101.19 Operative versus Non-Operative Management of High Grade Liver Trauma: A Single Center Experience

Posted on January 31, 2019

R. G. Ramos1, D. Newhouse1, K. Lemon1, J. Alvikas1, L. Alarcon1, B. Zuckerbraun1, A. Peitzman1, A. Humar1, M. Neal1, A. Tevar1  1University Of Pittsburg,Surgery,Pittsburgh, PA, USA

Introduction:  The liver is the most commonly injured abdominal organ, with American Association for the Surgery of Trauma (AAST) grade IV or V injuries comprising only 15% of these injuries. Although the majority of these safely undergo non-operative management (NOM), AAST grade IV and V liver injuries continue to be associated with high NOM failure rates and a 20% mortality rate. Patients who fail NOM have increased morbidity and mortality when compared to patients who receive up-front operative management (OM). In order to define the best management strategies for high grade liver injuries, we conducted an analysis of grade IV and grade V injuries managed at our institution from January 2010 to July 2018.

Methods:  This is a retrospective review of patients admitted to our institution with an AAST grade IV or V liver injury from January 2010 to July 2018. Demographic data, mechanism of injury, length of stay (LOS), intensive care unit (ICU) LOS, morbidity, and mortality were obtained from electronic medical records. Patients undergoing laparotomy in the first 6 hours were considered to have received OM. Attempted NOM was defined as no surgery in the first 6 hours. Failure of NOM was defined as surgical intervention after the first 6 hours. The type of OM, operative time, complications of OM, IR interventions, need for endoscopic retrograde cholangiopancreatography (ERCP), failed NOM, angioembolization, morbidity, and mortality were described.

Results: During the study period, our institution admitted 123 patients with high grade liver trauma. Mechanism of injury was blunt in 102 patients (83%) and penetrating in 21 patients (17%). Median age was 30 years (IQR 22-43). Median LOS was 12 days (IQR 6-21). AAST grade of their liver injuries was grade IV in 85 patients (69%) and  grade V in 38  patients (31%). Seventy three patients (59%) underwent OM, 50 (41%) underwent NOM, and 7 (6%) failed NOM. The overall mortality was 13 (11%). Mortality in the OM group was 13 (18%), 8 (62%) of these patients died within 24 hours of admission. The indication for surgery was hemodynamic instability (systolic blood pressure < 100 mm Hg and/or heart rate > 120 bpm) in all 13 patients. There were no fatalities in the failed NOM group or the NOM group.

Conclusion: Despite advances in ICU care and NOM strategies, high grade liver injuries continue to be associated with significant morbidity and mortality. This study describes the most severely injured liver trauma cohort in the literature with 85 (69%) grade IV injuries, and 38 (31%) grade V injuries. Our overall mortality (11%) and our OM group mortality (18%) are lower than the mortality reported in the most recent National Trauma Data Bank analysis of severe blunt liver injury (20%). This suggests that operative management continues to be a viable option in selected patients with high grade liver injuries.

101.18 Gastrostomy in Traumatic Brain Injury: A Comparative Analysis of Technique to Obtain Feeding Access

Posted on January 31, 2019

B. E. Love1, K. Inaba1, K. Matsushima1, D. Clark1, M. Lewis1, D. Demetriades1, A. Strumwasser1  1LAC+USC Medical Center,Acute Care Surgery,Los Angeles, CA, USA

Introduction:  Bedside percutaneous gastrostomy (PEG) tube placement in patients with traumatic brain injury (TBI) is central to providing enteral access in the intensive care unit. It obviates the need for a trip to the operating theater or interventional radiology suite and can expedite ICU discharge in patients awaiting rehabilitation beds. However, optimal placement may require image guidance to ensure appropriate placement. We compared outcomes between the different techniques used for gastrostomy tube placement in these patients. 

Methods:  A retrospective chart review of all patients admitted for TBI at our Academic Level I Trauma Center was performed (2009-2017). All adult patients with TBI that underwent gastrostomy placement were eligible for analysis. Outcomes included hospital length-of-stay (HLOS), ICU LOS, ventilator days, and complications related to PEG placement.

Results: A total of 206 patients with TBI and gastrostomy tubes were admitted during the study period. Average ISS was 22 and ICU LOS was 32 days; 119 (58%) patients underwent bedside gastrostomy (PEG); 70 (34%) underwent image-guided gastrostomy (IGG); 17 (8%) underwent open gastrostomy (OG). Complications related to the gastrostomy occurred in 10 (5%) of all the tubes placed; 7 (70%) occurred in the PEG group, 2 (20%) in the IGG group, and 1 (10%) occurred in the OG group.  

Conclusion:In patients with severe traumatic brain injury that require gastrostomy tube placement, tubes placed by surgeons in the operating room remains the most durable option for gastrostomy placement. However, image-guided tubes provide a reliable alternative when surgically-placed feeding access is not an option. 

 

101.17 Stimulants and Traumatic Brain Injury: Outcomes at a Level I Trauma Center

Posted on January 31, 2019

B. E. Love1, K. Inaba1, K. Matsushima1, D. Clark1, M. Lewis1, D. Demetriades1, A. Strumwasser1  1LAC+USC Medical Center,Acute Care Surgery,Los Angeles, CA, USA

Introduction:  Stimulant use has multiple physiologic effects. In traumatic brain injury patients, these effects include clouding the physical and neurologic exam. The effects of stimulant use on in-hospital outcomes for patients with traumatic brain injury has been largely unexamined in the current literature. 

Methods:  We performed a retrospective chart review of all adult patients with traumatic brain injury admitted to our Level I trauma center in Los Angeles from March 2008 to May of 2017. Only patients with urine drug screens performed on admission were included in the study. Patients tested for methamphetamines, cocaine, and PCP were selected for analysis. All patients with alcohol and other depressants were excluded from the study. Patients that died within the first 48 hours of admission (n = 276) were excluded. In-hospital interventions, outcomes, and ICU complications were collected and analyzed.  

Results: A total of 1,946 patients met inclusion criteria for the study. Methamphetamines were the most commonly found stimulant (88%).  Table 1 demonstrates patient demographics and ICU outcomes. As can be seen in Table 2, patients that tested positive for stimulants tended to be younger and had longer ICU courses with longer ventilator days. More patients that tested positive for stimulants were intubated in the emergency department. The stimulant group also had more ICU complications during their hospitalization (39% vs 24%), though mortality was slightly better in the stimulant group (9% vs 13%). None of the stimulant patients developed ARDS during their hospital course, while 9 (0.5%) in the stimulant negative group did. 

Conclusion: Stimulant use in patients with traumatic brain injury are associated with slightly improved survival, but more in-hospital complications. The absence of ARDS from the stimulant group might be due to the more aggressive, early intubation in the emergency department, explained by increased combativeness and the lower GCS upon presentation. This suggests a possible protective effect of early intubation in patients with stimulants and traumatic brain injury. Further study on stimulants is needed to better parse their effects on patients with varying injury patterns. 

 

101.16 Analysis of Vaginal and Vulvar Trauma: Risk Factors for Operative Intervention

Posted on January 31, 2019

S. Gambhir1, A. Grigorian1, V. Gabriel1, S. Schubl1, C. Barrios1, N. Bernal1, J. Victor1, J. Nahmias1  1University Of California – Irvine,Surgery,Orange, CA, USA

Introduction: Vaginal and vulvar trauma may occur accidentally or because of an act of violence. Due to its rarity, little is known about risk factors effecting need for operative repair. We sought to perform a large database analysis of adult external genitalia to determine possible risk factors for requiring operative repair.

Methods: A retrospective analysis of the National Trauma Data Bank was performed between 2007-2015. Patients ≥  16 years old with vaginal or vulvar trauma were identified. Risk factors for surgical repair were identified using a multivariate logistic regression analysis.

Results: From 2,040,235 female patients, 2,445 (<0.2%) were identified to have external genitalia trauma with the majority being injury to the vagina (68.6%). In patients with injury to the vagina, age≥65 (OR=0.41, CI=0.26-0.62, p<0.001), injury severity score (ISS) ≥ 25 (OR=0.66, CI=0.50-0.86, p<0.05) or victims of rape (OR=0.39, 95% CI=0.26-0.57, p<0.001) were less likely to require repair. In patients with injury to the vulva, age≥65 (OR=0.45, CI=0.21-0.94, p<0.05), victims of rape (OR=0.26, CI=0.08-0.87, p<0.05) or gunshot violence (OR=0.10, CI=0.02-0.59, p<0.05) were less likely to require repair but those with a concomitant injury to the vagina were more likely to require repair (OR=2.56, CI=1.63-4.03, p<0.001).

Conclusion: Injuries to the vagina or vulva occur in < 0.2% of traumas. Interestingly, in both vulvar and vaginal trauma, age≥65, ISS≥25 and involvement in rape or gunshot violence was associated with lower risk for operative intervention. A combined injury to the vagina and vulva increases the need for repair.

101.15 Enteral nutrition in septic patients does not significantly contribute to excess fluid accumulation

Posted on January 31, 2019

D. Aronowitz1, B. T. Faliks1, V. Patel1, J. Nicastro1, R. Barrera1  1North Shore University And Long Island Jewish Medical Center,Surgical Critical Care,Manhasset, NY, USA

Introduction:  The association between malnutrition and poor outcomes in critically ill patients is well documented. International guidelines for the treatment of septic shock recommend early initiation of enteral nutrition. Enteral nutrition should be included in net fluid accumulation when considering a patient’s risk of fluid overload. Here we examine the impact of enteral nutrition on fluid balance in septic shock patients.

Methods:  This retrospective chart review evaluated fluid balance in septic shock patients admitted to medical, surgical, neurosurgical, cardiothoracic intensive care, and/or coronary care units at Northwell Health campuses between January 2015 and December 2016. Total fluid volume received and net fluid balance were recorded from the time of admission to the time vasopressors were discontinued. “Fluid overload” was defined as having a percent fluid accumulation (PFA) of 10% or greater relative to baseline bodyweight. PFA was calculated by dividing the net fluid balance (liters) by the admission bodyweight (kilograms) and then multiplying by 100. Patients were stratified as either having received (Group 1) or not received (Group 2) enteral nutrition, either orally or via feeding tube. Appropriate statistical tests were used to compare PFA, 28-day mortality, days in the hospital and ICU, and ventilation days with a p<0.05 considered statistically significant.

Results: The charts of 100 patients were reviewed. Overall, net fluid balance was positive in 88/100 patients, with a median fluid balance of 6 liters. Forty patients were fluid overloaded in terms of PFA. Seventy-eight patients received enteral nutrition (Group 1) and the remaining 22 patients did not (Group 2). Groups 1 and 2 shared similar baseline characteristics. Mean age, BMI, and BSA in Group 1 were 73 years, 28.0, and 1.93, respectively. Mean age, BMI, and BSA in Group 2 were 76 years, 27.8, and 1.84, respectively. Median fluid balance was 5.4 liters in Group 1 and 6.5 liters in Group 2 (p = 0.89). Fluid overload (PFA ≥10%) occurred at a rate of 38.4% in Group 1 and a rate of 45.5% in Group 2 (p = 0.56).). In-hospital mortality or mortality within 28 days of discharge occurred in a total of 42/100 patients. Mortality rate appeared higher in Group 2 than Group 1 (38.5% vs. 54.5%, p = 0.18). Mean hospital days (13+18 vs. 9+12 p = 0.31), mean ICU days (15+22 vs. 6+8, p = 0.08), and average duration of mechanical ventilation were all greater in Group 1 than Group 2 (17+24 vs. 5+8 days, p = 0.02). 

Conclusion: In our cohort, patients were not more or less likely to have received enteral nutrition based on age, BMI, or BSA. Fluid overload was not significantly associated with enteral feeding. When comparing mortality, days in the hospital, days in the ICU, and days on a ventilator, only duration of mechanical ventilation was significantly increased in patients who received enteral nutrition.

 

101.14 A Cross Sectional Survey of Factors Influencing Mortality of Rwandan Surgical Patients in the ICU

Posted on January 31, 2019

G. BUNOGERANE JURU1, J. Rickard2  1National University Of Rwanda,Surgery/General Surgery/College Of Medicine And Health Sciences,Butare, SOUTH, Rwanda 2University Of Minnesota,Minneapolis, MN, USA

Introduction:

The disease burden of surgical patients remains a global problem especially in low- and middle-income countries. This challenge extends to critically ill patients where there is a paucity of trained staff, infrastructure, resources and drugs to provide the best care to the critically ill patient. A clear understanding on the demographics, diagnosis and factors influencing the outcome of surgical intensive care unit (ICU) patients is needed to better understand critical care provided in limited resource settings. We aimed to study the disease patterns of surgical patients admitted in an ICU in a limited resource setting and determine factors influencing their outcome in order to define strategies to improve care.

Methods:

This was a cross-sectional observational study of all surgical patients admitted to the ICU of a tertiary referral hospital in Rwanda from September 2017 to March 2018. This included all patients followed by a surgical service who underwent either operative or non-operative management. We collected data on demographics, diagnosis, management and outcomes. Chi square test was used to determine factors associated with in-hospital mortality.

Results:

Over a 7-month period, there were 126 surgical patients admitted to the ICU. Most (n=86, 68%) were male with a mean age of 41 years. Many (n=56, 44%) patients had only 1 day of symptoms and presented emergently (n=105, 83%). Common indications for ICU admission included respiratory support (n=62, 49%) and postoperative recovery (n=40, 32%). The most common diagnoses were head injury (n=55, 44%), peritonitis (n=33, 26%), brain tumor (n=15, 12%) and trauma (n=13, 10%). Most (n=124, 98%) patients required mechanical ventilation while only 42 (33%) patients required vasopressors. The mean ICU length of stay was 4 days. The overall ICU mortality was 46% with the highest mortality seen in patients with peritonitis (76%). Temperature, heart rate, blood pressure, duration of symptoms, admitting team, surgical diagnosis, type of surgery (Emergency/Elective), reoperation, nutrition and vasopressors were found to be associated with an increased risk of mortality (p<0.05).

Conclusions:

Surgical patients admitted to the ICU bear a significant mortality. Common surgical ICU diagnoses include head injury and peritonitis with the highest mortality rates seen in patients with peritonitis. We recommend a review of the admission policy to optimize utility of the ICU, favoring those patients who are more likely to benefit from ICU admission. The factors found to correlate with an increased risk of mortality were fever, tachycardia and hypotension on admission, duration of symptoms, surgical diagnosis, delayed nutrition, being on vasopressors in the first hours of admission, and the length of stay.

 

101.13 Transfusion Reactions are Not Associated with FFP Administration During Burn Shock Resuscitation

Posted on January 31, 2019

R. Ball1,2, J. S. Vazquez1,2, T. E. Travis1,2,3, M. M. McLawhorn2, L. S. Johnson1,2,3, L. T. Moffatt2,4, J. W. Shupp1,2,3,4  1MedStar Washington Hospital Center,The Burn Center,Washington, DC, USA 2MedStar Health Research Institute,Firefighters’ Burn And Surgical Research Laboratory,Washington, DC, USA 3Georgetown University School of Medicine,Department Of Surgery,Washington, DC, USA 4Georgetown University School of Medicine,Department Of Biochemistry,Washington, DC, USA

Introduction: Burn shock frequently occurs in patients with large cutaneous thermal injuries. Vasodilation, vasoplegia, and capillary leak each contribute to a decrease in end organ perfusion seen in these patients. Restoration of cardiac output and correction of end organ malperfusion has traditionally been achieved by large-volume crystalloid fluid administration, although this can lead to edema-related complications. Colloid inclusive resuscitations (CIR) have been described using either human albumin (HA) or fresh frozen plasma (FFP). Both HA and FFP can be useful in restoring intravascular volume and reducing edema formation. However, FFP has been linked to various transfusion reactions including acute hemolytic transfusion reaction (AHTR), transfusion related acute lung injury (TRALI), transfusion associated circulatory overload (TACO), and allergic transfusion reactions (ATR). A single burn center’s use of FFP during burn shock resuscitation was evaluated over a two year period with respect to the incidence of these reactions.

Methods:  Patients with large thermal cutaneous injuries and burn shock who received FFP for the resuscitation from July 2016 to July 2018 were identified for review. The electronic medical records were queried to collect demographic, laboratory, and mortality data. Signs and symptoms of TRALI were defined by the Canadian Blood Services Consensus Conference. The primary outcome of interest was the frequency of transfusion related reactions.

Results:A total of 46 patients were identified as having large thermal cutaneous injuries and received treatment with FFP for burn resuscitation.Twenty patients met criteria for having an alternate etiology of acute lung injury (ALI), such as concomitant inhalation injury and/or blunt trauma to the chest; these were excluded from the analysis. The remaining twenty-six patients had a mean age of 51.2 years; 57.1% were male. The average TBSA involved was 31.6%. Flame burns (82.1%) were the most common mechanism of injury seen in this patient population. Patients received a mean IV fluid volume of 6.7cc/kg/%TBSA during the first 24 hours after injury.  Of the patients that did receive FFP during the initial 24 hours, the average start time of FFP infusion was 12.7 hours after injury. Patients received a mean of 21 units of FFP, with a total of 535 units of FFP administered between all 26 patients. No patients were identified as having any signs and symptoms of any acute transfusion reaction associated with FFP administration. 

Conclusion: Patients admitted to this regional burn center with large thermal cutaneous injuries generally receive FFP administration as part of the burn resuscitation. Although there are reports describing adverse impacts of FFP administration in this patient population, these were not observed in the study. A multicenter randomized prospective observational study is warranted to adequately evaluate the risk benefit of using HA or FFP during a burn resuscitation. 

101.12 Patients with Active Cancer and Emergent Appendectomy: A Case-Control Study of Surgical Outcomes

Posted on January 31, 2019

J. Chen3, C. R. Horwood1, S. A. Byrd2, G. Metzger1, R. G. Eaton3, A. P. Rushing1  1The Ohio State University,Division Of Trauma, Critical Care, And Burn,Columbus, OH, USA 2Indiana University,School Of Medicine,Indianapolis, IN, USA 3The Ohio State University,College Of Medicine,Columbus, OH, USA

Introduction:  
Due to increasing technological and therapeutic advances, cancer is now shifting from an acute to a chronic care model. This leads to a potential increase in patients living with cancer who present with acute surgical emergencies such as appendicitis. However, clinical decision-making for these patients is largely anecdotal. The goal of this study was to evaluate a single institution’s appendectomy outcomes amongst patients with active cancer compared to those without cancer. We hypothesized that patients with cancer who underwent appendectomy for acute appendicitis would have similar surgical outcomes compared to patients without cancer.

Methods:  
A single academic institution’s registry was queried to identify patients with and without active cancer who presented with a diagnosis of acute appendicitis and underwent emergent appendectomy between 2011 and 2016. Records were retrospectively reviewed for patient demographics, baseline clinical characteristics, pertinent oncologic information, intraoperative information, and outcomes. Primary outcomes included post-operative complications, need for additional invasive procedures, index-hospitalization mortality, hospital length of stay (LOS), and discharge disposition.

Results:
A total of 131 patients were included in the analysis; 19 patients had cancer (14.5%) and 112 did not have cancer (85.5%). The cancer cohort was older than the control group (51.7±15.3 vs 35.3±17.5, p<0.001). The cancer cohort had a lower median WBC (7.4 vs 13.0, p=0.045), lower median hemoglobin (13.0 vs 14.0, p=0.020), and lower median albumin (3.7 vs 4.4, p=0.026) compared to the control group. Cancer patients were also more likely to have higher ASA classifications than the control group (p<0.001) and were more likely to go to the ICU post-operatively (10.5% vs 1.8%, p=0.041). There was a slight difference in discharge disposition amongst the cancer group compared to the control group, with a slightly higher proportion of patients being discharged to a skilled nursing facility than home (2 vs 1 patient, p=0.022). There was no difference in post-operative complication rates (p=0.200), post-operative LOS (p=1.000), need for additional invasive procedures (p=1.000), or index-hospitalization mortality (1 death per group, p=0.270). There were no increased odds for index-hospitalization mortality (OR=6.17, p=0.205, 95% CI 0.37 to 103.06) or complications (OR=2.44, p=0.221, 95% CI 0.58 to 10.15) based on active cancer status.

Conclusion:
Despite differences in pre-operative characteristics between patients with and without cancer, post-operative outcomes were similar after emergency appendectomies. Thus, while more data is still needed, these preliminary outcomes suggest that patients with active cancer are not at greater risk for post-operative morbidity and mortality following emergent appendectomy for acute appendicitis.

101.11 Fluid accumulation of 10% or more than bodyweight in septic patients contributes to adverse outcomes

Posted on January 31, 2019

D. Aronowitz1, B. T. Faliks1, V. Patel1, J. Nicastro1, R. Barrera1  1North Shore University And Long Island Jewish Medical Center,Manhasset, NY, USA

Introduction:  Given the adverse effects of end-organ edema from fluid overload, recent guidelines encourage minimizing cumulative fluid balance in the treatment of septic shock. We further examined the effects of fluid excess on septic patient outcomes.

Methods:  We conducted a retrospective chart review of septic shock patients admitted to intensive care units at Northwell Health campuses between January 2015 and December 2016. Total fluid volume administered and net fluid balance were calculated from the time of admission to the time vasopressors were discontinued. For each patient, net fluid balance was divided by the baseline bodyweight (kilograms) at admission and the quotient was multiplied by 100 to obtain the percentage fluid accumulation (PFA). Since fluid overload is often defined as fluid accumulation of 10% or more than baseline bodyweight, we used this as a cutoff to stratify patients into two groups: patients with a PFA ≥10% (Group 1) and patients with a PFA <10% (Group 2). Appropriate statistical tests were used to evaluate 28-day mortality, length of hospital and ICU stay, and ventilation days with a p<0.05 considered statistically significant.

Results: The charts of one hundred patients were reviewed. Net fluid balance was positive in 88/100 patients, with a median fluid balance of 6 liters. Percentage fluid accumulation was ≥10% in 40 patients (Group 1) and <10% in the remaining 60 patients (Group 2). Mean age, BMI, and BSA in Group 1 were 76 years, 25.9, and 1.85, respectively. Mean age, BMI, and BSA in Group 2 were 72 years, 29.3, and 1.94, respectively. Comparison of Groups 1 and 2 showed increased mean hospital days (18+22 vs. 9+9, p = 0.003), mean ICU days (19+30 vs. 9+7, p = 0.01), and mean ventilation days (21+32 vs. 10+9, p = 0.013). In-hospital mortality or mortality within 28 days of discharge occurred in a total of 42/100 patients. There were 24 mortalities in Group 1 and 18 mortalities in Group 2. The higher mortality rate in Group 1 was statistically significant (58.5% vs 30.5%, p = 0.003). 

Conclusion: A net fluid accumulation greater than or equal to 10% of admission bodyweight at the time of vasopressor discontinuation in septic shock patients was significantly associated with longer ICU and hospital stays, longer duration of mechanical ventilation and increased mortality.

 

101.10 Penetrating Extracranial Vertebral Artery Injuries Collective Review of Rare and Difficult Injuries

Posted on January 31, 2019

J. A. Asensio1, P. J. Dabestani1, C. A. Fernandez1, T. Becker1, R. Bertellotti1, D. Cornell1, T. Kraner1, A. B. Olsen1, D. K. Agrawal1, J. A. Asensio1  1Creighton University Medical Center,Trauma Surgery And Surgical Critical Care,Omaha, NE, USA

Introduction:

Penetrating vertebral artery injuries (VAI) are rare. Their clinical presentation range from asymptomatic to exsanguination. Given their rarity, complex anatomy and difficult surgical exposure, few Trauma Surgeons or Trauma Centers have significant experience with these injuries. The objectives of this study are to review their incidence, clinical presentation, radiologic identification, management – both angiographic and operative, incidence of aneurysms, pseudoaneurysms, arteriovenous fistulas, and outcomes, as well as to review operative approaches for their surgical management.

Methods:

A literature search was conducted on MEDLINE Complete-PubMed. From 1893-2018 all series describing management and outcomes of penetrating VAI's were selected. PRISMA guidelines were employed. Original series and case reports yielded a total 181 studies. They were winnowed to 72 studies, including series and case reports, which form the basis of this collective review. Operative procedures and outcomes were recorded, along with methods of diagnostic imaging, angiographic, and operative management.

Results:

There were a total of 462 patients with penetrating VAI's. Incidence of vertebral artery injury military population ­– 0.2%, civilian population – 3.1%. More complete data was available from 13 collected VAI specific series and 37 case reports for a total of 362 patients. Mechanism of injury data was available for 341 patients (94.2%): GSW’s – 178 patients (52.2%), SW’s – 131 (43.2%), miscellaneous mechanisms of injury – 32 (9.4%). Anatomic site of injury data was available for 177 (49%) patients: 92 (52%) left, 84 (47.5%) right, and bilateral ­– 1 (0.5%). Anatomic segment of injury data was available for 206 patients (57%): 28 (13.6%) V-1, 126 (61.2%) V-2, and 52 (25.2%) V-3. Treatment data was available for 212 patients: Operative management – 89 (38.7%), angiography and angioembolization – 67 (29.1%), combined – 16 (7%) and observation – 58 (25.2%). Stenting and repair were less frequently employed – 10 (4.3%). Incidence of aneurysms/pseudoaneurysms – 61 (16.9%), AVF – 67 (21.6%). Calculated mortality VAI specific series ­– 15.1%, individual case report group –10.5%.

Conclusion:

The majority of VAI's injuries are asymptomatic upon presentation but may present with exsanguinating hemorrhage. CTA is the first line imaging modality to establish diagnosis, if hemodynamically stable. Gunshot wounds account for the majority of these injuries. Most frequently injured segment is V-2. Operative interventions were required in 38.7% and includes: ligation, clipping and packing. Angiography and angioembolization are diagnostic and therapeutic and was required in 29.1%. Trauma surgeons must be adept to surgically expose this vessel, control hemorrhage, prevent exsanguination, and address associated injuries.

101.09 Trocar Site Hernia Is Common Following Laparoscopic Appendectomy

Posted on January 31, 2019

S. Hawkins1, G. Emmanuel2, L. Khoury1, S. Shams3, G. Yarmish2, V. Sim1, A. Gave1, M. Panzo1, S. M. Cohn1  1Staten Island University Hospital-Northwell Health,Surgery,Staten Island, NY, USA 2Staten Island University hospital-Northwell Health,Radiology,Staten Island, NY, USA 3Stanford Medical Center,Radiology,Stanford, CA, USA

Introduction:
Trocar site hernia (TSH) after laparoscopic cholecystectomy is found routinely (ie: >30% in the elderly) (1). The incidence of this complication after laparoscopic appendectomy (LA) is unknown but is reported to be extremely low. We sought to determine the incidence of TSH following LA.

Methods:
We reviewed abdominal CTs performed in patients >60 years old after LA and characterized them by the presence or absence of pre-operative hernia or TSH.

Results:
2475 patients underwent LA at our institution between 2006 and 2016. 166 (7%) were 60 years of age or older. In this high-risk age group, 49 (30%) underwent a CT of the abdomen for any indication following LA. 17 (35%) were found to have a TSH on their interval CT scan. Notably, 25 (51%) of this group were found to have umbilical hernia on the pre-operative CT, and of those patients 14 (56%) were found to have a TSH on their interval scan.

Conclusion:

We found that trocar site hernias after laparoscopic appendectomy are common (35%).  Umbilical hernias are very often present at baseline and represent a major risk factor for trocar site hernia after laparoscopic appendectomy. Further prospective studies to determine the potential benefit of prophylactic mesh placement (Ref 1) in the setting of laparoscopic appendectomy appear warranted.

Ref: 1: Armañanzas L, Ruiz-Tovar J, Arroyo A, García-Peche P, Armañanzas E, Diez M, Galindo I, Calpena R. Prophylactic mesh vs suture in the closure of the umbilical trocar site after laparoscopic cholecystectomy in high-risk patients for incisional hernia. A randomized clinical trial. J Am Coll Surg. 2014 May;218(5):960-8. doi: 10.1016/j.jamcollsurg.2014.01.049. Epub 2014 Feb 18. PubMed PMID: 24680572.

101.08 The Epidemiologic Characteristics and Outcomes of Intentional Burn Injuries at a Regional Burn Center

Posted on January 31, 2019

K. D. Atwell1, C. Bartley1, B. Cairns1, A. Charles1  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA

Introduction: The predictors of burn mortality have been well studied, which include age, burn size, presence of inhalational injury and pre-existing comorbidities. There are limited studies that describe the role of burn injury intentionality on mortality outcome. Intentional burn injury outcomes are usually more severe, have a high mortality and are seen more often in low and middle income countries.1,2 This study will examine the epidemiological characteristics of intentional burn injury patients and mortality outcome at the UNC Jaycee Burn Center in North Carolina.

Methods: A retrospective study of patients admitted to the UNC Jaycee Burn Center from 2002-2015. Variables analyzed were basic demographics, total body surface area (TBSA) of burn, type of burn, presence of inhalation injury, Charlson comorbidity index (CCI), burn intent, mortality and intensive care unit (ICU) and hospital length of stay (LOS). Chi-square tests, bivariate analysis and logistic regression models were used to determine statistical significance between the two study groups.

Results:11,786 adult and pediatric patients from 2002-2015 were included in the study. 348 (3%) patients had intentional burn injuries (IBI). Patients with IBI had a lower mean age of 26.5 ±20.4 vs. 32 ±22 in the non-intentional burn injury (NIBI) group, p<0.001.  Mean %TBSA was significantly higher in the IBI vs. NIBI group at 14.6 ±20 vs. 6.4 ±10, p<0.001, respectively. Non-whites (66%) were more likely to have IBI compared to Whites (34%), p<0.001. Inhalation injury and mortality were statistically significant in the IBI burn cohort, 16% (n=54) and 9% (n=30), respectively vs. 6% (n=647) and 2.9% (n=329) in the NIBI group, respectively, p<0.001. Median hospital LOS was significantly higher in IBI patients compared to NIBI patents, 10 days (IQR=22) vs. 5 days (IQR=10), p<0.001. Median ICU LOS was also significantly higher in IBI patients compared to NIBI patents, 7 days (IQR=33) vs. 3 days (IQR=10), p<0.001. Multivariate logistic regression for odds ratio showed that IBI patients have a 2.6x increased odds of mortality, an increased hospital LOS of over twice the mean LOS and a prolonged ICU LOS 1.6x over the mean ICU LOS.

Conclusion:Our study findings showed that patients with intentional burn injuries have high burn injury severity attributable to the associated increased %TBSA and Inhalation injury. Furthermore, patients with intentional burn injury have higher odds of mortality and increased ICU and hospital LOS. Intentional burns, both self-harm or assault burns, increase health care expenditures attributable to additional resources for medical, psychiatric, social services and other health care expenses.  There must be a high index of suspicion for intentional injury for large %TBSA burn and associated inhalation injury. Violence prevention initiatives that target the male and minority demographic may be beneficial in reducing intentional burn injury burden.

101.07 Early Tracheostomy in Severe Traumatic Brain Injury Reduces Incidence of Ventilator Associated Pneumonia

Posted on January 31, 2019

A. Nordin1,2, K. Jalal2, J. Wilkins2, J. Jordan1,2  1State University Of New York At Buffalo,Buffalo, NY, USA 2Erie County Medical Center,Buffalo, NY, USA

Introduction:
Patients sustaining severe Traumatic Brain Injury (TBI; Glasgow Coma Scale [GCS] ≤8) require airway securement, often progressing to tracheostomy. The benefits of tracheostomy are well-documented, including improved patient comfort, more rapid ventilator weaning, and decreased risk of pneumonia. However, the optimal time to perform tracheostomy remains unclear. The literature on the timing of tracheostomy is contradictory, especially in this patient population. We sought to evaluate the relationship between timing of tracheostomy in severe TBI and the development of ventilator-associated pneumonia (VAP) at our level 1 trauma center.

Methods:
We performed a retrospective analysis of all patients admitted with a TBI and GCS ≤8 who underwent tracheostomy from 2002 to 2017 at our level 1 trauma center. Data points collected included age, gender, Injury Severity Score (ISS), ventilator days, time to tracheostomy, and the development of VAP. We compared patients who developed VAP against those who did not using chi square analysis and Wilcoxon rank-sum tests; multivariate logistic regression analysis was also performed to determine the odds of developing VAP based on time to tracheostomy.

Results:
A total of 457 TBI patients were identified, 207 (45.3%) of whom developed pneumonia.  Interestingly, males were more likely to develop pneumonia, although there were no other noted differences in demographics. In this sample, the mean duration of mechanical ventilation was 18.7 days (SD 22.3), and patients underwent tracheostomy an average of 9.8 days (SD 6.6) after intubation. On univariate analysis, patients who did not develop pneumonia had a shorter time to tracheostomy (9.46 days vs 10.29 days; p = 0.026) and consequently had decreased ventilator days (16.22 days vs 21.83 days; p = 0.006). On multivariate analysis, increased ventilator days increased the odds of developing pneumonia (OR = 1.018; 95% CI 1.00-1.04).

Conclusion:
In conclusion, among severe TBI patients requiring tracheostomy, a decreased time to tracheostomy, and therefore a decreased duration of mechanical ventilation, was associated with a reduced risk of ventilator-associated pneumonia. Further analysis will clarify the individual roles of demographics and other traditional risk factors in VAP development. Future studies should examine the potential benefits of early tracheostomy in a prospective fashion and determine the optimal time for tracheostomy in this patient population. 
 

101.06 Amputation Following Burn Injury

Posted on January 31, 2019

C. N. Bartley1, K. Atwell1, B. Cairns1, A. Charles1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA

Introduction: Amputation following burn injury is a rare occurrence. Nevertheless, the physical, psychological, and socioeconomic consequences are substantial. Previous studies describe the risk of amputation after electrical burn injuries and/or only involve a small number of patients. Therefore, we will describe the distribution of amputations and evaluate for predictors of amputation after burn injury for all burns admitted to a large regional burn center.

Methods:  We conducted a retrospective analysis of patients ? 17 years admitted from January 2002 to December 2015. Baseline patient and injury characteristics included sex, age, %TBSA, race, burn etiology, and the presence of a concomitant inhalation injury. Patients who underwent an amputation procedure were compared to those who did not. A multivariate logistic regression model was used to determine the risk factors for amputation. Amputations were further categorized by location (upper vs lower extremity) and type (major vs minor) for comparison. Additionally, patient characteristics of those who underwent an amputation procedure were compared by etiology (electrical vs thermal) to assess for potential differences.

Results: Of the 8,313 patients included for analysis, 1.4% underwent an amputations(s) (n = 119). Amputees were older (46.7 ± 17.4 years) than patients with no amputations (42.6 ± 16.8 years) (p = 0.009). Black (39.5%) and Hispanic (8.4%) patients were more likely to have an amputation procedure. The most common burn etiology for amputees was flame (41.2%) followed by electrical (23.5%) and other (21.9%). Median CCI was 0 for both the amputation and no amputation patients (p = 0.030). Patients in the amputation group had a higher median TBSA compared to those in the no amputation group (6% vs 3%, p <0.001). Black race (OR 2.29; 95% CI 1.22 – 4.30), CCI (OR 1.29; 95% CI 1.05 – 1.59), electric (OR 13.54; 95% CI 6.23 – 29.45) and other (OR 4.24; 95% CI 1.84 – 9.81) burn etiology, and %TBSA (OR 1.03; 95% CI 1.02 – 1.05) were found to be associated with an increased odds of amputation.

Conclusion: Our study confirms previous findings that electrical burns are associated with an increased risk of amputation. We also found that other burn types, the presence of pre-existing comorbidities, black race, and increased %TBSA are predictors of amputation in a population of burn patients admitted to a regional burn center. The role of comorbidities and race on the risk of amputation requires further investigation.

 

101.05 Bedside Ultrasound Assessment of Diaphragm Function in Traumatic Rib Fractures: A Feasibility Study

Posted on January 31, 2019

D. N. O’Hara1, S. Randazzo1, S. Ahmad1, D. Pasternak1, E. Huang1, R. Jawa1  1Stony Brook University Medical Center,Trauma And Critical Care,Stony Brook, NY, USA

Introduction: Rib fractures following blunt trauma are a major cause of morbidity. Patient age, number of rib fractures, presence of pulmonary contusion, and inspiratory capacity (IC) have all been used to assist in resource allocation. In medical patients, ultrasound measurements of diaphragm thickness have been previously shown to efficiently represent relative diaphragm function by way of the calculated diaphragm thickening fraction (TF). We sought to evaluate the feasibility of incorporating TF into the evaluation of this patient population.

Methods:  This prospective, IRB-approved study enrolled adults (age ≥18 years) who were admitted to a level 1 ACS trauma center with blunt traumatic rib fractures. Exclusion criteria included injuries requiring a chest tube and mechanical ventilation at study enrollment. We evaluated TF and IC within 48 hours of admission. The TF was determined by measuring the minimum and maximum diaphragm thickness (Tdi) during spontaneous tidal breathing and calculating the TF ratio (TF= (Tdimaximum-Tdiminimum)/Tdiminimum). Inspiratory Capacity was determined via bedside incentive spirometry as the maximum recorded IC of 5 attempts.

Results: Twenty-five subjects (15 male, 10 female) were enrolled in the study. Demographic characteristics of this pilot sample include a median age of 59 (IQR 51.5-73.5) years, median Injury Severity Score of 10 (IQR 10-14), and BMI of 29.0 (IQR 26.44-31.66). Five patients had pulmonary contusions. One patient had lung disease and 8 patients were current smokers. Nine patients had ≥2 comorbidities. Each complete bedside evaluation (i.e. IC and TF) by trained medical students was completed in fewer than 10 minutes. Diaphragm ultrasound evaluation required approximately 5 minutes for accurate measurements. All patients tolerated the procedure. The median TF was 0.31 (IQR 0.24-0.45). The median IC was 1875 mL (IQR 1250-2438). The median hospital LOS was 3 days (IQR 3-5).  No patients required mechanical ventilation during hospitalization and no patients had a complication. 

Conclusion: Bedside ultrasound, as part of the eFAST exam, is commonly used to assess blunt trauma patients. Incorporation of diaphragmatic thickening fraction as part of the ultrasound exam could be rapidly accomplished. In this feasibility study, as no patients required mechanical ventilation nor developed any respiratory complications, correlation with these outcomes was not possible. Given its ease and feasibility, patients are now being enrolled to evaluate association with outcomes. With validation, diaphragm thickening fraction, an objective measure of pulmonary mechanics, could be used to identify patients at increased risk of respiratory failure.    

 

101.04 Antithrombin III Activity in Critically Ill Surgical Patients: Is It as Normal as We Think?

Posted on January 31, 2019

N. Rottler1, N. K. Dhillon1, A. Wang1, R. Mason1, T. Lin1, N. T. Linaval1, G. Barmparas1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction: Antithrombin III (AT III) deficiency occurs from hereditary or acquired reduction in AT III levels and leads to an increase in venous thromboembolism (VTE).  Low AT III levels have not been characterized in critically ill surgical patients so the management of these patients and the VTE rate is unknown. The objective of this study was to describe AT III levels in this population and to determine if activity levels fluctuated with time.

Methods:  AT III levels of all patients admitted to the SICU at a tertiary, urban center were reviewed from 01/2017 to 12/2017. Levels were drawn at the discretion of the critical care team. An AT III level below 80% was considered decreased. For patients that had multiple levels drawn, a fluctuation was defined as a difference of at least 20% in AT III activity between the highest and lowest level during a patient’s stay. 

Results: The median age of the 145 patients reviewed was 59 years and 60.0% were male. The median initial AT III level was 64.0% (IQR: 41.0% – 84.5%). Overall, 68.3% of patients had reduced AT III activity initially; after excluding 20 patients with concomitant cirrhosis, 63.2% had decreased activity. There were 52 patients with multiple AT III levels drawn, with 48.1% having a fluctuation; AT III levels of 60.0% of these patients increased over time while it decreased in the remaining.

Conclusion: The majority of critically ill surgical patients have reduced AT III levels activity that fluctuates throughout the SICU course. Further investigation is necessary to understand the clinical implications of this finding.

 

101.03 Alarming Rate of Controlled Substance Use in Motor Vehicle Collisions at an Appalachian Trauma Center

Posted on January 31, 2019

R. E. Proctor1, M. P. Taylor1, M. A. Quinn2, J. B. Burns1  1East Tennessee State University,Department Of Surgery,Johnson City, TENNESSEE, USA 2East Tennessee State University,College Of Public Health,Johnson City, TENNESSEE, USA

Introduction:

Recent studies show an increased risk of motor vehicle collisions with controlled substance use and an overall increasing rate of opioid-positive fatalities. There is limited national data on outcomes of patients with controlled substance use presenting to trauma centers after motor vehicle collisions. The Appalachian region is known to have significant substance abuse within the population, and we aimed to identify the rate of controlled substance use and outcomes in patients who presented to a Level 1 Trauma Center after motor vehicle collision. 

Methods:

Data from our National Trauma Registry American College of Surgeons System (NTRACS) was collected for motor vehicle collision and motorcycle crash patients presenting to a single Level 1 Trauma Center between 2011-2015. Demographic and outcome data were analyzed based on the presence or absence of controlled substance use obtained by self-reporting or from screening on presentation.

Results:

There were a total of 2,570 patients, with 768 (29.9%) individuals using a controlled substance. 33% of drivers were found to be using a controlled substance. Non-motorcycle crash, driver position in vehicle, and male sex were significantly associated with presence of a controlled substance (p<0.01). There was a similar mortality rate in both groups (2.8% vs 3.6%) with no significant difference in hospital length of stay (LOS), ICU LOS, ventilator days, or injury severity score.

Conclusion:

In patients who presented to our trauma center after a motor vehicle collision, there was no difference in mortality or measured outcomes. However in this single institution review, our rate of controlled substance use in motor vehicle collision patients was observed to be much higher than the national average and thus warrants increased public outreach programs and further study in our community and greater Appalachia.

 

101.02 Blood Alcohol Concentration, Venous Thromboembolism and Mortality in Trauma Patients

Posted on January 31, 2019

R. B. Bashir1, A. Grigorian1, D. Spencer1, J. L. Phillips1, B. J. Hasjim1, S. Albertson1, C. Figueroa1, M. Lekawa1, J. Nahmias1  1University Of California – Irvine,Department Of Surgery,Orange, CA, USA

Introduction:  Alcohol can impair hemostasis, decreasing the risk of venous thromboembolism (VTE). However, a previous report demonstrated that a significantly elevated blood alcohol concentration (BAC) was associated with an increased risk of VTE. This may suggest an inflection threshold where BAC transitions patients from a hypocoagulable to hypercoagulable state. Therefore, compared to patients with negative BAC on admission, we hypothesized that trauma patients with severely elevated BAC levels are at higher risk for VTE while patients with moderate BAC level are at lower risk.

Methods:  We performed a retrospective cohort study of trauma patients ≥18 years admitted between 2010 and 2017 to a single Level-I trauma center. Patients were grouped based on known BAC: negative (0 mg/dL), moderate (1-80 mg/dL), and severe (>80 mg/dL). The primary outcome was the rate of VTE, including pulmonary embolism (PE) and deep vein thrombosis (DVT). Secondary endpoints included mortality and overall length of stay (LOS). We performed a chi-square analysis.

Results: From 18,798 trauma admissions, 13,624 (72.5%) had a negative BAC, 1,207 (6.4%) presented with moderate BAC and 3,967 (21.2%) had severe BAC. Compared to the negative and severe BAC groups, those that had a moderate BAC level had a higher median Injury Severity Score (5 vs. 2 vs. 4, p<0.001) but no significant difference in LOS (p=0.44). The severe BAC group had a lower mortality rate compared to the negative and moderate BAC group (1.8% vs. 2.7% vs. 2.7%, p=0.004). The overall incidence of VTE in this population was remarkably low (0.18%) and did not significantly deviate between BAC groups (p=0.41).

Conclusion: In a single Level-I trauma center, there was no difference in the rate of VTE or LOS between trauma patients with negative, moderate, and severe BAC levels. Surprisingly, patients with severe BAC had the lowest rate of mortality. Future basic science research investigating the differences in clotting factors and biochemical sequela after varying levels of BAC is warranted. 

101.01 The Use of Complementary Alternative Methods for Symptom Management in the Critically Ill

Posted on January 31, 2019

T. Bongiovanni1,3, R. Menza3, A. Stey1,3, K. Slown2, C. Bloom2, C. Wybourn1,2,3  1University of California, San Francisco,Department Of Surgery,San Francisco, CA, USA 2Zuckerberg San Francisco General Hospital,Department Of Critical Care,San Francisco, CA, USA 3Zuckerberg San Francisco General Hospital,Department Of Surgery,San Francisco, CA, USA

Introduction:
There is increased interest in the integration of complementary alternative medicine (CAM), such as music therapy or aromatherapy, as an adjunct to pharmaceutical management for pain, anxiety and nausea in post-operative and critically ill patients. However, it is unclear whether healthcare providers are adequately prepared to use CAM in their inpatient practice, and provider attitudes, beliefs and knowledge about CAM is unknown. Therefore, we aimed to investigate these attitudes, beliefs and knowledge, of a multi-disciplinary group of healthcare providers to both prescribe and provide CAM for critically ill and injured patients in the Surgical Intensive Care Unit (SICU) of a level one academic urban trauma center. 

Methods:
A 41 item survey, designed to measure providers’ attitudes, beliefs and knowledge with CAM, was developed by a multidisciplinary research team which included MDs, NPs and RNs. The survey was informed by prior literature and was reviewed for content and face validity prior to administration. The trauma team, including critical care physicians, trauma surgeons, SICU nurses, pharmacists and nurse practitioners, were surveyed through an email solicitation using Qualtrics software. This convenience sample was conducted prior to the introduction of any formal or informal CAM. 

Results:
Our survey of a critical care trauma team at a level one trauma center yielded a response rate of 48% (n=53/110). Of those, 48% were advanced practitioners (12 MDs and 13 NPs) with a mean range of 11-15 years of practice. The majority of respondents (89%) agreed or strongly agreed that they would be interested in implementing CAM clinically. However, one third of our respondents believed that there was insufficient evidence to use it in the hospital, and one third of respondents rated their knowledge of CAM for symptom management as “none”. There was no statistically significant difference between type of provider and willingness to implement CAM in clinical practice. Among those unwilling to implement CAM in their practice, they were worried that patients might not take them seriously (p<0.05), reported poor knowledge of CAM (p=0.05) or did not believe that the use of CAM would reduce medication use (p<0.05).  

Conclusion:
Our study found that healthcare providers on a surgical trauma team are overwhelmingly interested in implementing CAM for symptom management for critically ill patients. Despite this, many reported a lack of sufficient evidence, a lack of personal knowledge and lack of comfort with its use for the in their own practice. This work highlights the need for development of evidence surrounding the usefulness of CAM for critically ill trauma patients, as well as the inclusion of educational modules for CAM therapies in acute care.Further work should be done to explore barriers to implementation and programs to increase provider comfort and confidence with CAM. 
 

100.20 The Impact of Enhanced Recovery After Surgery (ERAS) on the Costs of Elective Colorectal Surgery

Posted on January 31, 2019

A. N. Khanijow1, L. E. Goss1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Department Of Surgery, Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA

Introduction:  ERAS pathways are standardized perioperative care programs that improve postoperative surgical outcomes, including reduced length of stay and readmissions. As more US hospitals adopt ERAS programs, evaluating its impact on healthcare costs is increasingly important in order to determine the value of implementing ERAS protocols. The purpose of this study was to assess the cost of an ERAS program for colorectal surgery through a retrospective analysis comparing surgeries done before ERAS and with ERAS.

Methods:  ERAS was implemented at a tertiary-care single-institution in January 2015. Variable cost data, the costs that vary with care decisions, were collected from the institution's financial department for the surgical inpatient stay for patients undergoing elective colorectal surgery from 2012-2014 (pre-ERAS) and 2015-2017 (ERAS). Costs were adjusted for inflation to 2017 US dollars using the Producer Price Index. Variable costs (overall and by categories) were compared using Wilcoxon tests between the two cohorts and with stratification by severity of illness (SOI) into minor, moderate, major, and extreme.

Results: Of 1,692 elective colorectal surgeries, pre-ERAS procedures (n=389) and ERAS procedures (n=1,303) had median total variable costs per surgery of $7,495.32 and $6,386.71, respectively; a difference of $1,108.61 (p<0.001). Additionally, comparing the average total variable costs between the two groups showed procedures with ERAS saved $128.51 (p<0.001). When comparing costs by categories, significantly (p<0.001) decreased median costs for ERAS surgeries were seen in the following: nursing ($670.29), surgery ($353.88), anesthesiology ($246.59), pharmacy ($75.31), and lab costs ($45.96). Mean variable costs by these categories followed a similar trend with significant cost savings per procedure in ERAS surgeries for the following: surgery ($487.49), anesthesiology ($238.59), nursing ($16.05), and lab costs ($7.19). Of note, mean variable pharmacy costs per surgery were significantly more expensive with the ERAS protocol ($342.17, p<0.001). Median variable costs stratified by SOI were consistent with the overall analysis, revealing significant savings in median total variable costs and in the same cost categories for the ERAS cohorts with mild and moderate SOIs, compared to the pre-ERAS cohort.

Conclusion: ERAS implementation at a large institution resulted in reduced median and mean variable costs associated with hospital stay, showing that ERAS implementation can have both clinical and financial benefits.

 

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