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Outcomes for surgical patients with limited English proficiency (LEP) may be worse compared to patients with English proficiency. We sought to evaluate the association of LEP with outcomes for trauma patients.Admitted adult patients on trauma service at two Level One trauma centers from 2015 to 2019 were identified.12,562 patients were included in total; 7.3% had LEP. On multivariable analyses, patients with LEP had lower odds of discharge to post-acute care versus home compared to patients with English proficiency (OR 0.69; 95% CI 0.58-0.83; p 0.001) but had similar length of stay (Beta coefficient 1.16; 95% CI 0.00-2.32; p = 0.05), and 30-day readmission (OR 1.08; 95% CI 0.87-1.35; p = 0.46).Trauma patients with LEP had comparable short-term outcomes to English proficient patients but were less likely to be discharged to post-acute care facilities. The role of structural barriers, family preferences, and other factors merit future investigation.

Results from single-region studies suggest that stay at home orders (SAHOs) had unforeseen consequences on the volume and patterns of traumatic injury during the initial months of the Coronavirus disease 2019 (COVID-19). The aim of this study was to describe, using a multi-regional approach, the effects of COVID-19 SAHOs on trauma volume and patterns of traumatic injury in the US.A retrospective cohort study was performed at four verified Level I trauma centers spanning three geographical regions across the United States (US). The study period spanned from April 1, 2020 - July 31, 2020 including a month-matched 2019 cohort. Patients were categorized into pre-COVID-19 (PCOV19) and first COVID-19 surge (FCOV19S) cohorts. Patient demographic, injury, and outcome data were collected via Trauma Registry queries. Univariate and multivariate analyses were performed.A total 5,616 patients presented to participating study centers during the PCOV19 (2,916) and FCOV19S (2,700) study periods. Blunt injury volume decreased (p = 0.006) due to a significant reduction in the number of motor vehicle collisions (MVCs) (p = 0.003). Penetrating trauma experienced a significant increase, 8% (246/2916) in 2019 to 11% (285/2,700) in 2020 (p = 0.007), which was associated with study site (p = 0.002), not SAHOs. Finally, study site was significantly associated with changes in nearly all injury mechanisms, whereas SAHOs accounted for observed decreases in calculated weekly averages of blunt injuries (p0.02) and MVCs (p = 0.003).Results of this study suggest that COVID-19 and initial SAHOs had variable consequences on patterns of traumatic injury, and that region-specific shifts in traumatic injury ensued during initial SAHOs. These results suggest that other factors, potentially socioeconomic or cultural, confound trauma volumes and types arising from SAHOs. Future analyses must consider how regional changes may be obscured with pooled cohorts, and focus on characterizing community-level changes to aid municipal preparation for future similar events.

Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 – −0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.

Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion.Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality.A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP2 (1,160 [12.6%]) (p0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18-2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74-4.24]).Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement.Therapeutic/Care Management; Level IV.

Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery.All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC.Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre- or intraoperative utilization of intra-aortic balloon pump or catheter-based assist devices (OR = 4.54), intraoperative transfusion requirement of4 RBC units(OR = 2.47), and cardiopulmonary bypass 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC.We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above-identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team.

The American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons provide guidelines for managing suspected common bile duct (CBD) stones. We sought to evaluate adherence to the guidelines among patients with choledocholithiasis and/or acute biliary pancreatitis (ABP) and to evaluate the ability of these guidelines to predict choledocholithiasis.We prospectively identified patients undergoing same-admission cholecystectomy for choledocholithiasis and/or ABP from 2016 to 2019 at 12 United States medical centers. Predictors of suspected CBD stones were very strong (CBD stone on ultrasound; bilirubin4 mg/dL), strong (CBD6 mm; bilirubin ≥1.8 to ≤4 mg/dL), or moderate (abnormal liver function tests other than bilirubin; age55 years; ABP). Patients were grouped by probability of CBD stones: high (any very strong or both strong predictors), low (no predictors), or intermediate (any other predictor combination). The management of each probability group was compared with the recommended management in the guidelines.The cohort was comprised of 844 patients. High-probability patients had 64.3% (n = 238/370) deviation from guidelines, intermediate-probability patients had 29% (n = 132/455) deviation, and low-probability patients had 78.9% (n = 15/19) deviation. Acute biliary pancreatitis increased the odds of deviation for the high- (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.06-2.8; p = 0.03) and intermediate-probability groups (OR, 1.6; 95% CI, 1.07-2.42; p = 0.02). Age older than 55 years (OR, 2.19; 95% CI, 1.4-3.43; p0.001) also increased the odds of deviation for the intermediate group. A CBD greater than 6 mm predicted choledocholithiasis in the high (adjusted OR (aOR), 2.16; 95% CI, 1.17-3.97; p = 0.01) and intermediate group (aOR, 2.78; 95% CI, 1.59-4.86; p0.001). Any very strong predictor (aOR, 2.43; 95% CI, 1.76-3.37; p0.0001) and both strong predictors predicted choledocholithiasis (aOR, 2; 95% CI, 1.35-2.96; p0.001).Almost 45% of patients with suspected CBD stones were managed discordantly from the American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons guidelines. We believe these guidelines warrant revision to better reflect the ability of the clinical variables at predicting choledocholithiasis.Therapeutic/Care Management; Level IV.

Background The Emergency Surgery Score was recently validated in a prospective multicenter study as an accurate predictor of mortality in emergency general surgery patients. The Emergency Surgery Score is easily calculated using multiple demographic, comorbidity, laboratory, and acuity of disease variables. We aimed to investigate whether the Emergency Surgery Score can predict 30-day postoperative mortality across patients undergoing emergency surgery in multiple surgical specialties. Methods Our study is a retrospective cohort study using data from the national American College of Surgeons National Surgical Quality Improvement Program database (2007-2017). We included patients that underwent emergency gynecologic, urologic, thoracic, neurosurgical, orthopedic, vascular, cardiac, and general surgical procedures. The Emergency Surgery Score was calculated for each patient, and the correlation between the Emergency Surgery Score and 30-day mortality was assessed for each specialty using the c-statistics methodology. Results Of 6,485,915 patients, 173,890 patients were included. The mean age was 60 years, 50.6% were female patients, and the overall mortality was 9.7%. The Emergency Surgery Score predicted mortality best in emergency gynecologic, general, and urologic surgery (c-statistics: 0.97, 0.87, 0.81, respectively). The Emergency Surgery Score predicted mortality moderately well in emergency thoracic, neurosurgical, orthopedic, and vascular surgery (c-statistics 0.73–0.79). For example, the mortality of gynecology patients with an Emergency Surgery Score of 5, 9, and 13 was 2%, 27%, and 50%, respectively. The Emergency Surgery Score performed poorly in cardiac surgery. Conclusion The Emergency Surgery Score accurately predicts mortality across patients undergoing emergency surgery in multiple surgical specialties, especially general, gynecologic, and urologic surgery. The Emergency Surgery Score can prove useful for perioperative patient counseling and for benchmarking the quality of surgical care.

Background Body mass index (BMI) does not reliably predict Surgical site infections (SSI). We hypothesize that abdominal wall thickness (AWT) would serve as a better predictor of SSI for patients undergoing emergency colon operations. Methods We retrospectively evaluated our Emergency Surgery Database (2007-2018). Emergency colon operations for any indication were included. AWT was measured by pre-operative CT scans at 5 locations. Only superficial and deep SSIs were considered as SSI in the analysis. Univariate then multivariable analyses were used to determine predictors of SSI. Results 236 patients met inclusion criteria. The incidence of post-operative SSI was 25.8% and the median BMI was 25.8kg/m2 [22.5-30.1]. The median AWT between patients with and without SSI was significantly different (2.1cm [1.4, 2.8] and 1.8cm [1.2, 2.5], respectively). A higher BMI trended toward increased rates of SSI, but this was not statistically significant. In overweight (BMI 25-29.9kg/m2) and obese (BMI ≥30kg/m2) patients, SSI versus no SSI rates were (50.0% versus 41.9% and 47.4% versus 36.4%, P = 0.365 and 0.230) respectively. The incidence of SSI in patients with an average AWT Conclusions AWT is a better predictor of SSI than BMI. Preoperative imaging of AWT may direct intraoperative decisions regarding wound management. Future clinical outcomes research in emergency surgery should include abdominal wall thickness as an important patient variable.

Background: There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes. Materials and Methods: We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit. Results: 10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001). Conclusion: The previously described volume-outcome association in septic patients was not identified in an intensive care setting.

Introduction Intestinal-cutaneous fistulas (ICFs) constitute a major surgical challenge. Definitive surgical treatment of ICFs continues to be associated with significant morbidity. The purpose of this study was to utilize a nationwide database to define the morbidity associated with current treatment strategies in the surgical management of ICFs. Methods The 2006–2017 American College of Surgeon National Surgical Quality Improvement datasets (ACS-NSQIP) were used to assess 30-day morbidity and mortality after surgical repair of ICFs. Outcomes for emergent repair were compared to elective repair of ICFs. Results Overall, 4197 patients undergoing ICF-repair were identified. Mean age was 55.9 (SD 15.3). Patients were generally comorbid (62.9% were in ASA class III). The observed in-hospital mortality was 2.3%. However, the observed morbidity rate was 47.3%. Of the observed morbidity, 35.6% was due to post-operative infectious complications (superficial surgical site infections (SSI), deep SSI, organ/space SSI, wound disruption, pneumonia, urinary tract infection (UTI) sepsis or septic shock). The most common infectious complication was sepsis (13.1%). 30-day readmission rate was 15.3% and the 30-day reoperation rate was 11.0%. Emergent repair was associated with a sevenfold increase in mortality (11.9% vs 1.8%, P Conclusion The management of patients with ICFs is complex and is associated with significant morbidity. Half of patients undergoing surgical management of ICFs developed in-hospital complications.

Background In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury. Methods Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables. Results A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery. Conclusion Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings. Level of evidence Prognostic, Level III.

Hypotension is a known risk factor for poor neurologic outcomes after traumatic brain injury (TBI). Current guidelines suggest that higher systolic blood pressure (SBP) thresholds likely confer a mortality benefit. However, there is no consensus on the ideal perfusion pressure among different age groups (i.e., recommended SBP ≥100 mm Hg for patients age 50-69 years; ≥ 110 mm Hg for all other adults). We hypothesize that admission SBP ≥110 mm Hg will be associated with improved outcomes regardless of age group. A retrospective database review of the 2010-2016 Trauma Quality Improvement Program database was performed for adults (≥ 18 years) with isolated moderate-to-severe TBIs (head Abbreviated Injury Scale [AIS] ≥3; all other AIS3). Sub-analyses were performed after dividing patients by SBP and age; comparison groups were matched with propensity score matching. Primary outcomes were early (6 h, 12 h, and 1 day) and overall in-hospital mortality. Overall, 154,725 patients met the inclusion criteria (mean age 62.8 ± 19.8 years, 89,431 [57.8%] males, Injury Severity Score13.9 ± 6.8). Multi-variate logistic regression showed that the risk of in-hospital mortality decreased with increasing SBP, plateauing at 110 mm Hg. Among patients of all ages, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-129 vs. 90-109 mm Hg: 12 h 0.4% vs. 0.8%

Trauma is one of the most common causes of death, particularly in younger individuals. The development of specialized trauma centers, trauma-specific intensive care units, and trauma-focused medical subspecialties has led to the formation of comprehensive multidisciplinary teams and an ever-growing body of research and innovation. The field of interventional radiology provides a unique set of minimally invasive, endovascular techniques that has largely changed the way that many trauma patients are managed. This article discusses the role of interventional radiology in the care of this complex patient population, and in particular how the specialty fits into the overall team management of these patients.

BACKGROUND: We sought to describe characteristics, multisystem outcomes, and predictors of mortality of the critically ill COVID-19 patients in the largest hospital in Massachusetts. METHODS: This is a prospective cohort study. All patients admitted to the intensive care unit (ICU) with reverse-transcriptase-polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 14, 2020, and April 28, 2020, were included; hospital and multisystem outcomes were evaluated. Data were collected from electronic records. Acute respiratory distress syndrome (ARDS) was defined as PaO2/FiO2 ratio of ≤300 during admission and bilateral radiographic pulmonary opacities. Multivariable logistic regression analyses adjusting for available confounders were performed to identify predictors of mortality. RESULTS: A total of 235 patients were included. The median (interquartile range [IQR]) Sequential Organ Failure Assessment score was 5 (3-8), and the median (IQR) PaO2/FiO2 was 208 (146-300) with 86.4% of patients meeting criteria for ARDS. The median (IQR) follow-up was 92 (86-99) days, and the median ICU length of stay was 16 (8-25) days; 62.1% of patients were proned, 49.8% required neuromuscular blockade, and 3.4% required extracorporeal membrane oxygenation. The most common complications were shock (88.9%), acute kidney injury (AKI) (69.8%), secondary bacterial pneumonia (70.6%), and pressure ulcers (51.1%). As of July 8, 2020, 175 patients (74.5%) were discharged alive (61.7% to skilled nursing or rehabilitation facility), 58 (24.7%) died in the hospital, and only 2 patients were still hospitalized, but out of the ICU. Age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.12), higher median Sequential Organ Failure Assessment score at ICU admission (OR, 1.24; 95% CI, 1.06-1.43), elevated creatine kinase of ≥1,000 U/L at hospital admission (OR, 6.64; 95% CI, 1.51-29.17), and severe ARDS (OR, 5.24; 95% CI, 1.18-23.29) independently predicted hospital mortality.Comorbidities, steroids, and hydroxychloroquine treatment did not predict mortality. CONCLUSION: We present here the outcomes of critically ill patients with COVID-19. Age, acuity of disease, and severe ARDS predicted mortality rather than comorbidities. LEVEL OF EVIDENCE: Prognostic, level III.

BACKGROUND The optimal timing for cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) stones is unknown. We hypothesized that a delay between procedures would correlate with more biliary complications and longer hospitalizations. METHODS We prospectively identified patients who underwent same admission cholecystectomy after ERCP for CBD stones from 2016 to 2019 at 12 US medical centers. The cohort was stratified by time between ERCP and cholecystectomy: ≤24 hours (immediate), >24 to ≤72 hours (early), and >72 hours (late). Primary outcomes included operative duration, postoperative length of stay, (LOS), and hospital LOS. Secondary outcomes included rates of open conversion, CBD explorations, biliary complications, and in-hospital complications. RESULTS For the 349 patients comprising the study cohort, 33.8% (n = 118) were categorized as immediate, 50.4% (n = 176) as early, and 15.8% (n = 55) as late. Rates of CBD explorations were lower in the immediate group compared with the late group (0.9% vs. 9.1%, p = 0.01). Rates of open conversion were lower in the immediate group compared with the early group (0.9% vs. 10.8%, p < 0.01) and in the immediate group compared with the late group (0.9% vs. 10.9%, p < 0.001). On a mixed-model regression analysis, an immediate cholecystectomy was associated with a significant reduction in postoperative LOS (β = 0.79; 95% confidence interval, 0.65-0.96; p = 0.02) and hospital LOS (β = 0.68; 95% confidence interval, 0.62-0.75; p < 0.0001). CONCLUSION An immediate cholecystectomy following ERCP correlates with a shorter postoperative LOS and hospital LOS. Rates of CBD explorations and conversion to open appear more common after 24 hours. LEVEL OF EVIDENCE Therapeutic, level III.

Background The Emergency Surgery Score (ESS) is an accurate mortality risk calculator for emergency general surgery (EGS). We sought to assess whether ESS can accurately predict 30-day morbidity, mortality, and requirement for postoperative Intensive Care Unit (ICU) care in patients with missing data variables. Methods All EGS patients with one or more missing ESS variables in the 2007–2015 ACS-NSQIP database were included. ESS was calculated assuming that a missing variable is normal (i.e. no additional ESS points). The correlation between ESS and morbidity, mortality, and postoperative ICU level of care was assessed using the c-statistics methodology. Results Out of a total of 4,456,809 patients, 359,849 were EGS, and of those 256,278 (71.2%) patients had at least one ESS variable missing. ESS correlated extremely well with mortality (c-statistic = 0.94) and postoperative requirement of ICU care (c-statistic = 0.91) and well with morbidity (c-statistic = 0.77). Conclusion ESS performs well in predicting outcomes in EGS patients even when one or more data elements are missing and remains a useful bedside tool for counseling EGS patients and for benchmarking the quality of EGS care.

Background: Early diagnosis and prompt debridement of necrotizing soft tissue infection (NSTI) improves the outcome. We sought to determine whether failure to admit NSTI patients to acute care surg...

We aimed to examine the prevalence of, and describe factors associated with, firearm-related injuries in American households.Using the 2010-2016 ACS-TQIP database, all ICD-9/10 external causes of injury for firearm-related injuries were queried with the place of occurrence designated as "home". Causes of injury were identified as assault, intentional self-injury, and unintentional injury. Univariate then multivariable regression analyses were performed to identify factors associated with each injury type.12,657 firearm-related injuries in households were identified. Of those, 49.9% were victims of assault, 35.7% were intentional self-injury, and 14.4% were unintentional. Mortality was highest among self-inflicted injuries (52.4%), followed by assault (12.9%), and unintentional injuries (5.9%). On multivariable analysis, age45 years, African-American race, and drug use were independently associated with an injury secondary to assault. Age65 years, White race, psychiatric illness, and alcohol use disorder were independently associated with intentional self-injury. White and American-Indian race were independently associated with unintentional injuries.Assault is the most common cause of home-related firearm injury requiring hospitalization, while intentional self-injury is the most lethal.

Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database.Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses.Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P 0.001), prehospital pulse60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P 0.001), emergency department pulse60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P 0.001), higher median intensive care unit LOS (19 d versus 6 d; P 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived.The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

BACKGROUND The Emergency Surgery Score (ESS) is a point-based scoring system validated to predict mortality and morbidity in emergency general surgery (EGS). In addition to demographics and comorbidities, ESS accounts for the acuity of disease at presentation. We sought to examine whether ESS can predict the destination of discharge of EGS patients, as a proxy for quality of life at discharge. METHODS Using the 2007 to 2017 American College of Surgeons National Surgical Quality Improvement Program database, we identified all EGS patients. EGS cases were defined as per American College of Surgeons National Surgical Quality Improvement Program as those performed by a general surgeon within a short interval from diagnosis or the onset of related symptomatology, when the patient's well-being and outcome may be threatened by unnecessary delay and patient's status could deteriorate unpredictably or rapidly. Emergency Surgery Score patients were then categorized by their discharge disposition to home versus rehabilitation or nursing facilities. All patients with missing ESS or discharge disposition and those discharged to hospice, senior communities, or separate acute care facilities were excluded. Emergency Surgery Score was calculated for each patient. C statistics were used to study the correlation between ESS and the destination of discharge. RESULTS Of 6,485,915 patients, 84,694 were included. The mean age was 57 years, 51% were female, and 79.6% were discharged home. The mean ESS was 5. Emergency Surgery Score accurately and reliably predicted the discharge destination with a C statistic of 0.83. For example, ESS of 1, 10, and 20 were associated with 0.9%, 56.5%, and 100% rates of discharge to a rehabilitation or nursing facility instead of home. CONCLUSION Emergency Surgery Score accurately predicts which EGS patients require discharge to rehabilitation or nursing facilities and can thus be used for preoperatively counseling patients and families and for improving early discharge preparations, when appropriate. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.

Emergency department (ED) crowding is associated with increased mortality and delays in care. We developed a rapid admission pathway targeting critically-ill trauma patients in the ED. This study investigates the sustainability of the pathway, as well as its effectiveness in times of increased ED crowding.This was a retrospective cohort study assessing the admission of critically-ill trauma patients with and without the use of a rapid admission pathway from 2013 to 2018. We accessed demographic and clinical data from trauma registry data and ED capacity logs. Statistical analyses included univariate and multivariate testing.A total of 1700 patients were included. Of this cohort, 434 patients were admitted using the rapid admission pathway, whereas 1266 were admitted using the traditional pathway. In bivariate analysis, mean ED LOS was 1.54 h (95% Confidence Interval [CI]: 1.41, 1.66) with the rapid pathway, compared with 5.88 h (95% CI: 5.64, 6.12) with the traditional pathway (p 0.01). We found no statistically significant relationship between rapid admission pathway use and survival to hospital discharge. During times of increased crowding, rapid pathway use continued to be associated with reduction in ED LOS (p 0.01). The reduction in ED LOS was sustained when comparing initial results (2013-2014) to recent data (2015-2018).This study found that a streamlined process to admit critically-ill trauma patients is sustainable and associated with reduction in ED LOS. As ED crowding remains pervasive, these findings support restructured care processes to limit prolonged ED boarding times for critically-ill patients.

Introduction Bilateral internal iliac artery embolization (BIIAE) with temporary embolic materials epitomizes damage-control principles in the treatment of exsanguinating hemorrhage from pelvic trauma. However, instances of ischemic complications have been reported. The aim of our study was to assess safety and effectiveness of BIIAE. Methods All patients who received BIIAE for pelvic trauma at a Level I Trauma Center between 1998 and 2018 were reviewed. Effectiveness was assessed by radiographic bleeding control and clinical bleeding control, i.e. stabilization of vital signs and reduction in blood transfusion. Safety was assessed by any evidence for ischemic damage of pelvic organs or tissues. Results Of 61 patients undergoing BIIAE, bleeding control was confirmed radiographically in 60 (98%) and clinically in 55 (90%), including 4 (7%) patients who required repeat embolization. Six (10%) patients died due to insufficient pelvic bleeding control. No BIIAE-related complications were identified. Conclusion The overall clinical effectiveness and safety rates of BIIAE for pelvic bleeding control, when combined with other methods of hemostasis, were 90% and 100% respectively.

Background Western Trauma Association guidelines recommend admitting patients 65 years or older with two or more rib fractures diagnosed by chest radiograph to the intensive care unit (ICU). Increased use of computed tomography has led to identification of less severe, "occult" rib fractures. We aimed to evaluate current national trends in disposition of older patients with isolated rib cage fractures and to identify characteristics of patients initially admitted to the ward who failed ward management. Methods A retrospective cohort study of patients 65 years or older with isolated two or more blunt rib cage fractures using the 2010 to 2016 American College of Surgeons Trauma Quality Improvement Program database was performed. Ward failure was defined as patients initially admitted to the ward with subsequent need for unplanned ICU admission or intubation. Multivariable analyses were derived to study the independent predictors of failure of ward management. Propensity score matching sub-analysis was used to assess outcomes in patients admitted to the ward versus ICU. Results There were 5,021 patients included in the analysis. Of these patients, 1,406 (28.0%) were admitted to the ICU. On multivariable analysis, age was an independent predictor of ICU admission. Of the 3,577 patients admitted directly to the ward, 38 (1.1%) patients required unplanned intubation or ICU admission. Independent predictors of failure of ward management included chronic renal failure (odds ratio [OR], 7.20; p ≤ 0.001; 95% confidence interval [CI], 2.50-20.76), traumatic pneumothorax (OR, 8.70; p = 0.008; 95% CI, 1.76-42.93), concurrent sternal fracture (OR, 6.52; p ≤ 0.001; 95% CI, 2.53-16.80), drug use disorder (OR, 6.58; p = 0.032; 95% CI, 1.17-36.96), and emergency department oxygen requirement or oxygen saturation less than 95% (OR, 2.38; p = 0.018; 95% CI, 1.16-4.86). Mortality was higher in patients with delayed ICU care versus patients with successful ward disposition (21.1% vs. 0.8%; p Conclusion Our results suggest that the majority of isolated rib cage fractures in older patients are safely managed on the ward with exceedingly low ward failure rates (1.1%). Patients with failure of ward management have significantly higher mortality, and we have identified predictors of failing the ward. Level of evidence Therapeutic/Care Management, level IV; Prognostic III.

Background Despite the presence of highly reliable data, studies on packed red blood cells (pRBC):fresh frozen plasma (FFP) ratio suffer from limited sample size and the presence of survivor bias. We sought to study the association between FFP:pRBC and early mortality in the hemorrhaging trauma patient. Study Design This was a retrospective nationwide cohort that included all TQIP participating hospitals (2013 to 2016). We included all trauma patients who were transfused ≥10 pRBCs and ≥1 FFP within 24 hours. We excluded transferred patients and those who died in the emergency department or had missing/inaccurate transfusion data. Patients were assigned to 7 FFP:pRBC cohorts (range 1:1 to 1:6, and 1:6+) only if the ratio was similar at 4 and 24 hours and, to avoid survival bias, were excluded otherwise. Multivariable analyses correcting for all available confounders (age, demographics, comorbidities, vital signs, Injury Severity Score [ISS] and mechanism, procedures performed) were derived to study the independent relationship between FFP:pRBC and 24-hour mortality. Results Of 1,002,595 patients, 4,427 patients were included. Mean age was 41 years, 79% were males, 61% had blunt trauma, and median ISS was 29. Most patients were transfused in a 1:1, 1:2, or 1:3 ratio (31%, 41%, and 11%, respectively); mortality ranged between 28% for 1:1 and 62% for 1:4. In multivariable analyses, the odds of mortality independently and incrementally increased to 1.23 (95% CI 1.02 to 1.48) for a 1:2 ratio, 2.11 (95% CI 1.42 to 3.13) for 1:4, and as high as 4.11 (95% CI 2.31 to 7.31) for 1:5 (all p Conclusions A 1:1 FFP:pRBC ratio is associated with the lowest mortality in the hemorrhaging trauma patient, and mortality increases with decreasing ratios.

BACKGROUND Despite the utilization of point-of-care ultrasound (POCUS) by trauma surgeons, formal POCUS requirements do not exist for general surgery residents. We sought to evaluate surgery resident comfort with performing and interpreting of Extended-Focused Assessment for Sonography in Trauma (E-FAST) scans after a brief educational session. METHODS A pre-survey, sent to PGY-2 and -3 surgical residents before their trauma rotation, evaluated comfort with eight components of the E-FAST. Residents were then required to watch a 15-min online video and attend a 1-h bedside training session moderated by emergency medicine ultrasound fellows during which residents practised E-FAST image acquisition and interpretation. After the rotation, residents completed a post-survey evaluating their comfort with the E-FAST. RESULTS All 27 residents rotating on the trauma service during the 2017-2018 academic year were eligible and, therefore, approached by the study team. Twenty-one (77.78%) residents completed the pre-survey, training and post-survey. Initially, only 52% (13/25) of residents reported feeling confident in performing the E-FAST. After the session, all (100%) reported feeling confident in their training in E-FAST. Self-reported mean comfort with each of the eight components of the E-FAST showed a statistically significant (P

Background Outcome data on the very elderly patients undergoing emergency general surgery (EGS) are sparse. We sought to examine short- and long-term mortality in the 80 plus years population following EGS. Methods Using our institutional 2008-2018 EGS Database, all the 80 plus years patients undergoing EGS were identified. The data were linked to the Social Security Death Index to determine cumulative mortality rates up to 3 years after discharge. Univariate and multivariable logistic regression analyses were used to determine predictors of in-hospital and 1-year cumulative mortality. Results A total of 385 patients were included with a mean age of 84 years; 54% were female. The two most common comorbidities were hypertension (76.1%) and cardiovascular disease (40.5%). The most common procedures performed were colectomy (20.0%), small bowel resection (18.2%), and exploratory laparotomy for other procedures (15.3%; e.g., internal hernia, perforated peptic ulcer). The overall in-hospital mortality was 18.7%. Cumulative mortality rates at 1, 2, and 3 years after discharge were 34.3%, 40.5%, and 43.4%, respectively. The EGS procedure associated with the highest 1-year mortality was colectomy (49.4%). Although hypertension, renal failure, hypoalbuminemia, hyperbilirubinemia, and elevated liver enzymes predicted in-hospital mortality, the only independent predictors of cumulative 1-year mortality were hypoalbuminemia (odds ratio, 2.17; 95% confidence interval, 1.10-4.27; p = 0.025) and elevated serum glutamic pyruvic transaminase (SGOT) level (odds ratio, 2.56; 95% confidence interval, 1.09-4.70; p = 0.029) at initial presentation. Patients with both factors had a cumulative 1-year mortality rate of 75.0%. Conclusion More than half of the very elderly patients undergoing major EGS were still alive at 3 years postdischarge. The combination of hypoalbuminemia and elevated liver enzymes predicted the highest 1-year mortality. Such information can prove useful for patient and family counseling preoperatively. Level of evidence Prognostic, Level III.

Management of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE).All adults (age16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups.Of 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03).Pelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.

As hospital systems plan for health care utilization surges and stress, understanding the necessary resources of a trauma system is essential for planning capacity. We aimed to describe trends in high-intensity resource utilization (operating room [OR] usage and intensive care unit [ICU] admissions) for trauma care during the initial months of the COVID-19 pandemic. Trauma registry data (2019 pre-COVID-19 and 2020 COVID-19) were collected retrospectively from 4 level I trauma centers. Direct emergency department (ED) disposition to the OR or ICU was used as a proxy for high-intensity resource utilization. No change in the incidence of direct ED to ICU or ED to OR utilization was observed (2019: 24%, 2020 23%; P = .62 and 2019: 11%, 2020 10%; P = .71, respectively). These results suggest the need for continued access to ICU space and OR theaters for traumatic injury during national health emergencies, even when levels of trauma appear to be decreasing.

The education of civilians and first responders in prehospital tourniquet (PT) utilization has spread rapidly. We aimed to describe trends in emergency medical services (EMS) and non-EMS PT utilization, and their ability to identify proper clinical indications and to appropriately apply tourniquets in the field.A retrospective cohort study was conducted to evaluate all adult patients with PTs who presented at two Level I trauma centers between January 2015 and December 2019. Data were collected via an electronic patient query tool and cross-referenced with institutional Trauma Registries. Medically trained abstractors determined if PTs were clinically indicated (limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). PTs were further designated as appropriately or inappropriately applied (based on tourniquet location, venous tourniquet, greater than 2-h ischemic time). Descriptive statistics and univariate analyses were performed.146 patients met inclusion criteria. The incidence of yearly PT placements increased between 2015 and 2019, with an increase in placement by non-EMS personnel (police, firefighter, bystander, and patient). Improvised PTs were frequently utilized by bystanders and patients, whereas first responders had high rates of commercial tourniquet use. A high proportion of tourniquets were placed without indication (72/146, 49%); however, the proportion of PTs placed without a proper indication across applier groups was not statistically different (p = 0.99). Rates of inappropriately applied PTs ranged from 21 to 46% across all groups applying PTs.PT placement was increasingly performed by non-EMS personnel. Present data indicate that non-EMS persons applied PTs at a similar performance level of those applied by EMS. Study LevelLevel III.

Background COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution’s surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period. Methods All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed. Results Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation. Conclusion Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.

Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients.This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused.A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%.Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock.Diagnostic test, level III.

Objective The relationship between total transfusion volume and infection in the trauma patient remains unclear, especially at lower volumes of transfusion. We sought to quantify the cumulative, independent impact of transfusion within 24 hours of admission on the risk of infection in trauma patients. Methods Using the Trauma Quality Improvement Program 2013 to 2016 database, we included all patients who received blood transfusions in the first 4 hours. Patients who were transferred or had incomplete/wrongly coded information on transfusion volume were excluded. Patients were divided into 20 cohorts based on the total blood product volume transfused in the first 24 hours. A composite infection variable (INF) was created, including surgical site infection, ventilator-associated pneumonia, urinary tract infection, central line associated blood stream infection, and sepsis. Univariate and stepwise multivariable logistic regression analyses were performed to study the relationship between blood transfusion and INF, controlling for demographics (e.g., age, sex), comorbidities (e.g., cirrhosis, diabetes, steroid use), severity of injury (e.g., vital signs on arrival, mechanism, Injury Severity Score), and operative and angiographic interventions. Results Of 1,002,595 patients, 37,568 were included. The mean age was 42 ± 18.6 years, 74.6% were males, 68% had blunt trauma, and median Injury Severity Score was 25 [17-34]. Adjusting for all available confounders, odds of INF increased incrementally from 1.00 (reference, 0-2 units) to 1.23 (95% confidence interval, 1.11-1.37) for 4 units transfused to 4.89 (95% confidence interval, 2.72-8.80) for 40 units transfused. Each additional unit increased the odds of INF by 7.6%. Conclusion Transfusion of the bleeding trauma patient was associated with a dose-dependent increased risk of infectious complications. Trauma surgeons and anesthesiologists should resuscitate the trauma patient until prompt hemorrhage control while avoiding overtransfusion. Level of evidence Retrospective cohort study, Therapeutic IV.

Background Recent small randomized trials suggest that primary anastomosis with a diverting loop ileostomy (PADLI) is a safe alternative to Hartmann's procedure (HP) for patients with acute diverticulitis necessitating emergent operation. We sought to examine the 30-day outcomes of patients undergoing emergent HP vs PADLI. Method Using the American College of Surgeons NSQIP Colectomy Procedure Targeted Database from 2012 to 2016, all patients with acute diverticulitis who underwent emergent HP or PADLI were identified. Multivariable logistic models were constructed to compare the 30-day mortality, overall morbidity, and individual postoperative complications (eg surgical site infection, bleeding, sepsis) of the 2 procedures, controlling for all preoperative variables (eg demographics, comorbidities, laboratory values, illness severity), as well as intraoperative and procedure-specific variables (eg wound classification). Results Of 130,963 patients, 2,729 patients were included. Median age was 64 years, 48.5% were male; the majority of patients underwent HP and only 208 (7.6%) underwent PADLI. Hartmann's procedure patients had more comorbidities (eg COPD: 9.8% vs 4.8%; p = 0.017), were more functionally dependent (6.3% vs 2.4%; p = 0.025), and were sicker (eg septic shock: 11.1% vs 5.3%; p = 0.015) compared with PADLI patients. The mortality rates for HP vs PADLI were 7.6% and 2.9%, respectively (p = 0.011). The morbidity rates were 55.4% and 48.6%, respectively (p = 0.056). In multivariable analyses, compared with HP, PADLI did not result in increased rates of mortality (odds ratio 0.21; 95% CI 0.03 to 1.58; p = 0.129) or morbidity (odds ratio 0.96; 95% CI 0.63 to 1.45; p = 0.834). The odds of most major postoperative complications were also similar for HP and PADLI overall. Conclusions Currently, surgeons perform HP more frequently than PADLI. When controlling for patient population differences, PADLI appears to be at least a safe alternative to HP for select patient populations needing emergent surgical management of acute diverticulitis.

Recent studies suggest that obesity is a risk factor for Clostridium difficile infection, possibly due to disruptions in the intestinal microbiome composition. We hypothesized that body mass index (BMI) is associated with increased incidence of C. difficile infection in surgical patients.In this nationwide retrospective cohort study in 680 American College of Surgeons National Surgical Quality Improvement Program participating sites across the United States, the occurrence of C. difficile infection within 30 days postoperatively between different BMI groups was compared. All American College of Surgeons National Surgical Quality Improvement Program patients between 2015 and 2016 were classified as underweight, normal-weight, overweight, or obese class I-III if their BMI was less than 18.5, 18.5 to 25, 25 to 30, 30 to 35, 35 to 40 or greater than 40, respectively.A total of 1,426,807 patients were included; median age was 58 years, 43.4% were male, and 82.9% were white. The postoperative incidence of C. difficile infection was 0.42% overall: 1.11%, 0.56%, 0.39%, 0.35%, 0.33% and 0.36% from the lowest to the highest BMI group, respectively (p0.001 for trend). In univariate then multivariable logistic regression analyses, adjusting for patient demographics (e.g., age, sex), comorbidities (e.g., diabetes, systemic sepsis, immunosuppression), preoperative laboratory values (e.g., albumin, white blood cell count), procedure complexity (work relative unit as a proxy) and procedure characteristics (e.g., emergency, type of surgery [general, vascular, other]), compared with patients with normal BMI, high BMI was inversely and incrementally correlated with the postoperative occurrence of C. difficile infection. The underweight were at increased risk (odds ratio, 1.15 [1.00-1.32]) while the class III obese were at the lowest risk (odds ratio, 0.73 [0.65-0.81]).In this nationwide retrospective cohort study, obesity is independently and in a stepwise fashion associated with a decreased risk of postoperative C. difficile infection. Further studies are warranted to explore the potential and unexpected association.Prognostic/Epidemiologic, Level IV.

BACKGROUND Outcomes of early enteral nutrition (EEN) in critically ill patients on vasoactive medications remain unclear. We aimed to compare in-hospital outcomes for EEN vs late EN (LEN) in mechanically ventilated patients receiving vasopressor support. METHODS This was a retrospective study using the national eICU Collaborative Research Database. Adult patients requiring vasopressor support and mechanical ventilation within 24 h of admission and for ≥2 days were included. Patients with an admission diagnosis that could constitute a contraindication for EEN (eg, gastrointestinal [GI] perforation, GI surgery) and patients with an intensive care unit (ICU) length of stay (LOS)

Background: Infections represent a major component of surgical practice. Risk mitigation, seeking eradication and optimal patient outcomes, require a concerted, multifocal effort to understand dise...

Importance The familial aspect of acute appendicitis (AA) has been proposed, but its hereditary basis remains undetermined. Objective To identify genomic variants associated with AA. Design, setting, and participants This genome-wide association study, conducted from June 21, 2019, to February 4, 2020, used a multi-institutional biobank to retrospectively identify patients with AA across 8 single-nucleotide variation (SNV) genotyping batches. The study also examined differential gene expression in appendiceal tissue samples between patients with AA and controls using the GSE9579 data set in the National Institutes of Health's Gene Expression Omnibus repository. Statistical analysis was conducted from October 1, 2019, to February 4, 2020. Main outcomes and measures Single-nucleotide variations with a minor allele frequency of 5% or higher were tested for association with AA using a linear mixed model. The significance threshold was set at P = 5 × 10-8. Results A total of 29 706 patients (15 088 women [50.8%]; mean [SD] age at enrollment, 60.1 [17.0] years) were included, 1743 of whom had a history of AA. The genomic inflation factor for the cohort was 1.003. A previously unknown SNV at chromosome 18q was found to be associated with AA (rs9953918: odds ratio, 0.99; 95% CI, 0.98-1.00; P = 4.48 × 10-8). This SNV is located in an intron of the NEDD4L gene. The heritability of appendicitis was estimated at 30.1%. Gene expression data from appendiceal tissue donors identified NEDD4L to be among the most differentially expressed genes (14 of 22 216 genes; β [SE] = -2.71 [0.44]; log fold change = -1.69; adjusted P = .04). Conclusions and relevance This study identified SNVs within the NEDD4L gene as being associated with AA. Nedd4l is involved in the ubiquitination of intestinal ion channels and decreased Nedd4l activity may be implicated in the pathogenesis of AA. These findings can improve the understanding of the genetic predisposition to and pathogenesis of AA.

Background: The quality of scientific literature is judged by study design, validity, and applicability to unique patient populations. Methods: We searched the available literature to explore the hierarchy of evidence, explain research fundamentals such as sample size calculation, and discuss common study designs employed in surgical research and the interpretation of trial designs. Results: Each unique study design has restraints created by some degree of systematic errors and bias. This article provides definitions for the scientific boundaries of case control, retrospective, before-and-after, prospective observational, randomized controlled designs, and meta-analyses. Conclusion: Critical thinking and appraisal of the literature is a skill that requires lifelong training and practice. Clinical research education and design need to garner more attention in the medical community.

Background: Post-operative infectious complications after repair of intestinal-cutaneous fistulas (ICF) represent a substantial burden and these outcomes vary widely in the literature. We aimed to evaluate the use of the modified frailty index-5 (mFI-5) to account for physiologic reserve to predict infectious complications in patients with ICF undergoing operative repair. Methods: We used the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) 2006-2017 dataset to include patients who underwent ICF repair. The main outcome measure was 30-day infectious complications (surgical site infection [SSI], sepsis, pneumonia, and urinary tract infection [UTI]). The risk of 30-day post-operative infectious complications was assessed based on mFI-5 score. We performed multivariable logistic regression analyses to evaluate the association between infectious complications and mFI-5. Results: We identified 4,197 patients who underwent an ICF repair. The median age (interquartile range [IQR]) was 57 (46, 67) years, and the majority of patients were female (2,260; 53.9%); white (3,348; 79.8%); and 1,586 (38.3%) were obese. After adjustment for relevant confounders such as baseline patient characteristics, and operative details, mFI-5 was independently associated with infectious complications (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.25-3.21), particularly SSI (OR, 2.16; 95% CI, 1.28-3.63) and pneumonia (OR, 5.31; 95% CI, 2.29-12.35), but not UTI or sepsis. Conclusions: We showed that the mFI-5 is a strong predictor of infectious complications after ICF repair. It can be utilized to account for physiologic reserve, therefore reducing the variability of outcomes reported for ICF repair.

Prehospital tourniquet (PHT) utilization has increased in response to mass casualty events. We aimed to describe the incidence, therapeutic effectiveness, and morbidity associated with tourniquet placement in all patients treated with PHT application.A retrospective observational cohort study was performed to evaluate all adults with a PHT who presented at two Level I trauma centers between January 2015 and December 2019. Medically trained abstractors determined if the PHT was clinically indicated (placed for limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). Prehospital tourniquets were further designated as appropriately or inappropriately applied (based on PHT anatomic placement location, occurrence of a venous tourniquet, or ischemic time defined as2 hours). Statistical analyses were performed to generate primary and secondary results.A total of 147 patients met study inclusion criteria, of which 70% met the criteria for trauma registry inclusion. Total incidence of PHT utilization increased from 2015 to 2019, with increasing proportions of PHTs placed by nonemergency medical service personnel. Improvised PHTs were frequently used. Prehospital tourniquets were clinically indicated in 51% of patients. Overall, 39 (27%) patients had a PHT that was inappropriately placed, five of which resulted in significant morbidity.In summary, prehospital tourniquet application has become widely adopted in the civilian setting, frequently performed by civilian and nonemergency medical service personnel. Of PHTs placed, nearly half had no clear indication for placement and over a quarter of PHTs were misapplied with notable associated morbidity. Results suggest that the topics of clinical indication and appropriate application of tourniquets may be important areas for continued focus in future tourniquet educational programs, as well as future quality assessment efforts.Epidemiological, level III; Therapeutic, level IV.

OBJECTIVE The incidence of venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) has increased significantly. The Eastern Association for the Surgery of Trauma recommends using low-molecular-weight heparin (LMWH) over unfractionated heparin (UH) in pediatric patients requiring VTE prophylaxis, although this strategy is unsupported by the literature. In this study, the authors compare the outcomes of pediatric TBI patients receiving LMWH versus UH. METHODS The authors performed a 4-year (2014–2017) analysis of the pediatric American College of Surgeons Trauma Quality Improvement Program. All trauma patients (age ≤ 18 years) with TBI requiring thromboprophylaxis with UH or LMWH were potentially eligible for inclusion. Patients who had been transferred, had died in the emergency department, or had penetrating trauma were excluded. Patients were stratified into either the LMWH or the UH group on the basis of the prophylaxis they had received. Patients were matched on the basis of demographics, injury characteristics, vital signs, and transfusion requirements using propensity score matching (PSM). The study endpoints were VTE, death, and craniotomy after initiation of prophylaxis. Univariate analysis was performed after PSM to compare outcomes. RESULTS A total of 2479 patients met the inclusion criteria (mean age 15.5 ± 3.7 years and 32.0% female), of which 1570 (63.3%) had received LMWH and 909 (36.7%) had received UH. Before PSM, patients receiving UH were younger, had a lower Glasgow Coma Scale score, and had a higher Injury Severity Score. Patients treated in pediatric hospitals were more likely to receive UH (12.9% vs 9.0%, p < 0.001) than patients treated in adult hospitals. Matched patients receiving UH had a higher incidence of VTE (5.1% vs 2.9%, p = 0.03). CONCLUSIONS LMWH prophylaxis in pediatric TBI appears to be more effective than UH in preventing VTE. Large, multicenter prospective studies are warranted to confirm the superiority of LMWH over UH in pediatric patients with TBI. Moreover, outcomes of VTE prophylaxis in the very young remain understudied; therefore, dedicated studies to evaluate this population are needed.

Background Major injury results in an early cascade of immunologic responses that increase susceptibility to infection and multiorgan dysfunction. Detailed immune profiling by mass cytometry has the potential to identify immune signatures that correspond to patient outcomes. Our objective was to determine the prognostic value of immune signatures early after major trauma injury. Methods Trauma patients (n = 17) were prospectively enrolled between September 2018 and December 2019. Serial whole blood samples were obtained from trauma patients (mean Injury Severity Score, 26.2; standard error of the mean, 3.7) at Days 1 and 3 after injury, and from age- and sex-matched uninjured controls using a standardized protocol for fixation, storage, and labeling. Computational analyses including K-nearest neighbor automated clustering of immune cells and Spearman's correlation analysis were used to identify correlations between cell populations, clinical measures, and patient outcomes. Results Analysis revealed nine immune cell clusters that correlated with one or more clinical outcomes. On Days 1 and 3 postinjury, the abundance of immature neutrophil and classical monocytes exhibited a strong positive correlation with increased intensive care unit and hospital length of stay. Conversely, the abundance of CD4 T-cell subsets, namely Th17 cells, is associated with improved patient outcomes including decreased ventilator days (r = -0.76), hospital-acquired pneumonia (r = -0.69), and acute kidney injury (r = -0.73). Conclusion Here, we provide a comprehensive multitime point immunophenotyping analysis of whole blood from patients soon after traumatic injury to determine immune correlates of adverse outcomes. Our findings indicate that alterations in myeloid-origin cell types may contribute to immune dysfunction after injury. Conversely, the presence of effector T cell populations corresponds with decreased hospital length of stay and organ dysfunction. Overall, these data identify novel immune signatures following traumatic injury that support the view that monitoring of immune (sub)-populations may provide clinical decision-making support for at-risk patients early in their hospital course. Level of evidence Prognostic/Epidemiologic, Level IV.

Background Optimal use of interventional procedures and diagnostic tests for patients with suspected choledocholithiasis depends on accurate pretest risk estimation. We sought to define sensitivity/specificity of transaminases in identifying choledocholithiasis and to incorporate them into a biochemical marker composite score that could accurately predict choledocholithiasis. Methods All adult patients who underwent laparoscopic cholecystectomy by our Emergency Surgery Service between 2010 and 2018 were reviewed. Admission total bilirubin (TB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) was captured. Choledocholithiasis was confirmed via intraoperative cholangiogram, endoscopic retrograde cholangiopancreatography, or magnetic resonance cholangiopancreatography. Area under receiver operating characteristic curve (AUC) or C-statistic for AST, ALT, ALP, and TB as a measure of detecting choledocholithiasis was calculated. For score development, our database was randomly dichotomized to derivation and validation cohort and a score was derived. The score was validated by calculating its C-statistic. Results 1089 patients were included; 210 (20.3%) had confirmed choledocholithiasis. The AUC was .78 for TB, .77 for ALP and AST, and .76 for ALT. 545 and 544 patients were included in the derivation and the validation cohort, respectively. The elements of the derived score were TB, AST, and ALP. The score ranged from 0 to 4. The AUC was .82 in the derivation and .77 in the validation cohort. The probability of choledocholithiasis increased from 8% to 89% at scores 0 to 4, respectively. Conclusions Aspartate aminotransferase predicted choledocholithiasis adequately and should be featured in choledocholithiasis screening algorithms. We developed a biochemical composite score, shown to be accurate in preoperative choledocholithiasis risk assessment in an emergency surgery setting.

Infections are the most common complications after trauma with over 20% of trauma admissions developing sepsis during their hospital stay. Prompt identification of trauma patients with sepsis can help promote early interventions, decrease hospital length of stay, decrease health care costs and save lives. In this chapter, we aim to discuss the risk factors, prevention strategies, and evidence-based therapeutic interventions for the most common infections that occur after traumatic injuries.

Background Peri-operative blood transfusion (BT) may lead to transfusion-induced immunomodulation. We aimed to investigate the association between peri-operative BT and infectious complications in patients undergoing intestinal-cutaneous fistulas (ICF) repair. Methods We queried the ACS-NSQIP 2006–2017 database to include patients who underwent ICF repair. The main outcome was 30-day infectious complications. Univariate and multivariable logistic regression analyses were performed to assess the predictors of post-operative infections. Results Of 4,197 patients included, 846 (20.2%) received peri-operative BT. Transfused patients were generally older, sicker and had higher ASA (III–V). After adjusting for relevant covariates, patients who received intra and/or post-operative (and not pre-operative) BT had higher odds of infectious complications compared (OR = 1.22, 95% CI 1.01–1.48). Specifically, they had higher odds of organ-space surgical site infection (OR = 1.61, 95% CI 1.21–2.13), but not other infectious complications. Conclusions Intra and/or post-operative (and not pre-operative) BT is an independent predictor of infectious complications in ICF repair.