Trauma Surgery & Acute Care Open最新文献

Summary:

Introduction: In critical care, there is often a lack of understanding regarding patient preferences toward end-of-life care. Goals of care discussions are poorly defined and inhibited by clinician apprehension, prognostic uncertainty, and discomfort from both sides. In the delivery of bad news, protocol-based discussions have proven beneficial, yet no such protocol exists for goals of care discussions in the intensive care unit (ICU). We therefore assembled a multidisciplinary team to define a specific protocol dedicated to leading goals of care discussions in the ICU setting.

Safe-goals protocol: S: set upA: acknowledgmentF: family understandingE: events of hospital courseG: get to know the patientO: optionsAL: active listening and discussionS: steps going forward.

Conclusion: This protocol provides a framework for leading goals of care conversations in the ICU. Specific training should be incorporated and better emphasized in the modern medical education.

The Trauma Survivors Network (TSN), a program of the American Trauma Society (ATS), has a unique history spanning decades with a vision to continue expanding and strengthening services to support survivors and families impacted by traumatic injury. Since the COVID-19 pandemic, the ATS has adapted TSN services to provide both virtual and in-person services for trauma survivors, increasing equity and inclusion for many survivors to access TSN services for the first time. The recent policy changes in the American College of Surgeons Committee on Trauma New Standards for Care of the Injured Patient provide an impetus for the TSN to grow and expand services in support of a diverse group of trauma survivors and their loved ones. This paper highlights the collateral impact of traumatic injury, the history and ongoing growth of the TSN and its services to date, the challenges encountered in establishing and maintaining the TSN program, and the equity and inclusion that the TSN offers internationally to support a diverse range of survivors with various forms of trauma and polytrauma.

Background: Patients with cervical spinal cord injuries (CSCIs) have a high incidence of respiratory complications. The effectiveness of non-invasive positive pressure ventilation (NPPV) in preventing respiratory complications such as pneumonia in acute CSCIs remains unclear. We evaluated whether intermittent NPPV (iNPPV) could prevent pneumonia in patients with acute CSCIs.

Methods: This single-center, retrospective study evaluated patients diagnosed with CSCIs with American Spinal Injury Association Impairment Scale scores of A-C between January 2012 and December 2022. Patients were categorized based on receipt of iNPPV into the iNPPV and usual care groups. Prophylactic iNPPV was defined as the initiation of iNPPV within 72 hours of admission. The primary outcome was the development of pneumonia. The secondary outcomes were other respiratory complications (tracheal intubation and tracheostomy) and adverse events (delirium and vomiting). The groups were compared with regard to outcomes after adjustment for patient backgrounds using inverse probability of treatment weighting (IPTW) with propensity scores.

Results: Of the 213 patients during the study period, 94 were included. Of these, 61 (64.9%) received prophylactic iNPPV. The incidence of pneumonia was 27.9% in the iNPPV group and 48.5% in the usual care group in the unadjusted cohort. In the propensity score analysis using IPTW, the iNPPV group showed a lower incidence of pneumonia than the usual care group (29.0% vs 56.5%, p<0.001). Tracheal intubation and tracheostomy were less common in the iNPPV group than those in the usual care group (10.6% vs 29%; p=0.001 and 10.6% vs 27.1%; p=0.003, respectively). The incidences of delirium and vomiting did not increase in the iNPPV group.

Conclusions: Prophylactic iNPPV was associated with a lower incidence of pneumonia in patients with acute CSCIs.

Level of evidence: Ⅳ.

Background: Bedside thoracic ultrasound (US) offers numerous advantages over chest X-ray (CXR) for identification of recurrent pneumothoraces (PTX) after tube thoracostomy (TT) removal. Technologic advancements have led to the development of hand-held devices capable of producing high-quality images termed ultra-portable US (UPUS). We hypothesized that UPUS would be as successful as CXR in detecting post-TT removal PTX and would be preferred by patients.

Methods: We conducted a single-center prospective, feasibility, study at a level I trauma center investigating the use of UPUS in patients with trauma with TT placement. UPUS images were obtained daily while the TT was in place and post-TT removal (ranging from 1 through 6 hours). A clinically concerning PTX on UPUS was defined as the absence of lung sliding on two or more intercostal spaces. Poststudy Likert surveys were administered to assess patient preferences.

Results: Ninety-two patients were included in the analysis. The majority were men (87%), and the median age was 47 years. Thirty-five patients (36%) had discordant imaging findings. There were 11 clinically concerning PTX, of which 10 (91%) were detected on UPUS and 8 (73%) on CXR. Three patients required an intervention for post-pull PTX, all of whom were identified on UPUS. Eighty-four percent (N=70) of surveyed patients preferred UPUS over CXR with 92% reporting no discomfort with UPUS compared with 49% with CXR.

Conclusion: Bedside UPUS is preferred by patients and can successfully identify clinically concerning post-TT removal PTX. Implementation of UPUS as a post-TT removal diagnostic tool is a safe and effective alternative to CXR.

Level of evidence: Level II, diagnostic tests or criteria.

Background: Morning postoperative labs are often obtained for emergency general surgery (EGS) patients. Studies in other surgical fields indicate that routine postoperative day 1 (POD1) labs are sometimes being performed excessively and do not require intervention. The purpose of this study is to identify predictors indicating the need for POD1 labs in EGS patients based on likelihood of intervention.

Methods: This is a retrospective review of non-critically ill EGS patients from 2022 to 2023 who received POD1 morning labs. The odds of having an abnormal result and likelihood of intervention were measured through multivariate logistic regression accounting for patient characteristics and procedure. Least absolute shrinkage and selection operator (LASSO) regression analysis was performed to determine significant predictors of an abnormal result and intervention.

Results: 502 EGS patients were included. LASSO revealed that procedure duration, fever, lysis of adhesions, preoperative systolic blood pressure <90 mm Hg, older age, heart failure, operative blood loss, chronic kidney disease, and anticoagulation use were independent predictors for any abnormal result (area under the receiver operation curve (AUC)=0.785). Independent predictors of intervention were procedure duration, older age, higher estimated blood loss (EBL), anticoagulant use, and lysis of adhesions (AUC=0.704). Procedures >400 min carried an 84.3% chance of an abnormal lab requiring intervention. EBL >200 mL carried a 75.5% chance of an abnormal lab requiring intervention.

Conclusion: POD1 labs for non-critically ill EGS patient rarely require intervention and can be safely omitted. Labs should be considered for longer procedures, higher EBLs, older patients, those on anticoagulation, or after lysis of adhesions.

Background: This study aims to compare outcomes of robotic cholecystectomy (RC) versus laparoscopic cholecystectomy (LC) in the setting of a level 1 trauma center.

Methods: We performed a retrospective study of our hospital data (2021-2024) on patients who underwent LC or RC. Using a previously validated intraoperative grading system, four grades of cholecystitis were defined as mild (A), moderate (B), severe (C), and extreme (D). Outcomes were operative times and rates of conversion to open surgery.

Results: In total, 260 patients (n=130 RC and n=130 LC) were included. Patients were primarily female (69.2%), with mean age of 47±18.3 years. The majority of cases had grade B cholecystitis (41.2%). Patients undergoing RC had lower operative times compared with LC in grade B (101.87±17.54 vs 114.96±29.44 min, p=0.003) and grade C (134.68±26.97 vs 152.06±31.3 min, p=0.038). Conversion rate to open cholecystectomy were similar in both groups (p=0.19).

Conclusion: RC had similar results as LC in terms of operative time and in fact has significantly lower operative time in patients with grade B and grade C cholecystitis.

Level of evidence: Level III-retrospective study.