Bradley M. Dennis

Safety of Bedside Percutaneous Tracheostomy in the Critically Ill: Evaluation of More than 3,000 Procedures

BACKGROUND Bedside percutaneous dilational tracheostomy has been demonstrated to be equivalent to open tracheostomy. At our institution, percutaneous dilational tracheostomy without routine bronchoscopy is our preferred method. My colleagues and I hypothesized that our 10-year percutaneous dilational tracheostomy experience would demonstrate that the technique is safe with low complication rates, even in obese patient populations. STUDY DESIGN We conducted a retrospective review of all bedside percutaneous dilational tracheostomy performed by the Division of Trauma and Surgical Critical Care faculty from 2001 to 2011, excluding patients younger than 18 years of age. All major airway complications and procedure-related deaths were evaluated during the early (≤48 hours postprocedure), intermediate (in hospital), and late (after discharge) periods. Incidence of post-tracheostomy stenosis was also evaluated. RESULTS There were 3,162 percutaneous dilational tracheostomies performed during the study period. Mean body mass index was 28 (16% with body mass index ≥35), mean Injury Severity Score was 32, and mean APACHE II score was 19. Major airway complications occurred in 12 (0.38%) patients, accounting for 5 (0.16%) deaths. Early major complications included 3 airway losses and 1 bleeding event requiring formal exploration with procedure-related deaths occurring in 3 patients. Intermediate major complications included 2 tube occlusion/dislodgement events with 2 related deaths. Late complications included 5 (0.16%) cases of tracheal stenosis requiring intervention without associated deaths. CONCLUSIONS Bedside percutaneous dilational tracheostomy is safe across a broad critically ill patient population. The safety of this technique, even in the obese population, is demonstrated by its low complication rate. Routine bronchoscopic guidance is not necessary. Specially trained procedure nurse and process improvement programs contribute to the safety and efficacy of this procedure.

Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions.

BACKGROUND Concerted management of the traumatic hemothorax is ill-defined. Surgical management of specific hemothoraces may be beneficial. A comprehensive strategy to delineate appropriate patients for additional procedures does not exist. We developed an evidence-based algorithm for hemothorax management. We hypothesize that the use of this algorithm will decrease additional interventions. METHODS A pre-/post-study was performed on all patients admitted to our trauma service with traumatic hemothorax from August 2010 to September 2013. An evidence-based management algorithm was initiated for the management of retained hemothoraces. Patients with length of stay (LOS) less than 24 hours or admitted during an implementation phase were excluded. Study data included age, Injury Severity Score, Abbreviated Injury Scale chest, mechanism of injury, ventilator days, intensive care unit (ICU) LOS, total hospital LOS, and interventions required. Our primary outcome was number of patients requiring more than 1 intervention. Secondary outcomes were empyema rate, number of patients requiring specific additional interventions, 28-day ventilator-free days, 28-day ICU-free days, hospital LOS, all-cause 6-month readmission rate. Standard statistical analysis was performed for all data. RESULTS Six hundred forty-two patients (326 pre and 316 post) met the study criteria. There were no demographic differences in either group. The number of patients requiring more than 1 intervention was significantly reduced (49 pre vs. 28 post, p = 0.02). Number of patients requiring VATS decreased (27 pre vs. 10 post, p < 0.01). Number of catheters placed by interventional radiology increased (2 pre vs. 10 post, p = 0.02). Intrapleural thrombolytic use, open thoracotomy, empyema, and 6-month readmission rates were unchanged. The “post” group more ventilator-free days (median, 23.9 vs. 22.5, p = 0.04), but ICU and hospital LOS were unchanged. CONCLUSION Using an evidence-based hemothorax algorithm reduced the number of patients requiring additional interventions without increasing complication rates. Defined criteria for surgical intervention allows for more appropriate utilization of resources. Level of Evidence Therapeutic study, level IV.

Coronary sinus and atrioventricular groove avulsion after motor vehicle crash

Simultaneous cardiac and pericardial rupture from blunt chest trauma is a highly lethal combination with rarely reported survival. We report of a case of young patient with a right atrioventricular groove injury, pericardial rupture and a unique description of a coronary sinus avulsion following blunt chest trauma. Rapid recognition of this injury is crucial to patient survival, but traditional diagnostic adjuncts such as ultrasound, echocardiography and computed tomography are often unhelpful. Successful repair of these injuries requires high suspicion of injury, early cardiac surgery involvement of and possible even placement of the patient on cardiopulmonary bypass.

Method of Hypertonic Saline Administration: Effects on Osmolality in Traumatic Brain Injury Patients

Hypertonic saline (HTS) is an effective therapy for reducing intracranial pressure (ICP). The ideal method of administration is unknown. The purpose of this study was to evaluate the method of HTS infusion and time to goal osmolality. A retrospective cohort analysis was conducted in severe TBI patients with ICP monitoring in place who received 2 doses of HTS. Patients were divided into bolus versus continuous infusion HTS cohorts. The primary outcome was median time to goal osmolality. Secondary outcomes included percentage of patients reaching goal osmolality, percent time at goal osmolality, mean cerebral perfusion pressure (CPP) and ICP, ICU length of stay, and mortality. Safety outcomes included rates of hyperchloremia, hypernatremia, and acute kidney injury (AKI). 162 patients were included with similar baseline characteristics. Time to goal osmolality was similar between cohorts (bolus 9.78h vs. continuous 11.4h, p=0.817). A significant difference in the percentage of patients reaching goal osmolality favoring the continuous group was found (93.9% vs 73.3%, p=0.003). The continuous group was maintained at goal osmolality for a higher percentage of osmolality values after reaching goal (80% vs. 50%, p=0.032). No difference was seen in CPP, ICP, length of stay and mortality. Rates of hypernatremia were similar, but significant higher rates of hyperchloremia (0.77vs 1.58 events per HTS days, p<0.001) and AKI (0% vs 12.9%, p=0.025) were observed in the continuous cohort. Although no difference in time to goal osmolality was observed, continuous HTS was associated with a higher percentage of patients achieving goal osmolality.

Surgical Management of Solid Organ Injuries

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Blunt and Penetrating Cardiac Trauma

Patients with traumatic cardiac injuries can present with wide variability in their severity of illness. The most severe will present in cardiac arrest, whereas the most benign may be altogether asymptomatic; most will fall somewhere in between. Management of cardiac injuries largely depends on mechanism of injury and patient physiology. Understanding the spectrum of injuries and their associated manifestations can help providers react more quickly and initiate potentially life-saving therapies more efficiently when time is critical. This article discusses the workup and management of both blunt and penetrating cardiac injuries.

The Diagnosis of Acute Cholecystitis

Diagnosis of acute cholecystitis involves clinical, laboratory, and radiographic findings. The Tokyo Guidelines for the Management of Acute Cholangitis and Cholecystitis (TG13) provide a diagnostic algorithm that optimizes specificity and sensitivity in those patients with a history suggestive of possible acute cholecystitis. Physical exam and laboratory findings should suggest acute inflammatory processes. Imaging should start with RUQ ultrasound and include HIDA if inconclusive. For patients with atypical symptoms, CT may be a better initial imaging modality. The role of MRI is less clear, but may become more important as radiation exposure concerns grow. In select patient populations and certain clinical settings, diagnosis may be difficult or delayed. A high index of suspicion and an attentive approach in at-risk populations is required to limit delays in diagnosis and possible complications.

1113: HYPERTONIC SALINE AND ACUTE KIDNEY INJURY IN TRAUMATIC BRAIN INJURY

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) to promote antimicrobial stewardship. Commonly this includes vancomycin to empirically cover methicillin-resistant Staphylococcus aureus (MRSA). This study assessed the impact and necessity of adding vancomycin to IAI treatment regimens. Methods: A post hoc analysis of the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial was performed. Patients who received piperacillin/tazobactam (P/T) and/or ertapenem, meropenem and imipenem were included with categorization into two groups based on presence or absence of vancomycin. Univariate and multivariate analysis compared the effect of including vancomycin on the composite outcome (recurrent IAI, surgical site infection, SSI or mortality) and individual components. Results: The cohort included 344 patients who received P/T and/or a carbapenem with 110 (32%) of these patients receiving vancomycin. The majority of the patients received P/T (>75%). Isolation of MRSA occurred in only 8 (2.3%) patients (1 received vancomycin). Vancomycin use resulted in a different occurrence of the composite outcome, 32.7% vs. 20.9% for vancomycin and no vancomycin, respectively (p=0.02), but patients prescribed vancomycin, values represented as mean (SD), had higher APACHE II scores-13.1 (6.6) vs. 9.4 (5.7), p<0.0001; extended length of stay-12.6 (10.2) vs. 8.6 (8.0) days, p<0.001; and prolonged antibiotic courses-9.1 (8.0) vs. 7.1 (4.9) days, p=0.02. After risk adjustment in a multivariate model, no significant difference existed for the composite outcome or the individual components: recurrent IAI (OR=1.50 p=0.23), SSI (OR=1.55, p=0.31) or mortality (OR=1.02, p=0.99) relative to vancomycin utilization. Conclusions: This post hoc analysis reveals that addition of vancomycin occurred in nearly a third of cases, more often in sicker patients. However, no appreciable difference in recurrent IAIs, SSIs or mortality were demonstrated suggesting limited utility for adding vancomycin to IAI treatment regimens.