Damon Clark

The prognostic value of neutrophil to lymphocyte ratio on mortality in critically Ill trauma patients.

BACKGROUND Recent studies suggest that the neutrophil-lymphocyte ratio (NLR) as a marker of inflammation is associated with mortality in surgical patients. The aim of this study was to determine the prognostic impact of NLR in critically ill trauma patients. METHODS This is a retrospective cohort study involving all trauma patients 16 years or older admitted to the surgical intensive care unit of a Level 1 trauma center (January 2013 to January 2014). The predictive capacity of NLR on mortality was assessed using a receiver operating characteristic curve analysis. To identify the effect of the NLR on survival, a separate log-rank test was used. Multivariable Cox proportional hazard modeling was used to identify independent predictors of mortality. RESULTS During the study period, 1,356 patients met inclusion criteria. Of these, 74% were male, 86% sustained blunt trauma, and the median age was 49 years (interquartile range [IQR], 35). The median Glasgow Coma Scale (GCS) score and Injury Severity Score (ISS) were 15 (IQR, 3) and 13 (IQR, 14), respectively. With the use of the receiver operating characteristic curve analyses at intensive care unit Days 2 and 5, optimal NLR cutoff values of 8.19 and 7.92 were calculated by maximizing the Youden index. Kaplan-Meier curves revealed an NLR greater than or equal to these cutoff values as a marker for increased in-hospital mortality (p < 0.001, log-rank test). The Cox regression model demonstrated that an NLR greater than 8.19 and 7.92 are independently associated with in-hospital mortality at Days 2 and 5, respectively (hazard ratio, 1.602 [p = 0.019] and 3.758 [p < 0.001]). CONCLUSION NLR is associated with mortality in critically ill trauma patients. Prospective validation of its role as a predictive marker for outcomes is warranted. LEVEL OF EVIDENCE Prognostic study, level III.

Hemodynamic monitoring of the injured patient: From central venous pressure to focused echocardiography.

H monitoring (assessment of volume status and cardiac function) of the injured patient is evolving. Traditional ‘‘static measures’’ of volume assessment using central and pulmonary artery catheters (PACs) are being replaced by dynamic measures such as pulse wave form analysis (PWA; LiDCO, PiCCO, VolumeView and FloTrac/Vigileo) and focused cardiac ultrasound (also known as hand-held cardiac ultrasound, point-of-care ultrasound, cardiac ultrasound). Similarly, indirect measurement of cardiac function by PACs is being replaced by systolic and diastolic evaluation of left-and-right atrial-and-ventricular global-and-regional function with echocardiogram (ECHO). As these newer technologies become increasingly available in the intensive care unit (ICU), the procedural skill set of the critical care surgeon must expand. Furthermore, educational programs must be created for the maintenance of competency and certification. This review will provide a historical context and comprehensive review of current controversies in the practice and interpretation of each technology. This discussion will also argue the superiority of ECHO to assess volume responsiveness and cardiac function and make a plea that acute care surgeons must master it not only to optimize outcomes but also to develop an ownership of the technology in the ICU.

Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma.

BACKGROUND Trauma training in general surgery residency is undergoing an evolution. Hour restrictions, the growth of subspecialty care, and the trend toward nonoperative management have altered resident exposure to operative trauma. We sought to identify trends in resident trauma training since the inception of the 80-hour workweek. METHODS The Accreditation Council for General Medical Education Case Log Statistical Reports for Surgery was abstracted for general surgery resident trauma operative volume for the years 1999–2014. Resident trauma experience (operative caseload [OC]) was compared before inception of the 80-hour workweek (1999–2002) to after the 80-hour workweek began (2003 to current). RESULTS A trend toward decreased operative trauma for general surgery residents was observed (mean OC [before 80-hour workweek vs. 80-hour workweek], 39,252 ± 1,065.2 cases vs. 36,065 ± 1,291.8; p = 0.06). Trauma laparotomies increased (range, 5,446–9,364 cases) with corresponding decreases in vascular trauma (4,704 to 799 cases), neck explorations (1,876 to 1,370 cases), and thoracotomies (2,507 to 2,284 cases). By comparison, an increase in vascular/integrated cases was noted (mean OC [before 80-hour workweek vs. 80-hour workweek], 845 ± 44.2 vs. 1,465 ± 88.4 cases; p < 0.01). Resident deficiencies analyzed by time period (before 80-hour workweek vs. 80-hour workweek) demonstrated deficiencies in thoracic, abdominal, solid organ, and extremity-vascular trauma domains (p < 0.01 for each). Nontrauma cases were also on the decline, specifically in open thoracic, vascular, and solid organ surgery (p < 0.05 for each). Both 1- and 2-year fellowships offset deficiencies in trauma education. CONCLUSIONS Based on the data, an alarming number of graduates complete training with substantially less experience in defined trauma categories. Because of a decline in operative trauma volume, advanced fellowship training should be encouraged specifically for those interested in a career in trauma and acute care surgery.

Care of the Patient with Liver Failure Requiring Transplantation

Patients undergo liver transplantation to address chronic liver failure, acute fulminant liver failure, or primary liver cancer. Depending on acuity, patients with decompensated chronic or acute fulminant liver failure generally require preoperative intensive care unit admission to manage organ dysfunction. Those with chronic liver failure are allocated an organ based on waiting list position determined by their local organ procurement organization (OPO). This position is dependent upon blood type and Model for End- Stage Liver Disease (MELD) score. These patients thus are critically ill and require preoperative ICU monitoring and care. Patients with hepatocellular carcinoma (HCC) who require liver transplantation are given a MELD exception and rarely require preoperative ICU care. The patient’s ability to undergo liver transplant in the setting of HCC is determined by the Milan criteria or the University of California, San Francisco (UCSF) criteria.

Balanced blood product transfusion during liver transplantation

This study was conducted to determine whether an intra‐operative ratio of at least 1:1:2 of fresh frozen plasma (FFP):platelets (PLTs):packed red blood cells (pRBCs) improves outcomes in orthotopic liver transplantation (OLT).