Chet A. Morrison

Chemical venous thromboembolic prophylaxis is safe and effective for patients with traumatic brain injury when started 24 hours after the absence of hemorrhage progression on head CT.

BACKGROUND Venous thromboembolism (VTE) continues to be an important complication for patients with trauma, including patients with intracranial hemorrhage. We implemented a protocol starting chemical prophylaxis 24 hours after the absence of progression of hemorrhage on computed tomography (CT) to increase consistency with the use of chemical venous thromboembolic prophylaxis in this population. The objective of this study was to review the protocol of VTE prophylaxis for patients with traumatic brain injury at our institution to determine whether it has been effective and safe in preventing VTE without increasing intracranial hemorrhage. METHODS A retrospective case series was conducted to study 205 patients with intracranial hemorrhage admitted to a Level I trauma center during a 24-month period. These patients were reviewed with respect to type of intracranial injury, need for surgery, injury severity, time to initiation of chemical prophylaxis, and progression of injury on brain CT. Patients with a hospital length of stay less than 3 days or nonstable CT were excluded in the analysis of administration of chemical prophylaxis. Time to chemical prophylaxis in relation to absence of progression on brain CT was examined as well as the subsequent risk of progression of hemorrhage and risk of VTE events. The overall rate of venous thromboembolism was compared with that of matched historical controls. RESULTS All patients received mechanical prophylaxis in the form of sequential compression devices. One hundred sixty-two intracranial hemorrhages were identified in 122 patients who met the study’s inclusion criteria. Of this group of patients who did not have progression of hemorrhage on follow-up CT, 76.2% received chemical prophylaxis during their hospitalization. No patients had progression of intracranial hemorrhage after initiation of chemical VTE prophylaxis, and no patients developed VTE. This represents a decrease of VTE from previous years. No other complications related to chemical VTE prophylaxis were identified. CONCLUSION A protocol based on an early use of chemical venous thromboembolic prophylaxis after the absence of progression of tramatic intracranial hemorrhage does not result in increased progression of intracranial hemorrhage and reduced the rate of venous thromboembolic events at our institution. LEVEL OF EVIDENCE Therapeutic study, level IV.

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.

INTRODUCTION Performance improvement driven by the review of surgical morbidity and mortality is often limited to critiques of individual cases with a focus on individual errors. Little attention has been given to an analysis of why a decision seemed right at the time or to lower-level root causes. The application of scientific performance improvement has the potential to bring to light deeper levels of understanding of surgical decision-making, care processes, and physician psychology. METHODS A comprehensive retrospective chart review of previously discussed morbidity and mortality cases was performed with an attempt to identify areas where we could better understand or influence behavior or systems. We avoided focusing on traditional sources of human error such as lapses of vigilance or memory. An iterative process was used to refine the practical areas for possible intervention. Definitions were then created for the major categories and subcategories. RESULTS Of a sample of 152 presented cases, the root cause for 96 (63%) patient-related events was identified as uni-factorial in origin, with 51 (34%) cases strictly related to patient disease with no other contributing causes. Fifty-six cases (37%) had multiple causes. The remaining 101 cases (66%) were categorized into two areas where the ability to influence outcomes appeared possible. Technical issues were found in 27 (18%) of these cases and 74 (74%) were related to disorganized care problems. Of the 74 cases identified with disorganized care, 42 (42%) were related to failures in critical thinking, 18 (18%) to undisciplined treatment strategies, 8 (8%) to structural failures, and 6 (6%) were related to failures in situational awareness. CONCLUSIONS On a comprehensive review of cases presented at the morbidity and mortality conference, disorganized care played a large role in the cases presented and may have implications for future curriculum changes. The failure to think critically, to deliver disciplined treatment strategies, to recognize structural failures, and to achieve situational awareness contributed to the morbidities and mortalities. Future research may determine if focused training in these areas improves patient outcomes.

Management of hemorrhagic shock when blood is not an option

OBJECTIVE To describe an alternative approach to management of severe life- threatening hemorrhagic shock and the outcome when blood was not a treatment option. DESIGN Case Report of the use of a Hemoglobin Based Oxygen Carrier (HBOC-201)when control of hemorrhage and intravenous crystalloids were unsuccessful in reversal of hemorrhagic shock and progressive ischemia. SETTING Trauma Center. PATIENTS Jehovahs Witness. OUTCOME Hospital discharge and 6 month follow-up uneventful.

Whole body imaging in the diagnosis of blunt trauma, ionizing radiation hazards and residual risk.

Ever since the introduction of radiographic imaging, its utility in identifying injuries has been well documented and was incorporated in the workup of injured patients during advanced trauma life support algorithms [American College of Surgeons, 8th ed. Chicago, 2008]. More recently, computerized tomography (CT) has been shown to be more sensitive than radiography in the diagnosis of injury. Due to the increased use of CT scanning, concerns were raised regarding the associated exposure to ionizing radiation [N Engl J Med 357:2277–2284, 2007]. During the last several years, a significant amount of research has been published on this topic, most of it being incorporated in the BEIR VII Phase 2 report, published by the National Research Council of the National Academies [National Academy of Sciences, Washington DC, 2006]. The current review will analyze the scientific basis for the concerns over the ionizing radiation associated with the use of CT scanning and will examine the accuracy of the typical advanced trauma life support work-up for diagnosis of injuries.

Survey of surgical infections currently known (SOSICK): A multicenter examination of antimicrobial use from the Surgical Infection Society Scientific Studies Committee

PURPOSE The Scientific Studies Committee of the Surgical Infection Society undertook the present study to examine the prevalence of and indications for antimicrobial use in intensive care units where members of the Society practice. METHODS Information and data collection sheets were posted on the Internet for download by members interested in participating. All centers were required to obtain approval from their local human subjects research office or equivalent. A one-week time was set during which the center could collect information on any one day, at the centers convenience. Data collection sheets were then sent to the lead author for analysis. Seventeen centers reported data for 371 patients in 22 intensive care units. RESULTS Trauma and general surgical patients comprised 224 of the patients (60%). The indications for anti-infective agents were prophylactic (22%), empiric (27%), therapeutic with known pathogen (41%), therapeutic without known pathogen (e.g., cellulitis) (4%), insistence of influential practitioner (4%), or non-anti-infective purposes (e.g., erythromycin for gastric motility) (2%). Only 44%, 29%, and 54% of the orders for prophylactic, empiric, and therapeutic antibiotics, respectively, had date-certain stop dates. The antimicrobial drugs most commonly used were vancomycin, piperacillin-tazobactam, and fluconazole. CONCLUSION Most patients were receiving antimicrobial agents. Polypharmacy was common. Most patients did not have a date-certain stop date. This study sets the benchmark for future study regarding antibiotic prescribing behavior in surgical intensive care units.

An analysis of neurosurgical practice patterns and outcomes for serious to critical traumatic brain injuries in a mature trauma state.

BACKGROUND We sought to characterize trends in neurosurgical practice patterns and outcomes for serious to critical traumatic brain injuries from 2003 to 2013 in the mature trauma state of Pennsylvania. METHODS All 2003 to 2013 admissions to Pennsylvanias 30 accredited Level I to II trauma centers with serious to critical traumatic brain injuries (head Abbreviated Injury Scale [AIS] score ≥ 3, Glasgow Coma Scale [GCS] score < 13) were extracted from the state registry. Adjusted temporal trend tests controlling for demographic and injury severity covariates assessed the impact of admission year on intervention rates (craniotomy, craniectomy, and intracranial pressure monitor/ventriculostomy [ICP]) and outcome measures for the total population as well as serious (head AIS score ≥ 3; GCS score, 9–12) and critical (head AIS score ≥ 3, GCS score ⩽ 8) subgroups. RESULTS A total of 22,229 patients met inclusion criteria. Admission year was significantly associated with an adjusted increase in craniectomy (adjusted odds ratio [AOR], 1.12 [1.09–1.14]; p < 0.001) and ICP rates (AOR, 1.03 [1.02–1.04]; p < 0.001) and a decrease in craniotomy rate (AOR, 0.96 [0.95–0.97]; p < 0.001). No significant trends in adjusted mortality were found for the total study population (AOR, 1.01 [1.00–1.02]; p = 0.150); however, a significant reduction was found for the serious subgroup (AOR, 0.95 [0.92–0.98]; p = 0.002), and a significant increase was found for the critical subgroup (AOR, 1.02 [1.01–1.03]; p = 0.004). CONCLUSION Total study population trends showed a reduction in rates of craniotomy and increase in craniectomy and ICP rates without any change in outcome. Despite significant adaptations in neurosurgical practice patterns from 2003 to 2013, only patients with serious head injuries are experiencing improved survival. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III; therapeutic study, level IV.

The prehospital treatment of the bleeding patient—Dare to dream

E-mail address: chet.morrison@hc.msu.e 0022-4804/

Inhibition of Rho kinase: the next hopeful salvo in the long war against sepsis?

e see front matter a 2013 Elsev doi:10.1016/j.jss.2011.12.022 Traumatic injuries have been with us since the beginning of civilization and not surprisingly are the topic of the oldest known medical documentdthe ‘Edwin Smith papyrus [1]. Numerous advances in the care of the injured patient have been accomplished with contributionsmade from virtually all aspects of surgical research. Nevertheless, there is still a notable fatality rate frompatientswho are encountered alive but die during prehospital care and transport; this problem is particularly acute in the military setting where as many as 90% of military casualties who die in combat die prior to reaching care [2]. Thus, it is a worthwhile effort to develop treatments that could alter this mortality; from prehospital administered hemostatic dressings, injections of hemostatic substances in to wounds, and high energy frequency ultrasound, effort continues on this worthwhile goal [3e5]. For an elegant study demonstrating a different approach, we turn to the current paper, by Dr. Ahmadi-Noorbakhsh and colleagues [6]. In this study, a technique of intraperitoneal fluid or gas administration was used in a rabbit model of intraperitoneal hemorrhage secondary to induced hepatic injury. Using an elegant experimental technique, the authors demonstrated that infusion of either carbon dioxide gas or peritoneal dialysate solution was associated with reduced blood loss and improved blood pressure in these animals, although there was an increased acidosis in the animals that received the

Hematocrit, systolic blood pressure and heart rate are not accurate predictors for surgery to control hemorrhage in injured patients.

DOI of original article: 10.1016/j.jss.2012.0 * Corresponding author. Department of Surg Tel.: þ1 517 267 2472; fax: þ1 517 267 2488. E-mail address: chet.morrison@hc.msu.e 0022-4804/

A Disciplined Approach to Implementation of Evidence-Based Practices Decreases ICU and Hospital Length of Stay in Traumatically Injured Patients

e see front matter a 2013 Elsev doi:10.1016/j.jss.2012.05.009 It is well known that sepsis is one of the most costly and difficult-to-treat conditions that physicians face, with 750,000 patients receiving this diagnosis every year [1], a 20%e40% mortality [2], and total costs being estimated at