Does saline resuscitation affect mechanisms of coagulopathy in critically ill trauma patients? An exploratory analysis.

Metabolic acidosis has been implicated in the development of coagulopathy, although the specific mechanisms have not been well characterized. We sought to explore whether resuscitation of injured patients with a balanced crystalloid solution affects coagulation, as measured by endogenous thrombin potential (ETP) and thromboelastography (TEG). We performed an exploratory analysis of a subset of subjects enrolled in a randomized trial comparing the effect of resuscitation with isotonic saline versus Plasma-Lyte A (PLA) on acidosis and electrolyte abnormalities. We collected plasma at admission and 6 h later for subsequent ETP and TEG analysis and compared subjects receiving isotonic saline to those receiving PLA. Among 18 evaluated subjects, baseline characteristics, including ETP and TEG parameters, were similar between the two arms. At 6 h, subjects receiving isotonic saline were more acidemic. At 6 h, there were no differences in ETP parameters between groups; however, TEG results showed the time from initial clot formation to an amplitude of 20 mm (K) was shorter (3.8 ±â€Š2.1 vs. 7.2 ±â€Š2.8 s) and the rapidity of fibrin build-up and cross-linking (α angle) was significantly greater (41 ±â€Š8 vs. 24 ±â€Š15 deg) for the PLA group than in the isotonic saline group. Relative to PLA, isotonic saline does not alter thrombin generation, but isotonic saline and PLA may differentially impact clotting factor availability. The shorter time to reach prespecified clot amplitude and the increased rate of fibrin generation imply faster amplification of clotting factors with PLA without effect on latency time or clot strength.

Bariatric surgery and the changing current scope of general surgery practice: implications for general surgery residency training.

IMPORTANCE: The scope of general surgery practice has evolved tremendously in the last 20 years. However, clinical experience in general surgery residency training has undergone relatively little change. OBJECTIVE: To evaluate the current scope of academic general surgery and its implications on surgical residency. DESIGN, SETTING, AND PARTICIPANTS: The University HealthSystem Consortium and Association of American Medical Colleges established the Faculty Practice Solution Center (FPSC) to characterize physician productivity. The FPSC is a benchmarking tool for academic medical centers created from revenue data collected from more than 90,000 physicians who practice at 95 institutions across the United States. MAIN OUTCOMES AND MEASURES: The FPSC database was queried to evaluate the annual mean procedure frequency per surgeon (PFS) in each calendar year from 2006 through 2011. The associated work relative value units (wRVUs) were also examined to measure physician effort and skill. RESULTS: During the 6-year period, 146 distinct Current Procedural Terminology codes were among the top 100 procedures, and 16 of these procedures ranked in the top 10 procedures in at least 1 year. The top 10 procedures accounted for more than half (range, 52.5%-57.2%) of the total 100 PFS evaluated for each year. Laparoscopic Roux-en-Y gastric bypass was consistently among the top 10 procedures in each year (PFS, 18.2-24.6). The other most frequently performed procedures included laparoscopic cholecystectomy (PFS, 30.3-43.5), upper gastrointestinal tract endoscopy (PFS, 26.5-34.3), mastectomy (PFS, 16.5-35.0), inguinal hernia repair (PFS, 15.5-22.1), and abdominal wall hernia repair (PFS, 21.6-26.1). In all years, laparoscopic Roux-en-Y gastric bypass generated the highest number of wRVUs (wRVUs, 491.0-618.2), and laparoscopic cholecystectomy was regularly the next highest (wRVUs, 335.8-498.7). CONCLUSIONS AND RELEVANCE: A significant proportion of academic general surgery is composed of bariatric surgery, yet surgical training does not sufficiently emphasize the necessary exposure to technical expertise and clinical management of the patient undergoing bariatric surgery. As the scope of general surgery practice continues to evolve, general surgery residency training will need to better integrate the exposure to bariatric surgery.

Sustainability and success of the acute care surgery model in the nontrauma setting.

BACKGROUND: The use of an acute care surgical model has been shown to improve patient care and efficiency. We propose that it is possible to apply this model to emergency general surgery patients at a nontrauma hospital. With this acute care surgery service, no change in the quality of care will occur, and improvements in quality, cost, and outcomes may be achieved and sustained. STUDY DESIGN: A retrospective review was performed of all emergency surgery operations performed at a tertiary referral community hospital without a trauma service. Data were collected from 1 year before and each year up to 4 years after the implementation of an acute care surgical (ACS) service. RESULTS: There were fewer overall complications with ACS (21% to 12%, p < 0.0001), and a shorter length of stay (6.5 days to 5.7 days, p = 0.0016). Hospital costs fell from $12,009 to $8,306 (p < 0.0001). Post-appendectomy complications decreased (13% to 3.7%, p < 0.0001), length of stay was shorter (3.0 to 2.3 days, p < 0.0001), and hospital costs decreased from $9,392 to $5,872 (p < 0.0001). Post-cholecystectomy complications decreased (21% to 9%, p = 0.012), length of stay was shorter (5.3 to 3.8 days, p = 0.0004), and hospital costs decreased from $12,526 to $9,348 (p < 0.0001). CONCLUSIONS: An acute care surgery service can be successfully implemented at a nontrauma hospital. The improvements seen in outcomes and finances are sustainable over time. This sort of coordinated, consistent care is successful and allows alignment of the goals of surgeons, hospitals, and patients.

Cost-minimization analysis of two fluid products for resuscitation of critically injured trauma patients.

PURPOSE: Results of a study to determine potential cost benefits of substituting an alternative electrolyte solution for 0.9% sodium chloride injection for the initial fluid resuscitation of trauma patients are presented. METHODS: Using data from a randomized clinical trial that compared 24-hour fluid resuscitation outcomes in critically injured trauma patients treated with 0.9% sodium chloride injection and those who received a balanced electrolyte solution (Plasma-Lyte A, Baxter Healthcare), a cost-minimization analysis was performed at a large medical center. The outcomes evaluated included fluid and drug acquisition costs, materials and nurse labor costs, and costs associated with electrolyte replacement. RESULTS: The use of Plasma-Lyte A was associated with a relatively higher fluid acquisition cost but a reduced need for magnesium replacement. During the first 24 hours of hospitalization, 4 of 24 patients (17%) treated with 0.9% sodium chloride injection and none of the patients who received the comparator product (n = 22) required supplemental magnesium. Patients treated with 0.9% sodium chloride injection received a median of 4 g of magnesium (interquartile range [IQR], 2.5-4.0 g), compared with a median of 0 g (IQR 0-2 g) in the comparator group. Taking into account the costs of consumable supplies and nursing labor, the cost-minimization analysis indicated a 24-hour cost differential of $12.35 in favor of Plasma-Lyte A. CONCLUSION: Substitution of Plasma-Lyte A for 0.9% sodium chloride injection for fluid resuscitation during the first 24 hours after traumatic injury was associated with decreased magnesium replacement requirements and a net cost benefit to the institution.

Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis.

BACKGROUND: Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH. METHODS: Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls. RESULTS: There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher. CONCLUSION: Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy. LEVEL OF EVIDENCE: Therapeutic care/management, level III.

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries.

OBJECT: Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS: This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS: The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS: Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

The utility of laparoscopic evaluation of the parietal peritoneum in the management of anterior abdominal stab wounds.

BACKGROUND: Trauma centres vary in their approaches to managing stable patients with anterior abdominal stab wounds (AASWs), with no approach yet proven superior. We sought to evaluate the performance of screening laparoscopy (i.e., parietal peritoneal penetration or not) in determining which patients should undergo laparotomy. METHODS: We conducted a retrospective case series study, including all patients with an AASW who presented to U.C. Davis Medical Center from January 2003 through March 2009. We collected data from medical records using a standardised, pre-tested instrument. Among laparoscopically screened cases, we determined the test characteristics of peritoneal penetration for detecting intra-abdominal injury. We sub-classified injuries as "requiring treatment" (e.g., full-thickness enterotomy or active haemorrhage) or not. RESULTS: Of 358 patients with AASWs, 163 underwent screening laparoscopy. Seventy-eight of the 163 (48%) had no peritoneal penetration and six (4%) had peritoneal penetration but a low-risk wound; none of these 84 underwent laparotomy nor had a missed injury. Of 79 patients with peritoneal penetration who underwent laparotomy, 61 had an intra-abdominal injury, of whom 42 were treated intraoperatively. Among these 42, 30 had an injury "requiring treatment." The PPV of peritoneal penetration for an injury requiring treatment was 38% (30/79) (95% CI 27-50%), NPV 100% (84/84) (95% CI 95-100%), sensitivity 100% (30/30) (95% CI 88-100%), and specificity 63% (84/133) (95% CI 54-71%). The negative and positive likelihood ratios were 0 (95% CI 0-0.4) and 2.7 (95% CI 2.2-3.4), respectively. CONCLUSIONS: Screening laparoscopic evaluation of the parietal peritoneum results in a negligible rate of missed injury and an approximately 40% rate of finding an injury requiring treatment.

Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial.

OBJECTIVE: We sought to compare resuscitation with 0.9% NaCl versus Plasma-Lyte A, a calcium-free balanced crystalloid solution, hypothesizing that Plasma-Lyte A would better correct the base deficit 24 hours after injury. BACKGROUND: Sodium chloride (0.9%) (0.9% NaCl), though often used for resuscitation of trauma patients, may exacerbate the metabolic acidosis that occurs with injury, and this acidosis may have detrimental clinical effects. METHODS: We conducted a randomized, double-blind, parallel-group trial (NCT01270854) of adult trauma patients requiring blood transfusion, intubation, or operation within 60 minutes of arrival at the University of California Davis Medical Center. Based on a computer-generated, blocked sequence, subjects received either 0.9% NaCl or Plasma-Lyte A for resuscitation during the first 24 hours after injury. The primary outcome was mean change in base excess from 0 to 24 hours. Secondary outcomes included 24-hour arterial pH, serum electrolytes, fluid balance, resource utilization, and in-hospital mortality. RESULTS: Of 46 evaluable subjects (among 65 randomized), 43% had penetrating injuries, injury severity score was 23 ± 16, 20% had admission systolic blood pressure less than 90 mm Hg, and 78% required an operation within 60 minutes of arrival. The baseline pH was 7.27 ± 0.11 and base excess -5.9 ± 5.0 mmol/L. The mean improvement in base excess from 0 to 24 hours was significantly greater with Plasma-Lyte A than with 0.9% NaCl {7.5 ± 4.7 vs 4.4 ± 3.9 mmol/L; difference: 3.1 [95% confidence interval (CI): 0.5-5.6]}. At 24 hours, arterial pH was greater [7.41 ± 0.06 vs 7.37 ± 0.07; difference: 0.05 (95% CI: 0.01-0.09)] and serum chloride was lower [104 ± 4 vs 111 ± 8 mEq/L; difference: -7 (95% CI: -10 to -3)] with Plasma-Lyte A than with 0.9% NaCl. Volumes of study fluid administered, 24-hour urine output, measures of resource utilization, and mortality did not significantly differ between the 2 arms. CONCLUSIONS: Compared with 0.9% NaCl, resuscitation of trauma patients with Plasma-Lyte A resulted in improved acid-base status and less hyperchloremia at 24 hours postinjury. Further studies are warranted to evaluate whether resuscitation with Plasma-Lyte A improves clinical outcomes.

Identification of barriers to adaptation of battlefield technologies into civilian trauma in California.

OBJECTIVE: To characterize the adoption of routine battlefield medical techniques (tourniquets, hemostatic agents, and tactical combat casualty care into civilian prehospital trauma care and to identify the barriers to their use in the state of California through anonymous electronic survey of local emergency medical services agency (LEMSA) directors. RESULTS: The response rate for this survey was 50% (14/28). The majority of LEMSA directors (86%) were emergency medicine physicians. Tourniquets were used by 57% of respondents. The top three reasons cited for not using tourniquets included different injury patterns in civilian trauma, no proven benefit of use, and increased risk of complications. Hemostatic agents were used even less frequently in civilian practice (7%) but had similar barriers to use. Only 36% of LEMSA directors use tactical combat casualty care with tactical emergency medical services, but when used, respondents had higher usage of tourniquets. Overall lack of training, no proven benefit, and expense were the reasons cited for not incorporating military medical techniques. CONCLUSIONS: Tourniquets, hemostatic agents, and tactical medical care are the integral components of battlefield medicine and have been lifesaving in these settings. The barriers to this transition are multifactorial. Physicians familiar with these technologies should become advocates for their integration in civilian trauma patient care.

Coagulation profile of liquid-state plasma.

BACKGROUND: Use of liquid plasma (LP) has been reported as early as the mid 1930s. Unlike fresh-frozen plasma (FFP), LP is maintained at 1 to 6°C for up to 40 days after collection and processing. Despite its approved use by the US Food and Drug Administration, the coagulation profile of LP is incompletely described. In this study we evaluate the coagulation profile of LP stored up to 30 days. STUDY DESIGN AND METHODS: LP was prepared by removing plasma from nonleukoreduced whole blood within 24 hours of collection. Three LP units from each ABO group were collected and stored at 1 to 6°C. Plasma aliquots were obtained at Postcollection Days 1 to 5, 10, 15, 20, 25, and 30 and then stored at -70°C. Each aliquot was tested for prothrombin time, activated partial thromboplastin time, and other coagulation and fibrinolytic factors. RESULTS: There was a significant decrease in Factor (F)V, FVII, FVIII, von Willebrand factor (VWF), protein S (PS) activity, and endogenous thrombin potential on Day 15 compared with Day 1. No significant difference was observed for PS antigen, D-dimer, or thrombin-antithrombin complex. At least 50% activity of all measured factors was noted on Day 15, compared to Day 1. Considerable heterogeneity was observed between the different blood groups for FVII, FVIII, and VWF. CONCLUSION: These data demonstrate that LP maintains at least 50% of factor activity and thrombin-generating capacity up to 15 days of refrigerated storage. It may be more appropriate to limit LP storage and supplement with FFP when used for management of massively bleeding patients.

The surgical residency baby boom: changing patterns of childbearing during residency over a 30-year span.

BACKGROUND: Birthrates during surgical residency appear to be rising. One assumption is that this is due to changes in the structure of surgical residencies. OBJECTIVE: The purpose of our study was to explore whether an increase in birthrates has occurred and the reasons for this. METHODS: We conducted an anonymous survey of current residents and alumni from 1976 to 2009 at a single university-based surgery training program. RESULTS: Alumni (46 of 116) and current residents (38 of 51) were surveyed, and our response rate was approximately 50% (84 of 167). Respondents were grouped into cohorts based on their residency start year. The early cohort consisted of residents starting residency between 1976 and 1999, and the late cohort consisted of residents starting residency between 2000 and 2009. The percentage of male residents with children during residency training was similar for the early and late cohorts (34% [10 of 29] versus 41% [9 of 22]). For female residents, there was a substantial increase in childbearing for the late cohort (7% [1 of 15] versus 35% [6 of 18]). Fifty-two percent (44 of 84) of the respondents who had children during residency reported that work hours and schedule had a negative effect on their decision to have children. Most respondents reported that availability or cost of child care, impact on residency, support from the program, increased length of training, or availability of family leave did not factor as concerns. CONCLUSIONS: Childbearing during residency has increased in female residents in our study. Surgical residency programs may need to accommodate this change if they want to continue to recruit and retain talented residents.

Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte.

OBJECTIVE: To assess the association of 0.9% saline use versus a calcium-free physiologically balanced crystalloid solution with major morbidity and clinical resource use after abdominal surgery. BACKGROUND: 0.9% saline, which results in a hyperchloremic acidosis after infusion, is frequently used to replace volume losses after major surgery. METHODS: An observational study using the Premier Perspective Comparative Database was performed to evaluate adult patients undergoing major open abdominal surgery who received either 0.9% saline (30,994 patients) or a balanced crystalloid solution (926 patients) on the day of surgery. The primary outcome was major morbidity and secondary outcomes included minor complications and acidosis-related interventions. Outcomes were evaluated using multivariable logistic regression and propensity scoring models. RESULTS: For the entire cohort, the in-hospital mortality was 5.6% in the saline group and 2.9% in the balanced group (P < 0.001). One or more major complications occurred in 33.7% of the saline group and 23% of the balanced group (P < 0.001). In the 3:1 propensity-matched sample, treatment with balanced fluid was associated with fewer complications (odds ratio 0.79; 95% confidence interval 0.66-0.97). Postoperative infection (P = 0.006), renal failure requiring dialysis (P < 0.001), blood transfusion (P < 0.001), electrolyte disturbance (P = 0.046), acidosis investigation (P < 0.001), and intervention (P = 0.02) were all more frequent in patients receiving 0.9% saline. CONCLUSIONS: Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline.

Laparoscopic transdiaphragmatic pericardial window: getting to the heart of the matter.

BACKGROUND: Penetrating wounds to the upper abdomen and lower precordium mandate exclusion of intra-abdominal and cardiac injuries. The most sensitive test to exclude cardiac injury is direct visualization of the pericardial fluid. Since 2001, we have examined the abdomen and performed transdiaphragmatic (central tendon) pericardial window via laparoscopy in stable patients at risk for both cardiac and peritoneal injuries. STUDY DESIGN: At our Level I trauma center we reviewed consecutive patients who underwent evaluation of pericardial fluid after trauma between 2001 and 2008 and identified those patients in whom laparoscopic pericardial window was performed. We collected data on demographics, technique, findings, complications, and follow-up. RESULTS: There were 393 patients who underwent diagnostic laparoscopy. Of those, 38 patients received laparoscopic transdiaphragmatic pericardial window. Six cardiac injuries (15.8%) were identified with 5 penetrating injuries to the right ventricle and 1 myocardial contusion. All 5 right ventricular injuries required median sternotomy for injury repair. None of the patients had significant hemodynamic compromise during operation. The pericardial window was left open in all patients, with no morbidity. The average length of stay for patients without chest tubes and a negative window was less than 24 hours. For patients with chest tubes, length of stay was 4.6 days. The interquartile range for follow-up was 21.5 to 315 days. CONCLUSIONS: Diagnostic laparoscopy with transdiaphragmatic pericardial window allows for thorough evaluation of both abdominal and cardiac injuries with a resultant short length of stay and no morbidity or mortality. In this, the largest series in the literature, laparoscopic pericardial window was a safe and effective modality to evaluate hemodynamically stable patients who are at risk for both cardiac and abdominal injuries.

Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multi-institutional study.

BACKGROUND: We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents. DESIGN: Retrospective review. SETTING: Seventeen general surgery training programs in the western United States. PARTICIPANTS: Six hundred seven residents who graduated in 2000-2007. MAIN OUTCOME MEASURES: First-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research. RESULTS: The first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]). CONCLUSIONS: Residents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

Effects of resident duty-hours restrictions on surgical and nonsurgical teaching faculty.

OBJECTIVE: To evaluate the effects of resident duty-hours restrictions on teaching faculty, patient care, and the institutional climate at a single center. METHODS: An anonymous questionnaire was provided to all teaching faculty (N = 606) at a single institution from March through October 2006. The questionnaire focused on perceptions of job satisfaction, workload changes, and effects on patient care and the institution. RESULTS: Overall response rate was 41% (n = 248). More than half of faculty (n = 140 [56%]) feel they have less time for teaching, 33% report less time for extracurricular activities, and 42% report increased work hours. Forty-three percent of respondents (n = 106) were less satisfied with their jobs after implementation of resident duty-hours restrictions, while only 2% (n = 5) were more satisfied. Of the respondent faculty, surgeons were more likely than nonsurgeons to report increased work hours (54% vs 34%; P = .002), decreased time for teaching (66% vs 51%; P = .03), lower job satisfaction (55% vs 35%; P = .003), and negative effects on their personal relationships outside of work (24% vs 12%; P = .01). Although most responses suggest that the restrictions on resident duty hours have not adversely affected patient care or the institutional climate, 33% of respondents (n = 82) felt that patient care was worse. CONCLUSIONS: Surgeons reported a particularly negative effect from resident duty-hours reform, especially within the areas of job satisfaction, time for teaching, and workload. Efforts to counteract these effects will be critical to maintain and recruit teaching faculty.

Trauma and emergency surgery: an evolutionary direction for trauma surgeons.

BACKGROUND: The success of nonoperative management of injuries has diminished the operative experience of trauma surgeons. To enhance operative experience, our trauma surgeons began caring for all general surgery emergencies. Our objective was to characterize and compare the experience of our trauma surgeons with that of our general surgeons. METHODS: We reviewed records to determine case diversity, complexity, time of operation, need for intensive care unit care, and payor mix for patients treated by the trauma and emergency surgery (TES) surgeons and elective practice general surgery (ELEC) surgeons over a 1-year period. RESULTS: TES and ELEC surgeons performed 253 +/- 83 and 234 +/- 40 operations per surgeon, respectively (p = 0.59). TES surgeons admitted more patients and performed more after-hours operations than their ELEC colleagues. Both groups had a mix of cases that was diverse and complex. CONCLUSION: Combining the care of patients with trauma and general surgery emergencies resulted in a breadth and scope of practice for TES surgeons that compared well with that of ELEC surgeons.

Videotape review leads to rapid and sustained learning.

BACKGROUND: Performance review using videotapes is a strategy employed to improve future performance. We postulated that videotape review of trauma resuscitations would improve compliance with a treatment algorithm. METHODS: Trauma resuscitations were taped and reviewed during a 6-month period. For 3 months, team members were given verbal feedback regarding performance. During the next 3 months, new teams attended videotape reviews of their performance. Data on targeted behaviors were compared between the two groups. RESULTS: Behavior did not change after 3 months of verbal feedback; however, behavior improved after 1 month of videotape feedback (P <0.05) and total time to disposition was reduced by 50% (P <0.01). This response was sustained for the remainder of the study. CONCLUSIONS: Videotape review can be an important learning tool as it was more effective than verbal feedback in achieving behavioral changes and algorithm compliance. Videotape review can be an important quality assurance adjunct, as improved algorithm compliance should be associated with improved patient care.

Improving ventricular-arterial coupling during resuscitation from shock: effects on cardiovascular function and systemic perfusion.

BACKGROUND: Efficacy of circulation depends on interactions between the heart and the vascular system. Ventricular-arterial coupling (VAC) has been described as an important determinant of cardiovascular function during resuscitation from shock. However, no prospective studies examining VAC and systemic perfusion have been performed. VAC is measured by the ratio of afterload (aortic input impedance [E ]) to contractility (end-systolic elastance [E ]). Lowering E /E is associated with better VAC and improved myocardial work efficiency. Our hypothesis was that optimizing VAC during resuscitation results in improved myocardial work efficiency while simultaneously improving systemic perfusion. METHODS: This was a prospective study in a consecutive series of critically injured patients. Hemodynamic variables, including E, E, and myocardial work efficiency were evaluated by constructing ventricular pressure-volume loops at the bedside during resuscitation. After pulmonary artery catheterization and adequate fluid resuscitation, left ventricular power output and E /E were optimized with inotropic agents and/or afterload reduction. Efficiency was calculated as stroke work/total left ventricular energy expenditure. Tissue perfusion was estimated by calculating base deficit clearance per hour. RESULTS: Twenty-three patients were studied over a 9-month period. Fifteen patients required inotropic support or afterload reduction. Improvements were seen in E /E (from 1.0 +/- 0.4 to 0.6 +/- 0.2 mm Hg/mL/m, p = 0.0004), and left ventricular power output (from 280 +/- 77 to 350 +/- 81 L/min/m. mm Hg, p = 0.003) with resuscitation. A concomitant improvement in myocardial efficiency (from 70% +/- 8.0% to 77% +/- 5.0%, p = 0.0001) and base deficit clearance (from 0.1 +/- 0.4 to -0.2 +/- 0.1 mEq/L/h, p = 0.006) was seen. CONCLUSION: Improved ventricular-arterial coupling during resuscitation is associated with improved myocardial efficiency and systemic tissue perfusion. Perfusion can be improved at lower energy cost to the heart by focusing on thermodynamic principles during resuscitation.