Adrian W. Ong

Trends in Central Line-Associated Bloodstream Infections in a Trauma-Surgical Intensive Care Unit

OBJECTIVEnTo report the impact of hospital-wide interventions on central line-associated bloodstream infection (CLABSI) rates in a 24-bed trauma-surgical intensive care unit.nnnDESIGNnData were gathered retrospectively from January 1, 2001, through June 30, 2009. Interventions to reduce CLABSI rates during this period included standardization of line insertion and maintenance processes, development of a mandatory education program incorporating practical line insertion simulation sessions, frequent audits, and intensive care unit staffing modifications. We used the χ(2) test and analysis of variance to analyze the data where appropriate.nnnSETTINGnUrban tertiary referral center providing level I trauma services.nnnPATIENTSnEight thousand four hundred eighty-one trauma-surgical intensive care unit admissions, of which 76% were owing to trauma.nnnRESULTSnDuring this period, the incidence of CLABSI declined from 6.1 to 0.3 per 1000 line-days. No CLABSIs occurred for 8 of the last 10 quarters (January 2007 to June 2009). Internal jugular sites were associated with a higher CLABSI rate than subclavian sites (Pxa0=xa0.03). The central line utilization ratio remained high for most of the study period. When compared with the 2006-2007 Centers for Disease Control and Prevention data, the trauma-surgical intensive care unit was at the 10th percentile in CLABSIs and at the 75th to 90th percentile in central line utilization ratios.nnnCONCLUSIONSnThe significant decline in the incidence of CLABSIs, which reflected the national trend, could be attributed to multiple interventions. The high central line utilization ratio compared with nationally available data represents a potential target for further improvement.

Characteristics and outcomes of trauma patients with ICU lengths of stay 30 days and greater: a seven-year retrospective study

IntroductionProlonged intensive care unit lengths of stay (ICU LOS) for critical illness can have acceptable mortality rates and quality of life despite significant costs. Only a few studies have specifically addressed prolonged ICU LOS after trauma. Our goals were to examine characteristics and outcomes of trauma patients with LOS ≥ 30 days, predictors of prolonged stay and mortality.MethodsAll trauma ICU admissions over a seven-year period in a level 1 trauma center were analyzed. Admission characteristics, pre-existing conditions and acquired complications in the ICU were recorded. Logistic regression was used to identify independent predictors of prolonged LOS and predictors of mortality among those with prolonged LOS after univariate analyses.ResultsOf 4920 ICU admissions, 205 (4%) had ICU LOS >30 days. These patients were older and more severely injured. Age and injury severity score (ISS) were associated with prolonged LOS. After logistic regression analysis, sepsis, acute respiratory distress syndrome, and several infectious complications were important independent predictors of prolonged LOS. Within the group with ICU LOS >30 days, predictors of mortality were age, pre-existing renal disease as well as the development of renal failure requiring dialysis. Overall mortality was 12%.ConclusionsThe majority of patients with ICU LOS ≥ 30 days will survive their hospitalization. Infectious and pulmonary complications were predictors of prolonged stay. Further efforts targeting prevention of these complications are warranted.

Starting the clock: defining nonoperative management of blunt splenic injury by time

BACKGROUNDnThere is no consensus when the designation of nonoperative management (NOM) for splenic injury (BSI) should start. We evaluated NOM success rates based on different time points after admission.nnnMETHODSnThe National Trauma Data Bank was evaluated for BSI for the year 2008. Observations were evaluated by facility, the time to splenectomy, and the volume of BSI admissions.nnnRESULTSnOf 15,732 BSIs identified, the overall splenectomy salvage rate was 81%. After the 5th hour, the NOM success rate was 95%. Multivariable analysis revealed that higher BSI grades, level 2 centers and community hospitals, and age ≥55 were associated with failed NOM.nnnCONCLUSIONSnThe grade of injury is an important predictor for failure of NOM. If a 5% failure rate is to be considered a benchmark, then the 5-hour time point after admission should be used for the calculation of NOM success rates.

The need for early angiography in patients with penetrating renal injuries

BackgroundRenal injuries occur in as many as 10% of penetrating abdominal wounds. Today, these wounds are often managed selectively, but there is little contemporary information on the natural history of kidney injuries after penetrating trauma. The purpose of this study was to examine the clinical outcomes of penetrating injuries to the kidney, and to determine if these patients may benefit from routine early angiography.MethodsAll trauma patients admitted to three Level I Trauma Centers with penetrating renal injuries over a 10xa0year study period were retrospectively reviewed.ResultsWe identified 237 patients with a penetrating renal injury, of whom 39 died within the first 24xa0h and were excluded from analysis. Among the remaining 198 individuals, 130 (66%) underwent immediate exploratory laparotomy. Of the 68 subjects not undergoing immediate surgery, seven had early angiography. The remaining 61 patients (31%) were observed, with 12 (20%) ultimately requiring an intervention to treat the renal injury. Those subjects who failed nonoperative management had significantly fewer hospital-free days compared to those who did not need a procedure (19.2xa0±xa08.1 vs. 25.7xa0±xa04.5, pxa0=xa00.002).ConclusionsNearly one in three patients with penetrating renal injuries are currently managed with serial observation, although one in five of these subjects ultimately require either angiographic or surgical treatment. We feel that routine use of early angiography may reduce the failure rate and improve outcomes for patients whose penetrating renal injuries are managed nonoperatively.

Do simple beside lung function tests predict morbidity after rib fractures

BACKGROUNDnWe evaluated if incentive spirometry volume (ISV) and peak expiratory flow rate (PEFR) could predict acute respiratory failure (ARF) in patients with rib fractures.nnnMETHODSnNormotensive, co-operative patients were enrolled prospectively. ISV and PEFR were measured on admission, at 24xa0h and at 48xa0h by taking the best of three readings each time. The primary outcome, ARF, was defined as requiring invasive or noninvasive positive pressure ventilation.nnnRESULTSn99 patients were enrolled (median age, 77 years). ARF occurred in 9%. Of the lung function tests, only a low median ISV at admission was associated with ARF (500xa0ml vs 1250xa0ml, pxa0=xa00.04). Three of 69 patients with ISV of ≥1000xa0ml versus six of 30 with ISV <1000xa0ml developed ARF (pxa0=xa00.01). Other significant factors were: number of rib fractures, tube thoracostomy, any lower-third rib fracture, flail segment.nnnCONCLUSIONnPEFR did not predict ARF. Admission ISV may have value in predicting ARF.

Trauma surgeon utilization of computerized tomography scanning: Room for improvement?

BACKGROUNDnWe aimed to evaluate computerized tomography (CT) utilization and yield rates for trauma team activations (TTA).nnnMETHODSnA retrospective review of all TTAs was conducted over nine months. TTAs consisted of two levels--trauma alert (TAL) and trauma response (TR). Yields of CT for significant findings (SF) for four CT types (brain, cervical, chest, abdomen/pelvis) were recorded.nnnRESULTSn647 patients were included. There was no difference in the utilization rates of CTs except for brain CTs (TAL, 98% vs TR, 94%, pxa0=xa00.008). There was no difference in the yield rates except for cervical spine CTs (TAL, 8% vs TR, 4%, pxa0=xa00.03). Over 80% received a pan scan regardless of TTA level; 63% who had any CT had no SF. The median ratio of scans with SF to the total number of scans per patient was 0.nnnCONCLUSIONSnRegardless of activation level, CT seems to be over utilized. More selective use of CT should be evaluated.

1579: NONOPERATIVE SPLENIC INJURY MANAGEMENT IN THE SETTING OF ANTICOAGULATION AND ANTIPLATELET THERAPY

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Patients on pre-injury anti-coagulation (AC) therapy present challenges for the trauma provider, as these patients have a reported increase in mortality following injury. There are suspected similar outcomes for patients on antiplatelet (AP) therapy, although the data is conflicting. The management of blunt splenic injuries has evolved over the last several years, to a shift away from operative intervention, and an increased use of splenic embolization (SE) for injuries deemed to be low-risk for failure of non-operative management (FNOM). We sought to examine the effects of AC/AP medications in the setting of blunt traumatic splenic injuries and rate of FNOM. Our hypothesis was that in patients following SE, pre-injury AC/AP therapy would be associated with a higher rate of FNOM. Methods: We performed a five-year registry review of our trauma database at our level II trauma center that evaluates over 2,500 injured patients annually. Our patient population is older (median age 57), with predominately blunt mechanisms of injury (94.4%). All patients with traumatic splenic injuries were included, and FNOM was defined as the need for unplanned splenectomy following SE. Results: From February 2012 to January 2017, a total of 196 patients with splenic injuries were identified, of which 39 patients underwent SE. For the SE cohort, the median (interquartile range [IQR]) age was 40 (25–59) years, and median (IQR) Injury Severity Score was 22 (17–30). All but one patient had a blunt mechanism of injury. Nine (23%) were on AC/AP therapy. There was no difference in the rate of FNOM after SE for patients not on AC/ AP vs. those on AC/AP therapy (3 of 30 [10%] vs. 3 of 9 [33%], p = 0.3, Fisher Exact test). Conclusions: Our findings represent a specific subset of patients at higher risk for FNOM following SE. The results are inconclusive despite our intuition that patients without intact clotting pathways would be at greater risk for FNOM. Although this is a singlecenter study with a small sample size, research on this clinically challenging population should be continued, particularly in the era of the aging of the trauma patient and the increased utilization of AC/AP agents.

Availability and use of hemostatic agents in prehospital trauma patients in Pennsylvania translation from the military to the civilian setting

Objective To understand the translation of one innovation in trauma care from the military to the civilian setting, the adoption of topical hemostatic agents in the Emergency Medical Services (EMS) community and in Trauma Centers in Pennsylvania. Method We utilized an anonymous electronic survey of EMS Agency Administrative Officers and Trauma Center Coordinators. Results We received responses from 23% (93/402) Advanced Life Support and Air Medical agencies in the State. Of the EMS agencies that responded, 46.6% (61/131) stock hemostatic products, with 55.5% (44/79) carrying QuickClot® Combat Gauze®. Of the agencies that carried hemostatic products, 50% utilized them at least once in the prior 6 months and 59% over the past 12 months. Despite the infrequent number of applications, prehospital providers ranked themselves as somewhat skilled and comfortable both with the application of the products and the indications for their use. Conclusion Our survey found that 46.6% of the respondents indicated they carry hemostatic products, a much greater number than found on prior surveys of EMS agencies. There is a steady acceptance by EMS of new innovations in trauma care although more work is needed in translating the exact role of hemostatic agents in the civilian setting.

Is it safe to discharge geriatric trauma patients with anemia

INTRODUCTIONnThe consequences of discharging anemic geriatric trauma patients are not well studied. We hypothesize that anemia at discharge is associated with adverse outcomes.nnnMETHODSnA 1-year retrospective review of patients ≥65 years was performed. Hemoglobin levels at admission (HbA), discharge (HbD) and the lowest inpatient level (HbL) were recorded. Severity of anemia was categorized as mild (Hbxa0≥xa010.0xa0g/dl), moderate (Hbxa0<xa010.0 andxa0≥xa08.5xa0g/dl) and severe (Hbxa0<xa08.5xa0g/dl). The study endpoint was death or unplanned readmission 60 days following discharge. Univariate and multivariable analysis were used to determine if anemia predicted the outcome. A p value of 0.05 was considered significant.nnnRESULTSn550 patients were included. Moderate and severe anemia for HbA each predicted the study endpoint. Both HbD and HbL were highly correlated with HbA but did not predict the study endpoint.nnnCONCLUSIONnThe degree of discharge anemia was not predictive of 60-day mortality or unplanned admissions in geriatric trauma patients.