Laparoscopic Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in Elderly Patients With Acute Gallstone Pancreatitis.

BACKGROUND: Gallstone pancreatitis (GSP) is common in elderly patients and carries worse outcomes. Laparoscopic cholecystectomy (LC) is recommended for prevention of recurrent GSP. In frail populations, an endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-s) is an alternative. Management guidelines of GSP in the elderly are lacking. This study aimed to investigate and compare management strategies for GSP in the elderly. MATERIALS AND METHODS: A retrospective comparison of outcome of patients aged ≥65 years with first presentation of GSP treated either with (1) LC only, (2) ERCP-s, (3) ERCP-S followed by LC, or (4) no intervention. RESULTS: 216 patients were included. Median age was 76 years (interquartile range 70-83). Most (80%, n = 172) had mild pancreatitis, whilst 12% (n = 26) had severe disease. 24% (n = 55) were treated with ERCP-s; 40% (n = 87) underwent LC alone; 11% (n = 23) had ERCP-s followed by LC; and 25% (n = 55) received no intervention. Patients without intervention were older (P < .001) and frailer (P < .001). The LC-only group had lower post-procedure re-admission rates of 6% (n = 5) compared to 27% (n = 14) for ERCP-s, 33% (n = 7) for ERCP-S + LC, and 31% (n = 17) for the no intervention group (P = .0001). Biliary cause mortality was highest in the no intervention group (n = 11, 20%). CONCLUSION: Laparoscopic cholecystectomy represents the gold standard for elderly patients with GSP.

The impact of anticholinergic burden on clinical outcomes in older hospitalised surgical patients.

Polypharmacotherapy is an ever-increasing issue with an ageing patient population. Anticholinergic medications make up a large proportion of patient medication but cause significant side effects, contributing to well-documented issues within the older population and in hospital medicine. This review explores the documented impact of anticholinergic burden in older surgical patients on postoperative delirium, infection, length of stay and readmission, urinary retention, ileus and mortality. It also highlights the need for further high-quality research into anticholinergic burden management among older surgical patients to further impact practice and policy in the area.

The Impact of Depression in Patients Undergoing Emergency Abdominal Surgery: An Exploratory Study.

BACKGROUND: Depression is associated with poorer outcomes in many disease states. However, its significance in abdominal surgery is unknown. This study investigated rates of depression in emergency abdominal surgery patients and its effects on outcomes. METHODS: A retrospective cohort study was conducted across two UK sites and included all adult patients undergoing emergency abdominal surgery. Primary outcome was the complication rate in depressed patients, including the incidence of post-operative delirium. Secondary outcomes included mortality, time to oral intake and analgesia. RESULTS: Two hundred and ten patients were identified. The commonest indication for surgery was appendicitis (53.3%) followed by small bowel obstruction (9.5%). There was a 17% (n = 36) incidence of depression amongst patients, most of whom (n = 26, 72.2%) were taking antidepressants. Depression was associated with male sex (M:F 27:9 p = 0.003), higher median BMI (28 vs. 25 p = 0.013) and previous surgery (47.2% vs. 28.7% p = 0.032). Despite a higher incidence of post-operative delirium, increased time to oral analgesia and greater 30-day readmission rates in the depression cohort, multivariate analyses showed depression was not a significant independent predictor of these (OR 2.181, 95%CI 0.310-15.344; p = 0.433, OR 0.07, 95%CI 0.499-1.408; p = 0.348 and OR 1.367, 95%CI 0.102-18.34, respectively). Complication and mortality rates between depressed and non-depressed individuals were similar. CONCLUSION: Significant numbers of patients undergoing emergency abdominal surgery have depression, but this did not adversely affect post-operative outcomes. The study included relatively small numbers of participants undergoing procedures with straightforward recovery. Larger population studies are therefore required and should focus on investigating the association between major emergency surgeries with post-operative delirium and uncontrolled pain.

A high-volume ERCP service led by surgeons is associated with good outcomes and meets national key performance indicators: results from a British district general hospital.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common, but technically challenging procedure used in the management of hepatopancreaticobiliary (HPB) disease. It is traditionally performed by medical gastroenterologists. In 2014, the British Society of Gastroenterology (BSG) proposed key performance indicators to evaluate and set standards of ERCP practice. This study aimed to compare our ERCP outcomes against these targets, in a centre where ERCP is exclusively performed by surgeons. METHODS: A retrospective analysis of all ERCPs undertaken over a 38 months in a District General Hospital in the United Kingdom (UK), by three Upper Gastrointestinal Surgeons. Study outcomes were based upon, and compared against, BSG key performance indicators, including number of ERCPs per annum, proportion of successful cannulations of bile duct and stone clearance, ERCP-specific complications and mortality. RESULTS: The unit's caseload over this period was 1324, equating to approximately 418 per annum (BSG minimum 200 per unit). Management of bile duct stones was the commonest indication for ERCP. Overall, 95% (1253/1324) of bile ducts were cannulated and 92% (645/698) for those undergoing their first ERCP. Bile duct clearance was achieved in 80% of patients (BSG recommend > 75%) and the successful stenting of extra-hepatic strictures in 94% (BSG recommend > 80%). The overall complication rate was 4.3% (BSG standard < 6%). Procedure-specific mortality was 0.3% (4/1324) where death was either caused by pancreatitis or sepsis. CONCLUSION: A high-volume ERCP service led and performed exclusively by surgeons meets all BSG performance indicators, with good procedural and patient outcomes. Formal training pathways should be developed to encourage more surgical centres to provide an ERCP service and deal with what are common surgical pathologies.

The Laparoscopic Management of Median Arcuate Ligament Syndrome and Its Long-Term Outcomes.

BACKGROUND: Case reports and small series of the surgical and radiological management of median arcuate ligament syndrome (MALS) have been described, however, long-term outcome data are lacking. The purpose of this study was to review our experience of the laparoscopic management of MALS, and describe the long-term outcomes after surgical intervention. METHODS: Data were collected between 2005 and 2016 in a single U.K. institution. All patients with MALS who underwent laparoscopic decompression of the celiac artery were included. Surgical outcomes were recorded from a prospectively collected database. Long-term outcomes were determined by outpatient review and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: Six patients were included. Five were female with a median age of 30 years (22.3-48.3). All six presented with abdominal pain and a bruit. Length of symptoms on presentation was 41 months (19-69). Duplex ultrasonography indicated celiac trunk stenosis in each case, with an elevated peak velocity flow in the celiac trunk of 230 cm/s (210-287.5). All six underwent successful laparoscopic decompression of the celiac artery with no conversions to open. Operating time was 137.3 minutes (95.6-166.3) and intraoperative blood loss was 110 mL (65-225). Length of stay was one day (1-2.3), with no postoperative complications or mortality. Median follow-up was 109.5 months (78-113.5). At this point, all patients remained symptom free with an overall GIQLI score of 129/144 (123.8-134.5). CONCLUSIONS: MALS is a rare condition. Laparoscopic decompression of the median arcuate ligament is safe and offers long-term resolution of symptoms, and improvement in patient quality of life.

Mechanisms Involved in Secondary Cardiac Dysfunction in Animal Models of Trauma and Hemorrhagic Shock.

Clinical evidence reveals the existence of a trauma-induced secondary cardiac injury (TISCI) that is associated with poor patient outcomes. The mechanisms leading to TISCI in injured patients are uncertain. Conversely, animal models of trauma hemorrhage have repeatedly demonstrated significant cardiac dysfunction following injury, and highlighted mechanisms through which this might occur. The aim of this review was to provide an overview of the animal studies describing TISCI and its pathophysiology.Basic science models of trauma show evidence of innate immune system activation via Toll-like receptors, the exact protagonists of which remain unclear. Shortly following trauma and hemorrhage, cardiomyocytes upregulate gene regulatory protein and inflammatory molecule expression including nuclear factor kappa beta, tumor necrosis factor alpha, and interleukin-6. This is associated with expression of membrane bound adhesion molecules and chemokines leading to marked myocardial leukocyte infiltration. This cell activation and infiltration is linked to a rise in enzymes that cause oxidative and nitrative stress and subsequent protein misfolding within cardiomyocytes. Such protein damage may lead to reduced contractility and myocyte apoptosis. Other molecules have been identified as cardioprotective following injury. These include p38 mitogen-activated protein kinases and heat shock proteins.The balance between increasing damaging mediators and a reduction in cardio-protective molecules appears to define myocardial function following trauma. Exogenous therapeutics have been trialled in rodents with promising abilities to favorably alter this balance, and subsequently lead to improved cardiac function.

Elderly patients have similar short term outcomes and five-year survival compared to younger patients after pancreaticoduodenectomy.

BACKGROUND: Outcomes following pancreaticoduodenectomy (PD) in elderly patients in the United Kingdom (UK) remain uncertain. This study aimed to analyse peri-operative outcomes in the elderly, and investigate the impact of age on five-year survival following PD in a UK tertiary centre. MATERIALS AND METHODS: All patients who underwent PD in a single Hepatobiliary and Pancreatic unit in the UK between January 2007 to December 2015 were analysed from a prospectively collected database. Individuals were divided into two groups (Group A <75 years and Group B ≥ 75 years "elderly") and outcomes compared. RESULTS: Five hundred and twenty-four patients were included (Group A n = 422, Group B n = 102). Post-operative cardiac events and peri-operative mortality were higher in the elderly (10.8 vs 3.6%, p = 0.008 and 5.9 vs 1.9%, 0.037, respectively). Multivariate analysis revealed only ASA score (OR 0.279, 95% CI 0.063-1.130), post-pancreatectomy haemorrhage (OR 0.055, 95% CI 0.006-0.518) and pulmonary embolism (OR 0.03, 95% CI 0.00-0.148) as independent risk factors for peri-operative mortality. Age was not (OR 0.978, 95% CI 0.911-1.049). Median survival was 22 months in Group A and 19 months in Group B (p = 0.165). Predictors of five-year survival included vascular resection (OR 0.171, 95% CI 0.053-0.549), positive margin (OR 0.256, 95% CI 0.102-0.641), lympho-vascular invasion (OR 0.392, 95% CI 0.160-0.958) and lymph node ratio (OR 67.381, 95% CI 3.301-1375.586), but not age (OR 1.012, 95% CI 0.972-1.054). CONCLUSION: Older patients have similar peri-operative outcomes and five-year survival compared to younger counterparts after PD in a UK tertiary centre, and should be considered for surgical resection of pancreatic and periampullary cancers.

Mentored Trainees have Similar Short-Term Outcomes to a Consultant Trainer Following Laparoscopic Colorectal Resection.

BACKGROUND: Laparoscopic colorectal surgery has a long learning curve. Using a modular-based training programme may shorten this. Concerns with laparoscopic surgery have been oncological compromise and poor surgical outcomes when training more junior surgeons. This study aimed to compare operative and oncological outcomes between trainees undergoing a mentored training programme and a consultant trainer. METHODS: A prospective study of all elective laparoscopic colorectal resections was undertaken in a single institution. Operative and oncological outcomes were recorded. All trainees were mentored by a National Laparoscopic Trainer (Lapco), and results between trainer and trainees compared. RESULTS: Three hundred cases were included, with 198 (66%) performed for cancer. The trainer undertook 199 (66%) of operations, whilst trainees performed 101 (34%). Anterior resection was the commonest operation (n = 124, 41%). There were no differences between trainer and trainees for the majority of surgical outcomes, including blood loss (p = 0.598), conversion to open (p = 0.113), anastomotic leak (p = 0.263), readmission (p = 1.000) and death rates (p = 0.549). Only length of stay (p = 0.034), stoma formation (p < 0.01) and operative duration (p = 0.007) were higher in the trainer cohort, reflecting the more complex cases undertaken. Overall, there were no significant differences in both short- and longer-term oncology outcomes according to the grade of operating surgeon, including lymph nodes in specimen, circumferential resection margin and 1- and 2-year radiological recurrence. CONCLUSION: When a modular-based training system was combined with case selection, both clinical and histopathological outcomes following resectional laparoscopic colorectal surgery were similar between trainees and trainer. This should encourage the use of more training opportunities in laparoscopic colorectal surgery.

CT screened arterial calcification as a risk factor for mortality after trauma.

BACKGROUND: Arterial calcification on Computerised Tomography (CT) is a marker of cardiovascular disease. It is predictive of future adverse cardiac events and mortality in many disease states. The incidence of arterial disease and its impact on outcomes of the injured is not known. The objectives of this study were to describe the incidence of arterial calcification in trauma patients, and establish its impact on mortality. METHODS: A retrospective cohort study of all injured patients aged over 45 years presenting to a major trauma centre over a 34-month period. The presence and quantity of coronary, aortic and abdominal arterial calcification on admission CT scans of the chest, abdomen and pelvis was established, and the association between cardiovascular disease and in-hospital mortality following trauma was determined. RESULTS: Five hundred ninety-one patients were included in the study. Cardiac calcium was visible on 432 (73 %) scans, and abdominal arterial calcification on 472 (79.9 %). Fifty (8.5 %) patients died. Patients with Superior Mesenteric (SMA) and Common Iliac Artery calcification had a significantly higher mortality than those without (p < 0.01). In multivariarate analysis, only SMA calcification was independently associated with mortality (OR 2.462, 95 % CI 1.08-5.60, p = 0.032). Coronary calcium demonstrated no independent statistical relationship with death (Left Anterior Descending Artery OR 1.189, 95 % CI 0.51-2.78, Circumflex OR 1.290, 95 % CI 0.56-2.98, Right Coronary Artery OR 0.483, 95 % CI 0.21-1.10). DISCUSSION: This study has demonstrated that the identification of arterial calcification on admission CT scans of trauma patients is possible. Calcification was common, and present in around three-quarters of injured individuals over the age of 45 years. SMA calcium was an independent predictor of mortality. However, whilst the presence of arterial calcium demonstrated a tendency towards lower survival, this association was not significant in other territories, including the coronary arteries. Future studies should investigate further the association and pathophysiology linking SMA disease and mortality in trauma, in addition to the relationship between longer tem survival, adverse cardiac events and arterial calcification in injured patients. CONCLUSIONS: Arterial calcification can be reliably identified on trauma CT scans, and is common in injured patients. Abdominal vascular calcification appears to be a better predictor of mortality than coronary artery disease.

Early changes within the lymphocyte population are associated with the development of multiple organ dysfunction syndrome in trauma patients.

BACKGROUND: Early survival following severe injury has been improved with refined resuscitation strategies. Multiple organ dysfunction syndrome (MODS) is common among this fragile group of patients leading to prolonged hospital stay and late mortality. MODS after trauma is widely attributed to dysregulated inflammation but the precise mechanics of this response and its influence on organ injury are incompletely understood. This study was conducted to investigate the relationship between early lymphocyte responses and the development of MODS during admission. METHODS: During a 24-month period, trauma patients were recruited from an urban major trauma centre to an ongoing, observational cohort study. Admission blood samples were obtained within 2 h of injury and before in-hospital intervention, including blood transfusion. The study population was predominantly male with a blunt mechanism of injury. Lymphocyte subset populations including T helper, cytotoxic T cells, NK cells and γδ T cells were identified using flow cytometry. Early cytokine release and lymphocyte count during the first 7 days of admission were also examined. RESULTS: This study demonstrated that trauma patients who developed MODS had an increased population of NK dim cells (MODS vs no MODS: 22 % vs 13 %, p < 0.01) and reduced γδ-low T cells (MODS vs no MODS: 0.02 (0.01-0.03) vs 0.09 (0.06-0.12) × 10^9/L, p < 0.01) at admission. Critically injured patients who developed MODS (n = 27) had higher interferon gamma (IFN-γ) concentrations at admission, compared with patients of matched injury severity and shock (n = 60) who did not develop MODS (MODS vs no MODS: 4.1 (1.8-9.0) vs 1.0 (0.6-1.8) pg/ml, p = 0.01). Lymphopenia was observed within 24 h of injury and was persistent in those who developed MODS. Patients with a lymphocyte count of 0.5 × 10(9)/L or less at 48 h, had a 45 % mortality rate. CONCLUSIONS: This study provides evidence of lymphocyte activation within 2 h of injury, as demonstrated by increased NK dim cells, reduced γδ-low T lymphocytes and high blood IFN-γ concentration. These changes are associated with the development of MODS and lymphopenia. The study reveals new opportunities for investigation to characterise the cellular response to trauma and examine its influence on recovery.

The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway.

INTRODUCTION: Laparoscopic surgery is well established in the modern management of colorectal disease. More recently, enhanced recovery after surgery (ERAS) protocols have been introduced to further promote accelerated discharge and faster recovery. However, not all patients are suitable for early discharge. The purpose of this study was to evaluate the early outcomes of patients undergoing such a regime to determine which peri-operative factors may predict safe accelerated discharge. METHODS: Data were prospectively collected on consecutive patients undergoing laparoscopic colorectal surgery. All patients followed the institution's ERAS protocol and were discharged once specific criteria were fulfilled. Clinical characteristics and outcomes were compared between patients who were discharged before and after 72 h post-surgery. Thereafter, the peri-operative factors that were associated with delayed discharge were determined using a binary logistic model. RESULTS: Three hundred patients were included in the analysis. The most common operation was laparoscopic anterior resection (n = 123, 41%). Mean length of stay was 4.8 days (standard deviation 5.9), with 185 (62%) patients discharged within 72 h. Ten (3%) patients had a post-operative complication. Three independent predictors of delayed discharge were identified; BMI (OR 1.06, 95%CI 1.01-1.11), operation length (OR 0.99, 95%CI 0.98-0.99) and complications (OR 16.26, 95%CI 4.88-54.08). CONCLUSIONS: A combined approach of laparoscopic surgery and ERAS leads to reduced length of stay. This enables more than 60% of patients to be discharged within 72 h. Increased BMI, duration of operation and complications post-operatively independently predict a longer length of stay.

Obese patients have similar short-term outcomes to non-obese in laparoscopic colorectal surgery.

AIM: To determine whether obese patients undergoing laparoscopic surgery within an enhanced recovery program had worse short-term outcomes. METHODS: A prospective study of consecutive patients undergoing laparoscopic colorectal resection was carried out between 2008 and 2011 in a single institution. Patients were divided in groups based on body mass index (BMI). Short-term outcomes including operative data, length of stay, complications and readmission rates were recorded and compared between the groups. Continuous data were analysed using t-test or one-way Analysis of Variance. χ(2) test was used to compare categorical data. RESULTS: Two hundred and fifty four patients were included over the study period. The majority of individuals (41.7%) recruited were of a healthy weight (BMI < 25), whilst 50 patients were classified as obese (19.6%). Patients were matched in terms of the presence of co-morbidities and previous abdominal surgery. Obese patients were found to have a statistically significant difference in The American Society of Anesthesiologists grade. Length of surgery and intra-operative blood loss were no different according to BMI. CONCLUSION: Obesity (BMI > 25) does not lead to worse short-term outcomes in laparoscopic colorectal surgery and therefore such patients should not be precluded from laparoscopic surgery.

Admission biomarkers of trauma-induced secondary cardiac injury predict adverse cardiac events and are associated with plasma catecholamine levels.

BACKGROUND: Secondary cardiac injury and dysfunction may be important contributors to poor outcomes in trauma patients, but the pathophysiology and clinical impact remain unclear. Early elevations in cardiac injury markers have been associated with the development of adverse cardiac events (ACEs), prolonged intensive care unit stays, and increased mortality. Studies of preinjury ß-blocker use suggest a potential protective effect in critically ill trauma patients. This study aimed to prospectively examine the association of early biomarker evidence of trauma-induced secondary cardiac injury (TISCI) and ACEs and to examine the potential contribution of circulating catecholamines to its pathophysiology. METHOD: Injured patients who met the study criteria were recruited at a single major trauma center. A blood sample was collected immediately on arrival. Serum epinephrine (E), norepinephrine (NE), and cardiac biomarkers including heart-related fatty acid binding protein (H-FABP) were assayed. Data were prospectively collected on ACEs. RESULTS: Of 300 patients recruited, 38 (13%) developed an ACE and had increased mortality (19% vs. 9%, p = 0.01) and longer intensive care unit stays (13 days, p < 0.001). H-FABP was elevated on admission in 56% of the patients, predicted the development of ACE, and was associated with higher mortality (14% vs. 5%, p = 0.01). Admission E and NE levels were strongly associated with elevations in H-FABP and ACEs (E, 274.0 pg/mL vs. 622.5 pg/mL, p < 0.001; NE, 1,063.2 pg/mL vs. 2,032.6 pg/mL, p < 0.001). Catecholamine effect on the development of TISCI or ACEs was not statistically independent of injury severity or depth of shock. CONCLUSION: Admission levels of H-FABP predict the development of ACEs and may be useful for prognosis and stratification of trauma patients. The development of TISCI and ACEs was associated with high admission levels of catecholamines, but their role in pathogenesis remains unclear. Clinical trials of adrenergic blockade may have the potential to demonstrate outcomes in patients presenting with TISCI. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level II.

Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma hemorrhage.

OBJECTIVE: To determine the effectiveness of blood component therapy in the correction of trauma-induced coagulopathy during hemorrhage. BACKGROUND: Severe hemorrhage remains a leading cause of mortality in trauma. Damage control resuscitation strategies target trauma-induced coagulopathy (TIC) with the early delivery of high-dose blood components such as fresh frozen plasma (FFP) and platelet transfusions. However, the ability of these products to correct TIC during hemorrhage and resuscitation is unknown. METHODS: This was an international prospective cohort study of bleeding trauma patients at three major trauma centers. A blood sample was drawn immediately on arrival and after 4, 8 and 12 packed red blood cell (PRBC) transfusions. FFP, platelet and cryoprecipitate use was recorded during these intervals. Samples were analyzed for functional coagulation and procoagulant factor levels. RESULTS: One hundred six patients who received at least four PRBC units were included. Thirty-four patients (32 %) required a massive transfusion. On admission 40 % of patients were coagulopathic (ROTEM CA5 ≤ 35 mm). This increased to 58 % after four PRBCs and 81 % after eight PRBCs. On average all functional coagulation parameters and procoagulant factor concentrations deteriorated during hemorrhage. There was no clear benefit to high-dose FFP therapy in any parameter. Only combined high-dose FFP, cryoprecipitate and platelet therapy with a high total fibrinogen load appeared to produce a consistent improvement in coagulation. CONCLUSIONS: Damage control resuscitation with standard doses of blood components did not consistently correct trauma-induced coagulopathy during hemorrhage. There is an important opportunity to improve TIC management during damage control resuscitation.

Trauma-induced secondary cardiac injury is associated with hyperacute elevations in inflammatory cytokines.

INTRODUCTION: Clinical evidence supports the existence of a trauma-induced secondary cardiac injury. Experimental research suggests inflammation as a possible mechanism. The study aimed to determine if there was an early association between inflammation and secondary cardiac injury in trauma patients. METHODS: A cohort study of critically injured patients between January 2008 and January 2010 was undertaken. Levels of the cardiac biomarkers troponin I and heart-specific fatty acid-binding protein and the cytokines tumor necrosis factor α (TNF-α), interleukin (IL)-6, IL-1ß, and IL-8 were measured on admission to hospital, and again at 24 and 72 h. Participants were reviewed for adverse cardiac events (ACEs) and in-hospital mortality. RESULTS: Of 135 patients recruited, 18 (13%) had an ACE. Patients with ACEs had higher admission plasma levels of TNF-α (5.4 vs. 3.8 pg/mL; P = 0.03), IL-6 (140 vs. 58.9 pg/mL, P = 0.009), and IL-8 (19.3 vs. 9.1 pg/mL, P = 0.03) compared with those without events. Hour 24 cytokines were not associated with events, but IL-8 (14.5 vs. 5.8 pg/mL; P = 0.01) and IL-1ß (0.55 vs. 0.19 pg/mL; P = 0.04) were higher in patients with ACEs at 72 hours. Admission IL-6 was independently associated with heart-specific fatty acid-binding protein increase (P < 0.05). Patients who presented with an elevated troponin I combined with either an elevated TNF-α (relative risk [RR], 11.0; 95% confidence interval [CI], 1.8-66.9; P = 0.015), elevated IL-6 (RR, 17.3; 95% CI, 2.9-101.4; P = 0.001), or elevated IL-8 (RR, 15.0; 95% CI, 3.1-72.9; P = 0.008) were at the highest risk of in-hospital death when compared with individuals with normal biomarker and cytokine values. CONCLUSIONS: There is an association between hyperacute elevations in inflammatory cytokines with cardiac injury and ACEs in critically injured patients. Biomarker evidence of cardiac injury and inflammation on admission is associated with a higher risk of in-hospital death.

A large ventricular septal defect complicating resuscitation after blunt trauma.

A young adult pedestrian was admitted to hospital after being hit by a car. On arrival to the Accident and Emergency Department, the patient was tachycardic, hypotensive, hypoxic, and acidotic with a Glasgow Coma Scale of 3. Despite initial interventions, the patient remained persistently hypotensive. An echocardiogram demonstrated a traumatic ventricular septal defect (VSD) with right ventricular strain and increased pulmonary artery pressure. Following a period of stabilization, open cardiothoracic surgery was performed and revealed an aneurysmal septum with a single large defect. This was repaired with a bovine patch, resulting in normalization of right ventricular function. This case provides a vivid depiction of a large VSD in a patient following blunt chest trauma with hemodynamic compromise. In all thoracic trauma patients, and particularly those poorly responsive to resuscitation, VSDs should be considered. Relevant investigations and management strategies are discussed.