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To mitigate future risk to limb and skin, we recommend that methylene blue infusions be delivered via central venous catheter. Extra care should be given to patients with risk factors for extravasation, such as sedation, presence of systemic disease, proximal intravenous puncture sites, and improperly placed catheters.

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Background: In situ trauma simulations allow for the trauma team and emergency department to practise team dynamics, resuscitation and logistics in a safe environment. The goal of this investigation was to show the feasibility of an in situ trauma simulation program at a Canadian level 1 trauma centre. Methods:We performed a retrospective review of in situ simulations (maximum 20 min, followed by a 10-min debriefing session) at a level 1 trauma centre from 2015 to 2017. Errors were categorized according to the National Patient Safety Agency risk assessment matrix by 3 independent raters and assigned consequence scores (assessing potential harm) and likelihood scores (assessing the likelihood of potential harm). A risk score was calculated as the product of the mean consequence and likelihood scores. Errors per simulation and the number of simulations required for error resolution were recorded. Results:We reviewed 8 in situ simulations and identified 54 errors, of which 7 were related to medications, 20 to equipment, 21 to environment/staffing and 6 to training. The mean consequence score was 2.85/5 (standard deviation [SD] 0.75, intraclass correlation coefficient [ICC] 28%), indicating minor to moderate harm. The mean likelihood score was 2.82/5 (SD 0.55, ICC 41%), indicating unlikely to possible. The mean risk score was 8.42/25 (SD 3.19, ICC 43%). One error (2%) was low risk, 23 (43%) were moderate risk, 26 (48%) were high risk, and 4 (7%) were extreme risk. Conclusion:In situ trauma simulations are feasible in a Canadian centre and provide a safe environment to identify and rectify errors. Contexte :Les simulations de catastrophes in situ permettent à l'équipe de traumatologie et au service d'urgence de tester la dynamique d'équipe, les techniques de réanimation et la logistique dans un environnement sécuritaire. L'objectif de cette étude était de montrer la faisabilité d'un programme de simulation in situ dans un centre canadien de traumatologie de niveau 1.Méthodes : Nous avons effectué une revue rétrospective des simulations in situ (maximum 20 min, suivies de séances de compte rendu) ayant eu lieu dans un centre de traumatologie de niveau 1 entre 2015 et 2017. Les erreurs ont été classées en catégories selon la grille d'évaluation des risques de la National Patient Safety Agency par 3 examinateurs indépendants, qui leur ont assigné des scores de conséquence (préjudices potentiels) et des scores de probabilité (probabilité de préjudices potentiels). Un score de risque a été calculé sous forme de produit des scores moyens de conséquence et de probabilité. Le nombre d'erreurs par simulation et le nombre des simu lations requises pour les résoudre ont été enregistrés.Résultats : Nous avons analysé 8 simulations in situ et relevé 54 erreurs, dont 7 concernaient les médicaments, 20, l'équipement, 21, l'environnement ou la dotation en personnel et 6, la formation. Le score de conséquence moyen était de 2,85/5 (écarttype 0,75; coefficient de corrélation intraclasse [CCI] 28 %), indiquant des préjudices de mineurs ...

Background Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) (https://clinicaltrials.gov/ct2/show/NCT03163095). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. Methods The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. Discussion OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of “damage control”; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. Trial registration: National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT03163095).