Karen Safcsak

Percutaneous Catheter Decompression in the Treatment of Elevated Intraabdominal Pressure

BACKGROUNDnIntraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) traditionally have been treated surgically through emergent laparotomy. Intensivist-performed bedside drainage of free intraperitoneal fluid or blood (percutaneous catheter decompression [PCD]) has been advocated as a less-invasive alternative to open abdominal decompression (OAD).nnnMETHODSnA single-center disease and severity of illness-matched case-control comparison of 62 patients with IAH/ACS treated with PCD vs traditional OAD was performed. The relative efficacy of each treatment in reducing elevated intraabdominal pressure (IAP) and improving organ dysfunction was assessed. Physiologic and demographic predictors of successful PCD therapy were determined.nnnRESULTSnPCD and OAD both were effective in significantly decreasing IAP and peak inspiratory pressure as well as in increasing abdominal perfusion pressure. PCD potentially avoided the need for subsequent OAD in 25 of 31 patients (81%) treated. Successful PCD therapy was associated with fluid drainage of > 1,000 mL or a decrease in IAP of > 9 mm Hg in the first 4 h postdecompression.nnnCONCLUSIONSnIntensivist-performed PCD is an effective and less-invasive technique for treating patients with IAH/ACS where free intraperitoneal fluid or blood is present as determined by bedside ultrasonography. Failure to drain at least 1,000 mL of fluid and decrease IAP by at least 9 mm Hg in the first 4 h postdecompression is associated with PCD failure and should prompt urgent OAD.

Longterm Impact of Abdominal Decompression: A Prospective Comparative Analysis

BACKGROUNDnAbdominal decompression is widely used to treat end-organ dysfunction associated with intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The longterm impact of abdominal decompression on physical and mental health, quality of life, and subsequent employment remains unclear.nnnSTUDY DESIGNnA prospective cohort study was performed at a tertiary referral/Level I trauma center. All patients who required abdominal decompression for more than 48 hours were asked to complete the SF-36v2 health survey at regular intervals for 2 years postdecompression. Patients discharged with a chronic incisional hernia (OPEN) were compared with those discharged with primary fascial closure (CLOSED) and with the general population. Quality-adjusted life years (QALYs) and successful return to employment were determined.nnnRESULTSnFrom June 2002 to May 2005, 245 consecutive patients required abdominal decompression for intraabdominal hypertension and abdominal compartment syndrome. Forty-four patients (30 OPEN, 14 CLOSED) met inclusion criteria and completed their health surveys. At 6 months postdecompression, physical and social functioning were significantly decreased among OPEN, but not CLOSED, patients when compared with the general population. By 18 months, OPEN patients demonstrated normal physical and mental health perception. OPEN and CLOSED patients exhibited decreased, but identical, quality-adjusted life years (1.20+/-0.11 versus 1.23+/-0.25 [mean +/- SD]; p=0.39) and similar ability to resume employment (41% versus 55%; p=0.49).nnnCONCLUSIONSnAbdominal decompression does not have a negative impact on longterm physical or mental health perception. Quality of life and ability to resume employment are not improved by same-admission primary fascial closure. Abdominal decompression is not as debilitating and life altering as might be expected.

Diagnosis of appendicitis in pregnancy.

BACKGROUNDnThe diagnosis of appendicitis in pregnant patients is challenging.nnnMETHODSnThe records of pregnant patients with suspected appendicitis were reviewed.nnnRESULTSnForty-seven patients with suspected appendicitis were identified. Twenty-four patients did not undergo surgery. Twenty-three patients had ultrasound (US), none of which visualized the appendix. Seventeen patients were followed up clinically and improved. Six patients had a negative computed tomography (CT) and none required surgery. Twenty-three patients underwent surgery for presumed appendicitis. Three patients had no imaging. Twelve patients had US only; US was positive in 5 patients and all had appendicitis. Seven patients who underwent surgery had a nondiagnostic US. One patient had appendicitis. Seven patients had a positive CT and appendicitis at surgery. One patient had a positive US and magnetic resonance imaging, and had appendicitis. A total of 43 patients had US, of which 86% were nondiagnostic. Six US were read as positive and all patients had appendicitis. Thirteen patients had CT with no false-positive or false-negative results.nnnCONCLUSIONSnUS, when read as positive, requires no further confirmatory test other than surgery. If US is nondiagnostic, further imaging may avoid a negative appendectomy.

Resuscitative Endovascular Balloon Occlusion of the Aorta and Resuscitative Thoracotomy in Select Patients with Hemorrhagic Shock: Early Results from the American Association for the Surgery of Trauma’s Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry

BACKGROUNDnAortic occlusion is a potentially valuable tool for early resuscitation in patients nearing extremis or in arrest from severe hemorrhage.nnnSTUDY DESIGNnThe American Association for the Surgery of Traumas Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry identified trauma patients without penetrating thoracic injury undergoing aortic occlusion at the level of the descending thoracic aorta (resuscitative thoracotomy [RT] or zone 1 resuscitative endovascular balloon occlusion of the aorta [REBOA]) in the emergency department (ED). Survival outcomes relative to the timing of CPR need and admission hemodynamic status were examined.nnnRESULTSnTwo hundred and eighty-five patients were included: 81.8% were males, with injury due to penetrating mechanisms in 41.4%; median age was 35.0 years (interquartile range 29 years) and median Injury Severity Score was 34.0 (interquartile range 18). Resuscitative thoracotomy was used in 71%, and zone 1 REBOA in 29%. Overall survival beyond the ED was 50% (RT 44%, REBOA 63%; pxa0= 0.004) and survival to discharge was 5% (RT 2.5%, REBOA 9.6%; pxa0= 0.023). Discharge Glasgow Coma Scale score was 15 in 85% of survivors. Prehospital CPR was required in 60% of patients with a survival beyond the ED of 37% and survival to discharge of 3% (all p > 0.05). Patients who did not require any CPR before had a survival beyond the ED of 70% (RT 48%, REBOA 93%; p < 0.001) and survival to discharge of 13% (RT 3.4%, REBOA 22.2%, pxa0= 0.048). If aortic occlusion patients did not require CPR but presented with hypotension (systolic blood pressure <90 mmHg; 9% [65% RT; 35% REBOA]), they achieved survival beyond the ED in 65% (pxa0= 0.009) and survival to discharge of 15% (RT 0%, REBOA 44%; pxa0= 0.008).nnnCONCLUSIONSnOverall, REBOA can confer a survival benefit over RT, particularly in patients not requiring CPR. Considerable additional study is required to definitively recommend REBOA for specific subsets of injured patients.

Psychological Effect of a Mass Casualty Event on General Surgery Residents

OBJECTIVEnTo evaluate the psychological effect of a mass casualty shooting event on general surgery residents.nnnDESIGNnThree and 7 months following the Pulse nightclub mass casualty shooting, the mental well-being of general surgery residents employed at the receiving institution was evaluated. A voluntary and anonymous screening questionnaire for posttraumatic stress disorder (PTSD) and major depression (MD) was administered. Responses were stratified into 2 groups; residents who worked (ON-CALL) and residents who did not work (OFF-CALL) the night of the event. Data were analyzed using Mann-Whitney U and Fishers exact tests and are reported as median with interquartile range (IQR) or percentage.nnnSETTINGnLevel I trauma center.nnnPARTICIPANTSnThirty-one general surgery residents.nnnRESULTSnTwenty-four residents (77%) returned the 3-month questionnaire: 10 ON-CALL and 14 OFF-CALL. There was no difference in PTSD and MD between the 2 groups (30% vs. 14%; p = 0.61) and (30% vs. 7%; p = 0.27), respectively. Twenty-three of the 24 residents responded to the 7-month questionnaire. Over time, the incidence of PTSD did not resolve in the ON-CALL group, but did resolve in the OFF-CALL group (30% vs. 0%; p = 0.07). There was no significant change in the incidence of MD in either group (30% vs. 8%; p = 0.28). At 7 months postevent, more residents in both groups stated that they had sought counseling (30% vs. 44%; p = 0.65) and (0% vs. 15%; p = 0.22).nnnCONCLUSIONSnThe emotional toll associated with this mass casualty event had a substantial effect upon the general surgery residents involved. With the incidence of PTSD and MD identified, we believe that all residents should be provided with counseling following such events.

Trauma Patients with an Open Abdomen Following Damage Control Laparotomy can be Extubated Prior to Abdominal Closure

BackgroundThe open abdomen (OA) is commonly utilized as a technique during damage control laparotomy (DCL). We propose that a selected group of these OA patients can be extubated prior to abdominal closure to decrease ventilator days and risk of pneumonia.MethodsA retrospective chart review was performed at a Level I trauma center on all adult trauma patients with an OA following DCL. Patients were stratified into two groups: extubated prior to (PRE) and extubated after (POST) abdominal closure. Successful extubation in the PRE group was measured by the absence of re-intubation. The two groups were compared using the Mann–Whitney U and Fisher’s exact tests. Multivariate logistic regression identified independent predictors for successful extubation prior to abdominal closure.ResultsThirty-one patients were in the PRE group, and 59 patients in the POST group. There were no differences between the groups with regard to age, gender, or hours from admission to completion of DCL. The PRE group had a significantly higher incidence of penetrating trauma (77 vs. 53%; pu2009=u20090.02), a significantly lower number of days from OA to extubation [0.6 (0.2–1.1) vs. 3.4 (2–-8) days; pu2009<u20090.001], and a significant decrease in pneumonia (10 vs. 31%; pu2009=u20090.04). Two patients in each group required re-intubation [PRE (6%) vs. POST (3%); pu2009=u20090.61]. In a multivariate binominal logistic regression, penetrating trauma (pu2009=u20090.024), GCS on admission (pu2009<u20090.0001), and Injury Severity Score (pu2009=u20090.024) were identified as independent predictors for successful extubation.ConclusionPresence of an OA following DCL does not require mechanical ventilation. Extubation of appropriate trauma patients prior to abdominal closure decreases pneumonia and hospital length of stay.

Intensive Care Unit Management of the Adult Open Abdomen

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), the pathophysiologic manifestations of elevated intra-abdominal pressure (IAP), are commonly encountered but under-appreciated causes of organ dysfunction, organ failure, and patient mortality in the ICU. Due to its detrimental physiologic effects, every attempt should be made to minimize the development of elevated IAP in the critically ill. Serial IAP measurements, optimization of systemic perfusion and end-organ function, institution of multimodality medical management strategies to minimize IAP, and prompt surgical decompression for refractory IAH/ACS are essential to reducing patient morbidity and mortality in the ICU setting.

Simulation-Based Testing of Pager Interruptions During Laparoscopic Cholecystectomy

OBJECTIVEnTo determine if pager interruptions affect operative time, safety, or complications and management of pager issues during a simulated laparoscopic cholecystectomy.nnnDESIGNnTwelve surgery resident volunteers were tested on a Simbionix Lap Mentor II simulator. Each resident performed 6 randomized simulated laparoscopic cholecystectomies; 3 with pager interruptions (INT) and 3 without pager interruptions (NO-INT). The pager interruptions were sent in the form of standardized patient vignettes and timed to distract the resident during dissection of the critical view of safety and clipping of the cystic duct. The residents were graded on a pass/fail scale for eliciting appropriate patient history and management of the pager issue. Data was extracted from the simulator for the following endpoints: operative time, safety metrics, and incidence of operative complications. The Mann-Whitney U test and contingency table analysis were used to compare the 2 groups (INT vs. NO-INT).nnnSETTINGnLevel I trauma center; Simulation laboratory.nnnPARTICIPANTSnTwelve general surgery residents.nnnRESULTSnThere was no significant difference between the 2 groups in any of the operative endpoints as measured by the simulator. However, in the INT group, only 25% of the time did the surgery residents both adequately address the issue and provide effective patient management in response to the pager interruption.nnnCONCLUSIONnPager interruptions did not affect operative time, safety, or complications during the simulated procedure. However, there were significant failures in the appropriate evaluations and management of pager issues. Consideration for diversion of patient care issues to fellow residents not operating to improve quality and safety of patient care outside the operating room requires further study.

Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Acute Care Surgery

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), the pathophysiologic manifestations of elevated intra-abdominal pressure (IAP), are commonly encountered, but underappreciated causes of morbidity and mortality among acute care surgery patients. Every attempt should be made to avoid elevated IAP due to its detrimental physiologic effects. The therapeutic decisions made by the acute care surgeon with regard to IAH/ACS have far-reaching implications on the patient’s subsequent hospital course and survival. In the operating room, staged laparotomy and temporary abdominal closure should be strongly considered in patients who are deemed too ill to tolerate definitive repair, when abdominal contamination cannot be safely controlled during a single procedure, or when primary fascial closure would place the patient at risk for postoperative IAH/ACS. In the intensive care unit, serial IAP measurements, optimization of systemic perfusion and end-organ function, institution of multi-modality medical management strategies to reduce IAP to less injurious levels, and prompt surgical decompression for refractory IAH/ACS are essential to the successful treatment of these patients. Throughout the patient’s hospital course, meticulous surgical management and attention to detail are essential to reducing patient morbidity and mortality as well as achieving the desired goal of definitive primary fascial closure.