Corina Tiruta

Active Negative Pressure Peritoneal Therapy After Abbreviated Laparotomy The Intraperitoneal Vacuum Randomized Controlled Trial

Supplemental Digital Content is Available in the Text. This randomized trial observed a survival difference between patients randomized to the ABThera versus Barkers vacuum pack after abbreviated laparotomy. As this difference did not seem to be mediated by improved peritoneal fluid drainage, fascial closure rates, or markers of systemic inflammation, it should be confirmed by a multicenter trial.

Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces.

BACKGROUND Patients with an occult pneumothoraces (OPTXs) may be at risk of tension pneumothoraces (TPTXs) without drainage or pleural drainage complications if treated. METHODS Adults with traumatic OPTXs and requiring positive-pressure ventilation (PPV) were randomized to pleural drainage or observation (one side only enrolled if bilateral). All subsequent care and method of pleural drainage was per attending physician discretion. The primary outcome was a composite of respiratory distress (RD) (need for urgent pleural drainage, acute/sustained increases in O2 requirements, ventilator dysynchrony, and/or charted respiratory events). RESULTS Ninety severely injured patients (mean [SD], Injury Severity Score [ISS], 33 [11]) were studied at four centers: Calgary (55), Toronto (27), Quebec (6), and Sherbrooke (3). Forty were randomized to tube thoracostomy, and 50 were randomized to observation. The risk of RD was similar between the observation and tube thoracostomy groups (relative risk, 0.71; 95% confidence interval, 0.40–1.27). There was no difference in mortality or intensive care unit (ICU), ventilator, or hospital days between groups. In those observed, 20% required subsequent pleural drainage (40% PTX progression, 60% pleural fluid, and 20% other). One observed patient (2%) undergoing PPV at enrollment had a TPTX, which was treated with urgent tube thoracostomy without sequelae. Drainage complications occurred in 15% of those randomized to drainage, while suboptimal tube thoracostomy position occurred in an additional 15%. There were three times (24% vs. 8%) more failures and more RDs (p = 0.01) among those observed with OPTXs requiring sustained PPV versus just for an operation, which increases threefold after a week in the ICU (p = 0.07). CONCLUSION Our results suggest that OPTXs may be safely observed in hemodynamically stable patients undergoing PPV just for an operation, although one third of those requiring a week or more of ICU care received drainage, and TPTXs still occur. Complications of pleural drainage remain unacceptably high, and future work should attempt to delineate specific factors among those observed that warrant prophylactic drainage. LEVEL OF EVIDENCE Therapeutic study, level III.

Admission base deficit and lactate levels in Canadian patients with blunt trauma: are they useful markers of mortality?

BACKGROUND Elevated base deficit (BD) and lactate levels at admission in patients with injury have been shown to be associated with increased mortality. This relationship is undefined in the Canadian experience. The goal of this study was to define the association between arterial blood gas (ABG) values at admission and mortality for Canadians with severe blunt injury. METHODS A retrospective review of 3,000 consecutive adult major trauma admissions (Injury Severity Score, ≥12) to a Canadian academic tertiary care referral center was performed. ABG values at the time of arrival were analyzed with respect to associated mortality and length of stay. RESULTS A total of 2,269 patients (76%) had complete data available for analysis. After exclusion of patients who sustained a penetrating injury or were admitted for minor falls (ground levels or low height), 445 had an ABG drawn within 2 hours of arrival. Patients who died displayed a higher median lactate (3.6 vs. 2.2, p < 0.0001), a worse median BD (−10 vs. −5, p < 0.0001), and a lower pH (7.23 vs. 7.31, p < 0.0001) at arrival compared with those of survivors. A statistically significant association was also observed between lactate and BD values at arrival and both mortality and length of stay (p < 0.0001). CONCLUSION Despite population differences, ABGs at admission in Canadian patients with blunt trauma accurately reflect mortality in a similar manner to the previously published literature. Survival curves with lactate and BD values at arrival should be available to all clinicians within their individual trauma centers for both acute care and quality assurance. LEVEL OF EVIDENCE Prognostic study, level III.

The song remains the same although the instruments are changing: complications following selective non-operative management of blunt spleen trauma: a retrospective review of patients at a level I trauma centre from 1996 to 2007

BackgroundDespite a widespread shift to selective non-operative management (SNOM) for blunt splenic trauma, there remains uncertainty regarding the role of adjuncts such as interventional radiological techniques, the need for follow-up imaging, and the incidence of long-term complications. We evaluated the success of SNOM (including splenic artery embolization, SAE) for the management of blunt splenic injuries in severely injured patients.MethodsRetrospective review (1996-2007) of the Alberta Trauma Registry and health records for blunt splenic trauma patients, aged 18 and older, with injury severity scores of 12 or greater, admitted to the Foothills Medical Centre.ResultsAmong 538 eligible patients, 150 (26%) underwent early operative intervention. The proportion of patients managed by SNOM rose from 50 to 78% over the study period, with an overall success rate of SNOM of 87%, while injury acuity remained unchanged over time. Among SNOM failures, 65% underwent surgery within 24 hours of admission. Splenic arterial embolization (SAE) was used in only 7% of patients managed non-operatively, although at least 21% of failed SNOM had contrast extravasation potentially amenable to SAE. Among Calgary residents undergoing SNOM, hospital readmission within six months was required in three (2%), all of whom who required emergent intervention (splenectomy 2, SAE 1) and in whom none had post-discharge follow-up imaging. Overall, the use of post-discharge follow-up CT imaging was low following SNOM (10%), and thus no CT images identified occult hemorrhage or pseudoaneurysm. We observed seven cases of delayed splenic rupture in our population which occurred from five days to two months following initial injury. Three of these occurred in the post-discharge period requiring readmission and intervention.ConclusionsSNOM was the initial treatment strategy for most patients with blunt splenic trauma with 13% requiring subsequent operative intervention intended for the spleen. Cases of delayed splenic rupture occurred up to two months following initial injury. The low use of both follow-up imaging and SAE make assessment of the utility of these adjuncts difficult and adherence to formalized protocols will be required to fully assess the benefit of multi-modality management strategies.

Efficacy and safety of active negative pressure peritoneal therapy for reducing the systemic inflammatory response after damage control laparotomy (the Intra-peritoneal Vacuum Trial): study protocol for a randomized controlled trial

BackgroundDamage control laparotomy, or abbreviated initial laparotomy followed by temporary abdominal closure (TAC), intensive care unit resuscitation, and planned re-laparotomy, is frequently used to manage intra-abdominal bleeding and contamination among critically ill or injured adults. Animal data suggest that TAC techniques that employ negative pressure to the peritoneal cavity may reduce the systemic inflammatory response and associated organ injury. The primary objective of this study is to determine if use of a TAC dressing that affords active negative pressure peritoneal therapy, the ABThera Open Abdomen Negative Pressure Therapy System, reduces the extent of the systemic inflammatory response after damage control laparotomy for intra-abdominal sepsis or injury as compared to a commonly used TAC method that provides potentially less efficient peritoneal negative pressure, the Barker’s vacuum pack.Methods/DesignThe Intra-peritoneal Vacuum Trial will be a single-center, randomized controlled trial. Adults will be intraoperatively allocated to TAC with either the ABThera or Barker’s vacuum pack after the decision has been made by the attending surgeon to perform a damage control laparotomy. The study will use variable block size randomization. On study days 1, 2, 3, 7, and 28, blood will be collected. Whenever possible, peritoneal fluid will also be collected at these time points from the patient’s abdomen or TAC device. Luminex technology will be used to quantify the concentrations of 65 mediators relevant to the inflammatory response in peritoneal fluid and plasma. The primary endpoint is the difference in the plasma concentration of the pro-inflammatory cytokine IL-6 at 24 and 48 h after TAC dressing application. Secondary endpoints include the differential effects of these dressings on the systemic concentration of other pro-inflammatory cytokines, collective peritoneal and systemic inflammatory mediator profiles, postoperative fluid balance, intra-abdominal pressure, and several patient-important outcomes, including organ dysfunction measures and mortality.DiscussionResults from this study will improve understanding of the effect of active negative pressure peritoneal therapy after damage control laparotomy on the inflammatory response. It will also gather necessary pilot information needed to inform design of a multicenter trial comparing clinical outcomes among patients randomized to TAC with the ABThera versus Barker’s vacuum pack.Trial registrationClinicalTrials.gov identifierhttp://www.clicaltrials.gov/ct2/show/NCT01355094

The feasibility of nurse practitioner-performed, telementored lung telesonography with remote physician guidance - ‘a remote virtual mentor’

BackgroundPoint-of-care ultrasound (POC-US) use is increasingly common as equipment costs decrease and availability increases. Despite the utility of POC-US in trained hands, there are many situations wherein patients could benefit from the added safety of POC-US guidance, yet trained users are unavailable. We therefore hypothesized that currently available and economic ‘off-the-shelf’ technologies could facilitate remote mentoring of a nurse practitioner (NP) to assess for recurrent pneumothoraces (PTXs) after chest tube removal.MethodsThe simple remote telementored ultrasound system consisted of a handheld ultrasound machine, head-mounted video camera, microphone, and software on a laptop computer. The video output of the handheld ultrasound machine and a macroscopic view of the NPs hands were displayed to a remote trauma surgeon mentor. The mentor instructed the NP on probe position and US machine settings and provided real-time guidance and image interpretation via encrypted video conferencing software using an Internet service provider. Thirteen pleural exams after chest tube removal were conducted.ResultsThirteen patients (26 lung fields) were examined. The remote exam was possible in all cases with good connectivity including one trans-Atlantic interpretation. Compared to the subsequent upright chest radiograph, there were 4 true-positive remotely diagnosed PTXs, 2 false-negative diagnoses, and 20 true-negative diagnoses for 66% sensitivity, 100% specificity, and 92% accuracy for remotely guided chest examination.ConclusionsRemotely guiding a NP to perform thoracic ultrasound examinations after tube thoracostomy removal can be simply and effectively performed over encrypted commercial software using low-cost hardware. As informatics constantly improves, mentored remote examinations may further empower clinical care providers in austere settings.

Telementorable "just-in-time" lung ultrasound on an iPhone.

Journal of Emergencies, Trauma, and Shock I 4:4 I Oct Dec 2011 more-prevalent technology to allow cost-minimal telementoring in lung telesonography. Therefore, despite the myriad of challenges for global health improvements, we believe that as the globe is shrunk by informatics, remote experts in developed nations could increasingly assist with education and clinical care delivery using affordable technologies that are likely to be already in our coat pockets.

How to set up a low cost tele-ultrasound capable videoconferencing system with wide applicability

BackgroundWorldwide ultrasound equipment accessibility is at an all-time high, as technology improves and costs decrease. Ensuring that patients benefit from more accurate resuscitation and diagnoses from a user-dependent technology, such as ultrasound, requires accurate examination, typically entailing significant training. Remote tele-mentored ultrasound (RTUS) examination is, however, a technique pioneered in space medicine that has increased applicability on earth. We, thus, sought to create and demonstrate a cost-minimal approach and system with potentially global applicability.MethodsThe cost-minimal RTUS system was constructed by utilizing a standard off-the-shelf laptop computer that connected to the internet through an internal wireless receiver and/or was tethered through a smartphone. A number of portable hand-held ultrasound devices were digitally streamed into the laptop utilizing a video converter. Both the ultrasound video and the output of a head-mounted video camera were transmitted over freely available Voice Over Internet Protocol (VOIP) software to remote experts who could receive and communicate using any mobile device (computer, tablet, or smartphone) that could access secure VOIP transmissions from the internet.ResultsThe RTUS system allowed real-time mentored tele-ultrasound to be conducted from a variety of settings that were inside buildings, outside on mountainsides, and even within aircraft in flight all unified by the simple capability of receiving and transmitting VOIP transmissions. . Numerous types of ultrasound examinations were conducted such as abdominal and thoracic examinations with a variety of users mentored who had previous skills ranging from none to expert. Internet connectivity was rarely a limiting factor, with competing logistical and scheduling demands of the participants predominating.ConclusionsRTUS examinations can educate and guide point of care clinical providers to enhance their use of ultrasound. The scope of the examinations conducted is limited only by the time available and the criticality of the subject being examined. As internet connectivity will only improve worldwide, future developments need to focus on the human factors to optimize tele-sonographic interactions.

Management of incidental findings in the trauma patient: is the trauma team a primary care provider as well?

Background: Computed tomographic scanning and tertiary surveys have resulted in an increase of incidental findings (IFs) unrelated to the trauma. The goals were to (1) characterize the frequency and nature of IFs and (2) explore their management by a trauma nurse practitioner. Methods: A prospective log of IFs and follow-up details was maintained by a trauma nurse practitioner. Supplemental data were obtained through hospital databases. Results: A total of 404 trauma patients were screened for IFs over a 6-month period, and 68% had IFs of varying severity. Conclusion: IFs are frequent in trauma. Appropriate management and follow-up is a major commitment that can be well managed by a trauma nurse practitioner.