Christy M. Lawson

Early evaluation of acute traumatic coagulopathy by thrombelastography

Posttraumatic coagulopathy is a major cause of morbidity. This prospective study evaluated the thrombelastography (TEG) system and PlateletMapping (Haemoscope Corporation, Niles, Ill) values posttrauma, and it correlated those values with transfusions and fatalities. After institutional review board approval, assays were performed on 161 trauma patients. One citrated blood sample was collected onsite (OS), and 1 citrate and 1 heparinized sample were collected within 1 h of arrival to the emergency department (ED). Paired and unpaired t-testing was performed for nominal data with chi square testing for categorical values. Except for a slight increase in clot strength (maximal amplitude (MA)), there were no significant changes from OS to the ED. None of the TEG parameters were significantly different for the 22 patients who required transfusion. PlateletMapping showed lower platelet adenosine diphosphate (ADP) responsiveness in patients who needed transfusions (MA = 22.7 +/- 17.1 vs MA = 35.7 +/- 19.3, P = 0.004) and a correlation of fibrinogen <100 mg/dL with fatalities (P = 0.013). For the 14 fatalities, TEG reaction (R) time was 3703 +/- 11,618 versus 270 +/- 393 s (P = < 0.001), and MA was 46.4 +/- 22.4 versus 64.7 +/- 9.8 mm (P < 0.001). Hyperfibrinolysis (percent fibrinolysis after 60 min (LY60) >15%) was observed in 3 patients in the ED with a 67% fatality rate (P = < 0.001 by chi-square testing). PlateletMapping assays correlated with the need for blood transfusion. The abnormal TEG System parameters correlated with fatality. These coagulopathies were already evident OS. The TEG assays can assess coagulopathy, platelet dysfunction, and hyperfibrinolysis at an early stage posttrauma and suggest more effective interventions.

Summary points and consensus recommendations from the North American Surgical Nutrition Summit.

http://pen.sagepub.com/content/37/5_suppl/99S The online version of this article can be found at: DOI: 10.1177/0148607113495892 2013 37: 99S JPEN J Parenter Enteral Nutr Beth Taylor and Paul E. Wischmeyer Drover, David Flum, Leah Gramlich, David N. Herndon, Clifford Ko, Kenneth A. Kudsk, Christy M. Lawson, Keith R. Miller, Stephen A. McClave, Rosemary Kozar, Robert G. Martindale, Daren K. Heyland, Marco Braga, Francesco Carli, John W. Summary Points and Consensus Recommendations From the North American Surgical Nutrition Summit

Nonsteroidal anti-inflammatory drugs' impact on nonunion and infection rates in long-bone fractures.

BACKGROUND There is a dearth of clinical data regarding the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on long-bone fracture (LBF) healing in the acute trauma setting. The orthopedic community believes that the use of NSAIDs in the postoperative period will result in poor healing and increased infectious complications. We hypothesized that, first, NSAID use would not increase nonunion/malunion and infection rates after LBF. Second, we hypothesized that tobacco use would cause higher rates of these complications. METHODS A retrospective study of all patients with femur, tibia, and/or humerus fractures between October 2009 and September 2011 at a Level 1 academic trauma center was performed . In addition to nonunion/malunion and infection rates, patient records were reviewed for demographic data, mechanism of fracture, type of fracture, tobacco use, Injury Severity Score (ISS), comorbidities, and medications given. RESULTS During the 24-month period, 1,901 patients experienced LBF; 231 (12.1%) received NSAIDs; and 351 (18.4%) were smokers. The overall complication rate including nonunion/malunion and infection was 3.2% (60 patients). Logistic regression analysis with adjusted odds ratios were calculated on the risk of complications given NSAID use and/or smoking, and we found that a patient is significantly more likely to have a complication if he or she received an NSAID (odds ratio, 2.17; 95% confidence interval, 1.15–4.10; p < 0.016) in the inpatient postoperative setting. Likewise, smokers are significantly more likely to have complications (odds ratio, 3.19; 95% confidence interval, 1.84–5.53; p < 0.001). CONCLUSION LBF patients who received NSAIDs in the postoperative period were twice as likely and smokers more than three times likely to suffer complications such as nonunion/malunion or infection. We recommend avoiding NSAID in traumatic LBF. LEVEL OF EVIDENCE Epidemiologic & therapeutic study; level II.

Appropriate Protein and Specific Amino Acid Delivery Can Improve Patient Outcome: Fact or Fantasy?

Protein utilization and requirements in critical illness are much researched and debated topics. The enhanced turnover and catabolism of protein in the setting of critical illness is well described and multifactorial in nature. The need to preserve lean body mass and enhance nitrogen retention in this state to improve immunologic function and reduce morbidity is well described. Debates as to the optimum amount of protein to provide in such states still exist, and a significant amount of research has contributed to our understanding of not only how much protein to supply to these patients, but how best to do so. Small peptide formulations, intact protein formulations, branched chain amino acids, and specialty formulas all exist, and their benefits, drawbacks, and potential uses have been investigated. Specific amino acid therapy has become part of the concept of immunonutrition, or the modification and enhancement of the immune response with specific nutrients. In this article, we describe the changes in outcomes demonstrated through the provision of protein, both as a macronutrient and as specific amino acids.

Factors That Impact Patient Outcome Nutrition Assessment

Defining malnutrition and nutrition risk has been a topic of many papers and discussions throughout the modern literature. Multiple definitions have been proposed, ranging from simple body weight measurements to a more all-encompassing concept looking at disease-specific inflammatory states. Biochemical markers, elements of a history examination, physical examination findings, calculations, and technical tests have all been proposed to help further characterize and delineate those who might be at risk for malnutrition, translating to an increased risk of adverse outcomes after major surgery. The purpose of this paper is to summarize some of the most utilized and most reliable ways to determine nutrition status within the scope of the North American Surgical Nutrition Summit (2012) and discuss how to incorporate these methods into the way that patients are screened preoperatively for elective surgery.

Effect of Rotational Therapy on Aspiration Risk of Enteral Feeds

BACKGROUND Enteral nutrition has been demonstrated to reduce ventilator days and the incidence of pneumonia, but the safest route for providing enteral nutrition to mechanically ventilated patients is unclear. Our objective was to determine if there is a difference between the incidences of microaspiration of gastric secretions in patients fed via a nasogastric tube vs a postpyloric tube while undergoing rotational therapy for acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS Institutional review board approval was obtained for this prospective, randomized study. Patients were randomized to gastric or postpyloric enteral feedings. Daily tracheal secretion samples were collected, and we used an immunoassay to detect pepsin. Using the data for aspiration and tube type, a univariate unadjusted odds ratio was calculated to assess the risk of aspiration between the 2 tube types. An independent samples t test was used to analyze the hypothesis that microaspiration significantly affects lung recovery from ARDS. RESULTS Of the 20 study patients, 9 (45%) received nasogastric feeds and 11 (55%) received postpyloric feeds. Western blot analysis for the presence of pepsin in each tracheal aspirate revealed microaspiration in 2 nasogastric (22%) and 2 (18%) postpyloric patients. The nasogastric tube provided a protective effect for aspirating with an odds ratio of .778 (95% confidence interval, .09-6.98). An independent samples t test was used and showed no significant change in PaO(2):FiO(2) ratio in the aspirating vs nonaspirating group (P = .552). CONCLUSION The results of this study indicate that enteral nutrition should not be delayed or stopped to position the tube in patients with ARDS on rotational therapy.

Introduction to Metabolism

Metabolism is defined as “1. The chemical processes occurring within a living cell or organism that are necessary for the maintenance of life. 2. The processing of a specific substance within the living body.” This definition simplifies a process that occurs at the cellular level in every living being and is the driving process of our existence. The consumption of energy is the basis of life; an innate and evolutionarily honed drive to maintain homeostasis and fulfill the needs for energy and cellular function. Derangements in metabolism are present with every disease process and may even be the cause. The quest to understand the exchange of energy at the cellular level and to develop novel techniques to manipulate, restore, or control this exchange is as old as medicine itself. The goal of this chapter is to review the history of our understanding of metabolic processes, to discuss normal cellular metabolism in a healthy subject, and to identify ways in which metabolism is altered in injury and illness.

Effect of local anesthetic on microorganisms in a murine model of surgical site infection.

BACKGROUND Surgical site infections are common, with an incidence of 1.5% to 5% for all types of surgery. In vitro studies suggest an antimicrobial effect of local anesthetic. We hypothesized that subcutaneous infiltration of local anesthetic before surgical incision would reduce the incidence of postoperative wound infection. METHODS In a wound infection model using 4- to 6-week-old female mice, Staphylococcus aureus and Escherichia coli were inoculated in surgical wounds infiltrated with local anesthetic or saline. On day 5, the mice were killed and tissues were evaluated for viable bacterial numbers, presence of bacteria histologically, and degree of inflammation on a scale of 0 to 3 based on number and types of inflammatory cells and presence of necrosis. RESULTS A one-way between-subjects analysis of variance with Tukey honestly significant difference post hoc comparisons showed no statistically significant difference in the degree of inflammation in mice infiltrated with lidocaine, lidocaine mixed with bupivacaine, or saline (p = 0.994, p = 0.337, and p = 0.792, respectively). A Tukey honestly significant difference post hoc analysis demonstrated that the saline (p = 0.038) and lidocaine mixed with bupivacaine (p = 0.006) had significantly lower degrees of inflammation than did the lidocaine group. A Bonferroni post hoc test demonstrated that those in the lidocaine (p = 0.003) and lidocaine mixed with bupivacaine (p = 0.008) groups had significantly higher inflammation than those in the saline group after controlling for the condition of the inocula. CONCLUSIONS Infiltrate, whether saline, lidocaine, or lidocaine mixed with Marcaine, did not result in significantly different bacterial presence or higher degree of inflammation when controlling for experimental condition of bacterial inocula. Thus, subcutaneous infiltration of local anesthetic before a surgical incision is made does not reduce the incidence of bacterial growth or influence the degree of inflammation which alters infection rates.

Carbohydrate Provision in the Era of Tight Glucose Control

Glycemic control in the critically ill patient has remained a controversial issue over the last decade. Several large trials, with widely varying results, have generated significant interest in defining the optimal target for blood-glucose control necessary for improving care while minimizing morbidity. Nutritional support has evolved into an additional area of critical care where appropriate practices have been associated with improved patient outcomes. Carbohydrate provision can impact blood-glucose levels, and the relationship between nutrition and glucose levels has become more complex in the era of improved glycemic control. This review discusses the controversy surrounding intensive-insulin therapy in the intensive care unit and explores the relationship with nutritional support, both in the enteral and parenteral form. Achieving realistic goals in both carbohydrate provision and glycemic control may improve patient outcome, and are not mutually exclusive practices.

Nutrition Risk Screening and Stratification

Nutritional risk is one of the key modifiable risk factors involved in major elective surgery. Stratifying patients according to their nutritional risk, while of critical importance, is often not done or done incompletely. Varied and often invalidated methods of screening patients for nutritional risk exist, adding confusion to the many reasons behind why patients are not adequately screened and optimized prior to surgery. The current literature supporting nutritional risk stratification in both malnourished and nourished patients is discussed, along with screening tools that are recommended by the American Society of Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics.