Trauma Surgery & Acute Care Open最新文献

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.

Introduction: The utility of pancreaticoduodenectomy (PD) for high-grade traumatic injuries remains unclear and data surrounding its use are limited. We hypothesized that PD does not result in improved outcomes when compared with non-PD surgical management of grade IV-V pancreaticoduodenal injuries.

Methods: This is a retrospective, multicenter analysis from 35 level 1 trauma centers from January 2010 to December 2020. Included patients were ≥15 years of age with the American Association for the Surgery of Trauma grade IV-V duodenal and/or pancreatic injuries. The study compared operative repair strategy: PD versus non-PD.

Results: The sample (n=95) was young (26 years), male (82%), with predominantly penetrating injuries (76%). There was no difference in demographics, hemodynamics, or blood product requirement on presentation between PD (n=32) vs non-PD (n=63). Anatomically, PD patients had more grade V duodenal, grade V pancreatic, ampullary, and pancreatic ductal injuries compared with non-PD patients (all p<0.05). 43% of all grade V duodenal injuries and 40% of all grade V pancreatic injuries were still managed with non-PD. One-third of non-PD duodenal injuries were managed with primary repair alone. PD patients had more gastrointestinal (GI)-related complications, longer intensive care unit length of stay (LOS), and longer hospital LOS compared with non-PD (all p<0.05). There was no difference in mortality or readmission. Multivariable logistic regression analysis determined PD to be associated with a 3.8-fold greater odds of GI complication (p=0.010) compared with non-PD. In a subanalysis of patients without ampullary injuries (n=60), PD patients had more anastomotic leaks compared with the non-PD group (3 (30%) vs 2 (4%), p=0.028).

Conclusion: While PD patients did not have worse hemodynamics or blood product requirements on admission, they sustained more complex anatomic injuries and had more GI complications and longer LOS than non-PD patients. We suggest that the role of PD should be limited to cases of massive destruction of the pancreatic head and ampullary complex, given the likely procedure-related morbidity and adverse outcomes when compared with non-PD management.

Level of evidence: IV, Multicenter retrospective comparative study.

Thirty-four per cent of deaths among Americans aged 1-46 are due to injury, and many of these deaths could be prevented if all hospitals performed as well as the highest-performing hospitals. The Institute of Medicine and the National Academies of Science, Engineering and Medicine have called for learning health systems, with emphasis on clinical practice guidelines (CPGs) as a means of limiting preventable deaths. Reduction in mortality has been demonstrated when evidence-based trauma CPGs are adhered to; however, guidelines are variably updated, redundant, absent, inaccessible, or perceived as irrelevant. Ultimately, these barriers result in poor guideline implementation and preventable patient deaths. This multidisciplinary group of injury providers, clinical guidance developers and end users, public health and health policy experts and implementation scientists propose key areas for consideration in the definition of an ideal future state for clinical guidance development and dissemination. Suggestions include (1): professional societies collaborate rather than compete for guideline development.(2) Design primary clinical research for implementation, and where relevant, with guideline development in mind.(3) Select clinical topics for guideline development through systematic prioritization, with an emphasis on patient-centered outcomes.(4) Develop guideline authorship groups with a focus on transparency, equity of opportunity and diversity of representation.(5) Establish a plan for regular review and updating and provide the date the guideline was last updated for transparency.(6) Integrate options for adapting the guideline to local resources and needs at the time of development.(7) Make guidelines available on a platform that allows for open feedback and utilization tracking.(8) Improve discoverability of guidelines.(9) Optimize user-experience with a focus on inclusion of bedside-ready, mobile-friendly infographics, tables or algorithms when feasible.(10) Use open access and open licenses.(11) Disseminate clinical guidance via comprehensive and equitable communication channels. Guidelines are key to improve patient outcomes. The proposed focus to ensure trauma guidelines are equitably and effectively developed and disseminated globally.