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Acute colonic pseudo-obstruction (ACPO) is a condition characterized by acute dilation of the large bowel without evidence of mechanical obstruction that occurs in a variety of hospitalized patients with many predisposing factors. Management includes supportive care and limitation of offending medications with mainstays of treatment of neostigmine administration and colonic decompression. We report the case of a critically ill patient with ACPO who experienced bradycardia and a brief episode of asystole when receiving concomitant dexmedetomidine and neostigmine infusions but who later remained hemodynamically stable when receiving propofol and neostigmine infusions. The bradycardia and associated hemodynamic instability experienced while on dexmedetomidine and neostigmine infusions were rapidly corrected with atropine and cessation of offending agents. Because ACPO is encountered frequently and the use of dexmedetomidine as a sedative agent in the ICU is increasing, practitioners should be aware of the additive risk of bradycardia and potential for asystole with the combination of neostigmine and dexmedetomidine. Electronic drug interaction databases should be updated and drug information sources should include a drug-drug interaction between dexmedetomidine and neostigmine to reduce the likelihood of concomitant administration.

Enterocutaneous fistulae (ECF) and enteroatmospheric fistulae (EAF) are difficult complications that primarily arise after abdominal surgical procedures. Development of an ECF or EAF carries significant mortality and morbidity. Effective management of patients with these disease states requires a multidisciplinary approach, which includes surgical, pharmacotherapeutic, and nutritional interventions. This review focuses on the medical and nutritional management of ECF/EAF, providing background on drug agents and nutritional strategies that may be helpful in reducing effluent volume, optimizing fistula healing, and maintaining nutritional health.

BackgroundAccurate medication reconciliation in trauma patients is essential but difficult. Currently there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS) based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.MethodsPlasma samples were collected from 356 patients who provided informed consent including-10 healthy controls, 19 known positive or negative controls and 327 trauma patients over 65 years of age who were evaluated at our large, urban Level 1 Trauma Center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage was compared with LCMS results to determine overall accuracy, sensitivity, specificity and positive and negative predictive values (PPV, NPV) of the assay.ResultsOf 356 patients, 39 were on DOACs (10.96%): 21 were on Apixaban, 14 on rivaroxaban and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.06%, (PPV 92.50% and NPV 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.11% (PPV 86.36% and NPV 99.40%). There were three false positive results and two false negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.ConclusionsThis LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.Study type: diagnostic testBasic Science paper: therefore does not require a level of evidence.

Traumatic injuries to the abdominal cavity are not uncommon trauma. Traumatic injuries requiring surgery mandate a consistent and reproducible entry into the abdominal cavity. This chapter will provide a sound and reproducible approach to the abdomen.

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

Purpose Results of an initiative at an academic medical center to reduce prescription opioid use in patients with acute traumatic injuries are reported. Methods In 2014, the University of Kentucky Hospital trauma service implemented a pain management strategy consisting of patient and provider education emphasizing the use of nonopioid analgesics to minimize opioid use without compromising analgesia effectiveness. To assess the impact of the initiative, a retrospective analysis of data on cohorts of patients admitted with acute trauma before ( n = 489) and after ( n = 424) project implementation was conducted. The primary endpoint was opioid use (prescribed daily milligram morphine equivalents [MME]) at discharge. Secondary endpoints included inpatient opioid and alternative analgesic use, pain control, ileus development, length of stay, and discharge disposition. Results Compared with the preintervention cohort, the postintervention cohort had a lower median daily discharge MME overall (45 MME versus 90 MME, p Conclusion Targeted provider and patient education on minimizing opioid use was associated with a reduction in MME on discharge from the hospital after traumatic injury.

Transfusion-related immunomodulation consists of both proinflammatory and anti-inflammatory responses after transfusion of blood products. Stored red blood cells (RBCs) suppress human T-cell proliferation in vitro, but the mechanism remains unknown. We hypothesized that cytokine synthesis by T cells may be inhibited when stored RBCs are present and that suppression between fresh and stored RBCs would be different.Purified human T cells were stimulated to proliferate with anti-CD3/anti-CD28 and then exposed to stored or fresh RBCs. Cells were placed in culture for 5 days. Cell culture supernatants were analyzed for the production of typical T-cell cytokines using multianalyte ELISArray kits.Stimulated T cells proliferated. RBC exposure markedly suppressed this proliferation. Interleukin 10, interleukin 17a, interferon γ, tumor necrosis factor α, and granulocyte macrophage colony-stimulating factor were increased in response to stimulation but depressed in the presence of stored RBCs. The use of fresh RBCs also resulted in depression of these cytokines when compared with stimulated T cells with no RBCs; however, this depression was less pronounced.T-cell activation is associated with both proinflammatory and anti-inflammatory cytokine release, comparable with patterns seen in trauma and acute injury. All of these responses are depressed by an exposure to stored RBCs. Decreased levels of these cytokines after RBC transfusion represents a potential contributor to the immunosuppressive complications seen in trauma patients after transfusion. This provides insight for future mechanistic studies to delineate the role of RBC transfusion in transfusion-related immunomodulation.

Surgical resident rotations on trauma services are criticized for little operative experience and heavy workloads. This has resulted in diminished interest in trauma surgery among surgical residents. Acute care surgery (ACS) combines trauma and emergency/elective general surgery, enhancing operative volume and balancing operative and nonoperative effort. We hypothesize that a mature ACS service provides significant operative experience.A retrospective review was performed of ACGME case logs of 14 graduates from a major, academic, Level I trauma center program during a 3-year period. Residency Review Committee index case volumes during the fourth and fifth years of postgraduate training (PGY-4 and PGY-5) ACS rotations were compared with other service rotations: in total and per resident week on service.Ten thousand six hundred fifty-four cases were analyzed for 14 graduates. Mean cases per resident was 432 ± 57 in PGY-4, 330 ± 40 in PGY-5, and 761 ± 67 for both years combined. Mean case volume on ACS for both years was 273 ± 44, which represented 35.8% (273 of 761) of the total experience and exceeded all other services. Residents averaged 8.9 cases per week on the ACS service, which exceeded all other services except private general surgery, gastrointestinal/minimally invasive surgery, and pediatric surgery rotations. Disproportionately more head/neck, small and large intestine, gastric, spleen, laparotomy, and hernia cases occurred on ACS than on other services.Residents gain a large operative experience on ACS. An ACS model is viable in training, provides valuable operative experience, and should not be considered a drain on resident effort. Valuable ACS rotation experiences as a resident may encourage graduates to pursue ACS as a career.

The emergency care of ventral hernias is complex. The key to improved morbidity and mortality is operating on these patients prior to progressing to strangulation. The type of operation depends on many factors, including location of the hernia, patient’s physiology, imaging findings, and prior repairs with or without mesh. The operations can be open, laparoscopic, or a combination of both. The use of laparoscopy has a significant role in assessing bowel viability and repair. Dealing with large ventral hernias in a damage control surgery should focus on sepsis source control and abdominal closure. In these patients, definitive and complex abdominal wall closures with non-biologic prosthesis should be avoided. The goal is survival and planning a formal abdominal wall construction in the future with a non-biologic prosthesis. This chapter will review these topics.

Despite the prevalence of acute pain in the trauma setting and known complications of its improper management, including risk of chronic pain, delayed recovery, and poorer quality of life, recent survey data suggest little has changed in the overall management of pain in the acute setting during the

Acute care surgery (ACS) includes trauma, surgical critical care, and emergent general surgery. There is a national shortage of institutions that can provide for patients needing access to emergency surgical care. Inability to fund ACS surgeons can be a barrier. We hypothesize that an ACS service, in an appropriately staffed hospital, generates a positive contribution margin (CM).Fiscal data for 2009 were retrospectively reviewed at the University of Kentucky, a Level I trauma center with an ACS service. Contribution margin (ie, net revenue minus direct costs) and mean length of stay were calculated for all patients admitted to the ACS service. Inpatient data were stratified by trauma vs general surgery, emergent vs elective, and by payor mix.Annual CM associated with the 5 ACS faculty was $21,799,000. Trauma generated higher CM than general surgery. General surgery had a greater CM, more if emergent than if elective ($9,500 vs $5,500; p0.01). Self-payment was lower with emergent general surgery vs trauma (20% vs 25%; p = 0.02).Acute care surgery generates a positive CM. Emergent general surgery generates a greater CM than elective general surgery because of increased case mix index. These data suggest that hospital subsidization of acute care surgeons is financially feasible and might address the surgical workforce shortage and the critical problem of access to emergency surgical services.

Background: Transfusion of packed red blood cells (PRBCs) is associated with morbidity and mortality. The mechanisms are not fully understood. Packed red blood cells deplete extracellular arginine and possess transporters for arginine, an amino acid essential for normal immunity. We hypothesize that the membrane yþ amino acid transporter contributes to arginine depletion in PRBCs. Materials and methods: We titrated PRBCs to a 10% hematocrit with phosphate-buffered saline, blocked PRBC yþ transporters using n-ethylmaleimide (0.2 mM), and measured arginine and ornithine levels using liquid chromatographyemass spectroscopy. We added radiolabeled L-arginine [4,5- 3 H] (10 mmol/L) added to similar culture conditions and measured arginine uptake in counts per minute (CPM). We examined storage periods of 6e 9d , 1e4 wk, and 6 wk, and correlated donor demographics with arginine uptake. Results: n-Ethylmaleimide blockade of yþ transporters impaired PRBC arginine depletion from culture media (117.6 � 8.6 mM versus 76.9 � 5.8 mM; P < 0.001) and reduced intracellular L-arginine (7,574 � 955 CPM versus 18,192 � 1,376 CPM; P < 0.01). Arginine depletion increased with storage duration (1 wk versus 6 wk; P < 0.002). With n-ethylmaleimide treatment, 6-wk-old PRBCs preserved more culture arginine (P < 0.008) than at shorter durations. Nine-day storage duration increased L-arginine uptake compared with 6- to 8-day storage (n ¼ 77, R ¼ 0.225, P < 0.05). Extracellular arginine depletion and extracellular ornithine synthesis varied among donors and correlated inversely (R ¼� 0.5, P ¼ 0.01). Conclusions: Membrane yþ transporters are responsible for arginine depletion by PRBCs. Membrane yþ activity increases with storage duration. Arginine uptake varies among donors. Membrane biology of RBCs may have a role in the negative clinical effects associated with PRBC transfusion.

INTRODUCTION Laparoscopic inguinal hernia repair can be performed totally extraperitoneal or transabdominal preperitoneal (TAPP). Both repairs are associated with mesh-related complications. This is the first report of a mesh-strangulated appendix, with subsequent necrosis and perforation, after TAPP inguinal hernia repair. CASE A 48-year-old male, 10-years status post-bilateral TAPP inguinal hernia repair presented with acute right groin bulge, pain, nausea, emesis, and fever. He was found to have a large, tender, nonreducible right groin mass. He was taken to the operating room for right groin exploration and found to have gross purulent material but no evidence of a recurrent hernia. A laparoscope was inserted into the abdomen where the appendix was found strangulated between the mesh and the transversalis fascia. CONCLUSIONS Mesh-related complications after TAPP inguinal hernia repair are rare. This is the first report of a strangulated appendix secondary to mesh entrapment after TAPP repair.

Studies of specific procedures have shown increases in infectious complications with operative duration. We hypothesized that operative duration is independently associated with increased risk-adjusted infectious complication (IC) rates in a broad range of general surgical procedures.We queried the American College of Surgeons National Surgical Quality Improvement Program database for general surgical operations performed from 2005 to 2007. ICs (wound infection, sepsis, urinary tract infection, and/or pneumonia) and length of hospital stay (LOS) were evaluated versus operative duration (OD, ie, incision to closure). Multivariable regression adjusted for 38 patient risk variables, operation type and complexity, wound class and intraoperative transfusion. We also analyzed isolated laparoscopic cholecystectomies in patients of American Society of Anesthesiologists class 1 or 2, without intraoperative transfusion and with a clean or clean-contaminated wound class.In 299,359 operations performed at 173 hospitals, unadjusted IC rates increased linearly with OD at a rate of close to 2.5% per half hour (chi-square test for linear trend, p0.001). After adjustment, IC risk increased for each half hour of OD relative to cases lastingor=1 hour, almost doubling at 2.1 to 2.5 hours (odds ratio = 1.92; 95% CI, 1.82 to 2.03; p0.001). In isolated laparoscopic cholecystectomy, IC rates increased linearly with OD (n = 17,018, chi-square test for linear trend, p0.001) with rates for 1.1 to 1.5 hour cases (1.4%) doubling those lastingor=0.5 hour (0.7%). Across all procedures, adjusted LOS increased geometrically with operative duration at a rate of about 6% per half hour (coefficient for natural log transformed LOS = 0.059 per half hour; 95% CI, 0.058 to 0.060; p0.001).Operative duration is independently associated with increased ICs and LOS after adjustment for procedure and patient risk factors.

Hernia is derived from the Latin word meaning “rupture or protrusion”. A hernia is the protrusion of tissue or an organ through a defect or weakness in the surrounding walls. Abdominal wall hernias occur at sites lacking a covering with overlapping aponeuroses and fascia. Hernias can be present at birth (congenital), develop spontaneously over time or as a result of surgery or trauma. Areas on the ventral abdominal wall prone to hernia formation are located at the arcuate line, epigastric, inguinal and umbilical hernias. Iatrogenic hernias on the abdominal wall occur at sites of surgical incisions (incisional hernias).

METHODS: A consecutive series of 119 rectal cancer patients were analyzed. Twenty match pairs were established identical regarding gender, tumor site, tumor stage, neoadjuvant radiotherapy and type of surgery. Urogenital and anorectal function was evaluated prospectively using standardized questionnaires (International Prostate Symptom Score, Quality of life due to urinary symptoms, Wexner score, International Index of Erectile Function and Female Sexual Function Index), measurement of residual urine volume and longterm-catheterization.

Mediastinal abscess can be managed through a variety of both invasive and minimally invasive methods, as determined by location and spread of infection. Thoracotomy remains the gold standard in treatment and is often employed. In the present case, a 54-year-old female with chronic pancreatitis presented with a 1-week history of severe epigastric pain, nausea and vomiting. On CT scan, a large abscess was discovered in the anterior inferior mediastinum. She was taken to the operating room and underwent laparoscopic drainage of the abscess. Laparoscopy represents a novel approach in management of anterior inferior mediastinal abscess.

Object The impact of surgeons and anesthesiologists, both individually and paired, on the length of operative procedures was studied. Methods Five general surgeons, six neurosurgeons, and 21 anesthesiologists all completed two personality assessments. A retrospective review of OR records of six procedure types performed by those in the study (2,087 neurosurgical and 2,107 general surgery) was conducted. Statistical analysis was employed to estimate various effects on OR times and to identify the importance of each factor. Results Surgeon effect on OR time varies with procedure type but was greater in neurosurgical cases: LMD (16%), ACDF (14.5%), cranioplasties (6.6%). The combination of surgeon and anesthesiologist had a significant effect on length of the operation: ACDF (7.6%) and LMD (12.5%). Conclusion In some procedures types a significant part of the variability in operative time is due to the interaction between the surgeon and anesthesiologist. Reviewing operative records should allow identification of efficient/inefficient combinations.