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This randomized, controlled trial involving patients with complicated intraabdominal infections and proper source control showed similar outcomes after fixed-duration antimicrobial therapy (4 days) and after a longer course (approximately 8 days). Complicated intraabdominal infection continues to be a common problem worldwide. Approximately 300,000 cases of appendicitis occur each year in the United States, 1 and at least twice that many cases of non-appendiceal infection require management. 2 Morbidity ranges from 5% among patients evaluated in broad observational studies 2 – 4 to close to 50% in some cohorts, such as the elderly or critically ill. 5 , 6 Despite the diversity of specific processes in these infections, the basic tenets of management are similar: resuscitate patients who have the systemic inflammatory response syndrome (SIRS), control the source of contamination, remove most of the infected or necrotic material, . . .

Early triage of trauma patients requiring massive transfusion (MT) may help to marshal appropriate resources and improve treatment and outcome. Artificial intelligence (AI) and machine learning (ML) offer theoretical advantages compared to conventional prediction algorithms but have not been thoroughly evaluated in this population. We hypothesized that AI/ML techniques incorporating all available data in a patient’s medical record could achieve similar, if not higher, performance in the prediction of mortality in MT patients as compared to existing models. Patients from the American College of Surgeons Trauma Quality Improvement Project database (TQIP) were retrospectively reviewed. Those receiving ≥ 5 units of red blood cells and/or whole blood within the first four hours of arrival were defined as MT patients. Those receiving ≥10 units were identified as ultramassive transfusion (UMT) patients. ML models were created to predict 6-hour mortality using variables available at different time points, including patient arrival. Of 5,481,046 patients in TQIP from 2017 to 2021, 47,744 received MT and 20,337 of these received UMT. Using only variables available on arrival, MT AUROC was 0.901 [95% CI 0.895–0.910] which increased to 0.943 [95% CI 0.938–0.948] with addition of 4-hour variables. For UMT, arrival AUROC was 0.858 [95% CI 0.846–0.872] and increased to 0.922 [95% CI 0.914–0.931] at 4 hours. ML models reliably predict mortality in both MT and UMT patients. These are the only ML models trained on MT and UMT patients. Future work can focus on prospective implementation of these models with potential direct integration into the electronic medical record. Real-time utilization of comprehensive patient data may enhance clinical decision-making regarding which patients should continue receiving massive transfusion, thus optimizing the allocation of this limited resource.

Several interventions are generally thought to be ‘life-saving’ in the management and care of traumatically injured patients. The evidence supporting the utility of some interventions, however, is tenuous, if not outright contradictory to what occurs in the modern practice of trauma care. This was the topic of the Point Counterpoint 2024 Charles C. Wolferth lecture given by Nicholas Namias. This article will summarize his talk by highlighting multiple examples of interventions felt to be critical to the preservation of life in the trauma patient that, upon closer inspection, are not as well supported by evidence as one might think. These interventions include the expansion of trauma systems, sternotomy for hemopericardium, resuscitative endovascular balloon occlusion of the aorta (REBOA), prehospital intubation, and needle decompression of traumatic pneumothorax. By discussing the controversy surrounding these interventions, we hope to prompt the reader to question not only the nature and utility of their continued use but also what other closely held ideas and interventions deserve renewed scrutiny.

Introduction Hemorrhage is one of the leading causes of preventable death in trauma patients. For decades, the Airway-Breathing-Circulation (ABC) approach has been the cornerstone of trauma care. However, emerging evidence suggests that prioritizing airway management in exsanguinating patients may worsen hypotension and increase mortality. This systematic review and meta-analysis aim to evaluate the effectiveness of the Circulation-Airway-Breathing (CAB) approach compared to the traditional ABC sequence in improving survival in trauma patients with severe hemorrhage. Methods A systematic review was conducted in accordance with the PRISMA guidelines. Databases including PubMed and Ovid MEDLINE, SCOPUS, web of science and EMBASE were searched for studies published up to September 2024. Eligible studies included observational and comparative studies reporting outcomes of trauma patients with exsanguinating hemorrhage. The Newcastle–Ottawa Scale was used for risk of bias assessment. A meta-analysis was performed using a random-effects model to calculate pooled odds ratios (OR) for mortality, with 95% confidence intervals (CI). Subgroup analysis was conducted to compare the ABC and CAB approaches in prospective and retrospective studies. Results Six studies ( N  = 11,855 patients) met the inclusion criteria. The meta-analysis revealed a significant increase in mortality associated with the ABC approach (pooled OR: 3.65, 95% CI: 1.74–7.65). Subgroup analysis of prospective cohort studies found an even higher mortality risk (POR: 9.99, 95% CI: 5.59–17.85) when compared with POR of retrospective studies (POR: 2.42, 95%CI: 1.08–5.36). High heterogeneity (I2 = 92%) was observed across the studies, likely due to variations in patient populations and resuscitation protocols. Conclusion Prioritizing circulation over airway management in trauma patients with exsanguinating injuries significantly reduces mortality compared to the traditional ABC approach. The present consensus paper, conducted according to the WSES methodology 3 , aims to provide a review of the literature comparing the CAB approach to the traditional ABC sequence in trauma patients with exsanguinating hemorrhage, to develop a shared consensus statement based on the currently available evidence

Desirability of outcome ranking and response adjusted for duration of antibiotic risk (DOOR/RADAR) are novel and innovative methods of evaluating data in antibiotic trials. We analyzed data from a noninferiority trial of short-course antimicrobial therapy for intra-abdominal infection (STOP-IT), and results suggest global superiority of short-duration therapy for intra-abdominal infections.

OBJECTIVE To concomitantly determine the differential degrees of air and environmental contamination by Acinetobacter baumannii based on anatomic source of colonization and type of ICU layout (single-occupancy vs open layout). DESIGN Longitudinal prospective surveillance study of air and environmental surfaces in patient rooms. SETTING A 1,500-bed public teaching hospital in Miami, Florida. PATIENTS Consecutive A. baumannii-colonized patients admitted to our ICUs between October 2013 and February 2014. METHODS Air and environmental surfaces of the rooms of A. baumannii-colonized patients were sampled daily for up to 10 days. Pulsed-field gel electrophoresis (PFGE) was used to type and match the matching air, environmental, and clinical A. baumannii isolates. RESULTS A total of 25 A. baumannii-colonized patients were identified during the study period; 17 were colonized in the respiratory tract and 8 were colonized in the rectum. In rooms with rectally colonized patients, 38.3% of air samples were positive for A. baumannii; in rooms of patients with respiratory colonization, 13.1% of air samples were positive (P=.0001). In rooms with rectally colonized patients, 15.5% of environmental samples were positive for A. baumannii; in rooms of patients with respiratory colonization, 9.5% of environmental samples were positive (P=.02). The rates of air contamination in the open-layout and single-occupancy ICUs were 17.9% and 21.8%, respectively (P=.5). Environmental surfaces were positive in 9.5% of instances in open-layout ICUs versus 13.4% in single-occupancy ICUs (P=.09). CONCLUSIONS Air and environmental surface contaminations were significantly greater among rectally colonized patients; however, ICU layout did not influence the rate of contamination. Infect Control Hosp Epidemiol 2016;37:777-781.

BackgroundThe use of low titer group O whole blood (LTOWB) for resuscitation of patients with traumatic hemorrhage is becoming increasingly common. Practices regarding the administration of RhD-positive LTOWB to childbearing age females (CBAFs) vary between institutions due to concerns about RhD alloimmunization. This study examined practices related to LTOWB transfusion as they pertain to age and sex.MethodsThis was a secondary analysis of the Shock, Whole blood, and Assessment of TBI (traumatic brain injury) trial, a prospective, multicenter observational cohort study where outcomes following LTOWB transfusion were analyzed at seven level 1 trauma centers between 2018 and 2021, as well as a survey on transfusion practices at these centers conducted in 2023. The proportion of patients who received LTOWB or components was examined over the course of the study and grouped by age and sex, and the RhD group of injured CBAFs was documented.ResultsA total of 1046 patients were evaluated: 130 females aged <50 years (CBAFs), 77 females aged ≥50 years; 661 males aged <50 years, and 178 males aged ≥50 years. Among them, 26.2% of CBAFs received RhD-positive LTOWB, whereas 57.1%–66.3% of other sex/age groups received LTOWB. The proportion of CBAFs who received LTOWB increased significantly throughout the 4 years of this study. Except for older women in years 2 and 4, CBAFs were significantly less likely to receive LTOWB than all other groups for the study period and individual years. Among the 33 CBAFs who received LTOWB and for whom an RhD type was available, 4/33 (12.1%) were RhD-negative, while 9/95 (9.5%) CBAFs who received component therapy were RhD-negative. RhD blood product selection practices varied considerably between institutions.ConclusionsMany institutions transfused LTOWB to CBAFs. Policies regarding RhD product selection varied. Of the total cohort, the proportion of RhD-negative CBAFs who received LTOWB increased over time but remained lower than all other groups.Level of evidence3.

IntroductionPediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes.MethodsThis was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts.Results4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1–17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities.ConclusionPediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center.Level of evidenceLevel IV, retrospective study.

ObjectivesAfter appendectomy for simple or complicated appendicitis, the optimal duration of postoperative antibiotics (postop abx) is unclear and great practice variability exists. We propose to compare restrictive versus liberal postop abx using a hierarchical composite endpoint which includes patient-centered outcomes and accounts for duration of antibiotic exposure.Methods/DesignParticipants with simple or complicated appendicitis undergoing appendectomy are randomly assigned to either restricted or liberal strategy. Eligible subjects declining randomization will be recruited to enroll in an observation only cohort. The primary endpoint is an ordinal scale of mutually exclusive clinical outcomes with within-category rankings determined by duration of antibiotic exposure. Subjects in both randomized and observation only cohorts will be analyzed as intention-to-treat, per-protocol, and as-treated. Exploratory Bayesian analyses will be performed.ConclusionThe complex and simple appendicitis: restrictive or liberal postoperative antibiotic exposure multicenter randomized controlled trial will enroll surgical appendectomy patients and seeks to analyze if a strategy of restricted (compared with liberal) postoperative antibiotics results in similar clinical outcomes with the benefit of reduced antibiotic exposure.Trial registration numberNCT05002829.

Objectives Other than automobiles, bicycles are connected to more pediatric injuries than any other consumer product. Whereas characterization of injury patterns following motor vehicle accidents has led to safety initiatives and treatment guidelines, knowledge related to bicyclist injuries is lacking. Our purpose is to identify major injury patterns and outcomes associated with pediatric bicycle accidents. Methods From January 2000 to December 2012, 1934 consecutive pediatric admissions (≤17 years) at a level I trauma center were retrospectively reviewed for mechanism injury, demographics, and outcomes. Parametric data were analyzed with student’s t test and are presented as mean ± standard deviation. Nonparametric data were analyzed with Mann–Whitney- U test and are presented as median (interquartile range). Analysis was performed to recognize injury patterns and outcomes significantly associated with bicycle related accidents. Results 80 pediatric patients were admitted following bicycle related trauma (4 % of all pediatric trauma admissions). The cohort was age 11 ± 4 years, ISS 11 ± 10, 48 % black, and 81 % male. Injury patterns included 21 % isolated head, 21 % isolated abdominal, 13 % isolated extremity, and 34 % multiple injuries. 5 % were age 0–4 years, 35 % were age 5–9 years, 45 % were 10–14 years, and 15 % were 15–17 years ( p  < 0.001). 16 % required operative intervention (6 % abdominal, 9 % orthopedic, 1 % vascular). Children under age 6 required an abdominal operation 20 % of the time. Length of stay was 2 (4) days with a mortality of 2.5 %. Conclusions Pediatric bicycle accidents more commonly occur in male children aged 10–14 years. Orthopedic injury is the most frequent overall indication for surgery, yet the youngest children more often required an abdominal operation. Level of evidence : Level III.