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Current Issue

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Trauma: Care of the Injured Part II

Vol. 47, No. 4, 2023

  • The Initial Assessment of Injured Patients

  • Specific Aspects of Early Injury Care in Children and the Elderly

  • Traumatic Brain Injury

  • Spine and Spinal Cord Injury

  • Selected Abdominal Injury Diagnosis and Management

  • Thoracic Injuries

  • Pulmonary Injury Management

  • Cardiac Injuries and Cardiac Arrest

  • Trauma in the Pregnant Patient

  • Mental Health Issues in Injured Patients

Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.


Citation of Articles Reviewed:

Association Between Time to Source Control in Sepsis and 90-Day Mortality.JAMA Surg. 2022;157(9):817-826. doi:10.1001/jamasurg.2022.2761
The Critical Importance of Timing of Source Control in Patients With Community-Acquired Sepsis.JAMA Surg. 2022;157(9):826-827. doi:10.1001/jamasurg.2022.2774

Commentary by: Donald E. Fry, MD, FACS

This study by Reitz et al.1 reports on the benefits of early versus delayed timing of source control in the management of patients with sepsis. The study population is 4962 patients from 14 community/academic hospitals in the Pittsburgh area, with 1315 patients undergoing source control within six hours of the onset of community-acquired sepsis. The authors used multivariate analysis to evaluate the impact of early (<6 hours) versus delayed (>6 hours) source control on the overall outcomes. The results at 90 days and one year following the surgical intervention demonstrated improved risk-adjusted survival in those patients with six-hour source control. Improved survival was seen in those patients with gastrointestinal, abdominal, and soft tissue primary infections.

Sepsis, by definition, is the activation of the systemic inflammatory response. This activation progressively damages vital organ functions of the host and leads to the progressive multiple organ dysfunction syndrome if the inciting infection is not controlled. Conventional wisdom dictates that the more protracted the unchecked systemic infection continues, the greater the risk for a fatal outcome. These observations led the Surviving Sepsis Campaign to advocate the early administration of appropriate antibiotics for improved results in these patients.2 While the Surviving Sepsis Campaign has advocated early source control, the evidence to support this recommendation has not been available. The data in this study support the position that early and aggressive antibiotic therapy combined with appropriate and early source control offers the best opportunity for the survival of the septic patient.

Why is source control necessary? Pyogenic infections in the abdominal cavity characteristically have large concentrations of bacteria. Colonic perforations have up to 1012 bacteria per ml of enteric content. The inflammatory response in the abdomen yields an acidic local environment rich in protein. With a large bacterial inoculum, environmental acidity, and a large protein concentration, the activity of systemic antibiotics is at least compromised and more than likely rendered ineffective. Similarly, in severe pyogenic and necrotizing soft tissue infections, the local environment of microbe-laden pus and necrotic tissue requires drainage and debridement before systemic antibiotics can hope to be beneficial.

Many details in the comprehensive treatment of the septic patient remain unclear. Appropriate volume resuscitation of the septic patient will result in a hyperdynamic systemic response with increased cardiac output and an expanded volume of distribution for therapeutic antibiotics, especially in younger patients. One of the potential failures of using systemic antibiotics in this situation is the failure to increase the dosing of the employed antimicrobial agents. Optimum antibiotic dosing of the septic patient could benefit from additional pharmacokinetic studies. Another issue relates to "what does source control mean." Plication, resection, oversewing, and/or stoma creation are events that are accepted to stem the flow of gastrointestinal contaminants from perforations into the abdominal cavity. Debridement of apparently non-viable tissue, omentum, loculated suppuration, and fibrinous debris is likely very different among clinicians caring for these patients. Our group conducted a clinical trial of radical peritoneal debridement many years ago, only to find that technical complications resulted in poorer results in those cases randomized to extensive debridement of the peritoneal cavity.3 Additional studies are necessary to detail the necessary and unnecessary details of effective "source control."

The management of sepsis and septic shock has advanced significantly over the last 50 years, but considerable progress is yet to be made. As identified by Lipsett in the commentary that accompanied the Reitz et al. publication,4 randomized clinical trials to test the appropriate time to source control will not likely be undertaken. Prospective databases generated by high-volume institutions subject to multivariate statistical analysis appear to have the best opportunity to address the many unanswered questions in the further improvements of the surgical sepsis patient. With detailed analyses such as the one reviewed here of large data sets, better directions for the care of these patients will be realized.

References

  1. Association Between Time to Source Control in Sepsis and 90-Day Mortality. JAMA Surg. 2022;157(9):817-826. doi:10.1001/jamasurg.2022.2761
  2. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y
  3. Radical peritoneal debridement for established peritonitis. The results of a prospective randomized clinical trial.&nbsp Ann Surg. 1980;192(3):350-355. doi:10.1097/00000658-198009000-00010
  4. The Critical Importance of Timing of Source Control in Patients With Community-Acquired Sepsis. JAMA Surg. 2022;157(9):826-827. doi:10.1001/jamasurg.2022.2774
Recommended Reading

The SRGS Recommended Reading List is a summary of the most pertinent articles cited in each issue; the editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstracts on , and free full texts are available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Tominago G, Bernstein M. 鶹ýTQIP Best Practices in Imaging. 2018

This publication, prepared by the 鶹ýCommittee on Trauma, provides "best practices" for obtaining high-quality medical imaging to diagnose injuries. These guidelines aim to strike a balance between ensuring accurate diagnoses, managing radiation exposure, and preventing potential adverse effects associated with medical imaging.

Western Trauma Association Critical Decisions in Trauma: Diagnosis and management of duodenal injuries. J Trauma Acute Care Surg. 2015;79(6):1096-1101. doi:10.1097/TA.0000000000000870

This clinical practice algorithm promulgated by the Western Trauma Association provides guidance for successfully treating patients with rare but dangerous injuries to the duodenum. Due to these complexities, managing duodenal injuries involves complex decision-making regarding when and how to perform repairs based on the specific injury. The article discusses the diagnosis of duodenal injuries, which can occur in different scenarios, including unstable patients undergoing emergent laparotomy, stable patients diagnosed through computed tomography (CT), or delayed diagnoses after 24 hours, often with signs of sepsis.

Trauma Management of the Pregnant Patient.&nbsp Crit Care Clin. 2016;32(1):109-117. doi:10.1016/j.ccc.2015.08.008

This article addresses the significant issue of trauma in pregnant patients, which remains a leading cause of maternal and fetal mortality globally. Lucia and Dantoni emphasize the importance of establishing a multidisciplinary team early on, comprising various medical specialists such as emergency medicine physicians, trauma surgeons, obstetricians, critical care intensivists, and neonatologists. While the well-being of the mother takes precedence in treatment decisions, the article highlights the general principle that what benefits the mother's health is usually beneficial for the fetus as well.

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