James K. Dzandu

Is there a difference in efficacy, safety, and cost-effectiveness between 3-factor and 4-factor prothrombin complex concentrates among trauma patients on oral anticoagulants?

PURPOSE The aim of this study was to compare the efficacy, safety, and cost-effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) vs 4-factor prothrombin complex concentrate PCC (4F-PCC) in trauma patients requiring reversal of oral anticoagulants. MATERIALS AND METHODS All consecutive trauma patients with coagulopathy (international normalized ratio [INR] ≥1.5) secondary to oral anticoagulants who received either 3F-PCC or 4F-PCC from 2010 to 2014 at 2 trauma centers were reviewed. Efficacy was determined by assessing the first INR post-PCC administration, and successful reversal was defined as INR less than 1.5. Safety was assessed by reviewing thromboembolic events, and cost-effectiveness was calculated using total treatment costs (drug acquisition plus transfusion costs) per successful reversal. RESULTS Forty-six patients received 3F-PCC, and 18 received 4F-PCC. Baseline INR was similar for 3F-PCC and 4F-PCC patients (3.1 ± 2.3 vs 3.4 ± 3.7, P = .520). The initial PCC dose was 29 ± 9 U/kg for 3F-PCC and 26 ± 6 U/kg for 4F-PCC (P = .102). The follow-up INR was 1.6 ± 0.6 for 3F-PCC and 1.3 ± 0.2 for 4F-PCC (P = .001). Successful reversal rates in patients were 83% for 4F-PCC and 50% for 3F-PCC (P = .022). Thromboembolic events were observed in 15% of patients with 3F-PCC vs 0% with 4F-PCC (P = .177). Cost-effectiveness favored 4F-PCC (

The importance of empiric antibiotic dosing in critically ill trauma patients: Are we under-dosing based on augmented renal clearance and inaccurate renal clearance estimates?

5382 vs

Trauma-associated pneumonia: time to redefine ventilator-associated pneumonia in trauma patients

3797). CONCLUSIONS Three-factor PCC and 4F-PCC were both safe in correcting INR, but 4F-PCC was more effective, leading to better cost-effectiveness. Replacing 3F-PCC with 4F-PCC for urgent coagulopathy reversal may benefit patients and institutions.

Identifying augmented renal clearance in trauma patients: Validation of the augmented renal clearance in trauma intensive care (ARCTIC) scoring system.

BACKGROUND An accurate assessment of creatinine clearance (CrCl) is essential when dosing medications in critically ill trauma patients. Trauma patients are known to experience augmented renal clearance (i.e., CrCl ≥130 mL/min), and the use of CrCl estimations may be inaccurate leading to under-/over-dosing of medications. As such, our Level I trauma center began using measured CrCl from timed urine collections to better assess CrCl. This study sought to determine the prevalence of augmented renal clearance and the accuracy of calculated CrCl in critically ill trauma patients. METHODS This observational study evaluated consecutive ICU trauma patients with a timed 12-hour urine collection for CrCl. Data abstracted were patient demographics, trauma-related factors, and CrCl. Augmented renal clearance was defined as measured CrCl ≥130 mL/min. Bias and accuracy were determined by comparing measured and estimated CrCl using the Cockcroft-Gault and other formulas. Bias was defined as measured minus calculated CrCl, and accuracy was calculated CrCl that was within 30% of measured. RESULTS There were 65 patients with a mean age of 48 years, serum creatinine (SCr) of 0.8 ± 0.3 mg/dL, and injury severity score of 22 ± 14. The incidence of augmented renal clearance was 69% and was more common when age was <67 years and SCr <0.8 mg/dL. Calculated CrCl was significantly lower than measured (131 ± 45 mL/min vs. 169 ± 70 mL/min, p < 0.001) and only moderately correlated (r = 0.610, p < 0.001). Bias was 38 ± 56 mL/min, which was independent of age quartile (p = 0.731). Calculated CrCl was inaccurate in 33% of patients and trauma-related factors were not predictive. CONCLUSION The prevalence of augmented renal clearance in critically ill trauma patients is high. Formulas used to estimate CrCl in this population are inaccurate and could lead to under-dosing of medications. Measured CrCl should be used in this setting to identify augmented renal clearance and allow for more accurate estimates of renal function. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Geriatric trauma G-60 falls with hip fractures: A pilot study of acute pain management using femoral nerve fascia iliac blocks.

BACKGROUND The high prevalence of ventilator-associated pneumonia (VAP) in trauma patients has been reported in the literature, but the reasons for this observation remain unclear. We hypothesize that trauma factors play critical roles in VAP etiology. METHODS In this retrospective study, 1,044 ventilated trauma patients were identified from December 2010 to December 2013. Patient-level trauma factors were used to predict pneumonia as study endpoint. RESULTS Ninety-five of the 1,044 ventilated trauma patients developed pneumonia. Rib fractures, pulmonary contusion, and failed prehospital intubation were significant predictors of pneumonia in a multivariate model. CONCLUSIONS It is time to redefine VAP in trauma patients based on the effect of rib fractures, pulmonary contusions, and failed prehospital intubations. The Centers for Disease Control and Prevention definition of VAP needs to be modified to reflect the effect of trauma factors in the etiology of trauma-associated pneumonia.

The impact of pre-injury direct oral anticoagulants compared to warfarin in geriatric G-60 trauma patients

BACKGROUND Augmented renal clearance (ARC) is common in trauma patients and associated with subtherapeutic antimicrobial concentrations. This study reported the incidence of ARC, identified ARC risk factors, and described a model to predict ARC (i.e., ARCTIC) that is specific to trauma patients. METHODS Consecutive trauma patients who were admitted to the intensive care unit between March 2015 and January 2016 and had a measured creatinine clearance (CrCl) were considered for inclusion. Patients were excluded if their serum creatinine (SCr) was greater than 1.3 mg/dL. ARC was defined as a measured CrCl of 130 mL/min or greater. Demographic and trauma-specific variables were then compared, and multivariate analysis was performed. Using these results, a weighted scoring system was constructed and evaluated using receiver operating characteristic curve analysis. ARCTIC score cutoffs were chosen based on sensitivity, specificity, positive predictive value, and negative predictive value. The derived scoring system was then compared to a previously published scoring system for accuracy. RESULTS There were 133 patients with a mean age of 48 ± 19 years and SCr of 0.8 ± 0.2 mg/dL. The mean measured CrCl was 168 ± 65 mL/min, and the incidence of ARC was 67%. Multivariate analysis revealed the following risk factors for ARC (age, <56: odds ratios [OR], 58.3; 95% confidence interval [CI], 5.2–658.9; age, 56 to 75: OR, 13.5; 95% CI, 1.2–151.7), SCr less than 0.7 mg/dL (OR, 12.5; 95% CI, 3–52.6), and male sex (OR, 6.9; 95% CI, 1.9–24.9). Using these results, the ARCTIC scoring system was: 4 points if younger than 56 years, 3 points if aged 56 years to 75 years, 3 points if SCr less than 0.7 mg/dL, and 2 points if male sex. Receiver operating characteristic curve analysis revealed an area (95% CI) of 0.813 (0.735–0.892) (p < 0.001). An ARCTIC score of 6 or higher had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.843, 0.682, 0.843, and 0.682, respectively. CONCLUSION The incidence of ARC in trauma patients is high. The ARCTIC score represents a practical, pragmatic system that can be easily applied at the bedside. An ARCTIC score of 6 or higher represents an appropriate cutoff to screen for ARC where antimicrobial adjustments should be considered. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Preperitoneal surgery using a self-adhesive mesh for inguinal hernia repair.

BACKGROUND Hip fractures due to falls cause significant morbidity and mortality among geriatric patients. A significant unmet need is an optimal pain management strategy. Consequently, patients are treated with standard analgesic care (SAC) regimens, which deliver high narcotic doses. However, narcotics are associated with delirium as well as gastrointestinal and respiratory failure risks. The purpose of this pilot study was to determine the safety and effectiveness of ultrasound-guided continuous compartmental fascia iliaca block (CFIB) in patients 60 years or older with hip fractures in comparison with SAC alone. METHODS We performed a retrospective study of 108 patients 60 years or older, with acute pain secondary to hip fracture (2012–2013). Patient variables were age, sex, comorbidities, and Injury Severity Score (ISS). Primary outcome was pain scores; secondary outcomes included hospital length of stay, discharge disposition, morbidity, and mortality. Statistical analysis was performed using (IBM SPSS version 22). For group comparison (SAC vs. SAC + CFIB) median test, repeated-measures analysis and Student’s t test of transformed pain scores were used. RESULTS Sixty-four patients received SAC only, and 44 patients received SAC + CFIB. Each CFIB placement was successful on first attempt without complications. Median time from emergency department arrival to block placement was 12.5 hours (interquartile range, 4–22 hours). Patients who received SAC + CFIB had significantly lower pain score ratings than patients treated with SAC alone. There were no differences in inpatient morbidity and mortality rates. Patients treated with SAC + CFIB were discharged home more often (p < 0.05). CONCLUSION Ultrasound-guided CFIB is safe, practical, and readily integrated into the G-60 service for improved pain management of hip fractures. We are now conducting a prospective randomized control trial to confirm our observations. LEVEL OF EVIDENCE Therapeutic study, level IV.

Geriatric (G60) trauma patients with severe rib fractures: Is muscle sparing minimally invasive thoracotomy rib fixation safe and does it improve post-operative pulmonary function?

PurposePre-injury oral anticoagulants are associated with worse outcomes in geriatric (G-60) trauma patients, but there are limited data comparing warfarin with direct oral anticoagulants (DOAC). We sought to compare outcomes in G-60 trauma patients taking pre-injury DOACs vs. warfarin.MethodsAll trauma patients, age ≥60 who were admitted to the hospital and taking an oral anticoagulant pre-injury were retrospectively identified. Patients were excluded if their reason for admission was a suicide attempt or penetrating extremity injury. Outcome measures included blood transfusions, hospital LOS, and mortality. A second analysis was performed, whereby patients were matched using ISS and age.ResultsThere were 3,941 patients identified; 331 had documentation of anticoagulant use, pre-injury (warfarin, n = 237; DOAC, n = 94). Demographics were similar, but ISS [9 (4–13) vs. 8 (4–9), p = .027], initial INR [2.2 (1.8–2.9) vs. 1.2 (1.1–1.5), p < .001], and the use of pharmacologic reversal agents (48 vs. 14%, p < .001) were higher in the warfarin group. There was no difference in the use of blood transfusions (24 vs. 17%, p = .164) or mortality (5.9 vs. 4.3%, p = .789) between warfarin and DOAC groups, respectively. However, LOS was longer in the warfarin group [5 (3–7.5) vs. 4 (2–6.3) days, p = .02]. Matched analysis showed no difference in blood transfusions (23 vs. 17%, p = .276), mortality (2.1 vs. 4.3%, p = .682) or LOS [5 (3–7) vs. 4 (2–6.3) days, p = .158] between warfarin and DOAC groups, respectively.ConclusionPre-injury DOACs are not associated with worse clinical outcomes compared to warfarin in G-60 trauma patients. Higher use of pharmacologic reversal agents with warfarin may be related to differences in mechanism of action and effect on INR.

Why Elderly Patients with Ground Level Falls Die Within 30 Days And Beyond

Background and Objectives: Laparoscopic preperitoneal hernia repair with mesh has been reported to result in improved patient outcomes. However, there are few published data on the use of a totally extraperitoneal (TEP) approach. The purpose of this study was to present our experience and evaluate early outcomes of TEP inguinal hernia repair with self-adhesive mesh. Methods: This cohort study was a retrospective review of patients who underwent laparoscopic TEP inguinal hernial repair from April 4, 2010, through July 22, 2014. Data assessed were age, sex, body mass index (BMI), hernia repair indications, hernia type, pain, paresthesia, occurrence (bilateral or unilateral), recurrence, and patient satisfaction. Descriptive and regression analyses were performed. Results: Six hundred forty patients underwent laparoscopic preperitoneal hernia surgery with self-adhesive mesh. The average age was 56 years, nearly all were men (95.8%), and the mean BMI was 26.2 kg/m2. Cases involved primary hernia more frequently than recurrent hernia (94% vs 6%; P < .05). After surgery, 92% of the patients reported no more than minimal pain, <1% reported paresthesia, and 0.2% had early recurrence. There were 7 conversions to an open procedure. The patients had no adverse reactions to anesthesia and no bladder injury. Postoperative acute pain or recurrence was not explained by demographics, BMI, or preoperative pain. There were significant associations of hernia side, recurrence, occurrence, and sex with composite end points. Nearly all patients (98%) were satisfied with the outcome. Conclusion: The use of self-adhesive, Velcro-type mesh in laparoscopic TEP inguinal hernia repair is associated with reduced pain; low rates of early recurrence, infection, and hematoma; and improved patient satisfaction.

Severe Traumatic Brain Injury: A Case Report

BACKGROUND Patient outcomes after muscle sparing minimally invasive thoracotomy rib fixation (MSMIT-ORF) in geriatric G60 trauma patients remain poorly studied. This study determined the effect of MSMIT-ORF on pulmonary function (PFT). Non-operatively managed (NOM) patients were also described. METHODS Medical records of G60 patients with severe rib fractures with PFTs measured before and after MSMIT-ORF were examined. Patient outcomes (MSMIT-ORF vs NOM) were adjusted in a multivariate logistic regression model. RESULTS 64 patients underwent MSMIT-ORF, 135 were NOM patients. MSMIT-ORF treated patients showed improvements in PFTs on postoperative day 5, p = 0.001. After adjustment analysis, MSMIT-ORF was associated with increased hospital length of stay (OR 44.9; 95% CI, 9.8-205, p < 0.001), but a more favorable discharge disposition. There was no difference in the rates of pneumonia (p = 0.996) or death (p = 0.140). CONCLUSIONS MSMIT-ORF is safe and improves pulmonary function in G60 trauma patients diagnosed with severe rib fractures. Future randomized control studies are needed for confirmation.