BACKGROUND:Liver transplantation is a life-saving procedure for patients with end-stage liver disease. Risk of post-transplantation infection remains high despite improvement in graft and patient survival. Antibacterial and antifungal prophylaxis plays an important role in reducing infection-related morbidity and mortality, but optimal timing and regimens are not well defined. METHODS:The Surgical Infection Society's (SIS) Therapeutics and Guidelines Committee and individuals with content expertise convened to develop guidelines on antibacterial and antifungal prophylaxis in liver transplant to prevent surgical site infection and other infections, shorten intensive care unit length of stay, and decrease mortality. PubMed, Embase, Web of Science, and the Cochrane Database were searched using Medical Subject Heading terms including "liver transplantation," "antibiotic prophylaxis," and "antifungal prophylaxis" for studies limited to randomized controlled trials, systematic reviews, meta-analyses, cohort, and case-control studies in adult patients. Evaluation of the published evidence was performed using the Grading of Recommendations Assessment, Development and Evaluation system, and final recommendations were developed by an iterative process. RESULTS:We cannot make a recommendation for or against using pre-operative (more than 1 h before incision) antibiotic agent prophylaxis in liver transplantation with available evidence. We suggest the use of broad-spectrum antibiotic agent prophylaxis in liver transplantation rather than gram-positive antibiotic agent prophylaxis alone (Grade 2B). We recommend limiting administration of antibiotic agent prophylaxis to 24 hours post-operatively after liver transplant (Grade 1B). We recommend against empiric antifungal prophylaxis for patients at low risk for invasive fungal infections (IFIs) after liver transplant; for patients at high risk for IFI, we recommend antifungal prophylaxis (Grade 1B). CONCLUSIONS:This guideline summarizes the current SIS recommendations on antibacterial and antifungal prophylaxis in liver transplantation.

Abstract Background Traumatic or surgical hemorrhage causes substantial morbidity and mortality. Electrical vagus nerve stimulation (VNS) reduces traumatic hemorrhage in animal models. VNS targets acetylcholine-producing T lymphocytes in the spleen to increase intracellular calcium within circulating platelets via α7 nicotinic acetylcholine receptors. Elevated calcium levels facilitate platelet activation (priming) after tissue injury to accelerate and increase clot formation that improves hemostasis. Trigeminal nerve stimulation (TNS) also decreases traumatic hemorrhage in mice, but the mechanism remains unknown. Recently, we showed that transcutaneous auricular neurostimulation (tAN; combined auricular VNS and TNS) reduces blood loss and days of menstruation in women with idiopathic or von Willebrand disease related heavy menstrual bleeding. The ability of tAN or transcutaneous auricular VNS (taVNS) to improve platelet function or laboratory hemostasis remains unknown. Methods Here we performed a prospective, randomized, double-blind, sham-controlled, single-center, first-in-human exploratory trial to determine the safety and efficacy of taVNS or tAN to prime platelets and augment clot formation. Healthy adult subjects received sham stimulation before taVNS or tAN, followed by serial measurements of platelet and hemostasis markers, including platelet functional analysis, thrombin generation, blood counts, coagulation assays, and thromboelastography. Repeated measures one-way ANOVA followed by Bonferroni’s test was used for comparisons between three or more time points. Two-tailed paired T-test was used for comparisons between two time points. Results Administration of taVNS or tAN was well tolerated without observable adverse events during the study period. taVNS or tAN primed platelets via collagen- or ADP-mediated signaling pathways, respectively. taVNS accelerated clot initiation, propagation, and stabilization as measured by thromboelastography. There were no differences in systemic or local thrombin generation, circulating white or red blood cell counts, platelet counts, prothrombin time, partial thromboplastin time, or INR assays after administration of taVNS or tAN. Conclusions These results provide evidence that taVNS or tAN primes human platelets and taVNS accelerates clotting kinetics as quantified by thromboelastography. taVNS and tAN warrant additional clinical study as therapies for traumatic or surgical hemorrhage and congenital or acquired coagulopathies. Trial registration This study is registered with the ClinicalTrials.gov database ( http://clinicaltrials.gov ). The registration number is NCT05977946. The study start is 10–31-2023.

BACKGROUND:The Surgical Infection Society (SIS) published evidence-based guidelines for prevention and management of pediatric intra-abdominal infection (IAI). Here we present updated guidelines on the basis of a systematic review of current literature. METHODS:The writing group included members of SIS' Therapeutics and Guidelines Committee, other SIS members with content or guideline expertise, and a professional medical librarian. A systematic literature review using PubMed®/MEDLINE, the Cochrane Library, Embase, and Web of ScienceTM was performed from January 2016 to October 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in pediatric patients limited to randomized controlled trials, systematic reviews, or meta-analyses. Additional relevant publications identified during literature review were included. Publications were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. The strength of each recommendation was rated strong (1) or weak (2). Quality of the evidence was rated high (A), moderate (B), or weak (C). Final recommendations were developed by an iterative review process. All writing group members voted to accept each recommendation included in the final article. RESULTS:This updated SIS guideline contains evidence-based recommendations for prevention and management of IAI in children. Recommendations include selection of preferred antimicrobial agents; timing and route of administration; duration of therapy; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; implementation of hospital-based infection control and prevention tactics; and implementation of hospital-based antimicrobial stewardship programs. SUMMARY:Herein are the most current recommendations for prevention and treatment of IAI in pediatric patients.

Metabolic stress during major surgery increases insulin resistance and causes post-operative hyperglycemia (POHG), which may in turn contribute to post-operative morbidity and mortality. Intensive insulin therapy for POHG is often ineffective and may even worsen patient outcomes. Non-invasive focused ultrasound stimulation (FUS) of glucose-sensing abdominal neurons improves glucose metabolism in animal models of diabetes, but its potential role in treating POHG remains unknown. In this study, we explored whether FUS of the superior mesenteric plexus (SMP) alters insulin sensitivity and post-operative fasting blood glucose (FBG) in a swine model of surgical stress-induced POHG. In each of 3 anesthetized animals, FUS targeting the porta hepatis (PH) of the liver or the SMP was delivered and insulin sensitivity was assessed in each case. In another series of experiments, 4 animals received SMP-FUS and 3 sham stimulation, after which surgical stress was induced via small bowel resection. In the 7 surgically operated animals, insulin sensitivity was measured before and after SMP-FUS (or sham), and fasting blood glucose (FBG) was measured before and 16 h after surgery. In all animals, insulin sensitivity was assessed using the hyperinsulinemic-euglycemic clamp (HEC) method. Results: SMP-FUS elicits a greater increase in insulin sensitivity than PH-FUS. On the day of surgery, SMP-FUS increases insulin sensitivity, compared to sham treatment. The day after surgery, surgically operated animals develop mild hyperglycemia. SMP-FUS-treated animals have higher FBG than sham-FUS-treated animals. No clear relationship is observed between FUS-induced changes in insulin sensitivity and next-day FBG. Conclusion: While SMP-FUS improves insulin sensitivity during surgery, it may exacerbate POHG.

Background: Implantable cervical vagus nerve stimulation (VNS) is an accepted therapy for the treatment of refractory epilepsy, depression, inflammation, and stroke. Recent studies have demonstrated that VNS reduces bleeding times and shed blood volumes by ~45% in animal models of soft tissue injury. These results have recently been confirmed in mice, including hemophilia mice deficient in FVIII, without evidence of systemic clotting, changes in global blood pressure, bradycardia, or hypotension. VNS induces a statistically significant upregulation of thrombin/antithrombin (TAT) complex formation in blood shed from a wound, but not in the circulation, suggesting enhanced localized, but not systemic, thrombin production and clot formation. Mechanistic studies demonstrate that VNS triggers release of acetylcholine in the spleen, which induces platelet calcium uptake through the alpha 7 subunit of nicotinic acetylcholine receptor (α7 nAChR). This efferent function of the vagus nerve to “prime” platelets has been termed the “neural tourniquet.” Ex vivo challenge of primed platelets with thrombin leads to increased surface expression of P selectin. While these preclinical data indicate that VNS can reduce bleeding time and shed blood volume, no studies to date have been conducted to determine if these approaches can modulate hemostasis in humans. Transcutaneous auricular vagus nerve stimulation (taVNS) is an emerging non-invasive alternative to cervical VNS and has been applied for headache, migraine, heart failure, asthma, tinnitus, and other conditions. Transcutaneous auricular neurostimulation (tAN) is an FDA-cleared technology (Sparrow Ascent System, K230796) that stimulates branches of the vagus and trigeminal nerves on and around the ear. tAN stimulates the release of central nervous system endorphins, shifts circulating monocytes to an anti-inflammatory phenotype, inhibits pro-inflammatory cytokine release, and has sustained antinociceptive effects. tAN is currently being tested in a healthy human population to determine whether it can alter platelet phenotype. This first-in-human trial will determine whether the neural tourniquet pathway exists in humans, and whether it can be accessed transcutaneously. Study design and Treatment: This study is designed as a randomized, double-blind, sham-controlled, single-center research study in which healthy adults will be randomized 1:1 into one of two experimental groups, to receive taVNS or tAN. Participants will receive 30 min of sham stimulation (taVNS or tAN), followed by 30 min of active stimulation (taVNS or tAN). Blood will be collected before and after sham stimulation and at several timepoints after stimulation. Samples will be analyzed by flow cytometry to assess platelet phenotype and thromboelastography to assess coagulation characteristics. Eligibility Criteria: Inclusion criteria are participants between 18-65 years of age. Exclusion criteria include a history of thrombocytopenia, coagulopathy, abnormal bleeding or blood disorder, or conditions that can cause coagulopathic conditions (e.g., atrial fibrillation, heart valve surgery or replacement, hip or knee replacement); or use of coagulation- or platelet-modifying therapies. Statistical Methods: Data will be collected at multiple timepoints and compared using two-way ANOVA Graphpad Prism. Endpoints: Platelet surface marker expression of P selectin, activated glycoprotein IIb/IIIaThromboelastography At the time of abstract submission, 23 subjects have completed the study, and two are in process. Enrollment is expected to conclude by October 2024.

Background: The Surgical Infection Society (SIS) published evidence-based guidelines for the management of intra-abdominal infection (IAI) in 1992, 2002, 2010, and 2017. Here, we present the most recent guideline update based on a systematic review of current literature.Methods: The writing group, including current and former members of the SIS Therapeutics and Guidelines Committee and other individuals with content or guideline expertise within the SIS, working with a professional librarian, performed a systematic review using PubMed/Medline, the Cochrane Library, Embase, and Web of Science from 2016 until February 2024. Keyword descriptors combined "surgical site infections" or "intra-abdominal infections" in adults limited to randomized controlled trials, systematic reviews, and meta-analyses. Additional relevant publications not in the initial search but identified during literature review were included. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was utilized to evaluate the evidence. The strength of each recommendation was rated strong (1) or weak (2). The quality of the evidence was rated high (A), moderate (B), or weak (C). The guideline contains new recommendations and updates to recommendations from previous IAI guideline versions. Final recommendations were developed by an iterative process. All writing group members voted to accept or reject each recommendation.Results: This updated evidence-based guideline contains recommendations from the SIS for the treatment of adult patients with IAI. Evidence-based recommendations were developed for antimicrobial agent selection, timing, route of administration, duration, and de-escalation; timing of source control; treatment of specific pathogens; treatment of specific intra-abdominal disease processes; and implementation of hospital-based antimicrobial agent stewardship programs.Summary: This document contains the most up-to-date recommendations from the SIS on the prevention and management of IAI in adult patients.

Background: Active and recent coronavirus disease 2019 (COVID-19) infections are associated with morbidity and mortality after surgery in adults. Current recommendations suggest delaying elective surgery in survivors for four to 12 weeks, depending on initial illness severity. Recently, the predominant causes of COVID-19 are the highly transmissible/less virulent Omicron variant/subvariants. Moreover, increased survivability of primary infections has engendered the long-COVID syndrome, with protean manifestations that may persist for months. Considering the more than 600,000,000 COVID-19 survivors, surgeons will likely be consulted by recovered patients seeking elective operations. Knowledge gaps of the aftermath of Omicron infections raise questions whether extant guidance for timing of surgery still applies to adults or should apply to the pediatric population. Methods: Scoping review of relevant English-language literature. Results: Most supporting data derive from early in the pandemic when the Alpha variant of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) predominated. The Omicron variant/subvariants generally cause milder infections with less organ dysfunction; many infections are asymptomatic, especially in children. Data are scant with respect to adult surgical outcomes after Omicron infection, and especially so for pediatric surgical outcomes at any stage of the pandemic. Conclusions: Numerous knowledge gaps persist with respect to the disease, the recovered pre-operative patient, the nature of the proposed procedure, and supporting data. For example, should the waiting period for all but urgent elective surgery be extended beyond 12 weeks, e.g., after serious/critical illness, or for patients with long-COVID and organ dysfunction? Conversely, can the waiting periods for asymptomatic patients or vaccinated patients be shortened? How shall children be risk-stratified, considering the distinctiveness of pediatric COVID-19 and the paucity of data? Forthcoming guidelines will hopefully answer these questions but may require ongoing modifications based on additional new data and the epidemiology of emerging strains.

Deficiency of coagulation factor VIII in hemophilia A disrupts clotting and prolongs bleeding. While the current mainstay of therapy is infusion of factor VIII concentrates, inhibitor antibodies often render these ineffective. Because preclinical evidence shows electrical vagus nerve stimulation accelerates clotting to reduce hemorrhage without precipitating systemic thrombosis, we reasoned it might reduce bleeding in hemophilia A. Using two different male murine hemorrhage and thrombosis models, we show vagus nerve stimulation bypasses the factor VIII deficiency of hemophilia A to decrease bleeding and accelerate clotting. Vagus nerve stimulation targets acetylcholine-producing T lymphocytes in spleen and α7 nicotinic acetylcholine receptors (α7nAChR) on platelets to increase calcium uptake and enhance alpha granule release. Splenectomy or genetic deletion of T cells or α7nAChR abolishes vagal control of platelet activation, thrombus formation, and bleeding in male mice. Vagus nerve stimulation warrants clinical study as a therapy for coagulation disorders and surgical or traumatic bleeding.

Background: Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involves open reduction and internal fixation of fractures with an implantable titanium plate to restore and maintain anatomic alignment. The presence of this foreign, non-absorbable material presents an opportunity for infection. Although surgical site infection (SSI) and implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for management of SSIs or implant-related infections after SSRF or SSSF. PubMed, Embase, Web of Science and the Cochrane database were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF who develop an SSI or an implant-related infection, there is insufficient evidence to suggest a single optimal management strategy. For patients with an SSI, systemic antibiotic therapy, local wound debridement, and vacuum-assisted closure have been used in isolation or combination. For patients with an implant-related infection, initial implant removal with or without systemic antibiotic therapy, systemic antibiotic therapy with local wound drainage, and systemic antibiotic therapy with local antibiotic therapy have been documented. For patients who do not undergo initial implant removal, 68% ultimately require implant removal to achieve source control. Conclusions: Insufficient evidence precludes the ability to recommend guidelines for the treatment of SSI or implant-related infection following SSRF or SSSF. Further studies should be performed to identify the optimal management strategy in this population.

Background: Open fractures, defined as fractures communicating with the environment through a skin wound, cause substantial morbidity after traumatic injury. Current evidence supports administration of prophylactic systemic antibiotic agents to patients with open extremity fractures to decrease infectious complications.Methods: The Therapeutic and Guidelines Committee of The Surgical Infection Society convened to revise guidelines for antibiotic use in open fractures. PubMed was queried for pertinent studies. Evaluation of the published evidence was performed using the GRADE framework. All committee members voted to accept or reject each recommendation.Results: In type I or II open extremity fractures, we recommend against administration of extended-spectrum antibiotic coverage compared with gram-positive coverage alone to decrease infections complications, hospital length of stay or mortality. In type III open extremity fractures, we recommend antibiotic therapy for no more than 24 hrs after injury, in the absence of clinical signs of active infection, to decrease infectious complications, hospital length of stay or mortality, and we recommend against extended antimicrobial coverage beyond gram-positive organisms to decrease infectious complications, hospital length of stay or mortality. In type III open extremity fractures with associated bone loss, we recommend antibiotic therapy in addition to systemic therapy to decrease infectious complications.Conclusions: Although antibiotic agents remain a standard of care for infection prevention after open extremity fractures, our findings and surveys of clinical practice patterns clearly show that additional robust clinical trials are needed to provide stronger corroborating evidence.

Background: Manifestations of gallbladder disease range from intermittent abdominal pain (symptomatic cholelithiasis) to potentially life-threatening illness (gangrenous cholecystitis). Although surgical intervention to treat acute cholecystitis is well defined, the role of antibiotic administration before or after cholecystectomy to decrease morbidity or mortality is less clear.Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic use in patients undergoing cholecystectomy for gallbladder disease to prevent surgical site infection, other infection, hospital length of stay, or mortality. PubMed, Embase, and the Cochrane Database were searched for relevant studies. Evaluation of the published evidence was performed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Using a process of iterative consensus, all authors voted to accept or reject each recommendation.Results: We recommend against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy. We recommend use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis. We recommend against use of post-operative antibiotic agents after elective laparoscopic cholecystectomy for symptomatic cholelithiasis. We recommend against use of post-operative antibiotic agents in patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis. We recommend a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis.Conclusions: This guideline summarizes the current Surgical Infection Society recommendations for antibiotic use in patients undergoing cholecystectomy for gallbladder disease.

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory diagnosis of C. difficile infection with leukocytosis (white blood cell count of ≥15,000 cells/mL) or elevated creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse, descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal colectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of the published evidence was performed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or fulminant, non-perforated C. difficile infection.

Focused ultrasound (FUS) modulation of activity of glucose sensing neurons in the porta hepatis (PH) has been shown to suppress hyperglycemia in animal models of diabetes. In this study, we hypothesized that FUS of glucose-sensing neurons in the PH, liver or in the abdomen, could prevent the development of post-operative hyperglycemia (POH) in swine. First, we sought to optimize the mode of FUS delivery to produce the largest, most consistent glucose-lowering effect. We assessed the short-term, glucose-lowering effect of FUS by (a) establishing hyperinsulinemic, euglycemic clamp (HEC), (b) delivering FUS while at HEC equilibrium, (c) registering the FUS-induced change in glucose infusion rate required to maintain the HEC equilibraium, for up to 90 min post-FUS. We found that FUS of the PH has a more consistent glucose-lowering effect than FUS of the liver parenchyma. In other studies happening in parallel to this research, we found that FUS of the superior mesenteric plexus (SMP) has a more prolonged, short-term glucose-lowering effect. Second, we sought to determine whether FUS can prevent the development of POH. On day 1 of the experiment, fasting blood glucose at baseline was measured. We then delivered FUS of the SMP (n=4) or sham-FUS (n=3) under HEC equilibrium. Shortly after, we subjected the animals to surgical stress by inducing intestinal ischemia and performing enterotomy. Animals recovered and returned to their cages. On day 2 of the experiment, fasting blood glucose was measured. We found that all animals exhibited POH; fasting blood glucose on day 2 was higher than on day 1. Animals that received FUS showed a more significant increase in gasting blood glucose than animals that received sham-FUS.

INTRODUCTION: Hemophilia A, factor VIII deficiency, decreases thrombin and fibrin formation, resulting in abnormal bleeding. Vagus nerve stimulation (VNS) increases thrombin generation via α7 nicotinic acetylcholine receptors (α7nAChR). We reasoned that VNS would improve local clot stability in a FeCl3-induced thrombosis model in wild-type (WT) and factor VIII–deficient (F8-KO), but not in α7nAChR-deficient (α7-KO) mice. METHODS: Mice underwent left cervical VNS (1 V, 30 Hz, 2 ms, 5 minute), and then FeCl3 solution was applied to the right carotid artery. For WT and α7-KO experiments, a 5% solution was applied for 1 minute. For F8-KO experiments, a 10% solution was applied for 3 minutes. Time to occlusion (TTO) was defined as absence of arterial waveform for greater than 1 minute. RESULTS: In WT mice, VNS significantly decreases TTO (VNS vs sham: 7.1 ± 1.3 vs 15.8 ± 3.4 minutes, n = 5, p < 0.05), but fails to decrease TTO in α7-KO mice (VNS vs sham: 19.3 ± 3.7 vs 17.9 ± 4.3 minutes, n = 5, p = NS). F8-KO mice have significantly longer TTO vs WT mice (WT vs F8-KO sham: 6.55 ± 0.63 minutes vs 25 ± 0 minutes, n = 6, p <0.0001). VNS significantly decreases TTO in F8-KO mice (F8-KO VNS vs F8-KO sham: 9.26 ± 1.38 minutes vs 25 ± 0 minutes, n = 6, p < 0.0001) (Figure).Figure.: F8-KO, factor VIII–deficient; VNS, vagus nerve stimulation.CONCLUSION: VNS improves local clot stability. VNS requires α7nAChR, but bypasses factor VIII deficiency, suggesting that vagal control of thrombin generation is independent of this critical clotting factor.

Background: Surgical stabilization of rib fractures is recommended in patients with flail chest or multiple displaced rib fractures with physiologic compromise. Surgical stabilization of rib fractures (SSRF) and surgical stabilization of sternal fractures (SSSF) involve open reduction and internal fixation of fractures with a plate construct to restore anatomic alignment. Most plate constructs are composed of titanium and presence of this foreign, non-absorbable material presents opportunity for implant infection. Although implant infection rates after SSRF and SSSF are low, they present a challenging clinical entity often requiring prolonged antibiotic therapy, debridement, and potentially implant removal. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee and Chest Wall Injury Society's Publication Committee convened to develop recommendations for antibiotic use during and after surgical stabilization of traumatic rib and sternal fractures. Clinical scenarios included patients with concomitant infectious processes (sepsis, pneumonia, empyema, cellulitis) or sources of contamination (open chest, gross contamination) incurred as a result of their trauma and present at the time of their surgical stabilization. PubMed, Embase, and Cochrane databases were searched for pertinent studies. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: For patients undergoing SSRF or SSSF in the absence of pre-existing infectious process, there is insufficient evidence to suggest existing peri-operative guidelines or recommendations are inadequate. For patients undergoing SSRF or SSSF in the presence of sepsis, pneumonia, or an empyema, there is insufficient evidence to provide recommendations on duration and choice of antibiotic. This decision may be informed by existing guidelines for the concomitant infection. For patients undergoing SSRF or SSSF with an open or contaminated chest there is insufficient evidence to provide specific antibiotic recommendations. Conclusions: This guideline document summarizes the current Surgical Infection Society and Chest Wall Injury Society recommendations regarding antibiotic use during and after surgical stabilization of traumatic rib or sternal fractures. Limited evidence exists in the chest wall surgical stabilization literature and further studies should be performed to delineate risk of implant infection among patients undergoing SSSRF or SSSF with concomitant infectious processes.

Introduction: Uncontrolled hemorrhage is the most common preventable cause of traumatic death. Direct pressure or tourniquets limit extremity bleeding, but non-compressible hemorrhage requires surgical control. Systemic hemostatic therapies are limited. In preclinical models of hemorrhage, electrical vagus nerve stimulation (VNS) accelerates thrombosis and decreases traumatic hemorrhage in a spleen-dependent manner. Here, we demonstrate that non-invasive high intensity focused ultrasound (HIFU) stimulation targeting the spleen significantly reduces bleeding in a murine tail transection model. Methods: Adult male C57BL/6J mice were anesthetized (ketamine/xylazine), placed in the right lateral decubitus position, and shaved after identifying the spleen by anatomical markers and palpation. The ultrasound probe was directed at the splenic hilum, followed by 1 min stimulation (1.1 MHz, 200 mV/pulse, 150 burst cycles, 500 μs burst period), a 30 s rest, and 1 min stimulation for a 5 min total stimulation. Animal tails were warmed in water (37°C, 5 min), transected 2 mm from the tip, and bled into water until hemorrhage stops for a minimum of 10 s to record the duration of bleeding (bleeding time). Results: Compared with sham stimulation, HIFU significantly reduces bleeding time after tail transection (Sham = 110.5 ± 7.7 s vs HIFU = 72.9 ± 6.6 s, Mean ± SEM, n = 10/group, p < 0.01 (two-tailed t-test). Conclusion: These data demonstrate that HIFU stimulation of the spleen provides a novel method to reduce traumatic hemorrhage. HIFU warrants additional study in traumatic and surgical bleeding, and as a treatment for bleeding disorders.

Since the outbreak of the COVID-19 pandemic, races across academia and industry have been initiated to identify and develop disease modifying or preventative therapeutic strategies has been initiated. The primary focus has been on pharmacological treatment of the immune and respiratory system and the development of a vaccine. The hyperinflammatory state ("cytokine storm") observed in many cases of COVID-19 indicates a prognostically negative disease progression that may lead to respiratory distress, multiple organ failure, shock, and death. Many critically ill patients continue to be at risk for significant, long-lasting morbidity or mortality. The human immune and respiratory systems are heavily regulated by the central nervous system, and intervention in the signaling of these neural pathways may permit targeted therapeutic control of excessive inflammation and pulmonary bronchoconstriction. Several technologies, both invasive and non-invasive, are available and approved for clinical use, but have not been extensively studied in treatment of the cytokine storm in COVID-19 patients. This manuscript provides an overview of the role of the nervous system in inflammation and respiration, the current understanding of neuromodulatory techniques from preclinical and clinical studies and provides a rationale for testing non-invasive neuromodulation to modulate acute systemic inflammation and respiratory dysfunction caused by SARS-CoV-2 and potentially other pathogens. The authors of this manuscript have co-founded the International Consortium on Neuromodulation for COVID-19 to advocate for and support studies of these technologies in the current coronavirus pandemic.

Background: As the coronavirus disease-2019 (COVID-19) pandemic continues globally, high numbers of new infections are developing nationwide, particularly in the U.S. Midwest and along both the Atlantic and Pacific coasts. The need to accommodate growing numbers of hospitalized patients has led facilities in affected areas to suspend anew or curtail normal hospital activities, including elective surgery, even as earlier-affected areas normalized surgical services. Backlogged surgical cases now number in the tens of millions globally. Facilities will be hard-pressed to address these backlogs, even absent the recrudescence of COVID-19. This document provides guidance for the safe and effective resumption of surgical services as circumstances permit. Methods: Review and synthesis of pertinent international peer-reviewed literature, with integration of expert opinion. Results: The "second-wave" of serious infections is placing the healthcare system under renewed stress. Surgical teams likely will encounter persons harboring the virus, whether symptomatic or not. Continued vigilance and protection of patients and staff remain paramount. Reviewed are the impact of COVID-19 on the surgical workforce, considerations for operating on a COVID-19 patient and the outcomes of such operations, the size and nature of the surgical backlog, and the logistics of resumption, including organizational considerations, patient and staff safety, preparation of the surgical candidate, and the role of enhanced recovery programs to reduce morbidity, length of stay, and cost by rational, equitable resource utilization. Conclusions: Resumption of surgical services requires institutional commitment (including teams of surgeons, anesthesiologists, nurses, pharmacists, therapists, dieticians, and administrators). Structured protocols and equitable implementation programs, and iterative audit, planning, and integration will improve outcomes, enhance safety, preserve resources, and reduce cost, all of which will contribute to safe and successful reduction of the surgical backlog.

Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous guidelines eliminating bite wounds and diabetic foot infections including their associated references. Relevant articles on the topic of complicated SSTIs from 2008-2020 were reviewed and graded individually. Comparisons were then made between the old and the new graded recommendations with review of the older references by two authors when there was disparity between the grades. Results: The majority of new studies addressed antimicrobial options and duration of therapy particularly in complicated abscesses. There were fewer updated studies on diagnosis and specific operative interventions. Many of the topics addressed in the original guidelines had no new literature to evaluate. Conclusions: Most recommendations remain unchanged from the original guidelines with the exception of increased support for adjuvant antimicrobial therapy after drainage of complex abscess and increased data for the use of alternative antimicrobial agents.