Trauma Surgery & Acute Care Open最新文献

Background: To evaluate the short-term clinical performance of Symvess (acellular tissue engineered vessel-tyod), formerly known as human acellular vessel, or HAV, compared with autologous vein for the treatment of extremity arterial injury.

Methods: Subjects treated with acellular tissue engineered vessel (ATEV) from two clinical trials were propensity score-matched on a 1:2 basis to PROspective Observational Vascular Injury Trial (PROOVIT) registry subjects with the same injured artery and treated with autologous vein. Matching characteristics included age, sex, trauma type (penetrating vs blunt), injury severity score, mangled extremity severity score, concomitant fracture, shunt use, and ischemia duration>6 hours. Incidence of outcomes (primary/secondary patency, amputation, conduit infection, reintervention for thrombosis/stenosis, pseudoaneurysm, and death) was assessed by a generalized linear model. Outcomes were assessed at Day 30 (ATEV group) or during initial hospitalization (autologous group).

Results: ATEV subjects lacking suitable autologous vein (n=67) and PROOVIT subjects treated with autologous vein (n=134) suffered injuries to axillary, brachial, femoral, popliteal, and posterior tibial arteries. Subgroups were clinically similar; Injury Severity Score, Mangled Extremity Severity Score, and duration of follow-up (16 vs 30 days) were higher for the ATEV subgroup.Primary patency for the ATEV versus autologous group was 86.6% versus 91.8%, secondary patency: 91.0% versus 97.7%; amputation: 7.5% versus 8.2%; conduit infection: 1.5% versus 0%; reintervention for thrombosis or stenosis: 6.0% versus 8.2%; and death 4.5% versus 4.5%, respectively. No cases of pseudoaneurysm, true aneurysm, or significant differences between the ATEV and autologous groups for any outcome were observed.

Conclusions: Short-term outcomes were similar between ATEV subjects without feasible autologous vein, and propensity score-matched autologous vein recipients from the PROOVIT registry. The ATEV may provide effective and safe revascularization in subjects with extremity arterial injury without feasible autologous vein.

Level of evidence: Level 3, Therapeutic/Care Management.

Background: Exsanguinating hemorrhage is the leading cause of death in combat casualty care. With improvement in body armor, risk for extremity injuries is increasingly making surgical control of vessels and extremity fasciotomies critically important for saving life and/or limb. Yet, surgeon hands-on experience with major trauma has decreased. In military settings, with limited surgical resources, surgeons could be required to work independently and outside their scope of expertise. We explored whether just-in-time skill refreshment with video review improves performance of selected procedures.

Methods: Surgeons (n=44) performed upper and lower extremity fasciotomies and axillary and femoral artery exposures on anatomic donors. They were divided into two groups: one group received Surgical Technical Assistance Tool (STAT) video procedure assistance and the other received no assistance (control group). Performance was evaluated using a five-component (anatomy, pathophysiology, patient management, technical skills, and procedural) Individual Procedure Score (IPS). The total number of compartment decompressions/constriction releases (maximum 10, combined fasciotomy procedures) and number of vessels controlled (maximum of four, combined vascular procedures) were measured. Each compartment decompression/constriction release and each vessel controlled are also single data points within the IPS.

Results: In combined fasciotomies, STAT significantly improved the number of successful compartment decompressions/constriction releases as well as procedural, anatomy, and technical IPS components. In combined vascular procedures, STAT improved anatomy IPS, but not the number of vessels successfully controlled. For successful compartment decompression/constriction release, there was a significant linear correlation with procedural, anatomy, and technical IPS components. For successful vascular control, there was a significant linear correlation with procedural and technical IPS components. There was no correlation between success and pathophysiology or patient management scores.

Conclusion: A video-based, just-in-time refresher tool can dramatically improve procedural success and performance scores in procedural, anatomy, and technical components during trauma-related extremity procedures.

Level of evidence: Level II, Original Research, Therapeutic/Care Management.

Background: Burnout is increasingly recognized as a critical occupational issue impacting physician well-being and patient care. Although surgeons are known to experience high burnout rates, the specific burden among trauma surgeons remains poorly researched. This systematic review and meta-analysis focuses on burnout exclusively among trauma surgeons. We aim to analyze the prevalence of burnout among trauma surgeons and identify associated factors by analyzing their alleviating and exacerbating influences through systematic review, meta-analysis, and meta-regression.

Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines, we used a combination of searching databases, individual journals and cross-referencing. Two independent reviewers screened studies measuring burnout in trauma surgeons. A random-effects meta-analysis was performed using logit-transformed proportions. Heterogeneity was assessed using I² statistics and meta-regression examined the impact of measurement tools.

Results: Analysis of 19 studies (n=4,634) revealed a pooled burnout prevalence of 60.0% (95% CI 46.9% to 74.4%) with substantial heterogeneity (I²=97.9%, p<0.0001). Studies using the Maslach Burnout Inventory (n=13) showed high emotional exhaustion (35.2%) and depersonalization (45.6%), but maintained strong personal accomplishment (75.3%). Key burnout-exacerbating factors included younger age, long working hours, and administrative burden, whereas protective factors included mentorship and protected non-clinical time.

Conclusions: Trauma surgeons experience among the highest burnout rates reported among surgical specialties, warranting systemic physician-centric interventions, with a shift in focus from diagnosis to prevention. Despite significant occupational stressors, persistently high personal accomplishment levels suggest specialty-specific resilience factors, meriting further investigation. Evidence-based strategies, including formal mentorship programs, psychological risk management models, and protected non-clinical time have the potential to mitigate burnout.

Background: Best practice guidelines from trauma-focused organizations support early (<72 hours) venous thromboembolism (VTE) chemoprophylaxis initiation in traumatic brain injury (TBI) patients. Recent literature suggests that an even more aggressive initiation (24 hours) is safe and efficacious. It is unknown how current practice aligns with the existing literature and best practice guidelines. We performed a national survey to characterize variation in trauma surgeons' reported practices and attitudes regarding VTE chemoprophylaxis initiation in TBI patients with the hypothesis that they will vary widely.

Methods: All 1700 American Association for the Surgery of Trauma members were surveyed online. Members who routinely cared for patients with TBI were asked to proceed with the survey. Descriptive data were reported. The questions characterized institutional guidelines, and if none existed, individual practice patterns regarding goal timeline of VTE chemoprophylaxis in TBI patients.

Results: 374 members (22%) completed the survey. Most respondents worked at academic institutions (40%) and represented a level one trauma center (44%). Enoxaparin was the most common VTE chemoprophylactic (73%) with most using weight-based dosing (76%) and anti-Xa testing (75%). Institutional policies that included a protocol for VTE chemoprophylaxis initiation in TBI patients were used by 86% of respondents. In those with established protocols, 59% reported being mostly compliant. Reasons for delay of VTE chemoprophylaxis included worry about progression of TBI and disagreement with consulting services. 293 (80%) of respondents reported protocolized repeat head CT within 4-12 hours after initial CT (60%). In response to a clinical scenario, 43% of respondents reported that their goal timeline for initiating VTE prophylaxis was within 24 hours of a stable head CT.

Conclusions: Despite national guidelines, substantial variation remains in the timing of VTE chemoprophylaxis in TBI patients. Passive strategies, such as institutional guidelines alone, are insufficient. Institutions must adopt more effective implementation tactics-including protocol-enforced order sets, automated clinical decision support, and shared governance models with ancillary services-to ensure timely, evidence-based care.

Level of evidence: Level V.

When we think about leadership in trauma and acute care surgery, we are often reminded of the direct impact we can have beyond immediate patient care. Leadership is not just about making decisions; it's about fostering growth within our institutions, among our colleagues and beyond the four walls of our centers. Importantly, leadership and its influence extend throughout the hospital and impact our trainees, mentees, colleagues, and peers alike. As guest speakers at the 2024 American Association for the Surgery of Trauma Annual Meeting Lunch Session entitled "Directorships, Leadership Roles, and Taking the Lead: Everything I Wish I Knew", KB, JWS and DMS all shared their journeys and thoughts on the complexities, hardships, and rewards of leadership in their roles as clinicians, educators, researchers, and surgeon administrators. This work represents a summary of the lunch panel and provides insights for surgeons seeking to navigate similar paths in academic surgical leadership.

Background: Culturally responsive care is a core recommendation to reduce health disparities. Language barriers contribute to misunderstandings, dissatisfaction, and worse outcomes. This is exacerbated in trauma when communication is constrained by time, complexity, and competing priorities. We hypothesized that Spanish-speaking trauma patients (SSP) would have less accurate comprehension of care (CC) and discharge instructions compared with English-speaking patients (ENG).

Methods: We retrospectively reviewed discharges from a level 1 trauma center (October 2021 to March 2022) who were aged ≥18, primarily ENG or SSP, discharge Glasgow Coma Scale score ≥14, and without memory loss. Patients were surveyed <48 hours from discharge to assess CC. Patients self-rated CC on a Likert scale and answered open-ended questions on CC and discharge instructions. Charts were reviewed to assess and rate concordance of CC with actual care and ENG and SSP cohorts compared.

Results: We included 46 patients (21 SSP, 25 ENG). Mean age was 48.3 years SSP, 43.3 years ENG; 47% SSP were female versus 32% ENG (p=0.28). 56% SSP had ≥high school diploma versus 72% ENG (p=0.34). Self-rated CC was similar, with both groups rating high understanding of their care and follow-up. SSP were less likely to accurately report diagnoses, home medications, and follow-up appointments than ENG. When corrected for health literacy, differences remained between groups in accuracy of diagnoses despite having high confidence in their CC.

Conclusions: Though both SSP and ENG self-rated their comprehension of their care highly, there were significant differences between groups' accuracy. Increased use of certified medical interpreters throughout hospitalization may improve language disparities in patient comprehension.

Level of evidence: Therapeutic/care management, level IV.

Background: Traumatic brain injury (TBI) remains a major healthcare burden, especially among older adults. Existing triage protocols, such as the Brain Injury Guidelines, may not be universally applicable due to institutional and implementation barriers. We evaluated the impact of a novel, evidence-based TBI triage tool-developed by a multidisciplinary team using high-risk and low-risk criteria-on hospital resource utilization at a high-volume Level 1 trauma center. The triage tool stratified patients into high-risk or low-risk pathways based on age, clinical criteria, and radiographic findings. We hypothesized that implementation would reduce intensive care unit (ICU) patient days and repeat head CT scans.

Methods: We conducted a retrospective pre-post implementation study at an American College of Surgeons-verified Level 1 trauma center. The pre-implementation group included patients retrospectively categorized as low-risk from January to November 2021. The post implementation group included patients prospectively triaged as low-risk from January 2023 to June 2024. The triage tool was created through consensus from all relevant clinical stakeholders. Patient demographics, clinical outcomes, and hospital resource use were compared using Fisher's exact test, χ², and Mann-Whitney U tests.

Results: A total of 145 patients were included (62 pre-implementation, 83 post implementation). Groups were well matched by demographics and clinical factors. Post implementation, 188 ICU-patient-days were projected to be saved, and ICU length of stay was significantly reduced (median (IQR): 1 (0-2) vs 0 (0-0) days; p<0.001). 38 repeat CT head scans were avoided, with overall scan frequency reduced (median (IQR): 2 (2-2) vs 2 (1-2); p<0.001). There were no neurosurgical interventions, in-hospital deaths, or 30-day readmissions in either group.

Conclusion: Implementation of a multidisciplinary, risk-based TBI triage tool significantly reduced unnecessary ICU stays and repeat head CTs without observed adverse patient outcomes in the low-risk cohort. This approach represents a scalable, value-based model for improving TBI care and optimizing resource utilization.

Level of evidence: Level III.

Introduction: In trauma care, there is a need to increase communication to ensure evidence-informed, best practice care guidelines are easily accessible to all providers to yield consistency of care. Clinical guidance use is one way to address this need while employing a patient-centered team approach.

Methods: During year 2 of the Design for Implementation: The Future of Trauma Research & Clinical Guidance conference series, participants gathered in person and virtually to further develop the minimum viable product (MVP) created during year 1. Professional facilitators used the purpose-to-practice framework to help structure and guide further consensus building.

Results: 70 in-person and up to 65 virtual attendees participated. 65 responses were collected on the MVP reflection and initial feedback survey. Themes were developed surrounding the pillars of 'Purpose', 'Principles', 'Participants', and 'Practices' while looking at the 'Structure' for 'Sustainability'. The 'Purpose' pillar addressed the importance of rigorous, standardized implementation guidance. 'Principles' exemplified the necessity of a collaborative approach and included all relevant stakeholders. Similarly, the central theme emphasized by the 'Participants' pillar was the inclusiveness of all members of the trauma team. 'Practices' dove into the deliverables of the initiative, including up-to-date decision-making support and logistics regarding guidance storage, management, and maintenance. Regarding 'Structure', the most highly ranked idea was developing a steering committee whose purpose would be primarily to prioritize strategic initiatives.

Discussion: Clinical guidance needs to be current and readily available to all providers. The next steps of this initiative include developing a steering committee and subcommittees to sustain momentum.

Level of evidence: VII.

The second Design for Implementation (DFI): The Future of Trauma Research and Clinical Guidance Conference gathered experts from diverse sectors to advance trauma clinical guidance design and implementation. Building on the previous year's minimum viable product, this conference progressed from conceptualization to design phase, focusing on creating scalable, sustainable solutions for trauma clinical guidance. Participants explored innovative approaches addressing critical challenges in trauma care, including interorganizational collaboration, resource-adaptable guidance, and patient-centered design. The conference highlighted the integration of artificial intelligence (AI) to enhance guidance development and maintain clinical expertise and ethical standards. A key advancement was the refinement of a central repository containing 258 guidance documents in the form of an app with improved accessibility features. Discussions emphasized the importance of implementation science principles, advocating for leadership engagement, maintaining academic recognition for guidance contributions, and continuous outcome tracking. The proposed 12-step guidance development process integrates AI capabilities and preserving clinician expertise. Patient voices and lived experiences were emphasized as essential elements in developing trauma-informed systems, with powerful testimonials from trauma survivors illustrating the critical need for comprehensive support services. Participants agreed that practical guidance must be contextually relevant, properly vetted, and integrate seamlessly with electronic health records. The conference concluded with plans to secure sustainable funding, formalize partnerships, and engage broader communities. The DFI series will continue in February 2026, focusing on testing and implementing innovative solutions to advance trauma care and improve patient outcomes.