Good morning, I'm Susan Evans, the Chair of the Surgical Section and I'd like to welcome you to the Year in Review for Surgery. In the past few years we have divided the Year in Review into three different segments and so Sal Ahmad who is the Chair-elect will do the trauma segment, Doug Naylor who is our Year in Review extraordinaire will do the surgical critical care section and I will end with the Emergency General Surgery section. Please enjoy. Good morning, I'm Sal Ahmad, Acute Care Surgeon from the University of Missouri, Chair-elect of the Surgical Section, honored to give you today's talk, Surgery Year in Review with Trauma. I have no further disclosures. Lots to talk about, lots of literature, clearly anybody can do a PubMed search. My job was to focus on papers that are relevant to us. The bibliography that we'll send shortly on another session should have 85 references. We're going to talk about these topics and respective articles as a summary. So we'll start with hemorrhage, coagulopathy, resuscitation, talk about these topics. TXA, always popular, always controversial, this paper demonstrated that pre-hospital TXA did not really demonstrate any mortality difference or increase in venous thromboembolism which is important, however a subgroup analysis did show that there was a mortality reduction if you gave repeat dosing and you gave the first dose within one hour and you reserved TXA for the worst shock index. This is a meta-analysis where they combined two studies, CRAS-2 and the woman trial. The woman trial used TXA in postpartum hemorrhage with 28,000 patients. Here they demonstrated that the benefit to mortality was not just reserved for the worst case scenario but anybody considered low risk of death within three hours of injury may also benefit from TXA. Here's another study where looking at TBI patients in the pre-hospital setting if you gave TXA within two hours of injury they were randomizing you to one gram, two gram or placebo. However at six months looking at the Glasgow outcome scale demonstrated no difference. Shifting gears to coagulopathy and platelet inhibition, looking at TBI patients who come to your institution with anti-platelet medications on board giving platelet transfusion here did not really demonstrate any benefit on all cause mortality, on hemorrhage progression nor on need for surgical intervention. What about vitamin K antagonists versus DOACs, so direct oral anticoagulants? This study looked at those patients both elderly and non-elderly trial patients and in a smaller group of elderly patients if you're older than 65 this demonstrated an improved mortality benefit with DOACs as opposed to vitamin K antagonists and fewer doses of FFP required. These differences were not seen in younger patients. Moving to resuscitation, again looking at 10A inhibitors and reversal agents PCC, prothrombic complex concentrate versus N-dexonate alpha. Here demonstrated that the two are fairly similar with some subjective improvement in hemostasis using N-dexonate alpha, however it was $7,500 per patient more expensive on average and increased risk of thrombotic complications which begs the question of whether N-dexonate alpha truly is clinically significant or indicated as opposed to PCC. Looking at plasma transfusion pre-hospital, this is a post hoc analysis of the PAMP or in combat trials and if you read the study carefully you demonstrate that clearly transport greater than 20 minutes increases your risk of mortality, however you can negate that mortality if you give FFP early. So short transfer times, not so much of a difference, however if you're going to be 20 minutes or out clearly in the austere or rural environment, FFP will certainly help you from a mortality standpoint. Shifting gears to pediatrics, here we're looking at crystalloid and blood product use in trauma, pediatric trauma, and the concern here is just adding on to what we really already know in a lot of adult patients which is that more crystalloid will only get more blood transfusions and in fact each bolus just increases the risk or likelihood of a transfusion. Unfortunately that increased transfusion then carries a mortality risk where you're looking at 22.8 versus .7%. Also in the pediatric literature, many of you are familiar with the ABC score which is the adult score used to predict the necessity of a massive transfusion protocol. Pediatric literature has adopted the ABCS score substituting the SIPA or the age adjusted shock index. Here this paper uses the ABCS score and adds lactate and base deficit calling it ABCD score. What they identified was that you were getting significant increases in sensitivity and specificity in predicting the need of mass transfusion protocol for your pediatric trauma patients using this ABCD score. Going to RBOA as we know, resuscitative endovascular balloon occlusion of the aorta, it's been around for many years now and so we're looking at different etiologies or indications and as well as different technologies. This first paper looked at an animal model of a prototype bilobe catheter where you have two balloons, two syringes, comparing that to the original ER RBOA as well as another prototype or P or partial RBOA where a semi-compliant balloon was used and here they demonstrated that you actually had better control of that flow rate where even the bilobe with two balloons you couldn't get complete occlusion or partial occlusion but you could do a little bit better with distal flow rate control in terms of deviation from your target with this new partial RBOA. What about comparing RBOA to traditional pre-peritoneal pelvic packing? The study looks at RBOA versus a combination of RBOA and peritoneal packing or just pre-peritoneal packing alone and demonstrating that with zone 3 implementation there's a higher survival with RBOA alone. They also demonstrated not only mortality but time to laparotomy, time to angioanalyzation and blood transfusion improvements compared to control. So RBOA here seemed to take the prize here. What about pediatric RBOA? So very limited use, so very few cases out there that have used it, certainly a lot more cases in Japan with a much bigger case studies, but here these papers were looking at pediatric and adolescent RBOA. This first one is interesting where they looked at severely injured pediatric patients and wanted to see whether they were amenable to RBOA, whether they would see any benefit and they thought and they basically hypothesized that 20% of injured pediatric patients may benefit looking at those criteria on the graph where ISS and elevated shock index and age, TBI had the reverse effect where a combination of TBI and hemorrhage requiring RBOA actually increased mortality. Further, this is a case series of 11 patients from AAST, again showing severe mortality, very limited survival. This is another case series of patients, seven patients, here penetrating and blunt, there were no blunt survivors, the only two survivors were penetrating. Again limited use, limited experience, but there is certainly room for more knowledge improvement in pediatric RBOA. Now that RBOA has been used for a while, the AAST Early Study Group looked at the last five years of its utilization and found that year on year improvements in mortality. Now the average across six centers for 30-day mortality is 52%. Utilization increased from 39% to 47%. The complication rate unchanged, combination of mixed and penetrating and blunt, more zone three, pelvic as we talked about before. What about predicting who could not benefit? The criteria of GCS less than 9, oxytocin over 90%, blood pressure less than 90 was used in the criteria which seemed to have pretty good discriminatory effect in predicting survival. They found that if they were to retrospectively put RBOA patients in the criteria positive or negative group, the positive criteria group had a 49% versus a 23% survival. So again, this is a complete statistical retrospective review, but it's an interesting criteria to use possibly going forward. Finally, a study of residents and staff who had trained in RBOA but had not done them in a while. Clearly practice makes perfect. If you haven't used it in a while, your skills will wane. Now moving on to thracoabdominal trauma, we're going to look at rib plating and blunt aortic injury. This is a prospective multicenters trial where non-FLAO rib fractures were given in rib plating and found to have significant improvements in pain score and fewer pleural space complications. Here this is a first T-VAR study using a very specific graph that seemed to have excellent performance over five years with no catheter device related deaths, no endleaks. However, if you move on to another meta-analysis using device blind T-VAR versus open repair, you had significant reductions in mortality, but at one year you had more interventions primarily for endleaks. Finally, considering a combination of blunt aortic injury requiring a T-VAR and TBI, doing the T-VAR immediately on admission, probably not recommended, but if you wait about nine to ten hours, that delay, late group, actually decreased mortality. So perhaps blood pressure control and delaying your T-VAR is the way to go. Retained hemothorax, so you have a hemothorax, the increased age, chest AIS, and higher pleural volume predicts 28% of a retained hemothorax despite your chest tube drainage, in fact about 100 cc's per, a 15% increase per 100 cc's on the CT is the odds ratio. Perhaps indication for earlier VATs. The chart you see there on the right now is talking about pelvic packing versus angioembolization. Again, there's no EBOA here. Here pre-pregnant pelvic packing or PPP demonstrates reduced time to bleeding control, reduced hemorrhage and overall mortality, fewer blood transfusions in the PPP angioembolization group. Again, there's the angioembolization and the PPP and then one after another group is what was studied in this paper. So let's shift to TBI, again these are just representative papers, much more in the references, but here a prospective decompressive craniotomy study was used to evaluate overall outcomes and quality of life and found that there was a trend toward better outcome with mild TBI, which of course begs the question is if you define mild TBI, why are we doing decompressive craniotomy? So again, a little bit confusing, but age might also play a factor, the older you are perhaps the better your overall quality of life would have been if you had a decompressive craniotomy. Again, many institutions are not doing this, unless it's a last resort. Similar to earlier studies about anticoagulants and platelets here, there is a study of desmopressin and platelet transfusion for patients with TBI that come in on antiplatelet medications. The issue here is that there was no benefit to either hemostasis expansion or outcome, but the groups were not entirely equal. The intervention group had a higher incidence of interparticular hemorrhage and expansion, which may explain some loss of effect. Finally from a TBI standpoint, looking at transport time, on a military paper, people who are severely injured in military environment and then have to fly to a definitive hospital, delaying that flight for at least a day to two days actually improves your outcome. By overall survival, not so much, but your GCS at discharge, whether you're discharged from the hospital or ventilator, all those things, you're more likely to be successful if you delay transport, suggesting that the hypoxic environment of an aircraft may not be the best place for the acutely injured brain. That's the most sensitive, perhaps waiting two to three days is best. As we're moving towards burn, what about the combination of burn and abdominal injuries? This is a retrospective NTTB study, demonstrated that if you have a combination of abdominal injuries that require laparotomy, you're far more likely to succumb, 33% versus 5.8% mortality. Here looking at laparotomy really being the key driver of mortality, this demonstrates that the burn itself doesn't necessarily contribute that much to mortality. We're not talking about isolated burn. If you have an abdominal operation, that's going to be the key. So with or without burn, it's the abdominal operation that's going to drive your mortality. This is a novel approach that's been entertaining the burn world for the last few years, which is enzymatic versus surgical debridement of your initial wound using GOMLIN, which is enriched proteolytic enzymes from pineapples. What they found is that if you do that, you actually get faster turnaround, so time between your burn and debridement only one day versus eight and a half days. When you're finally excising, you have fewer, at least loss of blood from a change in hematocrit or hemoglobin. There may or may not be significant differences in transfusions. Autograph performed a day earlier and the biggest difference was the subjective impression of patients of their scar, the cosmetic appearance. Looking at the same patient, two hands, patients left and right. On the screen on the left is the traditional standard of care approach, on the screen right is the BROMELIN approach, and you might be able to entertain that the hand on the right might have a little bit better improvement in terms of scar forms. Inhalation injury. Everyone's getting intubated for suspected inhalation injury. Most people would argue the complications might be worse if you're intubating somebody without a true inhalation injury. So they did a retrospective review and they applied their liberal versus restrictive guidelines as you see there on who should or should not get intubated, and they found that it was just as sensitive in terms of predicting who's going to need prolonged intubation or not, but far more specific, meaning if you didn't need it, you were not going to get prolonged intubation and you were not going to succumb to the complications. Likewise in prediction of inhalation injury, when you're not quite sure and you're intubating prophylactically, if you're restrictive, you'll get just as much sensitivity but far better specificity. So again, this criteria might limit who gets intubated for suspected inhalation injury. What about nebulized heparin? Here we use it for severe inhalation injury, but this study used the prospective 5 versus 10,000 units and found that the lower dose is much better, 5,000, which reduces your ventilator days, length of stay, and pneumonia. This study used a homegrown machine learning model to predict burn sepsis and had excellent results using the K and N nearest neighbor model using those criteria. Infection. Fair amount of research on negative pressure wound therapy, essentially equivocal. There was some Cochrane review data suggesting decrease in surgical site infections in closed wounds, but no significant recommendations for ortho wounds. Concerns that there's increased utilization, but the evidence is not quite there. The WISP trial showed no difference in SSI or any other outcome. Using it in austere environments doesn't help, just increases cost, while we focus more on lifestyle and nutrition instead of the wound care itself. The facial fractures and antibiotics, again there are three studies there that demonstrate again, fewer indications of benefits for prolonged antibiotics for facial fractures, no more than 24 hours. Nutrition, vitamin D supplementation helps in TBI, doesn't really help with strength training or preserving function as you get older, has some interesting side effects where it affects the blood pressure positively in males, but negatively in females, and actually increases risk for infection. Probiotics in TBI may show some benefit. Firearms, Baltimore 365 was an intervention where they called for a ceasefire on any given weekend, which was effective. The other study is a study of suicide in handguns in California, found significant increase, especially among female gun owners, in terms of immediate risk for suicide as well as 52% within a year. X-rays, so we're looking at FAST versus E-FAST, excuse me, E-FAST versus chest X-ray, just sensitive, equally specific. CAT scans for abdominal stab wounds, the clinical exam is just as good, but your CAT scan is going to predict a higher negative laparotomy rate. Total body CT, there's a REACT-2 study which has been modified with more refined criteria which will have the same sensitivity specificity but reduce the number of scans so that you have fewer radiation. And finally, if you get a blush on your head CT, extravasation, you're more likely to predict expansion of that hemorrhage and death. Inflammation, shallow needle for IJ placement, this is a 3D printed guide shown to have almost perfect discrimination to prevent back wall injuries. Team-based simulation training, excellent for leaders, may not show a difference in patient outcomes but a good leadership training tool. And finally, vascular heart signs, CT angiogram evolving is being far more helpful rather than just using heart signs for vascular injuries to operate or not. Finally, this is an interesting study where they simulated someone talking on a cell phone and walking down the street and they looked at several things, talking, texting, browsing on your phone or listening to music, nothing really made a difference other than texting or browsing when it came to looking left and right like when you're crossing the street. So perhaps this would be a good time to create an automatic GPS based warning on your phone that you're about to cross the street to remind you because clearly that's kind of where pedestrians get hit. Thank you very much for your time. I look forward to continuing the conversation. Don't hesitate to call me or email me and contact me for any further information or bibliography and I appreciate your time. I hope you have an excellent rest of your day. Thank you. Good morning. My name is Dr. Douglas Naylor and I'm a member of the surgical section of the Society of Critical Care Medicine. It is my distinct pleasure to have been asked to participate in this, the 21st rendition of the Year in Review in Surgery for the Society of Critical Care Medicine Surgical Section. This presentation is part of the 50th year anniversary of the Society of Critical Care Medicine which was founded in 1971. I am pleased to be part of an august group of presenters including Dr. Salman Ahmed and Susan Evans. A bit of housekeeping. As always in this presentation, a bibliography will be available at the end of the presentation by contacting myself, that's Douglas Naylor at UH Hospitals or my personal email which is listed. The important piece in this bibliography of all bibliographies which are compiled is that the ascension number or the PMID number will be noted in curly brackets. You merely enter this into PubMed and it will take you directly to the reference in the bibliography. I have divided my topic into seven sections that include statistics, primary injury prevention, pre-hospital care, initial care, secondary injury prevention, post-hospital care, and finally future directions. Let's begin with statistics. Statistics generally can be divided into multiple areas and multiple divisions. Country of origin, specific topic, or a narrow focus. This year we will begin with concentrating on statistical reports from large databases which were generated within the United States. These particular are snapshots of a specific disease or a specific disease burden and they have included a review by the AHRQ for the burden of orthopedic injuries for the years 2013 to 2014. Not surprisingly, the greatest majority or the majority of these injuries were incurred in or after falls. NSQIP data also has been looked at. This is a database as you're all well aware provided by the American College of Surgeons which has specifically focused on emergency general surgery during this period. Initial two references include validation of the emergency general surgery score. This will allow us to compare our performance to those of our peers across the country. Further, a further deep dive into this database provided an analysis of nutritional status in the elderly also obtained for that database specifically with the attention drawn to emergency general surgery. This was from the years 2007 to 2016. Finally, an even smaller subset of data extracted from this rather large database included those patients who during emergency general surgery underwent an unfortunate event such as an intraoperative cardiac arrest. American College of Surgeons has several other databases, most notably the trauma QI database. And this is noted for a year review that included non-operative management after abdominal gunshot wounds. It appears that over time with more comfort for imaging as well as non-invasive techniques non-operative management has increased in its presentation. Finally, the Eastern Association for the Surgery of Trauma looked also at emergency general surgery and provided a cost analysis, a benefit to hospitals which may or may not be considering an emergency general surgery service. Statistics continue in the United States, the National Trauma Database separate from the American College of Surgeons, this is a separate distinct database, looked at modifications to patients who presented with ARDS based on their racial origin and or insurance coverage. This was specifically those patients who presented with ARDS after a traumatic event. Firearm injuries is always a very important and very popular topic and source of review from the National Trauma Database. There are multiple reviews this year, not in difference to years past. Many are generated by groups that have dedicated an entire academic career to investigating this particular aspect. Finally, additional from the National Trauma Database, they looked at workload for emergency general surgery consult services. This was from the years 2014 at a single tertiary center. The statistics are quite sobering. There are 2.6 consults per each procedure that is generated, therefore, many are called and few are chosen. In the United Kingdom, to prove that they were not the sole ownership of interpersonal violence, there is a nice review on violence and specifically knife wounds. Not surprisingly, there are similarities between interpersonal violence, whether it be with a blunt object, a sharp object, or a projectile in terms of the association with intoxicants and changes in socioeconomic class as well as an overriding penetration of psychiatric illnesses. Canada looked at emergency general surgery, and so it appeared that for at least this year in the review, emergency general surgery took the forefront. Canada provided us with follow-up data from a large national database. They also focused on neurocognitive disorders following delirium in patients who had undergone emergency general surgical procedures. Sweden gave us a nice review over sepsis mortality over the years of 2008 to 2016, and unfortunately, during these years, there was no significant change in mortality despite the addition of new and somewhat hopeful modalities. Poland gave us a nice review on the history of their pancreatic transplant program from 1998 to 2015. Continuing with our evaluation of large statistical data sets, and it should be noted that these provide broad, sweeping generalizations towards large groups of people, however, care should be taken in identification or application to a specific individual. For disease-specific data sets, we included that with a large group that were focused on appendicitis. This included ones from a large Eastern Association for the Surgery of Trauma study group on appendicitis, which included a post hoc analysis, which, interestingly enough, revealed that appendicitis, which we all know has a bimodal distribution, when it occurs in middle years, that is greater than 40 years of age, or there is an enlarged appendix, there is an increased rate of malignancy, so care should be taken in specifically looking at the pathology of these resected specimens. We also looked at, through their appendicitis database, to evaluate the scope of antibiotic coverage, and not surprisingly, this scope of antibiotic coverage is very wide and broad. There are those who use short-term focused, narrowed coverage, as well as those who choose to use wide coverage for extended periods of time. Venous thromboembolism and spine surgery was also looked at. It appears that, although these are particularly devastating injuries, increased precaution, increased incidence of these injuries, as demonstrated by improved imaging, unfortunately leads to decreased mobility, which will drive up the appearance of venous thromboembolism. the take-home message from this particular review is once the injury is stabilized, please increase your mobilization. Basoactive infusions and CABG data, that was from a large, an additional large United States database, the Premier Organization. Continuous spike-specific data sets, we have disease-specific data sets, which include cochlear reviews. They had a specific review on basoactive substances, specifically and separate from that of cardio-coronary artery bypass grafting. They also looked at the use of perioperative iron substances, either oral or intravenous, in various formats, and or the addition of epigen to its impact on the reduction of morbidities post-operatively. That is, can preoperative anemic status be adjusted? Military databases were very, very prolific this year, and we had several nice reviews, including combat casualties from the onset of World War II to Operation Enduring Freedom. The French also revealed or contributed to this large body of literature, including a particular focus on high mortality injuries in the years 2004 and 2014. Finally, when there were no armed conflicts, they looked at the effect of peacetime on military medicine. This is the decay of tasks-oriented skills and knowledge. There were some interesting reviews on the use of fresh, whole blood using walking blood banks, that is to say, your partner or your transfusion buddy, the effect of that. Surgical response teams, some very dramatic salvage events that occurred while in flight or during evacuation, and then finally, what do we do in case of the civilian who is accidentally damaged or collaterally injured during a conflict? Finally, statistics generate large, sweeping generalizations from which guidelines can be drawn. A very important guideline this year was the ASPIRE trial, which highlighted on the use, the appropriate use of placebo controls in research. American Association for the Surgery of Trauma and the World's Society for Emergency Surgery in conjunction offered several guidelines, including diverticulitis, vascular injuries, abdominal and peripheral, and use of ultrasound in perioperative obtaining of vascular access. Eastern Association for Surgery of Trauma gave us guidelines on the care and management of blood cerebral vascular injury, as well as the use of evaluation of coagulation status using TAG and ROTEP guidelines for that. This was a very good year for guidelines, and in addition to collaborative efforts between large societies, the World's Society of Emergency Surgery provided several independently generated guidelines, including that of appendicitis in conjunction with their previous guideline with the AAST, one on pancreatitis, interabdominal infections in austere environments. This is particularly important with respect to the austerity that is produced by our overwhelming response to our COVID infection. As a separate side note, I will not address any statistics that have been related to the COVID environment. These are covered in other sessions. The World's Society also looked at care and management of bleeding perforated ulcers, I'm sorry, peptic ulcers, and liver trauma. The European Society of Anesthesia and European Society of Intensive Care Medicine jointly issued a statement and guideline on preoperative noninvasive ventilation management in the postoperative hypoxic patient. They also addressed the concomitant use of opioid agonist antagonists. This is in line with our unfortunate increasing appearance of opioid addicted individuals. Trauma-induced coagulopathy was looked at by a separate group of patients not affiliated with any particular organization. And then finally, our very own society, Society of Critical Care Medicine, published its long-awaited part one of the management of liver failure. We'll now move on to primary injury prevention. And primary injury prevention will focus on those things which the patient brings to the hospital prior to their injury. Most commonly in our aging population is atrial fibrillation and as always, there are questions of how does this occur, what is the cause of the aging, what can we do to prevent its reoccurrence if it has been controlled, as well as the use of anticoagulations and or agents and or aspirin. Before we begin and talk about what we can do to prevent pre-injury or prevent injuries from occurring, it is nice to consider this razor that was most notably attributed to Hanlon, who is a computer scientist. In the past, it's also been attributed to Napoleon Bonaparte. And it reads, never attribute to malice that which is adequately explained by either stupidity or in some versions of this, incompetence. That being said, one area of incompetence is that of alcohol. This is not the study of alcohol addiction or rehabilitation, however, our own personal use of alcohol. Motor vehicle crashes, fatality data from 2014 to 2018 was reviewed and alcohol is, as always has been over the past 21 years of this review, highly front and center in causative agents for motor vehicle crashes, as well as injuries which can be attributed to lack of judgment. This particular review asked for a call for lower limits. I will present to this august audience that they should carefully consider before ascribing to overall lower limits, when was the last time that a mandate or an edict in the form of a law reduced the presentation or the appearance of a dangerous or somewhat sketchy procedure? Unfortunately, alcohol has been looked at in a later review, no impact on geriatric trauma, perhaps this underscores the wisdom that is incurred by age. Occupational injuries, specifically burns in automotive mechanics. In the past, many automotive mechanics were burned with flash burns from the ignition of vapors from atmospherically aspirated fuel systems, specifically carburetors. Those have been largely replaced by fuel injectors in many automobiles, however, the presence of burns is somewhat decreased but is still present. This is with contact against hot surfaces and or hot surfaces generated during repair. Obesity, at times this can be paradoxically protective but generally is a weighty comorbidity. These are two particular references, numbers 57 and numbers 58. The first describes a paradoxically protective effect in blunt injury versus another in injuries related and secondary effects. Recreational watercraft injuries, again, unfortunately tied to lack of judgment or lapses in judgment and use of intoxicants. Smoking and vaping, there is no, appears to be no safe way to induce or introduce volatile agents into the pulmonary system. And finally, electric scooter injuries. This was a brief review from Southern California that looked at and described the distribution of injuries that are employed or encountered when dealing with patient patients who use motor or electric scooters. Moving to pre-hospital care. Preoperative modifications of anemia, we talked about this in the past. Briefly, when we looked at guidelines and specifically a Cochran database, there were also other modifications of anemia. What we can use in different tricks and traps to avoid. Use of novel oral anticoagulant agents versus warfarin in a non-head injury patient review. Do they lead to increased injury and increased bleeding risk? And in this review, the answer was no, there was no difference. However, those patients who are deemed to have a risk of a coagulopathy or development of coagulopathy, is there a benefit in en route or to the hospital administration of prothrombin complex products? Now, finally, they looked at socioeconomic and coping factors with relation to the appearance of presentation of delirium post-injury. It appears that certain socioeconomical groups as well as those with low coping skills have a preponderance to the presentation of delirium. Delirium was front and center in many of the reviews this year. We included certain triggering agents, specifically the use of anticholinergics, which for purposes of our review will include many antidepressants, antimuscarinics and antihistamines. This has been reviewed in the past and in this particular venue, we have cautioned and condemned the use of Benadryl as a sedative agent in the elderly. Initial care, resuscitation. Fluids is always front and center. There is a nice review from the anesthesia journals about types of fluids as well as risks and benefits thereof. Goal-directed therapy, at one time a very hot topic, but I must ask, who has moved the goalposts? It appears that goal-directed therapy and applied to early or enhanced recovery from colorectal surgery and or urological surgery has failed to meet the test of proof and has not reduced morbidity. Use of albumin is always controversial and will remain as long as I believe we have human subjects. Choice of crystalloid is one solution better than other. The SOLAR review, which compared normal saline versus lactated ringers, revealed there was no difference in morbidity or mortality when either normal saline or lactated ringers was employed. Thus ends that long-ending debate. The Hercules trial or Heracles trial looked at the use of hypertonic solutions. Most importantly, in the past we've looked at the downside of over-resuscitation. These particular two reviews, or three reviews rather, looked at the insidious aspects of fluid creep, that is the silent, oftentimes ignored administration of fluid. This is from IV flushes, flushes from tube feedings when they are not associated with the provision of total water or total hydration needs. And sometimes even the administration of fluids through other therapies such as antibiotics or sedative effects. Dysnatremias or alterations in sodium evaluation or sodium levels was also looked at and not surprisingly, those patients who had wide springs or wide swings rather of sodium suffered the most. It is most a careful, prudent physician will carefully look at these and avoid over or under correction. Resuscitative aid devices began in many years ago and we have a nice review on intraureic balloon pumps as well as other newer, more trendy circulatory support devices, LVADs, as well as impella devices. Use of blood enters into initial care. It can be said that hematologic malignancies that includes leukemia, lymphoma and other red cell disgraces are particularly deadly when they are apparent. Anemias treatment, we've talked about this in the past with our copper review, mentioned number 25. Preoperative treatment, what can we do to correct it? Concomitant or concurrent therapy and finally post-op maneuvers that can be used. The maneuvers most specifically are careful consideration of the need for blood draw and careful attention to hemostasis. Coagulopathy was also addressed. Use of massive transfusion protocols has been addressed in these two reviews highlighted. Use of transamic acid. There is no increased risk of seizures which had been a very large concern and was raised by many groups. This was in a group of orthopedic patients who had preoperative and post-operative administration of TXA in an attempt which was successful to reduce overall operative blood loss volumes. And again, prothrombin complex concentrates and factory replacements are addressed. Again, moving further or deeper into the realm of initial care, looking at specific injuries, we have reviews on head injury. There have been nice reviews on transfer of head injured patients and some of which have highlighted the risks of over as well as under triage. Specifically looking at under triage, the question was addressed with isolated subarachnoid bleeds and patients with a Glasgow Coma Scale of greater than 13. It appears that many of these do not benefit from triage to a higher level of care. And then finally, what appears a superficial analysis to be a quite scary event, a paraphalsine subdural hematoma, in many instances does not require excessive or intensive therapy. There's been a longstanding debate between the benefits of craniotomy versus a decompressive craniectomy. And you'll notice in the earlier stages, Dr. Ahmed did mention a study that looked at decompressive craniectomy. This is just a contrasting review, which realized that there are no specific or advanced benefits one versus the other. Severe aneurysmal bleeds were addressed in reference 104. The timing of resumption of anticoagulation, either heparin or heparinoids, or NOACs was talked at and looked at in this particular review. Ventilation of closed head injury patients was paid particular careful attention in this review. Cognitive recovery post head injury was also addressed. Spinal cord injury. The French researchers gave us their recommendations for spinal cord injury, which parenthetically also included early mobilization after stabilization. Obstetrical injuries and conditions, fortunately, quite infrequent. However, when they occur, they can be quite dramatic. What to do for the crashing obstetrical patient, the patient who has been afflicted with eclampsia, and those who have ventilatory problems and or circulatory problems with necessitating the use of ECMO. Toxological emergencies were addressed. In specifically, injuries to the inferior vena cava. This is a very nice review. Talked about operative techniques, exposure, as well as some intervening, I'm sorry, interventional radiology techniques. Hepatic trauma and IR modalities was specifically addressed. This came from their radiographic literature, and this is sort of a primer on what the interventional radiologist needs to know. Extraperitoneal bladder injuries were addressed. Shotgun injuries. Also, there seems to be a pattern of shotgun injuries that is geographic location, more rural, as well as, in many times, associated with interpersonal violence. Rib stabilization was a very hot topic this year, as can be seen from the large number of reviews. There are some that promote its care, others which reveal there is no change, and others, unfortunately, which reveal a downward trend in survival or increased morbidity and mortality after their use. Tracheostomies has always been, over the past 21 years, a very hot topic during this presentation, and for your review, I present two additional studies. We do know that the combination of a PEG and tracheostomy in geriatric patients who have incurred trauma in the long term will decrease their survival. They will live to exit the hospital. Unfortunately, many expire in a nursing home or a long-term acute care location. Use of vasopressors and inotropes. Again, this was our premier data. And then, finally, use in the intensive care unit in aspects of trauma, as well as circulatory shock. An important piece that was raised that from the cardiac literature, it is permissible, highly permissible, to exercise patients, low-impact exercise, even if low-dose vasopressors are being employed. This appeared to be contrary to popular opinion or conventional wisdom. However, the next review looks at complications in the obtaining or measurement of blood pressure values, specifically troubleshooting arterial lines. I urge caution to my audience. Just because it appears digital, it is new, it has multiple decimal places, it may not be exact if the measurement device is not appropriately adjusted and calibrated. Secondary injury prevention. Looking at ventilator management. Ventilators, specifically during our COVID epidemic, were widely employed. There were questions of availability. Should we have others? Should we share them? We are not addressing those here. What we're looking at is basics, some of which have been rooted in dogma. The choice of endotracheal tube size. Do all males need a particular size? Do females need a correspondingly smaller size? Are there minimum sizes required for the passage of therapeutic devices, such as bronchoscopes, and or suction devices? It appears from this review that we can safely downsize our endotracheal tubes by at least a half French diameter in the majority of cases without any impact on care. Ventilation in the brain injured patient, we particularly mentioned this in the past. Specifically with brain injured patients and following interoperative patients, I caution you to avoid excessive volumes, excessive rates, rates greater than that which is normally physiologic present, that is to say the 20, the 24, the 25 rates that we sometimes see. Excessive pressures and the use of PEEP. PEEP is a protective device, however excessive levels and garden variety or root, rote memorization values for PEEP should be condemned. For glucose control, be wary of stress hyperglycemia. This is a very novel approach to the treatment of hyperglycemia by this particular group of investigators who looked at stress hyperglycemia, that is to say, levels of glucose which would be in excess of those predicted by the patients admitting hemoglobin A1C value. When this occurred, there is a high preponderance of mortality and morbidity. Care of the vascular injured patient, again some reviews from the Western, I'm sorry, the Sub-American Association of Surgery of Trauma as well as others. There is a very large variation in the applicability of fasciotomies. In the past, it was often said perform them if you think of them, however a large survey revealed that despite those admonishments, in many instances there is a wide variation of presentation as well as performance and procedural details. Secondary Injury Repression, this year promoted three large Ds which I related directly to disability. That included the appearance of dementia, either in the pre-injury or pre-intensive care unit of the patient, or the unmasking or uncovering of it post-operatively. Delirium, which can generally be ascribed to many of our modalities including the use of benzos and anticholinergic agents and excessive sedation. To that end, certain rescue medications or secret sauces were employed. Melatonin has proponents in 153 as well as detractors in reference 154. Atypical antipsychotics, the most common of which used as quick piddling. Presidex or valproic acid have also been reviewed. This is Seroquel for the trademark patient, or those who use only trademarks, has been reviewed. These appear to work in a random event or a random fashion and there is no to this date overall protective medication. Dysphagia is our third D. Its appearance in the post-ventilated patient or the post-tracheostomized patient has been reviewed. Then finally, post-hospital care. The appearance and impact of frailty on our patients as well as a increasing body of literature on palliative care. Should this be introduced at the time of admission knowing trajectories which we can project from our review of databases or large groups of patients and which is the appropriate time to investigate the patient's wishes when they are alert and cognizant or after their level of consciousness has been wanted. Finally, future directions. Again, along the vein of palliative care, end-of-life discussions and care rituals which are provided by the patient's families seem to reduce the incidence of post-traumatic stress disorders in the surviving family members. A very nice review by our own president of the society, Dr. Lewis Kaplan, looked at conflict resolution in the intensive care unit. And finally, education this year, at least to my analysis, focused largely on curriculum development including curriculum development in cardiothoracic surgery, critical care training, medical student, fourth year training aspects and objectives, open emergency surgery training as open emergency surgeries are sometimes and many times supplanted by less invasive techniques. A call for nutritional training across all disciplines including medical school, all medical school graduates as well as a core ultrasound curriculum training. Thank you for your attention as well as to SCCM providing this educational venue. A special thanks to the program committee and SCCM surgical section for their continued support and maintenance of their interest in this program which has been in presentation for over 21 years. Thank you very much. Thank you, Dr. Ahmad and Dr. Naylor. I'm gonna continue now with the emergency general surgery portion at probably the same wicked fast pace but probably a slightly modified approach. So for emergency general surgery, I've divided it into 10 different portions all of which have search terms which are more extensive than this and using the OVID Medline Database. We obviously can't talk about all 1,700 of these articles and so I've picked one from each section. We'll start with emergency general surgery and I've actually combined emergency general surgery in the acute care surgery portions. And so our first article is about an elder-friendly approach. And so this elder-friendly approach is a combination of patient co-location, interdisciplinary team-based care, elderly-friendly evidence-based practices, patient-oriented rehabilitation, and early discharge planning. This is a before and after cohort. After the implementation of this EASE approach, they evaluated major complications and death as their primary outcome and found that major complications and death decreased by 19% after beginning this approach and more patients went home and they went home earlier, so certainly something for us to consider in the geriatric population. Appendicitis. For appendicitis, I've actually included an experimental study to look at monopolar electrocautery. Monopolar electrocautery was done in rabbits, eight rabbits, and the thermal spread was identified in a few different ways, one by high-resolution infrared imaging and then others by myeloperoxidase staining. This evaluates the lipid peroxidation and histology. These were done after euthanasia at five days. What they found was that heat spread was dependent upon the length of time of the electrocautery and if tubular structures were incorporated in the field, important for us to consider, particularly because the extent of spread could exceed two centimeters, something more than I think most of us think while we are evaluating our electrocautery. For the biliary disease, we're looking at ERCP. Determining in a randomized multi-center study, 26 centers in the Netherlands, evaluating the utility of ERCP versus non-intervention in patients who have severe acute gallstone pancreatitis but not cholangitis. 118 patients were randomized to ERCP, 116 to non-intervention. The primary outcome was mortality or major complications and there were no differences in the primary outcome. There was a slight increase in cholangitis in the non-intervention group, although because the primary outcome was not different, this group interpreted that non-intervention is a reasonable way for us to be managing our patients with gallstone pancreatitis moving forward. I added another one for biliary disease and I think it's because it's helpful for us to focus on the soft sciences sometimes. This study was an evaluation of aromatherapy. Bergamot orange was placed on a cotton ball and on the patient's collar and in half of the group and then the other half of the group received grapeseed oil which is odorless. Bergamot orange in the past has demonstrated some decrease in anxiety and so the groups prior to their cholecystectomy received this intervention and then they were assessed for anxiety by the state trait anxiety inventory and for salivary amylase and cortisol by ELISA. What we can see in the before and after evaluation is that the patients who had the Bergamot orange did have a decrease in their anxiety and in their alpha amylase. They did not have a decrease in their cortisol and the anxiety and alpha amylase decreases were fairly small, but present all the same. Small bowel obstruction. We've had lots and lots of studies that have demonstrated the value of laparoscopy regarding postoperative pain and return to work and that sort of thing. This one was looking at general surgical procedures and their development of subsequent adhesive small bowel obstruction. In this retrospective review of this very large study, very large database out of California with 1.6 million patients and a follow up at six years. The patients had these procedures that you can see which are generally standard emergency general surgery procedures and the primary outcome was the development of adhesive small bowel obstruction. The odds ratio for small bowel obstruction in patients with laparotomy compared to laparoscopy was significant in all of the procedures, the highest at 1.9 for the colectomy patients. The period of greatest risk for obstruction was less than two years. Yet another reason why we should probably be incorporating laparoscopy in our emergency general surgery procedures. Pancreatitis. This is yet another experimental study. It's based on the premise that cholecystokinin can contribute to pancreatic enzyme production, cell proliferation, and anti-apoptosis, all things that help the pancreas regenerate. This group wanted to determine if cholecystokinin decreased inflammation and improved well-being as well. Pancreatitis was induced in 38 swine using an intraductal glycodeoxycholic acid during a laparotomy. 18 of them then received cholecystokinin at the end of the procedure and 20 of them did not. Then fitness and porcine well-being were assessed over the next seven days. The animals were then sacrificed for the histology at that week. The porcine well-being was increased in the cholecystokinin group and acinar necrosis and edema were both lower in the cholecystokinin group. Perhaps a therapy that will be helping us move forward. Diverticulitis. The direct trial was published in 2017 and then the follow-up for the extended quality of life was completed in 2019. This is actually a study that evaluates that follow-up. The original study was a comparison of surgery versus non-operative management of patients with persistent or recurrent left-sided diverticulitis. 109 patients were able to be recruited for this block randomization and then the five-year follow-up was the gastrointestinal quality of life index. The surgical group had significantly higher gastrointestinal quality of life index, but it didn't achieve pre-selected the difference of 10 points, which essentially then meant that it didn't achieve the criteria to say that surgery resulted in improved quality of life. This study evaluated, assessed essentially perhaps some of the reasons why. There were things such as an imbalance in the males in the intervention versus the control group, the fact that the patients were non-blinded and the providers were non-blinded and that there was a fair amount of crossover outside the study from patients who were randomized to non-operative management to operative management. Most of the studies in colitis focused on medications such as TNF-alpha inhibitors, but I wanted to pick something a little bit more applicable to our surgical intervention, particularly the surgical critical care population. I have a couple of studies here on vitamin D deficiency. This was simply a cross-sectional comparison of patients who have inflammatory bowel disease, 185 patients with inflammatory bowel disease and assessing their vitamin D levels. Nearly 90% of the patients were evaluated as having either vitamin D deficiency or vitamin D insufficiency. Most of those were not treated despite the fact that they were deficient. The patients who had TNF-alpha inhibitor therapy did have higher vitamin D levels. Does the higher vitamin D really matter? Well, it may matter if it is affecting our inflammatory response. Angiogenesis is associated with the etiology of ulcerative colitis. This group wanted to determine the impact of vitamin D supplementation on the pro-angiogenic factors, bisfatin and VEGF, in some ulcerative colitis patients. 90 patients were randomized to receive either vitamin D or normal saline. What they found was there was really no difference at 90 days in those pro-angiogenic factors despite the fact that the vitamin D levels did increase. A sub-segment of the population though that had vitamin D insufficiency did have an improvement in their pro-angiogenic factors. Perhaps we shouldn't be giving it to everyone, but the patients who have insufficiency may benefit. Interabdominal abscess. Many of the studies for interabdominal abscess were focused on liver abscess. I wanted to get something a little bit more general and see if there's information on percutaneous drainage. This retrospective review was done simply to determine predictors of outcome following CT-guided percutaneous drain. They had 383 patients in this fishing expedition, which was trying to determine if there's anything that could be predictive for us. They looked at size, drain exchange, number of drains, number of abscessograms, and the total catheter time. They found that purulence did not predict the number of episodes of recurrence of the abscess or fistula. They found that the number of abscessograms was associated with larger initial drain size and more fistulas. They also found that small bowel resection was associated with a higher number of drains than non-resection. Can this help us at all? Because interabdominal abscess and drain placement is certainly a very common issue for emergency general surgery and we have a fair amount of variability in the way we do it. They did propose an algorithm based on this information for how we should be managing these drains and perhaps this would be helpful for us to determine how we can create some consistency of our practices. Necrotizing fasciitis. Many of the studies about necrotizing soft tissue infections have focused on medication therapy and decreasing the stress and inflammatory responses. This one wanted to focus on healthcare related quality of life in patients with necrotizing soft tissue infections. 31 patients who had had necrotizing soft tissue infections were asked to complete the short form 36 to assess for quality of life and they did this at a mean of four years after their debridement. What we can see is that the scores for these patients for quality of life were lower than the national baseline for half of the elements of the quality of life score and not lower for the other half. At least there is some limitation, fairly extended limitation of quality of life after someone has had a debridement for necrotizing soft tissue infection. I couldn't go without giving you a couple of COVID articles. Both of these are on appendicitis. The first one is evaluating the management of appendicitis and just what is being done. A comparison of pre-COVID to post which is really post initiation so during the pandemic and the patient started with no differences in comorbidities. Appendectomies were done in 100% of the patients pre-COVID but post-COVID half of the patients were receiving appendectomies. CT and MRI imaging was the reverse. Just over half of them were receiving CTs prior to COVID but all of them were receiving CTs or MRIs during the COVID pandemic. There were no differences in complications nor mortality in these groups. This group interpreted that this is an okay way to manage patients in a pandemic. They didn't discuss whether or not it was an okay way outside of a pandemic. Also, this group determined if there were predictive risk factors for developing complicated appendicitis due to the COVID-19 pandemic. This pre and post group found that the onset of symptoms to presentation prior to the pandemic was 17 hours and after was 65 hours and many fewer of the patients really had an intent to seek treatment and they were trying to essentially avoid treatment. This was used as a determiner for the increased risk of developing complicated appendicitis. Then finally, I've chosen an interesting case that fits within general surgery broadly, but I thought it was helpful for us to understand because many of our patients, our geriatric patients, are having to make big decisions during when they are developing emergency general surgery conditions. This was actually determining their decision to undergo surgery. 31 patients greater than 65 years of age who had a five-day length of stay after these general surgical cases were evaluated by a semi-structured phone interview. This was coded by surgeons and palliative care MDs. What they found was that the decision for surgery for these patients was really a life-over-death sort of scenario. They weren't able to make much more sophisticated decisions than that and that they were limited in their opportunity for decision making primarily because of things like lethargy, pain, or the urgency. What was probably most interesting was that in this delayed interview, even a few months later, the patients hadn't subsequently reconsidered their goals and they didn't really want to focus on advanced care planning even then. It is important for us to figure out when we can get these advanced care planning discussions happening. Surely, we ought to be doing it during the patient's care as preoperatively and as part of their general health screening. Those are samples of the 1,700 articles that represent emergency general surgery for the year 2020. I just wanted to end because we had our business meeting prior to this Congress. I wanted to thank all of the members of the surgical section leadership team. They have done a remarkable job. Many of them have been inundated with COVID, yet they were able to contribute substantially to the work of the society. They did a fabulous job with this. I just wanted to thank them and then invite all of you to participate in our continue the conversation in this next hour to talk with these folks or anybody else. Thank you very much. I just wanted to thank all of you for participating in this year's business meeting. I just wanted to

Year in Review

Surgery

Emergency General Surgery

Trauma

Hemorrhage

Resuscitation

Coagulopathy

Platelet Transfusions

Rib Plating

Burns

Vascular Injuries

COVID-19