Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer.

INTRODUCTION: Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI). METHODS: This was a secondary analysis of a multicenter, case-control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts. RESULTS: A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53). CONCLUSION: For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary. STUDY TYPE: Original article, case series. LEVEL OF EVIDENCE: III.

Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications.

BACKGROUND: The Brain Injury Guidelines provide an algorithm fortreating patients with traumatic brain injury (TBI) and intracranial hemorrhage(ICH) that does not mandate hospital admission, repeat head CT, orneurosurgical consult for all patients. The purposes of this study are toreview the guidelines' safety, to assess resource utilization, and to proposeguideline modifications that improve patient safety and widespreadreproducibility. METHODS: A multi-institutional review of TBI patients was conducted. Patients with ICH on CT were classified as BIG 1, 2, or 3 based on the guidelines. BIG 3 patients were excluded. Variables collected included demographics, Injury Severity Score (ISS), hospital length of stay (LOS), intensive care unit LOS, number of head CTs, type of injury, progression of injury, and neurosurgical interventions performed. RESULTS: 269 patients met inclusion criteria. 98 were classifiedas BIG 1 and 171 as BIG 2. The median length of stay (LOS) was 2 (2,4)days and the ICU LOS was 1 (0,2) days. Most patients had a neurosurgeryconsultation (95.9%) and all patients included had a repeat head CT. 370repeat head CT scans were performed, representing 1.38 repeat scans perpatient. 11.2% of BIG 1 and 11.1% of BIG 2 patients demonstratedworsening on repeat head CT. Patients who progressed exhibited a higherISS (14 vs. 10, p=0.040), and had a longer length of stay (4 vs. 2 days;p=0.015). After adjusting for other variables, the presence of epiduralhematoma (EDH) and intraparenchymal hematoma were independent predictors ofprogression. Two BIG 2 patients with EDH had clinical deteriorationrequiring intervention. DISCUSSION: The Brain Injury Guidelines may improve resourceallocation if utilized, but alterations are required to ensure patientsafety. The modified Brain Injury Guidelines refine the originalguidelines to enhance reproducibility and patient safety while continuing toprovide improved resource utilization in TBI management.

Trends in hematologic markers after blunt splenic trauma: Risk factor or Epiphenomenon?

BACKGROUND: Most blunt splenic injuries (BSI) are treated with nonoperative management (NOM) or embolization (EMBO). Little is known about the hematologic changes associated with these treatments. We aim to assess the temporal changes of hematologic markers in trauma patients who undergo splenectomy (SPL), packing and splenorrhaphy (P/S), EMBO, or NOM. We hypothesize that differences in trends of hematologic markers exist in patients undergoing EMBO or SPL, compared to NOM. METHODS: An 8-year review of adult patients with BSI and underwent SPL, EMBO, P/S, or NOM. White blood cell count (WBC), hematocrit (HCT) and platelet count (PLT) at presentation to 14 days post-admission were analyzed; post-procedural complications were reviewed. Temporal trends were compared using linear mixed-effects models. RESULTS: 478 patients sustained BSI, 298 (62.3%) underwent NOM, 100 (29.2%) SPL, 42 (8.8%) EMBO, and 38 (8.0%) P/S. After adjustment for age, ISS and splenic injury grade, SPL patients had a significantly higher upward trend compared to other management strategies (p < 0.05). Infection further increased this trend. Starting on day 6, SPL patients with infections had significantly higher WBC than those without infection. SPL and P/S were more likely than NOM to develop infections after adjustment for confounders (HR = 3.64; 95%CI: 1.79-7.39 and HR = 2.59; 95%CI: 1.21-5.55, respectively). Day 6 WBC>16,000 cells/ml post-SPL had a positive predictive value (PPV) of 65.2% and negative predictive value (NPV) of 76.9% for infections. Among P/S, Day 6 WBC >10,200 cells/ml had a PPV = 50% and NPV = 86.7% for infections. CONCLUSIONS: We observed distinct patterns of hematologic markers following BSI managed with SPL, EMBO, P/S, and NOM. Day 6 WBC increases after SPL or P/S should raise suspicion of infections and trigger a diagnostic investigation.

Evaluation of a water-soluble contrast protocol for small bowel obstruction: A southwestern surgical congress multicenter trial.

Differentiation between SBO that will resolve with supportive measures and those requiring surgery remains challenging. WSC administration may be diagnostic and therapeutic. The purpose of this study was to evaluate use of a SBO protocol using WSC challenge. A protocol was implemented at five tertiary care centers. Demographics, prior surgical history, time to operation, complications, and LOS were analyzed. 283 patients were admitted with SBO; 13% underwent immediate laparotomy; these patients had a median LOS of 7.5 days. The remaining 245 were candidates for WSC challenge. Of those, 80% received contrast. 139 (71%) had contrast passage to the colon. LOS in these patients was 4 days. Sixty-five patients (29%) failed contrast passage within 24 h and underwent surgery. LOS was 9 days. 8% of patients in whom contrast passage was observed at 24 h nevertheless subsequently underwent surgery. 4% of patients who failed WSC challenge did not proceed to surgery. Our multicenter trial revealed that implementation of a WSC protocol may facilitate early recognition of partial from complete obstruction.

Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study.

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

Obstruction reduction: Use of water-soluble contrast challenge to differentiate between partial and complete small bowel obstruction.

Differentiating SBO that will resolve conservatively from those requiring surgery remains challenging. Water-soluble contrast administration may be diagnostic and therapeutic. Our study evaluated use of a WSC challenge protocol. We hypothesize that protocol use discriminates between surgical SBO and obstructions which can be managed non-operatively. Demographics, prior surgeries, time to operation, complications, and LOS were analyzed. 108 patients were admitted with SBO. 13% underwent immediate laparotomy with concern for bowel compromise; these had a median LOS of 8.5 days. 91 received WSC protocol. Of these, 77% had contrast passage to the colon. Of the 48 in whom contrast passed between 0 and 12 h, LOS was 2 days. Of the 22 patients in whom contrast passed between 12 and 24 h, LOS was 4.5 days. 21 had failure of contrast passage; 18 of those underwent surgery after 24 h as a result. Of the 21 patients who failed WSC challenge, median LOS was 8 days. WSC protocol implementation facilitates early recognition of partial from complete obstruction and may decrease LOS. Our findings warrant further evaluation with a multicenter trial.

Size matters: Computed tomographic measurements of the appendix in emergency department scans.

BACKGROUND: Radiologists use a size cutoff in appendiceal diameter to assist surgeons in diagnosing appendicitis, however, no consensus exists as to the size of a normal adult appendix. We aim to evaluate radial appendiceal diameter on CT in adult patients both with and without appendicitis. METHODS: Retrospective review of adults who underwent abdominal CT was performed. Variables collected include: demographics, BMI, WBC count at presentation, radial diameter of appendix (mm), presence of fat stranding, fecalith, and free fluid. RESULTS: During the study period, 3099 patients underwent CT. The appendix was visualized on 74% of scans. Mean appendiceal diameter was 6.6 mm (±1.7). The appendix was larger in patients with appendicitis (6.6 vs. 11.4; p < 0.0001). Overall appendectomy incidence was 3.2%. Sensitivity and specificity of CT in diagnosing appendicitis in this cohort of patients were 90% and 94%. NPV was 99.5%. CONCLUSION: While appendiceal diameter was larger in patients with appendicitis, >20% of patients without appendicitis had an appendiceal diameter >7 mm. Diameter alone should not be relied upon to diagnose appendicitis.

Long-Term Effects of Decompressive Craniectomy on Functional Outcomes after Traumatic Brain Injury: A Multicenter Study.

Decompressive craniectomy (DC) is a surgical modality sometimes used in the management of elevated intracranial pressure. Questions remain as to its long-term benefits in traumatic brain injury patients. The extended Glasgow Outcome Scale (eGOS) is a scoring system based on a structured interview that allows for consistent and reproducible measurement of long-term functional outcomes. The purpose of this study was to determine the eGOS score of postcraniectomy patients after discharge and stratify survivors based on outcome. A multicenter review of patients who underwent DC was performed. Survivors underwent a phone survey at which time the eGOS was calculated. Patients with an eGOS ≥ 5 were considered to have a good functional outcome. Fifty-four patients underwent DC. Age (OR 1.038; confidence interval 1.003-1.074) and Glasgow Coma Scale (OR 0677; confidence interval 0.527-0.870) were predictors of mortality. Patients who were available for follow-up (n = 13) had poor functional outcomes at discharge (eGOS = 3); however, this improved at the time of follow-up survey (eGOS = 5; P = 0.005). DC is a controversial operation with high mortality and uncertain benefit. Among our cohort, the eGOS score was significantly higher at follow-up survey than it was at discharge. Although the mortality was high, if patients survived to discharge, most had a good functional outcome at follow-up survey.

A double-blind, randomized controlled trial of gabapentin vs. placebo for acute pain management in critically ill patients with rib fractures.

INTRODUCTION: Achieving adequate pain control for rib fractures remains challenging; prescription of alternatives to narcotics is imperative to curtail the current opioid epidemic. Although gabapentin has shown promise following elective thoracic procedures, its efficacy in patients with rib fractures remains unstudied. We hypothesized that gabapentin, as compared to placebo, would both improve acute pain control and decrease narcotic use among critically ill patients with rib fractures. MATERIALS AND METHODS: Adult patients admitted to the trauma surgery service from November 2016 - November 2017 at an urban, Level I trauma center with one or more rib fractures were randomized to either gabapentin 300 mg thrice daily or placebo for one month following their injury. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings during the index admission, as well as and one-month quality of life survey data were abstracted. RESULTS: Forty patients were randomized. The groups were well matched with respect to age, gender, prior narcotic use, tobacco use, and prior respiratory disease. Although the median RibScore did not differ between groups, the gabapentin group had a higher median number of ribs fractured as compared to the placebo group (7 vs. 5, respectively). Degree of pulmonary contusion and injury severity score were similar between groups. Use of loco-regional anesthetic modalities did not differ between groups. Daily numeric pain scores, opioid consumption, oxygen requirement, respiratory rate, and incentive spirometry recordings were similar between both groups. No benefit was observed when adding gabapentin to a multi-modal analgesic regimen for rib fractures. There were no instances of pneumonia, respiratory failure, or mortality in either group. Hospital and intensive care unit length of stay were similar between groups. Both overall and chest-specific quality of life was equivalent between groups at one month follow-up. CONCLUSIONS: In this group of critically ill patients with rib fractures, gabapentin did not improve acute outcomes for up to one month of treatment.

Survival after emergency department thoracotomy in the pediatric trauma population: a review of published data.

BACKGROUND/PURPOSE: The utility of EDT in the adult trauma population, using well-defined guidelines, is well established, especially for penetrating injuries. Since the introduction of these guidelines, reports on the use of EDT for pediatric trauma have been published, and these series reveal a dismal, almost universally fatal, outcome for EDT following blunt trauma in the child. This report reviews the clinical outcomes of EDT in the pediatric population. MATERIALS/METHODS: We performed a review of EDT in the pediatric population using the published data from 1980 to 2017. Variables extracted included mechanism of injury and mortality. To minimize bias, single case reports were not included in the review. RESULTS: Upon review of four decades of published literature on the use of emergency department thoracotomy (EDT) in the pediatric population, mortality rates are comparable between adults and pediatric patients for penetrating thoracic trauma. In contrast, in pediatric patients sustaining blunt trauma, no patient under the age of 15 has survived. CONCLUSION: In patients between 0 and 14 years of age presenting with no signs of life following blunt trauma, withholding EDT should be considered. Patients between the ages of 15 and 18 should be treated in accordance with adult ATLS principles for the management of thoracic trauma. LEVEL OF EVIDENCE: Level IV.

Aerial drone misadventure: A novel case of trauma resulting in ocular globe rupture.

PURPOSE: The purpose of this case report is to present the novel findings of a drone causing such a traumatic ocular injury and provide recommendations for how it might be prevented. OBSERVATIONS: We report on a recent case where a child presented to our Emergency Department after incurring a blow to the face by the propeller of a remote controlled drone. The patient suffered significant trauma including rupture of the right globe. CONCLUSIONS: As drone sales continue to rise, it is important that physicians be prepared to treat the potential injuries that may result from using these devices. Furthermore, in an attempt to reduce the number of visits associated with remote controlled drones, physicians should be prepared to provide advice as to how patients can reduce the risks of injury. IMPORTANCE: We hope that the framework and recommendations below will help physicians decrease adverse outcomes related to this unusual injury pattern.

Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures.

BACKGROUND: Open pelvic fractures are life-threatening injuries. Preperitoneal pelvic packing (PPP) has been suggested to be ineffective for hemorrhage control in open pelvic fractures. We hypothesize that PPP is effective at hemorrhage control in patients with open pelvic fractures and reduces mortality. METHODS: Patients undergoing PPP from 2005 to 2015 were analyzed. Patients with open pelvic fractures were defined as direct communication of the bony injury with overlying soft tissue, vagina, or rectum. RESULTS: During the 10-year study, 126 patients underwent PPP; 14 (11%) sustained an open pelvic fracture. After PPP, 1 patient (7%) underwent angioembolization with a documented arterial blush. PPP controlled pelvic hemorrhage in all patients. Overall mortality rate was 7% with one death due to traumatic brain injury. CONCLUSIONS: PPP is effective for hemorrhage control in patients with open pelvic fractures. PPP should be used in a standard protocol for hemodynamically unstable patients with pelvic fractures regardless of associated perineal injuries.

Post-operative delirium is associated with increased 5-year mortality.

BACKGROUND: Post-operative delirium is associated with increased short term morbidity and mortality. Limited data exists on long term outcomes for older adults with postoperative delirium. We hypothesize that postoperative delirium is associated with increased 5-year mortality. METHODS: Patients ≥50 years undergoing elective operations with planned intensive care unit (ICU) admissions were prospectively enrolled. The Confusion Assessment Method ICU (CAM-ICU) was used to diagnose delirium. The primary outcome variable was 5-year mortality. RESULTS: 172 patients were enrolled with an average age of 64 years. The overall incidence of delirium was 44% (75/172). At 5-years post-operatively, mortality was higher (59%, 41/70) in patients with delirium compared to patients without delirium (13%, 12/94, p < 0.001). These results remained true after multivariable risk adjustment, showing the odds of five year mortality following delirium were 7.35 fold greater (95% CI: 1.49-36.18). CONCLUSIONS: Postoperative delirium is associated with increased long term mortality.