A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study.

BACKGROUND: Dense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. METHODS: A multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. RESULTS: In 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. CONCLUSION: Laparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial.

BACKGROUND: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(ß -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE: IV.

Managing career transitions in the profession of acute care surgery.

Career shifts are a naturally occurring part of the trauma and acute care surgeon's profession. These transitions may occur at various timepoints throughout a surgeon's career and each has their own specific challenges. Finding a good fit for your first job is critical for ensuring success as an early career surgeon. Equally, understanding how to navigate promotions or a change in job location mid-career can be fraught with uncertainty. As one progresses in their career, knowing when to take on a leadership position is oftentimes difficult as it may mean a change in priorities. Finally, navigating your path towards a fulfilling retirement is a complex discussion that is different for each surgeon. The American Association for the Surgery of Trauma (AAST) convened an expert panel of acute care surgeons in a virtual grand rounds session in August 2023 to address the aforementioned career transitions and highlight strategies for successfully navigating each shift. This was a collaboration between the AAST Associate Member Council (consisting of surgical resident, fellow and junior faculty members), the AAST Military Liaison Committee and the AAST Healthcare Economics Committee. Led by two moderators, the panel consisted of early, mid-career and senior surgeons, and recommendations are summarized below and in figure 1.

Percutaneous thoracostomy with thoracic lavage for traumatic hemothorax: a performance improvement initiative.

Objectives: Percutaneously placed small-bore (14 Fr) catheters and pleural lavage have emerged independently as innovative approaches to hemothorax management. This report describes techniques for combining percutaneous thoracostomy with pleural lavage and presents results from a performance improvement series of patients managed with percutaneous thoracostomy with immediate lavage. Methods: This was a prospective performance improvement series of patients treated at a level 1 trauma center with percutaneous thoracostomy and immediate lavage between April 2021 and May 2023. Results: Percutaneous thoracostomy with immediate lavage was used to treat nine hemodynamically normal patients with acute hemothorax. Injuries included both blunt and penetrating mechanisms. 56% of patients presented immediately after injury, and 44% presented in a delayed fashion ranging from 2 to 26 days after injury. Median length of stay was 6 days (IQR 6, 9). Seven patients were discharged home in stable condition, one was discharged to an acute rehabilitation facility, and one was discharged to a skilled nursing facility. Conclusions: Percutaneous thoracostomy with pleural lavage is clinically feasible and effective and warrants further evaluation with a multicenter clinical trial. Level of evidence: Therapeutic/care management, level V.

Teamwork matters: The association between nontechnical skills and cardiac arrest in trauma patients presenting with hypotension.

BACKGROUND: The impact of trauma team dynamics on outcomes in injured patients is not completely understood. We sought to evaluate the association between trauma team function, as measured by a modified Trauma Non-Technical Skills assessment, and cardiac arrest in hypotensive trauma patients. We hypothesized that better team function is associated with a decreased probability of developing cardiac arrest. METHODS: Trauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centers. Hypotension at emergency department presentation was defined as an initial systolic blood pressure <90 mm Hg or an initial systolic blood pressure ≥90 mm Hg followed by a systolic blood pressure <90 mm Hg within the first 5 minutes. Team dynamics were scored using a modified Trauma Non-Technical Skills assessment composed of 5 domains with combined scores ranging from 5 (best) to 15 (worst). Scores were compared between cardiac arrest/noncardiac arrest cases in the trauma bay. Logistic regression was used to evaluate the independent association between the Trauma Non-Technical Skills assessment and cardiac arrest. RESULTS: A total of 430 patients were included (median age 43 years [interquartile range: 29-61]; 71.8% male; 36% penetrating mechanism; median Injury Severity Score 20 [10-33]; 11% experienced cardiac arrest in trauma bay). The median total Trauma Non-Technical Skills assessment score was 7 (6-9), higher in patients who experienced cardiac arrest in the trauma bay (9 [6-10] vs 7 [6-9]; P = .016). This association persisted after controlling for age, sex, mechanism, injury severity, initial systolic blood pressure, and initial Glasgow Coma Scale score (adjusted odds ratio: 1.28; 95% confidence interval:1.11-1.48; P < .001), indicating a ∼3% higher predicted probability of cardiac arrest per Trauma Non-Technical Skills point. CONCLUSION: Better team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. This suggests that trauma team training may improve outcomes in peri-arrest patients.

Handoffs and Transitions of Care: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: The Joint Commission reports at least half of communication breakdowns occur during handovers or transitions of care. There is no consensus on how best to approach the transfer of care within Acute Care Surgery (ACS). We conduct a systematic review and meta-analysis of the current data on handoffs and transitions of care in ACS patients and evaluate the impact of standardization and formalized communication processes. METHODS: Clinically relevant questions regarding handoffs and transitions of care with clearly defined patient Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes (PICO) were determined. These centered around specific transitions of care within the setting of ACS - specifically perioperative interactions, EMS and trauma team interactions, and intra/inter floor and ICU interactions. A systematic literature review and meta-analysis was conducted utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS: A total of 10 studies were identified for analysis. These included 5,113 patients in the standardized handoff group and 5,293 in the current process group. Standardized handoffs reduced handover errors for perioperative interactions and preventable adverse events for intra/inter floor and ICU interactions. There was insufficient data to evaluate outcomes of clinical complications and medical errors. CONCLUSION: We conditionally recommend a standardized handoff in in the field of ACS, including perioperative interactions, EMS and trauma team interactions, as well as intra-inter floor and ICU interactions. LEVEL OF EVIDENCE: Guideline; Systematic review/meta-analysis, Level III.

Primary Repair Versus Resection for AAST Grade I and II Colon Injuries: Does the Type of Repair Matter?

INTRODUCTION: The management of traumatic colon injuries has evolved over the past two decades. Recent evidence suggests that primary repair or resection over colostomy may decrease morbidity and mortality. Data comparing patients undergoing primary repair versus resection are lacking. We sought to compare the outcomes of patients undergoing primary repair versus resection for low-grade colon injuries. METHODS: A retrospective review of all patients who presented with American Association for the Surgery of Trauma grade I and II traumatic colon injuries to our Level I trauma center between 2011 and 2021 was performed. Patients were further dichotomized based on whether they underwent primary repair or resection with anastomosis. Outcome measures included length of stay data, infectious complications, and mortality. RESULTS: A total of 120 patients met inclusion criteria. The majority of patients (76.7%) were male, and the average age was 35.6 ± 13.1 y. Most patients also underwent primary repair (80.8%). There were no statistically significant differences between the groups in arrival physiology or in injury severity score. Length of stay data including hospital length of stay, intensive care unit length of stay, and ventilator days were similar between groups. Postoperative complications including pneumonia, surgical site infections, fascial dehiscence, the development of enterocutaneous fistulas, and unplanned returns to the operating room were also all found to be similar between groups. The group who underwent resection with anastomosis did demonstrate a higher rate of intra-abdominal abscess development (3.1% versus 26.1%, P < 0001). Mortality between both groups was not found to be statistically significant (7.2% versus 4.3%, P = 0.4) CONCLUSIONS: For low-grade (American Association for the Surgery of Trauma I and II) traumatic colon injuries, patients undergoing primary repair demonstrated a decreased rate of intra-abdominal abscess development when compared to patients who underwent resection with anastomosis.

Getting out of the bay faster: Assessing trauma team performance using trauma video review.

BACKGROUND: Minutes matter for trauma patients in hemorrhagic shock. How trauma team function impacts time to the next phase of care has not been rigorously evaluated. We hypothesized better team performance scores to be associated with decreased time to the next phase of trauma care. METHODS: This retrospective secondary analysis of a prospective multicenter observational study included hypotensive trauma patients at 19 centers. Using trauma video review, we analyzed team performance with the validated Non-Technical Skills for Trauma scale: leadership, cooperation and resource management, communication, assessment/decision making, and situational awareness. The primary outcome was minutes from patient arrival to next phase of care; deaths in the bay were excluded. Secondary outcomes included time to initiation and completion of first unit of blood and inpatient mortality. Associations between team dynamics and outcomes were assessed with a linear mixed-effects model adjusting for Injury Severity Score, mechanism, initial blood pressure and heart rate, number of team members, and trauma team lead training level and sex. RESULTS: A total of 441 patients were included. The median Injury Severity Score was 22 (interquartile range, 10-34), and most (61%) sustained blunt trauma. The median time to next phase of care was 23.5 minutes (interquartile range, 17-35 minutes). Better leadership, communication, assessment/decision making, and situational awareness scores were associated with faster times to next phase of care (all p < 0.05). Each 1-point worsening in the Non-Technical Skills for Trauma scale score (scale, 5-15) was associated with 1.6 minutes more in the bay. The median resuscitation team size was 12 (interquartile range, 10-15), and larger teams were slower ( p < 0.05). Better situational awareness was associated with faster completion of first unit of blood by 4 to 5 minutes ( p < 0.05). CONCLUSION: Better team performance is associated with faster transitions to next phase of care in hypotensive trauma patients, and larger teams are slower. Trauma team training should focus on optimizing team performance to facilitate faster hemorrhage control. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Automated segmentation of phases, steps, and tasks in laparoscopic cholecystectomy using deep learning.

BACKGROUND: Video-based review is paramount for operative performance assessment but can be laborious when performed manually. Hierarchical Task Analysis (HTA) is a well-known method that divides any procedure into phases, steps, and tasks. HTA requires large datasets of videos with consistent definitions at each level. Our aim was to develop an AI model for automated segmentation of phases, steps, and tasks for laparoscopic cholecystectomy videos using a standardized HTA. METHODS: A total of 160 laparoscopic cholecystectomy videos were collected from a publicly available dataset known as cholec80 and from our own institution. All videos were annotated for the beginning and ending of a predefined set of phases, steps, and tasks. Deep learning models were then separately developed and trained for the three levels using a 3D Convolutional Neural Network architecture. RESULTS: Four phases, eight steps, and nineteen tasks were defined through expert consensus. The training set for our deep learning models contained 100 videos with an additional 20 videos for hyperparameter optimization and tuning. The remaining 40 videos were used for testing the performance. The overall accuracy for phases, steps, and tasks were 0.90, 0.81, and 0.65 with the average F1 score of 0.86, 0.76 and 0.48 respectively. Control of bleeding and bile spillage tasks were most variable in definition, operative management, and clinical relevance. CONCLUSION: The use of hierarchical task analysis for surgical video analysis has numerous applications in AI-based automated systems. Our results show that our tiered method of task analysis can successfully be used to train a DL model.

A Real-Time Automated Machine Learning Algorithm for Predicting Mortality in Trauma Patients: Survey Says it's Ready for Prime-Time.

BACKGROUND: Though artificial intelligence ("AI") has been increasingly applied to patient care, many of these predictive models are retrospective and not readily available for real-time decision-making. This survey-based study aims to evaluate implementation of a new, validated mortality risk calculator (Parkland Trauma Index of Mortality, "PTIM") embedded in our electronic healthrecord ("EHR") that calculates hourly predictions of mortality with high sensitivity and specificity. METHODS: This is a prospective, survey-based study performed at a level 1 trauma center. An anonymous survey was sent to surgical providers and regarding PTIM implementation. The PTIM score evaluates 23 variables including Glasgow Coma Score (GCS), vital signs, and laboratory data. RESULTS: Of the 40 completed surveys, 35 reported using PTIM in decision-making. Prior to reviewing PTIM, providers identified perceived top 3 predictors of mortality, including GCS (22/38, 58%), age (18/35, 47%), and maximum heart rate (17/35, 45%). Most providers reported the PTIM assisted their treatment decisions (27/35, 77%) and timing of operative intervention (23/35, 66%). Many providers agreed that PTIM integrated into rounds and patient assessment (22/36, 61%) and that it improved efficiency in assessing patients' potential mortality (21/36, 58%). CONCLUSIONS: Artificial intelligence algorithms are mostly retrospective and lag in real-time prediction of mortality. To our knowledge, this is the first real-time, automated algorithm predicting mortality in trauma patients. In this small survey-based study, we found PTIM assists in decision-making, timing of intervention, and improves accuracy in assessing mortality. Next steps include evaluating the short- and long-term impact on patient outcomes.

Reliability of the safety threats and adverse events in trauma (STAT) taxonomy using trauma video review.

PURPOSE: The STAT (Safety Threats and Adverse Events in Trauma) taxonomy was developed through expert consensus, and groups 65 identified trauma resuscitation adverse events (AEs) into nine distinct categories. It provides a framework for standardized analysis of trauma resuscitations and creates a foundation for targeted quality improvement and patient safety initiatives. This study aims to evaluate the reliability of the STAT taxonomy in identifying AEs during video-recorded trauma resuscitations. METHODS: High-definition audiovisual data from 30 trauma resuscitations were reviewed. Videos were assessed and scored by four independent reviewers (two trainees and two staff). The STAT taxonomy was used to identify AEs based on binary responses: yes and no. Inter-rater reliability was calculated using Gwet's AC1. The frequencies of AEs were tallied and reported as counts and percentages. RESULTS: The most common AEs identified in the videos were failure to measure temperature (86.7%) and inadequate personal protective equipment (86.7%), followed by inability to use closed-loop communication (76.7%). The agreement on all AEs between reviewers was 0.94 (95% CI: 0.93-0.95). The Gwet's AC1 agreement across the 9 AE categories was paramedic handover (0.82), airway and breathing (0.99), circulation (0.95), assessment of injuries (0.91), management of injuries (0.96), procedure-related (0.97), patient monitoring and IV access (0.99), disposition (0.98), team communication and dynamics (0.87). CONCLUSION: The STAT taxonomy demonstrated excellent inter-rater reliability between reviewers and can be used to identify AEs in video-recorded trauma resuscitations. These results provide a foundation for adapting video review to objectively quantify and assess AEs in the trauma bay.

Parkland Trauma Index of Mortality in Orthopaedic Trauma Patients: An Initial Report.

OBJECTIVES: The extent and timing of surgery in severely injured patients remains an unsolved problem in orthopaedic trauma. Different laboratory values or scores have been used to try to predict mortality and estimate physiological reserve. The Parkland Trauma Index of Mortality (PTIM) has been validated as an electronic medical record-integrated algorithm to help with operative timing in trauma patients. The aim of this study was to report our initial experience with PTIM and how it relates to other scores. METHODS: A retrospective chart review of level 1 and level 2 trauma patients admitted to our institution between December 2020 and November 2022 was conducted. Patients scored with PTIM with orthopaedic injuries were included in this study. Exclusion criteria were patients younger than 18 years. RESULTS: Seven hundred seventy-four patients (246 female patients) with a median age of 40.5 (18-101) were included. Mortality was 3.1%. Patients in the PTIM high-risk category (≥0.5) had a 20% mortality rate. The median PTIM was 0.075 (0-0.89) and the median Injury Severity Score (ISS) was 9.0 (1-59). PTIM (P < 0.001) and ISS (P < 0.001) were significantly lower in surviving patients. PTIM was mentioned in 7.6% of cases, and in 1.7% of cases, providers indicated an action in response to the PTIM. PTIM and ISS were significantly higher in patients with documented PTIM. CONCLUSION: PTIM is better at predicting mortality compared with ISS. Our low rate of PTIM documentation in provider notes highlights the challenges of implementing a new algorithm. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

How do we PI? Results of an EAST quality, patient safety, and outcomes survey.

Background: Quality improvement is a cornerstone for any verified trauma center. Conducting effective quality and performance improvement, however, remains a challenge. In this study, we sought to better explore the landscape and challenges facing the members of the Eastern Association for the Surgery of Trauma (EAST) through a survey. Methods: A survey was designed by the EAST Quality Patient Safety and Outcomes Committee. It was reviewed by the EAST Research and Scholarship Committee and then distributed to 2511 EAST members. The questions were designed to understand the frequency, content, and perceptions surrounding quality improvement processes. Results: There were 151 respondents of the 2511 surveys sent (6.0%). The majority were trauma faculty (55%) or trauma medical directors (TMDs) (37%) at American College of Surgeons level I (62%) or II (17%) trauma centers. We found a wide variety of resources being used across hospitals with the majority of cases being identified by a TMD or attending (81%) for a multidisciplinary peer review (70.2%). There was a statistically significant difference in the perception of the effectiveness of the quality improvement process with TMDs being more likely to describe their process as moderately or very effective compared with their peers (77.5% vs. 57.7%, p=0.026). The 'Just Culture' model appeared to have a positive effect on the process improvement environment, with providers less likely to report a non-conducive environment (10.9% vs. 27.6%, p=0.012) and less feelings of assigning blame (3.1% vs. 13.8%, p=0.026). Conclusion: Case review remains an essential but challenging process. Our survey reveals a need to continue to advocate for appropriate time and resources to conduct strong quality improvement processes. Level of evidence: Epidemiological study, level III.

Assessing North Texas Regional Trauma Handoffs: A Multicenter Mixed-Methods Needs Assessment.

INTRODUCTION: Trauma video review of Emergency Medical Services (EMS) handoffs demonstrates frequent problems including interruptions and incomplete information transfer. This study aimed to perform a regional needs assessment of handoff perceptions and expectations to guide future standardization efforts. METHODS: A multidisciplinary team of trauma providers through consensus building created an anonymous survey which was then distributed through the North Central Texas Trauma Regional Advisory Council and four regional level-1 trauma institutions. Qualitative data underwent content analysis; quantitative data are presented with descriptive statistics. RESULTS: Survey responses (n = 249) were submitted by trauma nurses (38%), EMS (24%), emergency physicians (14%), and trauma physicians (13%). Median overall handoff quality was rated well (4, scale 1-5) despite some variability between hospitals (3, scale 1-5). The top five most important handoff details were the same for both stable and unstable patients: primary mechanism, blood pressure, heart rate, Glasgow Coma Scale, and location of injuries. While providers felt neutral about the data order, the vast majority supported immediate bed transfer and primary survey in unstable patients. The majority of receiving providers report interrupting handoff at least once (78%); and 66% of EMS clinicians found interruptions disruptive. Content analysis revealed top priority categories for improvement: environment, communication, information relayed, team dynamics, and flow of care. CONCLUSION: Although our data demonstrated satisfaction and concordance with respect to the EMS handoff, 84% of EMS clinicians reported some to high amounts of variability across institutions. Gaps in the development of standardized handoffs identified include exposure, education, and enforcement of these protocols.

Under the Lens: Team Perception of Trauma Video Review.

BACKGROUND: Video-based assessment and review are becoming increasingly common, and trauma video review (TVR) has been shown to be an effective educational, quality improvement, and research tool. Yet, trauma team perception of TVR remains incompletely understood. OBJECTIVE: We evaluated positive and negative perceptions of TVR across multiple team member groups. We hypothesized that members of the trauma team would find TVR educational and that anxiety would be low across all groups. METHODS: An anonymous electronic survey was provided to nurses, trainees, and faculty during weekly multidisciplinary trauma performance improvement conference following each TVR activity. Surveys assessed perception of performance improvement and anxiety or apprehension (Likert scale: 1 "strongly disagree" to 5 "strongly agree"). We report individual and normalized cumulative scores (average of responses for each positive [n = 6] and negative [n = 4] question stem). RESULTS: We analyzed 146 surveys over 8 months, with 100% completion rate. Respondents were trainees (58%), faculty (29%), and nurses (13%). Of the trainees, 73% were postgraduate year (PGY) 1-3 and 27% were PGY 4-9. Of all respondents, 84% had participated previously in a TVR conference. Respondents reported an improved perception of resuscitation education quality and personal leadership skills development. Participants found TVR to be more educational than punitive overall. Analysis of team member types showed lower scores for faculty for all positive stemmed questions. Trainees were more likely to agree with negative stemmed questions if they were a lower PGY, and nurses were least likely to agree with negative stemmed questions. CONCLUSIONS: TVR improves trauma resuscitation education in a conference setting, with trainees and nurses reporting the greatest benefit. Nurses were noted to be the least apprehensive about TVR.

Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review.

BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Outcomes among trauma patients with duodenal leak following primary versus complex repair of duodenal injuries: An Eastern Association for the Surgery of Trauma multicenter trial.

BACKGROUND: Duodenal leak is a feared complication of repair, and innovative complex repairs with adjunctive measures (CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak are sparse, and its impact on duodenal leak outcomes is nonexistent. We hypothesized that primary repair alone (PRA) would be associated with decreased duodenal leak rates; however, CRAM would be associated with improved recovery and outcomes when leaks do occur. METHODS: A retrospective, multicenter analysis from 35 Level 1 trauma centers included patients older than 14 years with operative, traumatic duodenal injuries (January 2010 to December 2020). The study sample compared duodenal operative repair strategy: PRA versus CRAM (any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy). RESULTS: The sample (N = 861) was primarily young (33 years) men (84%) with penetrating injuries (77%); 523 underwent PRA and 338 underwent CRAM. Complex repairs with adjunctive measures were more critically injured than PRA and had higher leak rates (CRAM 21% vs. PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more interventional radiology drains, prolonged nothing by mouth and length of stay, greater mortality, and more readmissions than PRA (all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, nothing by mouth duration, need for interventional radiology drainage, hospital length of stay, or mortality between PRA leak versus CRAM leak patients (all p > 0.05). Furthermore, CRAM leaks had longer antibiotic duration, more gastrointestinal complications, and longer duration until leak resolution (all p < 0.05). Primary repair alone was associated with 60% lower odds of leak, whereas injury grades II to IV, damage control, and body mass index had higher odds of leak (all p < 0.05). There were no leaks among patients with grades IV and V injuries repaired by PRA. CONCLUSION: Complex repairs with adjunctive measures did not prevent duodenal leaks and, moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest that CRAM is not a protective operative duodenal repair strategy, and PRA should be pursued for all injury grades when feasible. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.