I'd like to welcome you to the 51st Critical Care Congress. I'm Debra Kuhls. I'm a trauma and critical care surgeon at the Kirkuk Korean School of Medicine at UNLV in Las Vegas, and I'm the current SCCM Surgery Section Chair. I'm going to present trauma and burns as part of the surgery year in review. The first study I'm going to review looks at the impact of COVID-19 infection on outcomes after injury in a Pennsylvania statewide trauma system. They categorized patients COVID-positive, COVID-negative, or not tested. Those that were COVID-positive were less likely to be white, had higher incidence of firearm injuries, and after performing multivariate analysis, they found that those patients that were COVID-positive had increased hospital death, increased complications, and increased pulmonary complications. The bar graph to the right reports on mortality according to injury severity, age, and chest injury, and across all these dimensions, there was a higher mortality in those patients that were COVID-positive. The next study I'd like to review with you is Changes in Traumatic Mechanisms of Injury in Southern California Related to COVID-19. This was a retrospective study of 11 level one and level two trauma centers, and they grouped their patients into one of three groups. A control group, which was pre-COVID, second group was pre-stay-at-home orders, and third group was post-stay-at-home orders. What they consistently found when comparing post-stay-at-home order groups was that there was a higher incidence of penetrating injury, shortfalls, sports injuries, they presented with lower systolic blood pressure. Also, there was a higher percentage of Latino, as well as Medicare and Medicaid patients. I should mention that there were several other studies that had very similar results, all pointing towards increased violence-related mechanisms of injury. To address violence and its root causes, the American College of Surgeons formed an ISAFE group. This consisted of diverse, multidisciplinary health care workers of multiple specialties, as well as community organizations that represent other stakeholders. They met several times, developed consensus-based recommendations, and they recommend four strategies to trauma centers. One, that trauma-informed care be adopted at all trauma centers. Number two, that social care be integrated into trauma care. Number three, that trauma centers invest in at-risk communities. And four, that advocacy be used to meet these objectives. Firearm deaths now exceed motor vehicle crash deaths in the U.S. The American College of Surgeons decided to survey its membership to learn their views on firearm ownership, as well as to inform ACS initiatives to decrease firearm injuries and deaths. They had a response rate of approximately 20%. They found that 42% of respondents keep a firearm in the home. 75% felt it was very or extremely important for the American College of Surgeons to support policies to decrease firearm injuries and deaths. There was broad variability on opinions about private citizen firearm ownership. However, there was very broad support for 16 of 25 policy and advocacy issues to decrease firearm injuries and deaths. The next few studies I'm going to review have to do with blood resuscitation. This study is a secondary analysis of the PAMPER trial involving pre-hospital use of resuscitative products. And they had four groups, crystalloid, pacred blood cells, plasma, and plasma plus pacred blood cells. And looking at 30-day mortality, they found that the lowest mortality was in patients that were resuscitated with pacred blood cells plus plasma. This study looks at never-afrozen plasma and compares it with FFP using the TQIP database. And they looked at several outcome measures, mortality, length of stay, and various complications, which are presented in the table to the right. And while there were no differences in these outcome measures, there was a decreased time to transfusion in the never-frozen plasma group. This may represent the potential to expand available blood product options for resuscitation. There continues to be increasing interest in whole blood. And I cite three studies. I'm going to start with number two. And it compares component therapy versus low titer group O whole blood in adult patients. And overall, they did not find significant difference in outcomes, including mortality. However, there was statistically lower incidence of multi-organ dysfunction in the whole blood group. The volume of blood transfused was lower in the whole blood group compared to component therapy. Number three on your slide is a small study in pediatric patients where they found, again, no difference in outcomes. Number one on the slide is a review article. And while they do not find any significant differences, they indicate there are too few articles and urge future studies. This next study is a proof of concept operationalizing the deployment of low titer O positive whole blood within a regional trauma system that's well established. That involves helicopter units, ground EMS units, a level one, level four trauma center. The figure to the right depicts donation and a blood rotation system so that if blood is not used at one site, it is rotated to a higher blood use site. All of this results in one to 2% wastage, which is considered very low. And it really is the first demonstration of a multidisciplinary, multi-institutional system wide system using low titer O positive whole blood. This next study looks at the gap between the evidence and practice of pre-hospital and in-hospital blood product usage for trauma resuscitation. It uses both the TQIP database and the NEMSIS database. And over the study period of 2015 to 2020, in-hospital usage of whole blood increased from only 16.7% to 24.5%. When we look at the NEMSIS database, less than 1% of those patients who are hypotensive with systolic blood pressure of less than 90 and heart rate of greater than 120 received whole blood. In 2021, the Joint Trauma System Defense Committee on Trauma and Armed Services Blood Program published a consensus statement on whole blood. And I just give you a couple of highlights here. They indicate that fresh whole blood improves outcomes in military settings compared to component therapy. Cold stored whole blood improves outcomes in trauma patients and is FDA approved, whereas fresh whole blood is not FDA approved. So therefore, they recommend that whole blood should be used to treat hemorrhagic shock. And that low titer O whole blood is a resuscitation product of choice. Component therapy should be used when whole blood is not available. There are many other important details, but I wanted to make you aware of this consensus statement. The next few studies are going to address TXA. The first one is a phase 3 multicenter double-blind placebo-controlled randomized superiority trial that was conducted at four US trauma centers. And they found that the 30-day mortality was lower when TXA was administered within one hour of injury. And that in the cases of severe shock with systolic blood pressure less than 70, there was also a lower 30-day mortality. There were no higher thrombotic complications in the TXA group. The next study is a multi-institutional retrospective study involving 17 level 1 and 2 trauma centers comparing TXA and non-TXA cohorts. They found that mortality was higher and more blood products were given in the no-TXA group. There was no difference in thrombotic events of MICVA or pulmonary embolus. Interestingly, the DVT rate was higher in the no-TXA group. This next study looks at fibrinolytic activation patients with progressive intracranial hemorrhage after traumatic brain injury. It's a single level 1 trauma center study. The aim was to look at the progression of intracranial hemorrhage and TAG as well as other labs. They drew Q6-hour labs. The only association they found was between rising D-dimer levels and progressive intracranial hemorrhage. This is somewhat consistent with the CRASH-2 results. And there's a suggestion that TXA may end up being a treatment that is helpful to these patients. Next, we're going to switch briefly to Roboa. And I reported a retrospective TQIP study using Roboa in pelvis fractures. It was compared with preperitoneal packing. The results indicated that there was decreased mortality time to the OR in transfusion requirements using Roboa versus preperitoneal packing. The Denver group has protocolized the use of Roboa in pelvis fractures, which is depicted in the figure on this slide. Next is a study on the FAST exam. And the title is Trust the FAST. Confirmation of the FAST examination is highly specific for intra-abdominal hemorrhage in over 1,200 patients with pelvic fractures. This is a 10-year single-center retrospective review of these patients. And as background, FAST examination has not been considered to be reliable for intra-abdominal fluid detection in the event of a pelvis fracture. This study went on to look at positive and negative FAST and calculated a sensitivity of 85.4%, specificity of 98.7%, positive predictive value of 83.5%, and a negative predictive value of 98.9%. This study looks at the clinical impact of a dedicated trauma hybrid, OR. It's a retrospective cohort analysis at a level one trauma center. The two groups are hybrid OR versus historic controls. The hybrid group had more use of Roboa, 9% versus 1%. Time to OR was shorter in the hybrid group, 49 versus 60 minutes. Angio was used in 21% of the cases. There were decreased ventes, transfusions, and infections in the hybrid OR group. We're going to switch gears to mass casualty events. So this was a cross-sectional survey of 17 academic level one trauma centers using a computerized model that was designed to realistically model consumption of limited resources, including blood products. Blood products could not be replenished during the event. Under what was considered to be one of the least demanding computerized mass casualty events, 20% of the patients would require blood, 6% of the mass of transfusion. One of the findings was that more than 50% of those trauma centers could not meet the blood requirements of 100 patients during the mass casualty event. The median size event that resulted in failure was 80 patients. If we considered platelets, as the above numbers did not include platelets in the calculation, but if we did consider platelets, more than half would fail at 60 patients. This slide is a continuation of the same study with Table 2 indicating the median number of units of blood products of various types. On the right is a graph depicting the number of admitted patients on the x-axis, and on the y-axis is the percentage of successful model runs. We can see that trauma centers fail to meet the blood product needs at well below 100 patients, and when you go upwards of 200, they fail to meet the needs of a large number of patients. I'd like to switch gears to burns. This study looks at the resuscitation practices in North America, and it is called the ABRUPT trial. It's a prospective non-interventional observational study of burn resuscitation practices among 21 burn centers in the US and Canada. During the first 48 hours following a burn of 20% or greater, it compares an albumin group versus crystalloid, and the outcomes were worse in the albumin group. There were increased need for limb fasciotomies, renal replacement therapy, longer ventilator days, longer length of stay, and decreased survival. These results have informed a prospective study that is underway. I'd like to thank you for your attention, and I hope you enjoy the rest of the Society of Critical Care Medicine Critical Care Congress. Welcome to the Year in Review, a review of literature relevant to the practice of surgical critical care. This presentation represents the collective work of 17 surgeon-intensivists from the Education Committee of the Surgery Section. We have no conflicts to disclose. For calendar year 2021, the committee recommended the following categories for literature review. Sepsis. The first study of note is by the Chiriozopila Group, who looked at the discontinuation of antimicrobials using a procalcitonin guidance program. They observed a rate of infection-associated adverse events of 7% versus 15% using a standard of care plan, a 28-day mortality that was 15% versus 28% with the standard plan, and a median length of antibiotic therapy that was half of the standard plan. The cost of hospitalization was also reduced. They concluded that procalcitonin guidance was effective in reducing infection-associated adverse events, 28-day mortality, and the cost of hospital care. The Al-Hazani Group implemented a living guideline model for providers who care for patients with COVID-19 in the intensive care unit. They made nine recommendations, including the use of dexamethasone for corticosteroid therapy, as well as standard venous thromboprophylaxis. They also recommended against the use of hydroxychloroquine. The Dankowitz Group reported their findings of patients who underwent targeted temperature management compared to normothermia after cardiac arrest. They found, by six months, that the mortality rates were the same and the disability rates were the same. They also observed a higher incidence of arrhythmia in the hypothermia group. They concluded that targeted hypothermia did not lead to a lower incidence of death at six months or a lower incidence of disability, but it was associated with a slightly higher incidence of arrhythmia. This collaborative effort of investigators studied the use of therapeutic anticoagulation in the care of patients with COVID-19. In their open-label trial, patients were randomized to receive either heparin anticoagulation or usual pharmacologic thromboprophylaxis. The trial was stopped when they found that the survival to discharge was similar in both groups, as was the major bleeding rate. The authors concluded that therapeutic anticoagulation did not improve survival to discharge. The Recovery Collaborative Group published their work on dexamethasone in COVID-19 patients. They randomized patients to receive either 10 days of dexamethasone therapy or usual care. In the dexamethasone group, the incidence of death was lower than that in the usual care group for patients who received mechanical ventilation or oxygen support. There was no benefit observed in patients who were receiving neither oxygen nor mechanical support. The authors concluded that the use of dexamethasone resulted in lower 28-day mortality in patients receiving mechanical ventilation or oxygen therapy, but not among those receiving no support. The Kauffman Group reported their findings of the impact of COVID-19 on trauma patient outcomes. They did a retrospective study of their Pennsylvania Trauma Center, and they identified over 15,000 patients. Although only a small fraction of them were positive for COVID, those patients suffered a mortality rate that was double, a longer length of stay, and higher pulmonary complications. The Knisley Group reported their findings of perioperative morbidity and mortality in patients with COVID-19 who undergo urgent and emergent surgical procedures. They looked at their case experience at two hospitals in New York City. They found a mortality rate of 16% in COVID-positive patients compared to only 1% in COVID-negative patients. Similarly, serious complications were identified in 58% of COVID patients versus 6% of their non-infected counterparts. Other serious complications, including cardiac arrest, sepsis, and shock, were much more common in the COVID group. The Moskowitz Group reported their findings of a randomized multi-center trial in which patients were randomized to receive a drug cocktail versus standard of care for septic shock. They used ascorbic acid, steroids, and thiamine as their cocktail. By three days, patients did not have a difference in SOFA score, and by 30 days, the mortality rates were similar. The authors concluded that there was no benefit to administering this combination of medications for patients in septic shock. The Gelson Group attempted to characterize the relationship between the PAO2 and organ dysfunction observed in critically ill patients with systemic inflammatory response syndrome, or SIRS. In this multi-center randomized trial, which was performed in four intensive care units in the Netherlands over the course of a year and a half, they screened over 9,000 patients to identify the mere 400 that were enrolled in the study. Ultimately, they were unable to appreciate a significant difference in the mean duration of mechanical ventilation or in-hospital mortality, and ultimately, they determined that treatment with a low normal PAO2 target compared to a high normal PAO2 target did not result in a statistically significant reduction in organ dysfunction. In this important work, the lead group studied the timing of tranexamic acid in patients who were injured. Patients who received tranexamic acid within one hour of injury were compared to those who received it beyond one hour of injury. They found that patients who received tranexamic acid within one hour of injury had a survival benefit at 30 days, a lower incidence of multi-organ failure, and lower transfusion requirements. The Wilms Group studied the impact of the use of a visceral protective layer in preventing the formation of the dreaded enteroatmospheric fistula in patients undergoing open abdomen treatment. They identified 120 patients with peritonitis due to a holoviscus perforation or anastomotic leak. Overall, the mortality rate was 22%, and the mean duration of open abdomen therapy was 9 days. The use of a visceral protective layer resulted in a significant reduction in the risk of enteroatmospheric fistula formation, a risk reduction of approximately 89%. The authors concluded that the use of this layer effectively prevented enteroatmospheric fistula formation, and they recommended its consistent use as part of a standard open abdomen treatment algorithm. The Sabino Group reported their findings of enteral nutritional support in patients undergoing vasopressor therapy. They found that patients who were receiving vasopressor therapy had a higher incidence of an elevated gastric residual volume compared to those who were not on vasopressors, 20% versus 7%. However, there was no difference in the rate of bowel ischemia, emesis, or new abdominal pain in the two groups. These investigators concluded that enteral nutrition was generally well-tolerated and safe for patients simultaneously receiving vasopressors. The Al-Leswas Group studied the impact of omega-3 fatty acids on inflammation associated with pancreatitis. In their randomized trial, patients were randomized to receive a lipid emulsion with or without fish oil containing omega-3s. The recipients of omega had lower biomarker levels, fewer new organ failures, and a shorter critical care stay. The authors concluded that the administration of fish oil, which is a good source of omegas, improves clinical outcomes, which may be as a result of decreased inflammation. The Zimmerman Group attempted to identify five new ways for providers to choose wisely when caring for their patients who are critically ill. In this work, they made five recommendations for providers to follow in caring for critically ill patients. These included, don't retain catheters and drains without a reason, don't delay progression towards liberation from the ventilator, don't continue antibiotics without evidence of need, don't delay mobilizing ICU patients, and don't promote care that is discordant with patient goals. Last, but definitely not least, is the 2021 Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock. This work needs no introduction. Everybody's familiar with the Surviving Sepsis Campaign by now, and its recommendations are widely practiced. I strongly urge everyone to download this gem and read it, all 60-something pages, but if you don't have time for that, I still recommend you skim. Recommendations are bolded for easy identification. In the category of adrenal insufficiency, these works were noteworthy. The first is by the Thompson Group, who studied cost and cost-effectiveness for patients in septic shock receiving steroid therapy. In this work, which was performed in New Zealand, they studied patients with septic shock by randomizing them to receive a 7-day continuous infusion of hydrocortisone versus placebo. 405 patients were included in the study. Unfortunately, adjunctive hydrocortisone did not reduce total healthcare expenditure or improve outcomes when compared with placebo in patients with septic shock. The Huang Group studied practice patterns in management of critical illness-related corticosteroid insufficiency, or SIRSI, in surgical intensive care units. Using a survey, they found that only 5% of respondents used a formal protocol, and nearly one-third of them did not use laboratory testing. The authors felt that there was extreme variability in the diagnosis and management of SIRSI, and they felt that their work reflected an opportunity for national improvement in the management of SIRSI. This group performed a meta-analysis of currently available literature to determine the optimal timing of initiation of adrenal replacement therapy. They found a similar 28-day mortality rate in the earlier and later therapy groups. Patients who start earlier have shorter hospital and ICU stays, but patients who start later need less dialysis and have a lower rate of catheter-associated bloodstream infections. The Sol Group looked at acute kidney injury in the setting of torso trauma. They performed a retrospective review of 380 torso trauma patients. They found independent risk factors for acute kidney injury included bowel injury, fluid balance over 2.5 liters in 24 hours, and vasopressor use. Acute kidney injury occurred in 18.9% of patients, and those patients who developed acute kidney injury had a much higher mortality rate. The Lu Group constructed and tested a mortality prediction model against other machine learning models. In their work, they studied 7,548 patients with acute kidney injury in the intensive care unit. The overall in-hospital mortality of this group was 16%. The best performing algorithm in the study was the XGBoost with the highest area under the receiver operating curve, as well as accuracy. The precision and recall of this model ranked second among the four machine learning models. The authors concluded that this model had obvious advantages of performance compared to other machine learning models, which was helpful in the identification of patients with acute kidney injury at risk for death. The Santos group provided a review of acute heart failure treatment as it pertains to the elderly patient. They recommended a clinically-oriented, patient-tailored approach regarding assessment, treatment, and follow-up of elderly patients. The Jin group aimed to investigate the potential diagnostic value of a variety of biomarkers in acute heart failure. They studied 176 patients with acute heart failure and compared them with 60 healthy subjects. They graded the acute heart failure using the New York Heart Association functional classification. And they measured biomarker levels in the patients. They found that MIR214, BNP, NTProBNP, and SST2 can be used as effective biomarkers of acute heart failure, providing a new strategy for the diagnosis and assessment of severity of acute heart failure. Post-intensive care unit syndrome and rehabilitation. The first article in this category is by the Peach Group. These authors call on the World Health Organization to create international diagnostic codes for post-intensive care unit syndrome. The authors noted that without financial alignment, clinicians cannot diagnose post-intensive care unit syndrome, which hinders the tracking of its prevalence and impedes policy development for this condition. The authors encourage providers to screen for post-intensive care unit syndrome in all survivors of critical illness. The Lu group studied the impact of hyperbaric oxygen therapy on recovery from traumatic brain injury. They created a variety of scenarios, including daily and twice-daily rehabilitation with and without hyperbaric oxygen therapy. They assessed the patient's cognitive ability, activities of daily living, and movement ability using a variety of scoring systems. They found improvement in all scenarios, especially remarkable in patients who received twice-daily intense rehab with hyperbaric oxygen therapy. Venous thromboembolism. The Verham group reported their experience with a novel monoclonal antibody for the prevention of venous thromboembolism. Abolacimab is a monoclonal antibody that binds and inactivates factor XI. In their open-label, randomized trial, 412 patients received either abolacimab or standard-dose inoxaparin. Their results were impressive. Venous thromboembolism occurred in 13% of the low-dose group, 5% of the middle-dose group, and 4% of the higher-dose group of abolacimab recipients. This was compared to 22% of inoxaparin recipients. Bleeding events were low, 0% to 2% in all groups. The authors concluded that factor XI is an important part of postoperative venous thromboembolism. Factor XI inhibition with a single intravenous dose of abolacimab after total knee arthroplasty was effective in preventing venous thromboembolism and superior to inoxaparin. The K group hoped to use duplex screening to identify and treat DVTs to prevent progression to symptomatic or fatal pulmonary embolism. They studied nearly 2,000 trauma patients over the course of two years. They identified a lot of DVTs, and they had significantly fewer pulmonary embolisms compared to the non-screening group. However, by 90 days, there was no difference in the PE rate, DVT rate, or overall mortality. Extracorporeal membrane oxygenation. In this first work, the LaRusso group attempts to concisely and comprehensively analyze all aspects of postcardiotomy extracorporeal life support with an emphasis on indications, technique, management, and complication avoidance. They also touch on new approaches, ethics, education, and training. The Giuliani group published their experience with venoarterial ECMO as a support strategy for patients with massive pulmonary embolism. In their retrospective review, they identified 17 patients with advanced shock or cardiac arrest due to massive pulmonary embolism who received VA ECMO. 13 of 17 patients survived. 12 of 13 patients were discharged without evidence of neurologic insult. Only three patients required a percutaneous thrombectomy and catheter-directed thrombolysis to address persistent right heart dysfunction. The authors concluded that VA ECMO was an effective salvage strategy for patients with massive pulmonary embolism. Transfusion and fluid resuscitation. In the first of two studies published by the Basics Randomized Clinical Trial Group, authors determined the effect of a balanced solution versus saline solution on 90-day survival in critically ill patients. Among the 11,000 patients who were randomized, approximately half of them were surgical patients. 60% were hypotensive or required vasopressors, and 44% were on mechanical ventilation. By 90 days, death rates were the same. 26.4% for balanced recipients and 27.2% for saline recipients. The authors concluded that the use of a balanced solution compared with saline did not significantly reduce 90-day mortality, and their data did not support the use of a balanced solution. The Bodley Group presented their data on patient harm associated with serial phlebotomy and blood waste in the intensive care unit. In their retrospective review, they found that the average blood volume lost during an arterial draw was 3.9 mLs and a central venous draw 5.5 mLs. The authors concluded that a substantial portion of daily ICU phlebotomy was a waste. The average ICU phlebotomy volume was independently associated with ICU-acquired anemia and transfusion. These authors called for phlebotomy stewardship programs. In this interesting work, the Deschain Group compared whole blood transfusion to balanced component therapy transfusion for patients who arrived to the hospital in hemorrhage. They studied 253 patients in their single institution prospective trial. They found that the incidence of ARDS, duration of mechanical ventilation, massive transfusion protocol activation, and transfusion volumes were significantly reduced in the whole blood group. Unfortunately, there was no difference in survival rates when comparing the balanced group to the whole blood group. On behalf of the Education Committee of the Surgery Section, I'd like to thank each of you for tuning in today. I'd also like to thank the Society of Critical Care Medicine for the opportunity to present our work. Hello and welcome. My name is Niels Martin. I will be providing the emergency general surgery portion of this year's surgery year in review. As a means of disclosure, I have selected the following 27 articles based twofold. One, on my cache of prospectively collected landmark articles. And two, based on a retrospective review of the table of contents from several top surgical journals all from the past year. I then grouped the articles based on their EGS topic area. So the first EGS topic area that we will discuss is the management of appendicitis. There were two good quality articles that I found. The first is a single center study performed in Dublin, Ireland that randomized adult patients with uncomplicated appendicitis into receiving antibiotics only versus a surgical appendectomy. The authors enrolled 186 patients. And in the antibiotic only group, there was a 25.3% failure rate within the first year. Additionally, there was no difference in length of stay. And the surgical group did have higher expenses. But the authors found that the patient expenses. But the quality of life assessment scores was significantly higher in the surgical group than in the antibiotics alone group at both three months and 12 months postoperatively. The authors therefore concluded that surgical intervention should be the mainstay of treatment for patients with acute uncomplicated appendicitis. Now in this second study, which was a one year cohort study using the Healthcare Cost and Utilization Projects Nationwide Readmissions Database that is maintained by the Agency for Healthcare Research and Quality, the authors included all patients with acute uncomplicated appendicitis who were age 65 or greater. Additionally, they excluded patients with a modified frailty index below 0.4, thus ensuring they had both an elderly and comorbid population. Ultimately, they included over 5,000 patients, of which 23.7% were treated non-operatively. However, as you can see, 17.7% had a failure and had recurrent symptoms. Those patients requiring that delayed appendectomy underwent propensity matching with the initial operative cohort. Patients undergoing delayed appendectomy had longer hospital length of stays, incurred higher health care costs, and experienced more complications and mortality. The authors therefore concluded that appendectomy offers an evident advantage of complete and long term resolution of the appendicitis and related symptoms in this vulnerable population. Now the next section is biliary and pancreatic papers. There were several. In the first study, which was a single center randomized controlled trial called the Gallstone PANK trial, patients had either a cholecystectomy during 24 hours of admission, or they waited for resolution of their pancreatitis symptoms. Ultimately, the authors found no increase in complications, but a shorter hospital length of stay and a non-statistically significant cost savings of $1,200 for those patients who underwent early cholecystectomy. Therefore, the moral of this is do not delay for a mild pancreatitis. In the next paper, 350 patients were prospectively identified in the East multi-center trial who had both a cholecystectomy and an ERCP in the same admission. The authors found that immediate ERCP was associated with a shorter post-op and hospital length of stay. Additionally, common bile duct explorations and the need to convert to an open cholecystectomy occurred more frequently when surgery was delayed. So again, the moral of this paper is do not delay surgery and ensure that your ERCP is done in a timely manner. Pushing further into this topic, this study compared definitive single-stage laparoscopic cholecystectomy with an intraoperative ERCP versus those who had progressively longer periods between the two procedures. This multi-institutional study had over 350 patients and showed that performing a cholecystectomy and ERCP together shortened the post-op length of stay and the hospital length of stay. Further, conversion to an open-app cholecystectomy or the need for common bile duct exploration occurred more commonly when surgery was delayed. Next up, patients who present for an interval cholecystectomy after a percutaneous cholecystostomy tube. When is the optimal time for surgery? These authors used a nationwide readmission database and found over 2,700 patients who had a percutaneous cholecystostomy tube followed by an interval cholecystectomy during a separate admission. They found an increase in operative complications if surgery was performed within one month of placement of that percutaneous cholecystostomy. However, they also found an increase in percutaneous cholecystostomy-related complications and need for interventions if surgery was performed beyond eight weeks. Therefore, these authors suggested that the most favorable time for an interval cholecystectomy after a percutaneous cholecystostomy tube placement was between four and six weeks after the tube was placed. All right. Should you operate on perforated cholecystitis or should you drain it and do an interval cholecystectomy? These authors reviewed over 650 NISQUIP patients who presented with perforated cholecystitis over a 12-year period. The authors found that patients who underwent cholecystectomy during the index admission had a significantly higher 30-day morbidity and mortality rate as well as longer post-operative hospitalizations. Their findings, therefore, suggested to do an interval cholecystectomy if your initial report is perforated cholecystitis from your ultrasonographer or radiologic imaging reader. All right. Once the gallbladder is out, how much antibiotics is prudent? For uncomplicated cholecystitis, I think we have the answer. It's one and done. But how about if there are retained common bile duct stones? The authors here performed a post hoc analysis of a prospective observational multicenter e-study of patients undergoing same admission cholecystectomy for choledocolithiasis and gallstone pancreatitis. They found that the rates of post-operative infectious complications were similar among patients treated with prolonged versus just prophylactic antibiotics, the definition of which was at 24 hours. They further found that prolonged antibiotics, however, were associated with a longer length of stay and a higher incidence of acute kidney injury. And finally, in this multicenter randomized controlled trial of patients with mild to moderate acute pancreatitis, they were randomized to receive either immediate or conventional oral feeding. They had over 131 patients enrolled. And their conventional group took 2.8 days to achieve the start of feeding, whereas, of course, in the experimental arm, it was zero days. The authors found a significantly shorter hospital length of stay in the immediate feeding group, suggesting that we should be feeding patients with mild to moderate pancreatitis at admission. All right. Moving on to the next section. Bleeding in acute care surgery. There's one relevant paper here from the last year. Many of our peers and other surgical specialties have been using TXA to decrease intraoperative blood loss for quite some time. In this meta-analysis, the authors found 57 articles inclusive of orthopedics, OBGYN, OMFS and ENT, cardiac and plastic surgery. Ultimately, the authors surmised that a single dose of IV TXA reduced the perioperative blood loss by an average of 153 cc's per case, equating to a 72% decreased odds of transfusion. So perhaps the bigger general surgery and acute care surgery community should also be considering TXA in some of our bigger, more complex cases. All right. How about COVID-19 and surgery? One paper here. And I'm hoping that this paper becomes much less relevant with time. Here, the authors evaluated how much time should elapse after an acute COVID-19 infection before proceeding with elective surgery. This was an international, multi-center, prospective cohort study organized by the National Institute of Health in the UK. Outcomes are stratified by two-week intervals, and over 137,000 patients were included. Ultimately, the findings concluded that the risks of postoperative morbidity and mortality were greatest within the first six weeks of infection, and that surgery should be delayed thereafter. And this was even the case in patients who had asymptomatic COVID-19 infections. All right. Next big category, small bowel obstruction management. In the first study, which was a single institution retrospective study, the authors stratified patients by time between time of admission and the institution of a gastrographic challenge. And they evaluated the duration of stay. They ultimately found that if a gastrographic challenge was performed within 12 hours of admission, based on the receiver-operator curves, they were able to predict a less than five-day length of stay for non-operative patients, and even a shorter length of stay preoperatively for patients who required an operation. Thus, they concluded that a gastrographic challenge within 12 hours of admission should probably be the standard we all look to achieve. Next, this study, the authors reviewed patients who presented to a single emergency department over a three-year period before and after initiation of a protocol to observe patients with a small bowel obstruction in an observation unit as opposed to admitting them to the hospital. A total of 125 patients were included, just about half in each group. Interestingly, I found the exclusion criteria very helpful in this study as they were indications for immediate surgery, as you can see in the top left. Ultimately, the post-intervention group had a 51% decrease in median length of stay, which equated to 36 hours shorter length of stay. And for those with a non-operative resolution, the readmission rate decreased also from 16% to 8%, showing that they weren't just discharging patients who would bounce back. Finally, in this section, this was a single-center study of 116 patients where they evaluated the ability of CT scan to predict the cause of a small bowel obstruction as either being a single band versus matted adhesions, with the premise that delineation of this could influence surgical pathway. The studies were independently reviewed by a radiologist and compared to the ultimate surgical outcome. Several radiological findings were included in the regression model, as you can see listed on the left, and they had a pretty good receiver-operator curve. So, our radiologists may actually be more helpful than we think in determining the early trajectory of surgical patients. All right, next section, looking at tracheostomies and airway management. In this first study, which was a retrospective study from a large academic institution, the authors reviewed nearly 350 airway rapid response team activations, looking at the outcomes and the technical needs within those events. The authors found that nearly half of these events involved tracheostomies, and that establishing recannulation of a tracheostomy tract was the most common procedure performed. There was a significant cohort that required transfer to an operating room, and 3% required creation of a new surgical airway. The authors ultimately concluded that there is a real need for surgical expertise on airway response teams. The next everlasting question of the perfect timing of when to place a tracheostomy. This study was a meta-analysis, looking at early, as defined by less than or equal to seven days from admission, versus late tracheostomy patients in those with pneumonia. Ultimately, the authors included 17 trials inclusive of over 300,000 patients. The authors ultimately found that a significant odds ratio towards early tracheostomy in terms of ventilator-associated pneumonia, duration of mechanical ventilation, ventilator-free days, and mortality. So early tracheostomy is still good. All right, looking at predictors of outcome and measures of frailty. Several papers here. The first one was a retrospective study done within a large regional health system over 12 years, looking at nursing home-specific patients who were admitted to an acute care hospital with one of eight various emergency general surgery diagnoses. There were nearly 8,000 patients included, and a matched control cohort was created from the same local nursing home population who did not require surgery. As you can see from the Kaplan-Meier plots for operative cases at the top and non-operative cases at the bottom, EGS care of nursing home patients carries significant risk of mortality, but it was not futile. The authors therefore concluded that nursing home status alone should not preclude aggressive surgical management in this population. All right, next paper. These authors created an emergency surgery scoring system to predict 30-day mortality in EGS patients. This was done using 10 years of NISQIP data. Of over six million patients in the database, 173,000 had emergency procedures. The mean age of this group was 60, and the mortality rate was 9.7, which is not insignificant. The weighted scoring algorithm involved the variables seen here in table one on your left. The C-statistic performed relatively well, ranging from 0.81 to 0.97, depending on the type of emergency procedure. So perhaps we may one day see this calculator incorporated into our EMRs. This next study similarly used and generated a risk analysis using both the NISQIP and VAQIP data. These investigators not only tested the risk analysis index, but also incorporated an operative stress score. These two assessments integrated well together, giving a broader stratification of outcome, not just on frailty indices, but also on how to incorporate the stress of surgery and surgical recovery in their assessment. Looking beyond mortality now, this study looked at predictors of inpatient readmission following emergency surgery. This was a post hoc analysis of a multi-center prospect of observational trial. The authors obviously excluded all deaths and hospice discharges from their index admission cohort. Ultimately, they included over 1,300 patients. And there was a 17.4% readmission rate, the most common original admission diagnoses included hollow viscous perforation and small bowel obstruction. The predictors of readmission included disseminated cancer, a greater than 10% weight loss in the prior six months, dyspnea at baseline, wound complications, and discharge to a nursing home. Now building off those prior three studies, these authors use the same single institution data and used a frailty assessment and operative severity score to ultimately predict early postoperative loss of independence, which similarly can be used in preoperative outcome prediction and management of expectations. Age and frailty assessments did directly correlate with a loss of independence and mortality. Loss of independence should be an additional factor in preoperative discussions. All right, for the purposes of time, I will give you this bibliography. However, there are a couple other important sections just to go through briefly. This one is on guidelines, pathways, and processes. There were several good papers here in emergency general surgery, including fast track pathways in emergency general surgery, reducing operating room costs, preoperative patient activation or preparation to improve outcomes, and guidelines to mitigate C. diff infections. There was one good paper on surgical disparities. This elucidated contemporary racial disparities in surgical care. I believe this is a topic that warrants ongoing discussion as we improve our processes and was worthy of mention in this year in review. And finally, to round out this discussion, of course, ending on a supportive note for our community of intensivists, this paper looked at a process to support team members after an intraoperative death, which I think is an important aspect of supportive care. So I want to thank you for your time and attention. I hope you found this review helpful. More so, I hope you will reference this bibliography and further your own individual practices. Thank you again.

trauma

critical care surgery

COVID-19 infection

violence-related injuries

ISAVE group

packed red blood cells

traumatic brain injury

emergency general surgery

bleeding management