Comparison of a standardized negative pressure wound therapy protocol after midline celiotomy to primary skin closure and traditional open wound vacuum-assisted closure management.

A negative pressure wound therapy (NPWT) protocol using Hydrofera Blue® bacteriostatic foam wicks and silver-impregnated foam overlay to close midline skin incisions after emergency celiotomy was compared to primary skin closure only and traditional open wound vacuum-assisted closure management as part of a quality improvement initiative. This single-institution retrospective cohort study assessed all consecutive emergency celiotomies from July 2013 to June 2014 excluding clean wounds. Included variables were demographics, wound classification, NPWT days, and surgical site occurrences (SSOs). Primary outcome was days of NPWT. Secondary outcomes included SSOs (surgical site infections, fascial dehiscence, return to operating room). Analysis used exact chi-square between categorical variables, Kruskal-Wallis for analysis of variance for ordinal and categorical variables, and Wilcoxon rank sum for total days of NPWT. One hundred fifty-eight patients underwent emergency celiotomy with primary skin closure (n = 51), open NPWT (n = 63), or the NPWT protocol (n = 44). There was no difference in American Society of Anesthesiologists Physical Status score, body mass index, wound classification, or SSO between the three groups. Total NPWT days were reduced in protocol versus open NPWT (median 3 vs 20.5 days, range 3-51 vs 3-405 days, P = 0.001). Primary skin closure and NPWT protocol had fewer patients discharged with NPWT than open NWPT (0% and 14% vs 63.5%, P < 0.0001, odds ratio = 10.7, 95% confidence interval 3.7-35.1). Primary skin closure and NPWT protocol decrease NPWT usage days and maintain low SSOs in emergency midline celiotomy incisions.

Implementation of a standardized handoff protocol for post-operative admissions to the surgical intensive care unit.

BACKGROUND: The transfer of critically ill patients from the operating room (OR) to the surgical intensive care unit (SICU) involves handoffs between multiple providers. Incomplete handoffs lead to poor communication, a major contributor to sentinel events. Our aim was to determine whether handoff standardization led to improvements in caregiver involvement and communication. METHODS: A prospective intervention study was designed to observe thirty one patient handoffs from OR to SICU for 49 critical parameters including caregiver presence, peri-operative details, and time required to complete key steps. Following a six month implementation period, thirty one handoffs were observed to determine improvement. RESULTS: A significant improvement in presence of physician providers including intensivists and surgeons was observed (p = 0.0004 and p < 0.0001, respectively). Critical details were communicated more consistently, including procedure performed (p = 0.0048), complications (p < 0.0001), difficult airways (p < 0.0001), ventilator settings (p < 0.0001) and pressor requirements (p = 0.0134). Conversely, handoff duration did not increase significantly (p = 0.22). CONCLUSIONS: Implementation of a standardized protocol for handoffs between OR and SICU significantly improved caregiver involvement and reduced information omission without affecting provider time commitment.

Concurrent chart review provides more accurate documentation and increased calculated case mix index, severity of illness, and risk of mortality.

BACKGROUND: Case mix index (CMI) is calculated to determine the relative value assigned to a Diagnosis-Related Group. Accurate documentation of patient complications and comorbidities and major complications and comorbidities changes CMI and can affect hospital reimbursement and future pay for performance metrics. STUDY DESIGN: Starting in 2010, a physician panel concurrently reviewed the documentation of the trauma/acute care surgeons. Clarifications of the Centers for Medicare and Medicaid Services term-specific documentation were made by the panel, and the surgeon could incorporate or decline the clinical queries. A retrospective review of trauma/acute care inpatients was performed. The mean severity of illness, risk of mortality, and CMI from 2009 were compared with the 3 subsequent years. Mean length of stay and mean Injury Severity Score by year were listed as measures of patient acuity. Statistical analysis was performed using ANOVA and t-test, with p < 0.05 for significance. RESULTS: Each year demonstrated an increase in severity of illness, risk of mortality, and CMI compared with baseline values (p < 0.05). Length of stay was not significantly different, reflecting similar patient populations throughout the study. Injury Severity Score decreased in 2011 and 2012 compared with 2009, reflecting a lower level of injury in the trauma population. CONCLUSIONS: A concurrent documentation review significantly increases severity of illness, risk of mortality, and CMI scores in a trauma/acute care service compared with pre-program levels. These changes reflect more accurate key word documentation rather than a change in patient acuity. The increased scores might impact hospital reimbursement and more accurately stratify outcomes measures for care providers.

Tumor necrosis factor-α disruption of brain endothelial cell barrier is mediated through matrix metalloproteinase-9.

Traumatic brain injuries cause vascular hyperpermeability. Tumor necrosis factor-α (TNF-α), matrix metalloproteinase-9 (MMP-9), and caspase-3 may be important in these processes but the relationship between them has not been investigated. We hypothesized that TNF-α regulates caspase-3-mediated hyperpermeability and blood brain barrier damage and hyperpermeability directly or indirectly via activation of MMP-9. To test this, rat brain microvascular endothelial cells were treated with TNF-α with or without inhibition of MMP-9. Monolayer permeability was measured, zonula occludens-1 and F-actin configuration were examined, and MMP-9 and caspase-3 activities were quantified. TNF-α increased monolayer permeability, damaged zonula occludens-1, induced filamentous-actin stress fiber formation, and increased both MMP-9 and caspase-3 activities. Inhibition of MMP-9 attenuated these changes. These data highlight a novel link between TNF-α and MMP-9 and show that TNF-α regulated caspase-3-mediated hyperpermeability and vascular damage may be linked to MMP-9 in vitro. These findings augment the understanding of traumatic brain injury and pave the way for improved treatment.

Outpatient laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis.

BACKGROUND: In 2012, a protocol for routine outpatient laparoscopic appendectomy for uncomplicated appendicitis was published reflecting high success, low morbidity, and significant cost savings. Despite this, national data reflect that the majority of laparoscopic appendectomies are performed with overnight admission. This study updates our experience with outpatient appendectomy since our initial report, confirming the efficacy of this approach. METHODS: In July 2010, a prospective protocol for outpatient laparoscopic appendectomy was adopted at our institution. Patients were dismissed from the postanesthesia recovery room or day surgery if they met predefined criteria for dismissal. Patients admitted to a hospital room as either full admission or observation status were considered failures of outpatient management. An institutional review board-approved retrospective review of patients undergoing laparoscopic appendectomy for uncomplicated appendicitis from July 2010 through December 2012 was performed to analyze success of outpatient management, postoperative morbidity and mortality, as well as readmission rates. RESULTS: Three hundred forty-five patients underwent laparoscopic appendectomy for uncomplicated appendicitis during this time frame. There were 166 men and 179 women, with a mean age of 35 years. Three hundred five patients were managed as outpatients, with a success rate of 88%. Forty patients (12%) were admitted for preexisting comorbidities (15 patients), postoperative morbidity (6 patients), or lack of transportation or home support (19 patients). Twenty-three patients (6.6%) experienced postoperative morbidity. There were no mortalities. Four patients (1%) were readmitted for transient fever, nausea/vomiting, partial small bowel obstruction, and deep venous thrombosis. CONCLUSION: Outpatient laparoscopic appendectomy can be performed with a high rate of success, a low morbidity, and a low readmission rate. This study reaffirms our original pilot study and should serve as the basis for a change in the standard of care for appendicitis. LEVEL OF EVIDENCE: Therapeutic study, level V.

Are commercial negative pressure systems worth the cost in open abdomen management?

BACKGROUND: A commercial negative pressure product is compared with the Barker technique (sterile x-ray cassette cover, lap pads, adhesive drape with negative pressure) for temporary abdominal closure in open abdomen management. STUDY DESIGN: We performed a retrospective review of 37 open abdomen patients who had temporary abdominal closure with a commercial negative pressure device (ABThera, KCI) from 2010 to 2011. These patients were compared with the most recent 37 patients having open abdomen management using the Barker technique from 2009 to 2010. Patient demographics, body mass index (BMI), preoperative albumin, indication for open abdomen management, number of operations, use of sequential closure, and success with closure were analyzed. Patients were compared using chi square, t-test, and logistic regression analysis with significance of p < 0.05. RESULTS: Mean age and BMI were significantly higher in the ABThera patients. No statistically significant differences were seen in male:female ratio, indication for open abdomen management, preoperative albumin, number of operations, and use of sequential closure. In 33 patients (89%) ultimate midline fascial closure was achieved with the ABThera vs in 22 patients (59%) using the Barker technique (p < 0.05). Logistic regression analysis was performed on the 3 significant variables identified on bivariate analysis. Only the type of temporary abdominal closure proved significant, with an odds ratio of 7.97 favoring ABThera (95% CI 1.98 to 32.00). CONCLUSIONS: A commercially available negative pressure device for temporary abdominal closure had significantly greater success with ultimate closure after open abdomen management compared with the Barker technique. The added cost of the device is offset by improved patient results and savings from successful closure.

The number of operations negatively influences fascia closure in open abdomen management.

BACKGROUND: Open abdomen management applies to a variety of traumatic and inflammatory abdominal conditions. One complication of this technique is inability to achieve primary closure of the abdominal wall. The aim of this study was to determine if the number of abdominal reexplorations influences the success of abdominal closure. METHODS: A review of patients undergoing open abdomen management from January 2007 to 2010 was performed. The indication for surgery, number of operations, and success at primary fascia closure were tabulated. A synthetic or biologic mesh bridge was considered failure to achieve closure. RESULTS: One hundred four patients underwent open abdomen management for trauma, postoperative hemorrhage, infected pancreatic necrosis, and perforated viscus or anastomotic leak. Reoperations ranged from 2 to 25, with a mean of 4.5 reoperations. Primary fascia closure was achieved in 82 patients (79%). Fascia closure was successful in 93% of patients with ≤4 reoperations, whereas closure occurred in 32% of patients having ≥5 reoperations (P < .05). CONCLUSIONS: Greater than 4 reoperations is significantly associated with failure of the primary fascia closure. Efforts to obtain closure should be undertaken within 4 reoperations.

The Fort Hood Massacre: Lessons learned from a high profile mass casualty.

BACKGROUND: On November 5, 2009, an army psychiatrist at Fort Hood in Killeen, TX, allegedly opened fire at the largest US military base in the world, killing 13 and wounding 32. METHODS: Data from debriefing sessions, news media, and area hospitals were reviewed. RESULTS: Ten patients were initially transferred to the regional Level I trauma center. The remainder of the shooting victims were triaged to two other local regional hospitals. National news networks broadcasted the Level I trauma center's referral phone line which resulted in more than 1,300 calls. The resulting difficulties in communication led to the transfer of two victims (one critical) to a regional hospital without a trauma designation. CONCLUSIONS: Triage at the scene was compromised by a lack of a secure environment, leading to undertriage of several patients. Overload of routine communication pathways compounded the problem, suggesting redundancy is crucial. LEVEL OF EVIDENCE: Prognostic study, level V.

A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis.

BACKGROUND: Many laparoscopic procedures are currently performed on an outpatient basis. Laparoscopic appendectomy, however, continues to require postoperative hospitalization at most institutions. A treatment protocol for outpatient laparoscopic appendectomy was developed to determine if this could be successfully performed without increasing postoperative complications. We hypothesized that adopting an outpatient protocol for laparoscopic appendectomy will significantly increase the rate of outpatient management for uncomplicated appendicitis, without an increase in morbidity or mortality. STUDY DESIGN: We initiated a prospective outpatient protocol for laparoscopic appendectomy in July 2010 at our institution. All patients having laparoscopic appendectomy from July 2010 to March 2011 were included as protocol patients and were retrospectively reviewed. A separate group of patients having laparoscopic appendectomy from January to September 2009 were analyzed as historical controls. These 2 groups were compared for demographics, preoperative comorbidities, outpatient management, and postoperative morbidity by chi-square analysis, with a 0.95 confidence level for statistical significance. RESULTS: A total of 116 protocol patients were compared with 119 historical control patients. There were no significant differences in patient demographics, preoperative comorbidities, and pathologic findings between protocol patients and historical controls. Ninety-nine protocol patients (85.3%) had procedures as outpatients compared with 42 historical control patients (35.3%; p < 0.05). Postoperative morbidity occurred in 6 protocol patients (5.2%) and 10 historical controls (8.4%; p = NS). There were no readmissions or mortalities in the protocol group. CONCLUSIONS: An outpatient protocol for laparoscopic appendectomy significantly increased the rate of outpatient management with no increase in morbidity or mortality. This practice has now become standard of care at our institution.

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion.

BACKGROUND: Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence. DATA SOURCES: Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized. CONCLUSIONS: Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.

Outpatient laparoscopic appendectomy for acute appendicitis.

Laparoscopic appendectomy is the widely accepted treatment for acute appendicitis. This approach offers the potential of less pain, shorter hospital stay, and quicker return to activities. Traditionally, patients are hospitalized for 24 hours after laparoscopic appendectomy. This practice can be questioned due to the good results of other outpatient laparoscopic surgery. A retrospective review of 119 patients undergoing laparoscopic appendectomy for uncomplicated acute appendicitis was undertaken from January through September 2009; outpatient and inpatient laparoscopic appendectomies were compared. Patients were selected for outpatient management based upon physician discretion and their clinical course in operation and recovery rooms. Forty-two patients were dismissed on the day of surgery and 77 were admitted for 1 to 5 days postoperatively. No significant differences in age, gender, and preoperative comorbidities between outpatient and inpatient groups were found. Postoperative complications occurred in 2.4 per cent of outpatients and 11.7 per cent of inpatients (P = 0.16). Complications included superficial wound infections, urinary retention, urinary tract infection, intra-abdominal bleeding, pneumonia, and infected hematoma. Based upon this study, outpatient laparoscopic appendectomy can be performed safely in selected patients. This study provides the background for the present prospective protocol for routine outpatient laparoscopic appendectomy at our institution.

Modulation of tight junction properties relevant to fluid transport across rabbit corneal endothelium.

Paracellular junctions could play an important role in corneal endothelial fluid transport. In this study we explored the effects of different reagents on the tight junctional barrier by assessing the translayer specific electrical resistance (TER) across rabbit corneal endothelial preparations and cultured rabbit corneal endothelial cells' (CRCEC) monolayers, the paracellular permeability (Papp) for fluorescein isothiocyanate (FITC) dextrans across CRCEC, and fluid transport across de-epithelialized rabbit corneal endothelial preparations. Palmitoyl carnitine (PC), poly-L-lysine (PLL), adenosine triphosphate (ATP), and dibutyryl adenosine 3',5'-cyclic monophosphate (dB-cAMP) were used to modulate corneal endothelial fluid transport and tight junctions (TJs). After seeding, the TER across CRCEC reached maximal values (29.2+/-1.0 Omega cm2) only after the 10th day. PC (0.1 mM) caused decreases both in TER (by 40%) and fluid transport (swelling rate: 18.5+/-0.3 microm/h), and an increase in Papp. PLL resulted in increased TER rose and Papp but decreased fluid transport (swelling rate: 10+/-0.3 microm/h). dB-cAMP (0.1 mM) and ATP (0.1 mM) decreased TER by 16% and 6%, increased Papp slightly, and stimulated fluid transport; the rates of de-swelling (in microm/h) were -5.4+/-0.3 and -12.1+/-0.4, respectively. PC might cause the junctions to open up unspecifically and thus increase passive leak. PLL is a known junctional charge modifier that may be adding steric hindrance to the tight junctions. The results with dB-cAMP and ATP are consistent with fluid transport via the paracellular route.