The coronavirus disease 2019 pandemic restricted movement of individuals and altered provision of health care, abruptly transforming health care-use behaviors. It serves as a natural experiment to ...explore changes in presentations for surgical diseases including acute appendicitis. The objective was to determine if the pandemic was associated with changes in incidence of acute appendicitis compared to a historical control and to determine if there were associated changes in disease severity.
The study is a retrospective, multicenter cohort study of adults (N = 956) presenting with appendicitis in nonpandemic versus pandemic time periods (December 1, 2019–March 10, 2020 versus March 11, 2020–May 16, 2020). Corresponding time periods in 2018 and 2019 composed the historical control. Primary outcome was mean biweekly counts of all appendicitis presentations, then stratified by complicated (n = 209) and uncomplicated (n = 747) disease. Trends in presentations were compared using difference-in-differences methodology. Changes in odds of presenting with complicated disease were assessed via clustered multivariable logistic regression.
There was a 29% decrease in mean biweekly appendicitis presentations from 5.4 to 3.8 (rate ratio = 0.71 0.51, 0.98) after the pandemic declaration, with a significant difference in differences compared with historical control (P = .003). Stratified by severity, the decrease was significant for uncomplicated appendicitis (rate ratio = 0.65 95% confidence interval 0.47–0.91) when compared with historical control (P = .03) but not for complicated appendicitis (rate ratio = 0.89 95% confidence interval 0.52–1.52); (P = .49). The odds of presenting with complicated disease did not change (adjusted odds ratio 1.36 95% confidence interval 0.83–2.25).
The pandemic was associated with decreased incidence of uncomplicated appendicitis without an accompanying increase in complicated disease. Changes in individual health care–use behaviors may underlie these differences, suggesting that some cases of uncomplicated appendicitis may resolve without progression to complicated disease.
In-house calls contribute to loss of sleep and surgeon burnout. Although acknowledged to have an opportunity cost, home call is often considered less onerous, with minimal effects on sleep and ...burnout. We hypothesized home call would result in impaired sleep and increased burnout in acute care surgeons.
Data from 224 acute care surgeons were collected for 6 months. Participants wore a physiological tracking device and responded to daily surveys. The Maslach Burnout Inventory was administered at the beginning and end of the study. Within-participant analyses were conducted to compare sleep, feelings of restedness, and burnout as a function of home call.
One hundred seventy-one surgeons took 3,313 home calls, 52.5% were associated with getting called and 38.5% resulted in a return to the hospital. Home call without calls was associated with 3 minutes of sleep loss (p < 0.01), home call with 1 or more call resulted in a further 14 minutes of sleep loss (p < 0.0001), and home call with a return to the hospital led to an additional 70 minutes of sleep loss (p < 0.0001). All variations of home call resulted in decreased feelings of restedness (p < 0.0001) and increased feelings of daily burnout (p < 0.0001, Fig. 1).
Home call is deleterious to sleep and burnout. Even home call without calls or returns to the hospital is associated with burnout. Internal assessments locally should incorporate frequency of calls and returns to the hospital when creating call schedules. Repeated nights of home call can result in cumulative sleep debt, with adverse effects on health and well-being.
Abstract Background Damage control laparotomy (DCL) is performed for physiologically deranged patients. Recent studies suggest overutilization of DCL, which may be associated with potentially ...iatrogenic complications. Methods We conducted a retrospective study of trauma patients over a 2-year period that underwent an emergent laparotomy and received preoperative blood products. The group was divided into definitive laparotomy and DCL. Results A total of 237 received were included: 78 in definitive laparotomy group, 144 in the DCL group, and 15 who died in the operating room. The DCL group was more severely injured and required more transfusions. After propensity score matching, DCL was associated with an 18% increase in hospital mortality, a 13% increase in ileus, and a 7% increase in enteric suture line failure, an 11% increase in fascial dehiscence, and a 19% increase in superficial surgical site infection. Conclusions The potential overuse of DCL unnecessarily exposes patients to increased morbidity and mortality.
The lack of an accurate marker of prehospital hemorrhagic shock limits our ability to triage patients to the correct level of care, delays treatment in the emergency department, and inhibits our ...ability to perform prehospital interventional research in trauma. End-tidal carbon dioxide (ETCO2) is the measurement of alveolar carbon dioxide concentration at end expiration and is measured noninvasively in the ventilator circuit for intubated patients in continuous manner. Several hospital-based studies have been able to demonstrate that either low or decreasing levels of ETCO2 as well as disparities between ETCO2 and plasma carbon dioxide correlate with increasing mortality in trauma. We hypothesized that prehospital ETCO2 values will be predictive of mortality and need for massive transfusion following injury.
This is a single-center retrospective study from an urban level 1 trauma center. We reviewed all intubated adult patients transported for injury who had prehospital ETCO2 values available. Unadjusted comparisons of continuous variables were done with the Wilcoxon two-sample test. The predictive performance of prehospital ETCO2, the prehospital shock index, and prehospital systolic blood pressure were assessed and compared using areas under the receiver operating characteristic curves. Optimal cutoffs were estimated by maximizing the Youden index. Massive transfusion was defined as >10 U of blood or death in 24 hours.
A total of 173 patients were identified with prehospital ETCO2 values during the 2-year study period. Population was 78.5% male with a median age of 37.5 years (interquartile range, 23.5-53.5 years). Injury mechanism was penetrating in 22.8%. This cohort had a median Injury Severity Score of 26 (interquartile range, 17-36), massive transfusion rate of 34.7%, and mortality of 42.1%. In the evaluation of prediction of postinjury mortality and massive transfusion, ETCO2 outperformed systolic blood pressure and shock index, but these differences did not reach statistical significance.
End-tidal carbon dioxide is a novel prehospital predictor of mortality and massive transfusion after injury.
Prognostic/Epidemiologic, level III.
Many acute care surgeons (ACS) take in-house call (IHC), which leads to disrupted sleep and high levels of stress and burnout. We sought to quantify the effects of IHC on sleep patterns and burnout ...among ACS.
Physiological and survey data of 224 ACS with IHC were collected over six months. Participants continuously wore a physiological tracking device and responded to daily electronic surveys. Daily surveys captured work and life events as well as feelings of restfulness and burnout. The Maslach Burnout Inventory (MBI) was administered at the beginning and end of the study period.
Physiologic data were recorded for 34,135 days, which includes 4,389 nights of IHC. Feelings of moderate, very, or extreme burn out occurred 25.7% of days and feelings of being moderately, slightly, or not at all rested occurred 75.91% of days. Decreased amount of time since the last IHC, reduced sleep duration, being on call, and having a bad outcome all contribute to greater feelings of daily burnout (P<0.001). Decreased time since last call also exacerbates the negative effect of IHC on burnout (P<0.01).
ACS exhibit lower quality and reduced amount of sleep compared to an age-matched population. Furthermore, reduced sleep and decreased time since the last call led to increased feelings of daily burnout, accumulating in emotional exhaustion as measured on the MBI. A reevaluation of IHC requirements and patterns as well as identification of countermeasures to restore homeostatic wellness in ACS is essential to protect and optimize our workforce.
Whole blood resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of whole blood-based resuscitation on outcomes has not been established. The primary ...objective of this guideline was to develop evidence-based recommendations on whether whole blood should be considered in civilian trauma patients receiving blood transfusions.
An EAST working group performed a systematic review and meta-analysis utilizing the GRADE methodology. One PICO question was developed to analyze the effect of whole blood resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and ICU length of stay. English language studies including adult civilian trauma patients comparing in-hospital whole blood to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro was used to assess quality of evidence and risk of bias. The study was registered on PROSPERO (#CRD42023451143).
A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., ED, 3-, or 6-hour), 24-hour, late (i.e., 28- or 30-day), and in-hospital. On meta-analysis, whole blood was not associated with decreased mortality. Whole blood was associated with decreased 4-hour RBC (mean difference -1.82, 95% CI -3.12 to -0.52), 4-hour plasma (mean difference -1.47, 95% CI -2.94 to 0), and 24-hour RBC transfusions (mean difference -1.22, 95% CI -2.24 to -0.19) compared to component therapy. There were no differences in infectious complications or ICU length of stay between groups.
We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations.
Level III, Guidelines.
Use of the focused assessment with sonography for trauma (FAST) examination in patients with pelvic fractures has been reported as unreliable. We hypothesized that FAST is a reliable method for ...detecting clinically significant intra-abdominal hemorrhage in patients with pelvic fractures.
All patients with pelvic fractures over a 10-year period were reviewed at a Level I trauma center. The predictive ability of FAST was assessed by calculating the sensitivity, specificity, positive predictive value and negative predictive value against the criterion standard of either computed tomography (CT) or laparotomy findings. The FAST examination was considered "false negative" if findings at laparotomy indicated traumatic intra-abdominal hemorrhage. Likewise, the FAST examination was considered "false positive" if either CT or findings at laparotomy indicated no intra-abdominal hemorrhage. Hemodynamic instability scores were calculated for all patients.
There were 1,456 patients with pelvic fractures and an initial FAST reviewed; 1,219 (83.7%) underwent FAST and either CT or operative exploration. Median age was 43 years (interquartile range, 26-56 years) and mean Injury Severity Score was 18.5 ± 12.3. The sensitivity and specificity for FAST in this group of patients with pelvic fracture was 85.4% and 98.1%, respectively. The positive predictive value and negative predictive value were 78.4% and 98.8%, respectively. Of 21 patients with a false-positive FAST, 15 (71.4%) were confirmed with a negative CT scan, and 6 (28.6%) underwent laparotomy without findings of intra-abdominal hemorrhage. Of 13 patients with a false-negative FAST, all were identified with positive findings at the time of laparotomy. The specificity of the FAST examination remained high regardless of hemodynamic instability score grade.
The false positive rate of FAST examination for intra-abdominal hemorrhage is 1.1%. These data suggest that a positive FAST in this clinical scenario should be considered to represent intra-abdominal fluid. This series contradicts prior reports that FAST is unreliable in patients with pelvic fracture.
Diagnostic, level III.
The indications and outcomes associated with temporary intravascular shunting (TIVS) for vascular trauma in the civilian sector are poorly understood. The objective of this study was to perform a ...contemporary multicenter review of TIVS use and outcomes.
Patients sustaining vascular trauma, requiring TIVS insertion (January 2005 to December 2013), were retrospectively identified at seven Level I trauma centers. Clinical demographics, operative details, and outcomes were abstracted.
A total of 213 injuries (2.7%; 94.8% arterial) requiring TIVS were identified in 7,385 patients with vascular injuries. Median age was 27.0 years (range, 4-89 years), 91.0% were male, Glasgow Coma Scale (GCS) score was 15.0 (interquartile range, 4.0), Injury Severity Score (ISS) was 16.0 (interquartile range, 15.0), 26.0% had an ISS of 25 or greater, and 71.1% had penetrating injuries. The most common mechanism was gunshot wound (62.7%), followed by auto versus pedestrian (11.4%) and motor vehicle collision (6.5%). Shunts were placed for damage control in 63.4%, staged repair for combined orthopedic and vascular injuries in 36.1%, and for insufficient surgeon skill set in 0.5%. The most common vessel shunted was the superficial femoral artery (23.9%), followed by popliteal artery (18.8%) and brachial artery (13.2%). An argyle shunt (81.2%) was the most common conduit, followed by Pruitt-Inahara (9.4%). Dwell time was less than 6 hours in 61.4%, 24 hours in 86.5%, 48 hours in 95.9%, with only 4.1% remaining in place for more than 48 hours. Of the patients, 81.6% survived to definitive repair, and 79.6% survived overall. Complications included shunt thrombosis (5.6%) and dislodgment (1.4%). There was no association between dwell time and shunt thrombosis. The use of a noncommercial shunt (chest tube/feeding tube) did not impact shunt thrombosis but was an independent risk factor for subsequent graft failure. The limb salvage rate was 96.3%. No deaths could be attributed to a shunt complication.
In the largest civilian TIVS experience insertion to date, both damage control and staged orthopedic vascular injuries were common indications for shunting. With an acceptable complication burden and no associated mortality attributed to this technique, shunting should be considered a viable treatment option.
Therapeutic study, level V.
Burnout and depression is higher in trauma surgeons as compared to surgeons in other specialties. Clinical practice for many acute care surgeons (ACS) includes in-house call (IHC). The goal of this ...study was to quantitate physiologic stress among ACS who take IHC.
ACS with IHC responsibilities from two Level I trauma centers were studied. Participants wore a fitness and heart rate variability (HRV) device over 3 months. HRV was categorized as normal if 85% of baseline, moderate stress when HRV <85% but >50%, and high stress when HRV< 50%.
1421 nights were recorded among 17 surgeons (35.3% female; mean age 45.5 years). Excluding IHC, mean HRV = 32.23, and 95.63% of days were consistent with moderate or high stress. Post-call day 2 had significantly highest percentage of high stress (65.82%, p = 0.0495). High and moderate stress levels returned to baseline on post-call day 3.
High and moderate stress beyond IHC is common among ACS. Future study is needed to determine consequences of persistent stress and identify factors which impact recovery after IHC.
•Burnout and depression levels are higher in trauma surgeons compared to surgeons in other specialties.•A distinguishing feature of clinical practice for many trauma and acute care surgeons is that of in-house call.•Measurements of high and moderate stress are common among acute care surgeons and persist beyond nights of in-house call.•The highest levels of high and moderate stress occurred on post-call day 2, with heart rate variability recovery occuring on post-call day 3.
Open pelvic fractures are life-threatening injuries. Preperitoneal pelvic packing (PPP) has been suggested to be ineffective for hemorrhage control in open pelvic fractures. We hypothesize that PPP ...is effective at hemorrhage control in patients with open pelvic fractures and reduces mortality.
Patients undergoing PPP from 2005 to 2015 were analyzed. Patients with open pelvic fractures were defined as direct communication of the bony injury with overlying soft tissue, vagina, or rectum.
During the 10-year study, 126 patients underwent PPP; 14 (11%) sustained an open pelvic fracture. After PPP, 1 patient (7%) underwent angioembolization with a documented arterial blush. PPP controlled pelvic hemorrhage in all patients. Overall mortality rate was 7% with one death due to traumatic brain injury.
PPP is effective for hemorrhage control in patients with open pelvic fractures. PPP should be used in a standard protocol for hemodynamically unstable patients with pelvic fractures regardless of associated perineal injuries.
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