Alicia Mangram

Is there a difference in efficacy, safety, and cost-effectiveness between 3-factor and 4-factor prothrombin complex concentrates among trauma patients on oral anticoagulants?

PURPOSEnThe aim of this study was to compare the efficacy, safety, and cost-effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) vs 4-factor prothrombin complex concentrate PCC (4F-PCC) in trauma patients requiring reversal of oral anticoagulants.nnnMATERIALS AND METHODSnAll consecutive trauma patients with coagulopathy (international normalized ratio [INR] ≥1.5) secondary to oral anticoagulants who received either 3F-PCC or 4F-PCC from 2010 to 2014 at 2 trauma centers were reviewed. Efficacy was determined by assessing the first INR post-PCC administration, and successful reversal was defined as INR less than 1.5. Safety was assessed by reviewing thromboembolic events, and cost-effectiveness was calculated using total treatment costs (drug acquisition plus transfusion costs) per successful reversal.nnnRESULTSnForty-six patients received 3F-PCC, and 18 received 4F-PCC. Baseline INR was similar for 3F-PCC and 4F-PCC patients (3.1 ± 2.3 vs 3.4 ± 3.7, P = .520). The initial PCC dose was 29 ± 9 U/kg for 3F-PCC and 26 ± 6 U/kg for 4F-PCC (P = .102). The follow-up INR was 1.6 ± 0.6 for 3F-PCC and 1.3 ± 0.2 for 4F-PCC (P = .001). Successful reversal rates in patients were 83% for 4F-PCC and 50% for 3F-PCC (P = .022). Thromboembolic events were observed in 15% of patients with 3F-PCC vs 0% with 4F-PCC (P = .177). Cost-effectiveness favored 4F-PCC (

Trauma-associated pneumonia: time to redefine ventilator-associated pneumonia in trauma patients

5382 vs

Geriatric trauma hip fractures: is there a difference in outcomes based on fracture patterns?

3797).nnnCONCLUSIONSnThree-factor PCC and 4F-PCC were both safe in correcting INR, but 4F-PCC was more effective, leading to better cost-effectiveness. Replacing 3F-PCC with 4F-PCC for urgent coagulopathy reversal may benefit patients and institutions.

The impact of pre-injury direct oral anticoagulants compared to warfarin in geriatric G-60 trauma patients

BACKGROUNDnThe high prevalence of ventilator-associated pneumonia (VAP) in trauma patients has been reported in the literature, but the reasons for this observation remain unclear. We hypothesize that trauma factors play critical roles in VAP etiology.nnnMETHODSnIn this retrospective study, 1,044 ventilated trauma patients were identified from December 2010 to December 2013. Patient-level trauma factors were used to predict pneumonia as study endpoint.nnnRESULTSnNinety-five of the 1,044 ventilated trauma patients developed pneumonia. Rib fractures, pulmonary contusion, and failed prehospital intubation were significant predictors of pneumonia in a multivariate model.nnnCONCLUSIONSnIt is time to redefine VAP in trauma patients based on the effect of rib fractures, pulmonary contusions, and failed prehospital intubations. The Centers for Disease Control and Prevention definition of VAP needs to be modified to reflect the effect of trauma factors in the etiology of trauma-associated pneumonia.

Preperitoneal surgery using a self-adhesive mesh for inguinal hernia repair.

BackgroundAnnually in the US, there are over 300,000 hospital admissions due to hip fractures in geriatric patients. Consequently, there have been several large observational studies, which continue to provide new insights into differences in outcomes among hip fracture patients. However, few hip fracture studies have specifically examined the relationship between hip fracture patterns, sex, and short-term outcomes including hospital length of stay and discharge disposition in geriatric trauma patients.MethodsWe performed a retrospective study of hip fractures in geriatric trauma patients. Hip fracture patterns were based on ICD -9 CM diagnostic codes for hip fractures (820.00-820.9). Patient variables were patient demographics, mechanism of injury, injury severity score, hospital and ICU length of stay, co-morbidities, injury location, discharge disposition, and in-patient mortality.ResultsA total of 325 patient records met the inclusion criteria. The mean age of the patients was 82.2xa0years, and the majority of the patients were white (94%) and female (70%). Hip fractures patterns were categorized as two fracture classes and three fracture types. We observed a difference in the proportion of males to females within each fracture class (Femoral neck fractures Z-scoreu2009=u2009-8.86, pu2009<u20090.001, trochanteric fractures Z-scoreu2009=u2009-5.63, pu2009<u20090.001). Hip fractures were fixed based on fracture pattern and patient characteristics. Hip fracture class or fracture type did not predict short-term outcomes such as in-hospital or ICU length of stay, death, or patient discharge disposition. The majority of patients (73%) were injured at home. However, 84% of the patients were discharged to skilled nursing facility, rehabilitation, or long-term care while only 16% were discharged home. There was no evidence of significant association between fracture pattern, injury severity score, diabetes mellitus, hypertension or dementia.ConclusionsHip fracture patterns differ between geriatric male and female trauma patients. However, there was no significant association between fracture patterns and short-term patient outcomes. Further studies are planned to investigate the effect of fracture pattern and long-term outcomes including 90-day mortality, return to previous levels of activity, and other quality of life measures.

Geriatric (G60) trauma patients with severe rib fractures: Is muscle sparing minimally invasive thoracotomy rib fixation safe and does it improve post-operative pulmonary function?

PurposePre-injury oral anticoagulants are associated with worse outcomes in geriatric (G-60) trauma patients, but there are limited data comparing warfarin with direct oral anticoagulants (DOAC). We sought to compare outcomes in G-60 trauma patients taking pre-injury DOACs vs. warfarin.MethodsAll trauma patients, age ≥60 who were admitted to the hospital and taking an oral anticoagulant pre-injury were retrospectively identified. Patients were excluded if their reason for admission was a suicide attempt or penetrating extremity injury. Outcome measures included blood transfusions, hospital LOS, and mortality. A second analysis was performed, whereby patients were matched using ISS and age.ResultsThere were 3,941 patients identified; 331 had documentation of anticoagulant use, pre-injury (warfarin, nu2009=u2009237; DOAC, nu2009=u200994). Demographics were similar, but ISS [9 (4–13) vs. 8 (4–9), pu2009=u2009.027], initial INR [2.2 (1.8–2.9) vs. 1.2 (1.1–1.5), pu2009<u2009.001], and the use of pharmacologic reversal agents (48 vs. 14%, pu2009<u2009.001) were higher in the warfarin group. There was no difference in the use of blood transfusions (24 vs. 17%, pu2009=u2009.164) or mortality (5.9 vs. 4.3%, pu2009=u2009.789) between warfarin and DOAC groups, respectively. However, LOS was longer in the warfarin group [5 (3–7.5) vs. 4 (2–6.3) days, pu2009=u2009.02]. Matched analysis showed no difference in blood transfusions (23 vs. 17%, pu2009=u2009.276), mortality (2.1 vs. 4.3%, pu2009=u2009.682) or LOS [5 (3–7) vs. 4 (2–6.3) days, pu2009=u2009.158] between warfarin and DOAC groups, respectively.ConclusionPre-injury DOACs are not associated with worse clinical outcomes compared to warfarin in G-60 trauma patients. Higher use of pharmacologic reversal agents with warfarin may be related to differences in mechanism of action and effect on INR.

Stress Ulcer Prophylaxis in Neurocritical Care

Background and Objectives: Laparoscopic preperitoneal hernia repair with mesh has been reported to result in improved patient outcomes. However, there are few published data on the use of a totally extraperitoneal (TEP) approach. The purpose of this study was to present our experience and evaluate early outcomes of TEP inguinal hernia repair with self-adhesive mesh. Methods: This cohort study was a retrospective review of patients who underwent laparoscopic TEP inguinal hernial repair from April 4, 2010, through July 22, 2014. Data assessed were age, sex, body mass index (BMI), hernia repair indications, hernia type, pain, paresthesia, occurrence (bilateral or unilateral), recurrence, and patient satisfaction. Descriptive and regression analyses were performed. Results: Six hundred forty patients underwent laparoscopic preperitoneal hernia surgery with self-adhesive mesh. The average age was 56 years, nearly all were men (95.8%), and the mean BMI was 26.2 kg/m2. Cases involved primary hernia more frequently than recurrent hernia (94% vs 6%; P < .05). After surgery, 92% of the patients reported no more than minimal pain, <1% reported paresthesia, and 0.2% had early recurrence. There were 7 conversions to an open procedure. The patients had no adverse reactions to anesthesia and no bladder injury. Postoperative acute pain or recurrence was not explained by demographics, BMI, or preoperative pain. There were significant associations of hernia side, recurrence, occurrence, and sex with composite end points. Nearly all patients (98%) were satisfied with the outcome. Conclusion: The use of self-adhesive, Velcro-type mesh in laparoscopic TEP inguinal hernia repair is associated with reduced pain; low rates of early recurrence, infection, and hematoma; and improved patient satisfaction.

Severe Traumatic Brain Injury: A Case Report

BACKGROUNDnPatient outcomes after muscle sparing minimally invasive thoracotomy rib fixation (MSMIT-ORF) in geriatric G60 trauma patients remain poorly studied. This study determined the effect of MSMIT-ORF on pulmonary function (PFT). Non-operatively managed (NOM) patients were also described.nnnMETHODSnMedical records of G60 patients with severe rib fractures with PFTs measured before and after MSMIT-ORF were examined. Patient outcomes (MSMIT-ORF vs NOM) were adjusted in a multivariate logistic regression model.nnnRESULTSn64 patients underwent MSMIT-ORF, 135 were NOM patients. MSMIT-ORF treated patients showed improvements in PFTs on postoperative day 5, pu202f=u202f0.001. After adjustment analysis, MSMIT-ORF was associated with increased hospital length of stay (OR 44.9; 95% CI, 9.8-205, pu202f<u202f0.001), but a more favorable discharge disposition. There was no difference in the rates of pneumonia (pu202f=u202f0.996) or death (pu202f=u202f0.140).nnnCONCLUSIONSnMSMIT-ORF is safe and improves pulmonary function in G60 trauma patients diagnosed with severe rib fractures. Future randomized control studies are needed for confirmation.

General Evaluation, Risk Management, and Goals of Care

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today’s standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

Bilateral Pneumothoraces in a Trauma Patient After Dobhoff Tube Insertion

Patient: Male, 28 Final Diagnosis: Closed head injury Symptoms: Bilateral mydriasis • coma Medication: — Clinical Procedure: Ventriculostomy and hemicraniectomy Specialty: Neurology Objective: Unusual clinical course Background: Traumatic brain injury remains a challenging and complicated disease process to care for, despite the advance of technology used to monitor and guide treatment. Currently, the mainstay of treatment is aimed at limiting secondary brain injury, with the help of multiple specialties in a critical care setting. Prognosis after TBI is often even more challenging than the treatment itself, although there are various exam and imaging findings that are associated with poor outcome. These findings are important because they can be used to guide families and loved ones when making decisions about goals of care. Case Report: In this case report, we demonstrate the unanticipated recovery of a 28-year-old male patient who presented with a severe traumatic brain injury after being in a motorcycle accident without wearing a helmet. He presented with several exam and imaging findings that are statistically associated with increased mortality and morbidity. Conclusions: The care of severe traumatic brain injuries is challenging and dynamic. This case highlights the unexpected recovery of a patient and serves as a reminder that there is variability among patients.