The Critical Edge Podcast

By The Critical EdgeMedicine Health & Fitness

The Critical Edge Podcast episodes

October 16 Lit Review: Modern Burn Care Innovation Outcomes
This episode examines innovative therapeutic approaches for treating severe thermal burns, focusing on reducing the need for traditional autografting. One study highlights the safety and efficacy of StrataGraft, a bioengineered skin substitute that successfully promoted wound closure in a majority of adult patients with deep partial-thickness burns. Another research paper compares the outcomes of using autologous skin cell suspensions (ASCS) with different dressing types, specifically evaluating contact layer dressings against poly-lactic acid dressings (PLAD). The findings indicate that utilizing PLAD alongside cell suspensions significantly lowers infection rates, shortens hospital stays, and reduces overall medical costs. Together, these articles suggest that advancing skin substitute technology and optimizing post-surgical dressings can improve clinical recovery while sparing healthy donor skin. This collective research underscores a shift toward biosynthetic solutions that simplify burn management and enhance patient outcomes in real-world medical settings.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

DONOR-SPARING COVERAGE FOR DEEP PARTIAL-THICKNESS AND LARGE BURNS STUDY GUIDE
TOP TEN TAKEAWAYS
1. StrataGraft is a bioengineered bilayer construct used as a single application on deep partial-thickness (DPT) burns that still have intact dermal elements, with the explicit goal of avoiding or minimizing autograft harvest.
2. In the StrataCAT expanded-access cohort (n = 52; 3–50% TBSA), 88.5% of patients achieved complete wound closure without additional autografting; only 11% needed partial autograft at incomplete sites.
3. Confirmed closure by week 12 occurred in 63.5% of patients (71.9% of treatment sites); durable closure by week 24 occurred in 55.8% of patients (60.4% of sites).
4. Safety was consistent with ordinary burn-unit morbidity: 88.5% had at least one TEAE (most often mild pruritus); 19.2% had serious TEAEs, none attributed to StrataGraft; four deaths were unrelated.
5. Prior RCTs (STRATA2011, STRATA2016) already showed that most DPT wounds treated with StrataGraft needed no autograft by day 28 and closed at rates comparable to autograft by month 3; StrataCAT extends that experience into a real-world, broader-access population.
6. Autologous skin cell suspension (ASCS) expands a small thin donor harvest at approximately 1:80 and can be used alone or with split-thickness skin graft (STSG) on larger TBSA injuries.
7. The kit’s default contact-layer dressing (CLD) is prone to poor adherence, fluid pooling, and infection; a poly-lactic acid biosynthetic dressing (PLAD) adheres more closely, permits fluid egress, and functions as a temporary epithelial barrier.
8. In a single-center before-after cohort of ≥10% TBSA burns treated with ASCS (± STSG), PLAD versus CLD was associated with shorter length of stay (17 vs 29 days) and fewer postoperative wound infections (approximately 7–9% vs 32–39%).
9. After adjustment for grafted area and TBSA, CLD carried an 8-fold higher odds of postoperative infection; antibiotic days were also substantially shorter with PLAD (0.47 vs 4.39 days).
10. Inflation-adjusted charges per %TBSA trended lower with PLAD ($18,459 vs $25,396); the biologic dressing therefore functions as both a clinical and a resource intervention, not merely a coverage layer.

STUDY GUIDE
I. StrataGraft for Deep Partial-Thickness Burns with Intact Dermis
Autograft remains the reference standard for definitive closure of deep burns, but donor-site morbidity—pain, infection, hypertrophic scar, and limited harvestable skin in the elderly or the thin-skinned—creates a standing need for donor-sparing alternatives. StrataGraft is a bioengineered, bilayered skin substitute applied as a single, meshed (≤1:1) sheet to DPT wounds that retain dermal elements. Earlier controlled studies (STRATA2011 Phase 1b, n = 30; STRATA2016 Phase 3, n = 71) established that most treated sites required no autograft by day 28 and that three-month closure rates approximated those of autograft, with a TEAE profile typical of burned patients.
A. StrataCAT design
StrataCAT (NCT04123548) was a Phase 3b, open-label, single-arm, multicenter expanded-access study intended to maintain product availability after the pivotal trials and to enlarge real-world safety experience. Fifty-two adults with 3% to less than 50% TBSA thermal burns received one application of StrataGraft and were followed for 24 weeks. The primary endpoint was the count and percentage of patients with treatment-emergent adverse events. Efficacy endpoints (confirmed and durable wound closure, need for rescue autograft, scar scores) were descriptive; the study was neither designed nor powered as a comparative efficacy trial.
B. Safety
At least one TEAE occurred in 88.5% of patients; mild pruritus was the most frequent. Twenty serious TEAEs occurred in 10 patients (19.2%); none were judged related to StrataGraft. Four deaths (7.7%)—aspiration, myocardial infarction, self-injury, and Gram-negative rod sepsis—were unrelated. The safety signal therefore remains that of the underlying burn injury and its comorbidities, not of the construct itself.
C. Closure and donor-site sparing
Complete wound closure without additional autograft was achieved in 88.5% of patients. Confirmed closure by week 12: 33 patients (63.5%; 95% CI 50.4–76.5%) and 69 treatment sites (71.9%). Durable closure by week 24: 29 patients (55.8%; 95% CI 42.3–69.3%) and 58 sites (60.4%). Six patients (11%) required partial autograft for incomplete sites. Patient- and observer-reported scar scores were stable through follow-up.
D. Limitations that constrain interpretation
No concurrent comparator arm; sample insufficiently diverse by race and Fitzpatrick type to support scar-outcome claims by skin type; COVID-era restrictions limited in-person observer scoring. The authors correctly frame the result as a favorable benefit-to-risk balance and donor-site sparing in adults with DPT burns that retain dermal elements, not as a license for use on full-thickness wounds or massive TBSA injuries until larger comparative data exist.

II. Dressing Choice Over Autologous Skin Cell Suspension in Larger Burns
ASCS is a point-of-care device that converts a small, thin donor harvest into a sprayable cell suspension with roughly 1:80 expansion. It is used either as sole coverage or in combination with widely meshed STSG. The manufacturer-supplied contact-layer dressing is the historical default cover. PLAD is a biosynthetic sheet designed to mimic epithelium: it adheres tightly, is microporous enough to prevent exudate pooling, and presents a barrier to exogenous contamination. Larson and colleagues asked whether swapping CLD for PLAD changed infection, length of stay, and cost in burns ≥10% TBSA.
A. Cohort and practice change
Single-center retrospective cohort, January 2019–October 2022. All patients with ≥10% TBSA burns who underwent excision and ASCS were included. From 2019 through 2021 the cover was CLD; thereafter it was PLAD. Use of concomitant STSG was at surgeon discretion and did not differ significantly between eras (89% CLD vs 79% PLAD). Seventy-one patients were analyzed (28 CLD, 43 PLAD); mean TBSA 22.5%; mean grafted area approximately 3,641 cm² and comparable between groups.
B. Length of stay
Overall mean LOS was 22 days. CLD patients stayed 29 days versus 17 days with PLAD (p = 0.0079). Univariate predictors of LOS included dressing type, use of STSG, total area grafted, age, comorbidity, and %TBSA. In multivariate analysis, PLAD remained independently associated with shorter stay.
C. Infection and antibiotic exposure
Postoperative wound infection was substantially more common under CLD (user-reported 39% vs 9%, p = 0.006; corresponding abstract figures 32% vs 7%, p = 0.009). After adjustment for grafted area and TBSA, the odds of infection were 8.1 times higher with CLD (p = 0.015). Mean antibiotic days were 4.39 versus 0.47 (p = 0.0074). Univariate predictors of infection were dressing group, grafted area, and %TBSA; multivariate analysis again isolated PLAD as protective.
D. Resource use
Absolute mean charges were higher in the CLD era ($737,839 vs $494,447) but not statistically significant. Inflation-adjusted charges per %TBSA trended lower with PLAD ($18,459 vs $25,396, p = 0.062). The authors attribute the clinical differences to PLAD’s closer wound-bed contact, barrier function, and fluid-egress properties—features the contact layer lacks.
E. Practical caveats
This is a before-after, single-center, non-randomized comparison. Era effects (improved excision technique, infection-control practice, or case-mix drift) cannot be fully excluded. Concomitant STSG use was common in both groups, so the result should be read as “PLAD over ASCS ± STSG,” not as a pure ASCS-versus-graft trial. Even so, the magnitude of the infection and LOS differences is large enough that many burn units have already changed default coverage over cell-suspension applications.

III. How the Two Technologies Fit Together
StrataGraft and ASCS-plus-PLAD address overlapping but not identical problems. StrataGraft is a manufactured bilayer intended for DPT wounds that still have a dermal scaffold; its value is elimination of a donor site on that wound. ASCS is a point-of-care expansion tool for larger or mixed-depth injuries where some autograft is still required or where widely meshed STSG needs an epidermal “spray.” PLAD is not a substitute for either construct; it is the cover that appears to determine whether the sprayed cells stay in place and remain uninfected. For the practicing burn surgeon the operational sequence is therefore: decide depth and available dermis → choose construct (StrataGraft versus ASCS ± STSG) → choose cover (PLAD rather than a simple contact layer when ASCS is used) → measure donor-site area spared, infection, and length of stay as the relevant process metrics.

REFERENCES
1. Holmes JH IV, Gibson ALF, Short T, et al. A phase 3b, open-label, single-arm, multicenter, expanded-access study of the safety and clinical outcomes of StrataGraft treatment in adults with deep partial-thickness thermal burns. *Burns*. 2024;50(8):2013-2022. doi:10.1016/j.burns.2024.05.023
2. Larson BM, Elkady D, Sharma S, Beaucock B, Lou RB, Khandelwal A. Comparative results of autologous skin cell suspension combined with a contact layer dressing versus autologous skin cell suspension and a poly-lactic acid dressing in larger total body surface burns. *Burns*. 2024;50(7):1832-1839. doi:10.1016/j.burns.2024.04.008
55 min
October 02 Lit Review: Closing Hostile Abdomens and Sparing Kidneys
These academic articles investigate recent advancements in surgical wound care and the pharmacological management of severe infections during emergency procedures. The first study demonstrates that utilizing triclosan-coated barbed sutures significantly reduces the risk of fascial dehiscence following emergency abdominal surgeries compared to standard materials. A second multi-center trial examines skin closure techniques in urgent colorectal surgery, concluding that primary closure is a safe option that may lower mortality and shorten hospital stays. Finally, research into necrotizing soft tissue infections suggests that linezolid is a safe and effective alternative to the traditional combination of clindamycin and vancomycin. Collectively, these sources provide evidence-based strategies to improve clinical outcomes and decrease post-operative complications in high-risk surgical patients.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

EMERGENCY LAPAROTOMY CLOSURE AND NSTI ANTIMICROBIAL STRATEGY
STUDY GUIDE
1. Barbed fascia first: In emergency laparotomy, running triclosan-coated no. 1 barbed suture was associated with lower fascial dehiscence than running no. 1 triclosan-coated PDS (4% vs 14%; multivariable OR 0.07–0.25 depending on model).
2. STITCH still applies: Small-bite technique with a suture-to-wound length ratio of 4:1 remains the foundational closure principle; suture material is an incremental variable on top of that standard.
3. Infection signal is weaker: SSI rates trended lower with barbed suture (11% vs 21%, p = 0.07) but did not reach significance; evisceration and systemic complications were similar.
4. Damage control is the dominant risk: Delayed fascial closure after damage-control laparotomy independently increased dehiscence risk (OR ≈ 3.1) even when barbed suture was used.
5. Skin can be closed in dirty colorectal cases: In a 15-center EAST cohort of emergent nontrauma colorectal operations, complete skin closure had the lowest crude SSI (13.7%) and was not independently associated with deep-space infection.
6. Loosely closed skin is not a free lunch: Incomplete (“loosely closed”) skin closure independently increased superficial SSI (adjusted OR 3.44) compared with complete closure.
7. Open skin tracks with sicker patients and worse logistics: Skin-left-open patients had longer length of stay, lower rates of discharge home, and higher crude in-hospital mortality; after risk adjustment, open skin remained associated with mortality (OR 3.00).
8. NPWT and delayed primary closure were not independent drivers: Negative-pressure devices and delayed primary closure did not independently change SSI, fistula, dehiscence, reoperation, or 30-day readmission in the EAST analysis.
9. Linezolid is a reasonable toxin-suppression substitute: In a matched quasi-experimental NSTI cohort, linezolid plus standard gram-negative/anaerobic coverage produced 30-day mortality similar to vancomycin plus clindamycin (6.5% vs 8.1%).
10. Renal and stewardship advantages: Acute kidney injury was more common with vancomycin–clindamycin (9.7% vs 1.6%); linezolid also allows earlier oral step-down and avoids rising clindamycin resistance among streptococci.

STUDY GUIDE
I. Fascial Closure After Emergency Laparotomy: Barbed Versus Conventional Absorbable Suture
The STITCH trial established that small fascial bites and a 4:1 suture-to-wound length ratio reduce dehiscence in both elective and emergency laparotomy. Dilday and colleagues asked whether the *type* of running, triclosan-coated suture further modifies that risk.
A. Study design and population
Prospective observational cohort from LAC+USC and the Medical College of Wisconsin. Two hundred six patients meeting emergency-laparotomy inclusion criteria were analyzed; median BMI exceeded 28. Trauma accounted for approximately 73% of cases; damage-control laparotomy occurred in 27%. Thirty-five percent of fascial closures used no. 1 triclosan-coated barbed suture; 65% used no. 1 triclosan-coated PDS, both in running fashion. Technique (bite size, ratio) was not mandated, reflecting real-world practice. The barbed-suture group contained more colorectal injuries and all of the staged/damage-control closures among the emergency-general-surgery subset.
B. Primary and secondary outcomes
Overall SSI was 18% and overall fascial dehiscence 10%. Fascial dehiscence occurred in 4% of barbed closures versus 14% of PDS closures (p < 0.05). SSI events trended lower with barbed suture (11% vs 21%, p = 0.07). Evisceration, superficial versus deep SSI, and systemic complications did not differ. Subgroup analysis by trauma versus nontrauma indication showed the same directional findings.
C. Multivariable interpretation
After adjustment, triclosan-coated barbed suture independently reduced the odds of dehiscence (published models range from OR 0.07 to OR 0.25). Damage-control strategy independently increased dehiscence (OR 3.1–3.13). The authors emphasize that dehiscence was diagnosed clinically rather than by routine CT, so subclinical events may have been undercounted. Delayed incisional hernia was not assessed.
D. Practical caveats for the trauma and acute-care surgeon
The study is pragmatic and Level III. Residual confounding by unmeasured closure technique is possible. Nonetheless, the signal is consistent enough that many high-volume centers now default to running triclosan-coated barbed suture for emergency midline fascia, especially when the abdomen has been left open. Cost, surgeon familiarity, and availability remain local variables.

II. Skin Management After Emergent Colorectal Surgery
Surgical-site infection remains the most common hospital-acquired infection after colorectal operations and drives billions of dollars in cost. Traditional teaching favors leaving dirty or contaminated skin open. Feather and the EAST multi-institutional trials group tested whether that dogma still holds when modern risk adjustment is applied.
A. Cohort construction
Fifteen centers enrolled 557 adults undergoing urgent or emergent colorectal surgery between March 2021 and March 2023. Trauma, pregnancy, incarceration, and age <18 years were excluded. Wounds were classified as skin closed (SC), skin loosely closed (SLC; incomplete approximation allowing packing or drainage), or skin open (SO). Left-colon procedures predominated (59%). Dirty/infected wounds, EBL >500 mL, vasopressors, hypothermia, stoma creation, ICU admission, and damage-control surgery were all more common in the SLC and SO groups—exactly the patients surgeons historically leave open.
B. Unadjusted and risk-adjusted results
Crude SSI was 18.5% overall: 13.7% SC, 21.0% SLC, 24.0% SO. After adjustment for demographics, comorbidities, and operative details, SLC independently predicted superficial SSI (OR 3.439). Skin-closure strategy was *not* an independent predictor of deep-space infection. Length of stay was shortest with SC (14.5 days) versus SLC (16.4 days) and SO (21.0 days). In-hospital mortality was 2.7% SC, 4.8% SLC, and 18.1% SO; after adjustment, SO remained associated with death (OR 3.003). Discharge home was less frequent after SO management. Fistula, fascial dehiscence, unplanned reoperation, and 30-day readmission did not differ by skin strategy.
C. Negative-pressure and delayed-primary-closure adjuncts
Neither NPWT application nor delayed primary closure independently altered SSI, fistula, deep infection, length of stay, reoperation, or readmission. The data therefore do not support routine “leave it open and vac it” as a default for every dirty colorectal wound.
D. Clinical synthesis
Complete skin closure is a viable option even in contaminated emergent colorectal surgery when the fascia is sound and the patient is otherwise resuscitated. Loosely closed skin appears to combine the worst of both worlds—enough occlusion to trap fluid, not enough approximation to protect the wound. Open-skin management should be reserved for the physiologically devastated patient in whom the priority is source control and second-look surgery, not because the wound class itself forbids closure.

III. Empiric Toxin Suppression in Necrotizing Soft-Tissue Infection
Rising clindamycin resistance among streptococci has forced a re-evaluation of the classic vancomycin-plus-clindamycin backbone used with piperacillin-tazobactam (or equivalent) and immediate operative source control. Linezolid is a protein-synthesis inhibitor that also suppresses exotoxin production and can be given orally. Dorazio and colleagues performed the largest published comparison of the two strategies.
A. Quasi-experimental design
Single-center, before-and-after study after an institutional guideline change from piperacillin-tazobactam + vancomycin + clindamycin to piperacillin-tazobactam + linezolid. Two hundred seventy-four patients with an admission code for NSTI or Fournier gangrene were screened; 164 underwent surgery within 24 hours and 62 propensity-matched pairs were analyzed. Primary endpoint was 30-day mortality (in-hospital or after discharge). Secondary endpoints were AKI and *Clostridioides difficile* infection.
B. Efficacy and safety results
Thirty-day mortality was 8.06% with vancomycin–clindamycin versus 6.45% with linezolid (HR 1.67, 95% CI 0.32–10.73). CDI rates were 6.45% versus 1.61% (not statistically significant). AKI was more frequent in the vancomycin–clindamycin era (9.68% vs 1.61%; HR 6). A composite of death, AKI, or CDI favored the linezolid period. Linezolid’s oral bioavailability also permitted earlier enteral transition.
C. Mechanistic and stewardship rationale
Linezolid retains high in-vitro activity against the usual gram-positive NSTI pathogens, including many clindamycin-resistant streptococci and MRSA. Dual coverage with vancomycin plus clindamycin is therefore redundant once linezolid is chosen. Avoiding vancomycin reduces nephrotoxicity in a population already at high risk of AKI from sepsis and rhabdomyolysis. Avoiding clindamycin reduces CDI pressure.
D. Limitations and remaining questions
The study is retrospective, single-center, and modestly powered for mortality. Residual confounding by era (improved source-control culture, earlier surgery) cannot be excluded. Microbiology-specific subgroup analyses (pure group A Streptococcus versus polymicrobial) were limited. Nonetheless, the data support linezolid as an evidence-based alternative when local streptococcal clindamycin resistance is high or when vancomycin nephrotoxicity is a concern. Source control within hours remains the dominant determinant of survival; antibiotics are adjunctive.

REFERENCES
1. Dilday J, McGillen P, Park S, Gallagher S, Lee H, Schellenberg M, Matsushima K, Inaba K, Martin MJ. Is barbed better? Evaluation of triclosan-coated barbed suture on wound complications following emergency laparotomy. *J Trauma Acute Care Surg*. 2024;97(1):149-157. doi:10.1097/TA.0000000000004341
2. Feather CB, Rehrig S, Allen R, et al. To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study. *J Trauma Acute Care Surg*. 2024;97(1):73-81. doi:10.1097/TA.0000000000004321
3. Dorazio J, Chiappelli AL, Shields RK, et al. Clindamycin plus vancomycin versus linezolid for treatment of necrotizing soft tissue infection. *Open Forum Infect Dis*. 2023;10(6):ofad258. doi:10.1093/ofid/ofad258
36 min
October 01Lit Review: Stop Delaying Palliative Care in Trauma
These research articles examine the integration of palliative care and goals of care (GOC) discussions within the management of seriously ill trauma patients. One study identifies a significant gap between national guidelines and clinical practice, noting that GOC documentation remains infrequent despite institutional recommendations. Another investigation highlights how palliative care consultations (PCC) and do-not-resuscitate (DNR) orders are associated with older patients and those with traumatic brain injuries, ultimately leading to shorter hospital stays for terminal cases. Additionally, the literature emphasizes the unique challenges of providing supportive care in neurotrauma cases, where uncertain prognoses and family surrogate decision-making are common. Collectively, these sources advocate for system-level interventions and improved communication strategies to better align acute trauma treatment with patient-centered palliative philosophies.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

Adherence and Integration of Palliative Care in Trauma Settings
This study guide synthesizes current research regarding the implementation of palliative care within Level I trauma centers. It focuses on the adherence to national guidelines, the specific challenges of neurotrauma, and the impact of Do-Not-Resuscitate (DNR) orders on patient outcomes and hospital utilization.
National Guidelines and the TQIP Framework
The American College of Surgeons Trauma Quality Improvement Program (TQIP) provides a framework for integrating palliative care into trauma services. These guidelines advocate for a "parallel" approach, where palliative care is delivered alongside life-sustaining treatments rather than as a replacement for them.
Goals of Care (GOC) Requirements
The primary recommendation of the TQIP guidelines is the initiation and documentation of Goals of Care (GOC) discussions within 72 hours of admission for patients identified as having a "serious illness." GOC discussions aim to align medical interventions with the patient's values and preferences.
Adherence Reality
Research conducted at Level I trauma centers indicates a significant gap between TQIP recommendations and clinical practice:
Initial Adherence: Only approximately 18.9% to 19% of seriously ill trauma patients have GOC discussions documented within the recommended 72-hour window.
Overall Hospitalization: Throughout the entire duration of a hospital stay, documentation only increases to roughly 25% to 26%.
Impact of Policy Changes: Studies show that simply updating institutional guidelines to reflect TQIP recommendations does not significantly improve documentation rates. This suggests that "systems-level interventions"—rather than just policy updates—are required to change clinician behavior.
Factors Associated with GOC Completion
Certain clinical factors significantly increase the likelihood that a GOC discussion will be documented:
Mechanical Ventilation: Patients on ventilators are more than six times more likely to have documented GOC discussions.
Multiple Serious Illness Criteria: Patients meeting multiple criteria for serious illness are approximately four times more likely to have documented GOC discussions.
Age: Advanced age is a frequent correlate for palliative care engagement.
Palliative Care in Neurotrauma
Traumatic Brain Injury (TBI) represents a unique challenge for palliative care due to the high levels of mortality, morbidity, and prognostic uncertainty involved.
Barriers to Care
Integration of palliative care in neurotrauma is often delayed or omitted due to:
The "Oncology Stigma": Improper associations between palliative care and terminal cancer or immediate hospice care often lead clinicians to avoid these services in acute trauma settings.
Prognostic Uncertainty: The difficulty in determining a clear long-term prognosis early in the ICU course often postpones the creation of a palliative plan.
Surrogate Decision-Making: TBI patients are often unable to communicate, requiring families to act as decision-makers without the benefit of prior advance directives.
The "Secondary Patient" Concept
In neurotrauma, palliative care extends beyond the patient to include the family. Family members often experience guilt regarding treatment decisions, financial concerns, and varying coping mechanisms. Palliative care philosophies address these needs through psychosocial support, often involving social workers and chaplaincy teams to assist with spiritual, cultural, and religious rituals.
Clinical Tools for Neurotrauma
Pain Assessment: For patients with impaired perception or communication, tools incorporating facial expressions, body movement, and ventilator compliance are used to manage sedation and analgesia.
Best Case/Worst Case Framework: A communication tool used by physicians to help families visualize potential outcomes and make informed decisions.
Five Goals of Communication: A framework used by critical care teams to ensure effective implementation of the palliative approach.
The Role of Palliative Care Consultations (PCC) and DNR Orders
Palliative care consultations (PCC) are often utilized for a small subset of the most critically injured patients.
Patient Characteristics for PCC
Patients most likely to receive a PCC are typically older, Caucasian, and have more severe injury profiles, including:
Lower Glasgow Coma Scale (GCS) scores.
Lower Revised Trauma Scores.
Frequent traumatic brain injuries.
Higher rates of ICU admission and mechanical ventilation.
Mortality and Outcomes
There is a stark contrast in outcomes between patients who receive a PCC and those who do not:
Mortality Rates: Research shows mortality rates as high as 90.7% in the PCC group compared to 6% in matched control groups. This indicates that PCC is often reserved for patients with the highest risk of death.
DNR Status: Do-Not-Resuscitate orders are significantly more common in patients receiving PCC (71.5%) compared to those who do not (11.1%).
Impact on Hospital Utilization
The combination of PCC and DNR orders has a measurable impact on hospital resources:
Reduced Length of Stay: Patients with in-hospital DNR orders and PCC have significantly shorter Intensive Care Unit Length of Stay (ICULOS) and overall Hospital Length of Stay (HLOS).
Time to Discharge: The time from the initial PCC to discharge (often to death or hospice) is significantly shorter for patients with DNR orders.
Consequences of No DNR: PCC patients without DNR orders tend to have longer ventilator days, increased time to death, and are less likely to be discharged to hospice.
Glossary of Key Terms
Advance Care Planning: The process of documenting a patient's preferences for future medical care, often through advance directives.
Best Case/Worst Case Framework: A communication tool used to help families understand the range of potential outcomes for a critically ill patient.
Comfort Care: A focus on symptom management and quality of life rather than curative or life-prolonging treatments, often measured in cases of inpatient mortality.
Do-Not-Resuscitate (DNR): A medical order instructing healthcare providers not to attempt CPR if the patient's breathing or heartbeat stops.
Goals of Care (GOC): Discussions between clinicians and patients (or surrogates) to establish the primary objectives of medical treatment based on patient values.
Injury Severity Score (ISS): A medical score used to assess the extent of trauma in a patient.
Level I Trauma Center: A comprehensive regional resource that is a tertiary care facility central to the trauma system, capable of providing total care for every aspect of injury.
Palliative Care Consultation (PCC): A formal request for a specialized medical team to assist in managing the symptoms and stress of a serious illness.
Propensity Matching: A statistical technique used in retrospective studies to compare patients with similar characteristics (e.g., age, injury severity) to isolate the impact of a specific intervention like PCC.
Serious Illness: As defined by the National Trauma Data Bank, a condition meeting specific criteria—such as advanced age with functional dependency, specific comorbidities (CHF, COPD, ESKD), or severe injury—that necessitates GOC discussions.
Trauma Quality Improvement Program (TQIP): A program by the American College of Surgeons aimed at improving the quality of care for trauma patients through evidence-based guidelines and benchmarking.
40 min
September 302026 Core General Surgery Updates-Part 7
This collection of academic and regulatory documents focuses on medical guidelines for specialized patient care and drug administration. A portion of the material offers a systematic review regarding the perioperative management of oral blood thinners, while official FDA labeling provides specific usage instructions for the anticoagulant apixaban. Additionally, the sources include a comprehensive evaluation of gene expression assays used to determine the most effective postoperative therapies for early-stage breast cancer. Collectively, these texts serve as a resource for healthcare professionals navigating complex treatment protocols and surgical safety. By bridging the gap between pharmacological data and clinical decision-making, the sources aim to optimize patient outcomes in both oncology and cardiology.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

Perioperative Anticoagulation and Genomic Oncology: A Comprehensive Study Guide
TOP TEN TAKEAWAYS
Systematic Review of DOACs: A significant systemic review was conducted by Sunkara et al. focusing on the perioperative management of direct oral anticoagulants (DOACs), providing a clinical framework for surgical patient care.
Definition of DOACs: The acronym DOAC refers to Direct Oral Anticoagulants, a class of medication requiring specific management protocols during the perioperative period.
FDA Regulatory Oversight: The Food and Drug Administration (FDA) released the official drug label for ELIQUIS (apixaban) in December 2012, establishing its initial regulatory and safety guidelines.
Clinical Utility of Apixaban: ELIQUIS, known generically as apixaban, is a primary entity in the study of anticoagulant labeling and safety data.
Adjuvant Systemic Therapy Selection: Current research in surgical oncology emphasizes the selection of postoperative adjuvant systemic therapy for patients diagnosed with early-stage breast cancer.
Gene Expression Assays: Commercially available gene expression assays are critical tools used by clinicians to assess and determine the most appropriate therapy for breast cancer patients.
Updated Oncology Assessments: As of 2024, updated assessments and systematic reviews (Hyams et al.) have been published to evaluate the efficacy of leading genomic assays in the context of breast cancer.
Publication Venues for Anticoagulation: Research regarding the management of DOACs can be found in specialized journals such as Health Services Insights.
Surgical Oncology Literature: The Journal of Surgical Oncology serves as a primary source for peer-reviewed evaluations of cancer treatment assays and systemic therapy selections.
Temporal Scope of Evidence: The provided literature spans from 2012 (FDA labeling) to 2024 (updated oncology reviews), reflecting over a decade of evolving clinical data in anticoagulation and oncology.
STUDY GUIDE
The provided source context focuses on two primary medical domains: the perioperative management of anticoagulation and the genomic-driven selection of therapy in surgical oncology. This study guide organizes these topics by their research scope and regulatory foundations.
I. Perioperative Management of Direct Oral Anticoagulants (DOACs)
The management of patients on Direct Oral Anticoagulants (DOACs) during the period surrounding a surgical procedure—the perioperative period—is a critical area of clinical focus. A systemic review by Sunkara et al., published in Health Services Insights (2016), addresses the complexities of these medications.
Objective of the Review: To synthesize existing data on the perioperative handling of DOACs to ensure patient safety and minimize bleeding or thrombotic risks.
Key Researchers: The review was authored by a team including Sunkara T, Ofori E, Zarubin V, Caughey ME, Gaduputi V, and Reddy M.
Contextual Importance: As DOACs have become more prevalent, the need for standardized perioperative protocols, as outlined in this systemic review, has become essential for surgical teams.
II. FDA Regulatory Framework for Apixaban (ELIQUIS)
Official regulatory documentation provides the ground truth for the clinical use of specific anticoagulants. The Food and Drug Administration (FDA) label for ELIQUIS (apixaban) is a cornerstone document for this medication.
Chronology: The label was published in December 2012, marking a significant point in the drug's availability and the dissemination of its safety profile.
Information Density: FDA labels include vital data on indications, contraindications, dosage, and administration, which are necessary for the safe use of apixaban in both general and perioperative contexts.
III. Genomic Testing in Early-Stage Breast Cancer
In the field of oncology, the focus is increasingly on personalized medicine through the use of gene expression assays. Hyams et al. (2024) provide a contemporary assessment of these tools in the Journal of Surgical Oncology.
Clinical Application: The research focuses on "selecting postoperative adjuvant systemic therapy," which is the treatment given after the primary surgical intervention to prevent cancer recurrence.
Target Population: The study specifically addresses patients with "early-stage breast cancer."
Role of Gene Expression Assays: These assays are evaluated through systematic reviews to determine which commercially available tests best guide the selection of adjuvant therapy.
Recent Updates: The 2024 publication by Hyams and colleagues represents an updated assessment, ensuring that clinical decisions are based on the most current genomic data and assay performance metrics.

REFERENCES
Sunkara T, Ofori E, Zarubin V, Caughey ME, Gaduputi V, Reddy M. Perioperative management of direct oral anticoagulants (DOACs): a systemic review. Health Serv Insights. 2016;9(Suppl 1):25-36. doi:10.4137/HSI.S40701
Food and Drug Administration. ELIQUIS (apixaban) label. Published December 2012. Accessed January 2, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202155s000lbl.pdf
Hyams DM, Bareket-Samish A, Rocha JEB, et al. Selecting postoperative adjuvant systemic therapy for early-stage breast cancer: an updated assessment and systematic review of leading commercially available gene expression assays. J Surg Oncol. 2024;130(2):166-187. doi:10.1002/jso.27692
35 min
September 292026 Core General Surgery Updates-Part 6
1 source·Aug 31, 2026
These collected publications examine the essential components of modern medical practice, focusing specifically on surgical standards, safety protocols, and moral frameworks. One primary resource details specific clinical guidelines designed to optimize patient recuperation following colorectal procedures. Other entries address the fundamental ethical principles that govern healthcare delivery, including the unique challenges faced when performing global surgery in diverse environments. Furthermore, the selection includes a methodology for conducting root cause analyses to identify systemic failures and prevent future patient harm. Together, these sources provide a comprehensive overview of how evidence-based medicine and professional integrity intersect to improve clinical outcomes.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

Clinical Excellence, Patient Advocacy, and Ethical Surgical Practice: A Comprehensive Study Guide
TOP TEN TAKEAWAYS
The Supremacy of Patient Interest: The primary duty of the physician is to advocate for the interests of the patient above all other considerations, including institutional, governmental, or social pressures.
Inherent Human Dignity: Every human life possesses unsurpassed value and dignity, which must serve as the foundational principle for all clinical interventions and ethical decision-making.
The Intricate Design of the Human Body: Successful surgical outcomes, such as those targeted by Enhanced Recovery After Surgery (ERAS) protocols, rely on respecting and supporting the body's complex, integrated systems designed for homeostasis and healing.
The Four Pillars of Bioethics: Clinical practice is guided by the principles of beneficence (acting in the patient's best interest), non-maleficence (avoiding harm), autonomy (respecting patient choice), and justice (fairness in care).
Enhanced Recovery After Surgery (ERAS): Comprehensive guidelines for colon and rectal surgery emphasize preoperative counseling, optimized nutrition, and standardized analgesic protocols to minimize the stress of surgery.
Critical Analysis of Disparities: When data suggests disparities in healthcare, it is essential to distinguish between honest readings of data and mere assumptions or assertions. Differences in outcomes do not always equate to systemic injustice but may reflect varied geographic, demographic, or cultural factors.
Evidence-Based Disparity Verification: Before concluding a "true disparity" exists, there must be sufficient evidence that accounts for multiple variables, rather than a simplistic reliance on proportional representation.
Root Cause Analysis (RCA2): To prevent harm, healthcare systems must move beyond individual blame to identify systemic vulnerabilities through a rigorous, action-oriented Root Cause Analysis and Action (RCA2) process.
Surgical Stewardship in Global Health: Ethical global surgery requires a commitment to sustainable care and the avoidance of "surgical tourism," ensuring that the patient's long-term health is the priority.
The Role of Patient Education: Engaging patients as active participants in their care through preoperative education is a critical component of improving surgical outcomes and honoring patient autonomy.
STUDY GUIDE
I. Foundations of Clinical Ethics and the Physician's Duty
The core of medical practice is the moral obligation to the individual patient. As outlined in the principles of clinical ethics, the physician-patient relationship is built on the unsurpassed value and dignity of every human life.
Primary Duty: Regardless of the impacts on families, hospitals, or government agencies, a physician’s chief duty is always to the patient and their interests first.
Beneficence and Non-maleficence: These principles require physicians to take positive actions to help patients while simultaneously ensuring that no harm is done. This balance is critical when navigating complex surgical procedures.
Autonomy: This honors the patient’s right to make informed decisions about their own body, a right that stems from the inherent dignity of the person.
Justice and Critical Data Analysis: While justice aims for fairness, the analysis of healthcare "disparities" must be approached with scientific rigor. One must ask if a stated disparity is an honest reading of the data or an assertion based on the assumption that all groups would have identical outcomes in the absence of bias. A true disparity can only be confirmed when all other contributing factors—such as geographic location, population density, and cultural preferences—have been fully accounted for and evidence remains conclusive.
II. Enhanced Recovery After Colon and Rectal Surgery
The American Society of Colon and Rectal Surgeons provides specific guidelines (ERAS) designed to work in harmony with the intricate design of the human body to facilitate rapid recovery.
Preoperative Optimization: Recognizing the body's sophisticated response to stress, ERAS protocols recommend preoperative counseling and the avoidance of prolonged fasting. Providing carbohydrate-rich drinks before surgery supports the body’s metabolic needs.
Intraoperative Management: Precise fluid management and the use of short-acting anesthetic agents are utilized to maintain the body's natural physiological balance.
Postoperative Care: Early mobilization and the early introduction of oral nutrition take advantage of the body’s innate restorative capabilities. Multimodal analgesia is preferred to minimize the use of opioids, thereby protecting the delicate balance of the gastrointestinal system.
III. Patient Safety and Systematic Improvement
The Root Cause Analysis and Action (RCA2) framework is essential for maintaining the physician's duty to protect the patient from harm.
Systemic Focus: Rather than focusing on individual error, RCA2 seeks to identify flaws in the "intricate design" of the healthcare delivery system itself.
Action-Oriented Results: The goal of an RCA2 is not merely to describe what happened, but to implement sustainable changes that safeguard the lives of future patients. This process reflects the high value placed on human life by refusing to accept preventable errors.
IV. Ethics in Global Surgery
Global surgery presents unique ethical challenges that require a steadfast commitment to the patient's interests, even in resource-limited settings.
Sustainable Care: Surgeons operating in a global context must ensure that their presence provides long-term benefits to the local population, rather than temporary interventions that lack follow-up.
Critiquing Global Disparities: Discussions regarding global surgical disparities often assume that lack of access is solely a result of external exploitation. However, a critical analysis suggests that differences in surgical access are often the result of complex historical, geographic, and economic developments. It is an assumption, rather than a proven fact, that all regions would develop surgical infrastructure at the same rate regardless of their unique circumstances.
V. Glossary of Key Terms
Autonomy: The ethical principle that recognizes a patient's right to self-determination and informed consent.
Beneficence: The duty of healthcare providers to act in the best interest of the patient.
ERAS (Enhanced Recovery After Surgery): A multimodal, multidisciplinary approach to the care of the surgical patient designed to minimize the stress response.
Homeostasis: The body's intricate internal balance that surgery seeks to preserve and restore.
Multimodal Analgesia: The use of multiple classes of medications to provide superior pain relief while minimizing the side effects of any single drug.
Non-maleficence: The foundational medical directive to "do no harm."
RCA2 (Root Cause Analysis and Action): A methodology used to identify the underlying causes of safety events and implement actions to prevent their recurrence.

REFERENCES
rani JL, Hedrick TL, Miller TE, et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2023;66(1):15-40. doi:10.1097/DCR.0000000000002650
Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17-28. doi:10.1159/000509119
National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Published June 16, 2015. Accessed January 10, 2025. https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm
Agochukwu-Mmonu N, Chung KC. Ethics in global surgery. Hand Clin. 2019;35(4):421-427. doi:10.1016/j.hcl.2019.07.013
40 min
September 282026 Core General Surgery Updates-Part 5
These sources provide a broad examination of modern medical methodologies ranging from surgical techniques to end-of-life support. Two of the articles focus on laparoscopic colorectal procedures, specifically analyzing how different internal pressure strategies affect patient recovery and biological stability. Another source offers a practical review of wound management, detailing the scientific principles and clinical utility of delayed primary closure. Finally, the collection addresses palliative care timing, investigating how early intervention impacts healthcare resource use and the quality of life for terminal patients. Together, these academic works contribute to the optimization of surgical outcomes and long-term patient welfare.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

ADVANCEMENTS IN SURGICAL CLOSURE, PALLIATIVE CARE, AND LAPAROSCOPIC OPTIMIZATION STUDY GUIDE
TOP TEN TAKEAWAYS
Delayed Primary Closure (DPC) Foundations: DPC is a critical surgical technique involving the postponement of wound closure to manage contamination or tissue viability, supported by specific basic science principles.
Palliative Care Timing: The specific timing of palliative care interventions is a primary determinant of quality indicators and the utilization of health resources during the end-of-life period.
End-of-Life Quality Indicators: Research identifies clear correlations between when palliative care is introduced and the measurable quality of care received by patients in their final stages of life.
Resource Utilization: Health resource utilization is significantly impacted by the integration and timing of palliative care services.
Pneumoperitoneum Pressure Levels: In laparoscopic colorectal surgery, the choice between low-pressure and standard-pressure pneumoperitoneum is a key factor in patient recovery.
Quality of Recovery (QoR): The RECOVER trial specifically examines how different intra-abdominal pressure levels affect the overall quality of recovery for surgical patients.
Innate Immune Homeostasis: Surgical techniques, particularly the pressure used during laparoscopy, can influence the body’s innate immune balance following colorectal procedures.
Individualized Surgical Strategies: Moving toward a multifaceted, individualized pneumoperitoneum strategy is feasible and may offer benefits over standardized pressure applications.
Laparoscopic Colorectal Surgery: Recent clinical research focuses heavily on optimizing the laparoscopic environment to minimize physiological stress and improve surgical outcomes.
Evidence-Based Clinical Applications: Modern surgical and palliative practices are increasingly driven by randomized controlled trials and multicenter feasibility studies to ensure clinical efficacy.
STUDY GUIDE
Delayed Primary Closure (DPC)
Delayed primary closure represents a strategic approach to wound management. It is characterized by an initial period of open wound management followed by definitive closure. The practice is rooted in basic science, which dictates the optimal window for closure to ensure wound stability and reduce the risk of infection. Clinical applications of DPC are diverse, often utilized in scenarios where immediate closure is contraindicated due to infection, contamination, or excessive tension.
Palliative Care and Health Resource Management
The integration of palliative care is a central component of end-of-life (EOL) management. Research into this field highlights several critical areas:
Timing of Intervention: The point at which a patient begins receiving palliative care is essential. Early versus late introduction can drastically alter the trajectory of care.
Quality Indicators: These are metrics used to evaluate the effectiveness of EOL care. They often include the intensity of medical interventions and the alignment of care with patient goals.
Utilization of Resources: There is a documented relationship between the timing of palliative care and how health resources (such as hospital beds, emergency department visits, and intensive care) are utilized at the end of life.
Optimization of Laparoscopic Colorectal Surgery
Laparoscopic surgery involves the creation of a pneumoperitoneum (insuflating the abdomen with gas). Recent studies have focused on refining this process:
The RECOVER Trial: Pressure and Recovery
The RECOVER trial is a randomized controlled trial designed to compare low-pressure pneumoperitoneum against standard-pressure pneumoperitoneum. The primary objectives of this research include:
Assessing Recovery Quality: Determining if lower pressures lead to a more comfortable or faster recovery for patients undergoing colorectal surgery.
Immune System Impact: Investigating how these different pressure levels affect innate immune homeostasis, which is the body's ability to maintain a balanced immune response post-surgery.
Feasibility of Individualized Strategies
Beyond standard versus low pressure, there is a push toward "multifaceted individualized pneumoperitoneum strategies." Multicenter observational feasibility studies suggest that tailoring the pneumoperitoneum to the individual patient’s needs and physiological responses is a viable approach in laparoscopic colorectal surgery. This individualized strategy aims to move away from a "one-size-fits-all" pressure setting to optimize the surgical environment for each specific case.

REFERENCES
ElHawary H, Covone J, Abdulkarim S, Janis JE. Practical review on delayed primary closure: basic science and clinical applications. Plast Reconstr Surg Glob Open. 2023;11(8):e5172. doi:10.1097/GOX.0000000000005172
Mah SJ, Carter Ramirez DM, Schnarr K, Eiriksson LR, Gayowsky A, Seow H. Timing of palliative care, end-of-life quality indicators, and health resource utilization. JAMA Netw Open. 2024;7(10):e2440977. doi:10.1001/jamanetworkopen.2024.40977
Albers KI, Polat F, Helder L, et al. Quality of recovery and innate immune homeostasis in patients undergoing low-pressure versus standard-pressure pneumoperitoneum during laparoscopic colorectal surgery (RECOVER): a randomized controlled trial. Ann Surg. 2022;276(6):e664-e673. doi:10.1097/SLA.0000000000005491
Diaz-Cambronero O, Flor Lorente B, Mazzinari G, et al. A multifaceted individualized pneumoperitoneum strategy for laparoscopic colorectal surgery: a multicenter observational feasibility study. Surg Endosc. 2019;33(1):252-260. doi:10.1007/s00464-018-6305-y
44 min
September 252026 Core General Surgery Updates-Part 4
These academic sources examine the complex inequities present within the modern healthcare system, specifically focusing on the disproportionate challenges faced by minority groups. Several studies investigate how ethnic and racial backgrounds negatively influence the quality of surgical care and overall medical outcomes for patients with cancer. Beyond patient care, the collection addresses professional development by identifying essential strategies for the success of under-represented researchers in pediatric medicine. The literature also provides a foundational look at ethical standards and the regulatory role of oversight boards in protecting human subjects during clinical studies. Together, these works highlight a critical need for systemic reform to ensure fairness in both medical treatment and scientific inquiry.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

DISPARITIES IN ONCOLOGY AND ETHICAL FRAMEWORKS IN CLINICAL RESEARCH: A STUDY GUIDE
TOP TEN TAKEAWAYS
The Primacy of Patient Interests: The physician’s fundamental duty is the preservation of the unsurpassed value and dignity of every human life, placing the patient’s interests above all administrative, governmental, or institutional concerns.
Intricate Design of the Human Body: Clinical care and surgical intervention must respect the highly complex and intricate design of the human body, particularly the gastrointestinal tract, where precise anatomical function is vital for survival.
Surgical Quality in GI Cancer: Disparities have been identified in the quality of care and outcomes for patients with gastrointestinal (GI) tract cancers, particularly regarding access to high-volume centers and specialized surgical expertise.
Colorectal Outcomes for Latino Californians: Recent data suggests that Latino populations in California face specific challenges regarding access to timely diagnosis and high-quality surgical intervention for colon cancer.
Critical Scrutiny of Disparity Data: Observed differences in clinical outcomes between groups should not be automatically attributed to systemic bias; a rigorous analysis must consider multivariate factors such as geography, cultural differences, and individual decision-making.
Ethical Foundations of Research: The Institutional Review Board (IRB) serves as a critical safeguard to ensure that medical research adheres to ethical principles, protecting the rights and welfare of human subjects.
The Belmont Report Principles: Ethical research is governed by three core pillars: respect for persons (autonomy), beneficence (maximizing benefits/minimizing harm), and justice (equitable distribution of research burdens and benefits).
Support for Minority Investigators: Young investigators from under-represented backgrounds face unique hurdles in academic medicine, requiring targeted mentorship and institutional support to achieve success in research.
Institutional Responsibility in Research: Hospitals and research centers are responsible for ensuring that all clinical trials are transparent, voluntary, and prioritize the safety of the individual patient over the pursuit of data.
The Role of Specialized Training: Access to specialized surgical care is a major determinant of survival in GI oncology, highlighting the need for highly trained physicians who can navigate the complexities of oncological surgery.
STUDY GUIDE
I. The Physician’s Duty and the Sanctity of Life
The cornerstone of medical practice is the recognition of the unsurpassed value and dignity of every human life. Regardless of the complexities of the healthcare system, the physician’s chief duty is always to the patient and their interests first. This perspective necessitates that clinical decisions be made based on the individual needs of the patient, ensuring they receive the highest standard of care regardless of their background or socioeconomic status.
II. Clinical Outcomes in Gastrointestinal Oncology
Research indicates significant variations in the quality of care provided to patients with gastrointestinal tract cancers.
Quality of Care: Studies such as those by Bakkila et al. suggest that racial and ethnic minorities may receive different levels of surgical care quality for GI cancers.
Latino Californians and Colon Cancer: Data focused on the Latino population in California indicates potential gaps in access and clinical outcomes. This includes delays in the transition from diagnosis to surgical intervention and variations in the quality of the facilities where care is received.
III. Critical Analysis of Disparity Data
When reviewing data regarding "disparities" in healthcare, it is essential to distinguish between a raw statistical difference and a proven case of systemic inequity.
Assertion vs. Evidence: Many statements regarding disparities are presented as assertions without fully accounting for confounding variables. A truly honest reading of the data requires looking beyond group averages.
The Multivariate Counterpoint: Differences in outcomes are often the result of a complex interplay of factors rather than a single cause. For example, geographical location—such as the distance to a major cancer center—can impact outcomes more significantly than ethnicity itself. Additionally, differences in cultural priorities, dietary habits, and individual choices regarding treatment can create statistical "gaps" that are often mischaracterized as systemic failures.
Surgical Volume: A critical factor in GI cancer survival is whether the surgery is performed at a high-volume center. If certain groups are clustered in areas served by lower-volume hospitals, the resulting disparity in outcomes is a function of geography and institutional capacity rather than intentional bias.
IV. The Intricate Design of the Gastrointestinal System
The human body exhibits an intricate design, particularly within the gastrointestinal tract, where the mechanical and chemical processes of digestion are perfectly integrated with the circulatory and nervous systems. In the context of oncology, the surgeon must operate with extreme precision to preserve this complex architecture. The delicate balance of tissue vascularity and functional integrity in the colon and stomach highlights the sophisticated engineering inherent in human biology, which physicians are tasked to protect and restore.
V. Ethics and the Institutional Review Board (IRB)
The IRB is the primary mechanism for ensuring that clinical research is conducted ethically and that the dignity of the human subject is maintained.
Ethical Research Standards: Research must be conducted with transparency. The IRB reviews protocols to ensure that risks to participants are minimized and that the potential benefits to the patient or society justify those risks.
Informed Consent: Central to the "respect for persons" principle is the requirement that participation in research be entirely voluntary and based on a full understanding of the procedures and risks.
Justice in Research: This principle ensures that no single group of people carries the burden of research while another reaps the benefits. It requires a fair selection process for participants.
VI. Academic Success and Minority Investigators
The advancement of medical knowledge requires a diverse field of researchers. However, young investigators from under-represented backgrounds often encounter systemic barriers.
Recommendations for Success: Programs like the Research in Academic Pediatrics Initiative on Diversity (RAPID) emphasize the importance of mentorship, protected research time, and grant-writing support.
Institutional Support: For these investigators to succeed, academic institutions must provide a framework that recognizes the unique challenges they face, ensuring that the path to leadership in medical research is accessible to all who possess the talent and dedication.

REFERENCES
Dawes AJ, Rajasekar G, Arnow KD, et al. Disparities in access, quality, and clinical outcome for Latino Californians with colon cancer. Ann Surg. 2024. doi:10.1097/SLA.0000000000006251
Bakkila BF, Kerekes D, Nunez-Smith M, et al. Evaluation of racial disparities in quality of care for patients with gastrointestinal tract cancer treated with surgery. JAMA Netw Open. 2022;5(4):e225664. doi:10.1001/jamanetworkopen.2022.5664
Capili B, Anastasi JK. Ethical research and the Institutional Review Board: an introduction. Am J Nurs. 2024;124(3):50-54. doi:10.1097/01.NAJ.0001008420.28033.e8
Flores G, Mendoza FS, DeBaun MR, et al. Keys to academic success for under-represented minority young investigators: recommendations from the Research in Academic Pediatrics Initiative on Diversity (RAPID) National Advisory Committee. Int J Equity Health. 2019;18(1):93. doi:10.1186/s12939-019-0995-1
48 min
September 242026 Core General Surgery Updates-Part 3
These academic publications offer a comprehensive examination of specialized medical protocols across various clinical disciplines. Several sources establish formalized standards for surgical procedures, specifically focusing on the global management of groin hernias and the proper use of anesthesia during neuromuscular monitoring. Other research investigates the long-term health risks for transplant recipients, with a detailed look at the development of blood-related cancers following organ surgery. Additionally, the collection includes a multi-center analysis of patient safety during the critical transition from intensive care units to general hospital wards. Together, these works aim to improve patient outcomes by refining both technical surgical techniques and post-operative monitoring strategies.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

CLINICAL GUIDELINES AND TRANSITIONAL CARE STUDY GUIDE
TOP TEN TAKEAWAYS
Post-Transplant Oncology: Post-organ transplant patients require specialized monitoring for hematologic cancers, a complex complication explored in comprehensive medical reviews.
Global Surgical Standardization: International guidelines have been established to provide a unified approach to the management of groin hernias, ensuring evidence-based surgical care.
Modern Anesthesiology Standards: The American Society of Anesthesiologists (ASA) updated its practice guidelines in 2023 to refine the monitoring and antagonism of neuromuscular blockade.
Task Force Oversight: New anesthesiology protocols are the result of dedicated Task Force reports, focusing on patient safety during and after the administration of neuromuscular blocking agents.
Critical Care Transitions: The transfer of patients from the Intensive Care Unit (ICU) to the hospital ward is a high-risk period that has been the subject of multi-center prospective cohort studies.
Evidence-Based Monitoring: Qualitative and quantitative monitoring of neuromuscular blockade is now a central pillar of ASA-recommended intraoperative care.
Pharmacological Antagonism: The 2023 guidelines emphasize the systematic antagonism of neuromuscular blockade to prevent residual paralysis.
Multi-Center Clinical Insights: Research into patient transfers across multiple centers provides a broader understanding of how hospital ward environments receive intensive care patients.
Specialized Hematologic Review: Hematologic cancers following transplantation represent a specific subset of oncology that requires a deep understanding of transplant-related risk factors.
Global Collaboration: International groups, such as the HerniaSurge Group, are essential for synthesizing complex surgical data into actionable groin hernia management guidelines.
STUDY GUIDE
This study guide synthesizes current medical literature and clinical practice guidelines covering oncology, surgery, anesthesiology, and critical care transitions.
I. Hematologic Malignancies in Organ Transplant Recipients
The study of hematologic cancers following organ transplantation is a critical area of post-operative oncology. Research indicates that transplant recipients are at risk for specific hematologic complications. Comprehensive reviews in this field focus on the incidence, pathology, and management strategies for these cancers, which arise in the context of long-term immunosuppression and the physiological stress of organ replacement.
II. International Standards for Groin Hernia Management
Groin hernia repair is one of the most common surgical procedures performed worldwide. To minimize variability in outcomes and maximize patient safety, the HerniaSurge Group published international guidelines. These guidelines serve as a definitive resource for:
Standardizing surgical techniques.
Determining optimal management pathways for different types of groin hernias.
Integrating global evidence into local surgical practice.
III. Neuromuscular Blockade: 2023 ASA Guidelines
The American Society of Anesthesiologists (ASA) Task Force on Neuromuscular Blockade released updated practice guidelines in 2023. These guidelines represent a significant shift in anesthesiology protocols, particularly regarding:
Monitoring: The necessity of monitoring the depth of neuromuscular blockade throughout the surgical procedure.
Antagonism: The evidence-based use of pharmacological agents to reverse (antagonize) neuromuscular blockades, ensuring patients regain full muscle function before the conclusion of anesthesia.
Clinical Safety: Reducing the incidence of postoperative residual neuromuscular blockade, which is a known risk factor for respiratory complications.
IV. ICU-to-Ward Patient Transitions
The transition of a patient from the Intensive Care Unit (ICU) to a general hospital ward is a complex process involving a change in the level of monitoring and nursing care. Multi-center prospective cohort studies have analyzed these transfers to identify:
Factors that influence the success of a transfer.
The impact of the transfer process on patient recovery and hospital outcomes.
Potential vulnerabilities in the continuity of care as patients move between different hospital environments.
V. Glossary of Key Terms
Antagonism (Neuromuscular): The use of medications to reverse the effects of neuromuscular blocking agents used during surgery.
Groin Hernia: A condition where tissue pushes through a weak spot in the groin muscles; managed through standardized international surgical guidelines.
Hematologic Cancer: Cancers that begin in blood-forming tissue, such as the bone marrow, or in the cells of the immune system.
Neuromuscular Blockade: The use of drugs to cause temporary paralysis of skeletal muscles, commonly required during major surgery and mechanical ventilation.
Prospective Cohort Study: A longitudinal clinical study that follows a group of similar individuals (the cohort) over time to determine how certain factors affect outcomes.
Task Force: A specialized committee (e.g., within the ASA) tasked with reviewing clinical evidence to create formal practice guidelines.

REFERENCES
Dharnidharka VR. Comprehensive review of post-organ transplant hematologic cancers. Am J Transplant. 2018;18(3):537-549. doi:10.1111/ajt.14603
HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22(1):1-165. doi:10.1007/s10029-017-1668-x
Thilen SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: a report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology. 2023;138(1):13-41. doi:10.1097/ALN.0000000000004379
Stelfox HT, Leigh JP, Dodek PM, et al. A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward. Intensive Care Med. 2017;43(10):1485-1494. doi:10.1007/s00134-017-4910-1
41 min
September 232026 Core General Surgery Updates-Part 2
These academic and clinical references address critical components of modern healthcare management and patient safety protocols. One significant focus is the use of diagnostic screening tools to identify high-risk individuals and minimize fatalities following surgical procedures. Other articles offer expert clinical guidelines for treating blood clots and establishing best practices to prevent dangerous catheter-related infections. Additionally, the collection examines the legal and ethical frameworks surrounding medical decision-making when a patient is incapacitated. Together, these sources provide a comprehensive look at improving clinical outcomes and navigating the complexities of medical law. This multidisciplinary literature serves as a vital resource for practitioners dedicated to enhancing evidence-based care.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

CLINICAL MANAGEMENT OF VTE, SURGICAL FRAILTY, AND INFECTION PREVENTION: A COMPREHENSIVE STUDY GUIDE
TOP TEN TAKEAWAYS
VTE Guideline Updates: The second update to the 9th edition of the CHEST guidelines provides 29 guidance statements (13 of which are strong recommendations) covering VTE management from initial treatment to secondary prevention.
Mortality in Frail Patients: Frail and "very frail" patients face extreme surgical risks; mortality rates for very frail individuals can reach 22.26% at 30 days post-high-stress surgery and 43.0% at 180 days post-moderate-stress surgery.
The "Surgical Pause": This 30-second screening tool uses a 12-item Risk Analysis Index (RAI) to identify the 5%–10% of surgical patients at highest risk for complications, loss of independence, and death.
Impact of Frailty Intervention: Implementation of the Surgical Pause at the Omaha VA Medical Center reduced 6-month mortality among frail patients from 25% to 8%.
CLABSI vs. CRBSI: Catheter-related bloodstream infection (CRBSI) is a clinical/research definition requiring specific microbiological proof, while central line-associated bloodstream infection (CLABSI) is a surveillance definition for patients with a central line within 48 hours of infection.
Closed ICU Benefits: Standardizing care through a "closed unit" model, where an intensive care team assumes primary responsibility, has been shown to reduce ventilator-associated pneumonia by 52% and CLABSI by 25%.
CVC Site Selection: The subclavian vein is the preferred insertion site for reducing CLABSI risk, though it should be avoided in patients with end-stage renal disease to prevent subclavian stenosis.
Essential Insertion Technologies: Real-time two-dimensional ultrasound guidance for central venous catheter (CVC) placement significantly reduces mechanical complications and the number of failed cannulation attempts.
The CDC 5-Point Strategy: Critical measures for preventing infection during CVC insertion include hand hygiene, full sterile barrier precautions, use of 2% chlorhexidine, avoidance of the femoral site, and prompt removal of unnecessary catheters.
Advanced Maintenance Tools: Chlorhexidine-impregnated dressings, sutureless securement devices (SSDs), and passive disinfection caps are evidenced-based tools that further decrease the incidence of hub colonization and bloodstream infections.
STUDY GUIDE
I. Antithrombotic Therapy for Venous Thromboembolism (VTE)
The management of VTE disease is governed by evidence-based guidelines developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The latest CHEST guideline update addresses 17 PICO (Population, Intervention, Comparator, Outcome) questions.
Scope of Guidance: The report covers the spectrum of antithrombotic management, including initial therapy, secondary prevention, and risk reduction for postthrombotic syndrome.
Key Revisions: Eight guidance statements from the 2016 update were substantially modified, and four new statements were added to address gaps in prior editions.
Research Needs: Significant uncertainty remains regarding "limited disease" and special patient populations, indicating a need for continued clinical research.
II. Perioperative Management of Frail Patients
As the population ages, surgeons increasingly encounter senior patients with multiple comorbidities. Traditional surgical approaches for young, healthy patients are often inappropriate for this demographic.
The Risk Analysis Index (RAI): A 12-item screening tool designed to flag frailty in approximately 30 seconds. This identification allows for a "Surgical Pause" to re-evaluate the care plan.
Interdisciplinary Intervention: Once flagged, at-risk patients receive:
Prehabilitation: Preoperative exercises to improve physical and respiratory function, along with nutritional supplementation to increase physiologic reserve.
Goal Clarification: Structured conversations using "best case/worst case" scenarios to ensure the patient’s personal goals align with the likely surgical outcomes.
Modified Clinical Protocols: Use of narcotic-sparing regional anesthetics and systematic delirium assessments during recovery.
Implementation Outcomes: Beyond reducing mortality, the Surgical Pause has been adopted by over 50 VHA medical centers and earned the 2023 John M. Eisenberg Patient Safety and Quality Award.
III. Prevention of Central Line-Associated Bloodstream Infections (CLABSI)
Central venous catheters (CVCs) are essential for administering medications that cannot be given peripherally and for hemodynamic monitoring, but they are significant sources of morbidity and mortality in the ICU.
Infection Definitions:
CRBSI: Requires positive cultures from a catheter segment or simultaneous quantitative blood cultures showing a 3:1 ratio (CVC vs. peripheral).
CLABSI: A simplified surveillance definition identifying primary bloodstream infections in patients with a central line within 48 hours, where no other secondary source is obvious.
Site Selection and Technique:
Subclavian: Preferred for infection reduction.
Femoral: Generally avoided due to higher rates of infectious and thrombotic complications (e.g., deep venous thrombosis).
Ultrasound Guidance: Recommended for all placements to ensure successful cannulation on the first attempt, as multiple attempts increase complication risks.
Catheter Choice:
Lumen Count: Guidelines recommend using the minimum number of ports or lumens essential for patient management.
Impregnated Catheters: Catheters coated with antiseptics (chlorhexidine/silver sulfadiazine) or antibiotics (minocycline/rifampin) provide a 2% absolute risk reduction in CLABSI, primarily in high-risk settings like the ICU.
Maintenance and Securement:
Dressings: Chlorhexidine-impregnated dressings (e.g., Biopatch or Tegaderm CHG) significantly reduce catheter tip colonization.
Sutureless Securement Devices (SSDs): These use adhesives instead of sutures to prevent dislodgement, reducing the risk of localized skin infection and occupational needlestick injuries.
Disinfection Caps: Passive hub decontamination using alcohol-impregnated caps has been shown to reduce CLABSI rates more effectively than active "scrub the hub" techniques, which are prone to human error in duration (optimally 15 seconds).
Catheter Removal: The most effective strategy is the daily assessment and prompt removal of unnecessary lines. Scheduled replacement of catheters is not supported by evidence and may increase mechanical complications.
REFERENCES
Stevens SM, Woller SC, Baumann Kreuziger L, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest. 2021;160(6):e545-e608. doi:10.1016/j.chest.2021.07.055
Jacobs LM Jr. Easy-to-use screening tool can reduce postoperative mortality among frail patients. ACS Bulletin. May 8, 2024. Accessed November 20, 2024.
Bell T, O'Grady N. Prevention of central line-associated bloodstream infections. Infect Dis Clin North Am. 2017;31(3):551-559. doi:10.1016/j.idc.2017.05.007
52 min
September 222026 Core General Surgery Updates-Part 1 Overview
These collected sources establish a framework for modern surgical excellence by combining clinical protocols with ethical and administrative oversight. They offer specialized guidance on managing complex procedures, such as laparoscopic surgeries and organ transplants, while addressing patient safety through the prevention of infections and blood clots. Beyond technical skills, the literature emphasizes healthcare equity by examining racial disparities in cancer treatment and supporting minority researchers. Legal and ethical considerations are also prominent, covering topics from informed consent and end-of-life decision-making to the role of institutional review boards. Furthermore, the articles advocate for enhanced recovery pathways and the use of screening tools to minimize mortality in vulnerable populations. Together, these references serve as a comprehensive toolkit for improving clinical outcomes and maintaining high standards of professional conduct in the medical field.

DISCLAIMER
The Critical Edge is for educational and informational purposes only and is not intended to diagnose, treat, cure, or prevent any disease, nor does it substitute for professional medical advice, diagnosis, or treatment from a qualified healthcare provider—always seek in-person evaluation and care from your physician or trauma team for any health concerns.

MODERN CLINICAL GUIDELINES AND SURGICAL CARE STANDARDS: A COMPREHENSIVE STUDY GUIDE
TOP TEN TAKEAWAYS
Prioritization of Patient Frailty: Implementing easy-to-use screening tools for frailty can significantly reduce postoperative mortality by identifying high-risk patients before surgery.
Physician Duty and Human Dignity: The primary obligation of the physician is the interest of the patient, recognizing the unsurpassed value and dignity of every human life in every clinical decision.
Antithrombotic Precision: Updated guidelines emphasize tailored antithrombotic therapy for venous thromboembolism (VTE) and the careful perioperative management of direct oral anticoagulants (DOACs).
Infection Prevention: Central line-associated bloodstream infections (CLABSI) are largely preventable through strict adherence to evidence-based insertion and maintenance bundles.
Neuromuscular Safety: The 2023 ASA guidelines mandate quantitative monitoring and specific antagonism strategies to prevent residual neuromuscular blockade, protecting the intricate design of the respiratory system.
Ethical Decision-Making: Clear statutes and ethical frameworks are essential for identifying alternate decision-makers when a patient lacks capacity, ensuring the patient's prior wishes are respected.
Optimized Surgical Physiology: Low-pressure pneumoperitoneum and individualized pressure strategies in laparoscopic surgery help maintain innate immune homeostasis and improve recovery quality.
Enhanced Recovery (ERAS): Comprehensive protocols for colorectal surgery, including early mobilization and optimized nutrition, facilitate faster return to function.
Critical Analysis of Disparities: Observed differences in clinical outcomes among demographic groups must be rigorously analyzed to distinguish between systemic barriers and internal group variables such as geography, age distribution, and human capital.
Multidisciplinary Palliative Care: Integrating palliative care early in the treatment of life-limiting illnesses improves quality indicators at the end of life and ensures patients receive care aligned with their inherent dignity.
STUDY GUIDE
I. Preoperative Assessment and Frailty
The intricate design of the human body requires a robust physiological reserve to withstand the stress of surgery. Frailty serves as a critical indicator of diminished reserve. Research from the American College of Surgeons indicates that the use of simple screening tools can effectively identify frail patients, allowing for prehabilitation or modified surgical plans that can reduce postoperative mortality. This proactive approach honors the physician’s duty to protect the patient from foreseeable harm.
II. Perioperative Management and Physiology
Optimizing the surgical environment is essential for maintaining the body's homeostatic balance.
Neuromuscular Blockade: The American Society of Anesthesiologists (ASA) emphasizes the necessity of quantitative monitoring. Residual blockade poses a significant threat to the patient’s respiratory integrity; therefore, appropriate antagonism is a safety mandate.
Pneumoperitoneum Strategy: In laparoscopic colorectal surgery, the use of low-pressure pneumoperitoneum (compared to standard pressure) has been shown to better preserve innate immune homeostasis. Individualized pressure strategies are recommended to tailor the surgical environment to the patient’s specific physiological needs, minimizing the impact on the intricate design of the circulatory and respiratory systems.
Direct Oral Anticoagulants (DOACs): The management of medications like apixaban requires precise timing. Perioperative protocols must balance the risk of thromboembolism against the risk of surgical bleeding, always placing the patient’s survival and physical integrity at the forefront.
III. Clinical Ethics and Patient Advocacy
The foundational principles of clinical ethics—autonomy, beneficence, non-maleficence, and justice—are centered on the unsurpassed value of the individual.
Alternate Decision-Makers: When a patient is unable to make their own medical decisions, physicians must navigate state-specific statutes to identify legal surrogates. This ensures that care remains patient-centered even when the patient's voice is temporarily silenced.
Global Surgery Ethics: Surgeons operating in resource-limited settings must maintain the same high standards of ethical care and commitment to the patient’s best interests as they would in any other environment.
Research Ethics: The Institutional Review Board (IRB) serves as a vital safeguard in clinical research, ensuring that the quest for knowledge never supersedes the protection and dignity of the human subjects involved.
IV. Infection Control and Surgical Care
CLABSI Prevention: Prevention strategies for central line infections are a primary duty of the care team. This includes maximal sterile barrier precautions and regular assessment of line necessity.
Groin Hernia and Wound Closure: International guidelines for groin hernia management and the application of delayed primary closure in contaminated wounds demonstrate the importance of technical precision. Delayed primary closure allows the intricate design of the body’s inflammatory response to manage contamination before final skin apposition, reducing the risk of deep-seated infection.
V. Critical Analysis of Clinical Disparities
Current literature, such as studies on colon cancer outcomes in Latino Californians or racial disparities in gastrointestinal tract cancer, identifies significant differences in quality of care and clinical outcomes.
Critical Factual Analysis: While these reports often label differences as "disparities" (implying systemic inequity), it is necessary to ask if the data constitutes an honest reading or an assumption. For a "true disparity" to be confirmed, one must control for all variables.
Counterpoint Perspective: Observed differences in outcomes are not always the result of external bias. They may reflect "human capital" variables, including differences in median age between populations, geographical concentration in areas with different hospital tiers, or varying levels of specific technical experience within different communities. When these factors are not fully accounted for, the assertion of systemic disparity may lack a complete factual basis.
VI. Oncology and End-of-Life Care
The management of complex conditions, such as post-organ transplant hematologic cancers or early-stage breast cancer (utilizing gene expression assays), requires a highly individualized approach. Furthermore, as the physician’s chief duty is to the patient’s interests, the integration of palliative care is essential. Early palliative intervention is associated with higher quality-of-life indicators and ensures that the transition toward the end of life is handled with the utmost respect for the dignity of the human person.
VII. Patient Safety and Systems Improvement
Root Cause Analysis (RCA2) is a tool used to move beyond individual blame and identify systemic vulnerabilities. By preventing future harm, healthcare systems fulfill their collective obligation to protect the life and health of every patient who enters their care.

REFERENCES
Lenworth JM Jr. Easy-to-use screening tool can reduce postoperative mortality among frail patients. American College of Surgeons. Published May 8, 2024. Accessed November 27, 2024. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2024/may-2024-volume-109-issue-5/easy-to-use-screening-tool-can-reduce-postoperative-mortality-among-frail-patients/
Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17-28. doi:10.1159/000509119
Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report [published correction appears in Chest. 2022 Jul;162(1):269. doi: 10.1016/j.chest.2022.05.028]. Chest. 2021;160(6):e545-e608. doi:10.1016/j.chest.2021.07.055
Bell T, O'Grady NP. Prevention of central line-associated bloodstream infections. Infect Dis Clin North Am. 2017;31(3):551-559. doi:10.1016/j.idc.2017.05.007
Thilen SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: a report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology. 2023;138(1):13-41. doi:10.1097/ALN.0000000000004379
DeMartino ES, Dudzinski DM, Doyle CK, et al. Who decides when a patient can't? statutes on alternate decision makers. N Engl J Med. 2017;376(15):1478-1482. doi:10.1056/NEJMms1611497
Albers KI, Polat F, Helder L, et al. Quality of recovery and innate immune homeostasis in patients undergoing low-pressure versus standard-pressure pneumoperitoneum during laparoscopic colorectal surgery (RECOVER): a randomized controlled trial. Ann Surg. 2022;276(6):e664-e673. doi:10.1097/SLA.0000000000005491
Diaz-Cambronero O, Flor Lorente B, Mazzinari G, et al. A multifaceted individualized pneumoperitoneum strategy for laparoscopic colorectal surgery: a multicenter observational feasibility study. Surg Endosc. 2019;33(1):252-260. doi:10.1007/s00464-018-6305-y
Irani JL, Hedrick TL, Miller TE, et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2023;66(1):15-40. doi:10.1097/DCR.0000000000002650
Sunkara T, Ofori E, Zarubin V, Caughey ME, Gaduputi V, Reddy M. Perioperative management of direct oral anticoagulants (DOACs): a systemic review. Health Serv Insights. 2016;9(Suppl 1):25-36. doi:10.4137/HSI.S40701
Food and Drug Administration. ELIQUIS (apixaban) label. Published December 2012. Accessed January 2, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202155s000lbl.pdf
Agochukwu-Mmonu N, Chung KC. Ethics in global surgery. Hand Clin. 2019;35(4):421-427. doi:10.1016/j.hcl.2019.07.013
Capili B, Anastasi JK. Ethical research and the Institutional Review Board: an introduction. Am J Nurs. 2024;124(3):50-54. doi:10.1097/01.NAJ.0001008420.28033.e8
HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018;22(1):1-165. doi:10.1007/s10029-017-1668-x
ElHawary H, Covone J, Abdulkarim S, Janis JE. Practical review on delayed primary closure: basic science and clinical applications. Plast Reconstr Surg Glob Open. 2023;11(8):e5172. doi:10.1097/GOX.0000000000005172
Dawes AJ, Rajasekar G, Arnow KD, et al. Disparities in access, quality, and clinical outcome for Latino Californians with colon cancer. Ann Surg. Published online February 26, 2024. doi:10.1097/SLA.0000000000006251
Bakkila BF, Kerekes D, Nunez-Smith M, et al. Evaluation of racial disparities in quality of care for patients with gastrointestinal tract cancer treated with surgery. JAMA Netw Open. 2022;5(4):e225664. Published 2022 Apr 1. doi:10.1001/jamanetworkopen.2022.5664
Flores G, Mendoza FS, DeBaun MR, et al. Keys to academic success for under-represented minority young investigators: recommendations from the Research in Academic Pediatrics Initiative on Diversity (RAPID) National Advisory Committee. Int J Equity Health. 2019;18(1):93. doi:10.1186/s12939-019-0995-1
Dharnidharka VR. Comprehensive review of post-organ transplant hematologic cancers. Am J Transplant. 2018;18(3):537-549. doi:10.1111/ajt.14603
Hyams DM, Bareket-Samish A, Rocha JEB, et al. Selecting postoperative adjuvant systemic therapy for early-stage breast cancer: an updated assessment and systematic review of leading commercially available gene expression assays. J Surg Oncol. 2024;130(2):166-187. doi:10.1002/jso.27692
Mah SJ, Carter Ramirez DM, Schnarr K, Eiriksson LR, Gayowsky A, Seow H. Timing of palliative care, end-of-life quality indicators, and health resource utilization. JAMA Netw Open. 2024;7(10):e2440977. doi:10.1001/jamanetworkopen.2024.40977
Stelfox HT, Leigh JP, Dodek PM, et al. A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward. Intensive Care Med. 2017;43(10):1485-1494. doi:10.1007/s00134-017-4910-1
National Patient Safety Foundation. RCA2: improving root cause analyses and actions to prevent harm. Published June 16, 2015. Accessed January 10, 2025. https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm on 21 November 2024.
47 min

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Welcome to The Critical Edge, the podcast where cutting-edge trauma surgery and critical care research meets clear, actionable insight—curated by a Harvard-trained, AAST-certified trauma surgeon dual-boarded in Surgical Critical Care and General Surgery.

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