INTRODUCTION:The management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non-intensive care unit (ICU) setting after stratifying them using the mBIG criteria. METHODS:A retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3. RESULTS:Of the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups. CONCLUSIONS:Select patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

BACKGROUND:Higher center-level operative volume is associated with lower mortality after complex elective surgeries, but this relationship has not been robustly demonstrated for operative trauma. We hypothesized that trauma centers in Pennsylvania with higher operative trauma volumes would have lower risk-adjusted mortality rates than lower volume institutions.METHODS:We queried the Pennsylvania Trauma Outcomes Study database (2017-2019) for injured patients 18 years or older at Level I and II trauma centers who underwent an International Classification of Diseases, Tenth Revision (ICD-10), procedure code -defined operative procedure within 6 hours of admission. The primary exposure was tertile of center-level operative volume. The primary outcome of interest was inpatient mortality. We entered factors associated with mortality in univariate analysis (age, injury severity, mechanism, physiology) into multivariable logistic regression models with tertiles of volume accounting for center-level clustering. We conducted secondary analyses varying the form of the association between the volume and mortality to including dichotomous and fractional polynomial models.RESULTS:We identified 3,650 patients at 29 centers meeting the inclusion criteria. Overall mortality was 15.9% (center-level range, 6.7-34.2%). Operative procedure types were cardiopulmonary (7.3%), vascular (20.1%), abdominopelvic (24.3%), and multiple (48.3%). The mean annual operative volume over the 3 years of data was 10 to 21 operations for low-volume centers, 22 to 47 for medium-volume centers, and 47 to 158 for high-volume centers. After controlling for patient demographics, physiology, and injury characteristics, there was no significant difference in mortality between highest and lowest tertile centers (odds ratio, 0.92; confidence interval, 0.57-1.49). Secondary analyses similarly demonstrated no relationship between center operative volume and mortality in key procedure subgroups.CONCLUSION:In a mature trauma system, we found no association between center-level operative volume and mortality for patients who required early operative intervention for trauma. Efforts to standardize the care of seriously injured patients in Pennsylvania may ensure that even lower-volume centers are prepared to generate satisfactory outcomes.LEVEL OF EVIDENCE:Prognostic and Epidemiological; Level III.

Imran, Jonathan B. MD; Benjamin, Andrew J. MD; Bass, Gary A. MD; Hornor, Melissa MD; Cannon, Jeremy W. MD, FACS; Seamon, Mark J. MD, FACS; Bloom, Matthew B. MD, FACS; DuBose, Joseph J. MD, FACS; Raza, Shariq S. MD Author Information

Severe burn leads to substantial skeletal muscle wasting that is associated with adverse outcomes and protracted recovery. The purpose of our study was to investigate muscle tissue homeostasis in response to severe burn. Muscle biopsies from the right m. lateralis were obtained from 10 adult burn patients at the time of their first operation. Patients were grouped by burn size (total body surface area of <30% vs ≥30%). Muscle fiber size and factors of cell death and muscle regeneration were examined. Muscle cell cross-sectional area was significantly smaller in the large-burn group (2174.3 ± 183.8 µm2 vs 3687.0 ± 527.2 µm2, P = .04). The expression of ubiquitin E3 ligase MuRF1 and cell death downstream effector caspace 3 was increased in the large-burn group (P < .05). No significant difference was seen between groups in expression of the myogenic factors Pax7, MyoD, or myogenin. Interestingly, Pax7 and proliferating cell nuclear antigen (PCNA) expression in muscle tissue were significantly correlated to injury severity only in the smaller-burn group (P < .05). In conclusion, muscle atrophy after burn is driven by apoptotic activation without an equal response of satellite cell activation, differentiation, and fusion.

The impact of surgical research is far reaching, necessitating the importance of ongoing changes in this large and heterogeneous community. Given the intensity and duration of surgical training, surgical investigators may be at a disadvantage given the difficulties of procuring non-clinical time, which may be reflected by the paucity of pinnacle studies (randomized controlled-trials) within the surgical literature.1,2 Surgeons dedicated to advancing the field through research sometimes rely on weaker, albeit more pragmatic, study designs.

Background: While the prevalence of HIV infection in the population is 0.5%, it is higher among trauma patients as are rates of unknown seropositivity. Routine HIV screening for all trauma evaluations was implemented at our urban level I center in 2009. We aimed to evaluate use and results of the program in our trauma population. Methods: This was a retrospective analysis of all trauma evaluations between July 2015 and February 2018. After passage of legislation rescinding the requirement for consent to perform HIV testing, our trauma service instituted an order set which automatically tested for HIV unless the ordering physician opted out. Patients found to be infected with HIV were to be counseled and referred to specialty care. Results: Of 6175 consecutive trauma evaluations during the study period, 449 (7.3%) patients had been screened within the prior year and were excluded. Of the remaining cohort, 2024 (35.3%) patients were screened with 27 (1.3%) testing positive. Among those testing positive for infection, 100% were male, 77% white, 63% non-Hispanic, and 70% lacked insurance. Twenty-five (92.6%) patients received counseling and 19 were referred to specialty care. Age, gender, race, ethnicity, Injury Severity Score, trauma activation level, and payor type were not significant predictors for positive HIV screen on logistic regression analysis. Conclusions: Despite a significantly higher rate of HIV in the trauma population, only a third of patients are screened. Such high infection rates justify the existence of this screening program but steps must be taken to increase screening rate. Published by Elsevier Inc.

Tumescence is administered to burn patients intra-operatively to reduce blood loss from donor sites and excised wounds. At our institution, standard practice is to inject a mixture of lactated ringers and phenylephrine. The physiologic effects of this practice are unknown, but anecdotally, our providers note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with clinically significant hypertension in our pediatric burn patients. This was a retrospective, cohort study of pediatric burn patients who underwent tangential excision with split thickness autografting, excision alone, or autografting alone with or without tumescence for burn injury from January 2013 to August 2017 at our ABA verified urban burn center. Anesthesia records were reviewed for episodes of hypertension, defined as at least 2 consecutive blood pressure (BP) readings that were >2 standard deviations above normal and were sustained for >3 minutes. Published, intra-operative age and gender adjusted BP standards were used to define reference values. Hypertension was analyzed as a binary outcome (present/absent). Parametric and non-parametric tests were used for statistical analysis when appropriate. In total, 258 operative trips were evaluated. Mean patient age was 7.6±5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated total body surface area, and weight adjusted volume of tumescence were significant predictors of intra-operative hypertension (p<0.01). On multi-variate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% CI 1.33–3.04). Of the 162 operative trips which had at least one episode of significant hypertension, 128 cases (79%) were treated with opioids, deepening of anesthesia, anti-hypertensives, or a combination of these modalities. Intra-operative administration of vasopressor-containing tumescence in pediatric burn patients is associated with clinically significant intra-operative hypertension requiring additional medical management. Administration of vasopressor containing tumescence should be used with caution in pediatric burn operations until its clinical implications are defined. This study’s results show that vasopressor-containing tumescence has a significant physiologic impact for pediatric burn patients and should be used with caution.

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33-3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined.

Despite international efforts to increase performance of laparoscopic cholecystectomy (LC) in rural Guatemala, the vast majority of cholecystectomies are still performed via the open cholecystectomy (OC) approach. Our goal was to explore barriers to the adoption of LC in Guatemala as well as possible mechanisms to overcome them.

Pre-morbid psychiatric disorders are common among burn survivors and psychiatric symptoms often persist or worsen post-injury, leading to increased suicide risk. The prevalence of suicide risk is unknown and providers caring for burn survivors do not routinely screen for suicide risk and may miss the opportunity for early intervention to prevent injury or death. The characteristics of at-risk burn patients have yet to be elucidated. Using a brief, standardized tool to identify at-risk patients may be an important first step in reducing risk. The aims of this study are to report the prevalence of suicide risk in burn patients and identify demographic and burn-related characteristics of these patients. The Columbia-Suicide Severity Rating Scale, screener version, recent (C-SSRS) was administered by nursing staff to burn patients 18 and older upon admission, or as soon as clinically feasible. Adult burn patients with screening data between February 2015 and February 2018 were included. Patients were classified as at risk if any item was positively endorsed on the C-SSRS and no risk if all responses were negative. Significance was set at α = 0.05. Statistical analysis was performed using Student t test and χ2 test where appropriate. Out of 1,474 burn patients evaluated during the study period, 1,444 (97.96%) were screened for suicide risk. Suicide risk was identified in 64 (4.43%) patients. At-risk patients did not have a partner (n = 52, 81.25%), had higher TBSA (16.25% vs 9.23% and had a longer LOS (24.4 days vs 8.6). Overall, female patients had higher proportion of at risk status (8.21% vs 3.23%, p < 0.05). There were no differences in age, race/ethnicity, payor status and mortality. Our universal suicide screening process identifies an at risk subpopulation of burn patients. Higher injury burden and poor social support system are associated with suicide risk. Our findings suggest that a portion of patients admitted for burn injuries endorse suicide risk factors. This risk may go undetected without standardized screening. These findings suggest at risk patients may be identified by standardized screening tools and referred for appropriate management and follow-up.

Background: Trauma prediction scores such as Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS)) are used to predict mortality, but do not include comorbidities. We analyzed the American Society of Anesthesiologists physical status (ASA PS) for predicting mortality in trauma patients undergoing surgery. Methods: This multicenter, retrospective study compared the mortality predictive ability of ASA PS, RTS, Injury Severity Score (ISS), and TRISS using a complete case analysis with mixed effects logistic regression. Associations with mortality and AROC were calculated for each measure alone and tested for differences using chi-square. Results: Of 3,042 patients, 230 (8%) died. The AROC for mortality for TRISS was 0.938 (95%CI 0.921, 0.954), RTS 0.845 (95%CI 0.815, 0.875), and ASA PS 0.886 (95%CI 0.864, 0.908). ASA PS + TRISS did not improve mortality predictive ability (p = 0.18). Conclusions: ASA PS was a good predictor of mortality in trauma patients, although combined with TRISS it did not improve predictive ability. (C) 2019 Elsevier Inc. All rights reserved.

Delays to the operating room (OR) or discharge (DC) lead to longer lengths of stay and increased costs. Surprisingly, little work has been done to quantify the number and cost of delays for inpatients to the OR, and to DC to outpatient status. They reviewed their burn admissions to determine how often a patient experiences delays in healthcare delivery. Data for all burn admissions were prospectively collected from 2014 to 2016. A quality improvement filter was created to define acceptable parameters for patient throughput. Every hospital day was labeled as 1) No delay, 2) Operation, 3) Delay to the OR, or 4) Delay to DC. They had 1633 admissions: 432 ICU admissions (26%) and 1201 floor admissions (74%). Six hundred fifteen patients (37.7%) received an operation. Patients with delays included 331 with OR delays (20.3%) and 503 with DC delays (30.8%). Average delay days included (Mean ± SD): OR delay days = 4.7 ± 6.2 and DC delay days = 4.1 ± 4.4. Total number of hospital days was 13,009, divided into 1616 OR delay days (12%) and 2096 DC delay days (16%). Significant OR delays were due to patient unstable for OR (n = 387 [24%]), OR space availability (n = 662 [41%]), indeterminate wound depth (n = 437 [27%]), and donor site availability (n = 83 [5%]). Significant DC delays were due to medical goals not reached (n = 388 [19%]), pain control and wound care (n = 694 [33%]), PT/OT clearance (n = 168 [8.0%]), and DC placement delays (n = 754 [36%]). Costs for OR and DC delays ranged between US$1,000,000 and US$5,000,000. Costs of increasing OR capacity and/or additional social work ancillary staff can be justified through millions of dollars of savings annually.

Their group previously demonstrated high-patient satisfaction for the treatment of hypertrophic burn scar (HBS) with the erbium: yttrium aluminum garnet (Er:YAG) laser, but this and other literature supporting the practice suffer from a common weakness of a reliance on subjective assessments by patients or providers. Herein, they sought to prospectively study the effects of Er:YAG fractional ablation on HBS using noninvasive, objective technologies to measure outcomes. Patients with HBS had identical regions of scar designated for treatment by the Er:YAG laser (TREAT) or to be left untreated (CONTROL). They prospectively collected scar measurements of TREAT and CONTROL regions preoperatively, 3 weeks, and 3 months after Er:YAG treatment. Scar measurements included viscoelastometry, transepidermal water loss, optical coherent tomography, and high-frequency ultrasound. Outcomes were measured for the aggregate difference between the TREAT group vs the CONTROL group, as well as within each group in isolation. Seventeen patients were seen preoperatively, followed by n = 15 at 3 weeks and n = 11 at 3 months. A mixed-model repeated measures analysis showed no significant effect of fractional ablation when comparing the overall TREAT group measurements with those of the CONTROL group. However, when considered as within-group measurements, TREAT scars showed significant improvement in viscoelastic deformity (P = .03), elastic deformity (P = .004), skin roughness (P = .05), and wrinkle depth (P = .04) after fractional ablation, whereas CONTROL scars showed no such within-group changes. HBS treated by the Er:YAG laser showed objective improvements, whereas no such changes were seen within the untreated scars over the same time frame.

Background: Little information exists on the value of online question banks in preparing residents for the American Board of Surgery In-Training Examination (ABSITE). Methods: We reviewed surgical residents' use of an online question bank (TrueLearn) and compared it to their ABSITE performance. Results: The 2016-2017 records of 44 PGY 2-5 general surgery residents were examined. The total number of TrueLearn questions answered significantly correlated (p <0.05) with correct answers and percentile rank on the 2017 ABSITE. If a resident was to complete the entire online TL question bank consisting of 1000 questions, the overall percentage correct and overall percentile on the ABSITE is estimated to increase by 3% and 20%, respectively. Conclusions: The use of the TrueLearn question bank is associated with an improved percentage of ABSITE questions answered correctly and improved PGY percentile scores. (C) 2019 Elsevier Inc. All rights reserved.

Background: The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties’ attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty’s ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so. Methods: A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine. Results: Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions. Conclusions: Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.

Background: It is reported that performing laparoscopic cholecystectomy (LC) at night leads to increased rates of complications and conversion to open. We hypothesize that it is safe to perform LC at night in appropriately selected patients. Materials and methods: We performed a retrospective review of nonelective LC in adults at our institution performed between April 2007 and February 2015. We dichotomized the cases to either day or night. Results: Five thousand two hundred four patients underwent LC, with 4628 during the day and 576 at night. There were no differences in age, body mass index, American Society of Anesthesiologists class, race, insurance type, pregnancy rate, or white blood cell count. There were also no differences in the prevalence of hypertension, diabetes, or renal failure. However, daytime patients had higher median initial total bilirubin (0.6 [0.4, 1.3] versus 0.5 [0.3, 1.0] mg/dL, P = 0.002) and lipase (33 [24, 56] versus 30 [22, 42] U/L, P < 0.001) values. There was no difference in case length, estimated blood loss, rate of conversion to open, biliary complications, length of stay (LOS) after operation, unanticipated return to the hospital in 60 d, or 60-d mortality. Daytime patients spent more time in the hospital with longer median LOS before surgery (1 [1, 2] versus 1 [0, 2] d, P < 0.001) and median total LOS (3 [2, 4] versus 2 [1, 3] d, P < 0.001) compared with night patients. Conclusions: At our institution, we perform LC safely during day or night. The lack of complications and shorter LOS justify performing LC at any hour. (C) 2018 Elsevier Inc. All rights reserved.

Background: Ambulatory surgery centers (ASCs) are frequently utilized; however some ambulatory procedures may be performed in hospital outpatient departments (HOPs). Our aim was to compare operating room efficiency between our ASC and HOP. Methods: We reviewed outpatient general surgery procedures performed at our ASC and HOP. Total case time was divided into five components: ancillary time, procedure time, exit time, turnover time, and nonoperative time. Results: Overall, 220 procedures were included (114 ASC, 106 HOP). Expressed in minutes, the mean turnover time (29.8 +/- 9.6 vs. 24.5 +/- 12.7; p < 0.01), ancillary time (32.2 +/- 7.0 vs. 22.2 +/- 4.5; p < 0.01), procedure time (77.4 +/- 44.9 vs. 56.2 +/- 23.0 p < 0.01), exit time (11.8 +/- 4.4 vs. 8.5 +/- 4.3; p < 0.01), and nonoperative time (62.9 +/- 21.9 vs. 48.7 +/- 15.0; p < 0.01) were longer at the HOP than at the ASC. Conclusion: ASC outpatient procedures are more efficient than those performed at our HOP. A system evaluation of our HOP operating room efficiency is necessary. (C) 2019 Published by Elsevier Inc.