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Background Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals (NTHs). Methods A retrospective review of data from the Maryland Health Services Cost Review Commission database from 2009 to 2018 for OAs undergoing EGSPs was undertaken. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index (CCI), EGSPs (partial colectomy (PC), small bowel resection, cholecystectomy, operative management of peptic ulcers, lysis of adhesions, appendectomy, and laparotomy, categorized hospital charges, length of stay (LOS), and mortality. Results Of the 55,401 OAs undergoing EGSPs in this study, 28,575 (51.6%) were treated at THs and 26,826 (48.4%) at NTHs. OAs at THs presented with greater APR-ROM (major 25.6% vs 24.9%, extreme 22.6% vs 22.0%, P=.01), and CCI (3.1±3 vs 2.7±2.8, PConclusion While acuity of illness appears similar, cost of undergoing EGSPs for OAs is higher in THs vs NTHs due to increased LOS. Future work is warranted to determine and mitigate factors that increase LOS at THs.

BACKGROUND Rib fractures (RFx) remain the most prevalent injury in an elderly population that will increase from 40 to 81 million for the next 30 years. We sought to create an accurate cost-effective algorithm to triage elderly patients with RFx that accounted for both frailty and trauma burden. METHODS Retrospective analysis evaluated 400 patients older than 55 years with RFx admitted to a level 1 trauma center from 2007 to 2012. Comorbidities included chronic obstructive pulmonary disease, congestive heart failure, tobacco use, obesity, and nutrition and functional status. Trauma burden included RFx, tube thoracostomy, pulmonary contusions, and spine and extremity fractures. Patients with Glasgow Coma Scale scores lower than 13, thoracoabdominal surgery, or deaths from other causes were excluded. Comparative analysis used bivariate and logistic regression. Variables contributing to intubation (INT) and pneumonia (PNA) were then used to create a scoring system to predict the need for intensive care unit (ICU) admission. RESULTS Six variables increased the risk for INT or PNA: chronic obstructive pulmonary disease, low albumin, assisted status, tube thoracostomy, Injury Severity Score, and RFx (p < 0.05). These six variables and congestive heart failure (odds ratio, 1.9; p = 0.06) were used to create a predictive model with the following scores assigned respectively: 1.4, 1.1, 1, 0.9, 0.1(n), 0.1(n), and 0.6. A score lower than 3.7 had a sensitivity and specificity of 78.5% and 78.9%. The negative predictive value was 94.5% for INT or PNA, suggesting a low risk for ICU requirement. Ninety-two ICU admissions had a score lower than 3.7. Forty had no other indication for ICU admission aside from RFx. These patients had an average ICU length of stay of 1.7 days, resulting in an increased cost of $2,200 per patient. CONCLUSION A scoring system combining frailty and trauma burden may provide more accurate and cost-effective triage of the elderly trauma patient with RFx. Further prospective studies are required to verify our scoring system. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Background Damage-control surgery frequently results in open abdomen. The objective of this study was to determine whether resuscitation with goal-directed fluid therapy (GDT) using “dynamic” hemodynamic indices via modern pulse contour analysis devices such as the FloTrac Vigileo monitor leads to lower fluid requirements, subsequent quicker abdominal closure, and overall improved outcomes in these patients. Methods Patients admitted to the surgical intensive care unit with open abdomen were retrospectively reviewed. Those resuscitated with Vigileo-guided GDT were matched to those resuscitated by static clinical parameters. Results Total fluid intake and vasopressor requirements were similar in both groups. GDT with the Vigileo allowed earlier lactate clearance and reduced the number of days until abdominal wall closure by an average of .99 days. Conclusions Vigileo-mediated GDT did not affect fluid volume or vasopressor use in open abdomen patients, but facilitated more effective resuscitation and decreased the number of days to fascial closure, leading to shorter hospital stays. Vigileo-mediated GDT, therefore, may improve overall outcomes in open abdomen patients.