Acute Care Surgery: Part 2

Educational Objectives

The goals of this program are to improve outcomes associated with hemorrhages, use of feeding tubes, and endovascular re­pair and to enhance the clinician’s ability to effectively deliver unwelcome news and conduct death assessments. After hear­ing and assimilating this program, the clinician will be better able to:

1.   Choose appropriate methods (eg, tourniquets, hemostatic dressings) for controlling excessive bleeding.

2.   Prevent complications associated with enteral and parenteral feeding.

3.   Identify lesions eligible for endovascular repair.

4.   Establish protocols for delivering unwelcome news and attending to grieving families.

5.   Conduct evaluations determining preventability of trauma-related deaths.  

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Bebarta presents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgments

Drs. Bebarta, Scherer, Sise, and Wisner were recorded at Trauma, Critical Care, and Acute Care Surgery, held April 6-8, 2009, in Las Vegas, NV, and sponsored by the Trauma and Critical Care Foundation. The Audio-Digest Foundation thanks the speakers and the Trauma and Critical Care Foundation for their cooperation in the production of this program.

Emergent Hemorrhage Control

Vikhyat Bebarta, MD, Chief, Medical Toxicology and Staff Emergency Physician, Wilford Hall Medical Center, San Antonio, TX

Hemorrhage in combat: 50% of combat victims die from hemorrhages (80% civilian casualty rate); 5% to 10% of combat patients undergo mass transfusions (increases mortality rates 20%-50%)

Tourniquets: speaker recommends keeping tourniquets constantly available and applying to all eligible patients; reviews found high rate of death associated with extremity hemorrhages (in combat), and benefits of tourniquets outweighed risks; study (Beekley)  —  patients receiving tourniquets had faster control of bleeding and reduced amputation rates (with no neurologic effects detected); second study —no correlation between time in tourniquets and morbidity, and no result­ing loss of limbs; design  —  created for easy application with one hand (ie, self-application possible); civilian use  —  indicated for extremity injuries (eg, gunshot wounds, crushing injuries, amputations, explosion injuries, bombings, pre­hospital amputations); nerve injury  —  major associated morbidity (especially when applied before arriving at hospital); patients with tourniquet in place for >2 hr at highest risk (rare in United States due to availability of rapid medical trans­port)

Hemostatic dressing: recommended for wounds not suitable for control with tourniquet (eg, axillary wounds, femoral wounds, wounds surrounding neck); popularized by use in penetrating extremity injuries; characteristics of ideal tourni­quet agent  —  septicemic control of arterial and venous bleeding; adheres to wound without increasing risk for disease; does not cause tissue reactions; requires minimal training; durable and flexible; inexpensive; intuitively recognizable as wound dressing; granular mineral-based hemostatic agent (QuikClot)  —  manufactured from volcanic rock with water-ab­sorbing characteristics (concentrates wound factors and platelets); recommended for venous and mixed bleeding models; inexpensive ($10 per dressing); granules difficult to remove from wound after exposure to moisture; small risk of exother­mic reaction (specialized training required for safe application); chitosan-based hemostatic dressing (HemCon)   —non­toxic complex carbohydrate formulated into sponge; attracts red blood cells; efficacious in models of venous bleeding (but not arterial or mixed models); expensive; only available as rigid wafer (complicates insertion into difficult wounds [eg, subclavian injury]); least effective chitosan-based dressing (per recent studies); no longer recommended by Department of Defense’s Tactical Combat Casualty Care committee; QuikClot Combat Gauze  —  impregnated with nanoparticles of kaolin; easily and intuitively recognized as wound dressing; highly efficacious; smectite granules (Woundstat)  —  no longer recommended due to preclinical models showing increased risk for thrombosis

Additional applications: small wounds; epistaxis; patients with glycopathy; postsurgical wounds; difficult scalp wounds; removal of catheters (eg, cardiovascular access catheters, central line catheters); intraabdominal bleed­ing; dental procedures

Feeding Tube Blues

Lynette A. Scherer, MD, Associate Professor of Surgery, and Chief, Division of Trauma and Emergency Surgery, University of California Davis Medical Center, Sacramento

Background on enteral nutrition: studies show gut should be utilized for nutrition whenever possible and total par­enteral nutrition (TPN) should be discouraged; effects of gut absorption prevent infectious complications (impor­tant in critically ill patients); caloric intake  —  hypermetabolism and malnourishment common in critically ill patients; ideal level of nutrition and feeding rate remain uncertain; providing 25% to two-thirds of goal calories considered sufficient by speaker (at low end of scale, providing 25% of goal calories requires delivery of 20 mL/hr); majority of patients tolerate trickle (trophic) rate of feeding; providing two-thirds of nutrition typically requires delivery of 50 mL/hr (ultimately tolerated by majority of patients); supplementing calories alone via TPN  —  shows no additional benefit; possibly associated with worse outcomes; combined enteral nutrition (EN) and TPN  —  ie, supplementing trophic tube feeding (20 mL/hr) with TPN to achieve caloric goals; not recommended over enteral feeding alone (even when EN does not meet patient’s caloric goals); study found patients receiving only 500 kcal per day via enteral tube showed fewer nosocomial infections and reduced rates of late acute respiratory distress syndrome (ARDS), compared to patients given supplemental TPN

Composition of nutritional formulations: many studies show methodological and interpretation biases; immune-enhancing diets not currently validated by data; standard formulations sufficient in nearly all cases; glutamine  —  nonessential amino acid under normal circumstances; essential during significant physiologic stress; data confirm benefits of glutamine supple­mentation; inexpensive and easily administered

Starting EN: dependent on patient (eg, patient with low physiologic stress after isolated head injury may be eligible for early feeding); patients continually subject to major physiologic stress (eg, resuscitation, residual hemorrhaging) should not re­ceive enteral feeding (typically 24-48 hr window); trophic feeding sufficient during early recovery; placement and positioning  —  some patients (eg, with isolated head injuries or burns) tolerate gastric feeding (direct nutrition to stomach with orogastric [OG] tube); for patients intolerant of gastric feeding, speaker recommends postpyloric feeding tube; patients easily fed through stomach  —place nasogastric feeding tube (inexpensive and easily handled by nursing staff); postpyloric tubes  —  available as flexible weighted-tipped feeding tubes; also inexpensive and easily placed by nursing staff; morbidities easily mitigated; success rate for blind placement approaches 80%; fluoroscopically guided feeding tube placement  —  increases costs; requires physician to conduct study; transport of patient creates risks; success rates £95% (when utilized in conjunction with contrast medium and erythromycin); endoscopically guided feeding tube placement  —  expensive; requires physician; time-consuming; transport of patient not required; 80% success rate; magnetically guided feeding tube  —  heavy magnet placed over patient’s abdomen detects and indicates magnetic connection with feeding tube (assists in guiding tube to position); 95% success rate; speaker reports 78% success rate in patients normally difficult to intubate; tube must be re­moved before magnetic resonance imaging; electromagnetic tube placement device (eg, Cortrak)  —sensing device placed over patient’s abdomen detects frequency emitted by tube; course of tube traced on monitor; 100% placement accuracy re­ported (but not experienced by speaker); intraoperative tube placement  —  eg, positioning tube while performing laparotomy; data on success rates limited; successful positioning not always possible; speaker recommends using tube with large bulleted end (surgeon feeds to him- or herself, then pulls preferentially past ligament of Treitz)

Complications associated with feeding tube placement: speaker’s institution mandates kidney, ureter, and bladder (KUB) x-rays with all feeding tubes; avoiding accidental feeding of lungs or pleural space critical; tubes associated with perforation of pharynx, esophagus, and gastrointestinal (GI) tract (rare); improper taping of tube may result in nasal alar necrosis

Endovascular Approach

Michael J. Sise, MD, Clinical Professor of Surgery, University of California San Diego School of Medicine, and Trauma Medical Director, Scripps Mercy Hospital, San Diego, CA

Background on endovascular procedures: physicians often rely on colleagues with skills necessary for catheteriza­tion; practicing with unfamiliar colleagues without agreed upon methods for collaboration complicates procedures; endovascular approach not suitable for unstable patients (operating room [OR] required); necessary equipment and staff  —possible to bring C-arm device (has digital subtraction capability) from orthopedic department to OR; power injector; other supplies (eg, catheters, wires, stents, grafts, coils); support staff critical when planning movement of patient from interventional radiology (IR) suite to OR; limitations  —limited to high-flow vessels or aorta (and proximal branches); stent graft  —  must be able to cross lesion to apply; best device for covering lesions; typically made from polytetrafluoroethylene (PTFE); not resistant to infection, but useful for temporizing in difficult areas

Endovascular repair: ideal in stable patients with trauma in inaccessible areas (where operations associated with high morbidity); aortic pseudoaneurysm  —  located in inaccessible area; requires large incision; significant morbid­ity rate even with expert care (clamping and grafting increases risk for paraplegia); aortic arch  —  endovascular re­pair not yet proven; not recommended without dedicated thoracic-aortic program and thorough planning; pseudoaneurysm of superficial femoral artery (SFA)  —  endovascular repair not recommended due to unproven effi­cacy of SFA stents (need to drain hematoma in OR, so surgical approach logical); pseudoaneurysm of proximal ax­illary artery  —  requires extensive operation with risk of morbidity; hematoma stable and does not require drainage in OR; can be repaired with covered stent graft in IR suite

Medical Communications: Delivering Bad News

Dr. Sise

Goals: thoroughly inform; direct family’s efforts effectively; begin healthy coping; initiate grieving process

Communication technique: prepare, inform, listen, leave (PILL) approach  —  prepare to tell story effectively; in­form patient’s family thoroughly, and guide them toward answers to any unknown details; negative experience with physician when receiving bad news may constitute second trauma; take time to listen; when leaving, arrange immediate “hand-off” (to, eg, chaplain, social worker)

Preparation: find ideal location for communicating (eg, with place for physician to sit down and some degree of pri­vacy); never go alone (especially with death notices in emergency department [ED]); wear clean scrubs and white coat (clean appearance important); find out who specifically should receive communication; identify pa­tient’s family members immediately; plan words you will use to relate information before meeting

Informing: speak directly and clearly; eye level should be same or lower than family during communication (sit or kneel down, if possible [unless everyone stands]); refer to mortality with “died,” “dead”, or “death” and avoid softened lan­guage (eg, “passed on”); communicate honestly, briefly, and thoroughly; do not preach, show condescension, argue, become defensive, or say “I’m sorry” (when alone; saying “I’m sorry for your loss” acceptable; patients may mistake apology for admission of wrongdoing); be honest with consolation (eg, “I don’t think [he or she] suffered”); saying “I wish it could be different” found to immediately communicate understanding and compassion

Listening: pay attention to initial response; avoid appearing judgmental; provide opportunity to ask questions, and offer to help find answers to lingering questions; when appropriate, ask familiarizing questions (eg, “what was [he or she] like?” or “how long were you married?”); do not leave until hand-off ready; let patients know what happens next, and who will provide assistance (eg, when loved one’s remains can be visited and how); facilitate visit to decedent as quickly as possible (after clean-up); stand with family members briefly before stepping away; provide business card or telephone number (assure family of future availability for answering questions)

Leaving: do not leave family completely alone, but leaving important after death notification; physicians should de­brief after leaving

Further recommendations: speaker stresses modeling appropriate behavior for colleagues less experienced in deliver­ing bad news; avoid relying on family members to interpret (certified translator or fluent staff member recommended); armed security should be available, but not in room during death notifications; intensive care unit (ICU) phase  —  identify family spokesperson; set up weekly conferences; make family communication one of essential systems dur­ing daily turnover; create effective bond of compassion; remember that families look for empathy, not sympathy

Death Assessment: Preventable
or Possibly Preventable?

David H. Wisner, MD, Professor and Acting Chairman, Department of Surgery, University of California Davis, Sacramento

Rates of preventable death: significantly variable; institutional self-assessment often finds rates of 0% to 0.2%; ob­jective assessment often shows 10% of deaths preventable; at speaker’s hospital, internal assessment found 7% of deaths possibly preventable; however, outside evaluations found 25% to 30% of deaths possibly preventable

Assessing preventable deaths: causes  —  technical errors (10%); treatment delays (most frequent cause; 50%-55%); majority occur in ICU (second highest rate in OR); other types of errors less often judged as preventable and given more leniency; deaths in patients with minor illnesses more often deemed preventable; deaths from penetrating injuries infrequently judged preventable; deaths from low falls, low mechanism of injury, and low severity commonly viewed as mistakes; reproducibil­ity study  —  preventability assessed in deaths of 20 patients (noncentral nervous system [CNS]-related) by 3 groups using dif­fering protocols; 11 deaths deemed preventable by ³1 group, but only 1 death deemed preventable by all 3; different methods of determining preventability showed widely varying results; independent judgments rarely resulted in agreement; discussion before judgments produced greater consistency; second preventable deaths study  —  CNS-related deaths found preventable more often than non-CNS deaths; more agreement on early deaths, patients with less severe injuries, and younger patients with non-CNS injuries; trauma injury severity score (TRISS) study  —  compared number of deaths deemed preventable by TRISS and numerical methodologies (33) to number determined by peer review (2); more similarity between numbers deemed possibly preventable; autopsy  —  studies yielded conflicting results; avoiding personal bias  —  collect infor­mation from maximum number of possible sources (eg, nurse practitioners, bedside nurses, trauma nurse managers); closed discussions yield unreliable outcomes; discuss cases in which better care possible (even if outcome unlikely to have changed); speaker recommends cross-institutional assessment of trauma cases; final advice  —  focus on systems in­stead of individuals when judging deaths; emphasize improvement instead of punishment

Suggested Reading

Beekley AC et al: Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma 64:S28, 2008; Cahill NE et al: Nutrition therapy in the critical care setting: what is "best achievable" practice? An international multi­center observational study. Crit Care Med 38:395, 2010; Dayan L et al: Complications associated with prolonged tourniquet applica­tion on the battlefield. Mil Med 173:63, 2008; Kheirabadi BS et al: Safety evaluation of new hemostatic agents, smectite granules, and kaolin-coated gauze in a vascular injury wound model in Swine. J Trauma 68:269, 2010; MacKenzie EJ et al: Inter-rater reliabil­ity of preventable death judgments. The Preventable Death Study Group. J Trauma 33:292, 1992; Nose K et al: Glutamine prevents total parenteral nutrition-associated changes to intraepithelial lymphocyte phenotype and function: a potential mechanism for the pres­ervation of epithelial barrier function. J Interferon Cytokine Res 30:67, 2010; Petros S, Engelmann L: Enteral nutrition delivery and energy expenditure in medical intensive care patients. Clin Nutr 25:51, 2006; Rheaume P et al: Open vs endovascular repair of blunt traumatic thoracic aortic injuries. J Vasc Surg 51:763, 2010; Sise MJ et al: Surgeons' attitudes about communicating with patients and their families. Curr Surg 63:213, 2006; Szeto WY et al: Transapical deployment of endovascular thoracic aortic stent graft for an as­cending aortic pseudoaneurysm. Ann Thorac Surg 89:616, 2010; Testerman GM et al: CT angiogram and endovascular stent graft for an axillary artery gunshot wound. South Med J 101:831, 2008; Wilson DS et al: Identification of preventable trauma deaths: con­founded inquiries? J Trauma 32:45, 1992.