Erik Barquist

Blood transfusion, independent of shock severity, is associated with worse outcome in trauma.

BACKGROUND We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/systolic blood pressure) as covariates. METHODS Prospective data were collected on 15,534 patients admitted to a Level I trauma center over a 3-year period (1998-2000) and stratified by age, gender, race, Glasgow Coma Scale score, and Injury Severity Score. Admission anemia and blood transfusion were assessed as independent predictors of mortality, ICU admission, ICU LOS, and hospital LOS by logistic regression analysis, with base deficit, serum lactate, and shock index as covariates. RESULTS Blood transfusion was a strong independent predictor of mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.82-4.40; p < 0.001), ICU admission (OR, 3.27; 95% CI, 2.69-3.99; p < 0.001), ICU LOS (p < 0.001), and hospital LOS (Coef, 4.37; 95% CI, 2.79-5.94; p < 0.001) when stratified by indices of shock (base deficit, serum lactate, shock index, and anemia). Patients who underwent blood transfusion were almost three times more likely to die and greater than three times more likely to be admitted to the ICU. Admission anemia (hematocrit < 36%) was an independent predictor of ICU admission (p = 0.008), ICU LOS (p = 0.012), and hospital LOS (p < 0.001). CONCLUSION Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.

Adrenal insufficiency in the surgical intensive care unit patient

BACKGROUND Adrenocortical dysfunction is unusual in the unselected critically ill patient. Case reports document a state of corticosteroid responsive vasopressor dependence, resembling the systemic inflammatory response syndrome. The exact incidence of this disorder is unknown. METHODS We prospectively studied the incidence of adrenal insufficiency during a 9-month period in a surgical intensive care unit (ICU) population. Trauma, general surgery, urology, and gynecologic-oncology patients were included. Patients who met criteria were given a cosyntropin stimulation test. RESULTS Overall, the incidence of adrenal insufficiency was 0.66%. In the subgroup of patients with greater than 14 days stay in the ICU, 6% were found to have adrenal insufficiency. In patients aged more than 55 years and with ICU stays of 14 days or greater, 11% were adrenally insufficient. CONCLUSIONS Screening of critically ill patients for adrenal insufficiency, particularly those with prolonged ICU stay and age greater than 55 years, is warranted.

Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomized, prospective trial.

BackgroundCritically ill trauma patients frequently require prolonged endotracheal intubation and ventilator support. After extubation, swallowing difficulties may exist in ≤50% of patients. We sought to determine whether performing a swallowing evaluation would reduce the incidence of postextubation aspiration and subsequent pneumonia. DesignRandomized, prospective clinical trial of fiberoptic endoscopic evaluation of swallowing (FEES) vs. routine clinical management in patients after prolonged intubation. MethodsSeventy patients who were intubated for >48 hrs were randomized. FEES examinations were performed within 24 ± 2 hrs after extubation. Silent aspiration was defined as the appearance of liquid or puree bolus below the true vocal cords without coughing during a FEES examination. Clinical aspiration was defined as the removal of enteral content from below the vocal cords, usually during endotracheal tube placement. ResultsThere were five episodes of aspiration and pneumonia in the FEES group (14%, two silent) and two in the clinical group (6%, not significant, Fisher exact test). Patients aged >55 yrs and those with vallecular stasis on FEES examination were at significantly higher risk of postextubation aspiration. All patients with pneumonia had an associated aspiration episode. ConclusionsPatients with prolonged orotracheal intubation are at risk of aspiration after extubation. The addition of a FEES examination did not change the incidence of aspiration or postextubation pneumonia.

Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes Region of New York State.

BACKGROUND New York State instituted a statewide trauma system beginning in 1990. By 1993, that system included uniform emergency medical system triage guidelines, designated trauma centers, transfer agreements between trauma centers and noncenters, and a trauma registry containing data on seriously injured patients in each region and the state as a whole. We reviewed the first 4 years of registry data for the Finger Lakes Region to determine what effects the institution of a trauma system has had on the outcome of trauma care in this region. DESIGN Retrospective review of a regional trauma database. METHODS All qualifying injured patients in the region were entered into the registry beginning in 1993. Data from 1993 through 1996 for patients with blunt injuries were analyzed by both Trauma and Injury Severity Score (TRISS) methodology and logistic regression analysis. For comparison, two time periods were defined: 1993-1994 and 1995-1996. Outcomes for the two time periods were stratified by Revised Trauma Score and the presence or absence of head and/or cervical spine injury, and then compared by hospital type (regional trauma center, area trauma center, and noncenters). RESULTS In the later time period, there was a statistically significant decrease in the region-wide mortality rate. This was associated with a marked improvement in performance of the noncenters and with an increase in the proportion of patients who received definitive care at a trauma center. CONCLUSIONS Improved outcomes for patients with blunt trauma can occur early in the implementation of a trauma system. This improvement may be attributable in part to changes in field triage and early transport to trauma centers.

Unexpected findings in trauma patients dying in the intensive care unit: Results of 153 consecutive autopsies

BACKGROUND The true incidence of missed injuries in trauma-related deaths is unknown, because in only about 60% of injury-related deaths nationwide is an autopsy performed. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. We attempted to evaluate the incidence and nature of missed injuries and complications in trauma- and burn-related deaths in our ICU given an autopsy rate of close to 100%. STUDY DESIGN The medical records of all trauma- and burn-related deaths in the ICU over a 2-year period were reviewed retrospectively. Missed diagnoses were classified as class 1: major diagnosis that if recognized and treated appropriately might have changed outcomes; class II: major diagnosis that if recognized and treated appropriately would not have changed outcomes; and class III: minor diagnosis. RESULTS Complete antemortem records were available for 158 patients, of which 153 (97%) underwent autopsy. Mean age was 50 years, and 72% were males. Mean ICU stay was 10 15 days. Four (3%) patients had class I missed diagnoses: bowel infarction, meningitis, retroperitoneal abscess, and bleeding gastric ulcer. Twenty-five (16%) patients had class II diagnoses, and 12 (8%) patients had class III diagnoses. Overall, 81% of 153 patients had either class III diagnoses or no missed injuries or complications. Pneumonia was the most common missed diagnosis. CONCLUSIONS With an autopsy rate of 97%, 3% of deaths bad missed major diagnoses that might have affected outcomes if recognized antemortem. Autopsy findings can still provide valuable feedback in Improving the quality of care of critically ill trauma patients.

Comparison of antral tap with endoscopically directed nasal culture

Objectives/Hypothesis The diagnosis of acute bacterial rhinosinusitis continues to generate controversy in critically ill patients. The efficacy of endoscopically directed cultures in these patients is unknown. We compared antral tap (AT) with endoscopic tissue culture (ETC) of the osteomeatal complex in an intensive care unit (ICU) setting.

Inter- and Intrarater Reliability in Computed Axial Tomographic Grading of Splenic Injury: Why So Many Grading Scales?

OBJECTIVE After splenic trauma, critical decisions regarding operative intervention are often made with the aid of computed axial tomographic (CT) scan findings. No CT scan-based grading scale has been demonstrated to predict accurately which patients require operative or radiologic intervention for their splenic injuries. We hypothesized that use of the most common grading scale, the American Association for the Surgery of Trauma scale, would be associated with low intra- and interreliability scores. We assessed the ability of experienced trauma radiologists to differentiate grade III from grade IV splenic injuries. METHODS The films of patients who had undergone abdominal CT scanning before splenectomy for grade III or IV injuries were serially evaluated by four trauma radiology faculty weekly for 3 weeks. We assessed intra- and interrater reliability for grading and for presence of contrast blush. RESULTS Intrarater reproducibility yielded a weighted kappa score of 0.15 to 0.77. Interrater reliability weighted kappa scores ranged from 0 to 0.84, with a mean value of 0.23. CONCLUSION CT imaging is not reliable for identifying grades III and IV splenic injury, as experienced radiologists often underestimate the magnitude of injury. Interrater reliability is poor. Factors other than the CT grade of splenic injury should determine whether patients require operative or angiographic therapy.

Nonventilatory Interventions in the Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome was first described in 1967. Acute respiratory distress syndrome and acute lung injury are diseases the busy intensivist treats almost daily. The etiologies of acute respiratory distress syndrome are many. A significant distinction is based on whether the insult to the lung was direct, such as in pneumonia, or indirect, such as trauma or sepsis. Strategies for managing patients with acute respiratory distress syndrome/acute lung injury can be subdivided into 2 large groups, those based in manipulation of mechanical ventilation and those based in nonventilatory modalities. This review focuses on the nonventlilatory strategies and includes fluid restriction, exogenous surfactant, inhaled nitric oxide, manipulation of production, or administration of eicosanoids, neuromuscular blocking agents, prone position ventilation, glucocorticoids, extracorporeal membrane oxygenation, and administration of beta-agonists. Most of these therapies either have not been studied in large trials or have failed to show a benefit in terms of long-term patient mortality. Many of these therapies have shown promise in terms of improved oxygenation and may therefore be beneficial as rescue therapy for severely hypoxic patients. Recommendations regarding the use of each of these strategies are made, and an algorithm for implementing these strategies is suggested.

A technique for emergency liver packing.

Control of liver hemorrhage may present a daunting clinical scenario. Use of liver packing techniques is highly effective to control bleeding but can result in significant recurrent bleeding with pack removal. Such bleeding is particularly a problem when large portions of the hepatic parenchymal surface and Glisson’s capsule have been disrupted. We describe, herein, our approach to hepatic packing in scenarios where a large component of hepatic capsular disruption has occurred. Use of a non-stick bowel bag is employed on the disrupted liver surface, which, when removed, will not result in liver rebleeding. This technique has been used successfully in the management of five cases of severe liver injury with extensive capsular disruption. Familiarity with such an approach may facilitate management of similar liver injuries.

Geriatric outcomes for trauma patients in the state of Florida after the advent of a large trauma network.

BACKGROUND Florida State has one of the largest geriatric populations in the United States. However, recent data show that up to the year 2010, geriatric trauma patients were least served by designated trauma centers (TCs). One existing TC and five provisional Level 2 TCs were combined to create a large-scale trauma network (TN). The new TCs were placed in those areas with the lowest ratios of TC to residents based on census data. The aim of this study was to measure the TN impact on the population of geriatric trauma patients. METHODS Data from the Florida State Agency for Health Care Administration were used to determine mortality, length of stay, and complication rates for geriatric trauma patients (≥ 65 years). The potential effect of the TN was measured by comparing outcomes before and after the initiation of the TN. A total of 165,640 geriatric patients were evaluated. Multivariate regression methods were used to match and adjust for age, injury status (penetrating vs. nonpenetrating), sex, race, comorbidity, and injury severity (DRG International Classification of Diseases—9th Rev. Injury Severity Score). RESULTS Since the advent of the TN, an additional 1,711 geriatric patients were treated compared with the previous period. The TN was responsible 86% of these new patients. There was a temporal association with a decrease in both mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.85–0.96) and length of stay (p < 0.0001) for geriatric patients since the advent of the TN. The improved access was associated with a significant decrease in mortality in the regions serviced by the TN. CONCLUSION Geriatric patients make up a significant proportion of trauma patients within the TN. The temporal improvement in outcomes may be associated with the increased proportion of patients being treated in state-designated TCs as a result of the addition of the TN. LEVEL OF EVIDENCE Epidemiologic study, level III.