C. Anne Morrison

Hypotensive Resuscitation Strategy Reduces Transfusion Requirements and Severe Postoperative Coagulopathy in Trauma Patients With Hemorrhagic Shock: Preliminary Results of a Randomized Controlled Trial

BACKGROUND Trauma is a leading cause of death worldwide and is thus a major public health concern. Previous studies have shown that limiting the amount of fluids given by following a strategy of permissive hypotension during the initial resuscitation period may improve trauma outcomes. This study examines the clinical outcomes from the first 90 patients enrolled in a prospective, randomized controlled trial of hypotensive resuscitation, with the primary aim of assessing the effects of a limited transfusion and intravenous (IV) fluid strategy on 30-day morbidity and mortality. METHODS Patients in hemorrhagic shock who required emergent surgery were randomized to one of the two arms of the study for intraoperative resuscitation. Those in the experimental (low mean arterial pressure [LMAP]) arm were managed with a hypotensive resuscitation strategy in which the target mean arterial pressure (MAP) was 50 mm Hg. Those in the control (high MAP [HMAP]) arm were managed with standard fluid resuscitation to a target MAP of 65 mm Hg. Patients were followed up for 30 days. Intraoperative fluid requirements, mortality, postoperative complications, and other clinical data were prospectively gathered and analyzed. RESULTS Patients in the LMAP group received a significantly less blood products and total i.v. fluids during intraoperative resuscitation than those in the HMAP group. They had significantly lower mortality in the early postoperative period and a nonsignificant trend for lower mortality at 30 days. Patients in the LMAP group were significantly less likely to develop immediate postoperative coagulopathy and less likely to die from postoperatively bleeding associated with coagulopathy. Among those who developed coagulopathy in both groups, patients in the LMAP group had significantly lower international normalized ratio than those in the HMAP group, indicating a less severe coagulopathy. CONCLUSIONS Hypotensive resuscitation is a safe strategy for use in the trauma population and results in a significant reduction in blood product transfusions and overall IV fluid administration. Specifically, resuscitating patients with the intent of maintaining a target minimum MAP of 50 mm Hg, rather than 65 mm Hg, significantly decreases postoperative coagulopathy and lowers the risk of early postoperative death and coagulopathy. These preliminary results provide convincing evidence that support the continued investigation and use of hypotensive resuscitation in the trauma setting.

Modern management of traumatic subclavian artery injuries: a single institution's experience in the evolution of endovascular repair

BACKGROUND Subclavian artery injuries traditionally require morbid surgical procedures. Repair by way of an endovascular approach can potentially decrease the morbidity and mortality associated with these injuries. METHODS A 2-year retrospective review of trauma patients with subclavian artery injuries was performed at our institution. Relevant data were extracted from patient records and analyzed. These results were then used to develop an algorithm for the management of trauma patients with subclavian artery injuries. RESULTS Fifteen patients with subclavian artery injuries were identified. Five patients died in the emergency room. Of the 10 surviving patients, 8 had their diagnosis made at arteriogram. Six patients underwent endovascular repair, and 4 of these repairs were successful. Three patients were managed by way of open repair. Two deaths occurred in the endovascular group, and 1 death occurred in the open group. CONCLUSIONS Our findings suggest that endovascular management of subclavian artery injuries is an acceptable technique in appropriate candidates and compares favorably with open repair. However, as with open repair, the associated morbidity and mortality remains quite high. We propose an algorithm whereby hemodynamically stable patients with hard signs of vascular injury proceed directly to angiography, whereas open repair is reserved for those patients who are unstable or in whom a catheter-based approach has previously failed.

Effects of human immunodeficiency virus status on trauma outcomes: a review of the national trauma database.

BACKGROUND The prevalence of human immunodeficiency virus (HIV) is disproportionately elevated in trauma patients. Although HIV traditionally has been associated with poorer outcomes among the critically ill, recent evidence suggests that the outcomes of surgical patients have improved with the greater use of antiretroviral regimens. The purpose of this study was to utilize the National Trauma Data Bank (NTDB) to examine the impact of HIV on surgical outcomes in a large group of trauma patients. METHODS We identified all patients for whom HIV status at time of admission was recorded. Results were stratified by age and Injury Severity Score. Our primary outcome was death. Secondary outcomes were length of hospital stay (LOS), length of intensive care unit (ICU) stay, duration of mechanical ventilation, and complications. Data were analyzed using Student t-tests or chi-square analysis, as appropriate. RESULTS The overall mortality rates were not significantly different in the HIV-positive and HIV-negative groups. Mortality rates remained similar in the two groups even when stratifying by ISS and age, with the exception of those patients who were 65 years or older. The HIV-positive patients had significantly longer LOS (7.6 vs. 5.6 days), shorter duration of mechanical ventilation (6.3 vs. 8.3 days), and no difference in length of ICU stay. The HIV-positive patients were significantly more likely to develop pneumonia, bacteremia, or wound infection. CONCLUSIONS These findings are consistent with those of recent smaller studies that demonstrated no significant difference in the mortality rate for patients with HIV. Although mortality rates are similar, HIV-positive patients are more likely to develop certain infectious complications and to require a longer LOS. Infection with HIV remains a major public health issue in the U.S. and internationally, and further research is necessary to explore the relation between HIV status and trauma outcomes, particularly with regard to the possible effects of antiretroviral treatment and individual immune status.

Increased apoptosis of peripheral blood neutrophils is associated with reduced incidence of infection in trauma patients with hemorrhagic shock.

OBJECTIVE We aimed to describe the relationship between early peripheral leukocyte apoptosis and incidence of subsequent infection in trauma patients with hemorrhagic shock (T/HS). METHODS T/HS patients requiring emergency surgery were prospectively enrolled. Nucleosome ELISA and TUNEL staining were performed on peripheral blood drawn pre-operatively, post-operatively and at 24 h. Subjects were followed for 30 days or until death or hospital discharge to record all episodes of infection. RESULTS Forty-one subjects were enrolled. Six died within 24 h of surgery and were not included in the analysis. Nucleosome levels peaked post-operatively and dropped to baseline levels at 24 h (p = 0.03). TUNEL analysis revealed that polymorphonuclear neutrophils (PMNs) accounted for 72% of apoptotic leukocytes; the remaining apoptotic cells were mainly lymphocytes. Increased post-operative leukocyte apoptosis was associated with decreased systemic inflammatory response syndrome (SIRS) severity. Seventeen of the 35 survivors (48.6%) developed infections, while 18 (51.4%) did not. Pre-operative and post-operative nucleosome levels were 2.5 and 3 times higher, respectively, in T/HS patients who did not develop infection compared to those who did. Increased nucleosome levels were associated in particular with protection against sepsis (p=0.03) and multiple infections (p = 0.01). CONCLUSION Peripheral blood PMN apoptosis in the early resuscitative period is associated with decreased incidence of subsequent infection in T/HS patients.

Thoracoabdominal shotgun wounds: an evaluation of factors associated with the need for surgical intervention

BACKGROUND Shotgun wound classification systems attempt to predict the need for surgical intervention based on the size of wounds, pellet spread, or distance from the weapon rather than clinical findings. METHODS A 5-year retrospective review of patients sustaining a thoracoabdominal shotgun wound was performed. Factors believed to be associated with the need for surgical intervention were examined using the Fisher exact test or an independent sample t test. RESULTS Sixty-four patients suffered a thoracoabdominal shotgun wound. Fifty-nine percent required surgical intervention. Factors significantly associated with the need for surgical intervention were a low revised trauma score and systolic and diastolic blood pressure (P < .05). Distance from attacker, wound patterns, pellet size, and pellet spread were not found to have an association. CONCLUSIONS Clinical indicators of hemorrhage and shock are associated with the need for surgical intervention, whereas pellet spread, pellet size, and distance from the attacker are not. This is a significant departure from traditional classification systems.