Surgical critical care: Is work-life expectancy increasing? An analysis of American Board of Surgery recertification rates across subspecialties.

The practice of surgical critical care (SCC) has traditionally necessitated additional in-house, extended night and weekend clinical commitments, which can be viewed as less desirable for many surgeons. Therefore, the authors have observed that some SCC surgeons elect to transition their practice to focus solely on general surgery (GS) rather than continuing practicing both SCC and GS. We hypothesized that surgeons with a practice focused on SCC are more likely to make the transition to a GS practice than those who have certification in other subspecialties that are certified through the American Board of Surgery.

AWAreness during REsuscitation - II: A multi-center study of consciousness and awareness in cardiac arrest.

INTRODUCTION: Cognitive activity and awareness during cardiac arrest (CA) are reported but ill understood. This first of a kind study examined consciousness and its underlying electrocortical biomarkers during cardiopulmonary resuscitation (CPR). METHODS: In a prospective 25-site in-hospital study, we incorporated a) independent audiovisual testing of awareness, including explicit and implicit learning using a computer and headphones, with b) continuous real-time electroencephalography(EEG) and cerebral oxygenation(rSO2) monitoring into CPR during in-hospital CA (IHCA). Survivors underwent interviews to examine for recall of awareness and cognitive experiences. A complementary cross-sectional community CA study provided added insights regarding survivors' experiences. RESULTS: Of 567 IHCA, 53(9.3%) survived, 28 of these (52.8%) completed interviews, and 11(39.3%) reported CA memories/perceptions suggestive of consciousness. Four categories of experiences emerged: 1) emergence from coma during CPR (CPR-induced consciousness [CPRIC]) 2/28(7.1%), or 2) in the post-resuscitation period 2/28(7.1%), 3) dream-like experiences 3/28(10.7%), 4) transcendent recalled experience of death (RED) 6/28(21.4%). In the cross-sectional arm, 126 community CA survivors' experiences reinforced these categories and identified another: delusions (misattribution of medical events). Low survival limited the ability to examine for implicit learning. Nobody identified the visual image, 1/28(3.5%) identified the auditory stimulus. Despite marked cerebral ischemia (Mean rSO2 = 43%) normal EEG activity (delta, theta and alpha) consistent with consciousness emerged as long as 35-60 minutes into CPR. CONCLUSIONS: Consciousness. awareness and cognitive processes may occur during CA. The emergence of normal EEG may reflect a resumption of a network-level of cognitive activity, and a biomarker of consciousness, lucidity and RED (authentic "near-death" experiences).

Developing and Testing a Protocol for Managing Cardiopulmonary Resuscitation of Patients with Suspected or Confirmed COVID-19: In Situ Simulation Study.

BACKGROUND: Resuscitating patients with suspected or confirmed COVID-19 imposes unique challenges to organizations and code blue teams. Studies that applied the American Heart Association (AHA) COVID-19-related Interim Resuscitation Guideline and similar European guidelines are scarce. OBJECTIVE: This study aimed to develop and test a cardiopulmonary resuscitation protocol based on the AHA COVID-19-related Interim Resuscitation Guideline. METHODS: The study was conducted as an in situ simulation in a medical intensive care unit. The COVID-19 cardiopulmonary resuscitation protocol was created and validated by 11 health care team members and tested using 4 simulation sessions where 46 code blue team members participated. During the simulation, we observed role clarity, the effectiveness of communication, team dynamics, infection control measures, and the availability of essential supplies and equipment. RESULTS: The main issues identified in each simulation session were debriefed to the code blue teams and used to further revise the protocol. These include the assignment of tasks, availability of equipment and supplies, and failure of communication between the in-room and out-of-room teams. Solutions included changes in the placement of team members and roles and responsibilities; the creation of an isolation code medication package, a respiratory therapy kit, and an isolation code blue bag; and the use of two-way radios and N-95 masks with eye goggles to enhance communication between the teams. CONCLUSIONS: This study shed light on the challenges to implement the AHA COVID-19-related Interim Resuscitation Guideline. The in situ simulation was an effective approach for rapid training, identifying unreliable equipment and ineffective and inefficient workflow, and managing the complexity of the physical environment.

Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer.

INTRODUCTION: Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI). METHODS: This was a secondary analysis of a multicenter, case-control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts. RESULTS: A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53). CONCLUSION: For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary. STUDY TYPE: Original article, case series. LEVEL OF EVIDENCE: III.

The gut microbiome distinguishes mortality in trauma patients upon admission to the emergency department.

BACKGROUND: Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients. METHODS: We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and ß-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses. RESULTS: Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission ß-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). ß-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05). CONCLUSION: Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study.

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

The southwestern surgical congress multi-center trial on suspected common duct stones.

BACKGROUND: Choledocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones. METHODS: A retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p < 0.05 for paired variables and p < 0.017 for multiple comparisons. RESULTS: Twelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31-94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8-3.7 mg/dl) and median common duct size 7 mm (IQR 5-10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one. CONCLUSION: Significant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions.

Outpatient thyroidectomy is safe and reasonable: experience with more than 1,000 planned outpatient procedures.

BACKGROUND: Thyroidectomy has traditionally been performed as an inpatient hospital procedure, but low risk and high patient tolerance make it acceptable as an outpatient procedure. STUDY DESIGN: All thyroidectomies performed by a single surgeon between March 2003 and June 2009 were retrospectively and prospectively reviewed as planned outpatient or planned inpatient operations, noting the patient's American Society of Anesthesiologists (ASA) classification, success of completion as an outpatient procedure, time to same-day discharge, postoperative emergency room visit, hospital admission, and complications. RESULTS: Overall, 1,136 of 1,242 thyroidectomies were planned as outpatient procedures and 1,063 (93.6%) were successfully completed as such. Including 1 outpatient procedure initially planned as an inpatient procedure, 1,064 outpatient procedures were performed, of which 613 were total and 451 less-than-total thyroidectomies. These outpatient procedures had a mean time to day-surgery discharge of 2 hours and 42 minutes. Of discharged outpatients, a postoperative emergency room visit within 30 days occurred in 83 cases (7.8%), with subsequent hospital admission in 25 of these patients (2.3%). Excluding 153 cases of isolated and self-limited asymptomatic hypocalcemia (14.4%), substantial complications occurred in 122 discharged outpatients (11.5%), including 56 symptomatic hypocalcemias (5.2%), 39 transient recurrent laryngeal nerve injuries (3.7%), 4 permanent recurrent laryngeal nerve injuries (0.4%), and 2 hematomas (0.19%). None of the patients with postoperative hematoma required bedside decompression and only 1 occurred within 24 hours of the outpatient procedure. Discharged outpatient thyroidectomy patients were younger (53 years versus 60 years; p < 0.0001) and healthier (2.3 ASA versus 3.0 ASA; p < 0.0001) than planned inpatient thyroidectomies. CONCLUSIONS: Outpatient thyroidectomy in experienced hands is safe and reasonable with favorable patient acceptance and the potential for substantial health care cost savings.