Or Operating Room Research Articles

A comparative analysis of the Trauma and Injury Severity Score and the Injury Severity Score in predicting high-value care outcomes in children with traumatic brain injury.

Predicting high-value care outcomes is crucial in managing pediatric traumatic brain injuries (TBIs), where timely and accurate prognostication can significantly influence treatment decisions and resource allocation. This study aimed to enhance understanding of how well scoring systems such as the Trauma and Injury Severity Score (TRISS) can forecast high-value care outcomes. Furthermore, the authors compared the predictive power of TRISS with the routinely used Injury Severity Score (ISS). The authors performed a retrospective review of their institutional database from June 2016 to June 2023 to identify cases of TBI based on a modified Centers for Disease Control and Prevention framework. Prolonged length of stay (LOS) was defined as a hospital stay falling into the upper quartile of the overall cohort. Discharge to an inpatient rehabilitation facility, acute care hospital, or foster care or death was defined as a nonroutine discharge disposition. Emergency department (ED) transfer to the intensive care unit (ICU) or operating room (OR) was defined as a proxy for severity of injuries. Multivariate logistic regression models were used to explore the association between ISS, TRISS, and high-value care outcomes. The DeLong test was used to assess the differences between the areas under the receiver operating characteristic curve (AUROCs). This study included 2705 patients with a mean age ± SD of 7.28 ± 5.46 years (63% male). In the overall cohort, 28% experienced prolonged LOS, 7% had a nonroutine discharge disposition from the hospital, and 23% were transferred to the ICU/OR from the ED. In multivariate regression models, both TRISS and ISS were correlated with higher odds of prolonged LOS, nonroutine discharge disposition, and transfer to the ICU/OR from the ED (all p < 0.001). TRISS had a significantly greater AUROC than ISS for nonroutine discharge disposition (0.883 vs 0.849, p < 0.001) and transfer to the ICU/OR (0.898 vs 0.887, p = 0.045), but this result was not significant for prolonged LOS (0.873 vs 0.880, p = 0.140). TRISS and ISS are effective tools for predicting high-value care outcomes in pediatric TBI. Utilizing these resources can assist healthcare providers in making informed, risk-adjusted predictions.

Abstract 273: Development and Implementation of a Multicenter Registry for Resuscitation-Focused Transesophageal Echocardiography

Objectives: To evaluate the clinical impact, safety, and clinical outcomes of focused transesophageal echocardiography (TEE) in the evaluation of critically ill patients in the emergency department (ED) and intensive care units (ICU). Methods: We established a prospective, multicenter, observational registry involving adult critically ill patients in whom focused TEE was performed for evaluation of out-of-hospital cardiac arrest (OHCA), in-hospital cardiac arrest (IHCA), evaluation of undifferentiated shock, hemodynamic monitoring, and/or procedural guidance in the ED, ICU, or operating room (OR) setting. The primary objective of the current investigation was to evaluate the clinical impact and safety of focused, point-of-care TEE in critically ill patients. Data elements included patient and procedure characteristics, laboratory values, timing of interventions, clinical outcomes, and TEE video images. Results: A total of 771 cases were collected from 27 hospitals, including 506 (66%) intra and post arrest OHCA and IHCA, 221 (29%) initial evaluation of undifferentiated shock, 71 (9%) hemodynamic monitoring, and 93 (12%) procedural guidance. TEE changed management in 64% of cases of OHCA, in 71% of IHCA, and in 85% of patients with undifferentiated shock. There were no reported esophageal perforations or oropharyngeal injuries, and other procedural complications were rare. Conclusion: A prospective, multicenter, and multidisciplinary TEE registry was successfully implemented, and demonstrated that focused TEE is safe and clinically impactful across multiple critical care applications. Further studies from this research network will accelerate the development of outcome-oriented research and knowledge translation on the use of TEE in emergency and critical care settings.

Design and Application of IOT-Based Real-Time Patient Telemonitoring System Using Biomedical Sensor Network

The field of Internet of Things (IoT) and remote patient monitoring (RPM) system has been developing rapidly causing these technologies to be adopted in multiple domains all around the world. This paper presents the design of a real-time remote monitoring system for vulnerable patients. The proposed device measures body temperature, heart rate, blood pressure, oxygen saturation level and electrocardiogram signals (ECG) of patients admitted into intensive care unit (ICU) or operating room (OR), and automatically updates all these data on a corresponding hybrid cloud server in every 45 s to which a corresponding physician has access. More than 2000 cycles are conducted within a day where all five biomedical parameters are measured and stored on each cycle. Furthermore, the system includes alarm triggering system and emergency short message service (SMS) alert service using GSM technology to initiate proper control actions in case of emergencies. This device facilitates doctors, nurses, relatives of patients, or anyone around the world to monitor real-time parameters of patients. The process was tested on 10 patients obtaining a satisfactory outcome. The system proposed in this paper reveals a new vision of biomedical engineering which tends to the era of remotely controllable ICU environment with more interactive, efficient and fast response of both patient and corresponding physicians.

38 Resuscitative TEE Collaborative Registry: Development and Implementation of a Multicenter Registry for Focused Transesophageal Echocardiography (TEE) in the Emergency Department and Intensive Care Settings

38 Resuscitative TEE Collaborative Registry: Development and Implementation of a Multicenter Registry for Focused Transesophageal Echocardiography (TEE) in the Emergency Department and Intensive Care Settings

The Use of Hemostatic Agents to Decrease Bleeding Complications in Breast Cancer Surgery.

Following breast cancer surgery, patients often require adjuvant radiation and chemotherapy for locoregional and systemic disease control. These procedures may result in postoperative complications, which may delay adjuvant therapy. To potentially decrease these complications, hemostatic agents may be used. This study evaluated the rate of postoperative bleeding complications and duration of Jackson-Pratt (JP) drain use in oncologic breast surgery with and without hemostatic agents. After obtaining institutional review board approval, a retrospective chart review was performed. Patients who underwent oncoplastic breast surgery, mastectomy with or without expander/implant-based reconstruction, and subsequent reconstruction with expander to implant exchange were included. Data collected included indication for surgery, type of operation, use of hemostatic agent, specifically fibrin sealant (FS, EVICEL®, Ethicon, USA) or combination powder (CP, HEMOBLAST™ Bellows, biom'up, France), length of follow-up, time to JP drain removal, and post-operative complications (seroma, hematoma, or operating room (OR) takeback). This was a consecutive experience where initially no hemostatic agent was used, followed by use of FS, and then CP. The use of a hemostatic agent resulted in fewer bleeding complications and significantly decreased time until JP drain removal. Although not significant, subgroup analysis demonstrated that this was more pronounced in the CP group. JP drain duration was decreased among all procedures for CP compared to FS. The use of hemostatic agents in oncologic breast surgery may result in decreased postoperative complications and significantly reduce time to JP drain removal.

Proportions of Surgical Patients Discharged Home the Same or the Next Day Are Sufficient Data to Assess Cases' Contributions to Hospital Occupancy.

IntroductionWhen the hospital census is high, perioperative medical directors or operating room (OR) managers may need to consider postponing some surgical cases scheduled to be performed within the next three workdays. This scenario has arisen at hospitals in regions with large increases in admissions due to coronavirus disease 2019 (COVID-19). We compare summary measures for hospital length of stay (LOS) to guide the OR manager having to decide which cases may need to be postponed to ensure a sufficient reserve of available inpatient beds.MethodsWe studied the 1,201,815 ambulatory and 649,962 inpatient elective cases with a major therapeutic procedure performed during 2018 at all 412 non-federal hospitals in Florida. The data were sorted by the hospital, and then by procedure category. Statistical comparisons of LOS were made pairwise among all procedure categories with at least 100 cases at (the) each hospital, using the chi-square test (LOS ≤ 1 day versus LOS > 1 day), Student’s t-test with unequal variances, and the Wilcoxon-Mann-Whitney test. The comparisons among the three tests then were repeated having sorted the data by procedure category and making statistical comparisons among all hospitals with at least 100 cases for the procedure category.ResultsWhether using a criterion for statistical significance of P < 0.05 or P < 0.01, and whether compared with Student’s t-test with unequal variances or Wilcoxon-Mann-Whitney test, the chi-square test had greater odds (i.e., greater statistical power) to detect differences in LOS (all four with P < 0.0001 and all 95% lower confidence limits for odds ratios ≥ 3.00). The findings were consistent when the data, first sorted by procedure category and then by probability distributions of LOS, were compared between hospitals (all P < 0.0001 and the 95% lower confidence limits for odds ratio ≥ 3.72).ConclusionsFor purposes of comparing procedure categories pairwise at the same hospital, there was no loss of information by summarizing the probability distributions using single numbers, the percentages of cases among patients staying longer than overnight. This finding substantially simplifies the mathematics for constructing dashboards or summaries of OR information system data to help the perioperative OR manager or medical director decide which cases may need to be postponed, when the hospital census is high, to provide a sufficient reserve of inpatient hospital beds.

The Impact of the COVID-19 Pandemic on Plastic Surgery Consultations in the Emergency Department.

Background:Stay-at-Home (SAH) orders implemented in the United States to combat COVID-19 had a significant impact on health care delivery for patients with all conditions. In this study, we examined the effect SAH orders had on the Emergency Department (ED) consultation volume, injury patterns, and treatment of patients managed by our plastic surgery service.Methods:In Rhode Island, SAH orders were instituted from March 28, 2020, to June 30, 2020. A retrospective chart review of patients presenting to our Level-1 academic medical center was performed. Patient demographics, types of injuries, and need for treatment in the ED or operating room (OR) were collected. Tests of significance were conducted using a comparison group spanning the same time period, in 2019.Results:There was a 36% decrease in ED consultations to plastic surgery during SAH orders when compared with those in 2019. No observed differences were noted in patient demographics between time periods. There were significant increases in the proportions of hand injuries secondary to power tools and facial injuries secondary to falls. No observed differences were identified in injury severity and need for either operating-room interventions or ED interventions for patients seen in consultation during SAH orders.Conclusions:SAH orders resulted in a decreased volume of plastic surgery consults in the ED but did not alter patient demographics, injury severity, or need for procedural interventions. There was a 2.9% positivity rate for COVID-19 for asymptomatic patients presenting in the ED with primary hand and facial injuries.

Forecasting the Probability That Each Surgical Case Will Either Be Ambulatory or the Patient Will Remain in the Hospital Overnight Versus Having a Length of Stay of Two or More Days.

When the hospital census is high, perioperative medical directors or operating room (OR) managers sometimes need to review with surgical departments as to which surgical cases scheduled to be performed within the next three days may need to be postponed. Although distributions of hospital length of stay (LOS) are highly skewed, a surprisingly effective summary measure is the percentage of patients previously undergoing the same category of procedure as that scheduled whose LOS was zero or one day. We evaluated how to forecast each hospital's percentage of cases with LOS of <2 days, segmented by category of surgical procedure. The large teaching hospital studied included several inpatient adult surgical suites, an ambulatory surgery center, and a pediatric surgical suite.We included 98,540 cases in a training dataset to predict 24,338 cases in a test dataset. For each category of procedure, we calculated the cumulative count of cases among quarters, from the most recent quarter, second most recent quarter, and so forth up to the quarter resulting in at least 800 cases. If every quarter combined had fewer than 800 cases for a given category of procedure, we included all cases for that category. For each combination of category and quarter, we used the cumulative counts of cases and cases with LOS of <2 days, excluding the current quarter. Then, for each category of procedure, and for each of the preceding quarters included for the category, we used the cumulative counts to calculate the asymptotic standard error (SE) for the proportion of cases with LOS of <2 days. If all preceding quarters combined provided a sample size such that the estimated SE for the proportion exceeded 1.25%, we included all preceding quarters. The observed absolute percentage error was 0.76% (SE: 0.12%). This error was nearly 100-fold smaller than the percentage of cases to which it would be used (i.e., 0.76% versus 73.1% with LOS of <2 days). The principal weakness of the forecasting methodology was a small bias caused by a progressive reduction in the overall LOS over time. However, this bias is unlikely to be important for predicting cases’ LOS when the hospital census is high. When performing these time series calculations quarterly, a reasonable approach is to perform calculations of both case counts and SEs for each category of procedure. We recommend using the fewest historical quarters, starting with the most recent quarter, either with at least 800 cases or an estimated asymptotic SE for the estimated percentage no greater than 1.25%. Applying our methodology with local LOS data will allow OR managers to estimate the number of patients on the elective OR schedule each day who will be hospitalized for longer than overnight, facilitating communication and decision-making with surgical departments when census considerations constrain the ability to run a full surgical schedule.

Recurrent Respiratory Papillomatosis Office versus Operating Room: Systematic Review and Meta-Analysis.

Recurrent respiratory papillomatosis can be treated in the office or operating room (OR). The choice of treatment is based on several factors, including patient and surgeon preference. However, there is little data to guide the decision-making. This study examines the available literature comparing operative treatment in-office versus OR. A systematic review was performed following Preferred Reporting Items for Systematic Reviews guidelines. Of 2,864 articles identified, 78 were reviewed full-length and 18 were included. Outcomes of interest were recurrence and complication rates, number of procedures, time interval between procedures, and cost. Only one study compared outcomes of operative in-office to OR treatments. The weighted average complication rate for OR procedures was 0.02 (95% confidence interval [CI] 0.00-0.32), n = 8, and for office procedures, 0.17 (95% CI 0.08-0.33), n = 6. The weighted average time interval between OR procedures was 10.59 months (5.83, 15.35) and for office procedures 5.40 months (3.26-7.54), n = 1. The weighted average cost of OR procedures was $10,105.22 ($5,622.51-14,587.83), n = 2 versus $2,081.00 ($1,987.64-$2,174.36), n = 1 for office procedures. Only one study compares office to OR treatment. The overall data indicate no differences aside from cost and imply that office procedures may be more cost-effective than OR procedures. However, the heterogeneous data limits any strong comparison of outcomes between office and OR-based treatment of laryngeal papillomas. More studies to compare the two treatment settings are warranted.

Ethical Issues in Scarce Resource Allocation in a Global Pandemic: Relevance to Craniofacial Surgery

The response to the COVID-19 pandemic has necessitated a shift in how we apply the principles of biomedical ethics. The historical foundation of the ethical responsibility of the physician to the patient rests on the of that individual relationship. The patient comes first. However, in a pandemic, a public health ethics takes over, and the focus changes to what each individual member of society’s responsibility is to the collective. The greatest good for the greatest number trumps a given individual’s needs. Ethicists have focused primarily on creating guidelines that apply to allocating scarce life-and-death-determining resources. Very little attention has been paid to scarce resources that are more mundane, such as personal protective equipment (PPE) or operating room (OR) time. I present here a summary of the most recent ethical guidelines for allocation of scarce resources, note some concerns with these approaches, and discuss some of the shortcomings of applying these frameworks to the practice of craniofacial surgeons.

Mistriaged Advanced Life Support Patients in a Two-Tiered, Suburban Emergency Medical Services System.

IntroductionEmergency medical services (EMS) systems exist to provide prehospital care in diverse environments throughout the world. Advanced Life Support (ALS) services can provide advanced care including 12-lead electrocardiogram (ECG), endotracheal intubation and parenteral medication administration. Basic Life Support (BLS) can provide basic care such as splinting, wound care and cardiopulmonary resuscitation. ALS can release patients to BLS for transport to the hospital, and this is an area of high risk. Our study examines patients who were triaged and admitted to a critical care location, including an intensive care unit (ICU), cardiac catheterization laboratory, or operating room (OR).MethodsThe analysis included data from 2007–2015 of all patients who were triaged. We evaluated demographics, admission diagnoses, and dispositions using descriptive statistics. Diagnoses were grouped into categories based on the system.ResultsWe found that 372/17,639 (2%) of patients were mistriaged to BLS and admitted to a critical care location. The average age was 64. The most common diagnosis categories were neurological (24%), gastrointestinal (GI)/abdominal pain (15%), respiratory (12%), and cardiac (12%).ConclusionIt is uncommon for patients triaged from ALS to BLS to be admitted to an ICU, catheterization lab or OR, with a rate of 2%. Neurological, GI, respiratory, and cardiac diagnoses were the most frequent categories of patient complaints that were mistriaged. This study should lead to further studies to examine this patient population.

Beirut Port Ammonium Nitrate Explosion

Background: On the fourth of August, 2020 a major explosion struck the capital city of Lebanon. Our aim was to ascertain the number of casualties following the Beirut Port Ammonium Nitrate Explosion (BPANE). Methods: Retrospective review of emergency department (ED) statistics in the first 54 hours following BPANE. Hospitals within 99 km diameter were included. Results: ED utilization included the influx of 8,643 casualties in 33 private and nine public hospitals. A majority of patients suffered multiple soft tissue lacerations by shattered glass and were treated by suturing. Hospital admissions counted 1,056 patients representing 12·21% of ED admissions. Admissions to intensive care units (ICU) or operating room (OR) accounted respectively for 156 and 534 (1·80% and 6.18% of patients admitted to ED). ICU admissions were for cerebral contusion or hemorrhage (69·1%), lung injuries (9·1%), or polytrauma (9·1%). Primary surgeries included hand, upper or lower extremity fractures (36·7%), tendon repair (19·7%), open eye (14·5%), craniotomies (8·1%), polytrauma (7·5%) and plastic repairs (4·6%). In hospital, immediate ED mortality was 37, early mortality within 54 hours was 56, and the global official mortality at one month exceeded 200. Conclusions: BPANE resulted in several thousands of soft tissue lacerations, several hundreds of related operations including fractures, tendon repairs, ocular lacerations, and craniotomies, as well as several dozens of intensive care admissions mainly from brain or less often lung injury. We call for action so that the production, sales, transport, and storage of ammonium nitrate to be under strict regulations and supervision of the United Nations. Funding Statement: None. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The study received Institutional Review Board approval in 9 centers that supplied the diagnosis for admission to the hospital. The study conformed to the Declaration of Helsinki provisions.

Safety of in-hospital insertable cardiac monitor procedures performed outside the traditional settings: results from the Reveal LINQ in-office 2 international study

BackgroundHistorically, the majority of insertable cardiac monitor (ICM) procedures were performed in the cardiac catheterization (cath) lab, electrophysiology (EP) lab, or operating room (OR). The miniaturization of ICMs allows the procedure to be relocated within the hospital without compromising patient safety. We sought to estimate the rate of untoward events associated with procedures performed within the hospital but outside the traditional settings and to characterize resource utilization, procedure time intervals, and physician experience.MethodsThe Reveal LINQ in-Office 2 (RIO 2) International study was a single arm, multicenter, prospective study. Patients indicated for an ICM and willing to undergo device insertion outside the cath/EP lab or OR were eligible and followed for 90 days after insertion.ResultsA total of 191 patients (45.5% female aged 63.8 ± 26.9 years) underwent successful Reveal LINQ ICM insertion at 17 centers in Europe, Canada and Australia. The median total visit duration was 106 min (interquartile range [IQR]: 55–61). Patient preparation and patient education accounted for 10 min (IQR: 5–20) and 10 min (IQR: 8–15) of total visit duration, respectively. Preparation and education occurred in the procedure room for 90.6 and 60.2% of patients, respectively. There were no untoward events (0.0, 95% CI: 0.0–2.1%) though four patients presented with procedure-related adverse events that did not require invasive intervention. Physicians rated procedure location as convenient or very convenient.ConclusionsThe Reveal LINQ™ ICM insertion can be safely and efficiently performed in the hospital outside the cath/EP lab or OR.Trial registrationClinicalTrials.gov identifier NCT02412488; registered on April 9, 2015.

Mean Arterial Blood Pressure Management of Acute Traumatic Spinal Cord Injured Patients during the Pre-Hospital and Early Admission Period.

The optimization and maintenance of mean arterial blood pressure (MAP) and the general avoidance of systemic hypotension for the first 5-7 days following acute traumatic spinal cord injury (tSCI) is considered to be important for minimizing secondary spinal cord ischemic damage. The characterization of hemodynamic parameters in the immediate post-injury stage prior to admission to a specialized spine unit has not been previously reported. Here we describe the blood pressure management of 40 acute tSCI patients in the early post-injury phases of care prior to their arrival in a specialized spinal injury high dependency unit (HDU), intensive care unit (ICU), or operating room (OR). This study found that a significant proportion of these patients experience periods of relative hypotension prior to their admission to a specialized spinal unit. In particular, the mean calculated MAP was 78.8 mm Hg, with 52% of MAP measurements <80 mm Hg at primary receiving hospitals. Despite having a mean calculated MAP of 83.3 mm Hg in the emergency room of the tertiary hospital, 40% of the MAP measurements were <80 mm Hg. Although stringent monitoring and management of MAP may be facilitated and adhered to in a spinal HDU, ICU, or OR, it is important to recognize that acute traumatic SCI patients may experience many periods of relative hypotension prior to their arrival in such specialized units. This study highlights the need for education and awareness to optimize the hemodynamic management of acute SCI patients during the immediate post-injury period.

Prolonged Emergency Department Length of Stay is Not Associated with Worse Outcomes in Traumatic Brain Injury

BackgroundData suggest that prolonged Emergency Department length of stay (EDLOS) has a detrimental effect on outcomes in some critically ill patients. However, the relationship between EDLOS and outcomes in traumatic brain injury (TBI) has not been examined. ObjectiveOur objective was to determine the effect of EDLOS on neurologic outcomes in TBI patients. MethodsWe performed a retrospective analysis of a prospectively identified cohort of patients with moderate (Glasgow Coma Scale [GCS] score 9–13) and severe (GCS ≤ 8) TBI who presented to a Level 1 trauma center (2006–2010). Inclusion criteria were transfer to the intensive care unit (ICU) or operating room (OR) from the ED. Primary outcome was Glasgow Outcome Scale (GOS) score, a measure of neurologic function, at discharge. We used a proportional odds model to control for significant predictors of GOS in univariate analysis. ResultsTwo hundred and twenty-four patients were included in the analysis, 77 (34%) of which were transferred to the OR. Median EDLOS was 3.3 h and 81.2% of patients had a GOS score ≤3 (e.g., severe disability, vegetative, or deceased). In multivariable analyses, EDLOS was not associated with GOS score in either ICU bound (p = 0.57) or OR bound (p = 0.11) patients. Younger age, pupil reactivity, and absence of intubation were independent predictors of good outcomes in the ICU group. In OR patients, predictors of higher GOS score included presence of an epidural hemorrhage, absence of midline shift, and pupil reactivity. ConclusionsOur study demonstrates that EDLOS was not associated with poor outcomes in patients with moderate to severe TBI who required intensive care or early operative intervention in an academic Level 1 trauma center.

The “Coagulation Box” and a New Hemoglobin-Driven Algorithm for Bleeding Control in Patients With Severe Multiple Traumas

BackgroundExtensive hemorrhage is the leading cause of death in the first few hours following multiple traumas. Therefore, early and aggressive treatment of clotting disorders could reduce mortality. Unfortunately, the availability of results from commonly performed blood coagulation studies are often delayed whereas hemoglobin (Hb) levels are quickly available.ObjectivesIn this study, we evaluated the use of initial hemoglobin (Hb) levels as a guide line for the initial treatment of clotting disorders in multiple trauma patients.Patients and MethodsWe have developed an Hb-driven algorithm to initiate the initial clotting therapy. The algorithm contains three different steps for aggressive clotting therapy depending on the first Hb value measured in the shock trauma room, (SR) and utilizes fibrinogen, prothrombin complex concentrate (PCC), factor VIIa, tranexamic acid and desmopressin. The above-mentioned drugs were stored in a special “coagulation box” in the hospital pharmacy, and this box could be immediately brought to the SR or operating room (OR) upon request. Despite the use of clotting factors, transfusions using red blood cells (RBC) and fresh frozen plasma (FFP) were performed at an RBC-to-FFP ratio of 2:1 to 1:1.ResultsOver a 12-month investigation period, 123 severe multiple trauma patients needing intensive care therapy were admitted to our trauma center (mean age 48 years, mean ISS (injury severity score) 30). Fourteen (11%) patients died; 25 (mean age 51.5 years, mean ISS 53) of the 123 patients were treated using the “coagulation box,” and 17 patients required massive transfusions. Patients treated with the “coagulation box” required an average dose of 16.3 RBC and 12.9 FFP, whereas 17 of the 25 patients required an average dose of 3.6 platelet packs. According to the algorithm, 25 patients received fibrinogen (average dose of 8.25 g), 24 (96%) received PCC (3000 IU.), 14 (56%) received desmopressin (36.6 µg), 13 (52%) received tranexamic acid (2.88 g), and 11 (44%) received factor VIIa (3.7 mg). The clotting parameters markedly improved between SR admission and ICU admission. Of the 25 patients, 16 (64%) survived. The revised injury severity classification (RISC) predicted a survival rate of 41%, which corresponds to a standardized mortality ratio (SMR) of 0.62, which implies a higher survival rate than predicted.ConclusionsAn Hb-driven algorithm, in combination with the “coagulation box” and the early use of clotting factors, could be a simple and effective tool for improving coagulopathy in multiple trauma patients.

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Introduction: U.S. hospitals report 7.3 million injured patients require operative intervention annually. The current practices of anesthesiologists in the airway and resuscitation management of hemodynamically unstable patients in the emergency department (ED) or operating room (OR) are unknown. Hypothesis: Anesthesiologists who care for acutely injured patients practice per trauma surgery management guidelines. Methods: A 50-item survey was sent to all active attending members (n= 21,491) of the American Society of Anesthesiologists (ASA), distributed by email. Questions that determined preferred rapid sequence induction (RSI) agents, intubation techniques, training/certification, and resuscitation practices of participants when caring for hemodynamically unstable trauma patients in the ED or the OR were extracted. Results: 2,058 ASA members replied in the affirmative to providing care to trauma patients. 79% of respondents practiced in a designated trauma center, most of which were private institutions (65.8%) and in urban areas (59.5%). 36.2% of respondents were in practice for > 20 years and 36% of respondents were ATLS certified. 94.4% stated they were comfortable managing patients with multiple injuries, of whom 2/3 were not ATLS certified. Etomidate and succinylcholine were the RSI agents of choice. The preferred RSI intubation technique was direct or video-laryngoscopy except in patients with known cervical spine deficit, where 22% preferred a fiberoptic technique. 75.5% declared having an institutional massive transfusion protocol but only 13.2% would begin factor component therapy at initiation of red blood cell transfusion. Conclusions: Current practice of anesthesiologists caring for unstable trauma patients appears to differ from trauma surgery management guidelines with regard to RSI technique and initiation of massive transfusion. Etomidate is the preferred induction agent despite evidence suggesting an increase in mortality and organ dysfunction. Communication between trauma surgeon and anesthesiologist, and additional training and education of anesthesiologists, may bridge differences and provide optimal patient care.

A Roundtable Discussion: Embracing the Mobile Revolution

<i>A Roundtable Discussion:</i> Embracing the Mobile Revolution

Resuscitative emergency thoracotomy in a Swiss trauma centre

Resuscitative emergency thoracotomy (ET) is performed as a salvage manoeuvre for selected patients with trauma. However, reports from European trauma centres are scarce. A retrospective analysis was undertaken of injured patients who underwent resuscitative ET in the emergency department (ED) or operating room (OR) between January 1996 and September 2008. Survival in the ED and to hospital discharge was analysed using logistic regression. During the study interval 121 patients required a resuscitative thoracotomy, of which 49 (40·5 per cent) were performed in the ED and 72 (59·5 per cent) in the OR. Patients in the OR had higher blood pressure on arrival (median 110 versus 60 mmHg; P < 0·001), were less often in severe haemorrhagic shock (63 versus 94 per cent; P < 0·001), had fewer serious head injuries (Abbreviated Injury Score of 3 or above in 33 versus 53 per cent; P = 0·031) and more often had a penetrating stab wound as the dominating mechanism (25 versus 10 per cent; P = 0·042) compared with those in the ED. Ten patients (20 per cent) survived to hospital discharge after ED thoracotomy, compared with 53 (74 per cent) of those treated in the OR. Penetrating injury and Glasgow Coma Scale score above 8 were independent predictors of hospital survival following ED thoracotomy. No patient with a blunt injury and no detectable signs of life on admission survived. Three of 26 patients with blunt trauma and signs of life on admission survived to hospital discharge. Resuscitative ET may be life-saving in selected patients. Location of the procedure is dictated by injury severity and vital parameters. Outcome is best when signs of life are present on admission, even for blunt injuries.

Accuracy of stroke volume variation in predicting fluid responsiveness: a systematic review and meta-analysis

Stroke volume variation (SVV) appears to be a good predictor of fluid responsiveness in critically ill patients. However, a wide range of its predictive values has been reported in recent years. We therefore undertook a systematic review and meta-analysis of clinical trials that investigated the diagnostic value of SVV in predicting fluid responsiveness. Clinical investigations were identified from several sources, including MEDLINE, EMBASE, WANFANG, and CENTRAL. Original articles investigating the diagnostic value of SVV in predicting fluid responsiveness were considered to be eligible. Participants included critically ill patients in the intensive care unit (ICU) or operating room (OR) who require hemodynamic monitoring. A total of 568 patients from 23 studies were included in our final analysis. Baseline SVV was correlated to fluid responsiveness with a pooled correlation coefficient of 0.718. Across all settings, we found a diagnostic odds ratio of 18.4 for SVV to predict fluid responsiveness at a sensitivity of 0.81 and specificity of 0.80. The SVV was of diagnostic value for fluid responsiveness in OR or ICU patients monitored with the PiCCO or the FloTrac/Vigileo system, and in patients ventilated with tidal volume greater than 8 ml/kg. SVV is of diagnostic value in predicting fluid responsiveness in various settings.