Association Between Nil Per Os Status and Intubated Patients Undergoing Surgery.

INTRODUCTION: Patient outcomes heavily rely on nutritional support. However, holding enteric feeds prior to surgical operations in critically ill patients is still a common practice in intensive critical units. Our objective is to describe the relationship between duration of nil per os (NPO) and respiratory outcomes in intubated, critically ill patients requiring operative intervention. METHODS: We conducted a retrospective analysis on intubated, critically ill patients who underwent operative intervention between January 1, 2016, and December 31, 2018, to investigate how the duration of NPO status may affect respiratory outcomes. We compared adverse respiratory events among patients who maintain NPO ≥6 h (NPO group) versus those who were NPO <6 h (non-NPO group) prior to surgery. RESULTS: Two hundred patients met inclusion criteria: 104 for NPO and 96 for non-NPO. Aspiration event was found in 5.8% of NPO patients and 7.3% in non-NPO patients, P = 0.66. Desaturation event was found in 16.3% for NPO and 14.6% in non-NPO, P = 0.73. Pneumonia was found in 18.3% of NPO patients and 19.8% in non-NPO patients, P = 0.78. Reintubated rates were 13.5% for NPO and 16.7% for non-NPO, P = 0.57. Median (range) hours of NPO for non-NPO was 1.0 h (0-3.0) and 13.0 h (6.0-20.0) for NPO, P < 0.05. CONCLUSIONS: For intubated, critically ill patients requiring operative intervention, there was no difference observed in adverse respiratory events between those kept NPO for 6 h or greater compared to those kept NPO for less than 6 h. Patients were commonly without enteric nutrition for periods of time much greater than the American Society of Anesthesia's recommended 6-h period.

Non-operative Management of an Isolated Blunt Traumatic Retrohepatic Inferior Vena Cava Injury.

Traumatic inferior vena cava (IVC) injuries are often fatal. Blunt IVC injuries are encountered less often. Conservative management, albeit an option, is not often discussed in the literature. This report explores the non-operative management of a 52-year-old female unrestrained driver who presented with a blunt retrohepatic IVC injury identified on a computed tomography (CT) scan that revealed IVC disruption with extravasation of contrast. Here, we discuss the nonoperative management of the patient and review the literature concerning IVC anatomy, traumatic injuries, and management. We conclude that a hemodynamically stable patient with an isolated blunt traumatic IVC injury can be managed non-operatively.

Impact of Telemedicine on Extended Focused Assessment With Sonography for Trauma Performance and Workload by Critical Care Transport Personnel.

INTRODUCTION: There are currently no reports on whether telementoring for extended focused assessment with sonography for trauma (eFAST) improves critical care transport providers' performance in prehospital settings. Our objective was to determine the impact of teleguidance on eFAST performance and quantify workload experience. METHODS: Eight trauma injury modules were selected on simulated patients. Critical care transport (CCT) providers were tasked to complete one independent and one emergency physician-telementored eFAST. The time to completion and the percent of correct findings were obtained. Participants completed the NASA Task Load Index after each iteration to assess workload. RESULTS: Eight independent and 8 telementored eFASTs were completed. The mean times to complete the independent and telementored eFAST were 5 minutes 16 seconds (95% confidence interval [CI], 3 minutes 32 seconds, 6 minutes 59 seconds) and 8 minutes 27 seconds (95% CI, 5 minutes 14 seconds, 11 minutes 39 seconds), respectively (P = .06). The percentage of correctly identified injuries for the independent versus the teleguided eFAST was 65% versus 92.5% (P = .01). The CCT providers experienced higher mental (P = .004), temporal (P = .01), and effort (P = .004) demands; greater frustration (P = .001); and subjective lower performance (P = .003) during independent trials. The emergency physician experienced higher mental (P = .001), temporal (P = .02), effort (P = .005), and frustration (P = .001) demands than the CCT members. CONCLUSION: The teleguided eFAST yielded higher accuracy than the independent eFAST. The CCT providers relied on teleguidance of the remote physician when performing the eFAST. Teleguidance may improve the accuracy of ultrasounds performed by prehospital personnel in real-life scenarios.

Feasibility and Acceptance of a Teletrauma Surgery Consult Service to Rural and Community Hospitals: A Pilot Study.

BACKGROUND: Many trauma patients currently transferred from rural and community hospitals (RCH) to Level I trauma centers (LITC) for trauma surgery evaluation may instead be appropriate for immediate discharge or admission to the local facility after evaluation by a trauma and acute care surgery (TACS) surgeon. Unnecessary use of resources occurs with current practice. We aimed to demonstrate the feasibility and acceptance of a teletrauma surgery consultation service between LITC and RCH. STUDY DESIGN: LITC TACS surgeons provided telehealth consults on trauma patients from 3 local RCHs. After consultation, appropriate patients were transferred to LITC; selected patients remained at or were discharged from RCH. Participating TACS surgeons and RCH physicians were surveyed. RESULTS: A total of 28 patients met inclusion criteria during the 5-month pilot phase, with 7 excluded due to workflow issues. The mean ± SD age was 63 ± 17 years. Of 21 patients, 7 had intracranial hemorrhage; 12 had rib fractures. The mean ± SD Injury Severity Score was 8.1 ± 4.0). A total of 6 patients were discharged from RCH, 4 admitted to RCH hospitalist service, 2 transferred to a LITC emergency room, and 9 transferred to LITC as direct admission. There was one 30-day readmission and no missed injuries or complications, or deaths. RCH providers were highly satisfied with the teletrauma surgery consultation service, TACS surgeons, and equipment used. Mental demand and effort of consulting TACS surgeons decreased significantly as the consult number increased. CONCLUSIONS: Teletrauma surgery consultation involving 3 RCH within our system is feasible and acceptable. A total of 10 transfers and 19 emergency department visits were avoided. There was favorable acceptance by RCH providers and TACS surgeons.

Spatial Volume Necessary to Perform Open Appendectomy in a Spacecraft.

BACKGROUND: With the increase in crewed commercial spaceflight and expeditions to the Moon and Mars, the risk of critical surgical problems and need for procedures increases. Appendicitis and appendectomy are the most common surgical pathology and procedure performed, respectively. The habitable volume of current spacecraft ranges from 4 m³ (Soyuz) to 425 m³ (International Space Station). We investigated the minimum volume required to perform an appendectomy and compared that to habitable spacecraft volumes.METHODS: The axes of a simulated operating room were marked and cameras placed to capture movements. An expert surgeon, chief surgical resident, junior surgical resident, and a nonsurgeon physician each performed a Focused Assessment with Sonography for Trauma and an appendectomy on a simulated patient. Dimensions and volume needed were collected and compared using unpaired t-tests.RESULTS: Mean volume (± SD) needed was 3.83 m³ ± 0.47 m³ for standing and 3.68 m³ ± 0.49 m³ for kneeling (P = 0.638). Minimal volume needed was 3.20 m³ for standing and 3.26 m³ for kneeling. Minimal theoretical volume was 2.99 m³ for standing and 2.87 m³ for kneeling.DISCUSSION: The unencumbered volume needed for an appendectomy is between 2.87 m³ and 4.3 m³. It may be technically feasible to perform an open appendectomy inside the smallest of currently operating spacecraft, at 4 m³ (Soyuz-MS). Space vessels operating without rapid evacuation to Earth will need to consider this volume for potential surgical emergencies. Additional investigation on microgravity and standardization of procedures for novices must be completed.Kamine TH, Siu M, Kramer K, Kelly E, Alouidor R, Fernandez G, Levin D. Spatial volume necessary to perform open appendectomy in a spacecraft. Aerosp Med Hum Perform. 2022; 93(10):760-763.

Time Cost of Provider Skill: A Pilot Study of Medical Officer Occupied Time By Knowledge, Skill, and Ability Level.

INTRODUCTION: On space missions one must consider the operating cost of the medical system on crew time. Medical Officer Occupied Time (MOOT) may vary significantly depending on provider skill. This pilot study assessed the MOOT Skill Effect (MOOTSkE).METHODS: An expert surgeon (ES), fifth year surgical resident (PGY5), second year surgical resident (PGY2), and an expert Emergency Physician (EP) with only 4 mo direct surgical training each performed two simulated appendectomies. The completion times for endotracheal intubation, appendectomy, and two subprocedures (multilayer tissue repair and single layer tissue repair) were recorded.RESULTS: The ES performed the appendectomy in 410 s, the PGY-5 in 498 s, the PGY-2 in 645 s, and the EP in 973 s on average. The PGY-2 and EP time difference was significant compared to the expert. The PGY-5 was not. The EP's time was significantly longer for the appendectomy and the multilayer repair than either surgical resident. For the single layer repair, only the EP-ES difference was significant. A single intubation attempt by the PGY-2 took 73 s while the EP averaged 27 s. The average recorded MOOTSkE between novice and expert was 2.5 (SD 0.34).DISCUSSION: This pilot study demonstrates MOOTSkE can be captured using simulated procedures. It showed the magnitude of the MOOTSkE is likely substantial, suggesting that a more highly trained provider may save substantial crew time. Limitations included small sample size, limited number of procedures, a simulation that may not reflect real world conditions, and suboptimal camera angles.Levin DR, Siu M, Kramer K, Kelly E, Alouidor R, Fernandez G, Kamine T. Time cost of provider skill: a pilot study of medical officer occupied time by knowledge, skill, and ability level. Aerosp Med Hum Perform. 2022; 93(11):816-821.

Optimal Timing of Cholecystectomy for Acute Cholecystitis: A Retrospective Cohort Study.

Background Laparoscopic cholecystectomy performed less than 72 hours from hospital admission for acute cholecystitis has shown to decrease hospital cost without an increase in length of stay (LOS). Very few studies have examined clinical and cost outcomes of performing cholecystectomy less than 24 hours from hospital admission. The aim of this study was to examine the cost and LOS of laparoscopic cholecystectomy performed on an early (less than 24 hours from admission) and late (more than 24 hours from hospital admission) basis. Methods We performed a retrospective observational study of 569 patients at Baystate Medical Center, Springfield, USA, who underwent urgent laparoscopic cholecystectomy for acute cholecystitis between January 1, 2018 and February 28, 2020. We evaluated preoperative/postoperative LOS, operative duration, hospital cost, and patient complications. Results 468 patients underwent urgent laparoscopic cholecystectomy for acute cholecystitis during our study period. Early cholecystectomy (less than 24 hours from admission) had an overall decreased LOS (43.6 hours versus 102.9 hours, p-value < 0.01) and decreased hospital cost ($23,736.70 versus $30,176.40, p-value < 0.01) compared to late cholecystectomy (more than 24 hours from admission). There was also a significantly higher rate of bile leak in patients who underwent surgery more than 24 hours from hospital admission compared to those who had surgery less than 24 hours from admission (5.9% versus 0.4%, p-value < 0.01). Additionally, those procedures performed greater than 24 hours from hospital admission were significantly more likely to be converted to an open procedure (6.9% versus 2.2%, p-value = 0.02).  Conclusion Urgent laparoscopic cholecystectomy performed within 24 hours of hospital admission for acute cholecystitis decreased hospital cost, LOS, and operative complications in our institution's patient population. Our data suggests that performing laparoscopic cholecystectomy within 24 hours of hospital admission would be beneficial from a patient and hospital standpoint.

American Helicopter Emergency Medical Service Pilots Report to Work Despite High Rates of Sleepiness.

OBJECTIVE: Previous studies on helicopter emergency medical service (HEMS) pilots found a positive correlation among fatigue, nodding off in flight, and accidents. We sought to quantify the amount of sleepiness in HEMS pilots using the Epworth Sleepiness Scale (ESS). METHODS: An anonymous survey was sent via the National EMS Pilots Association emergency medical services listserv including demographics, the ESS, and subjective effects of fatigue on flying. Statistical analyses were performed using the t-test and analysis of variance. RESULTS: Thirty-one surveys were returned. Twenty-one (65%) reported an ESS > 10, indicating excessive daytime sleepiness. Twelve (39%) reported nodding off in flight; 20 (65%) indicated that they should have refused to fly, but only 14 (45%) actually did. En route was the most likely phase of flight to be affected by fatigue (23 [74%]), whereas takeoff (2 [7%]) and landing (2 [7%]) were the least likely to be affected. CONCLUSION: Many HEMS pilots in this small study reported excessive daytime sleepiness. Most respondents indicated that they should have turned down a flight because of fatigue. More research is necessary to quantify the burden of fatigue among HEMS pilots.

Prophylactic Splenectomy and Hyposplenism in Spaceflight.

BACKGROUND: There is debate whether astronauts traveling to space should undergo a prophylactic splenectomy prior to long duration spaceflight. Risks to the spleen during flight include radiation and trauma. However, splenectomy also carries significant risks.METHODS: Systematic review of data published over the past 5 decades regarding risks associated with splenectomies and risks associated with irradiation to the spleen from long duration spaceflight were analyzed. A total of 41 articles were reviewed.RESULTS: Acute risks of splenectomy include intraoperative mortality rate (from hemorrhage) of 3-5%, mortality rate from postoperative complications of 6%, thromboembolic event rate of 10%, and portal vein thrombosis rate of 5-37%. Delayed risks of splenectomy include overwhelming postsplenectomy infection (OPSI) at 0.5% at 5 yr post splenectomy, mortality rate as high as 60% for pneumococcal infections, and development of malignancy with relative risk of 1.53. The risk of hematologic malignancy increases significantly when individuals reach 40 Gy of exposure, much higher than the 0.6 Gy of radiation experienced from a 12-mo round trip to Mars. Lower doses of radiation increase the risk of hyposplenism more so than hematologic malignancy.CONCLUSION:For protection against hematologic malignancy, the benefits of prophylactic splenectomy do not outweigh the risks. However, there is a possible risk of hyposplenism from long duration spaceflight. It would be beneficial to prophylactically provide vaccines against encapsulated organisms for long duration spaceflight to mitigate the risk of hyposplenism.Siu M, Levin D, Christiansen R, Kelly E, Alouidor R, Kamine TH. Prophylactic splenectomy and hyposplenism in spaceflight. Aerosp Med Hum Perform. 2022; 93(12):877-881.

A Western Massachusetts hospital system's response to the COVID-19 pandemic.

OBJECTIVE: The objective of this paper was to outline a novel model created for the management of the critical care surge due to coronavirus disease 2019 (COVID-19) in a Western Massachusetts hospital. SETTING: This model was created and implemented at a Western Massachusetts Level 1 Trauma and tertiary referral center. CONCLUSIONS: This article outlines a model devised by an interdisciplinary team for rapid expansion of critical care services by increasing allocated space, staffing, and supplies via modifications of existing systems of care to accommodate a predicted large critical care patient surge due to the COVID-19 pandemic. We predict that this model can be utilized and adapted for future critical care surges in times of similar pandemic situations.

Retroperitoneal Necrosis as a Rare Complication After Celiac Plexus Block.

Long after surgical treatment, chronic pain continues to afflict many patients with pancreatic cancer. Multimodal pain management is the current approach to managing these complex patients. In patients with refractory pain, a celiac plexus block is a commonly used adjunct to optimize pain control. The sclerosing agents used in a celiac plexus block are known to cause local tissue necrosis as a rare complication. We present a case of extensive retroperitoneal necrosis following celiac plexus neurolysis. To our knowledge, this is the first report of extensive retroperitoneal necrosis after a celiac plexus block requiring operative management.

Mild Traumatic Brain Injuries Can Be Safely Managed without Neurosurgical Consultation: The End of a Neurosurgical "Nonsult".

In 2010, 2.5 million people sustained a traumatic brain injury (TBI), with an estimated 75 per cent being mild TBI. Mild TBI is defined as a Glasgow Coma Scale (GCS) of 13 to 15. Based on recent data and our institutional experience, we hypothesized that mild TBI patients, including patients on aspirin, could be safely managed by trauma surgeons without neurosurgical consultation. Trauma patients admitted to a single Level I trauma center from June 2014 through July 2015 aged 18 years or older were evaluated. Patients with a GCS ≥14, regardless of intoxication, with an epidural or subdural hematoma ≤4 mm, trace or small subarachnoid hemorrhage, and/or nondisplaced skull fracture were prospectively enrolled. The primary outcomes were needed for neurosurgical consultation and intervention. Secondary outcomes included readmission rate and neurologic morbidity and mortality rate. Of 1341 trauma admits, 77 were enrolled. No patients required neurosurgical intervention. Only 1/75 (1.3%) patients required neurosurgical consultation. Outpatient follow-up was achieved with 75/77 (97.4%) patients. No mortalities, major neurologic morbidities, or readmissions were observed (95% confidence interval 0-4%). None of the 21 patients on aspirin required neurosurgical intervention and only 1/21 (4.8%) patients required neurosurgical consultation with no mortalities observed at follow-up. Management of mild TBI can be safely accomplished by trauma surgeons without routine neurosurgical consultation. Larger multicenter prospective studies are required to evaluate our finding that this also may be safe in patients taking aspirin.

Selective Nonoperative Management of Abdominal Gunshot Wounds from Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT).

BACKGROUND: Selective nonoperative management (SNOM) of abdominal gunshot wounds is being practiced in certain trauma centers, but its broader acceptance in the surgical community is unknown. We hypothesized that SNOM has been adopted in New England as an acceptable method of abdominal gunshot wound management. STUDY DESIGN: We reviewed the medical records of abdominal gunshot wound patients admitted from January 1996 to June 2015, in 10 New England Level I and II trauma centers. Outcomes included the incidence, success, and failure of SNOM, and morbidity and mortality related to SNOM. RESULTS: Of 922 patients, 707 (77%) received immediate laparotomy (IMMLAP) and 215 (23%) were managed by SNOM. Compared with IMMLAP patients, those with SNOM had a lower median Injury Severity Score (16 vs 8; p < 0.001), lower incidence of complications (34.7% vs 8.5%; p < 0.001) and mortality (5.2% vs 0.5%; p = 0.002), and shorter ICU and hospital stays (median days 1 of 8 vs 0 of 2, respectively; p < 0.001). One SNOM patient died after 3 days due to a gunshot wound to the head. The overall incidence of SNOM increased from 18% before 2010 to 27% in the following years (p = 0.001). Eighteen patients (8.4%) had unsuccessful SNOM and underwent delayed laparotomy at an average of 12.5 hours (range 141 minutes to 48 hours) after arrival. Nine of them (4.2%) experienced complications that were not directly related to the delayed laparotomy, and none died. The rate of nontherapeutic laparotomies was 14.7% among IMMLAP and 5.5% among delayed laparotomy patients (p = 0.49). CONCLUSIONS: Selective nonoperative management of abdominal gunshot wounds, despite being a heresy only a few years ago, has now been established as an acceptable method of management in Level I and II trauma centers in New England.

Management of the most severely injured spleen: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).

OBJECTIVE: To determine the rate and predictors of failure of nonoperative management (NOM) in grade IV and V blunt splenic injuries (BSI). DESIGN: Retrospective case series. SETTING: Fourteen trauma centers in New England. PATIENTS: A total of 388 adult patients with a grade IV or V BSI who were admitted between January 1, 2001, and August 31, 2008. MAIN OUTCOME MEASURES: Failure of NOM (f-NOM). RESULTS: A total of 164 patients (42%) were operated on immediately. Of the remaining 224 who were offered a trial of NOM, the treatment failed in 85 patients (38%). At the end, 64% of patients required surgery. Multivariate analysis identified 2 independent predictors of f-NOM: grade V BSI and the presence of a brain injury. The likelihood of f-NOM was 32% if no predictor was present, 56% if 1 was present, and 100% if both were present. The mortality of patients for whom NOM failed was almost 7-fold higher than those with successful NOM (4.7% vs 0.7%; P = .07). CONCLUSIONS: Nearly two-thirds of patients with grade IV or V BSI require surgery. A grade V BSI and brain injury predict failure of NOM. This data must be taken into account when generalizations are made about the overall high success rates of NOM, which do not represent severe BSI.

Nonventilatory interventions in the acute respiratory distress syndrome.

Acute respiratory distress syndrome was first described in 1967. Acute respiratory distress syndrome and acute lung injury are diseases the busy intensivist treats almost daily. The etiologies of acute respiratory distress syndrome are many. A significant distinction is based on whether the insult to the lung was direct, such as in pneumonia, or indirect, such as trauma or sepsis. Strategies for managing patients with acute respiratory distress syndrome/acute lung injury can be subdivided into 2 large groups, those based in manipulation of mechanical ventilation and those based in nonventilatory modalities. This review focuses on the nonventlilatory strategies and includes fluid restriction, exogenous surfactant, inhaled nitric oxide, manipulation of production, or administration of eicosanoids, neuromuscular blocking agents, prone position ventilation, glucocorticoids, extracorporeal membrane oxygenation, and administration of beta-agonists. Most of these therapies either have not been studied in large trials or have failed to show a benefit in terms of long-term patient mortality. Many of these therapies have shown promise in terms of improved oxygenation and may therefore be beneficial as rescue therapy for severely hypoxic patients. Recommendations regarding the use of each of these strategies are made, and an algorithm for implementing these strategies is suggested.