Publications by authors named "Andrew W Kirkpatrick"

293 Publications

Pioneering Remotely Piloted Aerial Systems (Drone) Delivery of a Remotely Telementored Ultrasound Capability for Self Diagnosis and Assessment of Vulnerable Populations-the Sky Is the Limit.

J Digit Imaging 2021 Jun 25. Epub 2021 Jun 25.

Centre for Innovation and Research Into Unmanned Systems (CIRUS), Southern Alberta Institute of Technology (SAIT), Calgary, AB, Canada.

Remotely Piloted Aerial Systems (RPAS) are poised to revolutionize healthcare in out-of-hospital settings, either from necessity or practicality, especially for remote locations. RPAS have been successfully used for surveillance, search and rescue, delivery, and equipping drones with telemedical capabilities being considered. However, we know of no previous consideration of RPAS-delivered tele-ultrasound capabilities. Of all imaging technologies, ultrasound is the most portable and capable of providing real-time point-of-care information regarding anatomy, physiology, and procedural guidance. Moreover, remotely guided ultrasound including self-performed has been a backbone of medical care on the International Space Station since construction. The TeleMentored Ultrasound Supported Medical Interventions Group of the University of Calgary partnered with the Southern Alberta Institute of Technology to demonstrate RPAS delivery of a smartphone-supported tele-ultrasound system by the SwissDrones SDO50 RPAS. Upon receipt of the sanitized probe, a completely ultrasound-naïve volunteer was guided by a remote expert located 100 km away using online video conferencing (Zoom), to conduct a self-performed lung ultrasound examination. It proved feasible for the volunteer to examine their anterior chest, sides, and lower back bilaterally, correlating with standard recommended examinations in trauma/critical care, including the critical locations of a detailed COVID-19 lung diagnosis/surveillance examination. We contend that drone-delivered telemedicine including a tele-ultrasound capability could be leveraged to enhance point-of-care diagnostic accuracy in catastrophic emergencies, and allow diagnostic capabilities to be delivered to vulnerable populations in remote locations for whom transport is impractical or undesirable, speeding response times, or obviating the risk of disease transmission depending on the circumstances.
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http://dx.doi.org/10.1007/s10278-021-00475-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8232562PMC
June 2021

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy.

World J Emerg Surg 2021 Jun 10;16(1):30. Epub 2021 Jun 10.

Rothschild Hospital, AP-HP, Paris, and Université de Paris, Paris, France.

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.
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http://dx.doi.org/10.1186/s13017-021-00369-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190978PMC
June 2021

Longitudinal remotely mentored self-performed lung ultrasound surveillance of paucisymptomatic Covid-19 patients at risk of disease progression.

Ultrasound J 2021 May 30;13(1):27. Epub 2021 May 30.

Department of Medicine, Foothills Medical Centre, Calgary, Alberta, Canada.

COVID-19 has impacted human life globally and threatens to overwhelm health-care resources. Infection rates are rapidly rising almost everywhere, and new approaches are required to both prevent transmission, but to also monitor and rescue infected and at-risk patients from severe complications. Point-of-care lung ultrasound has received intense attention as a cost-effective technology that can aid early diagnosis, triage, and longitudinal follow-up of lung health. Detecting pleural abnormalities in previously healthy lungs reveal the beginning of lung inflammation eventually requiring mechanical ventilation with sensitivities superior to chest radiographs or oxygen saturation monitoring. Using a paradigm first developed for space-medicine known as Remotely Telementored Self-Performed Ultrasound (RTSPUS), motivated patients with portable smartphone support ultrasound probes can be guided completely remotely by a remote lung imaging expert to longitudinally follow the health of their own lungs. Ultrasound probes can be couriered or even delivered by drone and can be easily sterilized or dedicated to one or a commonly exposed cohort of individuals. Using medical outreach supported by remote vital signs monitoring and lung ultrasound health surveillance would allow clinicians to follow and virtually lay hands upon many at-risk paucisymptomatic patients. Our initial experiences with such patients are presented, and we believe present a paradigm for an evolution in rich home-monitoring of the many patients expected to become infected and who threaten to overwhelm resources if they must all be assessed in person by at-risk care providers.
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http://dx.doi.org/10.1186/s13089-021-00231-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8164889PMC
May 2021

Procedural Telementoring in Rural, Underdeveloped, and Austere Settings: Origins, Present Challenges, and Future Perspectives.

Annu Rev Biomed Eng 2021 Jul 26;23:115-139. Epub 2021 Mar 26.

Department of Surgery and the Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.

Telemedicine is perhaps the most rapidly growing area in health care. Approximately 15 million Americans receive medical assistance remotely every year. Yet rural communities face significant challenges in securing subspecialist care. In the United States, 25% of the population resides in rural areas, where less than 15% of physicians work. Current surgery residency programs do not adequately prepare surgeons for rural practice. Telementoring, wherein a remote expert guides a less experienced caregiver, has been proposed to address this challenge. Nonetheless, existing mentoring technologies are not widely available to rural communities, due to a lack of infrastructure and mentor availability. For this reason, some clinicians prefer simpler and more reliable technologies. This article presents past and current telementoring systems, with a focus on rural settings, and proposes aset of requirements for such systems. We conclude with a perspective on the future of telementoring systems and the integration of artificial intelligence within those systems.
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http://dx.doi.org/10.1146/annurev-bioeng-083120-023315DOI Listing
July 2021

Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review.

World J Emerg Surg 2021 Mar 11;16(1):10. Epub 2021 Mar 11.

Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.

Background: Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).

Methods: We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions.

Results: Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.

Conclusions: Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.
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http://dx.doi.org/10.1186/s13017-021-00352-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7951941PMC
March 2021

OPTICC: A multicentre trial of Occult Pneumothoraces subjected to mechanical ventilation: The final report.

Am J Surg 2021 06 20;221(6):1252-1258. Epub 2021 Feb 20.

Department of Surgery, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada; The Trauma Program, Foothills Medical Centre, Calgary, Alberta, Canada; Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada; Canadian Forces Medical Services, Ottawa, Ontario, Canada. Electronic address:

Introduction: Patients with occult pneumothorax (OPTX) requiring positive-pressure ventilation (PPV) face uncertain risks of tension pneumothorax or chest drainage complications.

Methods: Adults with traumatic OPTXs requiring PPV were randomized to drainage/observation, with the primary outcome of composite "respiratory distress" (RD)).

Results: Seventy-five (75) patients were randomized to observation, 67 to drainage. RD occurred in 38% observed and 25% drained (p = 0.14; Power = 0.38), with no mortality differences. One-quarter of observed patients failed, reaching 40% when ventilated >5 days. Twenty-three percent randomized to drainage had complications or ineffectual drains.

Conclusion: RD was not significantly different with observation. Thus, OPTXs may be cautiously observed in stable patients undergoing short-term PPV when prompt "rescue drainage" is immediately available. As 40% of patients undergoing prolonged (≥5 days) ventilation (PPPV) require drainage, we suggest consideration of chest drainage performed with expert guidance to reduce risk of chest tube complications.

Level Of Evidence: Therapeutic study, level II.
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http://dx.doi.org/10.1016/j.amjsurg.2021.02.012DOI Listing
June 2021

Trauma quality indicators: internationally approved core factors for trauma management quality evaluation.

World J Emerg Surg 2021 Feb 23;16(1). Epub 2021 Feb 23.

General Surgery, Brescia University Hospital, Brescia, Italy.

Introduction: Quality in medical care must be measured in order to be improved. Trauma management is part of health care, and by definition, it must be checked constantly. The only way to measure quality and outcomes is to systematically accrue data and analyze them.

Material And Methods: A systematic revision of the literature about quality indicators in trauma associated to an international consensus conference RESULTS: An internationally approved base core set of 82 trauma quality indicators was obtained: Indicators were divided into 6 fields: prevention, structure, process, outcome, post-traumatic management, and society integrational effects.

Conclusion: Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes.
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http://dx.doi.org/10.1186/s13017-021-00350-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901006PMC
February 2021

The next nine minutes: Lessons learned from the large-scale active shooter training prior to the STEM school shooting.

Am J Disaster Med 2020 Fall;15(4):241-249

Captain South Metro Fire Rescue, Centennial, Colorado.

Objective: As the incidence of active shooters increase, local emergency response has also changed. South Metro Fire Rescue coordinated a series of hyper-realistic active shooter simulation drills involving multiple agencies.

Methods: "The Next Nine Minutes" was one of the largest active shooter drills performed to date with 904 personnel that were trained in 18 mass casualty active shooter drills. Evaluation was from point of injury to and including care in the operating room (OR), and evaluation of real-time system logistics.

Results: A total of 126 patients in Cut Suits® received a total of 479 procedures such as needle decompressions, cricothyrotomies, tourniquets, wound packs, and chest tubes. Central to this exercise, law enforcement (LE) established a warm zone from the initial shooting. EMS was able to move into the facility, locate casualties, extract the first victim, move them to a casualty collection point (CCP), and transport them to safety within 12 minutes.

Conclusions: Strengths and weaknesses were identified in prehospital and in-hospital care. These included what roles agencies play in a true event, specific timing in establishing areas such as the warm zone and CCP, transportation, and logistics at the accepting hospitals. Only after the barriers to success were identified and addressed did the timing of casualty movement drastically improve. Lessons learned from this training were ultimately used to save lives at the STEM School, Highlands Ranch, and Colorado Shooting. This in situ immersion training should be practiced as a whole system.
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http://dx.doi.org/10.5055/ajdm.2020.0373DOI Listing
January 2021

Do we have the guts to go? The abdominal compartment, intra-abdominal hypertension, the human microbiome and exploration class space missions.

Can J Surg 2020 Nov-Dec;63(6):E581-E593

From the Tele-Mentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group Collaborators; Departments of Medicine and Engineering, University of Calgary, Calgary, Alta. (Kirkpatrick, Hamilton, McKee); the Departments of Critical Care Medicine and Medicine, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alta. (MacDonald); the Department of Surgical Sciences and Integrated Diagnostics, University of Genoa; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (Pelosi); Regional Trauma Services; Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alta. (Ball); the Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ont. (Roberts); the Tele-Mentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group Collaborators; Regional Trauma Services; Foothills Medical Centre; Departments of Engineering, Surgery and Critical Care Medicine, University of Calgary, Calgary, Alta. (McBeth); the Departments of Trauma and Emergency Surgery, Pisa University Hospital, Pisa, Italy (Cocolini); the Departments of General, Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy (Ansaloni); the Division of Trauma Surgery, University of Campinas, Campinas, São Paulo, Brazil (Peireira); the Department of Surgery, Letterkenny University Hospital, Letterkenny, Donegal, Ireland (Sugrue); the Paris Regional Medical Centre, Paris, Texas, United States (Campbell); the Departments of Surgery and Critical Care, Network Development and Telehealth, University of Utah, Salt Lake City, US (Kimball); the Faculties of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium (Malbrain).

Humans are destined to explore space, yet critical illness and injury may be catastrophically limiting for extraterrestrial travel. Humans are superorganisms living in symbiosis with their microbiomes, whose genetic diversity dwarfs that of humans. Symbiosis is critical and imbalances are associated with disease, occurring within hours of serious illness and injury. There are many characteristics of space flight that negatively influence the microbiome, especially deep space itself, with its increased radiation and absence of gravity. Prolonged weightlessness causes many physiologic changes that are detrimental; some resemble aging and will adversely affect the ability to tolerate critical illness or injury and subsequent treatment. Critical illness-induced intra-abdominal hypertension (IAH) may induce malperfusion of both the viscera and microbiome, with potentially catastrophic effects. Evidence from animal models confirms profound IAH effects on the gut, namely ischemia and disruption of barrier function, mechanistically linking IAH to resultant organ dysfunction. Therefore, a pathologic dysbiome, space-induced immune dysfunction and a diminished cardiorespiratory reserve with exacerbated susceptibility to IAH, imply that a space-deconditioned astronaut will be vulnerable to IAH-induced gut malperfusion. This sets the stage for severe gut ischemia and massive biomediator generation in an astronaut with reduced cardiorespiratory/immunological capacity. Fortunately, experiments in weightless analogue environments suggest that IAH may be ameliorated by conformational abdominal wall changes and a resetting of thoracoabdominal mechanics. Thus, review of the interactions of physiologic changes with prolonged weightlessness and IAH is required to identify appropriate questions for planning exploration class space surgical care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747844PMC
February 2021

Use of Critical Items in Determining Point-of-Care Ultrasound Competence.

Eval Health Prof 2021 Sep 28;44(3):220-225. Epub 2020 Nov 28.

70401 Department of Medicine, University of Calgary, Alberta, Canada.

We previously developed a workplace-based tool for assessing point of care ultrasound (POCUS) skills and used a modified Delphi technique to identify critical items (those that learners must successfully complete to be considered competent). We performed a standard setting procedure to determine cut scores for the full tool and a focused critical item tool. This study compared ratings by 24 experts on the two checklists versus a global entrustability rating. All experts assessed three videos showing an actor performing a POCUS exam on a patient. The performances were designed to show a range of competences and one included potentially critical errors. Interrater reliability for the critical item tool was higher than for the full tool (intraclass correlation coefficient = 0.84 [95% confidence interval [CI] 0.42-0.99] vs. 0.78 [95% CI 0.25-0.99]). Agreement with global ratings of competence was higher for the critical item tool (κ = 0.71 [95% CI 0.55-0.88] vs 0.48 [95% CI 0.30-0.67]). Although sensitivity was higher for the full tool (85.4% [95% CI 72.2-93.9%] vs. 81.3% [95% CI 67.5-91.1%]), specificity was higher for the critical item tool (70.8% [95% CI 48.9-87.4%] vs. 29.2% [95% CI 12.6-51.1%]). We recommend the use of critical item checklists for the assessment of POCUS competence.
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http://dx.doi.org/10.1177/0163278720975833DOI Listing
September 2021

Invasive fungal infection requiring explantation of a noncrosslinked porcine derived biologic mesh: a rare but catastrophic complication in abdominal wall reconstruction.

Can J Surg 2020 Nov-Dec;63(6):E533-E536

From the University of Calgary, Cumming School of Medicine, Calgary, Alta. (Ober, Nickerson, Caragea, Ball, Kirkpatrick); the Department of Surgery, University of Calgary, Calgary, Alta. (Nickerson, Ball, Kirkpatrick); the Department of Pathology, University of Calgary, Calgary, Alta. (Caragea); and the Department of Critical Care Medicine, University of Calgary, Calgary, Alta. (Kirkpatrick).

Summary: Biologic mesh is preferred over synthetic mesh for complex and contaminated abdominal wall repairs; however, there are very little data on the risks and complications associated with its use. We report the case of a 67-year-old man with failed synthetic mesh repair for recurrent ventral hernia, who subsequently required an abdominal wall reconstruction (AWR), including the intraperitoneal sublay of noncrosslinked biologic mesh. His postoperative course was complicated with catastrophic sepsis and sustained hemodynamic instability, responding only to mesh explantation. The biologic mesh was subsequently noted to be histologically infected with invasive . Although noncrosslinked biologic mesh is a valuable adjunct to AWR, it is not infection-resistant. Although it is rare, infection of any foreign tissue, including biologic mesh, can occur in the setting of complex ventral abdominal wall repairs. Clinicians should be watchful for such infections in complex repairs as they may require biologic mesh explantation for clinical recovery.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747838PMC
February 2021

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis.

World J Emerg Surg 2020 11 5;15(1):61. Epub 2020 Nov 5.

Department of Surgery, College of Medicine, UAE University, Al Ain, UAE.

Background: Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.

Materials And Methods: The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.

Results: The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.

Conclusions, Knowledge Gaps And Research Recommendations: ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.
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http://dx.doi.org/10.1186/s13017-020-00336-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643471PMC
November 2020

Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature.

World J Emerg Surg 2020 10 21;15(1):60. Epub 2020 Oct 21.

General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.

Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.
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http://dx.doi.org/10.1186/s13017-020-00339-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579897PMC
October 2020

Optimal treatments for hepato-pancreato-biliary trauma in severely injured patients: a narrative scoping review.

Can J Surg 2020 Sep-Oct;63(5):E431-E434

From the Department of Surgery, University of Calgary, Calgary, Alta. (Streith, Silverberg, Kirkpatrick, Bathe, Ball); and the Department of Surgery, University of British Columbia, Vancouver, BC (Hameed).

Summary: Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608711PMC
November 2020

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations.

Int J Infect Dis 2020 Oct 31;99:140-148. Epub 2020 Jul 31.

Department of Emergency Surgery, Maggiore Hospital, Parma, Italy.

Background: Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines.

Methods: The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020.

Results: The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible.

Conclusions: The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.
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http://dx.doi.org/10.1016/j.ijid.2020.07.046DOI Listing
October 2020

The Potential for Remotely Mentored Patient-Performed Home Self-Monitoring for New Onset Alveolar-Interstitial Lung Disease.

Telemed J E Health 2020 10 10;26(10):1304-1307. Epub 2020 Jul 10.

John A. Buchanan Chair, Division of General Internal Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

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http://dx.doi.org/10.1089/tmj.2020.0078DOI Listing
October 2020

Evaluation of an augmented reality platform for austere surgical telementoring: a randomized controlled crossover study in cricothyroidotomies.

NPJ Digit Med 2020 21;3:75. Epub 2020 May 21.

School of Industrial Engineering, Purdue University, West Lafayette, IN USA.

Telementoring platforms can help transfer surgical expertise remotely. However, most telementoring platforms are not designed to assist in austere, pre-hospital settings. This paper evaluates the system for telementoring with augmented reality (STAR), a portable and self-contained telementoring platform based on an augmented reality head-mounted display (ARHMD). The system is designed to assist in austere scenarios: a stabilized first-person view of the operating field is sent to a remote expert, who creates surgical instructions that a local first responder wearing the ARHMD can visualize as three-dimensional models projected onto the patient's body. Our hypothesis evaluated whether remote guidance with STAR could lead to performing a surgical procedure better, as opposed to remote audio-only guidance. Remote expert surgeons guided first responders through training cricothyroidotomies in a simulated austere scenario, and on-site surgeons evaluated the participants using standardized evaluation tools. The evaluation comprehended completion time and technique performance of specific cricothyroidotomy steps. The analyses were also performed considering the participants' years of experience as first responders, and their experience performing cricothyroidotomies. A linear mixed model analysis showed that using STAR was associated with higher procedural and non-procedural scores, and overall better performance. Additionally, a binary logistic regression analysis showed that using STAR was associated to safer and more successful executions of cricothyroidotomies. This work demonstrates that remote mentors can use STAR to provide first responders with guidance and surgical knowledge, and represents a first step towards the adoption of ARHMDs to convey clinical expertise remotely in austere scenarios.
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http://dx.doi.org/10.1038/s41746-020-0284-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242344PMC
May 2020

Executive summary: WSES Guidelines for the management of severe acute pancreatitis.

J Trauma Acute Care Surg 2020 06;88(6):888-890

From the Abdominal Center (A.L., M.T.), Helsinki University Hospital Meilahti, Helsinki, Finland; Department of Emergency Surgery (A.T., F.C.), Parma Maggiore Hospital, Parma, Italy; Hospital de Clinicas (H.S.-L.), Universidad Nacional de Asuncion, Asuncion, Paraguay; Anesthesia and Intensive Care Medicine (E.G.), Maurizio Bufalini Hospital, Cesena, Italy; Foothills Medical Centre & the University of Calgary (A.W.K., C.G.B.), Calgary, Alberta; London Health Sciences Centre (N.P.), London, Ontario, Canada; Department of Surgery (M.S.), Macerata Hospital, Macerata, Italy; Radboud University Nijmegen (D.W., H.v.G.), The Netherlands; Surgical Clinic, Department of Experimental and Clinical Sciences (G.B.), University of Brescia, Brescia; General, Emergency and Trauma Surgery Department (L.A.), Bufalini Hospital, Cesena, Italy; Trauma and Acute Care Surgery (W.B.), Scripps Memorial Hospital, La Jolla, CA; General, Trauma and Emergency Surgery Department (F.C.), Pisa University Hospital, Pisa; Department of Surgery (S.D.S.), University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Italy; Division of General Surgery (Y.K.), Rambam Health Care Campus, Haifa, Israel; and Shock Trauma Center at Denver Health (E.E.M.), Denver, Colorado.

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http://dx.doi.org/10.1097/TA.0000000000002691DOI Listing
June 2020

2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting.

World J Emerg Surg 2020 05 7;15(1):32. Epub 2020 May 7.

Trauma Service, Inkosi Albert Luthuli Central Hospital and Department of Surgery, Nelson R Mandela School of Clinical Medicine, Durban, South Africa.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.
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http://dx.doi.org/10.1186/s13017-020-00313-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206757PMC
May 2020

Consensus-Based Expert Development of Critical Items for Direct Observation of Point-of-Care Ultrasound Skills.

J Grad Med Educ 2020 Apr;12(2):176-184

Background: Point-of-care ultrasound (POCUS) is increasingly used in a number of medical specialties. To support competency-based POCUS education, workplace-based assessments are essential.

Objective: We developed a consensus-based assessment tool for POCUS skills and determined which items are critical for competence. We then performed standards setting to set cut scores for the tool.

Methods: Using a modified Delphi technique, 25 experts voted on 32 items over 3 rounds between August and December 2016. Consensus was defined as agreement by at least 80% of the experts. Twelve experts then performed 3 rounds of a standards setting procedure in March 2017 to establish cut scores.

Results: Experts reached consensus for 31 items to include in the tool. Experts reached consensus that 16 of those items were critically important. A final cut score for the tool was established at 65.2% (SD 17.0%). Cut scores for critical items are significantly higher than those for noncritical items (76.5% ± SD 12.4% versus 53.1% ± SD 12.2%, < .0001).

Conclusions: We reached consensus on a 31-item workplace-based assessment tool for identifying competence in POCUS. Of those items, 16 were considered critically important. Their importance is further supported by higher cut scores compared with noncritical items.
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http://dx.doi.org/10.4300/JGME-D-19-00531.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161337PMC
April 2020

Lung ultrasonography in a woman with COVID-19: This examination could be remote.

CMAJ 2020 04;192(16):E435

Project manager, TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Group, University of Calgary, Calgary, Alta.

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http://dx.doi.org/10.1503/cmaj.75302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207189PMC
April 2020

COVID-19 the showdown for mass casualty preparedness and management: the Cassandra Syndrome.

World J Emerg Surg 2020 04 9;15(1):26. Epub 2020 Apr 9.

Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy.

Since December 2019, the world is potentially facing one of the most difficult infectious situations of the last decades. COVID-19 epidemic warrants consideration as a mass casualty incident (MCI) of the highest nature. An optimal MCI/disaster management should consider all four phases of the so-called disaster cycle: mitigation, planning, response, and recovery. COVID-19 outbreak has demonstrated the worldwide unpreparedness to face a global MCI.This present paper thus represents a call for action to solicitate governments and the Global Community to actively start effective plans to promote and improve MCI management preparedness in general, and with an obvious current focus on COVID-19.
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http://dx.doi.org/10.1186/s13017-020-00304-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145275PMC
April 2020

Protocol for a parallel economic evaluation of a trial comparing two surgical strategies in severe complicated intra-abdominal sepsis: the COOL-cost study.

World J Emerg Surg 2020 02 21;15(1):15. Epub 2020 Feb 21.

Department of Critical Care Medicine, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1 N4, Canada.

Background: The risk of death in severe complicated intra-abdominal sepsis (SCIAS) remains high despite decades of surgical and antimicrobial research. New management strategies are required to improve outcomes. The Closed Or Open after Laparotomy (COOL) trial investigates an open-abdomen (OA) approach with active negative pressure peritoneal therapy. This therapy is hypothesized to better manage peritoneal bacterial contamination, drain inflammatory ascites, and reduce the risk of intra-abdominal hypertension leading to improved survival and decreased complications. The total costs and cost-effectiveness of this therapy (as compared with standard fascial closure) are unknown.

Methods: We propose a parallel cost-utility analysis of this intervention to be conducted alongside the 1-year trial, extrapolating beyond that using decision analysis. Using resource use metrics (e.g., length of stay, re-admissions) from patients at all study sites and microcosting data from patients enrolled in Calgary, Alberta, the mean cost difference between treatment arms will be established from a publicly-funded health care payer perspective. Quality of life will be measured at 6 months and 1 year postoperatively with the Euroqol EQ-5D-5 L and SF-36 surveys. A within-trial analysis will establish cost and utility at 1 year, using a bootstrapping approach to provide confidence intervals around an estimated incremental cost-effectiveness ratio. If neither operative strategy is economically dominant, Markov modeling will be used to extrapolate the cost per quality-adjusted life years gained to 2-, 5-, 10-year, and lifetime horizons. Future costs and benefits will be discounted at 1.5% per annum. A cost-effectiveness acceptability curve will be generated using Monte Carlo simulation. If all trial outcomes are similar, the primary analysis will default to a cost-minimization approach. Subgroup analysis will be carried out for patients with and without septic shock at presentation, and for patients whose initial APACHE II scores are > 20 versus ≤ 20.

Discussion: In addition to an estimate of the clinical effectiveness of an OA approach for SCIAS, an understanding of its cost effectiveness will be required prior to its adoption in any resource-constrained environment. We will estimate this key parameter for use by clinicians and policymakers.

Trial Registration: ClinicalTrials.gov, NCT03163095, registered May 22, 2017.
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http://dx.doi.org/10.1186/s13017-020-00294-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035651PMC
February 2020

A Randomized Trial of Mentored vs Nonmentored Military Medics Compared in the Application of a Wound Clamp Without Prior Training: When to Shut Up and Just Watch!

Mil Med 2020 01;185(Suppl 1):67-72

Faculty of Medicine, Bar-Ilan University, Ramat Gan 5290002, Israel.

Introduction: Hemorrhage control is a basic task required of first responders and typically requires technical interventions during stressful circumstances. Remote telementoring (RTM) utilizes information technology to guide inexperienced providers, but when this is useful remains undefined.

Methods: Military medics were randomized to mentoring or not from an experienced subject matter expert during the application of a wound clamp (WC) to a simulated bleed. Inexperienced, nonmentored medics were given a 30-second safety briefing; mentored medics were not. Objective outcomes were time to task completion and success in arresting simulated bleeding.

Results: Thirty-three medics participated (16 mentored and 17 nonmentored). All (100%) successfully applies the WC to arrest the simulated hemorrhage. RTM significantly slowed hemorrhage control (P = 0.000) between the mentored (40.4 ± 12.0 seconds) and nonmentored (15.2 ± 10.3 seconds) groups. On posttask questionnaire, all medics subjectively rated the difficulty of the wound clamping as 1.7/10 (10 being extremely hard). Discussion: WC application appeared to be an easily acquired technique that was effective in controlling simulated extremity exsanguination, such that RTM while feasible did not improve outcomes. Limitations were the lack of true stress and using simulation for the task. Future research should focus on determining when RTM is useful and when it is not required.
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http://dx.doi.org/10.1093/milmed/usz251DOI Listing
January 2020

Intraoperative surgical site infection control and prevention: a position paper and future addendum to WSES intra-abdominal infections guidelines.

World J Emerg Surg 2020 02 10;15(1):10. Epub 2020 Feb 10.

Department of Emergency and Trauma Surgery, University Hospital of Parma, 43100, Parma, Italy.

Background: Surgical site infections (SSI) represent a considerable burden for healthcare systems. They are largely preventable and multiple interventions have been proposed over past years in an attempt to prevent SSI. We aim to provide a position paper on Operative Room (OR) prevention of SSI in patients presenting with intra-abdominal infection to be considered a future addendum to the well-known World Society of Emergency Surgery (WSES) Guidelines on the management of intra-abdominal infections.

Methods: The literature was searched for focused publications on SSI until March 2019. Critical analysis and grading of the literature has been performed by a working group of experts; the literature review and the statements were evaluated by a Steering Committee of the WSES.

Results: Wound protectors and antibacterial sutures seem to have effective roles to prevent SSI in intra-abdominal infections. The application of negative-pressure wound therapy in preventing SSI can be useful in reducing postoperative wound complications. It is important to pursue normothermia with the available resources in the intraoperative period to decrease SSI rate. The optimal knowledge of the pharmacokinetic/pharmacodynamic characteristics of antibiotics helps to decide when additional intraoperative antibiotic doses should be administered in patients with intra-abdominal infections undergoing emergency surgery to prevent SSI.

Conclusions: The current position paper offers an extensive overview of the available evidence regarding surgical site infection control and prevention in patients having intra-abdominal infections.
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http://dx.doi.org/10.1186/s13017-020-0288-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7158095PMC
February 2020

Perforated and bleeding peptic ulcer: WSES guidelines.

World J Emerg Surg 2020 7;15. Epub 2020 Jan 7.

26Department of General Surgery, Rambam Health Care Campus, Haifa, Israel.

Background: Peptic ulcer disease is common with a lifetime prevalence in the general population of 5-10% and an incidence of 0.1-0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10-20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment.

Methods: The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached.

Conclusions: The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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http://dx.doi.org/10.1186/s13017-019-0283-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947898PMC
March 2021

WSES consensus conference guidelines: monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours.

World J Emerg Surg 2019 29;14:53. Epub 2019 Nov 29.

1Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100 Parma, Italy.

The acute phase management of patients with severe traumatic brain injury (TBI) and polytrauma represents a major challenge. Guidelines for the care of these complex patients are lacking, and worldwide variability in clinical practice has been documented in recent studies. Consequently, the World Society of Emergency Surgery (WSES) decided to organize an international consensus conference regarding the monitoring and management of severe adult TBI polytrauma patients during the first 24 hours after injury. A modified Delphi approach was adopted, with an agreement cut-off of 70%. Forty experts in this field (emergency surgeons, neurosurgeons, and intensivists) participated in the online consensus process. Sixteen recommendations were generated, with the aim of promoting rational care in this difficult setting.
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http://dx.doi.org/10.1186/s13017-019-0270-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884766PMC
July 2020

The prognostic value of serum procalcitonin measurements in critically injured patients: a systematic review.

Crit Care 2019 Dec 3;23(1):390. Epub 2019 Dec 3.

Department of Surgery, University of Calgary and the Foothills Medical Centre, North Tower 10th Floor, 1403-29th St. NW, Calgary, Alberta, T2N 2T9, Canada.

Background: Major trauma is associated with high incidence of septic complications and multiple organ dysfunction (MOD), which markedly influence the outcome of injured patients. Early identification of patients at risk of developing posttraumatic complications is crucial to provide early treatment and improve outcomes. We sought to evaluate the prognostic value of serum procalcitonin (PCT) levels after trauma as related to severity of injury, sepsis, organ dysfunction, and mortality.

Methods: We searched PubMed, MEDLINE, EMBASE, the Cochrane Database, and references of included articles. Two investigators independently identified eligible studies and extracted data. We included original studies that assessed the prognostic value of serum PCT levels in predicting severity of injury, sepsis, organ dysfunction, and mortality among critically injured adult patients.

Results: Among 2015 citations, 19 studies (17 prospective; 2 retrospective) met inclusion criteria. Methodological quality of included studies was moderate. All studies showed a strong correlation between initial PCT levels and Injury Severity Score (ISS). Twelve out of 16 studies demonstrated significant elevation of initial PCT levels in patients who later developed sepsis after trauma. PCT level appeared a strong predictor of MOD in seven out of nine studies. While two studies did not show association between PCT levels and mortality, four studies demonstrated significant elevation of PCT levels in non-survivors versus survivors. One study reported that the PCT level of ≥ 5 ng/mL was associated with significantly increased mortality (OR 3.65; 95% CI 1.03-12.9; p = 0.04).

Conclusion: PCT appears promising as a surrogate biomarker for trauma. Initial peak PCT level may be used as an early predictor of sepsis, MOD, and mortality in trauma population.
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http://dx.doi.org/10.1186/s13054-019-2669-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892215PMC
December 2019
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