasminogen deficiency, not high PAI-1 activity, is a significant contributor to intrapleural fibrinolytic failure. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03583931; URL: www. CLINICALTRIALS: gov.

Contemporary management of patients with multiple rib fractures: What you need to know.

ABSTRACT: Ten percent of all injured patients and 55% of patients with blunt chest trauma experience rib fractures. The incidence of death due to rib fractures is related to the number of fractured ribs, severity of fractured ribs, and patient age and comorbid conditions. Death due to rib fracture is mostly caused by pneumonia because of inability to expectorate and take deep breaths. Over the last 25 to 30 years, there has been renewed interest in surgical stabilization of rib fractures (SSRF), known colloquially as "rib plating." This review will present what you need to know in regard to triage decisions on whether to admit a patient to the hospital, the location to which they should be admitted, criteria and evidentiary support for SSRF, timing to SSRF, and operative technique. The review also addresses the cost-effectiveness of this operation and stresses nonoperative treatment modalities that should be implemented prior to operation.

Differentiating Pathologic from Physiologic Fibrinolysis: Not as Simple as Conventional Thrombelastography.

BACKGROUND: Conventional rapid thrombelastography (rTEG) cannot differentiate fibrinolysis shutdown from hypofibrinolysis, as both of these patient populations have low fibrinolytic activity. Tissue plasminogen activator (tPA) TEG can identify depletion of fibrinolytic inhibitors, and its use in combination with rTEG has the potential to differentiate all 3 pathologic fibrinolytic phenotypes after trauma. We hypothesize tPA-TEG and rTEG in combination can further stratify fibrinolysis phenotypes postinjury to better stratify risk for mortality. STUDY DESIGN: Adult trauma patients (981) with both rTEG and tPA-TEG performed less than 2 hours postinjury were included. rTEG lysis at 30 minutes after maximum amplitude (LY30) was used to initially define fibrinolysis phenotypes (hyperfibrinolysis >3%, physiologic 0.9% to 3%, and shutdown <0.9%), with Youden Index then used to define pathologic extremes of tPA-TEG LY30 (tPA sensitive [depletion of fibrinolytic inhibitors] vs resistant) resulting in 9 groups that were assessed for risk of death. RESULTS: The median New Injury Severity Score was 22, 21% were female, 45% had penetrating injury, and overall mortality was 13%. The tPA-TEG LY30 inflection point for increased mortality was >35.5% (tPA sensitive, odds ratio mortality 9.2, p < 0.001) and <0.3% (tPA resistance, odds ratio mortality 6.3, p = 0.04). Of the 9 potential fibrinolytic phenotypes, 5 were associated with increased mortality. Overall, the 9 phenotypes provided a significantly better prediction of mortality than rTEG or tPA-TEG alone (areas under the operating characteristics curves = 0.80 vs 0.63 and 0.75, respectively, p < 0.0001). These could be condensed to 3 pathologic phenotypes (true hyperfibrinolysis, early fibrinolysis shutdown, and hypofibrinolysis). CONCLUSIONS: The combination of rTEG and tPA-TEG increases the ability to predict mortality and suggests patient-specific strategies for improved outcomes.

Fibrinolysis Resistance After Injury Is a Risk Factor for a Hospital-Acquired Pneumonia-Like Disease Pattern.

Background: Pneumonia is associated with increased morbidity and costs in the intensive care unit (ICU). Its early identification is key for optimal outcomes, but early biomarkers are lacking. Studies suggest that fibrinolysis resistance (FR) after major abdominal surgery is linked to an increased risk of infection. Patients and Methods: Patients in a randomized controlled trial for hemorrhagic shock were evaluated for FR. Fibrinolysis resistance was quantified by thrombelastography with exogenous tissue plasminogen activator (tPA-TEG) at 24- and 48-hours post-injury and measuring LY30 (%). A receiver-operating characteristics (ROC) curve analysis was used to identify a cutoff for increased risk of pneumonia, which was then validated in ICU patients at risk for venous thromboembolism (VTE). Multivariable logistic regression was used to control for confounders. Results: Forty-nine patients in the hemorrhagic shock cohort had tPA-TEGs at 24- and 48-hours (median ISS, 27; 7% pneumonia). A composite tPA-TEG LY30 of less than 4% at 24 and 48 hours was found to be the optimal cutoff for increased risk of pneumonia. This cohort had a seven-fold increased rate of pneumonia (4% vs. 28%; p = 0.048). Eighty-eight patients in the VTE cohort had tPA-TEGs at 24 and 48 hours post-ICU admission (median ISS, 28; 6% pneumonia). The tPA-TEG LY30 of less than 4% was associated with a 10-fold increased rate of pneumonia (19% vs. 1.5%; p = 0.002). In patients with traumatic brain injury, the same association was found (33% vs. 3.2%; p = 0.006). Adjusting for confounders, the tPA-TEG persisted as a substantial risk factor for pneumonia (adjusted odds ratio [OR], 35.7; 95% confidence interval [CI], 1.9-682; p = 0.018). Conclusions: Fibrinolysis resistance quantified by tPA-TEG within 48 hours of ICU admission is associated with an increased risk of pneumonia in patients in hemorrhagic shock and those at risk for VTE. Prospective validation of the tPA-TEG LY30 optimal cutoff for pneumonia and further investigation into whether endogenous FR is a cause of an altered immunity is warranted.

Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample.

Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.

An initiative to assess and improve the resources and patient care processes used among Chest Wall Injury Society collaborative centers study (CWIS-CC2).

BACKGROUND: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers. METHODS: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded. RESULTS: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF. CONCLUSION: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Evolution of Pulmonary Contusions in Patients With Severe Rib Fractures: Cause for Concern?

INTRODUCTION: The progression of pulmonary contusions remains poorly understood. This study aimed to measure the radiographic change in pulmonary contusions over time and evaluate the association of the radiographic change with clinical outcomes and surgical stabilization of rib fractures (SSRF). METHODS: This retrospective cohort study included adults admitted with three or more displaced rib fractures or flail segment on trauma CT and when a chest CT was repeated within one week after trauma. Radiographic severity of pulmonary contusions was assessed using the Blunt Pulmonary Contusion Score (BPC18). Logistic regression was performed to evaluate the relation between SSRF and worsening contusions on repeat CT, adjusted for potential confounders. RESULTS: Of 231 patients, 56 (24%) had a repeat CT scan. Of these, 55 (98%) had pulmonary contusion on the first CT scan with a median BPC18 score of 5 (P25-P75 3-7). Repeat CTs showed an overall decrease of the median BPC18 score to 4 (P25-P75 2-6, P = .02), but demonstrated a worsening of the pulmonary contusion in 16 patients (29%). All repeat CTs conducted within 12 hours post-injury demonstrated increasing BPC18. Radiographic worsening of pulmonary contusions was not associated with SSRF, nor with worse respiratory outcomes or intensive care length of stay, compared to patients with radiographically stable or improving contusions. DISCUSSION: In patients with severe rib fracture patterns who undergo repeat imaging, pulmonary contusions are prevalent and become radiographically worse within at least the first 12 hours after injury. No association between radiographic worsening and clinical outcomes was found.

Door to door in 24: factors that allow surgical stabilization of rib fractures within 24 hours of admission.

Background: Surgical stabilization of rib fractures (SSRF) should be performed early after injury. Factors that influence timing remain unknown. Our objective was to identify inherent variables that allow for early identification and treatment. We hypothesized that certain demographic, injury, and logistical factors are associated with SSRF <24 hours from admission. Methods: Retrospective review from an urban level 1 trauma center (10/2010-8/2019). Patients were grouped as SSRF <24 hours from admission vs. ≥24 hours. Demographics, transfer from an outside hospital (OSH), timing documentation, injury descriptors, surgeon on-call, and operative surgeon were collected. SSRF for chronic non-union was excluded. Results: Data from 173 patients were analyzed. Eighty-five patients (49%) were in the <24 hours group and 88 (51%) were in the ≥24 hours group. Baseline demographics were similar between groups. Injury severity was significantly higher in the late group: increased Injury Severity Score (ISS; 16.5 vs. 21.0, P<0.01), lower Glasgow Coma Scale (GCS; 15 vs. 14, P<0.01), more rib fractures (7 vs. 9, P=0.01), and increased incidence of face (6% vs. 16%, P=0.03), spine (22% vs. 47%, P<0.01), and pelvis fractures (8% vs. 25%, P<0.01). Patients admitted on a Wednesday were more likely to undergo early SSRF as compared to other days of the week (P=0.01) There was also a shorter time from the decision to perform SSRF to the actual operation in the early group, as compared to the late group (13 vs. 44 hours, P<0.01). Fifty (28.9%) SSRF cases were performed by the on-call surgeon; this percentage did not differ in the early vs. late group (33% vs. 25%, P=0.25). Patients needing pelvic fixation were more likely to be in the late group. Patients transferred from an OSH for SSRF were more likely to be in the early group (29% vs. 10%, P<0.01). Finally, likelihood of early surgery increased with increasing study year. Conclusions: Approximately one-half of SSRF cases were performed within 24 hours of admission. Factors that influence surgery within 24 hours of admission appear related to overall injury severity and systems issues, including day of admission, transfer from another facility, additional urgent pelvic surgery, and institutional experience with SSRF. Surgeon availability did not drive this disparity.

Open Fixation After Preperitoneal Pelvic Packing Is Associated With a High Surgical Site Infection Rate.

OBJECTIVES: To evaluate the incidence of pelvic space surgical site infection (SSI) after preperitoneal pelvic packing (PPP) for persistent hemodynamic instability. DESIGN: Retrospective comparative study. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: 83 patients who received PPP and 55 patients who had open reduction and internal fixation (ORIF) of the anterior pelvic ring without PPP. INTERVENTION: Operative fixation. MAIN OUTCOME MEASUREMENTS: Pelvic space SSI. RESULTS: The SSI rate in the PPP group was 31.3% (26/83) compared with 10.9% (6/55) in the control group (proportional difference 20.4%, confidence interval (CI) 6.4-32.5, P = 0.007). Patients in the PPP group (n = 43) were 1:1 propensity score matched with patients in the control group to account for differences in Injury Severity Score and American Society of Anesthesiologists score. In this matched cohort, the rate of pelvic space SSI remained higher in the PPP group compared with that in the control group (30.2% vs. 9.3%; proportional difference 20.9%, CI, 3.7-36.3; P = 0.02). On multivariate analysis of the PPP group, anterior ORIF (odds ratio 6.56, CI, 2.00-21.47, P = 0.002) was found to be independently associated with SSI. CONCLUSIONS: PPP is an independent risk factor of space SSI. The likelihood of SSI after PPP is increased with anterior ORIF. The morbidity of SSI after PPP must be weighed against the risk of exsanguination. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improved chest wall trauma taxonomy: an interdisciplinary CWIS and ASER collaboration.

PURPOSE: Chest wall injury taxonomy and nomenclature are important components of chest wall injury classification and can be helpful in communicating between providers for treatment planning. Despite the common nature of these injuries, there remains a lack of consensus regarding injury description. The Chest Wall Injury Society (CWIS) developed a taxonomy among surgeons in the field; however, it lacked consensus and clarity in critical areas and collaboration with multidisciplinary partners. We believe an interdisciplinary collaboration between CWIS and American Society of Emergency Radiology (ASER) will improve existing chest wall injury nomenclature and help further research on this topic. METHODS: A collaboration between CWIS and ASER gathered feedback on the consensus recommendations. The workgroup held a series of meetings reviewing each consensus statement, refining the terminology, and contributing additional clarifications from a multidisciplinary lens. RESULTS: After identifying incomplete definitions in the CWIS survey, the workgroup expanded on and clarified the language proposed by the survey. More precise definitions related to rib and costal cartilage fracture quality and location were developed. Proposed changes include more accurate characterization of rib fracture displacement and consistent description of costal cartilage fractures. CONCLUSIONS: The 2019 consensus survey from CWIS provides a framework to discuss chest wall injuries, but several concepts remained unclear. Creating a universally accepted taxonomy and nomenclature, utilizing the CWIS survey and this article as a scaffolding, may help providers communicate the severity of chest wall injury accurately, allow for better operative planning, and provide a common language for researchers in the future.

Tissue plasminogen activator challenge thrombelastography is the most accurate assay in predicting the need for massive transfusion in hypotensive trauma patients.

BACKGROUND: Tissue plasminogen activator (tPA) added to thrombelastography (TEG) detects hyperfibrinolysis by measuring clot lysis at 30 min (tPA-challenge-TEG). We hypothesize that tPA-challenge-TEG is a better predictor of massive transfusion (MT) than existing strategies in trauma patients with hypotension. METHODS: Trauma activation patients (TAP, 2014-2020) with 1) systolic blood pressure <90 mmHg (early) or 2) those who arrived normotensive but developed hypotension within 1H postinjury (delayed) were analyzed. MT was defined as >10 RBC U/6H postinjury or death within 6H after ≥1 RBC unit. Area under the receiver operating characteristics curves were used to compare predictive performance. Youden index determined optimal cutoffs. RESULTS: tPA-challenge-TEG was the best predictor of MT in the early hypotension subgroup (N = 212) with positive (PPV) and negative predictive values (NPV) of 75.0%, and 77.6%, respectively. tPA-challenge-TEG was a better predictor of MT than all but TASH (PPV = 65.0%, NPV = 93.3%) in the delayed hypotension group (N = 125). CONCLUSIONS: The tPA-challenge-TEG is the most accurate predictor of MT in trauma patients arriving hypotensive and offers early recognition of MT in patients with delayed hypotension.

Development and validation of a pulmonary complications prediction model based on the Yang's index.

Background: Blunt chest trauma patients with pulmonary contusion are susceptible to pulmonary complications, and severe cases may develop respiratory failure. Some studies have suggested the extent of pulmonary contusion to be the main predictor of pulmonary complications. However, no simple and effective method to assess the severity of pulmonary contusion has been available yet. A reliable prognostic prediction model would facilitate the identification of high-risk patients, so that early intervention can be given to reduce pulmonary complications; however, no suitable model based on such an assumption has been available yet. Methods: In this study, a new method for assessing lung contusion by the product of the three dimensions of the lung window on the computed tomography (CT) image was proposed. We conducted a retrospective study on patients with both thoracic trauma and pulmonary contusion admitted to 8 trauma centers in China from January 2014 to June 2020. Using patients from 2 centers with a large number of patients as the training set and patients from the other 6 centers as the validation set, a prediction model for pulmonary complications was established with Yang's index and rib fractures, etc., being the predictors. The pulmonary complications included pulmonary infection and respiratory failure. Results: This study included 515 patients, among whom 188 developed pulmonary complications, including 92 with respiratory failure. Risk factors contributing to pulmonary complications were identified, and a scoring system and prediction model were constructed. Using the training set, models for adverse outcomes and severe adverse outcomes were developed, and area under the curve (AUC) of 0.852 and 0.788 were achieved in the validation set. In the model performance for predicting pulmonary complications, the positive predictive value of the model is 0.938, the sensitivity of the model is 0.563 and the specificity of the model is 0.958. Conclusions: The generated indicator, called Yang's index, was proven to be an easy-to-use method for the evaluation of pulmonary contusion severity. The prediction model based on Yang's index could facilitate early identification of patients at risk of pulmonary complications, yet the effectiveness of the model remains to be validated and its performance remains to be improved in further studies with larger sample sizes.

Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries.

INTRODUCTION: The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and outcomes of SSRF between patients with and without non-urgent operative pelvic injuries. PATIENTS AND METHODS: In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups. RESULTS: Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups. CONCLUSIONS: SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.

Mirizzi syndrome complicated by type IV cholecystobiliary fistula to the right hepatic duct.

Mirizzi syndrome is a rare complication of long-term chronic cholecystitis, characterized by extrinsic compression of the common hepatic duct that may progress to development of cholecystobiliary fistula. Here we report a case of a 38-year-old female patient who underwent laparoscopic cholecystectomy with intraoperative cholangiogram for acute cholecystitis and choledocholithiasis. Intraoperatively, the patient was found to have a Mirizzi syndrome complicated by cholecystobiliary fistula to the right hepatic duct. The gallbladder was successfully removed, cholelithiasis cleared and a ureteral stent was used in reconstruction. The patient was discharged on postoperative two and was doing well on routine follow-up. Ultimately, Mirizzi syndrome is a rare clinical entity that requires careful consideration during preoperative workup and a high suspicion when abnormal anatomy is encountered intraoperatively.

Duration of Antibiotic Therapy for Early VAP Trial: Study Protocol for a Surgical Infection Society Multicenter, Pragmatic, Randomized Clinical Trial of Four versus Seven Days of Definitive Antibiotic Therapy for Early Ventilator-Associated Pneumonia in Surgical Patients.

Background: Current guidelines recommend a seven-day course of antibiotic therapy for patients with ventilator-associated pneumonia (VAP). However, clinical and microbiologic resolution of infection may occur much sooner than seven days, particularly in patients with early VAP. Shortening the course of antibiotic therapy for early VAP likely results in lower antibiotic-associated complications, but it is unclear whether VAP recurrence rates will be higher in patients receiving fewer days of therapy. We propose to compare four days versus seven days of antibiotic therapy for early VAP in surgical patients in a multicenter, pragmatic, randomized clinical trial. Patients and Methods: Eligible patients admitted to a surgical intensive care unit with early VAP, defined as VAP occurring within two to seven days of intubation, will be randomized to receive four or seven days of antibiotic therapy. The two primary outcomes are: VAP recurrence, defined as VAP occurring two to 14 days after completion of initial therapy and antibiotic-free days, defined as the number of days without receiving any antibiotic agents within 30 days from completion of initial therapy. Data will be analyzed using both intention-to-treat and per-protocol strategies. Power analysis was performed assuming non-inferiority of four days vs. seven days for VAP recurrence and superiority of four days versus seven days for antibiotic-free days. The total sample size to detect a 10% difference between groups with 80% power and assuming a 10% dropout rate is 458 patients. Three separate data analyses are planned throughout the trial and sample size will be re-calculated at each interim analysis. Conclusions: The Duration of Antibiotic Therapy for Early VAP (DATE) Trial will enroll surgical patients with early VAP to analyze whether a shorter duration of antibiotic therapy results in similar clinical outcomes while decreasing antibiotic exposure.