Duraid Younan

Early Trauma-Induced Coagulopathy is Associated with Increased Ventilator-Associated Pneumonia in Spinal Cord Injury Patients.

Introduction: Early trauma-induced coagulopathy may increase susceptibility to nosocomial infections such as ventilator-associated pneumonia. However, the relationship between trauma- induced coagulopathy and the development of ventilator-associated pneumonia in spinal cord injury patients has not been evaluated. Methods: We conducted a 5-year retrospective study of 300 spinal cord injury patients admitted to Level 1 trauma center. Standard coagulation studies were evaluated upon arrival, prior to fluid resuscitative efforts, and at 24 h after admission. Based on these studies, three groups of patients were identified: no coagulopathy, latent coagulopathy, and admission coagulopathy. Ventilator- associated pneumonia was identified utilizing Centers for Disease Control and Prevention criteria. Since we used the data in the trauma registry and did not have the information on FiO2 and PEEP, we elected to use the VAP terminology and not the VAE sequence. Demographic, injury, and clinical characteristics were compared among no coagulopathy, latent coagulopathy, and admission coagulopathy groups using chi-square test and ANOVA for categorical and continuous variables, respectively. A logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between coagulopathy and both ventilator-associated pneumonia and mortality. Results: The incidence of ventilator-associated pneumonia was 54.5% (OR 4.01, 95% CI 1.76–9.15) in spinal cord injury patients with admission coagulopathy, compared with the 17.5% in spinal cord injury patients with no coagulopathy. Mortality was significantly higher in spinal cord injury patients with admission coagulopathy than in spinal cord injury patients with no coagulopathy (OR 6.14, 95% CI 1.73–21.73). After adjusting for age, race, injury mechanism, Injury Severity Score, base deficit at admission, the number of pRBC units transfused in the first 24 h, and hospital stay, only the association of ventilator-associated pneumonia among those with admission coagulopathy remained significant (OR 3.51, 95% CI 1.48–8.32). Compared with those with no coagulopathy, patients with admission coagulopathy had a higher odds of death (4.10, 95% CI 1.53–11.02), though this association lost significance after adjustment (OR 3.56, 95% CI 0.90–14.12). There was no statistical difference in mortality for latent coagulopathy compared with no coagulopathy patients. Conclusion: Coagulopathy on admission in patients with spinal cord injury is associated with a statistically significant increase in ventilator-associated pneumonia incidence. Additional research is warranted to further characterize this association.

Early Coagulopathy is Associated with Increased Incidence of Ventilator-Associated Events Among Burn Patients.

Objective: Coagulopathy is known to be associated with burn injury. Our group has shown that, in spinal cord injury patients, coagulopathy is associated with an increase in ventilator-associated pneumonia (VAP). We hypothesized that the same association exists between coagulopathic burn patients and ventilator-associated events. Methods: Patients admitted for burn care between January 1, 2011 and December 31, 2015 who required mechanical ventilation were included in the study. Ventilator-associated events (VAEs) as defined by the Center for Disease Control were categorized as no event, ventilator-associated condition, infection-related ventilator-associated complication, and possible VAP. Demographic, injury characteristics were compared among four international normalized ratio (INR) categories using analysis of variance and chi-square tests. Results: Four hundred four patients were admitted for burn care, of whom 263 met the inclusion criteria. One hundred eleven had normal INR, 59 had a slightly elevated INR (1.2–1.4), 33 had a moderately elevated INR (1.4–1.6), and 60 had a severely elevated INR (>1.6). Those with moderately and severely elevated INR were ventilated for a longer period (P = 0.0034), had more days in the ICU (P = 0.0010), and had longer hospital stay (P = 0.0016). After adjusting for inhalation injury and total body surface area, patients with severely elevated INR were over four times as likely to have any VAE (OR: 4.16, 95% CI: 1.33–13.05) and 4.5 times as likely to develop infection-related ventilator-associated complication or possible ventilator-associated pneumonia combined (OR: 4.59, 1.35–15.67). Conclusions: Early coagulopathy is associated with a significantly increased incidence of VAEs in burn patients. While additional studies need to be conducted to verify these findings, early recognition and treatment could decrease VAEs.

Right ventricular fractional area of change is predictive of ventilator support days in trauma and burn patients

Echocardiography has contributed to the care of critically ill patients but there remains a need for more publications about its association with outcomes to confirm its role. We conducted a retrospective review of trauma and burn patients that were admitted to our intensive care unit between 2015 and 2017 that underwent hemodynamic transesophageal echocardiography. Data collected included demographics, clinical and laboratory data. Right ventricle fractional area of change (RVFAC) measurements were performed on still mages obtained from mid-esophageal four-chamber-view clips. There were 74 patients, mean age was 51 years, and were predominantly white and male. Linear regression was used to test for the association between RVFAC and clinical outcomes. Adjusting for age, injury mechanism and injury severity, higher RVFAC was significantly associated with lower ventilator days (p = 0.03). Conclusion, higher right ventricle systolic function is associated with a lower number of ventilator support days in critically injured trauma and burn patients.

Respiratory oxygen uptake is associated with survival in a cohort of ventilated trauma and burn patients

Background: Little data is available in the literature about the role of end tidal oxygen in critically ill patients. We sought to identify the association between the level of respiratory oxygen and clinical outcomes in critically‐ill ventilated trauma and burn patients. Methods: A retrospective cohort of 55 trauma and burn patients from 2010 to 2016 was collected. Exposures of interest included a) expiratory end tidal oxygen (ETO2) and b) the difference between FiO2 and ETO2 (uptake). Associations of clinical characteristics with ETO2 and oxygen uptake were examined using a Spearman correlation. The relationships between discharge status, demographics, injury type, severity, and clinical characteristics were examined using chi‐square (or Fishers exact) tests and two‐sample t‐tests. Multivariable analyses using linear and logistic regression were performed to determine whether expiratory end tidal oxygen or oxygen uptake was an independent predictor of clinical outcomes. Results: Mean age for the patients was 46.3 ± 18.2 years with 41 (74.6%) male and 34 (61.8%) white. In the cohort, 27 (49.1%) of patients had burns and 28 (50.9%) blunt trauma. Oxygen uptake was negatively correlated with lactic acid, minute ventilation, total ICU days, and ventilator days (p < 0.05). Patients who died demonstrated lower oxygen uptake than those alive, oxygen uptake remained significantly associated with discharge status after adjusting for potential confounders (p = 0.028). Conclusion: A narrowed difference between ETO2 and inspiratory oxygen is associated with increased mortality in a cohort of ventilated trauma and burn patients. Future research is needed to further elucidate the role of respiratory oxygen level in larger, prospective studies.

Traumatic Intraparenchymal Pseudoaneurysm on Initial Imaging Predicts Injury Progression in Patients with Nonoperative Major Blunt Liver Injury

Abstract Objective: Identify factors that would predict which patients would benefit from repeat imaging after major blunt liver injury. Summary of Background Data: Most patients who present with hemodynamic stability and no evidence of peritonitis after blunt liver injury are successfully managed nonoperatively. Little information is available regarding the utility of reimaging major blunt liver injuries for patients who are managed nonoperatively. Methods: A retrospective review of patients admitted to a level I trauma center with major blunt liver injuries (AAST grades 3-5) was conducted. Inclusion criteria were those admitted from July 2012 to June 2014 with blunt liver trauma who survived the first 24 hours and underwent repeat imaging. Data included demographics, procedures performed and computerized tomography (CT) scan findings. Findings on the second CT scan were categorized as Unchanged, Worse, Improved, or Negative. Results: 128 patients had blunt major liver injuries; 66 patients underwent rep...

Burn patients with infection-related ventilator associated complications have worse outcomes compared to those without ventilator associated events

BACKGROUND The Centers for Disease Control and Prevention (CDC) replaced its definition for ventilator-associated pneumonia (VAP) in 2013. The aim of the current study is to compare the outcome of burn patients with ventilator associated events (VAEs). METHODS Burn patients with at least two days of ventilator support were identified from the registry between 2013 and 2016. Kruskal-Wallis and Fishers exact tests were utilized for continuous and categorical variables, respectively. A logistic regression was used for the association between VAE and in-hospital mortality. RESULTS 243 patients were admitted to our burn center, of whom 208 had no VAE, 8 had a VAC, and 27 had an IVAC or PVAP. There was no difference in hospital length of stay, ICU length of stay and ventilator support days between those with no VAE and a VAC. Those with IVAC-plus had significantly worse outcomes compared to patients with no VAEs. CONCLUSIONS Burn patients with IVAC-plus had significantly longer hospital and ICU lengths of stay, days on ventilator compared with patients with no VAEs.