Subtotal Fenestrating Cholecystectomy: A Safe and Effective Approach to the Difficult Gallbladder.

INTRODUCTION: Subtotal laparoscopic cholecystectomy (SUB) is an alternative to total laparoscopic cholecystectomy (TOT) when the critical view of safety (CVS) cannot be achieved. Little is known about the clinical factors and postoperative outcomes associated with SUB. The objective was to determine predictive factors and outcomes of SUB as compared to TOT. METHODS: Clinical data from patients admitted from our emergency department to the acute care surgery service who underwent SUB or TOT by an acute care surgery surgeon for acute biliary disease (2017-2019) were reviewed. Wilcoxon rank-sum and Fisher's exact tests were used. RESULTS: 355 patients underwent cholecystectomy for acute cholecystitis; 28 were SUB (7.9%). SUB patients were more likely to be older (57 versus 43 y; P = 0.015), male (60.7% versus 39.3%; P < 0.001), have a history of cirrhosis or liver disease (14.3% versus 2.1%; P = 0.007), and have a higher Charlson-Comorbidity Index (1 versus 0, P = 0.041). SUB had greater leukocytosis (14.6 versus 10.9; P < 0.001), higher total bilirubin (0.9 versus 0.6; P = 0.021), and a higher Tokyo grade (2 versus 1; P < 0.001), and had operative findings including gallbladder decompression (82.1% versus 23.2%; P < 0.001) and inability to achieve the CVS (78.6% versus 3.4%; P < 0.001). SUB patients had an increased length of stay (4 versus 2 d; P < 0.001) and more 1-y readmissions. No major vascular injuries occurred in either group with one biliary injury in the TOT group. CONCLUSIONS: SUB patients present with more significant markers of biliary disease and have more complicated intraoperative and postoperative courses. However, the lack of biliary or vascular injuries suggests that SUB may represent a safe alternative when the CVS cannot be achieved.

Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma.

BACKGROUND: The kidney is the most frequently injured component of the genitourinary system, accounting for 5% of all trauma cases. Several guidelines by different societies address the management of urological trauma. However, unanswered questions remain regarding optimal use of angioembolization in hemodynamically stable patients, indications for operative exploration of stable retroperitoneal hematomas and renal salvage techniques in the setting of hemodynamic instability, and imaging practices for patients undergoing non-operative management. We performed a systematic review, meta-analysis, and developed evidence-based recommendations to answer these questions in both blunt and penetrating renal trauma. METHODS: The working group formulated four population, intervention, comparator, outcome (PICO) questions regarding the following topics: (1) angioembolization (AE) usage in hemodynamically stable patients with evidence of ongoing bleeding; (2) surgical approach to stable zone II hematomas (exploration vs. no exploration) in hemodynamically unstable patients and (3) surgical technique (nephrectomy vs. kidney preservation) for expanding zone II hematomas in hemodynamically unstable patients; (4) frequency of repeat imaging (routine or symptom based) in high-grade traumatic renal injuries. A systematic review and meta-analysis of currently available evidence was performed. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members and concurrence was obtained for each final recommendation. RESULTS: A total of 20 articles were identified and analyzed. Two prospective studies were encountered; the majority were retrospective, single-institution studies. Not all outcomes projected by PICO questions were reported in all studies. Meta-analysis was performed for all PICO questions except PICO 3 secondary to the discrepant patient populations included in those studies. PICO 1 had the greatest number of articles included in the meta-analysis with nine studies; yet, due to differences in study design, no critical outcomes emerged; similar differences among a smaller set of articles prevented observation of critical outcomes for PICO 4. Analyses of PICOs 2 and 3 favored a non-invasive or minimally invasive approach in-line with current international practice trends. CONCLUSION: In hemodynamically stable adult patients with clinical or radiographic evidence of ongoing bleeding, no recommendation could be made regarding the role of AE vs. observation. In hemodynamically unstable adult patients, we conditionally recommend no renal exploration vs. renal exploration in stable zone II hematomas. In hemodynamically unstable adult patients, we conditionally recommend kidney preserving techniques vs. nephrectomy in expanding zone II hematomas. No recommendation could be made for the optimal timing of repeat imaging in high grade renal injury. LEVEL OF EVIDENCE: Guideline; systematic review, level III.

Challenges in Predicting Discharge Disposition for Trauma and Emergency General Surgery Patients.

BACKGROUND: Changes in discharge disposition and delays in discharge negatively impact the patient and hospital system. Our objectives were1 to determine the accuracy with which trauma and emergency general surgery (TEGS) providers could predict the discharge disposition for patients and2 determine the factors associated with incorrect predictions. METHODS: Discharge dispositions and barriers to discharge for 200 TEGS patients were predicted individually by members of the multidisciplinary TEGS team within 24 h of patient admission. Univariate analyses and multivariable logistic least absolute shrinkage and selection operator regressions determined the associations between patient characteristics and correct predictions. RESULTS: A total of 1,498 predictions of discharge disposition were made by the multidisciplinary TEGS team for 200 TEGS patients. Providers correctly predicted 74% of discharge dispositions. Prediction accuracy was not associated with clinical experience or job title. Incorrect predictions were independently associated with older age (OR 0.98; P < 0.001), trauma admission as compared to emergency general surgery (OR 0.33; P < 0.001), higher Injury Severity Scores (OR 0.96; P < 0.001), longer lengths of stay (OR 0.90; P < 0.001), frailty (OR 0.43; P = 0.001), ICU admission (OR 0.54; P < 0.001), and higher Acute Physiology and Chronic Health Evaluation II scores (OR 0.94; P = 0.006). CONCLUSION: The TEGS team can accurately predict the majority of discharge dispositions. Patients with risk factors for unpredictable dispositions should be flagged to better allocate appropriate resources and more intensively plan their discharges.

Electronic Medical Record Versus Bedside Assessment: How to Evaluate Frailty in Trauma and Emergency General Surgery Patients?

BACKGROUND: Screening patients for frailty is traditionally done at the bedside. However, recent electronic medical record (EMR)-based, comorbidity-focused frailty assessments have been developed. Our objective was to determine how a common bedside frailty assessment, the trauma and emergency surgery (TEGS) frailty index (FI), compares to an EMR-based frailty assessment in predicting geriatric TEGS outcomes. MATERIALS AND METHODS: We retrospectively reviewed our quality improvement project database consisting of TEGS patients ≥ 65 y old. Patients were screened with the TEGS FI, a 15-question bedside assessment, including comorbidities, physical activity, emotional health, and nutrition. Six of 15 items were retrievable from the enterprise data warehouse (EDW), storing all EMR data from Northwestern Memorial Hospital, and use to calculate the EDW frailty score. Patient characteristics and outcomes were compared between different groups. RESULTS: Two hundred thirty-six geriatric TEGS patients were included, of which 75 (31.8%) were TEGS FI frail and 60 (25.4%) were EDW frail. TEGS FI frail patients had increased length of stay (LOS), loss of independence (LOI), and complications compared to TEGS FI nonfrail patients. EDW frail patients had higher LOS and complications than EDW nonfrail patients but similar LOI. TEGS FI and EDW frail patients had similar outcomes except TEGS FI-only patients more often have LOI. CONCLUSIONS: Bedside frailty assessments and EMR-based assessments are both effective in identifying geriatric TEGS patients at risk for increased LOS and complications. However, bedside frailty screening was better at identifying patients who have LOI and may be a more appropriate choice when screening for frailty.

Simulation-Based Course Improves Resident Comfort, Knowledge, and Ability to Manage Surgical Intensive Care Unit Patients.

BACKGROUND: Simulation-based education can augment residents' skills and knowledge. We assessed the effectiveness of a simulation-based course for surgery interns designed to improve their comfort, knowledge, and ability to manage common surgical critical care (SCC) conditions. MATERIALS AND METHODS: For 2 y, all first year residents (n = 31) in general surgery, urology, interventional radiology, and the integrated plastics, vascular, and cardiothoracic surgery training programs at our institution participated in a simulation-based course emphasizing evidence-based management of SCC conditions. Precourse and postcourse surveys and multiple-choice tests, as well as summative simulation tests, assessed interns' comfort, knowledge, and ability to manage SCC conditions. Changes in these measures were assessed with Wilcoxon matched-pairs signed rank tests. Factors associated with summative performance were determined by linear regression. RESULTS: The course consisted of four simulation-based teaching sessions in year 1 and six in year 2. The course taught seven of the 18 core SCC conditions in the Surgical Council on Resident Education general surgery curriculum in year 1 and 10 in year 2. Interns' self-reported comfort, knowledge, and ability to manage each condition taught in the course increased (P < 0.02). Their knowledge of each condition, as assessed by written tests, also increased (P < 0.02). Their summative simulation test performance correlated with the number of course sessions attended (P < 0.03) and status as general surgery residents (P < 0.01). CONCLUSIONS: A simulation-based SCC training course for surgery interns that emphasizes evidence-based management of SCC conditions improves interns' comfort, knowledge, and ability to manage these conditions.

Impact and treatment success of new-onset atrial fibrillation with rapid ventricular rate development in the surgical intensive care unit.

BACKGROUND: Atrial fibrillation (AF) with rapid ventricular rate (RVR; heart rate >100) in noncardiac postoperative surgical patients is associated with poor outcomes. The objective of this study was to evaluate the practice patterns of AF management in a surgical intensive care unit to determine practices associated with rate and rhythm control and additional outcomes. MATERIALS AND METHODS: Adult patients (≥18 y) admitted to the surgical intensive care unit (SICU) from June 2014 to June 2015 were retrospectively screened for the development of new-onset AF with RVR. Demographics, hospital course, evaluation and treatment of AF with RVR, and outcome were evaluated and analyzed. RESULTS: Thousand seventy patients were admitted to the SICU during the study period; 33 met inclusion criteria (3.1%). Twenty-six patients (79%) had rate and rhythm control within 48 h of AF with RVR onset. ß-Blockers were the most commonly used initial medication (67%) but were successful at rate and rhythm control in only 27% of patients (6/22). Amiodarone had the highest rate of success if used initially (5/6, 83%) and secondarily (11/13, 85%). Failure to control rate and rhythm was associated with a greater likelihood of comorbidities (100% versus 57%; P = 0.06). CONCLUSIONS: New-onset AF with RVR in the noncardiac postoperative patient is associated with a high mortality (21%). Amiodarone is the most effective treatment for rate and rhythm control. Failure to establish rate and rhythm control was associated with cardiac comorbidities. These results will help to form future algorithms for the treatment of AF with RVR in the SICU.

Outcome of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) ECMO.

OBJECTIVE: To examine the outcomes of prolonged (≥14 days) extracorporeal membrane oxygenation (P-ECMO) for adult severe respiratory failure and to assess characteristics associated with survival. BACKGROUND: The use of ECMO for treatment of severe respiratory adult patients is associated with overall survival rates of 50% to 70% with median ECMO duration of 10 days. No prior multi-institutional studies have examined outcomes of P-ECMO for severe respiratory failure. METHODS: Data on all adult (≥18 years) patients who required P-ECMO for severe respiratory failure from 1989 to 2013 were extracted from the Extracorporeal Life Support Organization international multi-institutional registry. We examined outcomes over 23 years and compared the 2 more recent time periods of 1989 to 2006 versus 2007 to 2013. RESULTS: Up to 974 patients, mean age 40.2 (18-83) years, had ECMO duration of mean 25.2 days/median 21.0 days (range: 14-208 days). Venovenous ECMO support was most common (venovenous: 79.5%, venoarterial: 9.9%). Reason for ECMO discontinuation included native lung recovery (54%), organ failure (23.7%), family request (6.7%), hemorrhage (2.7%), and diagnosis incompatible with life (5.6%). Forty patients (4.1%) underwent lung transplant with 50% postoperative in-hospital mortality. Increased prevalence of P-ECMO was noted with 72% (701/974) of all cases reported since 2008. Survival to hospital discharge was 45.4% (443/974) and did not vary with ECMO duration. Multivariate logistic regression analysis confirmed that P-ECMO patients 2007 to 2013 had a lower risk of death [odds ratio (OR): 0.650; 95% confidence interval (CI), 0.454-0.929; P = 0.010] compared with 1989 to 2006. Factors independently associated with survival were younger age (OR: 0.983; 95% CI, 0.974-0.993; P < 0.001) and lower PaCO2 (OR, 0.991; 95% CI, 0.986-0.996; P < 0.001). CONCLUSIONS: Prolonged ECMO use for adult respiratory failure was associated with a lower (45.4%) hospital survival rate, compared with prior reported survival rates of short duration ECMO. Prolonged ECMO survival significantly increased in recent years, and increasing ECMO duration did not alter the survival fraction in the 1989 to 2013 study cohort. Although P-ECMO survival rates are less than short ECMO runs, P-ECMO support is justified.

How do we treat life-threatening anemia in a Jehovah's Witness patient?

The refusal of allogeneic human blood and blood products by Jehovah's Witness (JW) patients complicates the treatment of life-threatening anemia. For JW patients, when hemoglobin (Hb) levels decrease beyond traditional transfusion thresholds (<7 g/dL), alternative methods to allogeneic blood transfusion can be utilized to augment erythropoiesis and restore endogenous Hb levels. The use of erythropoietin-stimulating agents and intravenous iron has been shown to restore red blood cell and Hb levels in JW patients, although these effects may be significantly delayed. When JW patients have evidence of life-threatening anemia (Hb <5 g/dL), oxygen-carrying capacity can be supplemented with the administration of Hb-based oxygen carriers (HBOCs). Although HBOCs are not Food and Drug Administration (FDA) approved, they may be obtained and administered with FDA, institutional review board, and patient approval. We describe a protocol-based algorithm to the management of life-threatening anemia in JW patients and review time to anemia reversal and patient outcomes using this approach.

Optimal Management of Traumatic Abdominal Wall Hernias Remains Unclear.

High-energy, blunt force trauma to the abdomen results in an abdominal wall injury (AWI) in up to 9% of patients. In 1% of blunt abdominal trauma, they result in a traumatic abdominal wall hernia (TAWH). Optimal management of these injuries remains unclear. Because they are the result of a high-energy mechanism, concomitant serious abdominal organ injuries are common. This has prompted some to advocate that the presence of a TAWH on physical exam mandates exploratory laparotomy. However, delayed repairs have better outcomes and nontherapeutic celiotomy should be avoided. Similarly debated is the expanding use of minimally invasive techniques and the use of mesh for hernia repairs. Overall, the presence of a TAWH is likely not an absolute indication for emergency surgery. Rather, it is an indicator of high-energy impact and associated with a high rate of visceral injury. These patients require a close observation for clinical decline and development of typical indicators for laparotomy.

Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee.

Background: Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation. Methods: We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified. Results: Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings. Conclusion: Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.

Prospective derivation and validation of a NECROtizing Soft tissue InfectionS (NECROSIS) score: An EAST multicenter trial.

BACKGROUND: Although several risk indices have been developed to aid in the diagnosis of NSTIs, these instruments suffer from varying levels of reproducibility and failure to incorporate key clinical variables in model development. The objective of this study was to derive and validate a clinical risk index score - NECROSIS - for identifying NSTIs in emergency general surgery (EGS) patients being evaluated for severe skin and soft tissue infections. METHODS: We performed a prospective study across 16 sites in the US of adult EGS patients with suspected NSTIs over a 30-month period. Variables analyzed included demographics, admission vitals and labs, physical exam, radiographic, and operative findings. The main outcome measure was the presence of NSTI diagnosed clinically at the time of surgery. Multivariate analysis was performed to identify independent predictors for the presence of NSTI using the Hosmer-Lemeshow test and the Akaike information criteria. RESULTS: Of 362 patients, 297 (82%) were diagnosed with a NSTI. Overall mortality was 12.3%. Multivariate analysis identified 3 independent predictors for NSTI: systolic blood pressure ≤ 120 mmHg, violaceous skin, and WBC ≥15 (x103/uL). Multivariate modelling demonstrated Hosmer-Lemeshow goodness of fit (p = 0.9) with a c-statistic for the prediction curve of 0.75. Test characteristics of the NECROSIS score were similar between the derivation and validation cohorts. CONCLUSION: NECROSIS is a simple and potentially useful clinical index score for identifying at-risk EGS patients with NSTIs. Future validation studies are warranted. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria, Level III.

Warfarin, not direct oral anticoagulants or antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: Implications in this new era of novel anticoagulants: An EAST multicenter study.

INTRODUCTION: This study aimed to assess perioperative bleeding complications and in-hospital mortality in patients requiring emergency general surgery presenting with a history of antiplatelet (AP) versus direct oral anticoagulant (DOAC) versus warfarin use. METHODS: A prospective observational study across 21 centers between 2019 and 2022 was conducted. Inclusion criteria were age 18 years or older, and DOAC, warfarin, or AP use within 24 hours of an emergency general surgery procedure. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using analysis of variance, χ 2 , and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, and 40 (9.7%) warfarin use. The most common indications for surgery were obstruction (23% [AP], 45% [DOAC], and 28% [warfarin]), intestinal ischemia (13%, 17%, and 23%), and diverticulitis/peptic ulcers (7%, 7%, and 15%). Compared with DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (odds ratio [OR], 4.4 [95% confidence interval (CI), 2.0-9.9]). There was no significant difference in perioperative bleeding complication between DOAC and AP use (OR, 0.7 [95% CI, 0.4-1.1]). Compared with DOAC use, there was no significant difference in mortality between warfarin use (OR, 0.7 [95% CI, 0.2-2.5]) or AP use (OR, 0.5 [95% CI, 0.2-1.2]). After adjusting for confounders, warfarin use (OR, 6.3 [95% CI, 2.8-13.9]), medical history, and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR, 1.3 [95% CI, 0.39-4.7]), whereas intraoperative vasopressor use (OR, 4.7 [95% CI, 1.7-12.8]), medical history, and postoperative bleeding (OR, 5.5 [95% CI, 2.4-12.8]) were. CONCLUSION: Despite ongoing concerns about the increase in DOAC use and lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease and comorbidities rather than type of AP or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

How does Injury Severity Score derived from International Classification of Diseases Programs for Injury Categorization using International Classification of Diseases, Tenth Revision, Clinical Modification codes perform compared with Injury Severity Score derived from Trauma Quality Improvement Program?

BACKGROUND: Injury Severity Score (ISS) is a measurement of injury severity based on the Abbreviated Injury Scale. Because of the difficulty and expense of Abbreviated Injury Scale coding, there have been recent efforts in mapping ISS from administrative International Classification of Diseases ( ICD ) codes instead. Specifically, the open source and freely available International Classification of Diseases Programs for Injury Categorization (ICDPIC) in R (Foundation for Statistical Computing, Vienna, Austria) converts International Classification of Diseases, Ninth Revision, codes to ISS. This study aims to compare ICDPIC calculations versus manually derived Trauma Quality Improvement Program (TQIP) calculations for International Classification of Diseases, Tenth Revision ( ICD-10 ), codes. Moderate concordance was chosen as the hypothetical relationship because of previous work by both Fleischman et al. ( J Trauma Nurs. 2017;24(1):4-14) who found moderate to substantial concordance between ICDPIC and ISS and Di Bartolomeo et al. ( Scand J Trauma Resusc Emerg Med. 2010;18(1):17) who found none to slight concordance. Given these very different findings, we thought it reasonable to predict moderate concordance with the use of more detailed ICD-10 codes. METHODS: This was an observational cohort study of 1,040,728 encounters in the TQIP registry for the year 2018. International Classification of Diseases Programs for Injury Categorization in R was used to derive ISS from the ICD-10 codes in the registry. The resulting scores were compared with the manually derived ISS in TQIP. RESULTS: The median difference between ISS calculated by ICDPIC-2021 using ICD-10, Clinical Modification (ISS-ICDPIC), and manually derived ISS was -3 (95% confidence interval, -5 to 0), while the mean difference was -2.09 (95% confidence interval, -2.10 to -2.07). There was substantial concordance between ISS-ICDPIC and manually derived ISS ( κ = 0.66). The ISS-ICDPIC was a better predictor of mortality (area under the curve, 0.853 vs. 0.836) but a worse predictor of intensive care unit admission (area under the curve, 0.741 vs. 0.757) and hospital stay ≥10 days (AUC, 0.701 vs. 0.743). The ICDPIC has substantial concordance with TQIP for the firearm ( κ = 0.69), motor vehicle trauma ( κ = 0.71), and pedestrian ( κ = 0.73) injury mechanisms. CONCLUSION: When TQIP data are unavailable, ICDPIC remains a valid way to calculate ISS after transition to ICD-10 codes. The ISS-ICDPIC performs well in predicting a number of outcomes of interest but is best served as a predictor of mortality. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study.

BACKGROUND: While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS: This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS: Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION: Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

A Multifaceted Extubation Protocol to Reduce Reintubation Rates in the Surgical ICU.

BACKGROUND: Reintubation is associated with significant morbidity and mortality. The reintubation rate in surgical ICUs (SICUs) is ∼10% nationally but was 17.0% in our SICU. The objective of this study was to determine if the reintubation rate could be reduced with a protocol for extubation assessment and post-extubation care consisting of standardized extubation criteria and targeted interventions for patients at high risk for reintubation. METHODS: Standardized extubation criteria for all SICU patients were identified via literature review and best-practice guidelines. High reintubation risk criteria were identified (age ≥ 65 years, chronic cardiopulmonary disease, ≥ 4 days intubated, emergency intubation, and fluid balance ≥ 5 liters) through a literature review and 13-month retrospective review of reintubations in our institution's SICU. Patients meeting at least one criterion putting them at higher risk for reintubation received interventions including post-extubation high-flow nasal cannula for 24 hours and algorithm-guided respiratory therapy. RESULTS: During the 12-month period following protocol implementation, 36 of 402 extubations resulted in reintubations (9.0% vs. 17.0% preintervention, p < 0.001). Among all extubations, 305 (75.9%) were identified as high risk. Among reintubated patients, 34 (94.4%) met high-risk criteria. The mortality rate for reintubated patients was 40.0%, compared to 3.3% in those not reintubated (p < 0.001). The high-risk screening tool had a negative predictive value of 98%. CONCLUSION: A multifaceted and pragmatic extubation and post-extubation care protocol significantly reduced one SICU's reintubation rate. This protocol can be easily implemented in any SICU to improve patient outcomes following extubation.

Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization. METHODS: A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated. RESULTS: Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity. CONCLUSION: We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level IV.

Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry).

PURPOSE: Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. RESULTS: In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). CONCLUSION: Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL. LEVEL OF EVIDENCE: 2B.

Dexmedetomidine and paralytic exposure after damage control laparotomy: risk factors for delirium? Results from the EAST SLEEP-TIME multicenter trial.

PURPOSE: To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients. METHODS: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression. RESULTS: A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively. CONCLUSIONS: Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study.

Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS: Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS: There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION: The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

Classifying transfusions related to the anemia of critical illness in burn patients.

BACKGROUND: Critically ill patients require transfusions because of acute blood loss and the anemia of critical illness. In critically ill burn patients, typically, no distinction is made between transfusions related to acute surgical blood loss and those related to the anemia of critical illness. We sought to identify the percentage of blood transfusions due to the anemia of critical illness and the clinical characteristics associated with these transfusions in severely burned patients. METHODS: Sixty adult patients with ≥20% total body surface area (TBSA) burn who were transfused at least 1 unit of packed red blood cells during their hospitalization were studied. Clinical variables including age, %TBSA burn, Acute Physiology and Chronic Health Evaluation (APACHE) II score, number of ventilator days, inhalation injury, and number of operative events were correlated with the total number of packed red blood cell units and percentage of nonsurgical transfusions in these patients. Nonsurgical transfusions were defined as transfusions occurring after postoperative day 1 for each distinct operative event and were classified as being caused by the anemia of critical illness. RESULTS: Patients were transfused an average of 16.6 units ± 21.2 units. Nonsurgical transfusions accounted for 52% of these transfusions. APACHE II score, %TBSA burn, number of ventilator days, and number of operative events, all correlated with total transfusions. However, nonsurgical transfusions correlated with only APACHE II score (p = 0.01) and number of ventilator days (p = 0.03). There was no correlation between nonsurgical transfusions and other clinical variables. CONCLUSION: The anemia of critical illness is responsible for >50% of all transfusions in severely burned patients. The initial severity of critical illness (APACHE II score) and duration of the critical illness (number of ventilator days) correlated with transfusions related to anemia of critical illness. Further investigation into the specific risk factors for these transfusions may help to develop strategies to further reduce transfusion rates.