No abstract

Background Damage control laparotomy (DCL) is intended to limit deleterious effects from trauma induced coagulopathy. DCL has been associated with mortality reduction, but may increase complications including sepsis, abscess, respiratory failure, hernia, and gastrointestinal fistula. We hypothesized that (1) DCL incidence would vary between institutions; (2) mortality rates would vary with DCL rates; (3) standard DCL criteria of pH, INR, temperature and major intra-abdominal vascular injury (MVI) would not adequately capture all patients. Methods Trauma patients at 12 level 1 North American trauma centers were randomized based on transfusion ratios as described in the PROPPR trial. We analyzed outcomes following emergent laparotomy using a mixed-effects logistic model comparing DCL versus definitive surgical management (DSM) with random effect for study site. Primary outcomes were 24-hour and 30-day mortality. Results 329 patients underwent emergent laparotomy: 213 DCL (65%) and 116 DSM (35%). DCL rates varied between institutions (33%-83%), (p=0.002). Median ISS was higher in the DCL group, 29 (IQR: 13,34) versus 21 (IQR: 22,41) (p<0.001). 24-hour mortality was 19% with DCL versus 4% (p<0.001); 30-day mortality was 28% with DCL versus 19% (p<0.001). In a mixed-effects model, ISS and MVI were correlates of DCL (OR: 1.05, 95% CI: 1.02-1.07 and 2.7, 95% CI: 1.4-5.2). DCL was not associated with 30-day mortality OR 2.33 (CI 0.97-5.60). Correlates included ISS (OR: 1.06, 95% CI: 1.02, 1.09), PRBCs in 24hrs (OR: 1.10, 95% CI: 1.03, 1.18), and age (1.04, 95% CI: 1.01, 1.06). No significant mortality difference was detected between institutions (p=0.63). Sepsis and VAP occurred more frequently with DCL (p<0.05). 80% (135/213) of DCL patients met standard criteria. Conclusions Although DCL utilization varied significantly between institutions, there was no significant mortality difference between centers. This finding suggests tempering DCL use may not decrease mortality, but could decrease related complications.

Traumatic hemorrhage is the leading cause of preventable death after trauma. Early transfusion of plasma and balanced transfusion have been shown to optimize survival, mitigate the acute coagulopathy of trauma, and restore the endothelial glycocalyx. There are a myriad of plasma formulations available worldwide, including fresh frozen plasma, thawed plasma, liquid plasma, plasma frozen within 24 h, and lyophilized plasma (LP). Significant equipoise exists in the literature regarding the optimal plasma formulation. LP is a freeze-dried formulation that was originally developed in the 1930s and used by the American and British military in World War II. It was subsequently discontinued due to risk of disease transmission from pooled donors. Recently, there has been a significant amount of research focusing on optimizing reconstitution of LP. Findings show that sterile water buffered with ascorbic acid results in decreased blood loss with suppression of systemic inflammation. We are now beginning to realize the creation of a plasma-derived formulation that rapidly produces the associated benefits without logistical or safety constraints. This review will highlight the history of plasma, detail the various types of plasma formulations currently available, their pathophysiological effects, impacts of storage on coagulation factors in vitro and in vivo, novel concepts, and future directions.

No abstract

Therapeutic/care management, level III.

Objective The Thoracic Surgery Residents Association (TSRA) is a resident-led organization established in 1997 under the guidance of the Thoracic Surgery Directors Association (TSDA) to represent the interests and educational needs of cardiothoracic surgery residents. We aim to describe the past contributions, current efforts, and future directions of the TSRA within a conceptual framework of the TSRA mission. Methods Primary review of educational resources was performed to report goals and content of past contributions. TSRA Executive Committee input was utilized to describe current resources and activities, as well as the future goals of the TSRA. Podcast analytics were performed to report national and global usage. Results Since 2011, the TSRA has published 3 review textbooks, 5 reference guides, 3 test preparation textbooks, 1 supplementary publication, and 1 multiple choice question bank and mobile application, all written and developed by cardiothoracic surgery trainees. In total 108 podcasts have been recorded by mentored trainees, with over 175,000 unique listens. Most recently, the TSRA has begun facilitating trainee submissions to Young Surgeon’s Notes, fostered a trainee mentorship program, developed the monthly TSRA Newsletter, and established a wide-reaching presence on Facebook, Twitter, and Instagram to help disseminate educational resources and opportunities for trainees. Conclusions The TSRA continues to be the leading cardiothoracic surgery resident organization in North America, providing educational resources and networking opportunities for all trainees. Future directions include development of an integrated disease-based resource and continued collaboration within and beyond our specialty to enhance the educational opportunities and career development of cardiothoracic trainees.

Background The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial has demonstrated that damage control resuscitation, a massive transfusion strategy targeting a balanced delivery of plasma-platelet-RBC in a ratio of 1:1:1, results in improved survival at 3 hours and a reduction in deaths due to exsanguination in the first 24 hours compared to a 1:1:2 ratio. In light of these findings, we hypothesized that patients receiving 1:1:1 ratio would have improved survival after emergency laparotomy. Methods Severely injured patients predicted to receive a massive transfusion admitted to 12 level I North American trauma centers were randomized to 1:1:1 versus 1:1:2 as described in the PROPPR trial. From these patients, the subset that underwent an emergency laparotomy, defined previously in the literature as laparotomy within 90 minutes of arrival, were identified. We compared rates and timing of emergency laparotomy as well as post-surgical survival at 24-hours and 30-days. Results Of the 680 enrolled patients, 613 underwent a surgical procedure, 397 underwent a laparotomy, and 346 underwent an emergency laparotomy. The percentages of patients undergoing emergency laparotomy were 51.5% (174/338) and 50.3% (172/342) for 1:1:1 and 1:1:2, respectively (p=0.20). Median time to laparotomy was 28 minutes in both treatment groups. Among patients undergoing an emergency laparotomy, the proportions of patients surviving to 24 hours and 30 days were similar between treatment arms, 24-hour survival was 86.8% (151/174) for 1:1:1 and 83.1% (143/172) for 1:1:2 (p=0.29), and 30-day 79.3% (138/174) for 1:1:1 and 75.0% (129/172) for 1:1:2 (p=0.30). Conclusions We found no evidence that resuscitation strategy affects whether a patient requires an emergency laparotomy, time to laparotomy, or subsequent survival. Level of Evidence Level IV, therapeutic study.

Tachypnea with suspected thoracic injury is the strongest level 2 triage modification to reduce level 3 under-triage.