Simple signage and targeted education can lead to process improvement in acute appendicitis care.

INTRODUCTION: An institution-wide protocol for uncomplicated acute appendicitis was created to improve compliance with best practices between the emergency department (ED), radiology and surgery. Awareness of the protocol was spread with the publication of a smartphone application and communication to clinical leadership. On interim review of quality metrics, poor protocol adherence in diagnostic imaging and antimicrobial stewardship was observed. The authors hypothesised that two further simple interventions would result in more efficient radiographic diagnosis and antimicrobial administration. MATERIALS AND METHODS: Surgery residents received targeted in-person education on the appropriate antibiotic choices and diagnostic imaging in the protocol. Signs were placed in the emergency and radiology work areas, immediately adjacent to provider workstations highlighting the preferred imaging for patients with suspected appendicitis and the preferred antibiotic choices for those with proven appendicitis. Protocol adherence was compared before and after each intervention. RESULTS: Targeted education was associated with improved antibiotic stewardship within the surgical department from 30% to 91% protocol adherence before/after intervention (p<0.005). Visible signs in the ED were associated with expedited antimicrobial administration from 50% to 90% of patients receiving antibiotics in the ED prior to being brought to the operating room before/after intervention (p<0.005). Diagnostic imaging after the placement of signs showed improved protocol adherence from 35% to 75% (p<0.005). CONCLUSION: This study demonstrates that smartphone-based applications and communication among clinical leadership achieved suboptimal adherence to an institutional protocol. Targeted in-person education reinforcement and visible signage immediately adjacent to provider workstations were associated with significantly increased adherence. This type of initiative can be used in other aspects of acute care general surgery to further improve quality of care and hospital efficiency.

The last days: The medical response of United States and allied military teams during the Afghanistan Exodus.

OBJECTIVES: The objective of this study is to describe the United States and allied military medical response during the withdrawal from Afghanistan. BACKGROUND: The military withdrawal from Afghanistan concluded with severe hostilities resulting in numerous civilian and military casualties. The clinical care provided by coalition forces capitalized on decades of lessons learned and enabled unprecedented accomplishments. METHODS: In this retrospective, observational analysis, casualty numbers, and operative information was collected and reported from military medical assets in Kabul, Afghanistan. The continuum of medical care and the trauma system, from the point of injury back to the United States was captured and described. RESULTS: Prior to a large suicide bombing resulting in a mass casualty event, the international medical teams managed distinct 45 trauma incidents involving nearly 200 combat and non-combat civilian and military patients over the preceding 3 months. Military medical personnel treated 63 casualties from the Kabul airport suicide attack and performed 15 trauma operations. US air transport teams evacuated 37 patients within 15 hours of the attack. CONCLUSION: Lessons learned from the last 20 years of combat casualty care were successfully implemented during the culmination of the Afghanistan conflict. Ultimately, the effort, teamwork, and system adaptability exemplify not only the attitudes and character of service members who provide modern combat casualty care but also the paramount importance of the battlefield learning health care system. A continued posture to maintain military surgical preparedness in unique environments remain crucial as the US military prepares for the future.Retrospective observational analysis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Primary Lung Hernia After Blunt Chest Trauma: Chest Wall Repair Strategies.

Lung herniation is a rare pathology seen after trauma. A case of acquired lung hernia is presented after blunt thoracic trauma that was repaired primarily. Surgical management and decision-making for this process are discussed.

Comparison of Outcomes Between the National Surgical Quality Improvement Program and an Emergency General Surgery Registry.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) has become a prevalent tool for quality improvement. At our tertiary military hospital, NSQIP collects 20% of eligible cases. We implemented an emergency general surgery (EGS) registry to prospectively review all EGS cases. We compared our EGS registry with NSQIP, hypothesizing that NSQIP sampling under-represents EGS outcomes. METHODS: A formal EGS Process Improvement Program was implemented in 2016. From 2016 to 2018, the four most common operations were laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction, and nonelective hernia repair. Outcomes were compared between the EGS registry and NSQIP abstracted cases. RESULTS: In 2016, the EGS registry identified 11/112 (9.8%) patients with a complication. National Surgical Quality Improvement Program abstracted 16% of EGS cases with 16.7% (3/18) of patients having a complication. In 2017, the EGS registry identified 10/87 (11.5%) cases with complications. National Surgical Quality Improvement Program abstracted 23% of EGS with zero complications. In 2018, the EGS registry identified 9.5% of 74 cases with complications. National Surgical Quality Improvement Program abstracted 15% of EGS cases with zero complications. CONCLUSIONS: National Surgical Quality Improvement Program did not capture many important EGS outcomes. In 2 of 3 years, NSQIP did not identify a single complication for EGS. National Surgical Quality Improvement Program alone may be insufficient to target EGS improvements.

Surgery at Sea: Exploring the Training Gap for Isolated Military Surgeons.

OBJECTIVE: Newly-graduated military general surgeons often find themselves isolated at sea, solely responsible for all surgical care of several thousand sailors, regardless of the surgical specialty training required for any individual procedure. This educational need assessment explored trends in afloat surgical care over the last 25 years, and assessed trainees' preparedness for their expected role as an isolated surgeon. DESIGN: A sample of deidentified US Navy Ship's Surgeon case logs were reviewed to determine afloat case load trends in 5 common afloat case categories (urologic/gynecologic, anorectal, hernia, appendectomy, and hand/orthopedic/trauma) from 1990s to 2017. Individual procedures were mapped to American College of Surgeons/Military Health System Knowledge, Skills, and Attitudes line items to ensure afloat-relevant skills were identified. Recent military resident case logs were then compared with afloat cases to evaluate relevant trainee experience. SETTING: US Navy ships at sea from 1995 to 2017. PARTICIPANTS: US Navy afloat-deployed surgeons, totaling 1340 cases within the study period. RESULTS: Case log analysis of 1340 surgeries, comprising >200 months at sea, reflected 46 named procedures; 34 of 46 (74%) correlated to an intraoperative knowledge, skills, and attitudes item. The most common surgeries were vasectomy, (304 of 1340, 23%). No difference in case mix was apparent comparing pre- and post-2000 deployments (representing afloat laparoscopic integration) in 4 of 5 categories, while hernias proportionally declined. Case volume per deployment markedly declined overall (p < 0.001) and in each category. Resident case log analysis from 2012 to 2016 showed experience was limited in urologic/gynecologic, orthopedic, and open appendectomy categories. CONCLUSIONS: No formal case repository exists for afloat surgery, making detailed analysis problematic. Current training provides excellent surgical education but minimal exposure to rare-but-real cases expected on deployments, which may not translate to competency for the isolated, afloat surgeon. Military surgical leadership should embrace training for these cases and assertively invest in the development of the military's newest surgeons.

Treatment of Suspected Invasive Fungal Infection in War Wounds.

Invasive fungal wound infections (IFIs) were an unexpected complication associated with blast-related wounds during Operation Enduring Freedom. Between 2010 and 2012, IFI incidence rates were as high as 10-12% for patients injured during Operation Enduring Freedom and admitted to the intensive care unit at the Landstuhl Regional Medical Center. Independent risk factors for the development of IFIs include dismounted blast injuries, above knee amputations and massive (>20 units) packed red blood cell transfusions within 24 hours after injury. The Joint Trauma System developed a Clinical Practice Guideline on IFI prevention, identification and management. Aggressive and frequent surgical debridement remains the primary therapy accompanied by topical antifungal therapy (e.g., Dakins solution). Empiric systemic antifungal therapy with both liposomal amphotericin B and an intravenous broad-spectrum triazole (e.g., voriconazole or posaconazole) should be administered when there is strong suspicion of IFI based on the occurrence of recurrent wound necrosis following serial surgical debridements, since many cases involve multiple fungal species. Other recommendations include: (1) early tissue sampling for wound histopathology and fungal cultures, (2) early consultation with infectious disease specialists, and (3) coordination with surgical pathology and clinical microbiology.

Development of an emergency general surgery process improvement program.

BACKGROUND: The Joint Trauma System has demonstrated improved outcomes through coordinated research and process improvement programs. With fewer combat trauma patients, our military American College of Surgeons level 2 trauma center's ability to maintain a strong trauma Process Improvement (PI) program has become difficult. As emergency general surgery (EGS) patients are similar to trauma patients, our Trauma and Acute Care Surgery (TACS) service developed an EGS PI program analogous to what is done in trauma. We describe the implementation of our novel EGS PI program and its effect on institutional PI proficiency. METHODS: An EGS registry was developed in 2013. Inclusion criteria were based on AAST published literature. In 2015, EGS registrar and PI coordinator positions were developed and filled with existing trauma staff. A formal EGS PI program began January 1, 2016. Pre- and post-program data was compared to determine the effect including EGS PI events had on increasing yield into our trauma PI program. RESULTS: In 2016, TACS saw 1001 EGS consults. Four hundred forty-four met criteria for registry inclusion. Eighty-two patients had 131 PI events; re-admission within 30 days, unplanned therapeutic intervention, and unplanned ICU admission were the most common events. Capture of EGS PI events yielded a 49% increase compared with 2015. CONCLUSION: Overall patient volume and PI events post EGS PI program initiation exceeded those prior to implementation. These data suggest that extending trauma PI principles to EGS may be beneficial in maintaining inter-war military and/or lower volume trauma center readiness.

Review of an emergency general surgery process improvement program at a verified military trauma center.

INTRODUCTION: Decreasing combat-based admissions to our military facility have made it difficult to maintain a robust trauma process improvement (PI) program. Since emergency general surgery (EGS) and trauma patients share similarities, we merged the care of our EGS and trauma patients into one acute care surgery (ACS) team. An EGS PI program was developed based on trauma PI principles to facilitate continued identification of opportunities for improvement despite our decline in trauma admissions. Analysis of the first 18 months of combined ACS PI data is presented. METHODS: EGS registry inclusion criteria was based on published Association for the Surgery of Trauma's recommendations. Program components and PI categories were based on our existing trauma PI program. Dedicated coordinators actively reviewed and cataloged patient care and outcomes. Deviations from standard practice patterns, unplanned interventions, and other complications were abstracted, categorized, and evaluated through levels of review similar to accepted trauma PI principles. Data for the first six quarters were collated and trends were analyzed. RESULTS: Over 18 months, 696 EGS patients met registry inclusion criteria, with 468 patients (67%) undergoing operative intervention. Over the same time, 353 trauma patients were admitted with 158 undergoing operative intervention (56.4%). Of the 696 EGS patients and 353 trauma patients, 226 (32%) and 243 (69%) PI events were identified, respectively. Common events included unplanned therapies, re-admissions, and unplanned ICU admissions. Based on analysis of all events, four new areas for improvement initiatives were identified. Results of these initiatives included implementation of a multi-disciplinary EGS PI committee, consensus protocols, and departmental and hospital-wide actions. CONCLUSION: In an 18-month period, integration of our EGS patients into a novel, combined ACS PI program facilitated recognition of an additional 226 PI events and provided a substrate for continued improvements in patient care.

Identification of Abnormal Biliary Anatomy Utilizing Real-Time Near-Infrared Cholangiography: A Report of Two Cases.

Biliary duct anomalies are commonly encountered during laparoscopic cholecystectomy. Advancements in the field of surgery allow for enhanced intraoperative detection of these abnormalities. Fluorophore injection and near-infrared (NIR) imaging can provide real-time intraoperative anatomic feedback without intraoperative delays and ionizing radiation. This report details two cases where the PINPOINT Endoscopic Fluorescence Imaging System (NOVADAQ, Ontario, Canada) was used to identify anomalies of the biliary tree and guide operative decision-making.

TXA in combat casualty care--does it adversely affect extremity reconstruction and flap thrombosis rates?

INTRODUCTION: Tranexamic acid (TXA) is an antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin. In recent years, the military has adapted TXA's use in combat casualties suffering severe hemorrhagic injuries. The purpose of this study is to examine the association between TXA on complications such as venous thromboembolic events (VTEs) and flap-related thrombosis in combat trauma patients undergoing tissue transfer for extremity reconstruction. METHODS: A retrospective chart review of war wounded undergoing extremity reconstructions from 2003 to 2012 at Walter Reed National Military Medical Center was completed. Data collected included patient demographics and administration of TXA. Outcomes measured included VTE rates and flap complications in TXA and non-TXA cohorts. RESULTS: From 2003 to 2012, 173 extremity flap procedures were performed (100 pedicle, 73 free flaps). TXA was used in 11% of all patients reviewed. The overall VTE rate was 23.7%; however, there were no documented VTEs in patients who received TXA. Total flap complications, 26% versus 21%, or flap failure, 5% versus 4%, (p=0.571 and 0.564, respectively) did not differ significantly between those that received TXA versus those that did not. CONCLUSION: Given the increasing use of TXA in the combat casualties, concern over its impact on VTE rates and flap complications is of interest. However, in this early review, we did not find significant differences in patients who received TXA and those that did not. Further research is indicated to better determine the significance and the effect of TXA on complex limb salvages.

Risk factors for urinary retention after laparoscopic inguinal hernia repairs.

BACKGROUND: Postoperative urinary retention (POUR) is a common entity following surgery, particularly after laparoscopic inguinal hernia repair. Here the intent is to investigate the incidence of POUR in all comers at a single institution following laparoscopic inguinal hernia repair. METHODS: A retrospective chart review of all patients who underwent laparoscopic hernia repair at our institution from January 2010 through December 2013 was performed. POUR was defined as the inability to spontaneously urinate following surgery, requiring straight catheterization or placement of a Foley catheter. Perioperative data including narcotic use, operative time, type of mesh, and intraoperative fluid use were also recorded for each patient. RESULTS: A total of 346 patients underwent laparoscopic inguinal hernia repair in the specified time period, 340 patients were included in this study. The incidence of POUR after laparoscopic inguinal hernia repair at our institution was 8.2 % (n = 28) with the most common presentation of POUR being failure to void (n = 23). Postoperative narcotic use of 6.5 mg or greater of morphine or morphine equivalent was associated with higher risk of POUR via ROC analysis (OR 2.5, 95 % CI 1.2-5.6, p = 0.025). In univariate analysis, age greater than 50 years was also a risk factor for developing POUR (OR 2.8, 95 % CI 1.2-6.4, p = 0.02). Factors not found to be significant included intraoperative IV fluids, history of BPH, unilateral versus bilateral repair, and preoperative void time in relation to surgery start. CONCLUSIONS: Minimizing postoperative narcotic medications may reduce the risk of developing POUR after laparoscopic inguinal hernia repairs. If possible surgeons should consider non-steroidal anti-inflammatory drugs, acetaminophen, or regional anesthetic blocks to minimize postoperative narcotic requirements.

Flap coverage outcomes following vascular injury and repair: chronicling a decade of severe war-related extremity trauma.

BACKGROUND: Combat-related extremity injuries frequently require vascular repair within the combat theater before undergoing definitive reconstruction. This study examines the outcomes of early vascular repair with secondary soft-tissue extremity reconstruction over the past decade of war trauma. METHODS: War-related extremity injuries necessitating a downrange vascular procedure followed by a definitive limb reconstruction were reviewed. Patient demographics, type and location of vascular injuries, vascular intervention, and soft-tissue reconstruction procedures were examined. Outcomes of vascular repair, tissue transfer, and limb salvage were analyzed. RESULTS: From 2003 to 2012, 79 extremities in 78 patients had a vascular injury requiring in-theater intervention followed by 87 staged flap reconstructions performed distal to the vascular repair. Of the 74 arterial injuries requiring intervention, 27 were proximally located, with 73 percent requiring bypass. The early primary patency rate was 66 percent and the early primary-assisted patency rate was 93 percent for proximal artery repair procedures. The flap complication rate was 31 percent. Overall complications were examined by subtype and were not significantly different compared with flaps performed without a proximal vascular injury in the same limb. The flap success rate (93 percent) and the limb salvage rate (81 percent) were similar to the comparison cohort. CONCLUSIONS: This represents one of the largest series of traumatic extremity injuries requiring secondary limb reconstruction with tissue transfer following a vascular intervention. The authors identified no significant difference in outcomes related to flap coverage or limb salvage for patients with or without vascular injuries. Reconstructive options in combat extremity trauma are not limited by proximal vascular injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A decade of conflict: flap coverage options and outcomes in traumatic war-related extremity reconstruction.

BACKGROUND: War trauma patients who have sustained extremity trauma often exhibit extensive zones of injury with multiple concomitant injuries that can contribute to limited coverage options. Thus, flap availability and choice can become critical in the reconstruction algorithm of these severely traumatized patients. The authors' purpose was to analyze the outcomes of muscle and fasciocutaneous flaps during their extremity reconstructive experience to determine which option had better flap and limb salvage outcomes. METHODS: A retrospective review of servicemembers treated with flap-based limb salvage from 2003 through 2012 at the National Capital Consortium was completed. Patients were divided into cohorts of patients who underwent muscle or fasciocutaneous flaps. RESULTS: Three hundred fifty-nine flap procedures were performed. Of these procedures, 197 were muscle (55 percent) and 152 were fasciocutaneous flaps (42 percent). There was no difference in overall flap complications between groups (30 percent versus 26 percent; p = 0.475). However, there was a significantly higher flap failure rate in the muscle compared with the fasciocutaneous group (13 percent versus 6 percent; p = 0.030). Although there were more overall extremity complications in the muscle group (59 percent versus 47 percent; p = 0.030), there were no significant differences in soft-tissue infection, osteomyelitis, or amputation rates. CONCLUSIONS: There are many flap options that provide adequate coverage in extremity salvage. Complication rates did not differ significantly between muscle and fasciocutaneous flaps, with one exception--flap failure rates were significantly higher in our muscle-based flap cohort of patients. Nonetheless, each of these flap types has utility in our patients based on individual wounding patterns, flap availability for reconstruction, and rehabilitation goals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Hyperacute adrenal insufficiency after hemorrhagic shock exists and is associated with poor outcomes.

BACKGROUND: Adrenal insufficiency (AI) has been extensively described in sepsis but not in acute hemorrhage. We sought to determine the incidence of hyperacute AI (HAI) immediately after hemorrhage and its association with mortality. METHODS: Patients with acute traumatic hemorrhagic shock presenting to the R Adams Cowley Shock Trauma Center prospectively had serum cortisol levels collected on admission. Inclusion criteria were hypotension and active hemorrhage. Clinicians were blinded to results, and no patient received steroids in the acute phase. The primary outcome measure was death from hemorrhage within 24 hours of admission. RESULTS: Fifty-nine patients were enrolled during an 8-month period. Mean admission cortisol level was 18.3 ± 8.9 µg/dL. Acute mortality rate from hemorrhage was 27%. Overall mortality rate was 37%. Severe HAI (serum cortisol level <10 µg/dL) was present in 10 patients (17%). Relative HAI (<25 µg/dL) was present in 51 patients (86%). Those who died of acute hemorrhage had significantly lower mean cortisol levels (11.4 ± 6.2 µg/dL vs. 20.9 ± 8.4 µg/dL, p < 0.001) as did patients who ultimately died in the hospital (12.8 ± 7.6 µg/dL vs. 21.6 ± 8.1 µg/dL, p < 0.001). In multivariate analysis, cortisol levels were associated with mortality from acute hemorrhage, with an odds ratio of 1.17 (95% confidence interval, 1.02-1.35). Adjusted receiver operating characteristic analysis indicated that serum cortisol has a 91% accuracy in differentiating survivors of acute hemorrhage from nonsurvivors. CONCLUSION: This study is the first to report that AI occurs immediately after acute injury during hemorrhagic shock and is strongly associated with mortality. HAI may be a marker of depth of shock but is potentially rapidly modifiable as opposed to other markers, such as lactate or base deficit. Further work is needed to determine whether steroid administration can change outcome in selected patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Pulmonary artery and vein pseudoaneurysm after gunshot wound to the chest.

Traumatic pulmonary artery or vein pseudoaneurysms are extremely rare and angiographic management is gaining grounds. These pseudoaneurysms are caused by both penetrating and blunt chest trauma. We presents a unique case of coexisted pulmonary vein and artery pseudoaneurysm due to penetrating chest trauma managed by angioembolization and inferior vena cava filter insertion for concomitant deep vein thrombosis (DVT) due to contraindication to anticoagulation. The present case represents only the second case of coexisted pulmonary vein and artery pseudoaneurysm and the first with associated DVT making management decision complicated.