American journal of surgery最新文献

Background: Capnography has shown to be an invaluable tool in assessing trauma victims in different setups. To elucidate this, we conducted this meta-analysis to evaluate the utility of end-tidal CO₂ (ETCO₂) and the arterial CO₂ -ETCO₂ gap (PaCO₂-ETCO₂) measurements on predictiveness for mortality in trauma patients.

Methods: A systematic literature search was performed (01/1990-06/2023). The inclusion criteria included adult trauma patients, with mention of mortality. The primary outcome was evaluating the reliability of ETCO₂ in predicting mortality.

Results: Seventeen studies were included, with total of 3445 patients. Mean age was 39.08-year, 22.3 ​% female. Overall mortality was 25.6 ​%, mostly retrospective studies. Mean ETCO₂ in survivors was 31.45 ​mmHg, and 24.75 ​mmHg in deceased patients, (p ​= ​0.0128). Mean PaCO₂-ETCO₂ gap in survivors was 6.8 ​mmHg, and 15.0 ​mmHg in deceased patients, (p ​< ​0.001). Using receiver operator characteristic curve analysis, ETCO₂ of 30.2 ​mmHg with high sensitivity to predict mortality.

Conclusion: Low ETCO₂ or a wide PaCO₂-ETCO₂ gap were significantly correlated with poor outcomes in trauma patients. This easily obtained value can help predict those who need more aggressive treatments.

Background: Mechanically ventilated critically ill patients often develop pleural effusions, which may impact lung compliance and expansion. This systematic review explores the management of pleural effusion in the critically ill population.

Methods: A comprehensive literature search was performed. Quality of evidence rating and recommendation development utilized Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

Results: The full search retrieved 11,965 articles for screening, of which 28 studies ultimately met inclusion criteria. There were 15 cohort studies assessing oxygenation outcome and 17 cohort studies assessing pneumothorax outcome. Patients with drainage (n ​= ​418) had a pooled mean increase in PaO2/FiO2 ratio of 53 (P ​< ​0.00001, 95 ​% CI: 43-64, I² ​= ​0 ​%) compared to pre-drainage/no-drainage (n ​= ​432). In patients with drainage, the combined incidence of pneumothorax was 124/5995 (2.1 ​%).

Conclusion: In mechanically ventilated critically ill adult patients with pleural effusion and hypoxia, we conditionally recommend drainage of pleural effusion to improve oxygenation. P:F ratio <200 and pleural effusion volume estimate >500 ​mL are conditions in which drainage would have most benefit.

Background: The National Comprehensive Cancer Care Network (NCCN) provides recommendations for patients with colorectal cancer. Concordance with evidence-based guidelines improves outcomes. Our objectives were to 1) examine rates of guideline non-concordance in a large vertically integrated health system; 2) examine factors associated with non-concordant care, and 3) identify geographical patterns of non-concordant care.

Methods: Colorectal cancer patients were identified from a single-state 16 hospital health-system cancer registry diagnosed between 2011 and 2021. We defined major (MAJ) and minor (MIN) quality indicators of guideline-concordance based on NCCN guidelines. Regression methods were used to identify predictors of major quality criteria non-concordance. County-level mapping was used to identify geographical locations of the highest rates of non-concordance.

Results: Overall, 2324 patients with colon and rectal cancer were analyzed. There was a complete guideline concordance (an absence of guideline non-concordance) rate of 24.7​% (n ​= ​573), MIN only guideline non-concordance rate of 63.3​% (n ​= ​1471), and MAJ non-concordance rate of 12.4​% (n ​= ​280). Predictors of MAJ non-concordance for colon cancer were stage, >1 Charleson-Deyo Score, >60 days from diagnosis to treatment, and >1 hospital network used for care. Predictors of MAJ non-concordance for rectal cancer were >60 days from diagnosis to treatment, and >1 facility used for care. Marion county had the highest rates of non-concordance for colon and rectal cancer.

Conclusion: The majority of colon and rectal cancer patients in a large health system received guideline concordant major quality indicators, however 12​% of patients do not. An identifiable geographical location with the highest rates of non-concordance and its associated factors serves as a target for future quality improvement.

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) may benefit patients with severe subdiaphragmatic traumatic hemorrhage. This study compares outcomes in patients with penetrating abdominal vascular injury treated with REBOA versus those managed without REBOA.

Methods: Using the Trauma Quality Improvement Program (TQIP) database, we identified adult patients with penetrating abdominal vascular injury from 2017 to 2022. Propensity scores matched REBOA patients 1:3 with non-REBOA patients. The primary outcome was in-hospital mortality, with secondary outcomes including 24-h mortality, transfusion needs, and complications such as acute kidney injury (AKI), deep vein thrombosis (DVT), pulmonary embolism (PE), lower extremity compartment syndrome, fasciotomy, amputation, and femoral artery repair.

Results: Two hundred ninety-three REBOA patients were matched with 879 non-REBOA patients. REBOA patients had higher in-hospital mortality (46.8 ​% vs 36.3 ​%, p ​= ​0.002), packed-red blood cell (PRBC) transfusion requirements within 4 ​h (median 15.3 vs 8.2, p ​< ​0.001), AKI (8.5 ​% vs 4.7 ​%, p ​= ​0.013), fasciotomy (6.5 ​% vs 3.6 ​%, p ​= ​0.039), amputation (3.4 ​% vs 1.4 ​%, p ​= ​0.025), and femoral artery repair (3.4 ​% vs 0.6 ​%, p ​< ​0.001). In a subgroup analysis of patients without severe extra-abdominal injuries, REBOA was associated with higher in-hospital mortality (49.7 ​% vs. 38.2 ​%, p ​= ​0.013) and increased packed red blood cell (PRBC) transfusion requirements (median 14.1 vs. 8.3 units, p ​< ​0.001).

Conclusions: In penetrating abdominal vascular injuries, REBOA was associated with worse outcomes.

Introduction: This study aims to assess various models of psychological debriefing, their benefits, and the impact of their implementation on medical trainees & healthcare professionals' stress management skills, mental well-being, and clinical performance.

Methods: This review queried PubMed, ProQuest, Web of Science, and Google Scholar databases for articles regarding psychological debriefing in medical education published through May 2024. Included studies that assessed the utilization, implementation, and effectiveness of various psychological debriefing models in the hospital setting among nursing staff, medical trainees, and attending physicians. Outcomes evaluated were successful debriefing models, associated benefits, and attendees' attitudes toward implementation.

Results: Sixteen studies were included. In all psychological debriefing models, attendees had improved coping skills following a challenging clinical scenario and supported the future use of these sessions. However, several barriers to the success of these sessions like untrained facilitators and insufficient time devoted have been noted.

Conclusion: Psychological debriefing sessions assisted attendees cope with stressful situations, improved self-confidence, and advocate for themselves. Different models of psychological debriefing can be implemented depending on the resources of each facility.