Kelli H. Foulkrod

Barriers to obtaining family consent for potential organ donors.

BACKGROUND Our country suffers from a chronic shortage of organ donors, and the list of individuals in desperate need of life-saving organ transplants is growing every year. Family consent represents an important limiting factor for successful donation. We hypothesize that specific barriers to obtaining family consent can be identified and improved upon to increase organ donation consent rates. The purpose of this study was to compare families who declined organ donation to those who granted consent, specifically to identify barriers to family consent for successful organ donation. METHODS We performed a 4-year (2004-2007) retrospective study of potential organ donors covered by our regional organ procurement organization (OPO). Variables collected included age, gender, race, cause of brain death (trauma vs. medical) of the potential organ donor, and elapsed time from declaration of brain death to family approach by OPO. Potential organ donors whose family declined organ donation (DECLINE group) were compared with potential organ donors whose family consented to organ donation (CONSENT group). Groups were compared using univariate and multivariate analysis. RESULTS There were a total of 827 potential organ donors during the 4-year period within our OPO region. Overall, 471 families (57%) consented to organ donation, whereas 356 families (43%) declined. Although there was no difference in male gender between the DECLINE and CONSENT groups (59% vs. 53%, p = 0.12), the DECLINE group had more medical brain deaths (73% vs. 58%, p < 0.001), more potential donors aged 50 years or older (43% vs. 34%, p < 0.001), as well as more potential organ donors of Hispanic (67% vs. 43%, p < 0.001) and African American (10% vs. 4%, p < 0.001) descent. In addition, time from declaration of brain death to family approach by OPO was longer for the DECLINE group (350 minutes vs. 112 minutes, p = 0.001). Logistic regression identified race, older age, and death from a medical cause as independent risk factors for failure of obtaining consent. CONCLUSION Several barriers exist to family consent for successful organ donation. Family members of minority populations, medical brain deaths, and older potential donors more often decline consent for organ donation. Family education and resource utilization toward these specific populations of potential organ donors may help to improve organ donation consent rates. In addition, delayed family approach by OPO seems to be associated with decreased consent rates. System improvements to expedite family approach by OPO may likewise lead to improved consent rates.

Risk factors associated with early reintubation in trauma patients: A prospective observational study

BACKGROUND After mechanical ventilation, extubation failure is associated with poor outcomes and prolonged hospital and intensive care unit (ICU) stays. We hypothesize that specific and unique risk factors exist for failed extubation in trauma patients. The purpose of this study was to identify the risk factors in trauma patients. METHODS We performed an 18-month (January 2008-June 2009) prospective, cohort study of all adult (8 years or older) trauma patients admitted to the ICU who required mechanical ventilation. Failure of extubation was defined as reintubation within 24 hours of extubation. Patients who failed extubation (failed group) were compared with those who were successfully extubated (successful group) to identify independent risk factors for failed extubation. RESULTS A total of 276 patients were 38 years old, 76% male, 84% sustained blunt trauma, with an mean Injury Severity Score = 21, Glasgow Coma Scale (GCS) score = 7, and systolic blood pressure = 125 mm Hg. Indications for initial intubation included airway (4%), breathing (13%), circulation (2%), and neurologic disability (81%). A total of 17 patients (6%) failed extubation and failures occurred a mean of 15 hours after extubation. Independent risk factors to fail extubation included spine fracture, airway intubation, GCS at extubation, and delirium tremens. Patients who failed extubation spent more days in the ICU (11 vs. 6, p = 0.006) and hospital (19 vs. 11, p = 0.002). Mortality was 6% (n = 1) in the failed group and 0.4% (n = 1) in the successful extubation group. CONCLUSIONS Independent risk factors for trauma patients to fail extubation include spine fracture, initial intubation for airway, GCS at extubation, and delirium tremens. Trauma patients with these four risk factors should be observed for 24 hours after extubation, because the mean time to failure was 15 hours. In addition, increased complications, extended need for mechanical ventilation, and prolonged ICU and hospital stays should be expected for trauma patients who fail extubation.

Recombinant factor VIIa for the correction of coagulopathy before emergent craniotomy in blunt trauma patients.

BACKGROUND Recombinant activated factor VII (rFVIIa) has been associated with decreased blood transfusion requirements in trauma patients. Clinical use has recently been extended to the treatment of coagulopathic patients with traumatic brain injury, and results have been encouraging. However, the cost and possible thromboembolic complications of rFVIIa have been considered barriers to its widespread use. We hypothesize that rFVIIa would provide an effective and cost efficient means of correcting coagulopathy in patients with traumatic brain injury undergoing emergent craniotomy. METHODS We performed a 2-year (2005-2006) retrospective study of adult blunt trauma patients with traumatic brain injury who presented coagulopathic (international normalized ratio [INR] >1.3) and required emergent craniotomy. We compared patients who did (rFVIIa group) and did not (no-rFVIIa group) receive rFVIIa to correct coagulopathy before craniotomy. RESULTS There were 14 rFVIIa patients and 14 no-rFVIIa patients. The rFVIIa patients were older (59 years vs. 41 years, p = 0.04), but there was no difference in male gender (79% vs. 79%, p = 0.68), injury severity score (29 vs. 29, p = 1.0), or Glasgow Coma Scale score (10 vs. 7, p = 0.67). Although there was no difference in admission INR (2.6 vs. 1.9, p = 0.10), the rFVIIa group was more often taking preinjury coumadin (57% vs. 14%, p = 0.05). The rFVIIa group had a preoperative INR (1.2 +/- 0.4 vs. 1.4 +/- 0.2, p = 0.05), but there was no difference in the time from admission to craniotomy (135 minutes vs. 182 minutes, p = 0.51). The rFVIIa group received fewer units of packed red blood cells (PRBCs) and plasma during the perioperative period. In addition, the rVIIa group consumed fewer costs of PRBC (

Autologous Blood Transfusion During Emergency Trauma Operations

756 per patient vs.

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study

2,916 per patient, p < 0.001) and plasma (

Trauma surgeon personality and job satisfaction: results from a national survey.

369 per patient vs.

Computed tomography versus magnetic resonance imaging for evaluation of the cervical spine: How many slices do you need?

927 per patient, p = 0.001). The rFVIIa group still consumed fewer total costs of transfused blood products when cost of rFVIIa was included (

Intraoperative assessment of breast cancer specimens decreases cost and number of reoperations.

2,557 per patient vs.

Trauma healthcare providers' knowledge of alcohol abuse.

4,110 per patient, p = 0.04). There were no thromboembolic complications in either group. CONCLUSIONS rFVIIa provides a cost-efficient option to effectively correct coagulopathy in patients with traumatic brain injury undergoing emergent craniotomy. In addition, the use of rFVIIa is associated with decreased transfusion of PRBC and plasma and decreased transfusion-related hospital costs in this population.

Computed tomography versus magnetic resonance imaging for evaluation of the cervical spine

HYPOTHESIS Intraoperative cell salvage (CS) of shed blood during emergency surgical procedures provides an effective and cost-efficient resuscitation alternative to allogeneic blood transfusion, which is associated with increased morbidity and mortality in trauma patients. DESIGN Retrospective matched cohort study. SETTING Level I trauma center. PATIENTS All adult trauma patients who underwent an emergency operation and received CS as part of their intraoperative resuscitation. The CS group was matched to a no-CS group for age, sex, Injury Severity Score, mechanism of injury, and operation performed. MAIN OUTCOME MEASURES Amount and cost of allogeneic transfusion of packed red blood cells and plasma. RESULTS The 47 patients in the CS group were similar to the 47 in the no-CS group for all matched variables. Patients in the CS group received an average of 819 mL of autologous CS blood. The CS group received fewer intraoperative (2 vs 4 U; P = .002) and total (4 vs 8 U; P < .001) units of allogeneic packed red blood cells. The CS group also received fewer total units of plasma (3 vs 5 U; P = .03). The cost of blood product transfusion (including the total cost of CS) was less in the CS group (