Jonathan Grotts

Sensitivity and Specificity of Procalcitonin in Predicting Bacterial Infections in Patients With Renal Impairment

The objective of this study was to determine the sensitivity, specificity, positive and negative predictive values of procalcitonin levels for predicting bacterial infection in adult patients with renal impairment.

Periprosthetic Anesthetic for Postoperative Pain After Laparoscopic Ventral Hernia Repair: A Randomized Clinical Trial.

IMPORTANCE Laparoscopic ventral hernia repair (LVHR) using mesh is a well-established intervention for ventral hernia, but pain control can be challenging. OBJECTIVE To determine whether instillation of a long-acting local anesthetic between the mesh and the peritoneum after LVHR reduces pain or narcotic requirements. DESIGN, SETTING, AND PARTICIPANTS A prospective, double-blind, randomized clinical trial with data collection during a brief hospital stay in a tertiary care, community teaching hospital over 3 years between December 15, 2011, and March 28, 2014. Of 120 screened patients undergoing LVHR in this intention-to-treat analysis, 99 eligible patients were randomized. Forty-two patients received the study drug, and 38 patients received placebo. Patients with a history of chronic narcotic use were excluded. INTERVENTION After mesh placement, a long-acting local anesthetic (bupivacaine hydrochloride, 0.50%) or placebo (0.9% normal saline) was injected between the mesh and the peritoneum. MAIN OUTCOMES AND MEASURES Postoperative pain (on a standard scale ranging from 0 to 10), and narcotic medication use (intravenous morphine equivalents). There were no adverse events. RESULTS Baseline and operative characteristics were similar except that the treatment group was older (61.8 vs 52.3 years, P = .001). After surgery, pain scores in the recovery room (3.2 vs 4.7, P = .003), interval total narcotic use (6.7 vs 12.5 mg, P = .003 at <4 hours and 0 vs 2.7 mg, P = .01 at 8-12 hours), and total intravenous narcotic use (9.2 vs 17.2 mg of morphine sulfate equivalents, P = .03) were significantly less in the treatment group. CONCLUSIONS AND RELEVANCE Administration of a long-acting local anesthetic between the mesh and the peritoneum significantly reduces postoperative pain and narcotic use after LVHR. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01530815.

Prophylactic Fresh Frozen Plasma Infusion is Ineffective in Reversing Warfarin Anticoagulation and Preventing Delayed Intracranial Hemorrhage After Falls.

Background: Elderly patients, with considerable fall risk, are increasingly anticoagulated to prevent thromboembolic disease. We hypothesized that a policy of prophylactic fresh frozen plasma (FFP) infusion in patients having falls would reverse vitamin K antagonists (VKAs) and that reversal would decrease delayed intracranial hemorrhage (ICH). Methods: A retrospective review of patients with trauma admitted to a level 2 community trauma center was performed from January 2010 until November 2012. Inclusion criteria were: ground level fall (GLF) with suspected head trauma, on VKA, an international normalized ratio (INR) of >1.5, and a negative head computed tomography (CT). Patients were transfused with FFP to a goal INR of <1.5 while observed. Patients were classified as reversed (REV) if the lowest INR achieved within 4 to 24 hours after initial INR was <1.5 or unreversed (NREV) if lowest INR achieved was >1.5. Chi-square and logistic regression were performed. Results: A total of 194 patients met the criteria. In all, 43 (22%) patients were able to be REV, and 151 (78%) patients remained NREV. Unreversed patients were male and younger (P < .05). There was no difference in mean FFP received. Unreversed patients had a higher initial INR of 3.0 compared to REV patients (2.5; P = .018). One patient developed a delayed ICH and belonged to the REV group. Conclusion: The incidence of delayed hemorrhage was 0.5%. A strategy of prophylactic FFP infusion was ineffective in VKA reversal. We recommend against prophylactic infusion of FFP during a period of observation for patients on VKA with suspected head trauma and a negative initial CT.

Screening for osteoporosis after trauma: a new approach using quantitative computed tomography of the skull.

BACKGROUND The diagnosis of osteoporosis is important in the care of elderly patients at risk of trauma. While pelvis computed tomography (CT) is accurate in the measurement of bone mineral density, axial skull CT has not previously been evaluated for this purpose. This study investigated whether data from axial skull CT scans can screen for osteoporosis. METHODS Bone density measurements were derived from digital analysis of routine scans of the head and pelvis using quantitative CT. The study took place from October 2010 to November 2011 at a medium-sized community hospital. The first study phase included patients older than 18 years who had both a head and a pelvis CT scan within 30 days. The known diagnostic value for osteoporosis on pelvis CT scans was used to derive a diagnostic value for head CT. The second study phase included adult trauma patients who underwent noncontrast head CT during an initial trauma evaluation. A subgroup analysis was performed during Phase II on patients older than 65 years to identify the incidence of fracture as it is affected by age and bone mineral density. RESULTS Our data demonstrated that head CT was able to identify osteoporosis with a sensitivity of 0.70, a specificity of 0.81, and an accuracy of 0.76 compared with pelvic CT. Of 261 trauma patients, 54% had bone disease based on axial skull CT criteria. Patients older than 65 years with a positive screen result for osteoporosis on head CT were twice as likely to have a fracture. CONCLUSION Analysis of data from head CT scans has the potential to provide a useful screen for osteoporosis. Adding this analysis to CT scans performed for elderly trauma patients could result in improved diagnosis and treatment of osteoporosis. LEVEL OF EVIDENCE Diagnostic study, level II.