Carlos Brown

Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference?

BACKGROUNDnThe combination of bicarbonate and mannitol (BIC/MAN) is commonly used to prevent renal failure (RF) in patients with rhabdomyolysis despite the absence of sufficient evidence validating its use. The purpose of this study was to determine whether BIC/ MAN is effective in preventing RF in patients with rhabdomyolysis caused by trauma.nnnMETHODSnThis study was a review of all adult trauma intensive care unit (ICU) admissions over 5 years (January 1997-September 2002). Creatine kinase (CK) levels were checked daily (abnormal,>520 U/L). RF was defined as a creatinine greater than 2.0 mg/dL. Patients received BIC/MAN on the basis of the surgeons discretion.nnnRESULTSnAmong 2,083 trauma ICU admissions, 85% had abnormal CK levels. Overall, RF occurred in 10% of trauma ICU patients. A CK level of 5,000 U/L was the lowest abnormal level associated with RF; 74 of 382 (19%) patients with CK greater than 5,000 U/L developed RF as compared with 143 of 1,701 (8%) patients with CK less than 5,000 U/L (p < 0.0001). Among patients with CK greater than 5,000 U/L, there was no difference in the rates of RF, dialysis, or mortality between those who received BIC/MAN and those who did not. Subanalysis of groups with various levels of CK still failed to show any benefit of BIC/MAN.nnnCONCLUSIONnAbnormal CK levels are common among critically injured patients, and a CK level greater than 5,000 U/L is associated with RF. BIC/MAN does not prevent RF, dialysis, or mortality in patients with creatine kinase levels greater than 5,000 U/L. The standard of administering BIC/MAN to patients with post-traumatic rhabdomyolysis should be reevaluated.

Beta-Blockers in Isolated Blunt Head Injury

BACKGROUNDnThe purpose of this study was to evaluate the effect of beta-blockers on patients sustaining acute traumatic brain injury. Our hypothesis was that beta-blocker exposure is associated with improved survival.nnnSTUDY DESIGNnThe trauma registry and the surgical ICU databases of an academic Level I trauma center were used to identify all patients sustaining blunt head injury requiring ICU admission from July 1998 to December 2005. Patients sustaining major associated injuries (Abbreviated Injury Score > or = 4 in any body region other than the head) were excluded. Patient demographics, injury profile, Injury Severity Score, and beta-blocker exposure were abstracted. The primary outcomes measure evaluated was in-hospital mortality.nnnRESULTSnDuring the 90-month study period, 1,156 patients with isolated head injury were admitted to the ICU. Of these, 203 (18%) received beta-blockers and 953 (82%) did not. Patients receiving beta-blockers were older (50 +/- 21 years versus 38 +/- 20 years, p < 0.001), had more frequent severe (Abbreviated Injury Score > or = 4) head injury (54% versus 43%, p < 0.01), Glasgow Coma Scale < or = 8 less often (37% versus 47%, p = 0.01), more skull fractures (20% versus 12%, p < 0.01), and underwent craniectomy more frequently (23% versus 4%, p < 0.001). Stepwise logistic regression identified beta-blocker use as an independent protective factor for mortality (adjusted odds ratio: 0.54; 95% CI, 0.33 to 0.91; p = 0.01). On subgroup analysis, elderly patients (55 years or older) with severe head injury (Abbreviated Injury Score > or = 4) had a mortality of 28% on beta-blockers as compared with 60% when they did not receive them (odds ratio: 0.3; 96% CI, 0.1 to 0.6; p = 0.001).nnnCONCLUSIONSnBeta-blockade in patients with traumatic brain injury was independently associated with improved survival. Older patients with severe head injuries demonstrated the largest reduction in mortality with beta-blockade.

Using thyroid hormone in brain-dead donors to maximize the number of organs available for transplantation

Abstract:u2002 The aggressive management of brain‐dead (cadaveric) organ donors has been shown to increase organs available for transplantation. Some centers use hormone therapy with thyroid hormone (T4) in selected donors. The purpose of this study is to evaluate the effects of T4 on organs available for transplantation. A policy of aggressive donor management was adopted at our trauma center in 1998. T4 therapy is reserved for the hemodynamically unstable donors who require significant vasopressor support. The records of patients who successfully donated organs between January 2001 and December 2005 were reviewed. Organ donor demographics and whether T4 was used was examined for each donor. T4 was used in 96 of 123 donors (78%). Compared with donors who did not receive T4, those that did were similar in age (32u2003±u200314 vs. 38u2003±u200321, pu2003=u20030.148), had more organs donated (3.9u2003±u20031.7 vs. 3.2u2003±u20031.7, pu2003=u20030.048), and had no differences in brain‐death related complications. Despite the severe hemodynamic instability in the T4 group, the number of organs harvested from this group was significantly more than in patients who did not receive T4. The use of T4 in this group may result in the increased salvage of transplantable organs.

Mortality impact of hypothermia after cavitary explorations in trauma

BackgroundAdmission hypothermia (core temperaturexa0≤xa035°C) is an independent risk factor for mortality after trauma. The predictive value of perioperative core temperatures during acute trauma surgery, however, although widely employed as a criterion for initiating damage control, is unknown. We hypothesized that for trauma patients undergoing laparotomy or thoracotomy, early postoperative hypothermia is a predictor of mortality.MethodsAfter institutional review board (IRB) approval, all critically ill trauma patients undergoing cavitary surgery (laparotomy or thoracotomy) at a level 1 trauma center from 01/1998 to 07/2006 were identified from the trauma registry. Immediate postoperative core temperature (Tc) was used to classify patients as hypothermic (Tcxa0≤xa035°C) or normothermic (Tcxa0>xa035°C). The profoundly hypothermic subgroup of patients with a Tcxa0<xa033°C was also analyzed.ResultsDuring the study period, 2,489 patients required cavitary surgery, 1,252 of whom (50%) were admitted to the intensive care unit (ICU). On arrival in the ICU 15% of the patients had a Tcxa0≤xa035°C and were more likely to bexa0≥xa055xa0years old (12% versus 7%; pxa0=xa00.04); in addition, they were hypotensive on admission (25% versus 13%; pxa0<xa00.001), had a lower admission Glasgow Coma Score (GCS; 11xa0±xa05 versus 14xa0±xa03; pxa0<xa00.001), a higher Injury Severity Score (ISS; 29xa0±xa015 versus 22xa0±xa012; pxa0<xa00.001), higher head and chest Abbreviated Injury Scale (AIS), and greater intraoperative blood loss (2.6xa0±xa02.4xa0l versus 1.7xa0±xa01.8xa0l; pxa0<xa00.001). When compared to patients who were normothermic at the end of their operation, hypothermic patients had a significantly higher mortality (35% versus 8%; pxa0<xa00.001). With decreasing Tc, there was a stepwise increase in mortality. Compared to patients with a Tcxa0>xa035°C, the relative risk of death for patients with a Tc between 35°C and 33°C was 4.0, and that for patients with a Tcxa0≤xa033°C it was 7.1. After adjusting for multiple differences between groups, postoperative hypothermia remained an independent predictor of mortality (adjusted odds ratio [OR] 3.2; 95% confidence interval [CI] 1.9–5.3; pxa0<xa00.001).ConclusionsPostoperative hypothermia is common in critically injured patients requiring cavitary surgery and is an independent predictor of mortality. The impact of measures to maintain or restore normothermia in the operating room warrants further investigation.

Blunt cardiac rupture: A 5-year NTDB analysis

OBJECTIVEnBecause of its rarity and high rate of mortality, traumatic blunt cardiac rupture (BCR) has been poorly studied. The objective of this study was to use the National Trauma Data Bank to review the epidemiology and outcomes associated with traumatic BCR.nnnMETHODSnAfter approved by the institutional review board, the National Trauma Data Bank (version 5.0) was queried for all BCR occurring between 2000 and 2005. Demographics, clinical injury data, interventions, and outcomes were abstracted for each patient. Statistical analysis was performed using an unpaired Students t test or Mann-Whitney U test to compare means and chi analysis to compare proportions. Stepwise logistic regression analysis was performed to identify independent predictors of inhospital mortality.nnnRESULTSnOf 811,531 blunt trauma patients, 366 (0.045%) had a BCR of which 334 were available for analysis, with the mean age of 45 years, 65% were men, and their mean Injury Severity Score was 58 +/- 19. The most common mechanism of injury was motor vehicle collision (73%), followed by pedestrian struck by auto (16%), and falls from height (8%). Twenty-one patients (6%) died on arrival and 140 (42%) died in the emergency room. The overall mortality for patients arriving alive to hospital was 89%. Of the patients surviving to operation, 42% survived >24 hours of which 87% were discharged. Survivors were significantly younger (39 vs. 46 years, p = 0.04), had a lower Injury Severity Score (47 vs. 56, p = 0.02), higher Glasgow Coma Scale (10 vs. 6, p < 0.001), and were more likely to present with an systolic blood pressure >or=90 mm Hg (p = 0.01). Nevertheless, none of these factors was found to be an independent risk factor for mortality.nnnCONCLUSIONnBCR is an exceedingly rare injury, occurring in 1 of 2400 blunt trauma patients. In patients arriving alive to hospital, traumatic BCR is associated with a high mortality rate, however, is not uniformly fatal.

The consequences of obesity on trauma, emergency surgery, and surgical critical care

The era of the acute care surgeon has arrived and this new specialty will be expected to provide trauma care, emergency surgery, and surgical critical care to a variety of patients arriving at their institution. With the exception of practicing bariatric surgeons, many general surgeons have limited experience caring for obese patients. Obese patients manifest unique physiology and pathophysiology, which can influence a surgeons decision-making process. Following trauma, obese patients sustain different injuries than lean patients and have worse outcomes. Emergency surgery diseases may be difficult to diagnose in the obese patient and obesity is associated with increased complications in the postoperative patient. Caring for an obese patient in the surgical ICU presents a distinctive challenge and may require alterations in care. The following review should act as an overview of the pathophysiology of obesity and how obesity modifies the care of trauma, emergency surgery, and surgical critical care patients.

Cirrhosis and trauma are a lethal combination

BackgroundThe objective of this study was to evaluate the risk of mortality and complications associated with cirrhosis in trauma patients.MethodsThis is an IRB-approved retrospective trauma registry study of patients admitted to an academic level 1 trauma center from 1997 to 2006. The following parameters were abstracted for analysis: age, gender, mechanism of injury, Abbreviated Injury Score, Injury Severity Score, Glasgow Coma Scale, mortality, and complications (ARDS, acute renal failure, pneumonia, intra-abdominal abscess, trauma-associated coagulopathy). Multivariable analysis was utilized to compare the mortality and complication rates between cirrhotic and noncirrhotic trauma patients. The subgroup of patients who underwent laparotomy was also analyzed.ResultsDuring the 10-year study period there were 36,038 trauma registry patients, of which 468 (1.3%) had a diagnosis of cirrhosis. The mortality in the cirrhotic group was 12% vs. 6% in the noncirrhotic group [adjusted odds ratioxa0=xa05.65 (95% CIxa0=xa03.72xa0−xa08.41, pxa0<xa00.0001)]. ARDS, trauma-associated coagulopathy, and septic complications were significantly more common in the cirrhotic group. The overall severe complication rate in the two groups was 10 and 4%, respectively [adjusted odds ratioxa0=xa02.05 (95% CIxa0=xa01.45xa0−xa02.84, pxa0<xa00.0001)]. For the subgroup of patients who underwent emergent abdominal exploration, the mortality rate increased to 40% compared with that of noncirrhotics at 15% [adjusted odds ratioxa0=xa04.35 (95% CIxa0=xa02.00xa0−xa09.18, pxa0=xa00.0002)].ConclusionCirrhosis is an independent risk factor for increased mortality and higher complication rate following trauma. Injured patients who undergo laparotomy are significantly more likely to die than noncirrhotic patients. Injured patients with cirrhosis warrant aggressive monitoring and treatment.

What Happened to Total Parenteral Nutrition? The Disappearance of its Use in a Trauma Intensive Care Unit

BACKGROUNDnTotal parenteral nutrition (TPN) is associated with known costs, including the use of invasive procedures, which may be necessary to optimize care. Our purpose was to document TPN use in trauma patients over time as well as concurrent changes in TPN-associated complications.nnnMETHODSnRetrospective analysis of all consecutive trauma patients admitted to the surgical intensive care unit during a period of 6 years from a Level I trauma center. Comparative cohorts and the matched case-control approaches were used to analyze the difference in outcomes between patients with and without TPN during hospitalization. Logistic regression model was used to compare the outcomes of the two groups of patients adjusting for significant risk factors. The McNemars test was used to assess the differences in outcomes between the cases and their matched controls.nnnRESULTSnThere were 2,964 patients admitted to the surgical intensive care unit during the 6-year period and 464 patients received TPN during their hospital course. TPN use decreased significantly from 26% in the year 2000 to 3% in 2005 (p < 0.0001). Excluding those who died in the first 72 hours, the mortality rate was significantly lower (5.4% no TPN vs. 10.2% TPN, p = 0.001) in patients who were managed without TPN. Complication rates (wound infection, dehiscence, line sepsis, bacteremia, sepsis, pneumonia, renal failure, acute respiratory distress syndrome, multiple organ dysfunction syndrome, deep venous thrombosis, pulmonary embolism) were significantly higher in patients that were managed with TPN. Multivariate analysis adjusting for abbreviated injury score, injury severity score, mechanism, admission year, dialysis, ventilator use, hollow viscous injury, and solid organ injury found that TPN use was still an independent risk factor for increased complications but not death. The matched case-control approach confirmed this finding. TPN use was also associated with increase intensive care unit and hospital length of stay.nnnCONCLUSIONSnThe rate of TPN use has declined significantly from 26% to 3% during the 6-year period. The change in practice of minimizing TPN was concurrent with decreased complications and less hospital resource utilization without negatively impacting mortality.

Natural History and Outcomes of Renal Failure after Trauma

BACKGROUNDnThe natural history of posttraumatic renal failure (PTRF) is not well-established. Overall prognosis and risk factors for need for dialysis in the setting of PTRF need more precise definition.nnnSTUDY DESIGNnWe conducted a retrospective review of the trauma registry information from Los Angeles County-University of Southern California Medical Center from 1998 through 2005. PTRF was defined as the occurrence of serum creatinine > or = 2 mg/dL after admission for trauma. Clinical course and laboratory information from the trauma registry and ICU databases were analyzed.nnnRESULTSnOf 33,376 trauma patients identified, PTRF developed in 323 (1%), with an overall mortality of 38% (n = 120). Onset of PTRF occurred an average of 4 +/- 7 days after admission, with average peak serum creatinine occurring 7 +/- 1 days after admission and only 56% (n = 180) of patients normalizing serum creatinine before discharge. A total of 64 patients (20% of renal failure patients, 0.2% of all trauma patients) required hemodialysis. The only independent risk factor for the need for dialysis was laparotomy, with patients manifesting an elevated creatinine later in their course more likely to require dialysis. Although injury severity correlated well with outcomes, the only independent risk factors for mortality in this population were persistently elevated serum creatinine and head Abbreviated Injury Score > 3.nnnCONCLUSIONSnDevelopment of PTRF in severely injured patients represents a substantial risk for morbidity and mortality in this population. Additional study is needed to determine the importance of delayed onset of PTRF, particularly in the setting of multiorgan failure, in determining outcomes.

Alcohol exposure and outcomes in trauma patients.

ObjectiveTo determine the injury patterns, complications, and mortality after alcohol consumption in trauma patients.MethodsThe Trauma Registry at an American College of Surgeons (ACS) level I center was queried for all patients with a toxicology screen admitted between 1st January 2002 and 31st December 2005. Alcohol-positive (AP) patients were matched to control patients who had a completely negative screen (AN) using age, gender, mechanism, Injury Severity Score (ISS), head Abbreviated Injury Scale (AIS), chest AIS, abdominal AIS, and extremity AIS. Injuries and outcomes were compared between the groups.ResultsAs many as 5,317 patients had toxicology data, of which 471 (8.9%) had a positive alcohol screen (AP). A total of 386 AP patients were then matched to 386 control (AN) patients. The AP group had a significantly higher mortality than the AN group overall (23 vs. 13%; pxa0<xa00.001), and by ISS stratification: ISSxa0<xa016 (6 vs. 0.4%; pxa0<xa00.001), ISS 16–25 (53 vs. 28%; pxa0=xa00.01), and ISSxa0>xa025 (90 vs. 67%; pxa0=xa00.01). AP patients had a higher incidence of admission systolic blood pressure <xa090 (18 vs. 10%; pxa0<xa00.001) and Glasgow Coma Scale (GCS)xa0score ≤xa08 (25 vs. 17%; pxa0=xa00.002). AN patients had a significantly higher incidence of hemopneumothorax (11 vs. 7%; pxa0=xa00.03), while AP patients had a higher incidence of cardiac arrest (8 vs. 3%; pxa0=xa00.004). There was no difference in intensive care unit (ICU) and hospital length of stay.ConclusionIn a mixed population of trauma patients, an AP screen is associated with an increased incidence of admission hypotension and depressed GCS score. In this case-matched study, alcohol exposure appeared to increase mortality after injury.