Diaphragm pacing and independent breathing in individuals with severe Pompe disease.

Introduction: Pompe disease is an inherited disease characterized by a deficit in acid-α-glucosidase (GAA), an enzyme which degrades lysosomal glycogen. The phrenic-diaphragm motor system is affected preferentially, and respiratory failure often occurs despite GAA enzyme replacement therapy. We hypothesized that the continued use of diaphragm pacing (DP) might improve ventilator-dependent subjects' respiratory outcomes and increase ventilator-free time tolerance. Methods: Six patients (3 pediatric) underwent clinical DP implantation and started diaphragm conditioning, which involved progressively longer periods of daily, low intensity stimulation. Longitudinal respiratory breathing pattern, diaphragm electromyography, and pulmonary function tests were completed when possible, to assess feasibility of use, as well as diaphragm and ventilatory responses to conditioning. Results: All subjects were eventually able to undergo full-time conditioning via DP and increase their maximal tolerated time off-ventilator, when compared to pre-implant function. Over time, 3 of 6 subjects also demonstrated increased or stable minute ventilation throughout the day, without positive-pressure ventilation assistance. Discussion: Respiratory insufficiency is one of the main causes of death in patients with Pompe disease. Our results indicate that DP in Pompe disease was feasible, led to few adverse events and stabilized breathing for up to 7 years.

Inferior Vena Cava Ligation and Pancreaticoduodenectomy in a Patient With Penetrating Abdominal Trauma.

INTRODUCTION: Injury to the inferior vena cava (IVC) is often fatal. Pancreaticoduodenectomy for trauma is also rare. This case describes a patient who underwent both procedures. CASE PRESENTATION: A 30-year-old male presented status post gunshot to the abdomen. He was taken to the operating room and found to have 6 cm defect in the IVC, which was ligated. Despite resuscitation, the patient required emergent return to the OR where bleeding from the pancreaticoduodenal artery was noted in addition to injuries in the stomach, duodenum, and pancreas. He subsequently underwent a pancreaticoduodenectomy. He was discharged after a month-long hospital stay. CONCLUSIONS: This case demonstrates that IVC ligation is a form of damage of control surgery. Pancreaticoduodenectomy is rarely performed during the index operation for trauma patients. Patient with injuries to the pancreaticoduodenal complex can be life-threatening if not rapidly controlled. This patient is a rare example of someone who survived two morbid trauma surgery interventions.

Improved perioperative mortality after secondary aortoenteric fistula repair and lessons learned from a 20-year experience.

BACKGROUND: Secondary aortoenteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes. METHODS: We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints. RESULTS: A total of 57 patients (63% male; n = 36) presented with SAEF (median age, 69 years; interquartile range [IQR], 61-74 years). Median follow-up time was 10 months (interquartile range, 3-21 months. The most common presenting symptoms were gastrointestinal bleeding (60%; n = 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n = 17) underwent extra-anatomic bypass with aortic ligation, 30% (n = 17) rifampin-soaked Dacron graft, 26% (n = 15) femoral vein (eg, neoaortoiliac system), and 14% (n = 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n = 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n = 35). Thirty-day mortality was 35% (n = 20) with no significant difference between 90 days (39%; n = 22) and 180 days (42%; n = 24). Morbidity was 70% (n = 40), with gastrointestinal (30%; n = 17; leak [9%]), pulmonary (25%; n = 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n = 32). One-year and 3-year survival was 54% ± 6% and 48% ± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P = .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P = .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome. CONCLUSIONS: In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center.

Estimated vs measured energy expenditure in ventilated surgical-trauma critically ill patients.

BACKGROUND: The American and European guidelines recommend measuring resting energy expenditure (REE) using indirect calorimetry (IC). Predictive equations (PEs) are used to estimate REE, but there is limited evidence for their use in critically ill patients. The aim of this study is to evaluate the degree of agreement and accuracy between IC-measured REE (REE-IC) and 10 different PEs in mechanically ventilated critically ill patients with surgical trauma who met their estimated energy requirement. METHODS: REE-IC was retrospectively compared with REE-PE by 10 PEs. The degree of agreement between REE-PE and REE-IC was analyzed by the Bland-Altman test (BAt) and the concordance correlation coefficient (CCC). The accuracy was calculated by the percentage of patients whose REE-PE values differ by up to ±10% in relation to REE-IC. All analyses were stratified by gender and body mass index (BMI; <25 vs ≥25). RESULTS: We analyzed 104 patients and the closest estimate to REE-IC was the modified Harris-Benedict equation (mHB) by the BAt with a mean difference of 49.2 overall (61.6 for males, 28.5 for females, 67.5 for BMI <25, and 42.5 for BMI ≥25). The overall CCC between the REE-IC and mHB was 0.652 (0.560 for males, 0.496 for females, 0.570 for BMI <25, and 0.598 for BMI ≥25). The mHB equation was the most accurate with an overall accuracy of 44.2%. CONCLUSION: The effectiveness of PEs for estimating the REE of mechanically ventilated surgical-trauma critically ill patients is limited. [Correction added on 17 February 2022, after first online publication: The word "with" was deleted before "is limited" in the preceding sentence.] Nonetheless, of the 10 equations examined, the closest to REE-IC was the mHB equation.

Enteral Nutrition Administration Record Prescribing Process Using Computerized Order Entry: A New Paradigm and Opportunities to Improve Outcomes in Critically Ill Patients.

BACKGROUND: Prevalence of malnutrition has been reported in 60% of hospitalized and up to 78% of patients admitted to intensive care units. Malnutrition has been associated with complications, such as infection, increased hospital length of stay, morbidity, and mortality. Nutritional support has been shown to reduce avoidable readmissions, pressure ulcers, malpractice claims, and hospital costs. Creating a new electronic nutrition administration record (ENAR) with a linked nutrition tab within the electronic health record (EHR) would promote enhanced patient outcomes by improving adherence to established institutional enteral nutrition (EN) protocols and achieving early energy goals. Additionally, it would enable a clear and standardized method for documentation and administration of EN therapy. METHODS: The multidisciplinary nutrition support team was established and met on a weekly basis to discuss strategies and barriers, identify stakeholders, evaluate the current state, and establish a process and workflow from the point of order entry, delivery, administration, and electronic documentation of orders of EN supplements. The aim of this article is to describe a systematic approach and process of creating a new ENAR with a linked nutrition tab in the EHR, and to illustrate the order panel built and lessons learned from the process. RESULTS: A separate nutrition tab was created in the EHR with minimal disruption in patient care and end-users' positive feedback for the new order panel. CONCLUSION: ENAR allows for easier data collection and promotes nutrition-related research that may result in enhanced patient care. Utilizing technology to build a full ENAR would result in optimized patient care and safety.

Clinical Impact of a Dedicated Trauma Hybrid Operating Room.

BACKGROUND: Early hemorrhage control is essential to optimal trauma care. Hybrid operating rooms offer early, concomitant performance of advanced angiographic and operative hemostasis techniques, but their clinical impact is unclear. Herein, we present our initial experience with a dedicated, trauma hybrid operating room. STUDY DESIGN: This retrospective cohort analysis of 292 adult trauma patients undergoing immediate surgery at a Level I trauma center compared patients managed after implementation of a dedicated, trauma hybrid operating room (n = 186) with historic controls (n = 106). The primary outcomes were time to hemorrhage control (systolic blood pressure ≥ 100 mmHg without ongoing vasopressor or transfusion requirements), early blood product administration, and complication. RESULTS: Patient characteristics were similar between cohorts (age 41 years, 25% female, 38% penetrating trauma). The hybrid cohort had lower initial hemoglobin (10.2 vs 11.1 g/dL, p = 0.001) and a greater proportion of patients undergoing resuscitative endovascular balloon occlusion of the aorta (9% vs 1%, p = 0.007). Cohorts had similar case mixes and intraoperative consultation with cardiothoracic or vascular surgery (13%). Twenty-one percent of all hybrid cases included angiography. The interval between operating room arrival and hemorrhage control was shorter in the hybrid cohort (49 vs 60 minutes, p = 0.005). From 4 to 24 hours after arrival, the hybrid cohort had fewer red cell (0.0 vs 1.0, p = 0.001) and plasma transfusions (0.0 vs 1.0, p < 0.001). The hybrid cohort had fewer infectious complications (15% vs 27%, p = 0.009) and ventilator days (2.0 vs 3.0, p = 0.011), and similar in-hospital mortality (13% vs 10%, p = 0.579). CONCLUSIONS: Implementation of a dedicated, trauma hybrid operating room was associated with earlier hemorrhage control and fewer early blood transfusions, infectious complications, and ventilator days.

Audiovisual Modules to Enhance Informed Consent in the ICU: A Pilot Study.

Obtaining informed consent for commonly performed ICU procedures is often compromised by variability in communication styles and inadequate verbal descriptions of anatomic concepts. The objective of this study was to evaluate the efficacy of an audiovisual module in improving the baseline knowledge of ICU procedures among patients and their caregivers. DESIGN: Prospective, observational study. SETTING: Forty-eight-bed adult surgical ICU at a tertiary care center. SUBJECTS: Critically ill surgical patients and their legally authorized representatives. INTERVENTIONS: An audiovisual module describing eight commonly performed ICU procedures. MEASUREMENTS AND MAIN RESULTS: Fifty-nine subjects were enrolled and completed an 11-question pre- and postvideo test of knowledge regarding commonly performed ICU procedures and a brief satisfaction survey. Twenty-nine percent had a healthcare background. High school was the highest level of education for 37% percent of all subjects. Out of 11 questions on the ICU procedure knowledge test, subjects scored an average 8.0 ± 1.9 correct on the pretest and 8.4 ± 2.0 correct on the posttest (p = 0.055). On univariate logistic regression, having a healthcare background was a negative predictor of improved knowledge (odds ratio, 0.185; 95% CI, 0.045-0.765), indicating that those with a health background had a lower probability of improving their score on the posttest. Among subjects who did not have a healthcare background, scores increased from 7.7 ± 1.9 to 8.3 ± 2.1 (p = 0.019). Seventy-five percent of all subjects indicated that the video was easy to understand, and 70% believed that the video improved their understanding of ICU procedures. CONCLUSIONS: Audiovisual modules may improve knowledge and comprehension of commonly performed ICU procedures among critically ill patients and caregivers who have no healthcare background.

The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma.

BACKGROUND: Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma. METHODS: We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2-5) blunt abdominal trauma, comparing patients with prior laparotomy (n = 31) to patients with no prior laparotomy (n = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury. RESULTS: There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p = 0.010) and mesenteric injury (61 vs. 31%, p = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6-16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74-0.88). CONCLUSIONS: Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.

Occult bowel injury after blunt abdominal trauma.

BACKGROUND: Following blunt abdominal trauma, bowel injuries are often missed on admission computed tomography (CT) scan. METHODS: Multicenter retrospective analysis of 176 adults with moderate-critical blunt abdominal trauma and admission CT scan who underwent operative exploration. Patients with a bowel injury missed on CT (n = 36, 20%) were compared to all other patients (n = 140, 80%). RESULTS: The missed injury group had greater incidence free fluid without solid organ injury on CT scan (44% vs. 25%, p = 0.038) and visceral adhesions (28% vs. 6%, p = 0.001). Independent predictors of missed bowel injury included prior abdominal inflammation (OR 3.74, 95% CI 1.37-10.18), CT evidence of free fluid in the absence of solid organ injury (OR 2.31, 95% CI 1.03-5.19) and intraoperative identification of visceral adhesions (OR 4.46, 95% CI 1.52-13.13). CONCLUSIONS: Patients with visceral adhesive disease and indirect evidence of bowel injury on CT scan were more likely to have occult bowel injury.

The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy.

BACKGROUND: To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. STUDY DESIGN: We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. RESULTS: Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. CONCLUSIONS: Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The effects of beta blockade and clonidine on persistent injury-associated anemia.

BACKGROUND: Nonselective beta blockade (BB) and clonidine may abrogate catecholamine-mediated persistent injury-associated anemia. We hypothesized that critically ill trauma patients who received BB or clonidine would have favorable hemoglobin (Hb) trends when adjusting for operative blood loss (OBL), phlebotomy blood loss (PBL), and red blood cell (RBC) transfusion volumes, and that the effect would be greatest among the elderly, who have higher catecholamine levels. METHODS: We performed a 4-y retrospective cohort analysis of 280 consecutive trauma patients with ICU stay ≥48 h and moderate/severe anemia. Patients who received BB or clonidine for ≥25% of their hospital stay were grouped as the BB/clonidine cohort (n = 84); all other patients served as controls (n = 196). Admission and discharge Hb were used to calculate ΔHb. OBL, PBL, and RBC volume were used to calculate adjusted ΔHb assuming 300 mL RBC = 1 g/dL Hb. RESULTS: BB/clonidine and control patients had similar age, injury severity, comorbid illness, and admission Hb. BB/clonidine patients received fewer RBCs despite greater OBL, though neither association was statistically significant. BB/clonidine patients had higher discharge Hb (9.9 versus 9.5, P = 0.029) and adjusted ΔHb (+1.0 versus -0.8, P = 0.003). Hb curves separated after hospital day 10. The difference in adjusted ΔHb between groups increased with advanced age (all patients: 1.7, ≥50 y: 1.8, ≥60 y: 2.4, ≥70 y: 3.7). CONCLUSIONS: Critically ill trauma patients receiving BB or clonidine had favorable Hb trends when accounting for OBL, PBL, and RBC transfusions. These findings support the hypothesis that BB and clonidine alleviate persistent injury-associated anemia, with strongest effects among the elderly.

Adhesive Closed-loop Small Bowel Obstruction.

Complete small bowel obstruction (SBO) is a common surgical emergency often resulting from adhesive bands that form following iatrogenic peritoneal injury. Rarely, adhesive SBO may arise without previous intra-abdominal surgery through other modes of peritoneal trauma. We present the case of a male evaluated in the emergency department for a closed-loop small bowel obstruction due to an adhesive band that likely formed after blunt abdominal trauma over two decades earlier. We review the epidemiology, pathophysiology, and treatment options for similar cases of adhesive SBO.

Resuscitative Endovascular Balloon Occlusion of the Aorta: Implementation and Preliminary Results at an Academic Level I Trauma Center.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel method of controlling subdiaphragmatic hemorrhage while improving hemodynamic stability. This procedure achieves many of the goals of resuscitative thoracotomy (RT), but is less invasive. Here, we present the initial experience with REBOA at a level 1 academic trauma center. STUDY DESIGN: We performed a retrospective review. Orientation of surgeons and residents to REBOA was accomplished by an educational program including a hands-on simulation session (1.5 hours). Surgeons were not required to attend an external training course. Operating room personnel were oriented with a slide presentation. Initially, a 12-Fr introducer and aortic occlusion balloon were used. Subsequently, a 7-Fr device was used. All REBOAs were performed in a dedicated hybrid operating room. Resuscitative thoracotomy was performed in the trauma bays and operating room. RESULTS: During a 21-month period (June 2015 to March 2017), 16 patients (Injury Severity Score [ISS] 38.6 ± 22.3, Glasgow Coma Scale [GCS] 8.9 ± 5.9, lactate 4.91 ± 3.26 mmol/L) had REBOA placed. All patients were hemodynamically unstable (systolic blood pressure 96.5 ± 9.3 mmHg) due to hemorrhage. Preoperative hemoglobin ranged from 5 to 14.4 mg/dL. Etiology of hemorrhage was blunt trauma (n = 11), penetrating injury (n = 2), and nontraumatic mechanisms (n = 3). After REBOA, hemodynamic status improved in 10 of 16 patients. Fourteen patients survived the initial operative intervention and 6 survived 30 days; REBOA was successfully performed in all patients. One survivor developed a common femoral pseudoanuerysm. Survival for RT (ISS 31.3 ± 11.25) during same period was 0%. CONCLUSIONS: Resuscitative endovascular balloon occlusion of the aorta is an effective method of improving hemodynamic status in patients with sub-diaphragmatic hemorrhage. Extensive training is not required to implement a REBOA program, and REBOA is a useful technique for trauma surgeons.

Chronic Critical Illness: Application of What We Know.

Over the last decade, chronic critical illness (CCI) has emerged as an epidemic in intensive care unit (ICU) survivors worldwide. Advances in ICU technology and implementation of evidence-based care bundles have significantly decreased early deaths and have allowed patients to survive previously lethal multiple organ failure (MOF). Many MOF survivors, however, experience a persistent dysregulated immune response that is causing an increasingly predominant clinical phenotype called the persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The elderly are especially vulnerable; thus, as the population ages the prevalence of this CCI/PICS clinical trajectory will undoubtedly grow. Unfortunately, there are no proven therapies to prevent PICS, and multimodality interventions will be required. The purpose of this review is to: (1) discuss CCI as it relates to PICS, (2) identify the burden on healthcare and poor outcomes of these patients, and (3) describe possible nutrition interventions for the CCI/PICS phenotype.

A protocol for non-operative management of uncomplicated appendicitis.

BACKGROUND: We developed a protocol to identify candidates for non-operative management (NOM) of uncomplicated appendicitis. Our objective was to evaluate protocol efficacy with the null hypothesis that clinical outcomes, hospital readmission rates, and hospital charges would be unchanged after protocol implementation. METHODS: We performed a single-center 4-year propensity score matched retrospective cohort analysis of 406 patients with acute uncomplicated appendicitis. The protocol recommended NOM for patients with modified Alvarado score ≤6 and no appendicolith. Patients admitted before (n = 203) and after (n = 203) protocol implementation were matched by Charlson comorbidity index, duration of symptoms, and modified Alvarado score. Outcomes included operative management, days on antibiotic therapy, length of stay, and hospital charges, as well as readmissions, complications, and mortality within 180 days. RESULTS: Baseline characteristics were similar between groups (age 31 years, ASA class 2.0, Charlson comorbidity index 0.0). Protocol compliance was higher when the protocol recommended appendectomy (97%) rather than NOM (73%, p < 0.001). The incidence of operative management decreased from 99% to 82% after protocol implementation (p < 0.001). In the protocol group, there was a lower incidence of open surgery (4% vs. 10%, p = 0.044) despite a longer interval between admission and surgery (8.6 vs. 7.1 hours, p < 0.001). After protocol implementation, 51 patients had NOM: 18 failed NOM during admission and 6 failed NOM after discharge. Compared to the pre-protocol group, the protocol group had similar length of stay, antibiotic days, and overall complication rates, but more readmissions (6% vs. 1%, p = 0.019) and lower hospital charges for the index admission ($5,630 vs. $6,878, p < 0.001). CONCLUSIONS: Implementation of a protocol to identify candidates for NOM of acute uncomplicated appendicitis was associated with lower rates of open surgery, fewer appendectomies, decreased hospital charges, and no difference in overall complications despite high rates of readmission and failure of NOM. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Effect of Time to Operation on Value of Care in Acute Care Surgery.

BACKGROUND: As reimbursement models evolve, there is increasing emphasis on maximizing value-based care for inpatient conditions. We hypothesized that longer intervals between admission and surgery would be associated with worse outcomes and increased costs for acute care surgery patients, and that these associations would be strongest among patients with high-risk conditions. METHODS: We performed a 5-year retrospective analysis of three risk cohorts: appendectomy (low-risk for morbidity and mortality, n = 618), urgent hernia repair (intermediate-risk, n = 80), and laparotomy for intra-abdominal sepsis with temporary abdominal closure (sTAC; high-risk, n = 102). Associations between the interval from admission to surgery and outcomes including infectious complications, mortality, length of stay, and hospital charges were assessed by regression modeling. RESULTS: Median intervals between admission and surgery for appendectomy, hernia repair, and sTAC were 9.3, 13.5, and 8.1 h, respectively, and did not significantly impact infectious complications or mortality. For appendectomy, each 1 h increase from admission to surgery was associated with increased hospital LOS by 1.1 h (p = 0.002) and increased intensive care unit (ICU) LOS by 0.3 h (p = 0.011). For hernia repair, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 1.6 h (p = 0.007), increased hospital LOS by 3.3 h (p = 0.002), increased ICU LOS by 1.5 h (p = 0.001), and increased hospital charges by $1918 (p < 0.001). For sTAC, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 5.0 h (p = 0.006), increased hospital LOS by 3.9 h (p = 0.046), increased ICU LOS by 3.5 h (p = 0.040), and increased hospital charges by $3919 (p = 0.002). CONCLUSIONS: Longer intervals from admission to surgery were associated with prolonged antibiotic administration, longer hospital and ICU length of stay, and increased hospital charges, with strongest effects among high-risk patients. To improve value of care for acute care surgery patients, operations should proceed as soon as resuscitation is complete.

Hypertonic saline resuscitation after emergent laparotomy and temporary abdominal closure.

BACKGROUND: Our objective was to establish the safety of 3% hypertonic saline (HTS) resuscitation for trauma and acute care surgery patients undergoing emergent laparotomy and temporary abdominal closure (TAC) with the hypothesis that HTS administration would be associated with hyperosmolar hypercholoremic acidosis, lower resuscitation volumes, and higher fascial closure rates, without adversely affecting renal function. METHODS: We performed a retrospective cohort analysis of 189 trauma and acute care surgery patients who underwent emergent laparotomy and TAC, comparing patients with normal baseline renal function who received 3% HTS at 30 mL/h (n = 36) to patients with standard resuscitation (n = 153) by baseline characteristics, resuscitation parameters, and outcomes including primary fascial closure and Kidney Disease: Improving Global Outcomes stages of acute kidney injury. RESULTS: The HTS and standard resuscitation groups had similar baseline illness severity and organ dysfunction, though HTS patients had lower serum creatinine at initial laparotomy (1.2 mg/dL vs. 1.4 mg/dL; p = 0.078). Forty-eight hours after TAC, HTS patients had significantly higher serum sodium (145.8 mEq/L vs. 142.2 mEq/L, p < 0.001), chloride (111.8 mEq/L vs. 106.6 mEq/L, p < 0.001), and osmolarity (305.8 mOsm/kg vs. 299.4 mOsm/kg; p = 0.006), and significantly lower arterial pH (7.34 vs. 7.38; p = 0.011). The HTS patients had lower intravenous fluid (IVF) volumes within 48 hours of TAC (8.5 L vs. 11.8 L; p = 0.004). Serum creatinine, urine output, and kidney injury were similar between groups. Fascial closure was achieved for 92% of all HTS patients and 77% of all standard resuscitation patients (p = 0.063). Considering all 189 patients, higher IVF resuscitation volumes within 48 hours of TAC were associated with decreased odds of fascial closure (odds ratio, 0.90; 95% confidence interval, 0.83-0.97; p = 0.003). CONCLUSION: Hypertonic saline resuscitation was associated with the development of a hypernatremic, hyperchloremic, hyperosmolar acidosis, and lower total IVF resuscitation volumes, without adversely affecting renal function. These findings may not be generalizable to patients with baseline renal dysfunction and susceptibility to hyperchloremic acidosis-induced kidney injury. LEVEL OF EVIDENCE: Prognostic study, level II.

Successful nonoperative management of uncomplicated appendicitis: predictors and outcomes.

BACKGROUND: Our objective was to identify predictors of successful nonoperative management (NOM) of uncomplicated appendicitis. We hypothesized that the absence of diabetes, absence of an appendicolith, short duration of symptoms, absence of systemic inflammation, and low modified Alvarado score would predict successful NOM. METHODS: We performed a retrospective cohort analysis of 81 consecutive patients who underwent NOM of uncomplicated appendicitis. Successful NOM was defined as resolution of appendicitis with antibiotics alone and no recurrent appendicitis within 180 days. Patients with successful NOM (n = 36) were compared with patients who failed NOM (n = 45). Multivariable logistic regression was used to identify predictors of successful NOM, expressed as odds ratios (ORs) with 95% confidence intervals. Model strength was assessed by calculating area under the receiver operating characteristic curve (AUC). RESULTS: Patient age (35 years), the American Society of Anesthesiologists class (2.0), and Charlson comorbidity index (0.0) were similar between groups. Independent predictors of successful NOM were duration of symptoms prior to admission >25 hours: OR 4.17 (1.42-12.24), maximum temperature within 6 hours of admission <37.3°C: OR 8.07 (1.79-36.38), modified Alvarado score <4: OR 9.06 (1.26-64.93), and appendiceal diameter <13 mm: OR 17.55 (1.30-237.28); model AUC: 0.81 (0.72-0.90). CONCLUSIONS: Patients with a longer duration of symptoms prior to admission were more likely to have successful NOM. Other independent predictors of successful NOM included lower temperature, lower modified Alvarado score, and smaller appendiceal diameter. These findings provide a framework for clinical decision-making and large-scale derivation and validation of a model to predict successful NOM of uncomplicated appendicitis.

Characterization of hypoalbuminemia following temporary abdominal closure.

BACKGROUND: The purpose of this study was to characterize associations among serum proteins, negative-pressure wound therapy (NPWT) fluid loss, and primary fascial closure (PFC) following emergent laparotomy and temporary abdominal closure (TAC). We hypothesized that high levels of C-reactive protein (CRP) and NPWT output would be associated with hypoalbuminemia and failure to achieve PFC. METHODS: We performed a retrospective analysis of 233 patients managed with NPWT TAC. Serum proteins and resuscitation indices were assessed on admission, initial laparotomy, and then at 48 hours, 96 hours, 7 days, and discharge. Correlations were assessed by Pearson coefficient. Multivariable regression was performed to identify predictors of PFC with cutoff values for continuous variables determined by Youden index. RESULTS: Patients who failed to achieve PFC (n = 55) had significantly higher CRP at admission (249 vs. 148 mg/L, p = 0.003), initial laparotomy (237 vs. 154, p = 0.002), and discharge (124 vs. 72, p = 0.003), as well as significantly lower serum albumin at 7 days (2.3 vs. 2.5 g/dL, p = 0.028) and discharge (2.5 vs. 2.8, p = 0.004). Prealbumin (in milligrams per deciliter) was similar between groups at each time point. There was an inverse correlation between nadir serum albumin and total milliliters of NPWT output (r = -0.33, p < 0.001). Exogenous albumin administration (in grams per day) correlated with higher serum albumin levels at each time point: 48 hours: r = 0.26 (p = 0.002), 96 hours: r = 0.29 (p = 0.002), 7 days: r = 0.40 (p < 0.001). Albumin of less than 2.6 g/dL was an independent predictor of failure to achieve PFC (odds ratio, 2.59; 95% confidence interval, 1.02-6.61) in a multivariate model including abdominal sepsis, body mass index of greater than 40 kg/m, and CRP of greater than 250 mg/L. CONCLUSIONS: Early and persistent systemic inflammation and high NPWT output were associated with hypoalbuminemia, which was an independent predictor of failure to achieve PFC. The utility of exogenous albumin following TAC requires further study. LEVEL OF EVIDENCE: Prognostic study, level III; Therapeutic study, level IV.