Severely injured patients benefit from in-house attending trauma surgeons

Vliet, Quirine M.J. van der; Maarseveen, Oscar E. C. van; Smeeing, Diederik P.J.; Houwert, Roderick M.; Wessem, Karlijn J. P. van; Simmermacher, R. K. J.; Govaert, Geertje A M; Jong, Mirjam B. de; Bruin, Ivar G.J. de; Leenen, Luke P. H.; Hietbrink, Falco

doi:10.1016/j.injury.2018.08.006

Cited by 17 publications

(41 citation statements)

References 24 publications

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“…Although 10 years ago concerns were raised to maintain sufficient expertise in these settings, the residency program and ongoing training programs demonstrate similar or even somewhat improved outcomes in the current study [41]. Furthermore, dedication to trauma both with regard to physicians and logistics might have contributed to these results [17]. A trauma center should be prepared for the severely injured trauma patient that requires an emergency laparotomy.…”

Section: Discussionmentioning

confidence: 59%

“…In the past years, a trauma surgeon is physically present in the hospital 24 h, 7 days a week. In our center, all crash-room activated trauma calls and subsequent surgical procedures (both truncal and musculoskeletal) are directly supervised or carried out by a certified trauma surgeon, with a background in general surgery [17]. We have approximately 1800 trauma activations per year with nearby 200 per year arriving in severe shock.…”

Section: Methodsmentioning

confidence: 99%

“…The indication for an emergency laparotomy is based on patient's physiology as indicated by vital signs (pulse rate, blood pressure, urine output, temperature) and laboratory findings (coagulation, base deficit, hemoglobin levels) [21]. The objective is to complete the procedure within 60-90 min [17]. If appropriate, the abdomen is temporary closed, preferably with a vac-pack [22].…”

Section: The Performance Of a Laparotomy In Trauma And Damage Controlmentioning

confidence: 99%

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Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

et al. 2019

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Background: Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma. Methods: A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay. Results: A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days. Conclusion: This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.

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Section: Discussionmentioning

confidence: 59%

Section: Methodsmentioning

confidence: 99%

Section: The Performance Of a Laparotomy In Trauma And Damage Controlmentioning

confidence: 99%

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Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

et al. 2019

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“…Improving the availability of the appropriate surgeons and resources at the presenting hospital is crucial, since transfer, even to a center specialized in NSTIs, increases the delay and therefore the risk at mortality [21]. To improve immediate availability of the appropriate resources, the system using 24/7 inhouse attending surgeon and the 24/7 readiness of an operating room could significantly decrease the time to surgery and mortality [35,36].…”

Section: Discussionmentioning

confidence: 99%

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

et al. 2020

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Background: Although the phrase "time is fascia" is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods: A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models.Result: A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26-0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27-0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively.Conclusion: Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.

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“…In addition to the conventional two-arm randomized trials and the prospective cohort study, several other study designs are available for comparison of different treatment modalities. The first example is the pre-post design, which was applied in two recent studies on the introduction of 24/7 availability of trauma surgeons in Dutch level 1 trauma centers [36]. Both studies showed improvement of trauma care in the post intervention period compared to the preintervention period, however in one study mortality rates decreased over time, while in the other only an improvement in process related outcomes was found.…”

Section: Alternative Study Designsmentioning

confidence: 99%

Study methodology in trauma care: towards question-based study designs

Houwert

Beks

Dijkgraaf

et al. 2019

Eur J Trauma Emerg Surg

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The randomized controlled trial (RCT) in surgery may not always be ethical, feasible, or necessary to address a particular research question about the effect of a surgical intervention. If so, properly designed and conducted observational (nonrandomized) studies may be valuable alternatives for an RCT and produce credible results. In this paper, we discus differences between RCTs and observational studies and differentiate between three types of comparisons of surgical interventions. We assert that results of different designs should be regarded as complementary to each other when evaluating surgical interventions. Criteria for credible observational research are presented to provide guidance for future observational research of surgical interventions. We argue that the research question that is being asked should guide the discussion about the value of a particular study design.

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Severely injured patients benefit from in-house attending trauma surgeons

Cited by 17 publications

References 24 publications

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

Study methodology in trauma care: towards question-based study designs

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