Sixth Annual Enhanced Recovery After Surgery Symposium highlights: work in progress or standard care?

Enhanced Recovery After Surgery (ERAS) protocols have demonstrated effectiveness in accelerating patient recovery and improving outcomes. Since the systemwide implementation of ERAS protocols at Baylor Scott & White Health, an annual multidisciplinary conference has provided a review of outcomes and advancements in the ERAS program. This meeting, coined the ERAS symposium, allows providers who utilize recovery protocols to collaborate with national and international leaders in the field to improve the clinical care of patients. The sixth annual ERAS symposium was held on February 10, 2023, and provided key presentations that discussed the latest results from ERAS efforts across multiple surgical specialties along with updates in anesthesia, nursing, and nutrition. A summary of those presentations, which included perioperative glycemic control, misconceptions in pain management, and emerging ERAS protocols in different surgical specialties, is provided to document the system progress.

Adapting Compassionate Conversations for Virtual Mediated Communication.

OBJECTIVE: The Covid-19 pandemic resulted in a shift in communication of difficult, emotionally charged topics from almost entirely in-person to virtual mediated communication (VMC) methods due to restrictions on visitation for safety. The objective was to train residents in VMC and assess performance across multiple specialties and institutions. DESIGN: The authors designed a teaching program including asynchronous preparation with videos, case simulation experiences with standardized patients (SPs), and coaching from a trained faculty member. Three topics were included - breaking bad news (BBN), goals of care / health care decision making (GOC), and disclosure of medical error (DOME). A performance evaluation was created and used by the coaches and standardized patients to assess the learners. Trends in performance between simulations and sessions were assessed. SETTING: Four academic university hospitals - Virginia Commonwealth University Medical Center in Richmond, Virginia, The Ohio State University Wexner Medical Center in Columbus, Ohio, Baylor University Medical Center in Dallas, Texas and The University of Cincinnati in Cincinnati, Ohio- participated. PARTICIPANTS: Learners totaled 34 including 21 emergency medicine interns, 9 general surgery interns and 4 medical students entering surgical training. Learner participation was voluntary. Recruitment was done via emails sent by program directors and study coordinators. RESULTS: A statistically significant improvement in mean performance on the second compared to the first simulation was observed for teaching communication skills for BBN using VMC. There was also a small but statistically significant mean improvement in performance from the first to the second simulation for the training overall. CONCLUSIONS: This work suggests that a deliberate practice model can be effective for teaching VMC and that a performance evaluation can be used to measure improvement. Further study is needed to optimize the teaching and evaluation of these skills as well as to define minimal acceptable levels of competency.

From chaos to creativity: Designing collaborative communication training for the delivery of bad news.

BACKGROUND: Before the COVID-19 pandemic, teaching communication skills in health care focused primarily on developing skills during face-to-face conversation. Even experienced clinicians were unprepared for the transition in communication modalities necessitated due to physical distancing requirements and visitation restrictions during the COVID-19 pandemic. We aimed to develop and pilot a comprehensive video-mediated communication training program and test its feasibility in multiple institutional settings and medical disciplines. METHODS: The education team, consisting of clinician-educators in general surgery and emergency medicine (EM) and faculty specialists in simulation and coaching, created the intervention. Surgery and EM interns in addition to senior medical students applying in these specialties were recruited to participate. Three 90-minute sessions were offered focusing on 3 communication topics that became increasingly complex and challenging: breaking bad news, goals of care discussions, and disclosure of medical error. This was a mixed-methods study using survey and narrative analysis of open comment fields. RESULTS: Learner recruitment varied by institution but was successful, and most (75%) learners found the experience to be valuable. All of the participants reported feeling able to lead difficult discussions, either independently or with minimal assistance. Only about half (52%) of the participants reported feeling confident to independently disclose medical error subsequent to the session. CONCLUSION: We found the program to be feasible based on acceptability, demand, the ability to implement, and practicality. Of the 3 communication topics studied, confidence with disclosure of medical error proved to be the most difficult. The optimal length and structure for these programs warrants further investigation.

Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence.

Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.

Anisocoria Correlates With Injury Severity and Outcomes After Blunt Traumatic Brain Injury.

ABSTRACT: BACKGROUND: Automated infrared pupillometry (AIP) has been shown to be helpful in the setting of aneurysmal subarachnoid hemorrhage and stroke as an indicator of imminent irreversible brain injury. We postulated that the early detection of pupillary dysfunction after light stimulation using AIP may be useful in patients with traumatic brain injury (TBI). METHODS: We performed a retrospective review of the Establishing Normative Data for Pupillometer Assessment in Neuroscience Intensive Care database, a prospectively populated multicenter registry of patients who had AIP measurements taken during their intensive care unit admission. The primary eligibility criterion was a diagnosis of blunt TBI. Ordinal logistic modeling was used to explore the association between anisocoria and daily Glasgow Coma Scale scores and discharge modified Rankin Scale scores from the intensive care unit and from the hospital. RESULTS: Among 118 subjects in the who met inclusion, there were 6187 pupillometer readings. Of these, anisocoria in ambient light was present in 12.8%, and that after light stimulation was present in 9.8%. Anisocoria after light stimulation was associated with worse injury severity (odds ratio [OR], 0.26 [95% confidence interval (CI), 0.14-0.46]), lower discharge Glasgow Coma Scale scores (OR, 0.28 [95% CI, 0.17-0.45]), and lower discharge modified Rankin Scale scores (OR, 0.28 [95% CI, 0.17-0.47]). Anisocoria in ambient light showed a similar but weaker association. CONCLUSION: Anisocoria correlates with injury severity and with patient outcomes after blunt TBI. Anisocoria after light stimulation seems to be a stronger predictor than does anisocoria in ambient light. These findings represent continued efforts to understand pupillary changes in the setting of TBI.

Quantitative pupillometry in patients with traumatic brain injury and loss of consciousness: A prospective pilot study.

OBJECTIVE: Loss of consciousness (LOC) is a hallmark feature in Traumatic Brain Injury (TBI), and a strong predictor of outcomes after TBI. The aim of this study was to describe associations between quantitative infrared pupillometry values and LOC, intracranial hypertension, and functional outcomes in patients with TBI. METHODS: We conducted a prospective study of patients evaluated at a Level 1 trauma center between November 2019 and February 2020. Pupillometry values including the Neurological Pupil Index (NPi), constriction velocity (CV), and dilation velocity (DV) were obtained. RESULTS: Thirty-six consecutive TBI patients were enrolled. The median (range) age was 48 (range 21-86) years. The mean Glasgow Coma Scale score on arrival was 11.8 (SD = 4.0). DV trichotomized as low (<0.5 mm/s), moderate (0.5-1.0 mm/s), or high (>1.0 mm/s) was significantly associated with LOC (P = .02), and the need for emergent intervention (P < .01). No significant association was observed between LOC and NPi (P = .16); nor between LOC and CV (P = .07). CONCLUSIONS: Our data suggests that DV, as a discrete variable, is associated with LOC in TBI. Further investigation of the relationship between discrete pupillometric variables and NPi may be valuable to understand the clinical significance of the pupillary light reflex findings in acute TBI.

Surgical Site Infection After Autologous Cranioplasty for Decompressive Craniectomy in Traumatic Brain Injury: A Retrospective Review of Two Level 1 Trauma Centers.

OBJECT: Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI). METHODS: A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05. RESULTS: A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate. CONCLUSIONS: The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible.

Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury.

OBJECTIVE: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes. METHODS: We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied. RESULTS: Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n = 4) or ICP monitor placement (n = 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention. CONCLUSIONS: AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.

Osteodiskitis of Lumbar Spine Due to Migrated Fractured Inferior Vena Cava Filter.

BACKGROUND: Venous thromboembolism can be a significant cause of morbidity in the trauma population. Medical and surgical specialties have been pushing the indication for prophylactic filter placement. CASE DESCRIPTION: A 36-year-old man presented with axial lower back pain with a radicular right L2 component after lifting a heavy object. He had a history of penetrating brain trauma 3 years prior, with placement of a prophylactic inferior vena cava filter. His radiograph, computed tomography, and magnetic resonance imaging of the lumbar spine showed fracture of his filter, with migration of the fractured fragment through the inferior vena cava and into the L2-L3 disk space, and surrounding bony lysis and severe osteodiskitis. He was treated medically with intravenous and then oral antibiotics and improved clinically and radiographically. CONCLUSIONS: Conservative use of filter devices and early retrieval once their indication expires are paramount to avoid unnecessary complications.

Migration of a Ventriculoperitoneal Shunt into the Pulmonary Vasculature: Case Report, Review of the Literature, and Surgical Pearls.

BACKGROUND: Ventriculoperitoneal shunts are prone to common complications such as infection or mechanical failure, but more insidious events can easily be missed. Distal shunt migration into the vascular system is a rarely observed phenomenon, and there are no established guidelines for its management. We present a case of a distal catheter migration into the pulmonary vasculature, review existing cases in the literature, and present recommendations for their management. CASE DESCRIPTION: A 71-year-old man presented to the clinic with normal pressure hydrocephalus. He underwent the laparoscopic placement of a ventriculoperitoneal shunt. Surgery was uneventful except for increased venous bleeding noted at the retroauricular incision. Three weeks later, the patient returned with worsening motor and cognitive symptoms. A shunt series showed distal migration of the catheter through his heart. Computed tomography of the chest confirmed the distal wedging of the tube into his pulmonary artery. The migrated shunt catheter was withdrawn in the operating room with the assistance of colleagues from general surgery without complication. CONCLUSIONS: Although distal shunt migration into the heart and pulmonary vasculature is rare, early recognition is important and precautions should be taken to avoid potentially significant morbidity or mortality. Live fluoroscopic imaging and the help of specialty services can be of great assistance in safely removing the device. Early recognition of potential vascular injury signs during the subcutaneous tunneling procedure is also important.

Single-site laparoscopic surgery for inflammatory bowel disease.

BACKGROUND AND OBJECTIVES: Single-site laparoscopic colorectal surgery has been firmly established; however, few reports addressing this technique in the inflammatory bowel disease population exist. METHODS: We conducted a case-matched retrospective review of 20 patients who underwent single-site laparoscopic procedures for inflammatory bowel disease compared with 20 matched patients undergoing multiport laparoscopic procedures. Data regarding these patients were tabulated in the following categories: demographic characteristics, operative parameters, and perioperative outcomes. RESULTS: A wide range of cases were completed: 9 ileocolic resections, 7 cases of proctocolectomy with end ileostomy or ileal pouch anal anastomosis, 2 cases of proctectomy with ileal pouch anal anastomosis, and 2 total abdominal colectomies with end ileostomy were all matched to equivalent multiport laparoscopic cases. No single-incision cases were converted to multiport laparoscopy, and 2 single-incision cases (10%) were converted to an open approach. For single-incision cases, the mean length of stay was 7.7 days, the mean time to oral intake was 3.3 days, and the mean period of intravenous analgesic use was 5.0 days. There were no statistically significant differences between single-site and multiport cases. CONCLUSIONS: Single-site laparoscopic surgery is technically feasible in inflammatory bowel disease. The length of stay and period of intravenous analgesic use (in days) appear to be higher than those in comparable series examining outcomes of single-site laparoscopic colorectal surgery, and the outcomes are comparable with those of multiport laparoscopy. This may be because of the nature of inflammatory bowel disease, limiting the benefits of a single-site approach in this population.