Emergency Surgery Research Articles

Patient perspectives of shared decision-making in emergency surgery.

Shared decision-making (SDM) is now considered the gold standard approach to counselling and obtaining patient consent. Research into patient perceptions of SDM is lacking and barriers to its implementation remain, specifically in the time-pressurized, high-risk emergency general surgery (EGS) setting. The aim of this work was to explore what EGS patients understand about SDM, gaining insight into their perspectives and experiences to understand the potential barriers both clinicians and patients may face. This work consisted of two parts: part 1 was an initial scoping review to inform the development of part 2-a patient and public involvement (PPI) exercise. The scoping review determined the quantity and quality of research in this area enabling long-listing of known SDM concepts. This long-list developed questions and structured discussions for the PPI exercise. Responses were transcribed, then analysed using thematic analysis. The scoping review found limited evidence for both the implementation of SDM in EGS and patients' perspectives. Seven papers considered SDM in other settings that allowed long-listing of the values and concepts for the PPI exercise. Nine patients and four supporters were identified from an established EGS database. After open discussion of the values and SDM concepts, thematic analysis was performed that identified two key themes: patient perceptions of how surgeons make decisions, and patient experiences of EGS decision-making. Five subtheme analyses showed participants were not aware of surgeons' use of '30-day mortality' and could not quantify surgical risk, feeling time pressures and out of control. Almost all relied on surgeons to make their decision, valuing the surgeon's opinion over their own. With no previous reported evidence, this work provides the first patient insights into SDM in the EGS setting. With multiple barriers identified, further work is essential to increase implementation of this gold standard approach to patient consent.

An emergency operation strategy and motion planning method for autonomous vehicle in emergency scenarios

Ensuring driving operational safety in emergency scenarios is paramount for autonomous vehicles to prevent accidents, particularly when vehicle motion completely depends on autonomous systems. Numerous factors must be evaluated when designing emergency collision avoidance strategies for critical situations, such as trajectory feasibility, vehicle motion stability, and driver comfort. Therefore, this study proposes a framework for emergency operation that uses collision-free area calculations to inform maneuver decisions and facilitate collision avoidance trajectory planning, preventing vehicle collisions. In case of danger, the emergency maneuver decision module evaluates the safety level and selects safety terminal state by considering a pre-specified cluster of candidate maneuvers before generating trajectories. This process avoids infeasible trajectories and selects maneuvers for greater driver comfort when available. Subsequently, the dynamic trajectory planning module converts the collision-free area into mixed-integer constraints, utilizing time-varying Nonlinear Model Predictive Control (NMPC) for trajectory planning and ensuring vehicle motion stability by integrating dynamic and collision-free constraints throughout the motion planning process. Eventually, simulations and field testing validate the framework’s effectiveness, mitigating collisions in emergency scenarios with prompt and safe operations. The framework is designed to function autonomously, independent of the intelligent driving system, engaging only during risk events and restoring control to the driver or the intelligent system after the event.

Acute Carpal Tunnel Syndrome Secondary to Handcuffs Necessitating Emergency Orthopedic Consultation and Operative Intervention

Acute Carpal Tunnel Syndrome Secondary to Handcuffs Necessitating Emergency Orthopedic Consultation and Operative Intervention

Long-term outcomes after postponing surgery to optimise patients with acute right-sided obstructing colon cancer.

To retrospectively analyse the short- and long-term oncological, morbidity and mortality outcomes in patients diagnosed with acute right-sided obstructing colon cancer. Patients who underwent pre-optimisation prior to the oncological resection were compared to patients who did not undergo pre-optimisation. All consecutive patients with right-sided obstructing colon cancer, either with a high clinical suspicion or confirmed diagnosis by histological analysis, who underwent curative-intent treatment between March 2013 and December 2020 were included. Patients were divided into two groups: an optimised group and a non-optimised group. Preoperative optimisation included additional nutrition, physiotherapy, and, if needed, bowel decompression. Data about disease-free survival and mortality were collected up to three years after surgery. Sixty-two patients were included. Thirty patients underwent the optimisation protocol before postponed surgery, and 32 patients received emergency surgery, without optimisation (surgery performed with a median of 9.6 days versus 22h after admission). The postoperative complication rate was significantly lower in the optimisation group (50% vs 78%, p=0.033). No significant differences were found in the 90-day mortality rate (7% vs 13%, p=0.672) and three-year overall survival rate (43% vs 56%, p=0.49). After three years, sixteen (53%) patients in the optimised group and twenty (63%) in the non-optimised were deceased (p=0.672). Postponing the surgery with preoperative optimisation in patients with obstructing right-sided colon cancer results in a significantly lower 90-day complication rate and suggests no negative effect on survival rates compared to an acute resection. Although, further research with a larger sample size is needed.

A Step Beyond Mortality: Identifying Factors of Prolonged Hospital Stay for Emergency General Surgery Conditions in a Low- and Middle-Income Country.

While various factors leading to prolonged length of stay (LOS) have been identified for emergency general surgery (EGS), there is limited literature on specific factors for individual emergent specialties. This study aimed to identify patient factors and in-hospital complications associated with prolonged LOS for gastrointestinal (GI) and non-GI-related EGS presentations in a low-resource setting. Data from 2010 to 2019 were retrieved from one of the largest tertiary care centers in Pakistan. We included adult patients (≥18y) with index admissions for primary EGS conditions mapped to surgical areas defined by the American Association for Surgery of Trauma. Multivariable linear regression models were created to ascertain factors associated with prolonged LOS for 11 American Association for Surgery of Trauma -defined surgical areas. The mean age of 31,499 patients was 48.87±16.82y, where 23,198 (73.65%) patients underwent surgery. Undergoing emergency surgery was independently associated with increased LOS for all surgical areas (all P values < 0.05), except for hepatic-pancreatic-biliary. Sepsis and septic shock were the most common complications for both operated and nonoperated patients and were significantly associated with increased LOS for most of the surgical areas. For non-GI-related surgical areas, uninsured patients had significantly greater LOS for soft tissue conditions only (β: 0.85; 95% CI: 0.49, 1.21). Different specialties have different drivers for prolonged hospital stay in EGS. This underscores the need to identify and address patient factors and in-hospital complications early on, according to individual specialties. Specific strategies catered to these factors will optimize preoperative care and reduce complications, ultimately decreasing patients' stay after an EGS presentation.

Enhancing the reliance of emergency power supply systems for nuclear facilities using hybrid system

The performance of an atomic facility depends on the efficient supply of electricity, particularly emergency loads like monitoring and control equipment, radiation safety systems, and emergency lights. Most nuclear facilities rely on diesel generators to supply emergency loads during grid outages. Due to the diesel generator's imperfections, such as its starting time, it may fail to deliver power because it is unavailable due to maintenance, failure to start, or failure to run and supply the load. It cannot immediately supply the critical loads, resulting in a blackout and the release of radioactive substances into the environment. To address the previous issues, this paper proposes an improved method to enhance the reliability of nuclear facilities for providing electricity to safety and critical consumers during normal and emergency operating modes. The approach incorporates a photovoltaic (PV) system/battery, and its robustness and performance are tested using load flow and transient stability analysis. The simulation results demonstrated the effectiveness and speed of the proposed method when compared to the traditional method, as the emergency consumers were successfully powered within a very short time without fluctuations, and the voltage reduction and frequency were within the nominal values. The electrical transient analyzer program (ETAP) is used to validate these results.

Septic cardiomyopathy or myocardial infarction?: A case report of septic shock with ST-segment elevation on ECG.

Sepsis is one of the most prevalent and deadly diseases today. Sepsis involving the heart can progress to septic cardiomyopathy; however, there is a lack of uniform diagnostic criteria. A review of the literature reveals a paucity of literature on sepsis combined with acute myocardial infarction (AMI) and no reports on emergency surgical treatment. A 52-year-old patient with trauma-induced sepsis leading to acute heart failure with elevated ST-segment on electrocardiogram and postoperative coronary angiography suggestive of AMI. Small bowel rupture, infectious shock, AMI, hypertensive disease, old cerebral infarction. The patient was admitted to the hospital and immediately underwent emergency surgery to remove the infected focus, with treatment with meropenem for anti-infection, ambroxol for sputum, parenteral nutritional support, sedation and analgesia, esmolol to control the ventricular rate, uradil to control blood pressure, and transfusion of red blood cells and plasma for correction of anemia and coagulation functions. Coronary angiography was performed 6 months later. The patient was discharged after showing signs of improvement and was subsequently monitored in an outpatient clinic setting. At the time of writing, the patient is still alive and well. In cases of acute heart failure resulting from trauma-induced sepsis, it is crucial to consider myocardial ischemia as a potential factor. Early surgical removal of infected foci may prove beneficial in improving the patient's prognosis. However, differentiating between septic cardiomyopathy and sepsis-combined myocardial infarction can be challenging, and the appropriateness of the diagnostic criteria for sepsis at this stage is debatable.

Future directions in transfeminine genital gender-affirming surgery: tissue substitutes and transplant.

The present study reviews contemporary literature focused on uterine transplantation and tissue substitutes for the purposes of transfeminine genital gender affirming surgery (GAS). Additional background is provided for both topics to provide a more comprehensive understanding of the modern applications. Uterine transplant remains an experimental procedure in cisgender patients who wish to avoid surrogacy. A natural extension might be to apply these techniques to GAS. Technical barriers include anatomic differences and alterations to gender-affirming hormone administration protocols. Ethically, resource allocation, elective immunosuppression, societal response to organ donation, legal ramifications of parenthood as well as the potential, under-studied effects that such an elective procedure may have on the patient's offspring must be further investigated.Tissue substitutes have long been used in urologic reconstruction but more recently applied to gender affirmation surgery which has traditionally relied on autografting to line the neovaginal canal both in the context of primary and revision vaginoplasty. However, the advent of off-the-shelf xenografts have recently been posited to be safe and efficacious alternatives to autografts. Longer term studies are needed to validate whether these proposed methods are indeed noninferior to traditional approaches. The field of feminizing gender affirmation surgery remains an exciting frontier for surgeons and patients alike. Given the relative nascency of the specialty and its propensity to draw techniques from various surgical disciplines there exists a unique opportunity for rapid innovation to overcome challenging problems posed by these complex procedures as evidenced by discussions around applying uterine transplantation and the use of novel tissue grafting techniques.

Diagnosis and management of Auricular Lobe Keloid: A case report

Background: Keloid is an abnormal wound-healing process characterized by the formation of benign fibroproliferative tissue following trauma or injury. The auricular area is the most common area affected by keloid. Despite various treatments available, auricular keloid remains recalcitrant. Objective: To report a successful multimodal treatment of ear lobe keloid. Case Report: A 21-year-old male patient presented with bilateral keloids in the right and left earlobe areas sized 2 x 3 cm each. The keloid mass has been slowly growing for the last five months. He had a history of ear piercing in both ear lobes two years ago. The patient underwent bilateral keloid excision, followed by serial intralesional triamcinolone injections on days 3, 7, and 14 after surgery. The histopathological examination of resected tissue was also consistent with keloid tissue. Clinical question: What is the optimal management of auricular lobe keloid? Methods: We performed evidence-based literature reviews regarding optimal management of auricular lobe keloid. Result: Combination therapy is the most widely chosen treatment approach for auricular lobe keloids. This approach provides more aesthetic outcomes and lower recurrence rates than monotherapy. Conclusion: Surgical excision followed by serial intralesional triamcinolone injection is effective for managing auricular lobe keloid. Nevertheless, patients should be advised to avoid body piercing and elective cosmetic procedures to prevent the formation of keloids in the future.

Renal dysfunction contributes to deteriorated survival outcomes in patients with upper and lower gastrointestinal bleeding: insights from a cohort study of 1160 cases

Both acute kidney injury and chronic kidney disease are risk factors for many outcomes of gastrointestinal bleeding (GIB). These are associated with higher mortality, longer hospitalisation, and greater need for transfusion in case of overt GIB. Our study aimed to further evaluate the role of kidney function in several clinical outcomes of GIB patients. The Hungarian Gastrointestinal Bleeding Registry collected data on all-cause GIB between 2019 and 2022. A multi-level data-validation system provided high-quality data, which was retrospectively analysed. Numerous primary (in-hospital mortality, discharge, need for endoscopic intervention, in-hospital rebleeding, length of hospitalisation, need for emergency surgery, need for endoscopic examination and need for intensive care unit) and secondary (detection of Helicobacter pylori (H. pylori), recognition of cancer as the source of bleeding, need for any kind of transfusion or clotting factor, anticoagulation therapy) outcomes were observed. Descriptive statistical tools were used to summarize our data. Among others, estimated glomerular filtration rate (eGFR) (ml/min/1.73 m2) was used as continuous variable, mean, standard deviation, median, interquartile range and minimum/maximum values were calculated. Reduced kidney function was associated with in-hospital mortality (eGFR: 42.63 ± 28.78 ml/min/1.73 m2 vs. 57.08 ± 26.62 ml/min/1.73 m2, p < 0.001), need for red blood cells (RBC) transfusion (eGFR: 51.98 ± 27.90 ml/min/1.73 m2 vs. 60.11 ± 25.06 ml/min/1.73 m2, p < 0.001) and clotting factor supplementation (eGFR: 47.40 ± 27.41 ml/min/1.73 m2 vs. 56.68 ± 27.02 ml/min/1.73 m2, p < 0.001). Better eGFR values at admission were associated with discharge home after proper treatment, compared to any other outcome of the admission (eGFR: 58.12 ± 25.56 ml/min/1.73 m2 vs. 50.23 ± 29.69 ml/min/1.73 m2, p < 0.001), H. pylori positivity (eGFR: 59.63 ± 25.24 ml/min/1.73 m2 vs. 52.76 ± 25.44 ml/min/1.73 m2, p = 0.021) and the need for endoscopic intervention (eGFR: 58.65 ± 26.61 ml/min/1.73 m2 vs. 54.31 ± 27.64 ml/min/1.73 m2, p = 0.008). At admission, patients with better eGFR than 36.64 ml/min/1.73 m2 were discharged to their homes, mortality was higher with eGFR worse than 25.96 ml/min/1.73 m2, more RBC transfusion was needed if eGFR was lower than 49.61 ml/min/1.73 m2. Regulation of anticoagulation was examined extensively. Impaired kidney function at admission results higher in-hospital mortality in overt all-cause GIB and increases the need of RBC transfusion.

P-379. Timing Variations for Surgical Prophylaxis Within One Hour Pre-Incision: Impact on Surgical Site Infections in Elective Colorectal Surgery Procedures

Abstract Background The optimal timing of surgical infection prophylaxis (SIP) is generally recommended to be given 60 minutes, or in some cases 120 minutes, prior to incision. Conflicting results have hampered further optimization of prophylaxis timing within this timing window. This study aimed to assess the impact of alternative prophylaxis timing on surgical outcomes, particularly surgical site infections (SSIs). Methods A large, validated database of elective colorectal surgeries in Michigan was used to perform a multi-center, retrospective cohort study. Cohorts included patients who received SIP within 0-15 minutes and 16-60 minutes prior to incision. Adult patients who received colorectal surgeries spanning from July 2012 to June 2021 were included. Emergent or urgent surgeries, missing follow-up and antibiotic information, and patients who did not receive all prophylaxis prior to incision were excluded. The primary outcome was incidence of SSIs. A multivariable logistic regression model analyzed the impact of timing and other confounding variables on SSIs. Results A total of 21,061 procedures were included. Of these, 6,405 patients (30.4%) received prophylaxis 0-15 minutes pre-incision and 14,656 (69.6%) received prophylaxis within 16-60 minutes. Cohorts were generally similar with differences in patients receiving β-lactam prophylaxis (97.1% vs 96%; P = &amp;lt; 0.001), mechanical and oral bowel preparation (64.5% vs. 67; P = 0.023), and adherence to recommended dosing (82% vs. 83.7%; P =0.002). There was no difference between cohorts in total SSIs (6.8% vs. 7.1%, P = 0.419) or CDI (1.1% vs. 1%; P =0.324); however, deep SSIs were increased in the 16–60-minute cohort (0.8% vs. 1.1%; P = 0.032). Multivariable logistic regression showed no association between prophylaxis timing and SSIs (adjusted odds ratio (aOR) 0.98; 95% CI 0.86-1.13; P = 0.817). Conclusion Timing differences (0-15 minutes vs. 16-60 minutes pre-incision) did not significantly impacts overall SSIs incidence in elective colorectal surgeries. Disclosures Robert K. Cleary, MD, FASCRS, FACS, Intuitive Surgical, Inc: Honoraria

P-828. Risk of Invasive Escherichia Coli (E. coli) Disease After Elective Urologic Procedures among Older Adults in the United States

Abstract Background Little is known about the risk of invasive E. coli disease (IED) after elective urologic procedures with or without antibiotic prophylaxis. This study aimed to estimate the risk of IED after selected urologic procedures in patients with or without antibiotic prophylaxis, and in controls who had no urologic nor other procedures.Table 1.Patient demographic and clinical characteristics Methods The Komodo Research Database (01/01/2021–06/30/2023) was used to identify patients ≥60 years old with prostate biopsy, urologic endoscopy, or nephrostomy (index: first urologic procedure date), and a 1:3 control without procedures (index: random date). Patients with urologic procedures were classified into 2 study cohorts based on antibiotic prophylaxis use within 14 days prior to and on index date. Entropy balancing was used to adjust for differences in demographic and clinical characteristics in 6 months pre-index (baseline). IED rates within 30 days post-index were assessed based on recorded diagnosis of E. coli sepsis (ICD-10-CM code A41.51); odds ratios (OR) were estimated using weighted logistic regression. Sensitivity analyses within 90 days and using broader claims-based algorithm for IED were conducted.Figure 1.IED rates 30 days post index by IED case-identification algorithm Results Overall, 141,418 patients had urologic procedures with antibiotic prophylaxis, 200,062 had them without antibiotic prophylaxis, while control cohort included 424,254 patients who did not have any procedures (Table 1). Within 30 days post-index, IED rates were 0.48% and 0.72% among patients with or without antibiotic prophylaxis, respectively, vs 0.02% among those without procedures (Figure 1). Among patients with urologic procedures, &amp;gt;70% of IED events occurred within 30 days post-index. Patients who had urologic procedures without prophylaxis had a higher risk of IED than those with prophylaxis [OR=1.50, 95% CI (1.37,1.65); Table 2]. Patients without procedures had a lower risk of IED than those with procedures who received antibiotic prophylaxis [OR=0.04, 95% CI (0.03,0.05); Table 2]. Similar results were obtained within 90 days and/or using a broader definition of IED.Table 2.Comparison of IED outcomes among the weighted cohorts using logistic regression analysis Conclusion Urologic procedures were associated with an increased risk of IED even when antibiotic prophylaxis was used. Results suggest an unmet need for additional preventative measures to avoid the substantial burden of IED after urologic procedures. Disclosures Maureen P. Neary, PhD, MS, Janssen Global Services, LLC: Employee of Janssen Global Services, LLC Maryaline Catillon, PhD, Janssen Global Services, LLC: Employee of Analysis Group which has received consultancy fees from Janssen Global Services, LLC for the conduct of this study Nina Ahmad, MD, Janssen Global Services, LLC: Employee of Janssen Global Services, LLC Marjolaine Gauthier-Loiselle, PhD, Janssen Global Services, LLC: Employee of Analysis Group which has received consultancy fees from Janssen Global Services, LLC for the conduct of this study Jeroen Geurtsen, PhD, Janssen Vaccines &amp; Prevention BV: Advisor/Consultant|Janssen Vaccines &amp; Prevention BV: Employee of Janssen Vaccines &amp; Prevention BV Alice Qu, BA, Janssen Global Services, LLC: Employee of Analysis Group which has received consultancy fees from Janssen Global Services, LLC for the conduct of this study Corinne Willame, PhD, MPH, Johnson &amp; Johnson Innovative Medicine: Employee of Johnson &amp; Johnson Innovative Medicine Martin Cloutier, MSc, Janssen Global Services, LLC: Employee of Analysis Group which has received consultancy fees from Janssen Global Services, LLC for the conduct of this study Antoine El Khoury, PhD, Janssen Global Services: Advisor/Consultant|Janssen Global Services, LLC: Employee of Janssen Global Services, LLC Elie Saade, MD, Janssen: Grant/Research Support|Pfizer: Grant/Research Support|Pfizer: advisory board|Sanofi Pasteur: Grant/Research Support|Sanofi Pasteur: speaking and lecture fees and travel reimbursement|Seqirus: Grant/Research Support

P-1791. Low Utilization of Methicillin-Resistant Staphylococcus aureus Screening in Orthopedic Surgeries

Abstract Background Guidelines recommend screening for methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization to identify patients undergoing orthopedic implants who may benefit from perioperative vancomycin. Culture-based MRSA screening may take days to result, yet it is the only technique available in many centers, including ours. Therefore, we investigated the proportion of cases in which MRSA screening results are available at time of orthopedic implants at our center, and explored the rationale for perioperative choice when this information is absent. Methods We conducted a retrospective chart review of all consecutive patients 18 years or older who underwent orthopedic implant procedures for the calendar year 2023 at UPMC Mercy, Pittsburgh, PA. Patients undergoing multiple procedures within 24 hours were counted once. We report a preliminary analysis for 44% of the total population. Data was analyzed by MRSA screening status. Results In 251 surgeries performed in 247 patients, MRSA screening within one year prior to surgery was available only in 63 (25.1%). An additional 43 (17.1%) had results older than one year, while 145 (57.8%) had no MRSA screening. Patients that had MRSA available within a year did not defer from those with older or absent results in the proportion of emergent surgeries, types of surgeries, or perioperative prophylactic antibiotics received (Table 1). Only 43 (17.3%) patients had MRSA screen collected during the admission. Only four patients received perioperative vancomycin, only one had a clear indication for this choice (Table 2). Of six patients with an indication for perioperative vancomycin, none received this antibiotic. Conclusion In patients undergoing orthopedic implants, MRSA screening results were available at time of surgery in less than half of cases, screening was infrequently ordered during the admission for surgery, and the results did not seem to affect the antibiotic choice. Non-systematic input from the three orthopedic surgeons with the highest volume at our center suggests this low utilization is due to: a. questioning the value of the screening and vancomycin prophylaxis, b. lack of systematization (of ordering, reviewing), and c. the perception that the results are unlikely to be available at the time of surgery. Disclosures All Authors: No reported disclosures

Legal Lens on Hysteroscopy: A Retrospective Review of Medical Malpractice Claims of Hysteroscopic Procedures

Background: Given the expansiveness of diagnostic and therapeutic hysteroscopy, promptly recognizing complications and intervening as necessary to prevent adverse outcomes and minimize legal risk is imperative. We aim to describe the litigious trends in hysteroscopic procedures across the United States; Methods: Publicly available lawsuits published on a well-known legal database, Westlaw, were reviewed. The search term “’hysteroscop!’” was used to filter cases for court opinions containing words with this prefix, including “hysteroscopy”, “hysteroscopies”, and “hysteroscopic.” Adverse events, procedural outcomes, post-procedural surgery urgency, and resultant disabilities were extracted for themes; Results: The primary complication resulting in legal action was uterine perforation (52.9%), followed by claimed technical mistakes (23.5%) and damage to surrounding structures (11.8%). The most common outcome was the need for future corrective surgery (70.6%), and a number of cases resulted in permanent brain damage or death (23.6%). Of the patients that required subsequent corrective surgery (n = 12), 91.7% of them required emergent surgery. Patients sought damages most commonly from individual attending providers (41.2%), attending physician and practice groups/hospitals collectively (41.2%), and additional entities, including resident physicians in training and manufacturers. Awards ranged from $322,308 to $9,387,109; Conclusions: Medical malpractice litigation is challenging to patients and providers alike, often leading to financial, emotional, and professional burden. Our evaluation highlights the variability in adverse events from hysteroscopy which prompt litigation, financial burden of lawsuits, and legal risk of individual providers, in an attempt to improve safety of future procedures.

Clinical guidelines for a dry land: challenges in developing recommendations for DOAC management in emergent cardiac surgery.

Clinical guidelines for a dry land: challenges in developing recommendations for DOAC management in emergent cardiac surgery.

Use of Small Bowel Follow Through in Management of Small Bowel Obstruction

Background: Small bowel obstructions (SBO) are a burden to healthcare. Despite a common disease, significant inconsistencies exist within management, specifically use of small bowel follow through (SBFT). We evaluated patients who had SBFT and the early versus late use of SBFT on outcomes. Study Design: A retrospective chart review was performed for 799 SBO patients admitted between 2012 and 2019. Patients between 18 and 89 were included and those that required emergent operations on admission were excluded. The groups were evaluated by having SBFT compared to not, and further delineated on SBFT performance before (early) or after (late) 48 hours. Results: Of the 799 patients with a SBO, 757(94.7%) patients had SBFT and 42(5.2%) patients did not. Of those 757, 476(62.8%) performed early and 281(37.1%) completed late. In patients that received SBFT, the length of stay (LOS) was shorter (p&lt;0.003). If patients were admitted to the surgical service, they were more likely to receive a SBFT (p&lt;0.0042). When SBFT early, patients were more frequently admitted to an academic institution (p&lt;0.0001) and to a surgical service (p&lt;0.0001), had decreased LOS (p&lt;0.001), decreased readmissions (p&lt;0.0001), less likely to require surgery (p&lt;0.0009), decreased time to operation (p&lt;0.0001), and quicker operation to discharge (p&lt;0.0005). Conclusions: The use of SBFT for SBO resulted in improved outcomes, especially if performed early. This is supportive of surgical service admission with more frequent early SBFT with decreased LOS. There is a propensity for those patients with prior operations to have SBFT later in hospital stay and may correlate with increased need for surgery, and the use of early SBFT may help resolve SBO. Implementing early SBFT may improve outcomes and an area of future endeavors.

Development and validation of an EHR-based risk prediction model for geriatric patients undergoing urgent and emergency surgery

BackgroundClinical determination of patients at high risk of poor surgical outcomes is complex and may be supported by clinical tools to summarize the patient’s own personalized electronic health record (EHR) history and vitals data through predictive risk models. Since prior models were not readily available for EHR-integration, our objective was to develop and validate a risk stratification tool, named the Assessment of Geriatric Emergency Surgery (AGES) score, predicting risk of 30-day major postoperative complications in geriatric patients under consideration for urgent and emergency surgery using pre-surgical existing electronic health record (EHR) data.MethodsPatients 65-years and older undergoing urgent or emergency non-cardiac surgery within 21 hospitals 2017–2021 were used to develop the model (randomly split: 80% training, 20% test). The primary outcome was a 30-day composite outcome including several postoperative major complications and mortality; secondary outcomes included common individual complications included in the primary composite outcome (sepsis, progressive renal insufficiency or renal failure, and mortality). Patients’ EHR-based clinical history, vital signs, labs, and demographics were included in logistic regression, LASSO, decision tree, Random Forest, and XGBoost models. Area under the receiver operating characteristics curve (AUCROC) was used to compare model performance.ResultsOverall, 66,262 patients (median [IQR] age 78 [(70.9–84.0], female 53.9%, White race 68.5%) received urgent or emergency non-cardiac surgery (25.7% orthopedic cases, 21.9% general surgery cases). AUCROC ranged from 0.655 (Decision Tree) – 0.804 (XGBoost) for the primary composite outcome. XGBoost AUCROC was 0.823, 0.781, and 0.839 in predicting outcomes of sepsis, progressive renal insufficiency or renal failure, and mortality, respectively.ConclusionsWe developed a model to accurately predict major postoperative complications in geriatric patients undergoing urgent or emergency surgery using the patient’s own existing EHR data. EHR implementation of this model could efficiently support clinicians’ surgical risk assessment and perioperative decision-making discussions in this vulnerable patient population.

Frontline Voice: AO Spine Member Survey Regarding Spine Oncology Knowledge Generation and Translation Needs.

cross-sectional survey. To evaluate AO Spine members' practices and comfort in managing metastatic and primary spine tumors, explore the use of decision-support and patient assessment tools, and identify knowledge gaps and future needs in spine oncology. An online survey was distributed to AO Spine members to query comfort levels with key decisions in spinal oncology management, utilization of decision frameworks and spine oncology-specific instruments, and educational material preferences. Responses were obtained from 381 members across 82 countries. Most respondents were orthopedic spine surgeons (62%) or neurosurgeons (36%), with 42% performing 100-200 spine surgeries per year. Extradural primary and metastatic tumors were managed by 84% and 95% of respondents, respectively, with survival and frailty assessment tools used for both. While most surgeons felt comfortable determining when emergency surgery was needed (81% for primary and 82% for metastatic tumors), nuanced decisions about surgical timing were more challenging. Surgeons also noted challenges in tailoring the oncologic surgical plan to what the patient could safely tolerate. There was a strong desire for guidelines on tumor-related spinal pain (85%), treatment timing (85%), stabilization (85%), and glucocorticoid use for symptomatic extradural metastatic tumors (77%). Interest was high for classification systems for spine tumor pain (65%) and stabilization decisions (80%). Additional support is needed in decision-making regarding surgical timing, patient selection, and tailoring treatment invasiveness to life expectancy and frailty. Surgeons seek further guidance to prevent neurologic deterioration and optimize recovery. Guidelines and classification systems were highly coveted for daily practice.

Microbiological spectrum of pathogens in cardiac surgery patients in the intensive care unit

Background. Intensive care unit (ICU) patients are at high risk of hospital-acquired infections, which is a significant problem in modern medicine. Every year, 140,000 deaths from hospital-acquired infections are reported. For example, studies in the United States show that 30 % of infections occur in the ICUs. The presence of hospital-acquired flora in patients prolongs their stay in the ICU, increases the duration of antibiotic therapy, and treatment costs. The occurrence of such an infection is the result of a complex interaction of pathogenic (virulence, antibiotic resistance), patients’ (comorbidities, acute illnesses, emergency surgery), and treatment factors (invasive devices), and the work of the health care system (staffing, preventive measures). Mortality among individuals with a positive bacteriological blood test reaches 25 % among all patients in the intensive care unit, which emphasizes the importance of timely diagnosis and control of such infection. The analysis of the microbiological spectrum of pathogens in cardiac surgery patients is a complex process, but it is quite possible and necessary to improve the effectiveness of treatment of cardiac surgery patients. Objective: to analyze the microbiological spectrum of pathogens in cardiac surgery patients in the ICU. Materials and methods. The study included retrospective clinical data of 323 patients who were treated in the preoperative or postoperative period at the intensive care unit of the State Institution “Amosov National Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine” from January 1, 2021, to December 31, 2023. The entire cohort had a positive bacteriological blood test. The microbiological analysis was performed using a Vitek 2 Compact analyzer with a BACT/ALERT 3D60 colometric system for detecting bacterial growth (No. VK2C8748). The microbiological spectrum of pathogens in cardiac surgery patients in the intensive care unit was analyzed. Results. In 2021, 81 patients had a positive microbiological blood test. The incidence of pathogens was as follows: gram-positive infection — 69 (85.1 %), gram-negative infection — 11 (14.6 %), fungi of the genus Candida — 1 (0.3 %) case, respectively. In 2022, 95 patients had a positive microbiological blood test. The frequency of pathogens was as follows: gram-positive infection — 75 (78.9 %) cases, gram-negative infection — 20 (21.1 %). In 2023, 147 patients had a positive microbiological blood test. The incidence of pathogens was as follows: gram-positive infection — 97 (66.0 %) cases, gram-negative infection — 46 (31.3 %) cases, Candida fungi — 4 (2.7 %) cases, respectively. Conclusions. An increase was found in the frequency of Klebsiella spp. microorga-nisms from 60 to 84 % of cases from the total spectrum of gram-negative pathogens in the ICU in 2023. There was a decrease in the frequency of Enterobacter spp. from 22 % of cases in 2021 to 13 % in 2023. The proportion of identified Acinetobacter spp. pathogens decreased from 11 % of cases in 2021 to 3 % in 2023.

Blood lactate as a predictor of clinical outcomes and health-care resource needs in combat abdominal injuries

Background. Combat abdominal injuries (CAI) are cha­racterized by high mortality and occupy a leading position among the issues of battlefield surgery. It is very important to evaluate early and accurately the severity of CAI, which will allow starting correct treatment in time, preventing possible complications and improving clinical outcomes. The low sensitivity of commonly used cardiovascular parameters to detect the initial manifestations of tissue hypoperfusion induced by blood loss dictates the need to use more effective markers that reflect metabolic changes in tissues. The aim of this study is to determine the predictive efficacy of serum lactate regarding the risk of death and health-care resources needs in patients with CAI. Materials and methods. We examined 86 injured servicemen with CAI who were randomized into two groups — survivors and nonsurvivors. The predictive efficacy of capillary blood lactate and its clearance regarding the risk of death and health-care resource needs in CAI were studied. Six consecutive (within 48 h) measurements of lactate and lactate clearance corresponding to each measurement (except the first) were evaluated for each patient. Logistic regression models were constructed and analyzed to assess the influence of lactate level and lactate clearance on the risk of death and need for vasopressor support during medical evacuation to the Role 3 (after performing an emergency surgery). A correlation analysis was conducted on the association between lactate and the need for RBC transfusion, as well as assessment of the CAI severity using the Admission Trauma Score (AdTS). Results. In the group of nonsurvivors, lactate was higher (p = 0.001) at all stages of the study. We determined that an increase in the lactate level at the time of admission of a victim with CAI to the forward surgical team (LacpreOP) increased the risk of death by 1.5 times for every 1 mmol/l of lactate elevation (odds ratio (OR) 1.5, 95% confidence interval (CI) 1.22–1.85), and the chances of the need for vasopressor support during medical evacuation to the Role 3 — by 1.7 times for every 1 mmol/l of lactate elevation (OR 1.7, 95% CI 1.05–1.86). A strong positive correlation (ρ = 0.8) was found between LacpreOP and the need for RBC transfusion during the first 24 h after injury, as well as a moderate positive correlation (ρ = 0.5) between LacpreOP and CAI severity assessment on the AdTS. Conclusions. The results of the study indicate the high predictive efficacy of lactate regarding the risk of death (OR 1.5, 95% CI 1.22–1.85) and the need for vasopressor support during medical evacuation of victims with CAI to the Role 3 (OR 1.7, 95% CI 1.05–1.86). There was a positive correlation between lactate and the need for RBC transfusion du­ring first 24 h after injury (ρ = 0.8), as well as between lactate level and CAI severity according to the AdTS (ρ = 0.5).