pREBOA vs ER-REBOA impact on blood utilization and resuscitation requirements: A pilot analysis.

BACKGROUND: Partial occlusion of the aorta is a resuscitation technique designed to maximize proximal perfusion while allowing a graduated amount of distal flow to reduce the ischemic sequelae associated with complete aortic occlusion. The pREBOA catheter affords the ability to titrate perfusion as hemodynamics allows, however, the impact of this new technology for REBOA on blood use and other resuscitative requirements is currently unknown. We hypothesize pREBOA's ability to provide partial occlusion, when appropriate, decreases overall resuscitative requirements when compared to ER-REBOA. METHODS: The entire AAST AORTA Registry was used to compare resuscitation requirements between all ER-REBOA and pREBOA. Unpaired t-tests were used to compare resuscitation strategies including packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, cryoprecipitate, crystalloids, and need for pressors. RESULTS: When comparing ER-REBOA (n=800) use to pREBOA (n=155), initial patient presentations were similar except for age (44 vs 40 p=0.026) and rates of blunt injury (78.4% vs 78.7% p<0.010). Zone-1 occlusion was used less often in ER-REBOA (65.8 vs 71.7 p=0.046). Partial occlusion was performed in 85% of pREBOA compared to 11% in ER-REBOA (p<0.050). Vitals at the time of REBOA were worse in ER-REBOA, and received significantly more units of PRBCs, FFP, platelets, and liters of crystalloids than pREBOA (p<0.05). Rates of ARDS and septic shock were lower in pREBOA (p<0.05). CONCLUSION: When comparing pREBOA to ER-REBOA, there has been a rise in Zone-1 and partial occlusion. In our pilot analysis of the AORTA Registry, there was a reduction in administration of pRBC, FFP, platelets, and crystalloids. Though further prospective studies are required, this is the first to demonstrate an association between pREBOA, partial occlusion, and reduced blood use and resuscitative requirements.

Whole Blood Resuscitation for Injured Patients Requiring Transfusion: A Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.

INTRODUCTION: Whole blood resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of whole blood-based resuscitation on outcomes has not been established. The primary objective of this guideline was to develop evidence-based recommendations on whether whole blood should be considered in civilian trauma patients receiving blood transfusions. METHODS: An EAST working group performed a systematic review and meta-analysis utilizing the GRADE methodology. One PICO question was developed to analyze the effect of whole blood resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and ICU length of stay. English language studies including adult civilian trauma patients comparing in-hospital whole blood to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro was used to assess quality of evidence and risk of bias. The study was registered on PROSPERO (#CRD42023451143). RESULTS: A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., ED, 3-, or 6-hour), 24-hour, late (i.e., 28- or 30-day), and in-hospital. On meta-analysis, whole blood was not associated with decreased mortality. Whole blood was associated with decreased 4-hour RBC (mean difference -1.82, 95% CI -3.12 to -0.52), 4-hour plasma (mean difference -1.47, 95% CI -2.94 to 0), and 24-hour RBC transfusions (mean difference -1.22, 95% CI -2.24 to -0.19) compared to component therapy. There were no differences in infectious complications or ICU length of stay between groups. CONCLUSION: We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations. LEVEL OF EVIDENCE: Level III, Guidelines.

Home Is Not Always Where the Sleep Is: Effect of Home Call on Sleep, Burnout, and Surgeon Well-Being.

BACKGROUND: In-house calls contribute to loss of sleep and surgeon burnout. Although acknowledged to have an opportunity cost, home call is often considered less onerous, with minimal effects on sleep and burnout. We hypothesized home call would result in impaired sleep and increased burnout in acute care surgeons. STUDY DESIGN: Data from 224 acute care surgeons were collected for 6 months. Participants wore a physiological tracking device and responded to daily surveys. The Maslach Burnout Inventory was administered at the beginning and end of the study. Within-participant analyses were conducted to compare sleep, feelings of restedness, and burnout as a function of home call. RESULTS: One hundred seventy-one surgeons took 3,313 home calls, 52.5% were associated with getting called and 38.5% resulted in a return to the hospital. Home call without calls was associated with 3 minutes of sleep loss (p < 0.01), home call with 1 or more call resulted in a further 14 minutes of sleep loss (p < 0.0001), and home call with a return to the hospital led to an additional 70 minutes of sleep loss (p < 0.0001). All variations of home call resulted in decreased feelings of restedness (p < 0.0001) and increased feelings of daily burnout (p < 0.0001, Fig. 1). CONCLUSIONS: Home call is deleterious to sleep and burnout. Even home call without calls or returns to the hospital is associated with burnout. Internal assessments locally should incorporate frequency of calls and returns to the hospital when creating call schedules. Repeated nights of home call can result in cumulative sleep debt, with adverse effects on health and well-being.

Door to door in 24: factors that allow surgical stabilization of rib fractures within 24 hours of admission.

Background: Surgical stabilization of rib fractures (SSRF) should be performed early after injury. Factors that influence timing remain unknown. Our objective was to identify inherent variables that allow for early identification and treatment. We hypothesized that certain demographic, injury, and logistical factors are associated with SSRF <24 hours from admission. Methods: Retrospective review from an urban level 1 trauma center (10/2010-8/2019). Patients were grouped as SSRF <24 hours from admission vs. ≥24 hours. Demographics, transfer from an outside hospital (OSH), timing documentation, injury descriptors, surgeon on-call, and operative surgeon were collected. SSRF for chronic non-union was excluded. Results: Data from 173 patients were analyzed. Eighty-five patients (49%) were in the <24 hours group and 88 (51%) were in the ≥24 hours group. Baseline demographics were similar between groups. Injury severity was significantly higher in the late group: increased Injury Severity Score (ISS; 16.5 vs. 21.0, P<0.01), lower Glasgow Coma Scale (GCS; 15 vs. 14, P<0.01), more rib fractures (7 vs. 9, P=0.01), and increased incidence of face (6% vs. 16%, P=0.03), spine (22% vs. 47%, P<0.01), and pelvis fractures (8% vs. 25%, P<0.01). Patients admitted on a Wednesday were more likely to undergo early SSRF as compared to other days of the week (P=0.01) There was also a shorter time from the decision to perform SSRF to the actual operation in the early group, as compared to the late group (13 vs. 44 hours, P<0.01). Fifty (28.9%) SSRF cases were performed by the on-call surgeon; this percentage did not differ in the early vs. late group (33% vs. 25%, P=0.25). Patients needing pelvic fixation were more likely to be in the late group. Patients transferred from an OSH for SSRF were more likely to be in the early group (29% vs. 10%, P<0.01). Finally, likelihood of early surgery increased with increasing study year. Conclusions: Approximately one-half of SSRF cases were performed within 24 hours of admission. Factors that influence surgery within 24 hours of admission appear related to overall injury severity and systems issues, including day of admission, transfer from another facility, additional urgent pelvic surgery, and institutional experience with SSRF. Surgeon availability did not drive this disparity.

What Happens on Call Doesn't Stay on Call. The Effects of In-house Call on Acute Care Surgeons' Sleep and Burnout: Results of the Surgeon Performance (SuPer) Trial.

OBJECTIVE: We sought to quantify the effects of in-house call(IHC) on sleep patterns and burnout among acute care surgeons (ACS). BACKGROUND: Many ACS take INC, which leads to disrupted sleep and high levels of stress and burnout. METHODS: Physiological and survey data of 224 ACS with IHC were collected over 6 months. Participants continuously wore a physiological tracking device and responded to daily electronic surveys. Daily surveys captured work and life events as well as feelings of restfulness and burnout. The Maslach Burnout Inventory (MBI) was administered at the beginning and end of the study period. RESULTS: Physiological data were recorded for 34,135 days, which includes 4389 nights of IHC. Feelings of moderate, very, or extreme burnout occurred 25.7% of days and feelings of being moderately, slightly, or not at all rested occurred 75.91% of days. Decreased amount of time since the last IHC, reduced sleep duration, being on call, and having a bad outcome all contribute to greater feelings of daily burnout ( P <0.001). Decreased time since last call also exacerbates the negative effect of IHC on burnout ( P <0.01). CONCLUSIONS: ACS exhibit lower quality and reduced amount of sleep compared with an age-matched population. Furthermore, reduced sleep and decreased time since the last call led to increased feelings of daily burnout, accumulating in emotional exhaustion as measured on the MBI. A reevaluation of IHC requirements and patterns as well as identification of countermeasures to restore homeostatic wellness in ACS is essential to protect and optimize our workforce.

Early Surgical Stabilization of Rib Fractures is Feasible in Patients With Non-Urgent Operative Pelvic Injuries.

INTRODUCTION: The feasibility of prioritizing surgical stabilization of rib fractures (SSRF) in patients with other injuries is unknown. The purpose of this study was to evaluate the timing and outcomes of SSRF between patients with and without non-urgent operative pelvic injuries. PATIENTS AND METHODS: In this retrospective observational study, all patients between 2010 and 2020 who underwent SSRF (SSRF group) and those who underwent SSRF and non-urgent operative management of pelvic fractures (SSRF + P group) were included. Demographics, injury characteristics, operative details, and outcomes were compared between the 2 groups. RESULTS: Over 11 years, 154 SSRF patients were identified, with 143 patients in the SSRF group (93%) and 11 patients in the SSRF + P group (7%). Median number of rib fractures (7 vs 9, P = .04), total number of fractures (11 vs 15, P < .01), and flail segment (54% vs 91%, P = .02) were higher in SSRF + P group. Median time to SSRF was similar (0 vs 1 day, P = .20) between the 2 groups. Median time to pelvic fixation was 3 days in SSRF + P group and 8 out of 11 patients (73%) underwent SSRF prior to pelvic fixation. Median operative time (137 vs 178 mins, P = .14) and median number of ribs plated (4 vs 5, P = .05) were higher in SSRF + P group. There was no difference in SSRF-related complications, pelvic fracture-related complications from operative positioning, rates of pneumonia, or mortality between the 2 groups. CONCLUSIONS: SSRF can be performed early in patients with non-urgent operative pelvic injuries without a difference in pelvic fracture-related complications, SSRF-related complications, pneumonia, or mortality.

Titratable partial aortic occlusion: Extending Zone I endovascular occlusion times.

BACKGROUND: Extending the time to definitive hemorrhage control in noncompressible torso hemorrhage (NCTH) is of particular importance in the battlefield where transfer times are prolonged and NCTH remains the leading cause of death. While resuscitative endovascular balloon occlusion of the aorta is widely practiced as an initial adjunct for the management of NCTH, concerns for ischemic complications after 30 minutes of compete aortic occlusion deters many from zone 1 deployment. We hypothesize that extended zone 1 occlusion times will be enabled by novel purpose-built devices that allow for titratable partial aortic occlusion. METHODS: This is a cross-sectional analysis describing pREBOA-PRO zone 1 deployment characteristics at seven level 1 trauma centers in the United States and Canada (March 30, 2021, and June 30, 2022). To compare patterns of zone 1 aortic occlusion, the AORTA registry was used. Data were limited to adult patients who underwent successful occlusion in zone 1 (2013-2022). RESULTS: One hundred twenty-two patients pREBOA-PRO patients were included. Most catheters were deployed in zone 1 (n = 89 [73%]) with a median zone 1 total occlusion time of 40 minutes (interquartile range, 25-74). A sequence of complete followed by partial occlusion was used in 42% (n = 37) of zone 1 occlusion patients; a median of 76% (interquartile range, 60-87%) of total occlusion time was partial occlusion in this group. As was seen in the prospectively collected data, longer median total occlusion times were observed in the titratable occlusion group in AORTA compared with the complete occlusion group. CONCLUSION: Longer zone 1 aortic occlusion times seen with titratable aortic occlusion catheters appear to be driven by the feasibility of controlled partial occlusion. The ability to extend safe aortic occlusion times may have significant impact to combat casualty care where exsanguination from NCTH is the leading source of potentially preventable deaths. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

A proposed clinical coagulation score for research in trauma-induced coagulopathy.

BACKGROUND: Trauma-induced coagulopathy (TIC) has been the subject of intense study for greater than a century, and it is associated with high morbidity and mortality. The Trans-Agency Consortium for Trauma-Induced Coagulopathy, funded by the National Health Heart, Lung and Blood Institute, was tasked with developing a clinical TIC score, distinguishing between injury-induced bleeding from persistent bleeding due to TIC. We hypothesized that the Trans-Agency Consortium for Trauma-Induced Coagulopathy clinical TIC score would correlate with laboratory measures of coagulation, transfusion requirements, and mortality. METHODS: Trauma activation patients requiring a surgical procedure for hemostasis were scored in the operating room (OR) and in the first ICU day by the attending trauma surgeon. Conventional and viscoelastic (thrombelastography) coagulation assays, transfusion requirements, and mortality were correlated to the coagulation scores using the Cochran-Armitage trend test or linear regression for numerical variables. RESULTS: Increased OR TIC scores were significantly associated with abnormal conventional and viscoelastic measurements, including hyperfibrinolysis incidence, as well as with higher mortality and more frequent requirement for massive transfusion ( p < 0.0001 for all trends). Patients with OR TIC score greater than 3 were more than 31 times more likely to have an ICU TIC score greater than 3 (relative risk, 31.6; 95% confidence interval, 12.7-78.3; p < 0.0001). CONCLUSION: A clinically defined TIC score obtained in the OR reflected the requirement for massive transfusion and mortality in severely injured trauma patients and also correlated with abnormal coagulation assays. The OR TIC score should be validated in multicenter studies. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection.

Background: Patient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized. Results: Ten published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control. Conclusion: Although our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments. Level of evidence: Level 5, systematic review.

An Unencumbered Acute Care Surgeon Improves Delivery of Emergent Surgical Care for Cholecystectomy Patients.

Introduction: Many patients utilize the Emergency Room (ER) for primary care, resulting in overburdened ERs, strained resources, and delays in care. To combat this, many centers have adopted a Trauma/Acute Care Surgery (TACS) service providing specialty surgeons whose primary work is the unencumbered surgical availability to emergency surgery patients. To evaluate our programs' efficacy, we investigated cholecystectomies as a common urgent procedure representative of services provided. We hypothesized that the adoption of a TACS service would result in improved access to care as evidence by decreased ER visits prior to cholecystectomy, improved time to cholecystectomy, and decreased hospital length of stay (LOS). Methods: All patients that underwent urgent cholecystectomy from January 1, 2018 to December 31, 2018 were reviewed. The unencumbered TACS surgeon was implemented on July 1, 2018. Prior ER visits involving biliary symptoms, time from admission to cholecystectomy, and hospital LOS were compared. Results: Of the 322 urgent cholecystectomies over the study period, 165 were performed prior and 157 following adoption of the TACS structure. The average number of ER visits for biliary symptoms prior to cholecystectomy decreased from 1.4 to 1.2 (p = 0.01). Time from admission to cholecystectomy was 28.3 hours and 27.3 hours respectively (p = 0.74). Average LOS decreased following the restructure (3.1 vs 2.5 days; p = 0.03). Conclusion: Implementation of an unencumbered TACS surgeon managing urgent surgical disease improves access to and delivery of surgical services for cholecystectomy patients in a safety net, level one trauma center. Further research is necessary to determine potential improvements in hospital cost and patient satisfaction.

Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS: Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS: During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION: PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.

Time to Look for Another Infectious Source? White Blood Cell Trends during Ventilator-Associated Pneumonia.

Background: Ventilator-associated pneumonia (VAP) continues to plague patients in intensive care units (ICUs) throughout the world. Persistent leukocytosis despite antibiotic treatment for VAP can have many etiologies including normal inflammatory response, inadequate VAP antimicrobial therapy, and the presence of additional infectious diagnoses. Hypothesis: Surgical patients with VAP and a second infectious source have a different white blood cell count (WBC) trend than patients with VAP alone. Patients and Methods: Retrospective, single-center study of surgical ICU patients diagnosed with VAP (>104 CFU/mL on semi-quantitative culture) between January 2019 and June 2020. Chart review identified additional infections diagnosed during VAP treatment. White blood cell count values were compared between patients treated for VAP alone (VAP-alone) and those with additional infections (VAP-plus) using a Wilcoxon test. Univariable analysis compared admission type, surgeries, and steroid use between cohorts. Results: Eighty-eight VAPs were included for analysis; 61 (69%) were VAP-alone and 27 (31%) VAP-plus. Average age was 47.1 ± 16.7 years, 78% were male, and 93% were trauma admissions. Median hospital day of VAP diagnosis was six (interquartile range [IQR], 4-10). Nearly all patients (99%) were started on initial antibiotic agents to which the VAP organism was sensitive. Daily WBC was higher for VAP-plus compared with VAP-alone on days five, six, and seven of treatment. The maximum WBC was higher for VAP-plus (21.6 k/mcL vs. 16.1 k/mcL; p = 0.02). There were no differences in admission types, number of surgeries, or steroid use between groups. Conclusions: Providers should have increased suspicion for additional sources of infection when ICU patients with a VAP continue to have elevated WBC despite appropriate antibiotic therapy.

Assessment of Discharge Analgesic Prescription Patterns for Hospitalized Patients With Rib Fractures.

INTRODUCTION: There is a paucity of data describing opioid prescribing patterns for trauma patients. We investigated pain medication regimens prescribed at discharge for patients with traumatic rib fractures, as well as potential variables predictive of opioid prescribing. METHODS: A single-center, retrospective analysis was performed of 337 adult patients presenting with ≥1 traumatic rib fractures between January and December 2019. The primary outcome was oral morphine milligram equivalents (MME) prescribed on discharge. A multivariable logistic regression analysis was performed to determine factors independently associated with above median (150) MME prescription at discharge. RESULTS: The majority of patients were male (68.8%) with a median age of 53 y. Blunt trauma accounted for 97.3% of cases with a median Injury Severity Score(ISS) of 10. Locoregional pain procedures were utilized in 16.9% of patients. Opioids were the most common analgesic prescribed at discharge, and 74.1% of patients prescribed opioids on discharge were also prescribed a non-opioid adjunct. On multivariable analysis, daily MME prescribed during hospitalization (OR 1.01, 95% CI 1.01-1.02, P < 0.01) and number of rib fractures (OR 2.26, 95% CI 1.36-3.74, P < 0.01) were predictive of high MME prescribed on discharge. CONCLUSIONS: For patients with traumatic rib fractures, daily MME during hospitalization and number of rib fractures were predictive of high MME prescribing on discharge. Further prospective studies evaluating strategies for pain management and protocolized approaches to opioid prescribing are needed to reduce unnecessary and inappropriate opioid use in this patient population.

Appendectomy versus nonoperative management of simple appendicitis: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study using a hierarchical ordinal scale.

BACKGROUND: Controversy exists about the preferred initial treatment of appendicitis. We sought to compare the two treatments for initial management of simple appendicitis. METHODS: In this post hoc analysis of the Multicenter Study for the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, subjects were divided into appendectomy or nonoperative management (NOM; antibiotics only or percutaneous drainage) cohorts. A novel topic-specific hierarchical ordinal scale was created with eight mutually exclusive categories: mortality, reoperation, other secondary interventions, readmission, emergency department visit, wound complication, surgical site infection, and no complication. Pairwise comparisons of American Association for the Surgery of Trauma Imaging Severity Grade 1 (simple appendicitis) patients were compared using win-lose-tie scoring and the sums of appendectomy/NOM groups were compared. RESULTS: A total 3,591 subjects were included: 3,262 appendectomy and 329 NOM, with significant differences in baseline characteristics between groups. Across 28 sites, the rate of NOM ranged from 0% to 48%, and the loss to follow-up rate was significantly higher for NOM compared with appendectomy (16.5% vs. 8.7%, p = 0.024). In the simple appendicitis hierarchical ordinal scale analysis, 2,319 subjects resulted in 8,714,304 pairwise comparisons; 75% of comparisons resulted in ties. The median (interquartile range) sums for the two groups are as follows: surgical, 400 (400-400), and NOM, 400 (-2,427 to 400) (p < 0.001). A larger proportion of appendectomy subjects (88.1%) had an outcome that was equivalent (or better) than at least half of the subjects compared with NOM subjects (NOM, 70.5%; OR [95% confidence interval], 0.3 [0.2-0.4]). CONCLUSION: In contemporary American practice, appendectomy (compared with NOM) for simple appendicitis is associated with lower odds of developing clinically important unfavorable outcomes in the first year after illness. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Surgical Site Infection after Surgical Stabilization of Rib Fractures: Rare but Morbid.

Background: Although surgical stabilization for rib fractures (SSRF) has been adopted widely over the past decade, little information is available regarding the prevalence and outcomes of post-operative surgical site infection (SSI). We hypothesized that SSI after SSRF is uncommon but morbid. Patients and Methods: Patients undergoing SSRF at a level 1 trauma center from 2010-2020 were reviewed. The primary outcome was the prevalence of SSI, documented by clinical examination, radiography, systemic markers of infection, and microbiology. Results: Of 228 patients undergoing SSRF, 167 (73.2%) were male, the median age was 53 years (P25-P75; 41-63 years), injury severity score (ISS) was 19 (P25-P75, 13-26), with a median of eight fractured ribs (P25-P75, 6-11). All stabilization plates were titanium. SSRF was typically performed on post-injury day one (P25-P75, 0-2 days) after trauma. All patients received antibiotic agents within 30 minutes of incision, and a median of four ribs (P25-P75, 3-6) were repaired. Four (1.8%) patients developed an SSI and all underwent implant removal. Two patients required implant removal within 30 days (on post-operative day seven and 17) and two for chronic infection at seven and 17 months after SSRF. The causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) bacteria in all patients. After implant removal, three patients received intravenous and oral antibiotic agents, ranging from two to six weeks, without recurrent infection. No patient required additional SSRF. Conclusions: Surgical site infection after SSRF is rare but morbid and can become symptomatic within one week to 17 months. Implant removal results in complete recovery.

A decade of surgical stabilization of rib fractures: the effect of study year on patient selection, operative characteristics, and in-hospital outcome.

BACKGROUND: Many centers now perform surgical stabilization of rib fractures (SSRF). This single center study aimed to investigate temporal trends by year in patient selection, operative characteristics, and in-hospital outcomes We hypothesized that, over time, patient selection, time to SSRF, operative time, and in-hospital outcomes varied significantly. METHODS: A retrospective review of a prospectively maintained SSRF database (2010 to 2020) was performed. Patients were stratified by year in which they underwent SSRF. The primary outcome was operative time, defined in minutes from incision to closure. Secondary outcomes were patient and operative characteristics, and in-hospital outcomes. Multivariable regression analyses were performed to assess for temporal trends, corrected for confounders. The outcomes ventilator-, Intensive Care Unit-, and hospital-free days (VFD, IFD, and HFD, respectively) were categorized based on the group's medians, and complications were combined into a composite outcome. RESULTS: In total, 222 patients underwent SSRF on a median of one day after admission (P25-P75, 0-2). Patients had a median age of 54 years (P25-P75, 42-63), ISS of 19 (P25-P75, 13-26), RibScore of 3 (P25-P75, 2-5), and sustained a median of 8 fractured ribs (P25-P75, 6-11). In multivariable analysis, increasing study year was associated with an increase in operative time (p<0.0001). In addition, study year was associated with a significantly reduced odds of complications (Odds ratio [OR], 0.76; 95% Confidence Interval [95% CI], 0.63-0.92; p=0.005), VFD < 28 days (OR, 0.77; 95% CI, 0.65-0.92; p=0.003), IFD < 24 days (OR, 0.77; 95% CI, 0.66-0.91; p=0.002), and HFD < 18 days (OR, 0.64; 95% CI, 0.53-0.76; p<0.0001). CONCLUSION: In-hospital outcomes after SSRF improved over time. Unexpectedly, operative time increased. The reason for this finding is likely multifactorial and may be related to patient selection, onboarding of new surgeons, fracture characteristics, and minimally invasive exposures. Due to potential for confounding, study year should be accounted for when evaluating outcomes of SSRF.

A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures.

INTRODUCTION: Locoregional analgesia (LRA) remains underused in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF. METHODS: Noninferiority, single-center, randomized clinical trial (2017-2020) was performed. Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space), and LB involved thoracoscopic intercostal blocks of ribs 3 to 8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function score, measured daily for 5 days postoperatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality. RESULTS: Thirty-four patients were enrolled: 16 IC and 18 LB. Age, Injury Severity Score, RibScore, Blunt Pulmonary Contusion Score, and use of nonnarcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p = 0.23). There was no significant difference in Sequential Clinical Assessment of Respiratory Function score between the IC and LB groups. On postoperative days 2 to 4, narcotic requirements were less than half in the LB, as compared with the IC group; however, this difference was not statistically significant. Average wholesale price was US $605 for IC and US $434 for LB. CONCLUSION: In this noninferiority trial, LB provided at least comparable and potentially superior LRA as compared with IC among patients undergoing SSRF. LEVEL OF EVIDENCE: Therapeutic, level II.

Beyond the tube: Can we reduce chest tube complications in trauma patients?

BACKGROUND: We sought to identify opportunities for interventions to mitigate complications of tube thoracostomy (TT). METHODS: Retrospective review of all trauma patients undergoing TT from 6/30/2016-6/30/2019. Multivariable logistic regression identified independent predictors of complications. RESULTS: Out of 451 patients, 171 (37.9%) had at least one TT malpositioning or complication. Placement in the emergency department, placement by emergency medicine physicians, and body mass index >30 kg/m2 were independent predictors of complication. Malpositioning increased the likelihood of early complication (6.5%-53.5%), and early complication increased the likelihood of late complication (4.3%-13.6%). Patients with a late complication had, on average, a 7.56 day longer hospital stay than patients without a late complication. CONCLUSION: TT complications were associated with placement in the emergency department, placement by emergency medicine physicians, and BMI>30 kg/m2. We identified associations between malpositioning, early complications, and late complications, and demonstrated that TT complications impact patient outcomes.

Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center.

BACKGROUND: The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. METHODS: An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. RESULTS: Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. CONCLUSION: Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills. LEVEL OF EVIDENCE: Therapeutic, level V.

Temporary intravascular shunts after civilian arterial injury: A prospective multicenter Eastern Association for the Surgery of Trauma study.

INTRODUCTION: We sought to determine the impact of the indication for shunt placement on shunt-related outcomes after major arterial injuries. We hypothesized that a shunt placed for damage control indications would be associated with an increase in shunt-related complications including shunt dislodgement, thrombosis, or distal ischemia. PATIENTS & METHODS: A prospective, multicenter study (eleven level one US trauma centers) of all adult trauma patients undergoing temporary intravascular shunts (TIVS) after arterial injury was undertaken (January 2017-May 2019). Exclusion criteria included age <15years, shunt placement distal to popliteal/brachial arteries, isolated venous shunts, and death before shunt removal. Clinical variables were compared by indication and shunt-related complications. The primary endpoint was TIVS complications (thrombosis, migration, distal ischemia). RESULTS: The 66 patients who underwent TIVS were primarily young (30years [IQR 22-36]) men (85%), severely injured (ISS 17 [10-25]) by penetrating mechanisms (59%), and had their shunts placed for damage control (41%). After a median SDT of 198min [89-622], 9% experienced shunt-related complications. Compared by shunt placement indication (damage control shunts [n=27] compared to non-damage control shunts [n=39]), there were no differences in gender, mechanism, extremity AIS, MESS score, fractures, or surgeon specialty between the two groups (all p>0.05). Patients with shunts placed for damage control indications had more severe injuries (ISS 23.5 compared to 13; SBP 100 compared to 129; GCS 11 compared to 15; lactate 11.5 compared to 3.6; all p<0.05), and had more frequent shunt complication predictors, but damage control shunts did not have significantly more TIVS complications (11.1% compared to 7.7%, p=0.658). Shunt complication patients were discharged home less often (33% vs 65%; p<0.05) but all survived. CONCLUSION: Shunts placed for damage control indications were not associated with shunt complications in this prospective, multicenter study.