1. Explain the rationales of low-volume and high-volume resuscitation and the use of different types of resuscitation fluids.

2. Discuss the role of antioxidant supplementation in trauma patients.

3. Appropriately treat coagulopathies in trauma patients with massive blood loss.

4. Identify sources of preventable surgical complications.

5. Reduce rates of postoperative infections by implementing evidence-based guidelines for antibiotic prophylaxis.

New Concepts in Trauma: Fluid Resuscitation
Ronald V. Maier, MD, Jane and Donald D. Trunkey Professor and Vice Chair, Department of Surgery, Harborview Medical Center, Seattle, WA

Changing trends in resuscitation: underresuscitation—urine output and mean arterial pressure may appear adequate in patients with occult hypoperfusion, but patients have reduced splanchnic blood flow and compromised gastric mucosal perfusion; hypoperfusion increases risk for multiple organ failure; over- resuscitation—to force splanchnic bed open and avoid occult hypoperfusion, O2 delivery increased to 600 mL/min; high-volume resuscitation doubles risk for intracranial hypertension, almost triples risk for abdominal compartment syndrome, and more than doubles mortality; other associated problems include inability to extubate (because of unprotected airway) and pulmonary failure; stopping blood loss vs fluid resuscitation—massive blood loss resulting from some types of trauma (eg, gunshot wound to aorta) must be controlled before fluid resuscitation attempted, but rule does not apply to all trauma patients; speaker recommends avoiding extremes in blood pressure (BP)

Trauma-associated mortality: acute—blood loss; brain injury; post-acute—multiple organ failure (in part, caused by occult hypoperfusion); brain injury; hemorrhage less common; patients with brain injuries— hypotension increases risk for adverse outcomes, including death

Mechanism of injury: hemorrhage results in shock and ischemia; reperfusion generates oxidants, which damage tissue, causing secondary brain injury and multiple organ failure; activated neutrophils produce oxidants, contributing to tissue damage

Resuscitation fluids: lactated Ringer’s solution—standard of care; L-isomer of lactate beneficial, but D-isomer toxic to mammals; some products include both isomers; products with D-isomer cause massive activation of neutrophils, resulting in more oxidative damage; manufacturers addressing problem; hypertonic saline—does not cause activation of neutrophils in animal models; associated with significant reduction in mortality (in mice), compared to resuscitation with lactated Ringer’s solution (14% vs 77%) after cecal ligation and puncture; unfortunately, studies in humans have found no mortality benefit; addition of osmotic agent—military studies show addition of agent (eg, dextran) that retains fluid within intravascular space markedly reduces intracranial pressure yet maintains high level of oxygenation in brain; meta-analysis shows use of hypertonic saline plus osmotic agent results in best outcomes at 24 hr and after discharge; large clinical trial in progress

Antioxidant supplementation: endogenous antioxidants depleted within 12 to 24 hr in intensive care unit (ICU); inability to mitigate effects of stress-induced oxidant production may have role in development of multiple organ failure; pyruvate—good antioxidant, but quickly degraded; ethyl pyruvate—longer half-life than pyruvate; supplementation (in mice with cerebral ischemia) associated with lower stroke volume, and preserved function of brain and gut mucosa; similar benefits seen in animal models for sepsis; human studies in progress; vitamin C and vitamin E—in ICU patients, supplementation associated with reduced incidence of multiple organ failure (50%), decreased duration of ventilation (by 1 day), shorter stay in ICU (mean decrease \>1 day), and decreased 28-day mortality rate (1.5% vs 2.5%, without supplementation)

Blood transfusions: study population consisted of young otherwise healthy soldiers injured in combat (massive blood loss and tissue damage); mortality rate influenced by presence and severity of hypotension and hypoperfusion; ratio of fresh frozen plasma (FFP)—increasing amount of FFP relative to red blood cells (RBCs) increased survival; ratio of 1:1 (RBC/FFP) decreased mortality by 65%, compared to ratio of 10:1; treating coagulopathies early—injuries with massive blood loss quickly result in coagulopathies; FFP contains coagulation products necessary for correcting coagulopathy; risk for multiple organ failure—increasing FFP also associated with increased risk (partly explained by increased survival rates); practice change— most level-1 trauma centers have begun early initiation of FFP in patients with massive blood loss

Factor VIIa: protein involved in coagulation cascade; military studies show benefit in patients with massive blood loss, but inappropriate use may cause stroke or myocardial infarction

Fresh whole blood: patients who receive older (stored) blood have higher risk for multiple organ failure; fresh whole blood (never refrigerated) associated with significant survival benefit

The Surgical Care Improvement Project and Prophylactic Antibiotics: What are the Data Behind the Performance Measures
Samuel E. Wilson, MD, Professor of Surgery, University of California, Irvine, College of Medicine

Preventable complications: beginning October 1, 2008, Medicare no longer paying for care pertaining to certain preventable complications; background—research investigating disability and costs associated with preventable complications led Institute of Medicine (IOM) to publish 2 reports (To Err is Human [1999] and Crossing the Quality Chasm [2001]); examples—in 2006, 532 cases of wrong-site surgery and 522 cases of in-hospital suicide; high rates of postoperative wound infections

Initiatives: Surgical Care Improvement Project—areas of focus include surgical site infections, adverse cardiac events, proper use of β-blockers, and prevention of deep venous thrombosis and pulmonary embolism; National Quality Assurance Program—initiated by Department of Veterans Affairs; adopted by American College of Surgeons; implemented by some managed care facilities; National Nosocomial Infection Surveillance System— established risk index that incorporates characteristics of patient (eg, physical status) and surgery (eg, duration)

Surgeon responsibility: risk for postoperative infection highly dependent on individual surgeon; infection rates among surgical residents decrease with experience, from 25% to <9%, but individual rates vary; case loads and infection rates vary among experienced surgeons

Prophylactic antibiotics: administer ≤1 hr before surgical incision (≤2 hr for vancomycin); use recommended antibiotics; discontinue antibiotics ≤24 hr after surgery; antibiotic window—given too early, levels peak before surgery, leaving patient vulnerable to infection; appropriate timing of antibiotics ensures adequate levels in serum and tissues during surgery; practice—wide variation in timing; prophylactic antibiotics given \>2 hr before surgery to 10 hr after surgery; infection rates lowest when antibiotics administered during 1-hr window; dose and duration—single dose of long-acting agent sufficient; short course as effective as long course; antibiotics continued only if indication (eg, perforated appendix) discovered during surgery (record indication in operative notes); continuing prophylactic antibiotics longer than recommended does not improve outcomes and contributes to increased rates of resistance; important to base dose on weight (especially in bariatric setting); vancomycin dosed 15 mg/kg (not standard dose of 1 g); if using short-acting cephalosporin (eg, cefoxitin), second dose required 1.5 to 2 h after initial dose; Centers for Disease Control and Prevention (CDC) recommendations—first choice for surgical implantations and other clean surgeries, first-generation cephalosporin; vancomycin recommended if risk high for methicillin-resistant Staphylococcus aureus and for patients with penicillin allergy

Other factors that affect risk for infection: hypothermia—increases risk, likely because vasoconstriction limits immune response; recommended to achieve normothermia ≤10 min after certain abdominal procedures; tobacco use—increases odds ratio 10-fold; age—not independent risk factor; shaving—tiny nicks provide sites for colonization of gram-positive bacteria; blood transfusions—autologous blood recommended; bank blood has immunosuppressive qualities and increases risk for infection

Prophylaxis for gastrointestinal and colorectal surgery: second-generation cephalosporins recommended; quinolones indicated for patients with penicillin allergy; carbapenem also approved for use in this setting; combination oral and intravenous (IV) antibiotics—IV antibiotics effective against bacteria adherent to colon mucosa (protected against oral antibiotics by mucus layer); oral erythromycin achieves therapeutic levels in serum and has activity against anaerobic organisms; infection rates—studies show rates of 26% to 42% (some use composite outcomes, including surgical site infections, anastomotic leaks, intra-abdominal abscesses, and any unexplained antibiotic use ≤4 wk after surgery); factors that affect risk include obesity, duration of surgery, and albumin level

Emergency Surgical Care: How Fast is the Time Bomb Ticking?
Darrell W. Graham, MD, Administrative Chief Resident, University of Florida Health Science Center, Jacksonville

Surgeon shortage: workforce of general surgeons has declined \>25% over last 25 yr (relative to population); rural areas particularly affected; identified problems include fewer numbers of new surgeons, high workload, and potential for burnout

Survey of surgeons in Florida: polled community- and university-based surgeons in Jacksonville and community-based surgeons across state; time to retirement—in Jacksonville, median length of practice (in Florida), 16 yr; state-wide, median length of practice, ≈11 yr; ≈50% of general surgeons (state-wide) expected to retire within 10 yr; call schedule and reimbursement—median 5 calls/mo; 25% of community-based surgeons work \>10 calls/mo; <50% of Florida surgeons receive stipends for being on call; only 22% of surgeons receive monthly stipends of $500 to $1000; case load—100% of surveyed surgeons had cases of bowel obstruction within past 6 mo; other common cases include appendicitis and cholecystitis; perceptions of recent graduates— less extensive technical capability; limited exposure to common surgical cases; questionable ability to handle call schedule; concern about ability to manage complications

Government response: although some surveyed legislators ranked current shortage as high-priority and recognize importance of recruiting and retaining surgeons, only 13 of 149 Florida legislators responded to survey