Christopher P. Michetti

The utility of procalcitonin in critically ill trauma patients.

BACKGROUND Procalcitonin (PCT), the prohormone of calcitonin, has an early and highly specific increase in response to systemic bacterial infection. The objectives of this study were to determine the natural history of PCT for patients with critical illness and trauma, the utility of PCT as a marker of sepsis versus systemic inflammatory response syndrome (SIRS), and the association of PCT level with mortality. METHODS PCT assays were done on eligible patients with trauma admitted to the trauma intensive care unit (ICU) of a Level I trauma center from June 2009 to June 2010, at hours 0, 6, 12, 24, and daily until discharge from ICU or death. Patients were retrospectively diagnosed with SIRS or sepsis by researchers blinded to PCT results. RESULTS A total of 856 PCT levels from 102 patients were analyzed, with mean age of 49 years, 63% male, 89% blunt trauma, mean Injury Severity Score of 21, and hospital mortality of 13%. PCT concentration for patients with sepsis, SIRS, and neither were evaluated. Mean PCT levels were higher for patients with sepsis versus SIRS (p < 0.0001). Patients with a PCT concentration of 5 ng/mL or higher had an increased mortality when compared with those with a PCT of less than 5 ng/mL in a univariate analysis (odds ratio, 3.65; 95% confidence interval, 1.03–12.9; p = 0.04). In a multivariate logistic analysis, PCT was found to be the only significant predictor for sepsis (odds ratio, 2.37; 95% confidence interval,1.23–4.61, p = 0.01). CONCLUSION PCT levels are significantly higher in ICU patients with trauma and sepsis and may help differentiate sepsis from SIRS in critical illness. An elevated PCT level was associated with increased mortality. LEVEL OF EVIDENCE Prognostic study, level II.

Deep vein thrombosis screening and risk factors in a high-risk trauma population

BACKGROUND Trauma patients requiring acute inpatient rehabilitation are significantly injured, with increased risk for deep vein thrombosis (DVT). We evaluated routine screening for occult DVT in such patients, and analyzed DVT risk factors. MATERIALS AND METHODS Data from level I trauma center patients discharged to a single acute rehabilitation center (ARC) from 2007-2011 were retrospectively reviewed. Routine lower extremity duplex was performed on ARC admission. Follow-up data were collected for patients with occult DVT (ARC DVT). DVT predictors were evaluated using logistic regression. RESULTS Of 622 patients, 534 (86%) had screening duplex; 26 (4.8%) had an ARC DVT. A majority of 442 patients (71%) received enoxaparin prophylaxis in hospital, for a median 64% of hospital days. Of ARC DVT patients, 17 received full anticoagulation and 16 received vena cava filters. Thirty-seven patients had DVT diagnosed in the hospital (hospital DVT) before discharge to ARC. Hospital DVT and ARC DVT groups were comparable except shorter median hospital length of stay and lower head abbreviated injury scale in ARC DVT patients. On multivariate analysis, increased intensive care unit length of stay, age >65 y, a lower percentage of hospital days receiving chemoprophylaxis, and delayed initiation of chemoprophylaxis were significantly predictive of DVT after adjustment for sex, mechanism, injury severity score, and admission systolic blood pressure. Presence of pelvic fractures and ages 50-65 y also posed an increased risk. CONCLUSIONS The incidence of occult DVT on ARC admission is low in trauma patients. Several risk factors for DVT in the trauma ARC population were identified. Nonselective screening of all trauma patients on admission to ARC is not supported by this analysis.

Differences in management and mortality with a bronchoalveolar lavage-based diagnostic protocol for ventilator-associated pneumonia.

Background: Directed antibiotic therapy based on accurate bacteriology is critical to ventilator-associated pneumonia (VAP) treatment. Bronchoalveolar lavage (BAL) has been reported to be more accurate than endotracheal sputum aspirate (ESA) in VAP diagnosis. Our objective was to determine the frequency with which BAL results differ from ESA cultures and the outcomes of VAP with a BAL-based VAP protocol. Methods: Prospectively collected microbiologic data on all trauma patients with VAP from 2007 through 2009 were reviewed. Per protocol, a positive ESA prompts a BAL and initiation of broad empiric antibiotics with de-escalation based on BAL results. Patients diagnosed with VAP by the protocol were compared with those diagnosed outside of the protocol using univariate and multivariate linear regression analysis. Concordance of ESA and BAL results was evaluated, and cause of death was determined. Results: Of 137 patients with VAP, 96 were diagnosed by the protocol (protocol group) and had 102 pairs of cultures. Twenty-six patients (27%) with 28 pairs of cultures (27.4%) had discordant results. Of discordant pairs, 17 (61%) showed bacteria of a different Grams stain. Methicillin-sensitive Staphylococcus aureus was the most common causative organism. Mortality was lower in the protocol group (6.3%) than the nonprotocol group (22%, p = 0.014) and mechanically ventilated patients without VAP (24%, p = 0.35) but with comparable Injury Severity Score (ISS). VAP-attributable mortality in the protocol group was 1%. Conclusions: Use of a BAL-based diagnostic protocol affects management of trauma patients with VAP by improving identification of causative microorganisms and is associated with low overall mortality and VAP-attributable mortality.

Reducing Transfusions in Critically Injured Patients Using a Restricted-Criteria Order Set.

BACKGROUND We sought to examine the effect on blood usage of a new electronic order set restricting transfusion orders to specific evidence-based criteria for each unit (U) of red blood cells (RBC), plasma, and platelets. METHODS Prospectively collected transfusion data for Trauma ICU patients were compared for the 12 months before (PRE) and 8 months after (POST) order set implementation. Criteria for RBC transfusion were 1 U only for hemoglobin <7 g/dL in stable patients or <8 g/dL with angina, myocardial infarction, or cardiogenic shock; 2 U for hemoglobin <5 g/dL; and multiple U in the presence of shock, hypotension, or bleeding. Restrictive ordering criteria were also applied to plasma and platelets. Massive transfusion patients were excluded. Differences in demographics and outcomes were assessed with Wilcoxon–Mann–Whitney test or Wilcoxon rank sum test for continuous variables, and &khgr;2 test for categorical variables. The percentage of patients receiving transfusions over time was compared with trend tests. Severity of illness (SOI) was graded from 1 (minor) to 4 (extreme). RESULTS Of 1,038 Trauma ICU patients (583 PRE, 455 POST), 228 (22%) were transfused. Median SOI [IQR] (4 [3–4] vs. 4 [3–4]) and mortality (24.3% vs. 22.5%, p = 0.757) were similar for PRE and POST transfused patients, respectively. The percentage of patients getting transfused decreased for all transfusions (25.4% vs. 17.6%, p = 0.003), RBC (19.9% vs. 11.2%, p < 0.001), and plasma (9.3% vs. 5.9%, p = 0.047) in PRE and POST, respectively. After adjusting for age, Injury Severity Score, admission hypotension, and other variables, there was a lower odds of receiving any transfusion (OR 0.67 [0.49–0.92], p = 0.015), and RBCs specifically (OR 0.60 [0.41–0.86], p = 0.006), in the POST period. The frequency of pre-transfusion hemoglobin ≥7 g/dL decreased by 27%, and mean direct costs of transfusion decreased by approximately 28%, after the intervention. CONCLUSIONS A significant reduction in transfusions was achieved after introduction of an order set restricting orders to predefined evidence-based criteria. LEVEL OF EVIDENCE Therapeutic study, level III.

Single-drug sedation with fentanyl for prehospital postintubation sedation in trauma patients.

BACKGROUND: A fentanyl-only (FO) regimen for prehospital postintubation sedation in trauma patients was compared with the standard protocol (SP) of fentanyl + benzodiazepine. METHODS: Intubated patients transported to a Level I trauma center from December 1, 2005, to April 30, 2009, were retrospectively reviewed. Before 2007, only SP was used; afterward both regimens were used. Groups were compared for hemodynamic and neurologic parameters in the prehospital setting and trauma bay, fluid volumes, time until general or neurosurgical intervention (NSI), and other outcomes. RESULTS: Groups were comparable with respect to age, sex, mechanism, alcohol level, intensive care unit length of stay, and hospital length of stay. Comorbidities were similar except hypertension (p = 0.019), and stroke (p = 0.029) were more frequent in FO patients. Prehospital heart rate and Glasgow Coma Scale (GCS) were similar. Trauma bay hemodynamic parameters and fluid resuscitation volumes were comparable, but pupil nonreactivity was more frequent in the FO group both overall (p = 0.032) and when comparing only patients with traumatic brain injury (TBI; p = 0.014). The incidence of TBI was comparable. Although the frequency of craniotomy (13% FO vs. 7% SP) and mortality (17% FO vs. 11% SP) were not statistically different overall, in patients with TBI, there was a higher incidence of NSI (28% vs. 14%, p = 0.015), craniotomy (14% vs. 3%, p = 0.02), and time to initial NSI (446 minutes vs. 193 minutes, p = 0.042) in the FO patients. CONCLUSIONS: In this study, an FO regimen was associated with similar hemodynamic but worse neurologic variables compared with the SP regimen. Prospective evaluation is warranted before adoption of this regimen, especially in TBI patients. LEVEL OF EVIDENCE: IV, therapeutic study.

FRIEND or FOE: A prospective evaluation of risk factors for reintubation in surgical and trauma patients

BACKGROUND A Form for Re-Intubation Evaluation by Nurses and Doctors (FRIEND) was used to prospectively collect pre-extubation data, to determine failure of extubation (FOE) risk. METHODS FRIENDs, including airway, breathing, and neurologic variables, were completed before extubation on trauma & surgical patients in one ICU from 1/1/16 to 5/31/17. Those with failed vs. successful extubation were compared. We excluded those with tracheostomy, comfort measures, or death before extubation. RESULTS There were 464 eligible extubations in 436 patients. Thirty five reintubations (7.9% FOE rate) occurred in 32 patients within 96 h of extubation. FOE patients had higher ICU days (6 d vs. 2 d), ventilator days (6 d vs. 2 d), and mortality (15.6% vs. 2.7%) [all p < 0.001] compared to those without FOE. Odds of FOE (OR [CI]) increased with age (1.03, [1, 1.06]), delirium (3, [1.16, 7.76]), moderate/copious secretions (3.95, [1.46, 10.66]), and enteral opioid use (4.23, [1.28, 14.02]). CONCLUSIONS Several characteristics present at the time of extubation were risk factors for FOE in trauma and surgical patients. Patients with FOE had higher mortality.

Nutrition, Antibiotics, and Post-traumatic Seizure Prophylaxis

In the trauma intensive care setting, the delivery of adequate nutrition is a daily concern. Early enteral feeding is beneficial for multi-trauma patients and those with traumatic brain injury. However, assessment of a patient’s nutritional status at any given point in time is challenging because of the low specificity of available nutritional markers. It is also difficult to measure a patient’s response to nutritional interventions. Low calorie, high protein feeding is recommended to meet the nutritional needs and catabolic demands of critically ill trauma patients. Antibiotic use is extremely common in the ICU setting, for both prophylactic and therapeutic purposes. In recent years, the alarming increase in the prevalence of multi-drug-resistant microorganisms and virulent pathogens makes antibiotic stewardship a vital component of safe, effective critical care delivery. Here we discuss the use of prophylactic antibiotics in conjunction with the placement of intracranial pressure monitors and external ventricular drains in neurotrauma patients. Patients with traumatic brain injury are at risk for post-traumatic seizures. Antiepileptic drugs are commonly employed as prophylaxis against post-traumatic seizures in certain patients, based on evidence indicating a decreased rate of early, but not late seizures with prophylaxis. Past research has examined broad populations that included a wide variety of traumatic pathology, possibly leading to an over generalization in the application of these medications. A critical appraisal of the existing evidence for seizure prophylaxis in neurotrauma patients is presented.

Supine position and nonmodifiable risk factors for ventilator-associated pneumonia in trauma patients.

BACKGROUND We studied trauma-specific conditions precluding semiupright positioning and other nonmodifiable risk factors for their influence on ventilator-associated pneumonia (VAP). METHODS We performed a retrospective study at a Level I trauma center from 2008 to 2012 on ICU patients aged ≥15, who were intubated for more than 2 days. Using backward logistic regression, a composite of 4 factors (open abdomen, acute spinal cord injury, spine fracture, spine surgery) that preclude semiupright positioning (supine composite) and other variables were analyzed. RESULTS In total, 77 of 374 (21%) patients had VAP. Abbreviated Injury Score head/neck greater than 2 (odds ratio [OR] 2.79, P = .006), esophageal obturator airway (OR 4.25, P = .015), red cell/plasma transfusion in the first 2 intensive care unit days (OR 2.59, P = .003), and 11 or more ventilator days (OR 17.38, P < .0001) were significant VAP risk factors, whereas supine composite, scene vs emergency department airway intervention, brain injury, and coma were not. CONCLUSION Factors that may temporarily preclude semiupright positioning in intubated trauma patients were not associated with a higher risk for VAP.