Trauma and Acute Care Surgery

Patients with Acute Cholecystitis Should be Admitted to a Surgical Service Background In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis. Methods Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. 190 lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay, time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost. Results Patients admitted to surgical (n=106) versus medical (n=84) service had shorter mean LOS (1.4 vs 2.6 days), shorter time from admission to surgery (0.4 vs 0.8 days), and shorter time from surgery to discharge (0.8 vs 1.1 days). Surgical service patients had fewer CT (38% vs 56%) and MRI (5% vs 16%) studies. Cholangiography (30 vs 25%) and ERCP (3 vs 8%) rates were similar. Surgical service patients had 39% lower median total costs ($7787 vs $12572). Conclusions Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs. This is a retrospective comparative study without negative criterion and thus Level III evidence. The study type is "Therapeutic/Care Management." Presented at the 88th Annual Meeting of the Pacific Coast Surgical Association, February 17-20, 2017 in Indian Wells, California Ning Lu, Present address: Ryder Trauma Center, Jackson Memorial Hospital, 1800 NW 10th Ave, Miami, FL, 33136 USA Walter L. Biffl, Present address: Scripps Memorial Hospital La Jolla, 9888 Genesee Ave., La Jolla, CA, 92037, USA No conflicts of interest. Funding: There are no sources of funding. Correspondence: Walter L. Biffl, MD, 9888 Genesee Ave., MC LJ601, La Jolla, CA 92037, 858-626-6362, 858-626-6354, Biffl.walter@scrippshealth.org © 2019 Lippincott Williams & Wilkins, Inc.

Evaluation and Management of Abdominal Gunshot Wounds: A Western Trauma Association Critical Decisions Algorithm No abstract available

Predisposed to Failure? The Challenge of Rescue in the Medical Intensive Care Unit Background Medical Intensive Care Unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases. Methods All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality. Results Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p<0.05). Damage control procedures were performed in 64 patients (34%), with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (OR 13.07, 95%CI 2.86,59.79). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (OR 5.13, 95%CI 1.11,23.77). Conclusions Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk. Level of Evidence Level III Prognostic and Epidemiological Name / Address for Correspondence: Alexandra Briggs, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. Tel: 603.650.8050. Fax: 603.650.8030 Presentation: Oral Presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma, September, 2018 in San Diego, California Disclosures: The authors have no conflicts of interest. © 2019 Lippincott Williams & Wilkins, Inc.

Financial Toxicity Is Associated With Worse Physical and Emotional Long-term Outcomes After Traumatic Injury Background Increasing healthcare costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health related quality of life outcomes (HRQOL). The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQOL. Methods Adult patients with an injury severity score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1, 2, 4 and 12 months. Screens for depression and post-traumatic stress syndrome (PTSD) were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time. Results 500 patients were enrolled and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80-85%). Factors independently associated with financial toxicity were lower age (OR 0.96 [0.94-0.98]), and lack of health insurance (OR 0.28 [0.14-0.56]) and larger household size (OR 1.37 [1.06-1.77]). After risk adjustment, patients with financial toxicity had worse HRQOL, and more depression and PTSD in a step-wise fashion based on severity of financial toxicity. Conclusions Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified and interventions to counteract the negative effects should be developed to improve long-term outcomes. Level of Evidence Prognostic/epidemiologic study, level III Corresponding author: Ben L. Zarzaur, MD, MPH, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. zarzaur@surgery.wisc.edu. (608)-265-9574 Funding Sources: Research reported in this publication was supported by the National Institute of General Medical Science of the National Institutes of Health under award number K23GM084427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Conference: Earl G. Young Resident Prize for Clinical Research Competition at the 49th Annual Meeting of the Western Trauma Association, March 03-08, 2019 in Snowmass, Colorado Conflicts of Interest and Source of Funding: None declared © 2019 Lippincott Williams & Wilkins, Inc.

Abdominal pain in an adult with congenital biliary atresia No abstract available

Obesity is Associated with Postinjury Hypercoagulability Background Obesity is linked to hypercoagulability with an increased risk of venous thromboembolic events (VTE) in the uninjured population. Therefore, we hypothesize that obesity (Body Mass Index (BMI) ≥30 kg/m2) is associated with a hypercoagulable state postinjury characterized by increased clot strength and resistance to fibrinolysis. Methods Our prospective Trauma Activation Protocol database includes all trauma activations patients for whom a rapid thrombelastography (TEG) is obtained within 60 minutes postinjury prior to any transfusions. The dataset was then stratified by BMI and subjects with BMI ≥ 30 kg/m2 were compared to those with BMI<30 kg/m2). The following TEG measurements were obtained: activated clotting time (ACT), clot formation rate (angle), maximum clot strength (MA), and % clot lysis 30 min after MA (LY30, %). Fibrinolysis shutdown (SD) was defined as LY30 < 0.6% and hyperfibrinolysis (HF) as LY30 > 7.6%. Continuous variables are expressed as median (IQR). Results Overall, 687 patients were included of whom 161 (23%) had BMI ≥ 30kg/m2 (BMI30). The BMI30 group was older, had a lower proportion of males and of blunt trauma, and were less severely injured. After adjustment for confounders, BMI30 was independently associated with lower odds of MA<55mm (OR 0.28; 95% CI 0.130.60) and of HF (OR 0.31; 95% CI 0.10- 0.97) and higher odds of SD (OR 1.82; 95% CI 1.09-3.05). No independent association was observed with angle<650 (OR 0.57 95% CI 0.30-1.05). While VTEs were more frequent among BMI30 patients (5.0 vs 3.3%), this did not reach significance after confounding adjustment (p=0.11). Conclusion Obesity was protective against diminished clot strength and hyperfibrinolysis, and obesity was associated with an increased risk of fibrinolytic shutdown in severely injured patients. These findings suggest a relative hypercoagulability. Although no difference in VTEs was noted in this study, these findings may explain the higher rate of VTEs reported in other studies. Level of Evidence Level III, retrospective cohort study, prognostic Financial Disclosures: The authors appreciate research support from Haemonetics with shared intellectual property. Presentation history: portions of this manuscript will be presented at the 20th European Congress of Trauma and Emergency Surgery in Prague, Czech Republic, May 7th – 9th Ernest E. Moore MD Member of Western Trauma Association Acknowledgments: Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health (T32 GM008315 and P50 GM049222), The National Heart, Lung, and Blood Institute (UM 1HL 120877) and the Department of Defense (USAMRAA, W81XWH-12-2-0028). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (or other sponsors of the project). Corresponding Author: Angela Sauaia MD, PhD – Address: 13001 E. 17th Place, B119 Bldg 500, E3309 Aurora, CO 80045 Phone: (303) 724-2498, Email: angela.sauaia@ucdenver.edu © 2019 Lippincott Williams & Wilkins, Inc.

RE: Organ injury scaling 2018 update: Spleen, liver, and kidney. No abstract available

Development and validation of a clinical risk calculator for mortality after colectomy for fulminant Clostridium difficile colitis Background Clostridium difficile colitis is an increasingly important cause of morbidity and mortality. FCDC is a severe form of the colitis driven by a significant systemic inflammatory response, and managed with a total abdominal colectomy. Despite surgery, postoperative mortality rates remain high. The aim of this study was to develop a bedside calculator to predict the risk of 30-day postoperative mortality for patients with fulminant Clostridium difficile colitis (FCDC). Methods After Institutional Review Board approval, the ACS-NSQIP database (2005-2015) was used to include adult patients who underwent emergency surgery for FCDC. A priori preoperative predictors of mortality were selected from the literature: age, immunosuppression, preoperative shock, intubation, and laboratory values. The predictive accuracy of different logistic regression models was measured by calculating the area under the receiver-operating characteristic curve. A cohort of 124 patients from Québec was used to validate the developed mortality calculator. Results A total of 557 patients met the inclusion criteria and the overall mortality was 44%. After developing the calculator, no statistically significant differences were found in comparison with the ACS-NSQIP probability of mortality available in the database (AUC 75.61 vs. 75.14, p 0.79). External validation with the cohort of patients from Quebec showed an area under the curve of 74.0% (95%CI 65.0-82.9). Conclusion A clinically applicable calculator using preoperative variables to predict post-operative mortality for patients with FCDC was developed and externally validated. This calculator may help guide preoperative decision-making. Level of Evidence Level III in prognostic and epidemiological study. Study type: Prognostic Corresponding author: Marylise Boutros, MD MSc, 3755 Cote Sainte Catherine Road, G-304, Montreal, Quebec, H3T 1E2, Canada. Tel: 514-340-8222 ex. 3141. Fax: 514-340-7560. mboutros@jgh.mcgill.ca Conflict of Interest: The authors have no conflicts of interest to disclose. Funding: Maria Abou Khalil is a Richard and Edith Strauss fellow for clinician scientists at McGill University and acknowledges this program for the continued support. Maria Abou Khalil has received a General Surgery grant from the American Society of Colon and Rectal Surgeons (2016) and thanks the society for their continued support. Disclaimers: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. Presentation information: Presented as a poster at the Annual Meeting of the American College of Surgeons, October 22-26, 2017 in San Diego, CA. © 2019 Lippincott Williams & Wilkins, Inc.

Optimizing Energy Expenditure and Oxygenation Toward Ventilator Tolerance is Associated with Lower Ventilator and ICU Days Introduction We hypothesize that if both energy expenditure and oxygenation are optimized (EEOO) towards ventilator tolerance; this would provide patients with the best condition to be liberated from the ventilator. We defined ventilator tolerance as having a RQ value between 0.7 and 1.0, while maintaining saturations above 98% with FiO2 70% or less and a normal respiratory rate without causing disturbances to the patient's pH. Methods This is a single institution prospective cohort study of ventilator dependent patients within a closed trauma ICU. The study period was over 52 months. A total of 1,090 patients were part of the primary analysis. The test group (EEOO) was compared to a historical cohort, comparing 26 months in each study group. The primary outcome of this study was number of ventilator days. Secondary outcomes included in-hospital mortality, ICU LOS, overall hospital length of stay, tracheostomy rates, reintubation rates, and in hospital complication rates such as pneumonia and ARDS. Both descriptive and multivariable regression analysis were performed to compare the effects of the EEOO protocol to our standard protocols alone. Results The primary outcome of number of ventilator days was significantly shorter the EEOO cohort by nearly 3 days. This was significant even after adjustment for age, gender, race, comorbidities, nutrition type, and injury severity, (4.3 vs. 7.2 days, pvalue 0.0001). The EEOO cohort also had significantly lower ICU days, hospital days, and overall complications rates. Conclusions Optimizing the patient's nutritional regimen to ventilator tolerance and optimizing oxygenation by means of targeted pulmonary mechanics and inspired FiO2 may be associated with lower ventilator and ICU days as well as overall complication rates. Level of Evidence IV, comparative study *None of the authors report any conflict of interest and this study was not funded. This was an oral presentation at the 32nd EAST Annual Scientific Assembly, January 15-19, 2019 in Austin, Texas. Correspondence: Darwin Ang @ Darwin.Ang@hcahealthcare.com or darwinang@gmail.com © 2019 Lippincott Williams & Wilkins, Inc.

Implementation of a Prehospital Air Medical Thawed Plasma Program: Is It Even Feasible? Introduction The PAMPer trial demonstrated a 30-day survival benefit among hypotensive trauma patients treated with prehospital plasma during air medical transport. We characterized resources, costs and feasibility of air medical prehospital plasma program implementation. Methods We performed a secondary analysis using data derived from the recent PAMPer trial. Intervention patients received thawed plasma (5-day shelf-life). Unused plasma units were recycled back to blood bank affiliates, when possible. Distribution method and capability of recycling varied across sites. We determined the status of plasma units deployed, utilized, wasted, and returned. We inventoried thawed plasma use and annualized costs for distribution and recovery. Results The PAMPer trial screened 7,275 patients and 5,103 plasma units were deployed across 22 air medical bases over a 42-month time period. Only 368 units (7.2%) of this total thawed plasma pool were provided to plasma randomized PAMPer patients. Of the total plasma pool, 3,716 (72.8%) units of plasma were returned to the blood bank with the potential for transfusion prior to expiration and 1,019 (20.0%) thawed plasma units were deemed wasted for this analysis. The estimated average annual cost of implementation of a thawed plasma program per air medical base at an average courier distance would be between $24,343 and $30,077 depending on the ability to recycle plasma and distance of courier delivery required. Conclusion A prehospital plasma program utilizing thawed plasma is resource intensive. Plasma waste can be minimized depending on trauma center and blood bank specific logistics. Implementation of a thawed plasma program can occur with financial cost. Products with a longer shelf-life such as liquid plasma or freeze-dried plasma may provide a more cost-effective prehospital product relative to thawed plasma. Study Type Secondary Analysis of Clinical Trial Level of evidence III This paper was presented as an oral presentation at the annual meeting of the Western Trauma Association, March 3th-9th, 2019; Snowmass, CO. This research was funded by the US Army Medical Research and Materiel Command, Fort Detrick, Maryland 21702, Grant Number W81XWH-12-2-0023. There are no conflicts of interest for the current study Correspondence and Reprints: Jason L. Sperry, MD, MPH, Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, Phone: (412) 802-8270, Fax: (412) 647-1448, email: sperryjl@upmc.edu © 2019 Lippincott Williams & Wilkins, Inc.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com