Trauma Surgery & Acute Care Open最新文献

Background: In June 2021, the Injury Research Engagement Project (I-REP) was established. In 2022, we preformed focus group analysis with patients/caregiver and researchers that resulted in themes in preferences, motivations, and best practices to increase participation in trauma research. The importance of trust and well-established relationships was common across all groups. In this study, we aimed to further evaluate preferences regarding research procedures and outcomes, and develop a panel for sustained patient engagement.

Methods: We performed a multiphase, mixed methods study to elicit trauma stakeholders' perspectives regarding aspects of research. Previously published phase 1 involved focus group analysis. Phase 2 vignette-based surveys and phase 3 panel formation are described here. One survey was completed by patients/caregivers, and the second by trauma researchers. We compared the responses using independent t-tests. This was followed by a webinar and development of an I-REP panel of patients/caregivers.

Results: 60 patients/caregivers and 114 researchers participated in the online surveys, with completion rates of 68% and 69%, respectively. The majority of patients/caregivers were >45 years, female (66.7%), and >3 years out from their or their family member's injury (68.6%). The majority of the researchers were >35 years and male (56.2%). Participants were asked to gauge their perceptions of different research scenarios. The analysis identified themes emerging across groups. Several survey findings differed from phase 1, including motivations to participate (payment) and consent preferences (timing, approach). Racial and ethnic demographics of the participants were not collected.

Conclusions: Engaging trauma stakeholders results in research more relevant to patients' needs and priorities. Qualitative engagement methods that intentionally include a more diverse population and determining the appropriate format for specific questions may lead to results that are be more generalizable. The educational webinar was well received, and several participants opted to serve as I-REP panelists to collaborate with trauma researchers moving forward.

Level of evidence: IV.

Objectives: We sought to determine the optimal time to pre-activation for trauma team activation that resulted in maximum team efficiency, measured by the time to complete critical actions (TCCAs) during resuscitation. We hypothesized that there exists a time window for trauma team pre-activation that minimizes TCCA.

Methods: This is an exploratory retrospective analysis of video-reviewed traumas at a level 1 trauma center from January 1, 2018 to 28 February, 2022 that received the highest trauma team activation and had a pre-arrival notification. A total of 11 TCCA categories were calculated using video timestamps. To compare TCCAs from different categories, normalized TCCAs (nTCCAs) were calculated by dividing each TCCA by the median time of its category. Pre-activation times were categorized into three groups: long pre-activation (≥8 min), mid pre-activation (≥4 and ≤7 min), and short pre-activation (≥0 and ≤4).

Results: There were 466 video-recorded level 1 trauma activations, which resulted in 2334 TCCAs. Of the 466 activations, 152 occured on the patient's arrival (0 min pre-activation). The majority (425) of patients had a pre-activation time of <7 min. Pre-activation of 4-6 min resulted in all but blood transfusion TCCAs being <15 min. Furthermore, mid pre-activation category corresponded to the most efficient trauma teams, with nTCCAs significantly shorter (median=0.75 (IQR 0.3-1.3)) than long (median=1 (IQR 0.6-2)) or short activation groups (median=1 (IQR 0.6-1.6)). A greater proportion of nTCCAs were shorter than their category median in the mid pre-activation category compared with long and short categories (59.1% vs 48.3% and 40%, respectively; p<0.01).

Conclusions: In this exploratory study, a pre-activation time of 4-7 min is associated with the best team efficiency as measured by TCCAs during trauma team activations. This timeframe may be an optimal window for trauma team activations but needs prospective and external validation.

Level of evidence: Level 4 retrospective exploratory study.

Background: The use of low titer group O whole blood (LTOWB) for resuscitation of patients with traumatic hemorrhage is becoming increasingly common. Practices regarding the administration of RhD-positive LTOWB to childbearing age females (CBAFs) vary between institutions due to concerns about RhD alloimmunization. This study examined practices related to LTOWB transfusion as they pertain to age and sex.

Methods: This was a secondary analysis of the Shock, Whole blood, and Assessment of TBI (traumatic brain injury) trial, a prospective, multicenter observational cohort study where outcomes following LTOWB transfusion were analyzed at seven level 1 trauma centers between 2018 and 2021, as well as a survey on transfusion practices at these centers conducted in 2023. The proportion of patients who received LTOWB or components was examined over the course of the study and grouped by age and sex, and the RhD group of injured CBAFs was documented.

Results: A total of 1046 patients were evaluated: 130 females aged <50 years (CBAFs), 77 females aged ≥50 years; 661 males aged <50 years, and 178 males aged ≥50 years. Among them, 26.2% of CBAFs received RhD-positive LTOWB, whereas 57.1%-66.3% of other sex/age groups received LTOWB. The proportion of CBAFs who received LTOWB increased significantly throughout the 4 years of this study. Except for older women in years 2 and 4, CBAFs were significantly less likely to receive LTOWB than all other groups for the study period and individual years. Among the 33 CBAFs who received LTOWB and for whom an RhD type was available, 4/33 (12.1%) were RhD-negative, while 9/95 (9.5%) CBAFs who received component therapy were RhD-negative. RhD blood product selection practices varied considerably between institutions.

Conclusions: Many institutions transfused LTOWB to CBAFs. Policies regarding RhD product selection varied. Of the total cohort, the proportion of RhD-negative CBAFs who received LTOWB increased over time but remained lower than all other groups.

Level of evidence: 3.

Abstract:

Introduction: Graduate medical education (GME) lacks a standardized military training program for general surgery residents, and concern exists that they may not be prepared to serve as combat surgeons on training completion. The purpose of this study was to assess military surgery trainee satisfaction with their programs. Our hypothesis was that military residents were not completely confident to care for combat casualties on completion of current GME training.

Methods: We surveyed US Army, Navy, and Air Force general surgery residents and fellows between November 2023 and March 2024 to assess their confidence in managing combat injuries. Queried residents further rate their overall satisfaction with surgical training, perceived level of deployment preparedness and curriculum elements which they thought would be most beneficial to their training.

Results: The survey yielded an overall 43% response rate (132/305) with a response rate of 42% (61/147) from the Army, 56% (44/79) from the Navy, and 34% (27/79) from the Air Force. Most trainees were trained in military medical treatment facility residency programs (n=91, 68.9%) and nearly half of respondents (n=64, 49%) were senior trainees (postgraduate year (PGY)4, PGY5, and fellows). Among all trainees, only two-thirds (n=88, 67%,) thought they were adequately prepared to deploy and operate on military combat casualties by the end of residency but 114 (86%) were satisfied with the training they received during general surgery residency in adult trauma, 103 (78%) in critical care, and 112 (85%) in acute care surgery. However, more than half were unsatisfied with the training they received in obstetric/gynecologic and urologic emergencies (n=72, 55%; and n=67, 51%, respectively).

Conclusion: Although the majority of military surgical residents surveyed are satisfied with their training in adult trauma, critical care, and emergency general surgery, a large number of trainees thought they would not be ready to deploy and manage combat casualties.

Level of evidence: Prognostic and epidemiological, Level IV.

With the increasing age of the population in the USA, fall prevention events to target older patients are imperative. The American Association for the Surgery of Trauma hosted a fall prevention event at the host city of the 2023 Annual Meeting. We review the planning and implementation of this "Stop the Falls" event, in hopes that other institutions may benefit and sustainably effectuate fall prevention events for an increasingly geriatric population.

Background: Prior studies have associated nighttime transfer of patients from the intensive care unit (ICU) with increased morbidity. This study sought to examine this relationship in traumatically injured patients, as this has not been previously performed.

Methods: A retrospective review of traumatically injured patients admitted to a Level I Trauma Center's ICU from January 2021 to September 2022 was performed. "Day shift" (DS) was defined as 07:00 to 19:00 and "night shift" (NS) as 19:01 to 06:59. The time of transfer completion was based on the time of the patient arrival at the destination unit. The univariate analysis compared patients with completed transfers during DS and NS. Multivariate logistic regression was performed to predict readmission to the ICU.

Results: A total of 1,800 patients were included in the analysis, with 608 patients that had completed transfers during NS, and 1,192 during DS. Both groups were similar, with no significant differences in age, sex, Injury Severity Score (ISS), mechanism of injury, or median total comorbidities. The NS group had a longer median time to transfer completion (10.1 (IQR 5.5-13.6) hours vs 5.1 (IQR 2.9-8.4) hours; p<0.001). A significantly higher proportion of the NS group had a readmission to the ICU (60 (10.0%) vs 86 (7.0%); p=0.03) or a major complication (72 (11.9%) vs 107 (9.0%); p=0.048). When controlling for age, comorbidities, ISS, time to bed assignment and to transfer completed, and ICU length of stay, transfer completion during NS was associated with 1.56 times higher odds of having an ICU readmission (OR 1.56 (95% CI 1.05, 2.33); p=0.03).

Conclusions: Trauma patients transferred from the ICU during NS experienced longer delays, readmission to the ICU, and major complications significantly more often. With increasing hospital bed shortages, patient transfers must be analyzed to minimize worsened outcomes, especially in traumatically injured patients.

Level of evidence: Level III, therapeutic/care management.

Background: Retrohepatic inferior vena cava (IVC) injuries remain among the most lethal and serious liver injuries. Gauze packing is currently the first choice for IVC injuries; however, laparotomy itself poses the risk of circulatory collapse. Thus, less invasive treatment strategies are needed.

Methods: In this study, we conducted an animal experiment to replicate and validate successful treatments for an actual case of retrohepatic IVC injury that we had encountered.

Results: A woman in her 80s presented to our hospital due to cardiac arrest caused by a pulmonary artery embolism. Venoarterial extracorporeal membrane oxygenation (ECMO) was introduced, and the patient was resuscitated. After resuscitation, contrast-enhanced CT revealed liver and retrohepatic IVC injuries, possibly caused by chest compressions. Liver injury was treated using transarterial embolization of the left hepatic artery. To treat the retrohepatic IVC injury, ECMO flow was increased to enhance the negative drainage pressure. The extravasation of the contrast medium had resolved in IVC angiography, and we opted for nonoperative management. The patient's hemodynamic status gradually stabilized, and ECMO was withdrawn on day 6. We confirmed these findings in a dog model of retrohepatic IVC injury.

Conclusions: Our findings from the patient and the animal model suggest that the flow diversion effect of ECMO can effectively manage active bleeding from the IVC by inserting a drainage cannula across the injured lesion. We think this procedure represents a novel treatment option for retrohepatic IVC injuries.