David S. Shapiro

Detection of Hypoxia at the Cellular Level

Organ function is critically linked to the way tissues use available oxygen. In sepsis, tissue-related hypoxic injury is the result of hypoxemia and hypoperfusion and cytokine-mediated mitochondrial dysfunction termed cytopathic hypoxia. Organ dysfunction in sepsis is more likely related to derailment of the metabolic processes of cells to use available oxygen. Cellular dysoxia rather than hypoxia may be the most appropriate way of describing sepsis-related tissue injury. Lactate is a marker of aerobic mitochondrial dysfunction and anaerobic tissue metabolism and in some circumstances is considered the fuel of choice for certain tissues. The concept of cellular metabolic derangement or cytopathic hypoxia as a potential cause for multiorgan system dysfunction in sepsis may direct efforts to optimize outcome in septic patients from the classic targets of CO, tissue perfusion, DVo(2), and Vo(2) toward moderating sepsis-related early cytokine response, maximizing mitochondrial function, and using biomarkers to monitor treatment response.

Mean Arterial Pressure: Therapeutic Goals and Pharmacologic Support

The Surviving Sepsis Campaign targets central venous pressure, mean arterial pressure, and central venous oxygen saturation as guides for resuscitation. Fluid resuscitation and the use of vasopressors are paramount to the success of the campaigns end points. Although the achievement of supranormal physiologic parameters has been associated with higher mortality in some studies, these slightly higher blood pressures may enable better oxygen delivery, in some observations. This article focuses on the mean arterial pressure goals during sepsis, the measurement of the mean arterial pressure, and the manipulation of this target with volume resuscitation and pharmacologic interventions.

Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma

METHODS We queried our Trauma Quality Improvement Program registry for patients who presented between 6/1/2011 and 9/1/2015 with severe (injury severity score (ISS)>15) blunt traumatic injury during anticoagulant use. Patients were then grouped into those prescribed warfarin and patients prescribed any of the available novel Direct Oral Anticoagulants (DOAC) medications. We excluded severe (AIS≧4) head injuries. RESULTS There were no differences between DOAC and warfarin groups in terms of age, gender mean ISS, median hospital or intensive care unit lengths of stay, complication proportions, numbers of complications per patient, or the proportion of patients requiring transfusion. Finally, excluding patients who died, the observed proportion of discharge to skilled nursing facility was similar. In our sample of trauma patients, DOAC use was associated with significantly lower mortality (DOAC group 8.3% vs. warfarin group 29.5%, p<0.015). The ratio of units transfused per patient was also lower in the DOAC group (2.8±1.8 units/patient in the DOAC group vs. 6.7±6.4 units per patient in the warfarin group; p=0.001). CONCLUSION In conclusion, we report an association with decrease in mortality and a decrease in transfused blood products in severely injured trauma patients with likely minimal or no head injury taking novel DOACs over those anticoagulated with warfarin for outpatient anticoagulation.

Is a stepdown unit safe for patients with mild traumatic intracranial hemorrhages

PurposeTraumatic brain injuries (TBIs) are a major source of disability in the United States. The ideal unit in the hospital for patients with mild traumatic intracranial hemorrhages (ICHs) has not been elucidated. We sought to investigate whether patients treated in the surgical stepdown area had worse outcomes than those treated in the surgical ICU.MethodsWe compared patients with ICHs and a Glasgow Coma Scale (GCS) upon admission of 14 or 15 who went to the ICU to those who went to the stepdown area from April 2014 to November 2016. We compared age, gender, Injury Severity Score (ISS), admission GCS (14 or 15), operative intervention, discharge destination, hospital length of stay (HLOS), mortality, and cost between these two groups.ResultsPatients admitted to the ICU had a significantly longer HLOS. Admission costs for patients admitted to ICU were also significantly higher than their stepdown area counterparts. This was true for both total charges (p = 0.0001) and for net revenue (p = 0.002) (Table 2). There was no statistically significant difference in mortality, operative intervention, or discharge destination.ConclusionA surgical stepdown unit can be a safe disposition for patients with mild traumatic ICHs and represents an effective use of hospital resources.

Percutaneous Dilatational Tracheostomy

Tracheostomy, once thought of as a procedure with tremendous morbidity and mortality and only utilized in lifesaving circumstances, is now a routinely performed procedure in the intensive care unit. Indicated for patients with prolonged mechanical ventilator support, percutaneous dilatational tracheostomy can facilitate more aggressive ventilator weaning as well as liberate patients with poor airway control from mechanical ventilation. Since critically ill patients are maintained on mechanical ventilation for longer periods of time, the need for tracheostomy has grown and the development of the percutaneous dilatational tracheostomy (PDT) technique has revolutionized the procedure.