Isaac Tawil

Should More Patients Continue Aspirin Therapy Perioperatively?: Clinical Impact of Aspirin Withdrawal Syndrome

Objective:To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal. Background:For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned. Methods:We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion. Results/Conclusions:Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.

Family presence during brain death evaluation: a randomized controlled trial

Objective:To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress. Design:Randomized controlled trial. Setting:Four ICUs at an academic tertiary care center. Subjects:Immediate family members of patients suspected to have suffered brain death. Interventions:Subjects were group randomized to presence or absence at bedside throughout the brain death evaluation with a trained chaperone. All randomized subjects were administered a validated “understanding brain death” survey before and after the intervention. Subjects were assessed for psychological well-being between 30 and 90 days after the intervention. Measurements and Main Results:Follow-up assessment of psychological well-being was performed using the Impact of Event Scale and General Health Questionnaire. Brain death understanding, Impact of Event Scale, and General Health Questionnaire scores were analyzed using Wilcoxon nonparametric tests. Analyses were adjusted for within family correlation. Fifty-eight family members of 17 patients undergoing brain death evaluation were enrolled: 38 family members were present for 11 brain death evaluations and 20 family members were absent for six brain death evaluations. Baseline understanding scores were similar between groups (median 3.0 [presence group] vs 2.5 [control], p = 0.482). Scores increased by a median of 2 (interquartile range, 1–2) if present versus 0 (interquartile range, 0–0) if absent (p < 0.001). Sixty-six percent of those in the intervention group achieved perfect postintervention “understanding” scores, compared with 20% of subjects who were not present (p = 0.02). Median Impact of Event Scale and General Health Questionnaire scores were similar between groups at follow-up (Impact of Event Scale: present = 20.5, absent = 23.5, p = 0.211; General Health Questionnaire: present = 13.5, absent = 13.0, p = 0.250). Conclusions:Family presence during brain death evaluation improves understanding of brain death with no apparent adverse impact on psychological well-being. Family presence during brain death evaluation is feasible and safe.

Rapid progression of traumatic bifrontal contusions to transtentorial herniation: A case report

We report a case of mild to moderate traumatic brain injury in which ICP monitoring or quantitative cerebral perfusion data may have allowed earlier recognition of impending herniation, avoidance of a secondary insult, and ultimately resulted in a better outcome, even though the patient did not meet the standard guidelines of the Brain Trauma Foundation. A thirty-five year old male who presented with traumatic bifrontal contusions and GCS of fourteen and twelve hours later progressed rapidly to having dilated pupils and transtentorial/central herniation over the course of fifteen minutes. The patient was taken emergently for a bifrontal craniectomy. Post operatively he had an acute infarct in the posterolateral left temporal lobe with expected evolution of parenchymal contusions as well as infarcts in the splenium of the corpus callosum, left thalamus and medial right occipital lobe. This case signifies an exception from the guidelines submitted by the Brain Trauma Foundation for intracranial pressure monitoring in patients with severe brain injury.We also point out previous reports which state that in such a patient a more sensitive test for detection would perhaps be quantitative blood flow monitoring, and may have led to a better outcome. We recommend using intracranial pressure monitoring or blood flow measurements to trend patients with bifrontal intraparenchymal contusions and GCS greater than eight to prevent clinically undetected deterioration from transtentorial/central herniation.

ED intensivists and ED intensive care units

a Division of Emergency Critical Care, Mount Sinai School of Medicine, New York, NY, USA b Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA c Departments of Critical Care Medicine & Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA d Department of Surgery/ Department of Emergency Medicine, University of New Mexico Health Science Center, Albuquerque, NM, USA e Department of Emergency Medicine & Department of Surgery, Division of Trauma/Critical Care, Virginia Commonwealth University, Richmond, VA, USA f Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA

HBOC-201 use in traumatic brain injury: case report and review of literature

BACKGROUND: The first use of HBOC‐201 in severe traumatic brain injury (TBI) is presented. The use of noninvasive cerebral oximetric devices to follow clinical progress in a patient infused with HBOC‐201 is reported and the literature of hemoglobin‐based oxygen carriers (HBOCs) in brain injury is reported.

Impact of positive pressure ventilation on thoracostomy tube removal.

BACKGROUND Little data exist examining the impact of positive pressure ventilation on safe thoracostomy tube removal. We sought to evaluate the impact of positive-pressure ventilation (PPV) on recurrent pneumothoraces (PTX) after removal of thoracostomy tubes (TT). METHODS A retrospective cohort analysis was performed evaluating all trauma patients requiring TT drainage of PTX or hemothoraces during a 3-year period. All chest radiographs before and after TT removal were reviewed to identify PTX recurrence. The principle outcome was recurrent PTX after TT removal. The 95% confidence intervals were calculated to assess for significance. RESULTS We studied 234 TT removals in 190 patients. One hundred thirty-six (58%) TTs were removed under PPV. PTX recurred in 15 (11%) and 6 (4%) required reinsertion. In 10 patients (7.4%), there was a radiographically stable small PTX before and after removal not requiring TT reinsertion. In comparison, 98 (42%) TTs were removed under spontaneous ventilation. PTX recurred in 16 (16%) and 3 (3%) required reinsertion. There were 25 (25.5%) stable small PTXs before and after removal. The overall recurrence rate difference was -5.3% (confidence interval: -14.8 to 3.5) and reinsertion rate difference was 1.35% (confidence interval: -4.7 to 6.6). CONCLUSIONS The rate of recurrent PTX or TT replacement after removal is not associated with PPV status. The slightly lower recurrence rate on PPV combined with the smaller proportion of patients with stable small PTX before removal may reflect more careful clinician selection of ideal patients or technique of TT removal among patients on PPV. Prospective data are needed to clarify these associations.

Ultrasonographic Determination of Pubic Symphyseal Widening in Trauma: The FAST-PS Study

BACKGROUND The focused abdominal sonography in trauma (FAST) examination is a routine component of the initial work-up of trauma patients. However, it does not identify patients with retroperitoneal hemorrhage associated with significant pelvic trauma. A wide pubic symphysis (PS) is indicative of an open book pelvic fracture and a high risk of retroperitoneal bleeding. STUDY OBJECTIVES We hypothesized that an ultrasound image of the PS as part of the FAST examination (FAST-PS) would be an accurate method to determine if pubic symphysis diastasis was present. METHODS This is a comparative study of a diagnostic test on a convenience sample of 23 trauma patients at a Level 1 Trauma Center. The PS was measured sonographically in the Emergency Department (ED) and post-mortem (PM) at the State Medical Examiner. The ultrasound (US) measurements were then compared with PS width on anterior-posterior pelvis radiograph. RESULTS Twenty-three trauma patients were evaluated with both plain radiographs and US (11 PM, 12 ED). Four patients had radiographic PS widening (3 PM, 1 ED) and 19 patients had radiographically normal PS width; all were correctly identified with US. US measurements were compared with plain X-ray study by Bland-Altman plot. With one exception, US measurements were within 2 standard deviations of the radiographic measurements and, therefore, have excellent agreement. The only exception was a patient with pubic symphysis wider than the US probe. CONCLUSION Bedside ultrasound examination may be able to identify pubic symphysis widening in trauma patients. This potentially could lead to faster application of a pelvic binder and tamponade of bleeding.

Acute Respiratory Distress Syndrome after Onyx Embolization of Arteriovenous Malformation

Purpose. We report a case of a 60-year-old male who underwent sequential Onyx embolizations of a cerebral arteriovenous malformation (AVM) which we implicate as the most likely etiology of subsequent acute respiratory distress syndrome (ARDS). Methods. Case report and literature review. Results. Shortly after the second Onyx embolization procedure, the patient declined from respiratory failure secondary to pulmonary edema. Clinical entities typically responsible for pulmonary edema including cardiac failure, renal failure, iatrogenic volume overload, negative-pressure pulmonary edema, and infectious etiologies were evaluated and excluded. The patient required mechanical ventilatory support for several days, delaying operative resection. The patient met clinical and radiographic criteria for ARDS. After excluding other etiologies of ARDS, we postulate that ARDS developed as a result of Onyx administration. The Onyx copolymer is dissolved in dimethyl sulfoxide (DMSO), a solvent excreted through the lungs and has been implicated in transient pulmonary side effects. Additionally, a direct toxic effect of the Onyx copolymer is postulated. Conclusion. Onyx embolization and DMSO toxicity are implicated as the etiology of ARDS given the lack of other inciting factors and the close temporal relationship. A strong physiologic rationale provides further support. Clinicians should consider this uncommon but important complication.

Effects of ethnicity on deceased organ donation in a minority-majority state.

Objective:To define how ethnicity affects donation rates in New Mexico when compared with the United States. We hypothesized that deceased donation rates in New Mexico would reflect the ethnic rates of the population. Design:We performed a retrospective review of the Organ Procurement Database for New Mexico from 2009 to June 2012. Methods:Rates for donors and transplant candidates were calculated relative to 2010 census population estimates by ethnicity for non-Hispanic Whites, Hispanics, and American Indians. Poisson regression analyses were used to test whether United States and New Mexico rates differed. Rates were scaled to 100,000 patient-years for reporting. Setting:State of New Mexico population compared to United States population. Subjects:Reported deaths to New Mexico Donor Services and United Network for Organ Sharing from 2009 to 2012. Interventions:None. Measurements and Main Results:Non-Hispanic White age-adjusted donor rates per 100,000 patient-years were 2.58 in New Mexico versus 2.60 in the United States, Hispanic donor rates were 1.98 in New Mexico versus 2.03 nationwide, and American Indian donor rates in New Mexico were 0.26 versus 1.23 nationwide (rate ratio = 0.21; 95% CI, 0.05–0.86). American Indians have significantly lower donor rates in New Mexico compared to non-Hispanic Whites (rate ratio = 0.11) and Hispanics (rate ratio = 0.13) and nationally (non-Hispanic Whites: rate ratio = 0.32 and Hispanics: rate ratio = 0.43). Hispanics and non-Hispanic Whites had similar donor rates regardless of geographic strata (Hispanics vs non-Hispanic Whites, New Mexico: 0.83; United States: 0.75). In New Mexico, Hispanic patients were 1.43 times more likely to be listed as transplant candidates than non-Hispanic Whites and American Indians were 3.32 times more likely to be listed than non-Hispanic Whites. In the United States, Hispanic patients were 1.90 times more likely to be listed as transplant candidates than non-Hispanic Whites and American Indians were 1.55 times more likely to be listed than non-Hispanic Whites. Conclusions:Donor and transplant candidate rates did not show strong differences by geographic strata. These findings suggest that further work is needed to elucidate the causes for ethnic differences in rates of consent and donation, particularly in the American Indian population.

Resident Guideline Development to Standardize Intensive Care Unit Care Delivery: A Competency-Based Educational Method

PURPOSE We developed a system of resident-driven, evidence-based standardization of care in our trauma-surgical intensive care unit (TSICU). Our main purposes are to improve patient care and outcomes and to help the residents develop practical competency in practice-based learning and improvement and in systems-based practice. DEVELOPMENT OF THE ACTIVITY Since October 2006, each rotating TSICU resident has chosen a topic to research the available evidence and has developed a guideline, which the resident then presents to the TSICU faculty and residents for discussion, amendments, and acceptance or reevaluation. EVALUATION COMPONENT Evaluation of proposed guidelines is based on the quality of information presented in support of the recommendations. Ultimately, acceptance of a guideline requires consensus among the TSICU faculty. Immediate feedback is given to the presenting resident by the faculty. The residents evaluate the program via a Web-based evaluation tool. PROPOSED OUTCOME MEASURES We have qualitative data from residents that indicate this experience is positive. We are developing a tool to use both qualitative and quantitative means to evaluate resident, faculty, and nursing staff satisfaction with the process. We will use our clinical database to evaluate whether improved patient outcomes have resulted from standardization of care. IMPLEMENTATION DATES AND EXPERIENCE TO DATE We implemented this methodology in October 2006 and have thus far implemented 20 guidelines and 2 standardized order sets. CONCLUSION AND OR NEXT STEPS: We believe competency is achieved and demonstrated by actively participating in a process such as development of care guidelines. Researching and developing standardized guidelines for our TSICU seems to be an effective and practical way for residents to use multiple sources for practice-based learning and improvement. It also requires the resident to advocate for quality patient care and optimal patient care systems. We plan to use outcome and qualitative data to validate this method.