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Damage control laparotomy (DCL) has a high risk of SSI and as an attempt to mitigate this, surgeons often leave the skin open to heal by secondary intention. A recent retrospective study showed that DCL wounds could be closed with the addition of wicks or incisional wound vacs with acceptable rates of wound infection. The aim of this prospective trial was to corroborate these results. This is a prospective multicenter observational trial performed by 7 institutions from July 2020 to April 2022. Adult patients who underwent DCL and fascia/skin closure with the addition of wicks or an incisional wound vac were included. Patients who died within seven days of DCL were excluded. Demographics, mechanism of initial presentation, wound classification, antibiotics given, surgical site infections, procedures performed, and mortality data was collected. Fisher's Exact test was used for categorical data and Wilcoxon Rank Sum test for continuous data. Mean days to closure was assessed using Student's t-test for independent groups. P-values <0.05 were considered indicative of statistical significance. Over the 21-month period, a total of 119 patients analyzed. Most patients were male (n = 66, 63 %), and the average age was 51 years. The average number of days the abdomen was kept open was 2.6. A majority of the DCLs were performed on acute care patients (n = 76, 63.8 %) and 92 patients (77.3 %) had a wound classification of contaminated or dirty. Most of the patients' skin was closed with wicks in place (68.9 %). There was a 9.8 % infection rate in patient's skin closed with wicks versus 16.2 % closed with an incisional wound vac (p = 0.361). Although the wick group had a higher proportion of class III and IV wound types, patients primarily treated with wicks had a lower risk of wound infection compared to those treated with incisional wound VACs; however, this difference was not statistically significant., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: ABC-123, a novel Epic electronic medical record real-time score, assigns 0 to 3 points per bundle element to assess ABCDEF bundle compliance. We sought to determine if maximum daily ABC-123 score (ABC-MAX), individual bundle elements, and mobility were associated with mortality and delirium-free/coma-free intensive care unit (DF/CF-ICU) days in critically injured patients., Methods: We reviewed 6 months of single-center data (demographics, Injury Severity Score [ISS], Abbreviated Injury Scale of the head [AIS-Head] score, ventilator and restraint use, Richmond Agitation Sedation Score, Confusion Assessment Method for the ICU, ABC-MAX, ABC-123 subscores, and mobility level). Hospital mortality and likelihood of DF/CF-ICU days were endpoints for logistic regression with ISS, AIS-Head, surgery, penetrating trauma, sex, age, restraint and ventilator use, ABC-MAX or individual ABC-123 subscores, and mobility level or a binary variable representing any improvement in mobility during admission., Results: We reviewed 172 patients (69.8% male; 16.3% penetrating; median age, 50.0 years [IQR, 32.0-64.8 years]; ISS, 17.0 [11.0-26.0]; AIS-Head, 2.0 [0.0-3.0]). Of all patients, 66.9% had delirium, 48.8% were restrained, 51.7% were ventilated, and 11.0% died. Age, ISS, AIS-Head, and penetrating mechanism were associated with increased mortality. Restraints were associated with more than 70% reduction in odds of DF/CF-ICU days. Maximum daily ABC-123 score and mobility level were associated with decreased odds of death and increased odds of DF/CF-ICU days. Any improvement in mobility during hospitalization was associated with an 83% reduction in mortality odds. A and C subscores were associated with increased mortality, and A was also associated with decreased DF/CF-ICU days. B and D subscores were associated with increased DF/CF-ICU days. D and E subscores were associated with decreased mortality., Conclusion: Maximum daily ABC-123 score is associated with reduced mortality and delirium in critically injured patients, while mobility is associated with dramatic reduction in mortality. B and D subscores have the strongest positive effects on both mortality and delirium., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort., Methods: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC., Results: In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002)., Conclusion: Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL., Level of Evidence: 2B., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: To evaluate factors associated with ICU delirium in patients who underwent damage control laparotomy (DCL), with the hypothesis that benzodiazepines and paralytic infusions would be associated with increased delirium risk. We also sought to evaluate the differences in sedation practices between trauma (T) and non-trauma (NT) patients., Methods: We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry admitted from January 1, 2017 to December 31, 2018. We included all adults undergoing DCL, regardless of diagnosis, who had completed daily Richmond Agitation Sedation Score (RASS) and Confusion Assessment Method-ICU (CAM-ICU). We excluded patients younger than 18 years, pregnant women, prisoners and patients who died before the first re-laparotomy. Data collected included age, number of re-laparotomies after DCL, duration of paralytic infusion, duration and type of sedative and opioid infusions as well as daily CAM-ICU and RASS scores to analyze risk factors associated with the proportion of delirium-free/coma-free ICU days during the first 30 days (DF/CF-ICU-30) using multivariate linear regression., Results: A 353 patient subset (73.2% trauma) from the overall 567-patient cohort had complete daily RASS and CAM-ICU data. NT patients were older (58.9 ± 16.0 years vs 40.5 ± 17.0 years [p < 0.001]). Mean DF/CF-ICU-30 days was 73.7 ± 96.4% for the NT and 51.3 ± 38.7% in the T patients (p = 0.030). More T patients were exposed to Midazolam, 41.3% vs 20.3% (p = 0.002). More T patients were exposed to Propofol, 91.0% vs 71.9% (p < 0.001) with longer infusion times in T compared to NT (71.2 ± 85.9 vs 48.9 ± 69.8 h [p = 0.017]). Paralytic infusions were also used more in T compared to NT, 34.8% vs 18.2% (p < 0.001). Using linear regression, dexmedetomidine infusion and paralytic infusions were associated with decreases in DF/CF-ICU-30, (- 2.78 (95%CI [- 5.54, - 0.024], p = 0.040) and (- 7.08 ([- 13.0, - 1.10], p = 0.020) respectively., Conclusions: Although the relationship between paralytic use and delirium is well-established, the observation that dexmedetomidine exposure is independently associated with increased delirium and coma is novel and bears further study., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Surgical residency training requires Advance Care Planning (ACP) and Palliative Care (PC) education. To meet education needs and align with American College of Surgeons guidelines, our Surgical Intensivists and PC faculty developed courses on communication and palliation for residents (2017-18) and fellows (2018-19). We hypothesized that education in ACP would increase ACP communication and documentation., Methods: The trauma registry of an academic, level 1trauma center was queried for ICU admissions from 2016-2019, excluding incarcerated and pregnant patients. A retrospective chart review was performed, obtaining frequency of ACP documentation, ACP meetings, time from admission to documentation, and PC consultation. We collected ICU quality measures as secondary outcomes: ICU Length Of Stay (LOS), hospital LOS, ventilator days, invasive procedures, discharge disposition, and mortality. Comparisons were made between years prior to (Y 1) and following implementation (Y 2: residents, Y 3: fellows)., Results: For 1732 patients meeting inclusion criteria, patient demographics, injuries, and injury severity score were comparable. ACP documentation increased from 19.5% in Y 1 to 57.2% in Y 3 (P < 0.001). Time to ACP documentation was reduced from 47.6 to 13.1 h (P < 0.001) from time of admission. ICU LOS decreased from 6 to 4.8 d (P = 0.004). Patients in Y 3 had fewer tracheostomies and percutaneous endoscopic gastrostomies. PC consultations decreased. Mortality was unchanged., Conclusion: Following trainee education, we observed increases in ACP documentation, earlier communication and improvements in ICU quality measures. Our findings suggest that trainee education positively impacts ACP documentation, reduces LOS, and improves trauma critical care outcomes., (Copyright © 2021. Published by Elsevier Inc.)

Background: Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population., Methods: We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head., Results: Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001)., Conclusion: Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury., Level of Evidence: Therapeutic study, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)