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Traumatic chest wall injuries and rib fractures remain a prevalent injury. Despite many advances, these injuries result in high morbidity and mortality. Surgical stabilization of rib fractures (SSRF) is increasing in utilization with expanding indications. Recent studies have demonstrated that many patients may benefit from surgical intervention.Over the past 20 years the indications and timing of SSRF has evolved. Once reserved mainly for the most extreme of injuries, expanding indications demonstrate that even minimally injured patients may benefit from intervention regarding pain control, respiratory complications, and overall mortality.SSRF has become more prevalent with improving outcomes for patients. Understanding the indications will help expand utilization and improve patient outcomes.

Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.

Background Interpretations of the electrocardiogram (ECG) are often prepared using software outside the electronic health record (EHR) and imported via an interface as a narrative note. Thus, natural language processing is required to create a computable representation of the findings. Challenges include misspellings, nonstandard abbreviations, jargon, and equivocation in diagnostic interpretations. Objectives Our objective was to develop an algorithm to reliably and efficiently extract such information and map it to the standardized ECG ontology developed jointly by the American Heart Association, the American College of Cardiology Foundation, and the Heart Rhythm Society. The algorithm was to be designed to be easily modifiable for use with EHRs and ECG reporting systems other than the ones studied. Methods An algorithm using natural language processing techniques was developed in structured query language to extract and map quantitative and diagnostic information from ECG narrative reports to the cardiology societies' standardized ECG ontology. The algorithm was developed using a training dataset of 43,861 ECG reports and applied to a test dataset of 46,873 reports. Results Accuracy, precision, recall, and the F1-measure were all 100% in the test dataset for the extraction of quantitative data (e.g., PR and QTc interval, atrial and ventricular heart rate). Performances for matches in each diagnostic category in the standardized ECG ontology were all above 99% in the test dataset. The processing speed was approximately 20,000 reports per minute. We externally validated the algorithm from another institution that used a different ECG reporting system and found similar performance. Conclusion The developed algorithm had high performance for creating a computable representation of ECG interpretations. Software and lookup tables are provided that can easily be modified for local customization and for use with other EHR and ECG reporting systems. This algorithm has utility for research and in clinical decision-support where incorporation of ECG findings is desired.

Focused cardiac ultrasound (FoCUS) has become a valuable tool to assess unexplained hypotension in critically ill patients. Due to increasing availability of transthoracic echocardiography (TTE) equipment in the operating room, there is a widespread interest in its usefulness for intraoperative diagnosis of hypotension as an alternative to transesophageal echocardiography (TEE). The objective of this systematic review is to evaluate the utility of intraoperative FoCUS to assess patients experiencing unexplained hypotension while undergoing noncardiac surgery. We performed a systematic literature search of multiple publication databases for studies that evaluated the utility of intraoperative FoCUS for assessment and management of unexplained hypotension in patients undergoing noncardiac surgery, including retro- and prospective clinical studies. A summary of the study findings, study quality, and assessment of level of evidence is presented. We identified 2227 unique articles from the literature search, of which 27 were potentially relevant, and 9 were included in this review. The number of patients pooled from these studies was 255, of whom 228 had intraoperative diagnoses with the aid of intraoperative FoCUS. The level of evidence of all studies included was very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. This systematic review has demonstrated that FoCUS may be a useful, noninvasive method to differentiate causes of intraoperative hypotension and guide correcting interventions, although the quality of evidence is very low. Further prospective high-quality studies are needed to investigate whether intraoperative FoCUS has a diagnostic utility that is associated with improved outcomes.

Background Rapid sequence induction and tracheal intubation through direct laryngoscopy (DL) has been the most common approach to secure the airway in trauma patients. The introduction of video laryngoscopy (VL) has changed airway management in many clinical settings. In this retrospective study, we assessed if immediate availability of VL in the trauma suite has changed the approach and outcomes of airway management during acute resuscitation at a dedicated trauma center. Materials and methods We retrospectively collected data from emergency intubation in the 6 resuscitation bays at a high-volume, academic, Level 1 trauma center over a 42-month period following the introduction of immediately available VL in the resuscitation bay. We divided the data into 13-week bins to assess the trend in the use of VL over time. Our measured outcomes were the incidence of failed intubations requiring a surgical airway and the frequency of VL use for airway management. Results Among 1328 airway management events in the resuscitation bays when intubation was attempted, the failure rate resulting in the placement of a surgical airway was 0.38% (95% confidence interval [CI], 0.12% -0.88%). This was consistent with the surgical airway rate before the introduction of VL into trauma practice (0.3%). VL use (primary or as a rescue technique) throughout the study period was 4.14% (95% CI, 2.76%-5.74%), with no temporal trend. Conclusion The immediate availability of VL in the resuscitation bay has not changed the prevalence of its use during emergency airway management at our trauma center. DL remains a preferred primary modality for airway management by the trauma anesthesiologists working at this facility, with an acceptably low incidence of both primary failure and the need to establish a surgical airway.

Background The Trauma and Injury Severity Score (TRISS) uses anatomic/physiologic variables to predict outcomes. The National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC) includes functional status and comorbidities. It is unclear which of these tools is superior for high-risk trauma patients (American Society of Anesthesiologists Physical Status (ASA-PS) class IV or V). This study compares risk prediction of TRISS and NSQIP-SRC for mortality, length of stay (LOS), and complications for high-risk operative trauma patients. Methods This is a prospective study of high-risk (ASA-PS IV or V) trauma patients (≥18 years-old) undergoing surgery at 4 trauma centers. We compared TRISS vs NSQIP-SRC vs NSQIP-SRC + TRISS for ability to predict mortality, LOS, and complications using linear, logistic, and negative binomial regression. Results Of 284 patients, 48 (16.9%) died. The median LOS was 16 days and number of complications was 1. TRISS + NSQIP-SRC best predicted mortality (AUROC: .877 vs .723 vs .843, P = .0018) and number of complications (pseudo-R2/median error (ME) 5.26%/1.15 vs 3.39%/1.33 vs 2.07%/1.41, P < .001) compared to NSQIP-SRC or TRISS, but there was no difference between TRISS + NSQIP-SRC and NSQIP-SRC with LOS prediction ( P = .43). Discussion For high-risk operative trauma patients, TRISS + NSQIP-SRC performed better at predicting mortality and number of complications compared to NSQIP-SRC or TRISS alone but similar to NSQIP-SRC alone for LOS. Thus, future risk prediction and comparisons across trauma centers for high-risk operative trauma patients should include a combination of anatomic/physiologic data, comorbidities, and functional status.

The Trauma and Injury Severity Score (TRISS) uses anatomical and physiologic variables to predict mortality. Elderly (65 years or older) trauma patients have increased mortality and morbidity for a given TRISS, in part because of functional status and comorbidities. These factors are incorporated into the American Society of Anesthesiologists Physical Status (ASA-PS) and National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC). We hypothesized scoring tools using comorbidities and functional status to be superior at predicting mortality, hospital length of stay (LOS), and complications in elderly trauma patients undergoing operation.Four level I trauma centers prospectively collected data on elderly trauma patients undergoing surgery within 24 hours of admission. Using logistic regression, five scoring models were compared: ASA-PS, NSQIP-SRC, TRISS, TRISS-ASA-PS, and TRISS-NSQIP-SRC.Brier scores and area under the receiver operator characteristics curve were calculated to compare mortality prediction. Adjusted R2 and root mean squared error were used to compare LOS and predictive ability for number of complications.From 122 subjects, 9 (7.4%) died, and the average LOS was 12.9 days (range, 1-110 days). National Surgical Quality Improvement Program Surgical Risk Calculator was superior to ASA-PS and TRISS at predicting mortality (area under the receiver operator characteristics curve, 0.978 vs. 0.768 vs. 0.903; p = 0.007). Furthermore, NSQIP-SRC was more accurate predicting LOS (R2, 25.9% vs. 13.3% vs. 20.5%) and complications (R2, 34.0% vs. 22.6% vs. 29.4%) compared with TRISS and ASA-PS. Adding TRISS to NSQIP-SRC improved predictive ability compared with NSQIP-SRC alone for complications (R2, 35.5% vs. 34.0%; p = 0.046). However, adding ASA-PS or TRISS to NSQIP-SRC did not improve the predictive ability for mortality or LOS.The NSQIP-SRC, which includes comorbidities and functional status, had superior ability to predict mortality, LOS, and complications compared with TRISS alone in elderly trauma patients undergoing surgery.Prognostic and Epidemiologic; Level III.

In response to the growing opioid crisis, Florida recently implemented a law restricting the duration of opioid prescriptions for acute pain. Little is known about the impact of such legislation on opioid prescription practices at the time of discharge after surgery. The objective of this study was to determine whether Florida's new legislation changed opioid prescription practices for analgesia after surgery.Adults 18 years of age and older undergoing cholecystectomy, appendectomy, hernia repair, hysterectomy, mastectomy, or lymph node dissection were included in this retrospective cohort study at a large public university-affiliated hospital. We analyzed opioid prescriptions on discharge after these common outpatient surgical procedures between June 1, 2017, and December 31, 2018. Florida House Bill 21 was passed on March 2, 2018, and subsequent implementation of this law took place on July 1, 2018. The law restricts the duration of opioid prescriptions for acute pain to 3 days, which can be extended up to a maximum of 7 days with additional documentation. The outcomes studied included the following: the proportion of patients receiving opioid prescriptions on discharge, total opioid dose prescribed, daily opioid dose prescribed, and the proportion of patients receiving more than a 3-day supply of opioids. We colledted data on emergency department cumulative visits within 7 and 30 days after discharge. Drug doses were converted to morphine milligram equivalents and calculated for each selected procedure.A total of 1,467 surgical encounters were included. The cohort was predominantly female (963 [65.6%]) with a mean (SD) age of 49.6 (14.4) years. At 6 months after implementation of HB 21, the proportion of patients receiving opioid prescriptions decreased by 21% (95% CI 16.8% to 25.3%, P.001), mean total opioid dose prescribed decreased by 64.2 morphine milligram equivalents (95% CI 54.7 to 73.7, P.001) from a baseline mean (SD) of 172.5 (78.9) morphine milligram equivalents. The mean daily opioid dose prescribed increased by 3.5 morphine milligram equivalents (95% CI 1.8 to 5.1, P.001) from a baseline mean (SD) of 30.5 (9.4) morphine milligram equivalents. The proportion of patients receiving opioid prescriptions for longer than a 3-day supply decreased by 68% (95% CI 63.4% to 72.7%, P.001). We observed no change in the number of postoperative emergency department visits before and after implementation of the law.Opioid prescriptions for patients undergoing common outpatient surgical procedures at a large public university-affiliated hospital in Florida were substantially reduced within 6 months after implementation of state legislation limiting the duration of opioid prescriptions. This reduction was not associated with an increase in the number of postoperative emergency department visits. The legislation should significantly decrease the amount of unused opioid pills potentially available for diversion and abuse. Secondary effects from the enactment of this law remain to be evaluated.

Introduction A sepsis bundle instituted by the Centers for Medicare and Medicaid Services, known as SEP-1, mandates remeasuring lactate concentrations in patients with suspected sepsis who have an initial lactate level ≥ 2.0 mmol/L to identify those at risk of mortality or clinical deterioration. However, in the group with an intermediate lactate level (2.0 - 3.9 mmol/L), evidence for the predictive utility for such practice is lacking. The objective of this retrospective cohort study was to evaluate the potential utility of repeating the blood lactate measurement for the premonitory detection of clinical deterioration in patients admitted to a ward with a diagnosis of suspected sepsis and an initial intermediate lactate level. Methods Using electronic health records, we retrospectively evaluated all non-hospice adult patients admitted from the emergency department to a ward of an academic medical center between October 1, 2017, and November 30, 2019, in whom a blood culture was obtained on admission as part of their workup for suspected sepsis. Patient demographics, the times and values of lactate concentrations, the occurrence of subsequent intensive care unit (ICU) transfer during the admission, and hospital mortality were determined. We computed the relative risk of ICU transfer (i.e., clinical deterioration) and hospital mortality in patients whose initial lactate was in the intermediate range who failed to reduce their lactate concentration by at least 10% within six hours. We hypothesized that failure to clear the lactate would be associated with an increased risk of ICU transfer and hospital mortality. Results We studied 12,157 patients, of whom 25 hospice patients were excluded. Of the remaining 12,132 patients, 1,416 (11.7%) were initially admitted to an intensive care unit, and 10,716 (88.3%) were admitted to a ward. Repeat lactate determinations were performed in 10.7%, 77.1%, and 90.2% of the ward patients with initial normal (< 2.0 mmol/L), intermediate (2.0 - 3.99 mmol/L), and high (≥ 4.0 mmol/L) admission lactate concentrations, respectively. There was no increase in the relative risk of ICU transfer (relative risk [RR] = 0.90, 95% CI, 0.53 - 1.28, P = 0.55) or hospital mortality (RR = 1.23, 95% CI, 0.85 - 1.79, P = 0.27) within the intermediate lactate level group among those whose lactate remained within 10% of the initial value (i.e., no change) or increased by more than 10%, compared to those in whom the level decreased by more than 10%. Conclusions Failure to reduce lactate concentrations in ward patients admitted with possible sepsis and an intermediate lactate level was not associated with an increased risk of ICU transfer or mortality. These results call into question the mandate in SEP-1 to routinely repeat the lactate determination in patients presenting with an intermediate concentration.

Background The complexity of extracorporeal membrane oxygenation (ECMO) techniques continues to evolve. Different cannulation methods and configurations have been proposed as a response to a challenging cardiovascular and pulmonary physiology of the patients. The use of parallel ECMO circuits represents a unique and novel approach for patients with refractory respiratory failure and cardiovascular collapse with very large body surface areas. Case presentation We present the case of a 25-year-old morbidly obese male patient admitted for severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, requiring institution of double cannulation for veno-venous ECMO. Since his hypoxemia persisted, likely due to insufficient flows given his large body surface area, an additional drainage venous cannula was implemented to provide higher flows, temporarily addressing his oxygenation status. Unfortunately, the patient developed concomitant cardiogenic shock refractory to inotropic support and extracorporeal fluid removal, further worsening his oxygenation status, thus the decision was to institute four-cannulation/parallel-circuits veno-venous and veno-arterial ECMO, successfully controlling both refractory hypoxemia and cardiogenic shock. Conclusions Our case illustrates a novel and complex approach for combined severe ARDS and cardiovascular collapse through the use of parallel veno-venous and veno-arterial ECMO circuits, and exemplifies the expansion of ECMO techniques and its life-saving capabilities when conservative approaches are futile.

Background The impact of the Florida State law House Bill 21 (HB 21) restricting the duration of opioid prescriptions for acute pain in patients after cesarean delivery is unknown. Our objective was to assess the association of the passage of Florida State law HB 21 with trends in discharge opioid prescription practices following cesarean delivery, necessity for additional opioid prescriptions, and emergency department visits at a large tertiary care center. Methods This was a retrospective cohort study conducted at a large, public hospital. The 2 cohorts represented the period before and after implementation of the law. Using a confounder-adjusted segmented regression analysis of an interrupted time series, we evaluated the association between HB 21 and trends in the proportions of patients receiving opioids on discharge, duration of opioid prescriptions, total opioid dose prescribed, and daily opioid dose prescribed. We also compared the need for additional opioid prescriptions within 30 days of discharge and the prevalence of emergency department visits within 7 days after discharge. Results Eight months after implementation of HB 21, the mean duration of opioid prescriptions decreased by 2.9 days (95% confidence interval [CI], 5.2-0.5) and the mean total opioid dose decreased by 20.1 morphine milligram equivalents (MME; 95% CI, 4-36.3). However, there was no change in the proportion of patients receiving discharge opioids (95% CI of difference, -0.1 to 0.16) or in the mean daily opioid dose (mean difference, 5.3 MME; 95% CI, -13 to 2.4). After implementation of the law, there were no changes in the proportion of patients who required additional opioid prescriptions (2.1% vs 2.3%; 95% CI of difference, -1.2 to 1.5) or in the prevalence of emergency department visits (2.4% vs 2.2%; 95% CI of difference, -1.6 to 1.1). Conclusions Implementation of Florida Law HB 21 was associated with a lower total prescribed opioid dose and a shorter duration of therapy at the time of hospital discharge following cesarean delivery. These reductions were not associated with the need for additional opioid prescriptions or emergency department visits.

Injection ports used to administer medications and draw blood samples have inherent dead-volume. This volume can potentially lead to inadvertent drug administration, contribute to erroneous laboratory values by dilution of blood samples, and increase the risk of vascular air embolism. We sought to characterize provider practice in management of intravenous (IV) and arterial lines and measure dead-volumes of various injection ports. A survey was circulated to anesthesiology physicians and nurses to determine practice habits when administering medications and drawing blood samples. Dead-volume of one and four-way injection ports was determined by injecting methylene blue to simulate medication administration or blood sample aspiration and using absorption spectroscopy to measure sample concentration. Among the 65 survey respondents, most (64.52%) increase mainstream flow rate to flush medication given by a 1-way injection port. When using 4-way stopcocks, 56.45% flush through the same injection site. To obtain a sample from an arterial line, 67.74% draw back blood and collect the sample from the same 4-way stopcock; 32.26% use a different stopcock. Mean (SD) dead-volume in microliters ranged from 0.1 (0.0) to 5.6 (1.0) in 1-way injection ports and from 54.1 (2.8) to 126.5 (8.3) in 4-way injection ports. The practices of our providers when giving medications and drawing blood samples are variable. The dead-volume associated with injection ports used at our institution may be clinically significant, increasing errors in medication delivery and laboratory analysis.

BackgroundCurrent standard audible medical alarms are difficult to learn and distinguish from one another. Auditory icons represent a new type of alarm that has been shown to be easier to learn and identify in laboratory settings by lay subjects. In this study, we test the hypothesis that icon alarms are easier to learn and identify than standard alarms by anesthesia providers in a simulated clinical setting.MethodsTwenty anesthesia providers were assigned to standard or icon groups. Experiments were conducted in a simulated intensive care unit. After a brief group-specific alarm orientation, subjects identified patient-associated alarm sounds during the simulation and logged responses via a tablet computer. Each subject participated in the simulation twice and was exposed to 32 alarm annunciations. Primary outcome measures were response accuracy and response times. Secondary outcomes included assessments of perceived fatigue and task load.ResultsOverall accuracy rate in the standard alarm group was 43% (mean) and in the icon group was 88% (mean). Subjects in the icon group were 26.1 (odds ratio [98.75% CI, 8.4 to 81.5; P < 0.001]) times more likely to correctly identify an alarm. Response times in the icon group were shorter than in the standard alarm group (12 vs. 15 s, difference 3 s [98.75% CI ,1 to 5; P < 0.001]).ConclusionsUnder our simulated conditions, anesthesia providers more correctly and quickly identified icon alarms than standard alarms. Subjects were more likely to perceive higher fatigue and task load when using current standard alarms than icon alarms.

Many human factors and ergonomics problems are associated with clinical alarms, usaually referred to as ‘alarm fatigue’. Among these problems is the nature of auditory signals used to attract attention, as these signals are often difficult to learn, easily confusable, and sometimes prone to masking. Symptomatic of this problem is the poor quality of the audible alarms associated with a global medical device safety standard, IEC 60601-1-8. A project aimed at improving and updating these sounds according to best practice is being carried out. This paper charts the progress of this venture and summarizes the results and the published papers which present those results.

A patient with recent jaw reconstruction presented for treatment of postoperative oropharyngeal hemorrhage. Asleep nasal fiberoptic intubation was attempted, but a rare and unanticipated complication ensued: rupture of right facial artery pseudoaneurysm. The difficult airway algorithm was followed up to the point of surgical airway. While nasal or oral fiberoptic intubation is often perceived as the safest approach for management of a difficult airway, we discuss alternative treatment strategies for patients with a facial pseudoaneurysm. Such alternatives include preoperative angiographic endovascular embolization of the vessel(s) feeding the pseudoaneurysm, and/or elective tracheostomy.

Mechanical ventilation after general surgery is associated with worse outcomes, prolonged hospital stay, and increased health care cost. Postoperatively, patients admitted to the intensive care unit (ICU) may be categorized into 1 of 3 groups: extubated patients (EXT), patients with objective medical indications to remain ventilated (MED), and patients not meeting these criteria, called "discretional postoperative mechanical ventilation" (DPMV). The objectives of this study were to determine the incidence of DPMV in general surgery patients and identify the associated operative factors.At a large, tertiary medical center, we reviewed all surgical cases performed under general anesthesia from April 1, 2008 to February 28, 2015 and admitted to the ICU postoperatively. Patients were categorized into 1 of 3 cohorts: EXT, MED, or DPMV. Operative factors related to the American Society of Anesthesiologists Physical Status (ASA PS), duration of surgery, surgery end time, difficult airway management, intraoperative blood and fluid administration, vasopressor infusions, intraoperative arterial blood gasses, and ventilation data were collected. Additionally, anesthesia records were reviewed for notes indicating a reason or rationale for postoperative ventilation. Categorical variables were compared by χ test, and continuous variables by analysis of variance or Kruskal-Wallis H test. Categorical variables are presented as n (%), and continuous variables as mean ± standard deviation or median (interquartile range) as appropriate. Significance level was set at P≤ .05.Sixteen percent of the 3555 patients were categorized as DPMV and 12.2% as MED. Compared to EXT patients, those classified as DPMV had received significantly less fluid (2757 ± 2728 mL vs 3868 ± 1885 mL; P.001), lost less blood during surgery (150 [20-625] mL vs 300 [150-600] mL; P.001), underwent a shorter surgery (199 ± 215 minutes vs 276 ± 143 minutes; P.001), but received more blood products, 900 (600-1800) mL vs 600 (300-900) mL. The DPMV group had more patients with high ASA PS (ASA III-V) than the EXT group: 508 (90.4%) vs 1934 (75.6%); P.001. Emergency surgery (ASA E modifier) was more common in the DPMV group than the EXT group: 145 (25.8%) vs 306 (12%), P.001, respectively. Surgery end after regular working hours was not significantly higher with DPMV status compared to EXT. DPMV cohort had fewer cases with difficult airway when compared to EXT or MED. When compared to MED patients, those classified as DPMV received less fluid (2757 ± 2728 mL vs 4499 ± 2830 mL; P.001), lost less blood (150 [20-625] mL vs 500 [200-1350] mL; P.001), but did not differ in blood products transfused or duration of surgery.In our tertiary medical center, patients often admitted to the ICU on mechanical ventilation without an objective medical indication. When compared to patients admitted to the ICU extubated, those mechanically ventilated but without an objective indication had a higher ASA PS class and were more likely to have an ASA E modifier. A surgery end time after regular working hours or difficult airway management was not associated with higher incidence of DPMV.

Fat embolism syndrome (FES) most commonly can occur after trauma in patients with long bone fractures. While the majority of FES cases present as a mild decrease in mental status, some may manifest as seizure activity. We describe a case of a young patient with traumatic fractures who developed FES leading to refractory status epilepticus and simultaneously required damage controlled orthopedic surgery. The role of imaging modalities including magnetic resonance imaging, transcranial Doppler, and transesophageal echocardiography in diagnosis is discussed, and a multidisciplinary approach to successful perioperative management is described.

The reserved set of audible alarm signals embodied within the global medical device safety standard, IEC 60601-1-8, is known to be problematic and in need of updating. The current alarm signals are not only suboptimal, but there is also little evidence beyond learnability (which is known to be poor) that demonstrates their performance in realistic and representative clinical environments. In this article, we describe the process of first designing and then testing potential replacement audible alarm signals for IEC 60601-1-8, starting with the design of several sets of candidate sounds and initial tests on learnability and localizability, followed by testing in simulated clinical environments. We demonstrate that in all tests, the alarm signals selected for further development significantly outperform the current alarm signals. We describe the process of collecting considerably more data on the performance of the new sounds than exists for the current sounds, which ultimately will be of use to end users. We also reflect on the process and practice of working with the relevant committees and other practical issues beyond the science, which also need constant attention if the alarms we have developed are to be included successfully in an updated version of the standard.

BACKGROUND End-tidal carbon dioxide (EtCO2) is a valuable marker of the return of adequate circulation after cardiac arrest due to medical causes. Previously, the prognostic value of capnography in trauma has been studied among limited populations in prehospital and emergency department settings. We aimed to investigate the relationship between early intraoperative EtCO2 and nonsurvival of patients undergoing emergency surgery at a level 1 academic trauma center as a case series. If there is a threshold below which survival was extremely unlikely, it might be useful in guiding decision-making in the early termination of futile resuscitative efforts. METHODS After institutional review board approval, a data set was created to investigate the relationship between EtCO2 values at the onset of emergent trauma surgery and nonsurvival. Patients who were admitted and transferred to the operating room (OR) directly from a resuscitation bay were identified using the Ryder Center trauma registry (October 1, 2013, to June 30, 2016). Electronic records from the hospital's anesthesia information management system were queried to identify the matching anesthesia records. The maximum EtCO2 values within 5 and 10 minutes of the onset of mechanical ventilation in the OR were determined for patients undergoing general anesthesia with mechanical ventilation. Patients were divided into 2 groups: those who were discharged from the hospital alive (survivors) and those who died in the hospital before discharge (nonsurvivors). The threshold EtCO2 giving a positive predictive value of 100% for in-hospital mortality was determined from a graphical analysis of the data. Association of determined threshold and mortality was analyzed using the 2-tailed Fisher exact test. RESULTS There were 1135 patients who met the inclusion criteria. Within the first 5 minutes of the onset of mechanical ventilation in the OR, if the maximum EtCO2 value was ≤20 mm Hg, hospital mortality was 100% (21/21, 95% binomial confidence interval, 83.2%-100%). CONCLUSIONS A maximum EtCO2 ≤20 mm Hg within 5 minutes of the onset of mechanical ventilation in the OR may be useful in decision-making related to the termination of resuscitative efforts during emergent trauma surgery. However, a large-scale study is needed to establish the statistical reliability of this finding before potential adoption.

Coagulopathy induced by trauma or cirrhosis is a well-recognized entity. Viscoelastic testing has been used in either condition for goal-directed transfusion and detection of fibrinolysis since conventional coagulation tests do not correlate with clinical risk of bleeding. Hemostatic resuscitation may not be adequate for a trauma patient with liver disease due to complex alterations in coagulation systems and occasionally require adjuvant therapy. We report a case of trauma-induced coagulopathy presenting as severe hyperfibrinolysis in a cirrhotic patient who was refractory to hemostatic resuscitation but was rapidly corrected by the administration of tranexamic acid and recombinant Factor VIIa.

Postpartum hemorrhage (PPH) contributes to 25% of maternal deaths worldwide. Abnormal placentation is a well-known culprit of PPH. Although controversial, iliac artery balloon occlusion has been used in patients to decrease bleeding. The use of antifibrinolytic agents, such as tranexamic acid (TXA), have gained popularity in the management of PPH. We present a 35-year-old parturient with placenta percreta that was managed with internal iliac artery balloon occlusion with concomitant use of TXA during urgent cesarean hysterectomy with subsequent aortoiliac thrombosis formation. The role of both TXA and arterial balloons in PPH, along with their respective limitations, are discussed.

Background Trauma prediction scores such as Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS)) are used to predict mortality, but do not include comorbidities. We analyzed the American Society of Anesthesiologists physical status (ASA PS) for predicting mortality in trauma patients undergoing surgery. Methods This multicenter, retrospective study compared the mortality predictive ability of ASA PS, RTS, Injury Severity Score (ISS), and TRISS using a complete case analysis with mixed effects logistic regression. Associations with mortality and AROC were calculated for each measure alone and tested for differences using chi-square. Results Of 3,042 patients, 230 (8%) died. The AROC for mortality for TRISS was 0.938 (95%CI 0.921, 0.954), RTS 0.845 (95%CI 0.815, 0.875), and ASA PS 0.886 (95%CI 0.864, 0.908). ASA PS + TRISS did not improve mortality predictive ability (p = 0.18). Conclusions ASA PS was a good predictor of mortality in trauma patients, although combined with TRISS it did not improve predictive ability.

Accurate and timely identification of existing audible medical alarms is not adequate in clinical settings. New alarms that are easily heard, quickly identifiable, and discernable from one another are indicated. The "auditory icons" (brief sounds that serve as metaphors for the events they represent) have been proposed as a replacement to the current international standard. The objective was to identify the best performing icons based on audibility and performance in a simulated clinical environment.Three sets of icon alarms were designed using empirical methods. Subjects participated in a series of clinical simulation experiments that examined the audibility, identification accuracy, and response time of each of these icon alarms. A statistical model that combined the outcomes was used to rank the alarms in overall efficacy. We constructed the "best" and "worst" performing sets based on this ranking and prospectively validated these sets in a subsequent experiment with a new subject sample.Experiments were conducted in simulated ICU settings at the University of Miami.Medical trainees were recruited from a convenience sample of nursing students and anesthesia residents at the institution.In Experiment 1 (formative testing), subjects were exposed to one of the three sets of alarms; identical setting and instruments were used throughout. In Experiment 2 (summative testing), subjects were exposed to one of the two sets of alarms, assembled from the best and worst performing alarms from Experiment 1.For each alarm, we determined the minimum sound level to reach audibility threshold in the presence of background clinical noise, identification accuracy (percentage), and response time (seconds). We enrolled 123 medical trainees and professionals for participation (78 with6 yr of training). We identified the best performing icon alarms for each category, which matched or exceeded the other candidate alarms in identification accuracy and response time.We propose a set of eight auditory icon alarms that were selected through formative testing and validated through summative testing for adoption by relevant regulatory bodies and medical device manufacturers.

Oscillations from cardiac pulsations are normally transmitted to mediastinal structures without any consequence. Autotriggering (AT) of mechanical ventilation occurs when an inspiratory trigger, typically negative inspiratory flow in anesthesia ventilators, is met in the absence of patient effort. AT can lead to respiratory alkalosis, opioid overdose, prolonged mechanical ventilation, and lung hyperinflation. This entity has been reported in both critical care and operating room environments. Increasing the flow trigger usually resolves AT in all cases. We report a case of AT that failed to respond to increasing the flow trigger threshold to its maximal value on the GE Datex-Ohmeda Avance S5® anesthesia station.

Damage-controlled hemostatic resuscitation has become a standard of care for critically injured patients. Recently completed PROPRR trial demonstrated hemostatic benefits of 1:1:1 Platelets:FFP:RBC transfusion approach, although overall mortality did not decrease. Improved logistics of resuscitation (decreased crystalloid administration), optimization of blood product delivery with adoption of massive transfusion protocols (short time to first unit of plasma transfused), and better early post-MTP management are the factors that contributed to lower than expected mortality in this study. Liquid plasma and pre-thawed Type A fresh frozen plasma (FFP) are safe alternatives to universal donor Type AB FFP and have been adopted by few trauma centers in North America due to shortage of AB FFP supply.

Cardiothoracic trauma represents a significant challenge for the anesthesiologist, and little robust investigational evidence exists to guide management decisions. Injury patterns are potentially diverse and often severe, and mortality rates are second only to those of traumatic brain injury. As such, anesthesiologists must be familiar both with the fundamentals of trauma patient care and considerations unique to cardiothoracic injury. Herein, we discuss anesthetic considerations related to traumatic injury of the heart, great vessels, conducting airways, and lungs. As the rate of respiratory failure and acute respiratory distress syndrome (ARDS) exceeds that of the general trauma population, we then review the relevant fundamental aspects of mechanical ventilation and treatment of ARDS.

Patient screening was performed either in person or over the phone by Advanced Registered Nurse Practitioners and Registered Nurses working under the direction of the anesthesiologist medical director of the preoperative clinic (SE) Prospective collection of pulmonary outcomes data in patients who are vaping is needed to assess the risks involved and provide more informed decision-making as to the timing of elective surgery and the need for preoperative evaluation by a pulmonologist in the context of such use Scott Eber: This author helped screening the patients in the preoperative clinic, design of the assessment tool, data gathering and manuscript review

Extracorporeal membrane oxygenation has emerged as a treatment of choice for refractory hypoxemia in the intensive care unit. Severe hypoxemia unresponsive to conventional lung-protective mechanical ventilation could also occur in the operating room from severe bronchospasm, pulmonary contusions, or acute respiratory distress syndrome. We report a case of acute hypoxic respiratory failure in an adolescent with blunt chest trauma that was successfully managed with the intraoperative initiation of venovenous extracorporeal membrane oxygenation during the initial damage control surgery.

Operating rooms are identified as being one of the noisiest of clinical environments, and intraoperative noise is associated with adverse effects on staff and patient safety. Simulation-based experiments would offer controllable and safe venues for investigating this noise problem. However, realistic simulation of the clinical auditory environment is rare in current simulators. Therefore, we retrofitted our operating room simulator to be able to produce immersive auditory simulations with the use of typical sound sources encountered during surgeries. Then, we tested the hypothesis that anesthesia residents would perceive greater task load and fatigue while being given simulated lunch breaks in noisy environments rather than in quiet ones. As a secondary objective, we proposed and tested the plausibility of a novel psychometric instrument for the assessment of stress.In this simulation-based, randomized, repeated-measures, crossover study, 2 validated psychometric survey instruments, the NASA Task Load Index (NASA-TLX), composed of 6 items, and the Swedish Occupational Fatigue Inventory (SOFI), composed of 5 items, were used to assess perceived task load and fatigue, respectively, in first-year anesthesia residents. Residents completed the psychometric instruments after being given lunch breaks in quiet and noisy intraoperative environments (soundscapes). The effects of soundscape grouping on the psychometric instruments and their comprising items were analyzed with a split-plot analysis. A model for a new psychometric instrument for measuring stress that combines the NASA-TLX and SOFI instruments was proposed, and a factor analysis was performed on the collected data to determine the model's plausibility.Twenty residents participated in this study. Multivariate analysis of variance showed an effect of soundscape grouping on the combined NASA-TLX and SOFI instrument items (P = 0.003) and the comparisons of univariate item reached significance for the NASA Temporal Demand item (P = 0.0004) and the SOFI Lack of Energy item (P = 0.001). Factor analysis extracted 4 factors, which were assigned the following construct names for model development: Psychological Task Load, Psychological Fatigue, Acute Physical Load, and Performance-Chronic Physical Load. Six of the 7 fit tests used in the partial confirmatory factor analysis were positive when we fitted the data to the proposed model, suggesting that further validation is warranted.This study provides evidence that noise during surgery can increase feelings of stress, as measured by perceived task load and fatigue levels, in anesthesiologists and adds to the growing literature pointing to an overall adverse impact of clinical noise on caregivers and patient safety. The psychometric model proposed in this study for assessing perceived stress is plausible based on factor analysis and will be useful for characterizing the impact of the clinical environment on subject stress levels in future investigations.

A massive transfusion protocol (MTP) presents a logistical challenge for most blood banks and trauma centers. We compare the ratio of packed red blood cells (PRBC) and plasma transfused over serial time points in those requiring MTP (10-30 U PRBC/24 h) to those requiring "super" MTP (S-MTP;30 U PRBC/24 h) and test the hypothesis that changes in allocation of blood products with use of readily transfusable liquid plasma (LP) improves the ratio of PRBC and plasma during S-MTP.All transfused trauma patients (n = 1305) from January 01, 2009-April, 03, 2015 were reviewed. PRBC:plasma ratio was compared for MTP (n = 277) and S-MTP (n = 61) patients, before and after the availability of LP at our institution. Data are reported as mean ± standard deviation or median (interquartile range).Age was 41 ± 19 y, 52% blunt mechanism, injury severity score 32 ± 16, and 46.3% mortality. In 24 h, requirements were 17 (14) U PRBC and 10 (11) U plasma, with a PRBC:plasma of 1.6 (0.8). Within the first hour, PRBC:plasma for S-MTP versus MTP was 2.1:1 versus 1.7:1 (P = 0.017). With LP, S-MTP patients received significantly lower PRBC:plasma at the first hour (P0.001). Before institutional changes, PRBC:plasma positively correlated with PRBC transfused at hour 1 (r = 0.410, R(2) = 0.168, P0.001); after institutional changes and the advent of LP, there was no correlation (r = 0.177, R(2) = 0.031, P = 0.219).Within the first hour of transfusion, units of PRBC transfused positively correlated with PRBC:plasma, and patients receiving S-MTP had higher PRBC:plasma than those receiving MTP. Changes in our institution's MTP protocol to include LP improved the early PRBC:plasma transfused in patients requiring S-MTP.

The association between tranexamic acid (TXA) and fibrinolysis shutdown is unknown. We hypothesize that TXA is associated with fibrinolysis shutdown in critically injured trauma patients.Two hundred eighteen critically injured adults admitted to the intensive care unit at an urban Level I trauma center from August 2011 to January 2015 who had thromboelastography performed upon intensive care unit admission were reviewed. Groups were stratified based on fibrinolysis shutdown, which was defined as LY30 of 0.8% or less. Continuous variables were expressed as mean ± standard deviation or median (interquartile range). Poisson regression analysis was used to determine predictors of shutdown.Patients were age 46 ± 18 years, 81% male, 75% blunt trauma, Injury Severity Score of 28 ± 13, 16% received TXA, 64% developed fibrinolysis shutdown, and mortality was 15%. In the first 24 hours, 4 (2-9) units packed red blood cells and 2 (0-6) units fresh frozen plasma were administered. Those with shutdown had worse initial systolic blood pressure (114 ± 38 mm Hg vs. 129 ± 43 mm Hg, p = 0.006) and base deficit (-5 ± 6 mEq/L vs -3 ± 5 mEq/L, p = 0.013); received more packed red blood cells [6 (2-11) vs. 2 (1-5) units, p0.0001], and fresh frozen plasma [3 (0-8) vs. 0 (0-4) units, p0.0001]; and more often received TXA (23% vs. 4%, p0.0001). After controlling for confounders, TXA (relative risk, 1.35; 95% confidence interval, 1.10-1.64; p = 0.004) and cryoprecipitate transfusion (relative risk, 1.29; 95% confidence interval, 1.07-1.56; p = 0.007) were independently associated with fibrinolysis shutdown.Patients who received TXA were at increased risk of fibrinolysis shutdown compared with patients who did not receive TXA. We recommend that administration of TXA be limited to severely injured patients with evidence of hyperfibrinolysis and recommend caution in those with evidence of fibrinolysis shutdown.Therapeutic, level III.

Supplemental Digital Content is available in the text., INTRODUCTION: Noise in health care settings has increased since 1960 and represents a significant source of dissatisfaction among staff and patients and risk to patient safety. Operating rooms (ORs) in which effective communication is crucial are particularly noisy. Speech intelligibility is impacted by noise, room architecture, and acoustics. For example, sound reverberation time (RT60) increases with room size, which can negatively impact intelligibility, while room objects are hypothesized to have the opposite effect. We explored these relationships by investigating room construction and acoustics of the surgical suites at our institution. METHODS: We studied our ORs during times of nonuse. Room dimensions were measured to calculate room volumes (VR). Room content was assessed by estimating size and assigning items into 5 volume categories to arrive at an adjusted room content volume (VC) metric. Psychoacoustic analyses were performed by playing sweep tones from a speaker and recording the impulse responses (ie, resulting sound fields) from 3 locations in each room. The recordings were used to calculate 6 psychoacoustic indices of intelligibility. Multiple linear regression was performed using VR and VC as predictor variables and each intelligibility index as an outcome variable. RESULTS: A total of 40 ORs were studied. The surgical suites were characterized by a large degree of construction and surface finish heterogeneity and varied in size from 71.2 to 196.4 m3 (average VR = 131.1 [34.2] m3). An insignificant correlation was observed between VR and VC (Pearson correlation = 0.223, P = .166). Multiple linear regression model fits and β coefficients for VR were highly significant for each of the intelligibility indices and were best for RT60 (R2 = 0.666, F(2, 37) = 39.9, P < .0001). For Dmax (maximum distance where there is