Akella Chendrasekhar

Rectal pH measurement in tracking cardiac performance in a hemorrhagic shock model.

OBJECTIVE AND DESIGN We evaluated the utility of rectal mucosal pH measurement for tracking cardiac performance in hemorrhagic shock as compared with gastric tonometry. MATERIALS AND METHODS Hemorrhagic shock was induced in five adult swine to a mean arterial pressure of 45-65 mm Hg. Hypotension was maintained for 30 minutes, resuscitation was accomplished with the shed blood and lactated Ringers solution (3x blood volume). Gastric tonometry, rectal pH, and oxygen transport data were obtained at baseline, 0, and 30 minutes after onset of hypotension and after resuscitation. RESULTS Intramucosal pH readings from gastric tonometry and rectal mucosal pH both showed a significant change from baseline to 0 and 30 minutes after onset of hypotension. Data after resuscitation were found to be statistically the same as baseline values. CONCLUSIONS Rectal mucosal pH tracks cardiac performance as well as does gastric tonometry in hemorrhagic shock without as many limitations.

Systemic inflammatory response syndrome and platelet count ≥250×10 9 are associated with venous thromboembolic disease

Introduction Prior research has demonstrated that platelet count and inflammation are dominant contributors to hypercoagulability. Our objective is to determine whether elevated platelet count and systemic inflammatory response syndrome (SIRS) have an association with the development of venous thromboembolism (VTE) in hospitalized patients with a high clinical index of suspicion for thromboembolic disease. Methods We performed a retrospective medical record review of 844 medical and surgical patients with suspected VTE hospitalized from July 2012 to May 2013 who underwent screening by venous duplex and computed tomography pulmonary angiogram. For our purposes, thrombocytosis was arbitrarily defined as platelet count ≥250×109/L. Results Venous thromboembolic disease was detected in 229 patients (25.9%). Thrombocytosis was present in 389 patients (44%) and SIRS was present in 203 patients (23%) around the time of imaging. Thrombocytosis and SIRS were positively correlated with VTE (P<0.001). There was no correlation between thrombocytosis and SIRS. Multivariate analysis revealed that SIRS (odds ratio 1.91, 95% confidence interval 1.36–2.68, P<0.001) and thrombocytosis (odds ration 1.67, 95% confidence interval 1.23–2.26, P=0.001) were independently associated with VTE. Conclusion Patients at high risk for VTE should be routinely assessed for thrombocytosis (≥250×109/L) and SIRS; if either is present, consideration for empiric anticoagulation should be given while diagnostic imaging is undertaken.

Correlation of Doppler derived velocity change with cardiac index.

Doppler ultrasound may be used as a screen to determine the need for placement of a pulmonary artery catheter. We tested the utility of Doppler derived acceleration, in correlation with pulmonary artery catheter derived cardiac index, as a screen for pulmonary artery catheter placement in 40 trauma patients. We found the expected quadratic relationship between acceleration and cardiac index. We also found that acceleration less than 200 cm/s2 correlates well with cardiac index less than 3.0 liter/min/m2.

Venous thromboembolism risk assessments on trauma patients has suboptimal interobserver reliability among inexperienced clinicians (fourth-year medical students)

Background Venous thromboembolic disease is a major cause of morbidity and mortality in hospitalized patients worldwide. The objective of this study is to compare interobserver reliability for qualitative and quantitative venous thromboembolism (VTE) risk assessments in hospitalized trauma patients. Methods We conducted a retrospective medical record review of 40 randomly selected trauma patients admitted to a 448-bed urban level-I trauma center from January 2013 to January 2014. Interclass correlation coefficient (ICC) was calculated based on a two-way mixed model. The sample was equally distributed between patients admitted to the floor and the intensive care unit (ICU). Eight fourth-year medical students performed the risk assessments by the medical record. Two forms for risk assessment were used: a qualitative screening and a quantitative screening. The composite of intraobserver and interobserver variabilities was determined. Results The ICC for qualitative VTE risk assessments was 0.845 and for quantitative VTE risk assessment was 0.628. Conclusion To optimize accuracy of VTE risk stratification and appropriate prophylaxis, medical students and first-year residents should be formally trained to perform quantitative assessments.

1599: CONCOMITANT CHEST INJURY IN HEAD-INJURED PATIENTS ASSOCIATED WITH INCREASED MORBIDITY AND MORTALITY

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Traumatic Brain Injury (TBI) is the most common cause of death among trauma patients. Although isolated injury is well characterized in the literature, patients commonly present with combined injury. At our level 1 trauma center, we compared outcomes in patients with isolated head injury versus patients with head and chest injury. Methods: A retrospective data analysis was performed comparing patients with isolated head injury with patients with combined head and chest injury. Data obtained included age, Injury Severity Score (ISS), Revised Trauma Score (RTS), development of pneumonia, Hospital Length of Stay, ICU length of stay, ventilator days, and survival. Data were analyzed with one-way analysis of variance (ANOVA). Results: 199 patients were enrolled with average injury severity over 3, 99 with isolated head injury, 100 with combined head and chest injury. Mean age (years) of individuals with isolated head trauma was greater (53.8 vs. 45.8, 0.185). Overall complication rates were found to be greater in patients with combined injury with regard to incidence of pneumonia development (14% vs. 39%, p < 0.0001), hospital length of stay (days) (6.4 vs. 10.3, p = 0.01), ICU length of stay (days) (3.1 vs. 6.2, p = 0.006), ventilator days (1.3 vs. 4.2, p = 0.0006), and survival to hospital discharge (96.9% vs. 86.0%, p = 0.0142). Difference in ISS (p = 0.0615) and RTS (0.1647) were insignificant. Conclusions: Patients with combined head and chest injury had worse worse in-hospital morbidity including development of pneumonia, hospital length of stay, ICU length of stay, ventilator days and greater mortality than patients with isolated head trauma.

Older patients have increased risk of poor outcomes after low-velocity pedestrian–motor vehicle collisions

Background Motor vehicle collisions (MVCs) are a leading cause of injury in the US. While the probability of collision with a pedestrian (PMVC) has declined in recent years, the probability of a pedestrian fatality has risen. Our objective was to determine whether older age impacts potential outcomes in patients involved in low-velocity PMVCs. Materials and methods We performed a retrospective-cohort study of adult patients aged >14 years involved in low-velocity pedestrian–MVCs (<15 miles per hour [24.14 km/h]), presenting to an urban level I trauma center from January to November 2013. Subjects were identified via trauma registry and stratified: ages 15–49 years and ≥50 years. Electronic medical records were reviewed for demographics, vital signs, and laboratory results on initial presentation, presence or absence of systemic inflammatory response syndrome (SIRS), shock index (SI), injury-severity score (ISS), length of stay (LOS), and survival to discharge. For statistical analysis, χ2 or Student’s t-tests were utilized. Results Our study included 145 patients (77 female) with a mean age of 41.9±3 years; 95 patients were aged 15–49 years (mean 31.9±2.2 years), and 50 patients were aged ≥50 years or older (mean 62.44±2.9 years). Mean ISS was 10.05±1.95, mean SI was 0.68±0.03, and mean LOS was 3.67±0.57 days. A total of 41 patients met SIRS criteria on arrival, and nine patients expired (6.2%). Mean ISS (15.64±4.42 vs 7.1±1.64, P<0.001) and mean SI (0.75±0.07 vs 0.65±0.03, P=0.002) were higher in patients aged ≥50 years. Mean LOS was longer in older patients (5.22±1.14 vs 2.85±0.58 days, P<0.001). Older age was associated with SIRS on arrival (P=0.023) and associated with mortality (P=0.004). Conclusion Age ≥50 years is associated with greater severity of injury and poor outcomes for patients involved in low-velocity PMVCs. Increased clinical attention and resource allocation should be directed toward older patients after low-velocity PMVCs.

Pyomyositis in the setting of complicated diverticulitis: case report

Pyomyositis is typically thought of as a disease of the tropics. However, it is becoming more prevalent in temperate regions, and may be underdiagnosed. Here, pyomyositis is encountered as a complication of perforated diverticulitis, which has not been previously reported. A 61-year-old Caucasian man initially presented in respiratory distress and was diagnosed with respiratory failure due to COPD exacerbation. The patient was taking high-dose prednisone, 60 mg daily for the past 2 years. Initially, he was afebrile, normotensive, tachycardic to 178 beats/minute and tachypneic to 28 breaths/minute, requiring noninvasive ventilation to maintain oxygenation. Blood tests revealed leukocytosis of 16.7×103/μL, and blood cultures grew Escherichia coli. Broad-spectrum antibiotics were started but leukocytosis and bacteremia persisted on repeated tests. On the seventh hospital day, a CT scan of the abdomen was performed for complaints of abdominal pain, and the patient was diagnosed with Hinchey stage 3 diverticulitis. A Hartmann’s procedure was performed with intraoperative findings of purulent peritonitis. Intraoperative cultures grew E. coli and vancomycin-resistant Enterococcus faecium. The patient continued to have leukocytosis of 15.1×103/μL despite surgical therapy. He began to complain of left lower extremity pain, and a CT scan on hospital day 24 revealed gluteal intramuscular abscesses, which were percutaneously drained. Persistent symptoms prompted another CT scan on hospital day 28, which revealed additional intramuscular abscesses in the vastus lateralis muscle, which was also drained, with subsequent resolution of pain and normalization of inflammatory markers. This is the first case demonstrating pyomyositis as a complication of diverticulitis. While the mechanism of pyomyositis may not be unique, it is important to recognize the potential complications of frequently encountered diseases. In this critically ill and immunosuppressed patient, there was delayed diagnosis of both diverticulitis and pyomyositis, but the patient quickly improved once the diseases were recognized and treated.

Initial Prealbumin Level and Ability to Normalize Prealbumin Are Highly Predictive of Increased Mortality and Morbidity in Elderly Trauma Patients

Prealbumin is a well characterized indicator of nutritional status more recently found to be an inverse inammatory marker. At our urban level 1 trauma center, we sought to study the relationship between malnutrition and outcomes in elderly trauma patients. Using prealbumin as a surrogate marker for nutritional status, we hypothesized that patients with reduced prealbumin on initial evaluation have worse outcomes, and in patients where initial prealbumin that was reduced, ability to correct is associated with improved outcomes. We performed a retrospective cohort study involving 200 consecutive patients over the age of 65 admitted to our trauma service. Based on initial prealbumin, patients were divided into 3 groups below 5 mg/dL, 5-10 mg/dL and greater than 10 mg/dL. Prealbumin was then re-assessed 4 days after admission and patients were again divided into 2 groups based on ability to normalize prealbumin. Data obtained included age, gender, revised trauma score (RTS), injury severity score (ISS), days on a ventilator, ICU length of stay (ICU-LOS), hospital length of stay (HLOS), survival, initial prealbumin, and ability to correct prealbumin within 4 days after admission. Of the 200 patients enrolled, patients were divided into 3 groups using initial prealbumin 71 patients below 5 mg/dL, 101 patients 5-10 mg/dL, and 28 patients greater than 10 mg/dL. There were 180 patients who were hospitalized for over a 4 day period. Normalization of prealbumin was achieved in 128 patients while 52 patients did not. Mean age was 79.2 years. RTS was found to be decreased in patients with initial prealbumin below 5 mg/dL in comparison to the other groups (11.3 vs. 11.8 vs. 11.8, p = 0.0002), with greater ISS (25.1 vs. 18.8 vs. 19.7, p < 0.0001), ICU LOS (days) (11.3 vs. 3.9 vs. 3.0, p < 0.0001), ventilator days (7.9 vs. 0.8 vs. 0.1, p < 0.0001), HLOS (days) (17.4 vs 7.8 vs. 7.1, p < 0.0001) and decreased survival (66% vs. 95% vs. 100%, p < 0.0001). Patients with prealbumin corrected within 4 days had lower ISS (19.9 vs. 29.2, p < 0.0001), as well as reduction in ventilator days (0.9 vs. 10.1, p < 0.0001), ICU LOS (days) (4.2 vs. 13.8, p < 0.0001), HLOS (days) (8.3 vs. 21.3, p < 0.0001) and improved survival (94% vs. 63%, p < 0.0001). Prealbumin is able to provide short term information regarding current nutritional status and response to therapy. Recent evidence suggest prealbumin may be a prognostic indicator for risk of malnutrition and inammation in critically ill trauma patients. In management of critically ill trauma patients, prealbumin can provide a valuable clinical indication of response to therapeutic intervention and potentially guide management strategy.

Evolution of venous thromboembolism risk assessment in trauma and surgical patients

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Bullet to the femoral head

A bullet being lodged in the femoral head is a unique trauma situation, which can be managed either operatively or non-operatively. We present two different scenarios of a bullet being lodged in the femoral head with a discussion of both operative and non-operative manage- ment as well as diagnostic considerations.