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As a result of many years of research, the intricate cellular mechanisms of burn injury are slowly becoming clear. Yet, knowledge of these cellular mechanisms and a multitude of resulting studies have often failed to translate into improved clinical treatment for burn injuries. Perhaps the most valuable information to date is the years of clinical experience and observations in the management and treatment of patients, which has contributed to a gradual improvement in reported outcomes of mortality. This review provides a discussion of the cellular mechanisms and pathways involved in burn injury, resultant systemic effects on organ systems, current management and treatment, and potential therapies that we may see implemented in the future.

OBJECTIVES To evaluate the improvement in lung donation and immediate lung function after the implementation of a 360° rotational positioning protocol within an organ procurement organization in the Midwest. DESIGN Retrospective observational study. SETTING The Midwest Transplant Network from 2005 to 2017. Rotational positioning of donors began in 2008. SUBJECTS Potential deceased lung donors. INTERVENTIONS A 360° rotational protocol. Presence of immediate lung function in recipients, change in PaO2:FIO2 ratio during donor management, initial and final PaO2:FIO2 ratio, and proportion of lungs donated were measured. Outcomes were compared between rotated and nonrotated donors. MEASUREMENTS AND MAIN RESULTS A total of 693 donors were analyzed. The proportion of lung donations increased by 10%. The difference between initial PaO2:FIO2 ratio and final PaO2:FIO2 ratio was significantly different between rotated and nonrotated donors (36 ± 116 vs 104 ± 148; p < 0.001). Lungs transplanted from rotated donors had better immediate function than those from nonrotated donors (99.5% vs 68%; p < 0.001). CONCLUSIONS There was a statistically significant increase in lung donations after implementing rotational positioning of deceased donors. Rotational positioning significantly increased the average difference in PaO2:FIO2 ratios. There was also superior lung function in the rotated group. The authors recommend that organ procurement organizations consider adopting a rotational positioning protocol for donors to increase the lungs available for transplantation.

Intestinal malrotation is a well-known surgical disease in the pediatric population with 90 % of cases presenting by 1 year of age (Palmer et al. in Dig Dis Sci). Laparoscopic Ladd procedures have been described in the pediatric population with good outcomes, and there are limited data suggesting this as an acceptable approach in adults (Palmer et al. in Dig Dis Sci; Draus et al. in Am Surg 73:693–696, 2007; Bass et al. in J Pediatr Surg 33:279–281, 1998). To date, there have been no documented cases of robotic assistance for this procedure. In this case, we describe a 22-year-old female with intestinal malrotation who was treated successfully with the first described robotic-assisted laparoscopic Ladd procedure.

Problem Despite clear prophylactic guidelines and national quality emphasis, a minority of hospitalized patients receive appropriate prophylaxis for venous thromboembolism (VTE). Data from the University of Kansas Hospital (KUH) revealed an unacceptably high incidence of VTE. Approach The authors aligned continuing education with quality improvement through formation of an interprofessional, multidisciplinary team to develop strategic educational and system operational plans to decrease VTE incidence. The authors reviewed 261 charts with the secondary diagnosis of VTE for identification of themes or causes of VTE to develop multipronged educational and system-based action plans. The authors reviewed a "menu" of evidence-based content delivery techniques to develop the educational plan. Multiple noneducational adjunct system strategies were also developed and implemented. Outcomes After implementation of all specific action plans, the KUH VTE incidence decreased 51% from November 2010 to June 2012 (from 12.68 to 6.10 per 1,000 patients). Insertion of peripherally inserted central catheters, a common identified theme, dropped from almost 360 insertions in December of 2010 to less than 200 insertions in April 2012. Next steps Aligning continuing education with quality improvement through an interprofessional, multidisciplinary team approach was associated with a decrease in VTE. The authors describe challenges and lessons learned to inform implementation of similar quality-improvement-driven continuing education initiatives elsewhere. Challenges included time, resources, multiple service lines, and departments with variable acceptance of data. Lessons learned included the value of leadership commitment, interprofessional team work, assessing individual data, expertise of continuing education, using multiple educational methods, and the need for overall champions.

Jessica Heimes *, Elizabeth Carlton , Jessica McDonnell , Tracy Rogers , Khadi Udobi , Michael Moncure a Department of Surgery, The University of Kansas Medical Center, United States The University of Kansas Medical Center, Department of Surgery, Division of Trauma, United States University of Kansas Hospital, Department of Surgery, Division of Trauma, United States b u r n s 3 9 ( 2 0 1 3 ) e 2 9 – e 3 3

BACKGROUND Rib fractures are common in trauma admissions and are associated with an increased risk of pulmonary complications, intensive care unit admissions, and mortality. Providing adequate pain control in patients with multiple rib fractures decreases the risk of adverse events. Thoracic epidural analgesia is currently the preferred method for pain control. This study compared outcomes in patients with multiple acute rib fractures treated with posterior paramedian subrhomboidal (PoPS) analgesia versus thoracic epidural analgesia (TEA). METHODS This prospective study included 30 patients with three or more acute rib fractures admitted to a Level I trauma center. Thoracic epidural analgesia or PoPS catheters were placed, and local anesthesia was infused. Data were collected including patients' pain level, adjunct morphine equivalent use, adverse events, length of stay, lung volumes, and discharge disposition. Nonparametric tests were used and two-sided p < 0.05 were considered statistically significant. RESULTS Nineteen (63%) of 30 patients received TEA and 11 (37%) of 30 patients received PoPS. Pain rating was lower in the PoPS group (2.5 vs. 5; p = 0.03) after initial placement. Overall, there was no other statistically significant difference in pain control or use of oral morphine adjuncts between the groups. Hypotension occurred in eight patients, 75% with TEA and only 25% with PoPS. No difference was found in adverse events, length of stay, lung volumes, or discharge disposition. CONCLUSION In patients with rib fractures, PoPS analgesia may provide pain control equivalent to TEA while being less invasive and more readily placed by a variety of hospital staff. This pilot study is limited by its small sample size, and therefore additional studies are needed to prove equivalence of PoPS compared to TEA. LEVEL OF EVIDENCE Therapeutic study, level IV.

We hypothesized that strict enforcement of ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP and improve patient outcomes.This retrospective study examined 696 consecutive ventilated patients in a Level One trauma center. Three study groups were compared: Pre-VAPP, VAPP implementation, and VAPP enforcement. Ventilator days were compared with occurrences of VAP, defined by the U.S. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to evaluate the effect of VAP on patient outcome. Fisher exact, Kruskal-Wallis, and chi-square analyses were used, and p0.05 was considered significant.During the pre-VAPP protocol period, 5.2 cases of VAP occurred per 1,000 days of ventilator support. The number of cases of VAP decreased to 2.4/1,000 days (p = 0.172) and 1.2/1,000 days (p = 0.085) in the implementation and enforcement periods, respectively. However, when including all trauma patients, regardless of head Abbreviated Injury Score (AIS) score, the difference in the rate of VAP was statistically significant in the enforcement period, but not in the implementation period, compared with the pre-VAPP period (p = 0.014 and 0.062, respectively). A significant decrease was seen in the mortality rate (p = 0.024), total hospital days (p = 0.007), intensive care unit days (p = 0.002), ventilator days (p = 0.002), and hospital charges (p = 0.03) in patients without VAP compared with patients having VAP.There was a statistically significant decrease in the occurrence of VAP with strict enforcement of a VAPP protocol, regardless of head AIS score. Although the difference in patients with a head AIS score3 was not statistically significant, it was clinically meaningful, decreasing the already-low rate of VAP by half. Strict enforcement of VAPP protocols may be cost efficient for hospitals and prevent decreased reimbursement under the Medicare pay-for-performance strategies.

Currently, specific triage criteria, such as blood pressure, respiratory status, Glasgow Coma Scale, and mechanism of injury are used to categorize trauma patients and prioritize emergency department (ED) and trauma team responses. It has been demonstrated in previous literature that an abnormal shock index (SI = heart rate [HR]/systolic blood pressure,0.9) portends a worse outcome in critically ill patients. Our study looked to evaluate the SI calculated in the field, on arrival to the ED, and the change between field and ED values as a simple and early marker to predict mortality in traumatically injured patients.A retrospective chart review of the trauma registry of an urban level I trauma center. Analysis of 2,445 patients admitted over 5 years with records in the trauma registry of which 1,166 also had data for the field SI. An increase in SI from the field to the ED was defined as any increase in SI regardless of the level of the magnitude of change.Twenty-two percent of patients reviewed had an ED SI0.9, with a mortality rate of 15.9% compared with 6.3% in patients with a normal ED SI. An increase in SI between the field and ED signaled a mortality rate of 9.3% versus 5.7% for patients with decreasing or unchanged SI. Patients with an increase in SI ofor=0.3 had a mortality rate of 27.6% versus 5.8% for patients with change in SI of0.3.Trauma patients with SI0.9 have higher mortality rates. An increase in SI from the field to the ED may predict higher mortality. The SI may be a valuable addition to other ED triage criteria currently used to activate trauma team responses.

We hypothesized that implementing evidence-based ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP, and that VAP affects patient outcomes.A prospective study was performed with 331 consecutive ventilated trauma patients in a level one university teaching hospital. The VAPP protocol was modified to include elevation of the head of the bed more than 30 degrees , twice-daily chlorhexidine oral cleansing, a once-daily respiratory therapy-driven weaning attempt, and conversion from a nasogastric to an orogastric tube whenever possible. Ventilator days were compared with occurrences of nosocomial pneumonia, as defined by the U.S. Centers for Disease Control National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to discern the effect VAP has on outcome.In 2003, there were 1,600 days of ventilator support with 11 occurrences of VAP (6.9/1,000 ventilator days). In 2004, there were two occurrences of VAP in 703 days of ventilation (2.8/1,000 ventilator days). In the analysis of outcomes of the patients with and without VAP, there was a statistically significant difference in total hospital days (38.7 +/- 26.2 vs. 13.3 +/- 15.5), ICU days (27.8 +/- 12.6 vs. 7.5 +/- 9.7), ventilator days (21.1 +/- 9.8 vs. 6.0 +/- 10.3), Functional Independence Measures (7.25 +/- 2.3 vs. 10.8 +/- 1.8), and hospital charges ($371,416.70 +/- $227,774.31 vs. $138,317.39 +/- $208,346.64)(p0.05 for all). The mortality rate did not decrease significantly (20% vs. 7.5%; p = NS). The difference in the mean Injury Severity Score in the two groups was not significant (21.9 +/- 9.6 vs. 16.7 +/- 11.4 points) and thus could not account for the differences in outcomes.These data suggest that a VAPP protocol may reduce VAP in trauma patients. Ventilator-associated pneumonia may result in more hospital, ICU, and ventilator days and higher patient charges.

Objective The quantity of nutrition that is provided to intensive care unit (ICU) patients has recently come under more scrutiny in relation to clinical outcomes. The primary objective of this study was to assess energy intake in severely ill ICU patients and to evaluate the relationship of energy intake with clinical outcomes. Design Prospective cohort study. Subjects/Settings Seventy-seven adult surgery and medical ICU patients with length of ICU stay of at least 5 days. Statistical Analyses Performed Student's t test and χ 2 tests were used to examine ICU populations. To determine the relationship of patient variables to hospital length of stay and ICU, length of stay regression trees were calculated. Results Both groups were underfed with 50% of goal met in surgical ICU and 56% of goal met in medical ICU. Medical ICU patients received less propofol and significantly less dextrose-containing intravenous fluids when compared to surgical ICU patients ( P =0.013). From regression analysis, approaching full nutrient requirements during ICU stay was associated with greater hospital length of stay and ICU length of stay. For combined groups, if % goal was ≥82%, the estimated average value for ICU length of stay was 24 days; whereas, if the % goal was Conclusions Medical and surgical ICU patients were insufficiently fed during their ICU stay when compared with registered dietitian recommendations. Medical ICU patients received earlier nutrition support, on average more enteral nutrition, with fewer kilocalories supplied from lipid-based sedatives and intravenous fluid relative to surgical ICU patients. Based upon length of stay, the data suggest that the most severely ill patient may not benefit from delivery of full nutrient needs in the ICU.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Pseudoaneurysm of the inferior epigastric artery (IEA) is a recognized complication of surgery; however, it is a very rare clinical occurrence. The anatomic position of the IEA subjects patients to possible IEA injury during abdominal wall procedures that are close to the artery, such as insertions of drains, Tenckhoff catheters, laparoscopic trocars, or paracentesis. Treatment options include open surgery, percutaneous coil embolization, embolization with N-butyl cyanoacrylate, sonographic-guided thrombin injection, or sonographic-guided compression. We report the first case of a pseudoaneurysm arising from the IEA after a laparoscopic ventral hernia repair. To our knowledge, 17 IEA pseudoaneurysms have been reported, only 3 of which were spontaneous. The pseudoaneurysm in our patient was successfully treated by percutaneous injection of thrombin by interventional radiology.

Enteric duplication cysts are hollow, epithelium-lined, cystic, spherical, or tubular structures that are firmly attached to the wall of the gastrointestinal tract. Commonly they are supplied by surrounding mesenteric blood vessels. However, completely isolated duplication cysts do not communicate with the normal bowel segment and have their own exclusive blood supply. They are a very rare variety of gastrointestinal duplications. In the English medical literature there are 5 earlier reported cases: 4 in pediatrics and 1 in an adult male age 28 years. We report a case of a 27-year-old female patient presenting with a completely isolated (noncontiguous) enteric duplication cyst with its own vascular pedicle. This case represents a rare clinical example of an isolated enteric duplication cyst removed by laparoscopic excision. To the best of our knowledge, this is the first reported case of its kind in an adult female and the first case to use laparoscopy to remove the cyst.

BACKGROUND: The pathogenesis of generalized microvascular injury after hemorrhagic shock is known to involve the generation of platelet-activating factor (1-O-alkyl-2-acetyl-sn-glycero-3-phosphocholine [PAF]). The release of PAF is manifested in several ways, including by increased vascular permeability, altered vascular reactivity, and increased leukocyte adherence to the endothelium. WEB 2086 is a PAF antagonist that has been shown experimentally to improve survival after hemorrhagic shock. The purpose of this study was to examine the efficacy of WEB 2086 in attenuating leukocyte adherence before, during, and after hemorrhagic shock. METHODS: After a control period, blood was withdrawn to reduce the mean arterial pressure to 40 mm Hg for 30 minutes in urethane-anesthetized rats. Mesenteric venules in a transilluminated segment of the small bowel were examined to quantitate leukocyte adherence using intravital microscopy. RESULTS: In sham-operated rats (control), there was minimal to no leukocyte adherence throughout the experiment. Hemorrhagic shock resulted in a significant increase in leukocyte adherence postshock during resuscitation (10.9 +/- 1.8 cells/100 microm, p < 0.01) when compared with controls. WEB 2086, when given before shock, significantly attenuated leukocyte adherence (0.1 +/- 0.08 cells/100 microm, p < 0.01) when compared with hemorrhagic shock alone. This effect of WEB 2086 on adherence could be demonstrated even when it was given during (3.5 +/- 0.9 cells/100 microm, p < 0.01) and 10 minutes into (5.8 +/- 1.1 cells/100 microm, p < 0.05) hemorrhagic shock. CONCLUSION: Our findings suggest that WEB 2086 may be of therapeutic benefit against the microvascular damage sustained after hemorrhagic shock.

Background: Plasma viral load has recently been associated with clinical outcome in patients with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). We hypothetized that, in addition to CD4 lymphocytes, plasma HIV-1 RNA counts are predictive of postoperative outcome. Methods: HIV-infected and AIDS patients admitted to a major teaching hospital requiring invasive or surgical procedures were retrospectively analyzed for postoperative outcome. Preoperative and postoperative immune cell counts including plasma HIV-1 RNA counts were recorded. Chi-square analysis, Fisher’s exact test, and multivariate regression were performed with statistical significance P ≤0.05. Results: Fifty-five consecutive patients between 14 and 62 years of age were admitted in a 1-year period and underwent 64 diagnostic and therapeutic procedures. Fourteen (22%) postoperative infections and 18 (28%) complications other than infection, with an overall mortality of 11%, were documented. Total preoperative white blood cell count ([WBC] P

Actin-scavenging proteins, e.g., plasma gelsolin, counteract the pathophysiological consequences of actin leaked into the circulation from dying cells, but the capacity of this defense system can be overwhelmed by massive tissue injury. We examined the prognostic implications of plasma gelsolin levels obtained near the time of admission to our level I Trauma Unit on the subsequent clinical course in a group of patients with severe traumatic injuries. Blood samples were obtained from 13 patients shortly after major trauma and 11 healthy volunteers who served as the control group. Plasma gelsolin levels were assayed by quantitative Western blotting. Duration of mechanical ventilation, stay in the Trauma Intensive Care Unit, and development of acute respiratory distress syndrome (ARDS) were measured as clinical outcomes reflecting the complexity of the hospital course. Subsequently, we evaluated an additional 52 patients after major and minor trauma to extend our earlier observations. Plasma gelsolin concentrations were significantly lower in our 13 original patients compared with healthy controls. Levels below 250 mg/L (2 standard deviations below the mean of the control group) were associated with prolonged mechanical ventilation and a stay in the intensive care unit/= 13 days. Both patients whose gelsolin level was100 mg/L in this first series developed ARDS. Including all 65 patients, 6 of the 10 patients who developed ARDS had admission gelsolin levels less than 250 mg/L, compared with only 7 of the 55 patients without ARDS (p = 0.0028). The mean gelsolin levels were 193 and 400 mg/L in patients with and without ARDS, respectively (p0.0001) and 398 mg/L in survivors versus 259 mg/L for patients who expired (p0.0001). Ten of the 13 patients (77%) with gelsolin levels at the time of admission more than 2 SD below the control mean had "bad outcomes," defined as mechanical ventilation for/= 13 days in the Trauma Intensive Unit, ARDS, and/or death. Plasma gelsolin levels appear to be an early prognostic marker in patients experiencing major trauma. Whether circulating gelsolin serves a biologically vital function or is simply depleted after massive trauma cannot be determined from our study. The potential therapeutic benefits of infusions of recombinant human plasma gelsolin for patients in whom multiorgan dysfunction commonly follows a serious but self-limited insult have not yet been investigated.

Anesthetic standard of care is to restrict oral intake for 8 hours before elective surgery. There is no research addressing appropriate preoperative discontinuation of jejunostomy tube (J-tube) feedings. We hypothesized that patients could be fed safely, via a J-tube, until the time of surgery.Patients admitted to a Level I Trauma Center, having J-tubes and undergoing a nonabdominal operation, were prospectively evaluated. Group I patients received J-tube feedings until transport to the operating room. Group II patients had tube feedings discontinued for at least 8 hours before surgery. Data were compared using the Student's t test and contingency table analysis.There were 46 patients in group I and 36 in group II. There was no incidence of aspiration. Patient groups did not differ in age, mortality, length of stay, injury severity score, or ventilator days. Group I patients had tube feedings discontinued for fewer hours before and after surgery than group II patients (before surgery: 1.40 +/- 1.20 vs 11.61 +/- 5.01, respectively; p.001; after surgery: 2.99 +/- 7.49 vs 7.11 +/- 9.03, respectively; p = .043); received more kilocalories/ grams of protein on the day of surgery (group I vs group II, 1676.15/89.57 +/- 1133.21/38.04 vs 791.14/57.58 +/-498.66/79.87, respectively; p = .001/p = .032) and more kilocalories/grams of protein on the first postoperative day (group I vs group II, 1580.74/92.57 +/- 600.53/37.96 vs 1152.47/63.53 +/- 733.96/39.40, respectively; p = .006/p = .001).Patients receiving J-tubes who are undergoing nonabdominal operations may safely continue enteral nutrition at maximum protein and caloric intake until surgery.

BackgroundInfection and organ failure are the most common causes of death or serious complication in trauma patients surviving initial resuscitation and operation. Of the many possible causes of these complications, bacterial translocation and release of harmful cytokines and oxygen free radicals ma

Management of a patient with a closed head injury is based on neurologic status and computerized tomography scan results. We hypothesized that those patients with an epidural hematoma (EDH) or subdural hematoma (SDH)1 cm in thickness could safely be treated nonoperatively.We retrospectively reviewed charts of 204 consecutive patients with either an EDH or SDH.There were 122 lesionsor =1 cm and 82 lesions1 cm. In the first group, 115 were managed nonoperatively, with 111 good outcomes (minimal deficit with a Rancho Los Amigos score [RLAS]or =3), two poor outcomes (severely disabled with RLAS3), and two deaths. Twenty-eight patients with lesions greater than 1 cm had concomitant cerebral edema (CE) with an 89% mortality rate. The mortality rate in this group without CE was 20%, demonstrating the presence of CE in this group may have adversely affected the mortality rate, regardless of intervention.This data suggests that EDH or SDH1 cm thick can be safely managed nonoperatively unless there is concomitant CE.

Objectives The authors present a novel approach to nonresectional therapy in major hepatic trauma utilizing intraabdominal perihepatic vacuum assisted closure (VAC) therapy in the porcine model of Grade V liver injury. Methods A Grade V injury was created in the right lobe of the liver in a healthy pig. A Pringle maneuver was applied (4.5 minutes total clamp time) and a vacuum assisted closure device was placed over the injured lobe and connected to suction. The device consisted of a perforated plastic bag placed over the liver, followed by a 15 cm by 15cm VAC sponge covered with a nonperforated plastic bag. The abdomen was closed temporarily. Blood loss, cardiopulmonary parameters and bladder pressures were measured over a one-hour period. The device was then removed and the animal was euthanized. Results Feasibility of device placement was demonstrated by maintenance of adequate vacuum suction pressures and seal. VAC placement presented no major technical challenges. Successful control of ongoing liver hemorrhage was achieved with the VAC. Total blood loss was 625 ml (20ml/kg). This corresponds to class II hemorrhagic shock in humans and compares favorably to previously reported estimated blood losses with similar grade liver injuries in the swine model. No post-injury cardiopulmonary compromise or elevated abdominal compartment pressures were encountered, while hepatic parenchymal perfusion was maintained. Conclusion These data demonstrate the feasibility and utility of a perihepatic negative pressure device for the treatment of hemorrhage from severe liver injury in the porcine model.

BACKGROUND Distal intestinal obstructive syndrome (DIOS) is the partial or complete obstruction of the colon or the terminal ileum by abnormally viscous intestinal contents and is a common sequela of cystic fibrosis (CF) in adults. Medical management of this entity is well described, but often falls short for those with signs of peritonitis or bowel ischemia. Current surgical options are not widely reported. These procedures usually require laparotomy, occasionally with enterotomy, and are complicated by the typically poor medical condition of patients with DIOS. A minimally invasive approach to the surgical care of CF patients with DIOS could effectively relieve obstruction refractory to medical management. METHODS A 39-year-old woman with CF presented with nausea, severe abdominal pain, and obstipation. She was diagnosed with DIOS and underwent aggressive medical management unsuccessfully. The patient underwent successful hand-assisted laparoscopic antegrade milking of a 15-cm obstructive segment of the small bowel into the colon and placement of an appendicostomy tube. This was followed by postoperative administration of antegrade enemas and nasogastric osmotic cathartics. RESULTS The patient had resumption of bowel function and was subsequently discharged to her home. CONCLUSIONS This is a reported case of laparoscopic exploration and treatment for DIOS, and provides a minimally invasive alternative to laparotomy and enterotomy in the treatment of DIOS.

While the prevalence of obesity continues to increase in our society, outdated resting energy expenditure (REE) prediction equations may overpredict energy requirements in obese patients. Accurate feeding is essential since overfeeding has been demonstrated to adversely affect outcomes.The first objective was to compare REE calculated by prediction equations to the measured REE in obese trauma and burn patients. Our hypothesis was that an equation using fat-free mass would give a more accurate prediction. The second objective was to consider the effect of a commonly used injury factor on the predicted REE.A retrospective chart review was performed on 28 patients. REE was measured using indirect calorimetry and compared with the Harris-Benedict and Cunningham equations, and an equation using type II diabetes as a factor. Statistical analyses used were paired t test, +/-95% confidence interval, and the Bland-Altman method.Measured average REE in trauma and burn patients was 21.37 +/- 5.26 and 21.81 +/- 3.35 kcal/kg/d, respectively. Harris-Benedict underpredicted REE in trauma and burn patients to the least extent, while the Cunningham equation underpredicted REE in both populations to the greatest extent. Using an injury factor of 1.2, Cunningham continued to underestimate REE in both populations, while the Harris-Benedict and Diabetic equations overpredicted REE in both populations.The measured average REE is significantly less than current guidelines. This finding suggests that a hypocaloric regimen is worth considering for ICU patients. Also, if an injury factor of 1.2 is incorporated in certain equations, patients may be given too many calories.

Objective This study proposes to evaluate the efficacy of routine posttracheostomy chest radiography. Design A retrospective chart review provided the framework of this study. Setting The study took place at a university teaching hospital-level one trauma center. Patients The study included 293 patients undergoing elective tracheostomy between 1989 and 1993. Measurements and results Data extracted from the charts included indication for tracheostomy, immediate preoperative and postoperative chest radiograph reports, management changes made secondarily to radiographic findings, including chest tube placement, institution of chest physiotherapy, and need for tracheal tube reposition. Complications were defined as findings not noted on the preoperative radiographs; these were pneumothorax, tube malposition, atelectasis, or clinical information resulting in management changes. All patients received postoperative chest radiographs in the trauma ICU. Statistical analysis of our data was carried out using the χ 2 test. Patients with chest tubes in place at the time of surgery were the only group who were excluded so as not to confuse whether pneumothorax developed postoperatively. Of the initial 293 patients, 25 patients were excluded on the basis of having a chest tube. The remaining 268 charts were analyzed; 220 (82%) patients underwent tracheostomy for ventilator-dependent respiratory failure, 31 (12%) due to multiple facial fractures, 6 (2.1%) secondary to penetrating neck wounds, and 11 (4%) as a result of refractory vocal cord edema. One (0.3%) patient was found to have a postoperative 10% apical pneumothorax. Eight (2.4%) patients were found to have postoperative subsegmental atelectasis. There were no significant (p>0.05) management changes implemented as a result of these findings. No new infiltrates, effusions, or malpositioned tubes were noted. Deletion of routine posttracheostomy radiographs would save $52.39 per patient (cost) or $15,350 for 293 patients and $35,453 in total patient charges. Conclusions Abnormalities revealed by routine chest radiography after tracheostomy did not appear to alter patient management frequently enough to warrant the costs. A randomized, prospective study should be performed to analyze the safety of abandoning this practice.

Objective: Rapid Emergency Medicine Score (REMS) is an attenuated version of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and has utility in predicting mortality in non-surgical patients, but has yet to be tested among the trauma population. The objective was to evaluate REMS as a risk stratification tool for predicting in-hospital mortality in traumatically injured patients and to compare REMS accuracy in predicting mortality to existing trauma scores, including the Revised Trauma Score (RTS), Injury Severity Score (ISS) and Shock Index (SI). Design and setting: Retrospective chart review of the trauma registry from an urban academic American College of Surgeons (ACS) level 1 trauma centre. Participants: 3680 patients with trauma aged 14 years and older admitted to the hospital over a 4year period. Patients transferred from other hospitals were excluded from the study as were those who suffered from burn or drowning-related injuries. Patients with vital sign documentation insufficient to calculate an REMS score were also excluded. Primary outcome measures: The predictive ability of REMS was evaluated using ORs for in-hospital mortality. The discriminate power of REMS, RTS, ISS and SI was compared using the area under the receiver operating characteristic curve. Results: Higher REMS was associated with increased mortality (p

The activation and adherence of leukocytes to the venular endothelium are critical steps in the pathogenesis of generalized microvascular injury following hemorrhagic shock. Previous studies have shown that the integrins CD11/CD18 play a significant role in this interaction. The purpose of this study is to examine the efficacy of anti-LFA-1beta, an antibody to CD11a/CD18, in attenuating leukocyte adherence before, during, and after hemorrhagic shock. Following a control period, blood was withdrawn to reduce the mean arterial pressure to 40 mm Hg for 30 min in urethane-anesthetized rats. Mesenteric venules in a transilluminated segment of the small intestines were examined to quantitate leukocyte adherence using intravital microscopy. In sham-operated rats (control), there was minimal to no leukocyte adherence throughout the experiment. Hemorrhagic shock resulted in significant leukocyte adherence during resuscitation (10.8 +/- 1.7 cells/100 microm, P0.01) when compared to control. Anti-LFA-1beta, when given before hemorrhagic shock, significantly attenuated leukocyte adherence during resuscitation (1.1 +/- 0.8, P0.01) when compared with hemorrhagic shock alone. This protective effect of anti-LFA-1beta on leukocyte adherence was even demonstrated when it was given during (1.6 +/- 0.3, P0.01) and 10 min after hemorrhagic shock (5.8 +/- 0.4, P0.05). These results suggest that anti-LFA-1beta may be of potential therapeutic benefit against microvascular injury caused by hemorrhagic shock.

SESSION TITLE: Outcomes/Quality Control Posters SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM 02:30 PM PURPOSE: To assess the value of CareVeillance (CV), an electronic surveillance tool that continuously samples data from the electronic medical record (EMR) for early identification of severe sepsis. METHODS: This is a prospective and retrospective descriptive analysis of CV, developed at the University of Kansas Hospital (KUH). Patients with severe sepsis were identified in 3 ways: 11 day real-time pilot of CV software in 2/12, comparison of hospital discharge (administrative) data with a retrospective application of CV software to all KUH patients discharged in 2/12, and retrospective adjudication of patients in both categories (gold standard). Random number generation was used to determine a statistical sample of the CV-identified severe sepsis patients for adjudication. RESULTS: During the real-time pilot, CV identified 19 patients who were concurrently determined to have severe sepsis by trained CV monitoring personnel; 16 were discharged in 2/12 and were evaluated in the retrospective CV application where all 16 were, likewise, identified. Of this 16, adjudication diagnosis agreed with CV diagnosis 100% of the time. Only 13 of the 16 (81.3%) were diagnosed by their care team with severe sepsis during their hospitalization; 2 of the remaining 3 had severe sepsis on adjudication. Administrative data identified 104 patients with severe sepsis who were discharged in 2/12 (not limited to the pilot period). CV retrospectively identified all 104 of these patients and an additional 110 patients as having severe sepsis. Adjudication of 22 (20%) of these additional patients revealed that 8 (36.4%) had severe sepsis, suggesting that of the 110 patients, 40 had severe sepsis but were not diagnosed during their hospitalization. CV falsely identified 70 patients as having severe sepsis. CONCLUSIONS: CV identified severe sepsis patients when it was applied to EMR data either prospectively or retrospectively; it was more sensitive than hospital care teams. CV identified all patients with severe sepsis according to the administrative data but also identified patients the care team and therefore the administrative data missed. However, CV has relatively low specificity. CLINICAL IMPLICATIONS: CV identifies patients with severe sepsis that may otherwise go unrecognized. Applied prospectively and judiciously, CV can bring this information to the attention of the patient's care team and has the ability to reduce these patients' length of ICU and hospital stay, overall cost of care, and mortality. DISCLOSURE: The following authors have nothing to disclose: Bristol Brandt, Amanda Gartner, Michael Moncure, Chad Cannon, Liz Carlton, Steven Simpson No Product/Research Disclosure Information Copyright © 2014 American College of Chest Physicians

PURPOSE: Sepsis is a common cause of mortality nationwide. To improve the identification and care of septic patients at our institution, we have provided bundled care, adopting a sepsis bundle based on the Surviving Sepsis Campaign (SSC) guidelines. We hypothesized that we could successfully track the appropriate identification of patients with severe sepsis, as well as their overall mortality, using our hospital discharge database. METHODS: Our hospital discharge database was prospectively queried over 6 fiscal years, beginning July 1 and ending June 30, annually, during 2005-2010. This period coincided with adoption of the SSC database and care bundles. An annual estimate of the number of severe sepsis cases in our institution throughout this period was made using a method derived from Angus, et al. Physician-diagnosed severe sepsis was identified by ICD-9 codes 995.92, 785.52. Additionally, the database was queried for all-cause mortality of these patients. RESULTS: In FY 2005, only 171 of 426 patients identified to have severe sepsis by the modified Angus method were given an ICD-9 diagnosis of severe sepsis or septic shock (40%). This grew to 958 out of 1,205 (80%) by FY 2010. Simultaneously, the all-cause in-hospital mortality rate of patients diagnosed with severe sepsis fell from 49% in FY 2005 to 25% in FY 2010. The mortality index (observed mortality/expected mortality) fell from 1.56 in FY 2005 to 0.88 in FY 2010. Average LOS declined from 24.4 days in FY 2005 to 15.9 days in FY 2010. Severe sepsis as a recognized contribution to overall hospital mortality rose from 18.5% in FY 2005 to 48.4% in FY 2010. CONCLUSIONS: The comparison of the modified Angus method with coded discharges for severe sepsis and septic shock demonstrated improved recognition of severe sepsis. Enhanced recognition, combined with systematic improvements in patient care, effectively reduced the mortality of severe sepsis by approximately 50% over a five-year period. CLINICAL IMPLICATIONS: The hospital discharge database is an effective tool for measuring the outcomes of performance improvement efforts in severe sepsis. DISCLOSURE: The following authors have nothing to disclose: Lucas Pitts, Michael Moncure, Chad Cannon, Steven Simpson No Product/Research Disclosure Information