Kelly Bochicchio

Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury.

OBJECTIVES There is an absence of prospective data evaluating the impact of prehospital intubation in adult trauma patients. Our objectives were to determine the outcome of trauma patients intubated in the field who did not have an acutely lethal traumatic brain injury (death within 48 hours) compared with patients who were intubated immediately on arrival to the hospital. METHODS Prospective data were collected on 191 consecutive patients admitted to the trauma center with a field Glasgow Coma Scale score < or = 8 and a head Abbreviated Injury Scale score > or = 3 who were either intubated in the field or intubated immediately at admission to the hospital. Patients who died within 48 hours of admission and transfers were excluded from the study. RESULTS Of the 191 patients, 176 (92%) sustained blunt trauma and 25 (8%) were victims of penetrating trauma. Seventy-eight (41%) of the 191 patients were intubated in the field and 113 (59%) were intubated immediately at admission. There was no significant difference in age, Glasgow Coma Scale score, head Abbreviated Injury Scale score, or Injury Severity Score between the two groups. Patients who were intubated in the field had a significantly higher morbidity (ventilator days, 14.7 vs. 10.4; hospital days, 20.2 vs. 16.7; and intensive care unit days, 15.2 vs. 11.7) compared with patients intubated on immediate arrival to the hospital and nearly double the mortality (23% vs. 12.4). Field-intubated patients had a 1.5 times greater risk of nosocomial pneumonia compared with hospital-intubated patients. CONCLUSION Prehospital intubation is associated with a significant increase in morbidity and mortality in trauma patients with traumatic brain injury who are admitted to the hospital without an acutely lethal injury. A randomized, prospective study is warranted to confirm these results.

Early aggressive use of fresh frozen plasma does not improve outcome in critically injured trauma patients.

Objectives:Recent data from Iraq supporting early aggressive use of fresh frozen plasma (FFP) in a 1:1 ratio to packed red blood cells (PRBCs) has led many civilian trauma centers to adopt this resource intensive strategy. Methods:Prospective data were collected on 806 consecutive trauma patients admitted to the intensive care unit over 2 years. Patients were stratified by PRBC:FFP transfusion ratio over the first 24 hours. Stepwise regression models were performed controlling for age, gender, mechanism of injury, injury severity, and acute physiology and chronic health evaluation (APACHE) 2 score to determine if early aggressive use of PRBC:FFP improved outcome. Results:Seventy-seven percent of patients were male (N = 617) and 85% sustained blunt injury (n = 680). Mean age, injury severity score (ISS), and APACHE score were 43 ± 20 years, 29 ± 13, and 13 ± 7, respectively. Mean number of PRBCs and FFP transfused were 7.7 ± 12 U, 6 U, and 5 ± 12 U, respectively. Three hundred sixty-five (45%) patients were transfused in the first 24 hours. Sixty-eight percent (n = 250) of them received both PRBCs and FFP. Analyzing these patients by stepwise regression controlling for all significant variables, the PRBC:FFP ratio did not predict intensive care unit days, hospital days, or mortality even in patients who received massive transfusion (≥10 U). Furthermore, there was no significant difference in outcome when comparing patients who had a 1:1 PRBC:FFP ratio with those who did not receive any FFP. Conclusion:Early and aggressive use of FFP does not improve outcome after civilian injury. This may reflect inherent differences compared with military injury; however, this practice should be reevaluated.

Tight glycemic control in critically injured trauma patients.

Objectives:Evaluate the impact of a tight glucose control (TGC) protocol during the first week of admission in critically injured trauma patients. Methods:A prospective quasi-experimental interrupted time-series design was used to evaluate the impact of TGC [24-month preintervention phase (no TGC) vs. 24-month postintervention phase]. Patients were stratified by serum glucose level on day 1 to 7 (low, 0–150 mg/dL; medium-high, 151–219 mg/dL; and high, ≥220 mg/dL), age, gender, and injury severity. Patients were further stratified by pattern of glucose control (all low, all medium high, all high, improving, worsening, highly variable). Outcome was measured by ventilator days, infection, hospital (HLOS) and ICU (ILOS) length of stay, and mortality. Results:One thousand twenty-one patients were evaluated in the preintervention phase as compared with 1108 patients in the postintervention phase. There was no significant difference in mechanism of injury (83% vs. 84% blunt), gender (74% vs. 73% male), age (44 vs. 43 years), and Injury Severity Score (ISS) (26 vs. 25). The TGC group was more likely to be in the all low and improving pattern of glucose control (P < 0.001). The incidence of infection significantly decreased (over the first 2 weeks) from 29% to 21% in the TGC group (P < 0.001). Ventilator days (OR = 3.9, 1.8, 8.1), ILOS (OR = 4.3, 2.1, 7.5), and HLOS (OR = 5.5, 2.2, 11) and mortality (OR = 1.4, 1.1, 10) were significantly higher in the non-TGC group when controlled for age, ISS, obesity, and diabetes (P < 0.01). Conclusion:The positive outcomes associated with the implementation of a TGC protocol necessitates further evaluation in a randomized prospective trial.

Early hyperglycemic control is important in critically injured trauma patients

BACKGROUND Our objectives were to determine whether persistent hyperglycemia when compared with normoglycemia was predictive of outcome in the later stages of hospitalization in critically injured trauma patients. METHODS A prospective study was conducted on 896 consecutive trauma patients admitted to the intensive care unit during a 2-year period. Patients were stratified by serum glucose level on day 1 to day 28 (low = 0-139 mg/dL, medium to high = 140-219 mg/dL, and high = >220 mg/dL), age, gender, race, insulin dependent diabetes, obesity, and Injury Severity Score (ISS). Patients were further stratified by pattern of glucose control (all low, all moderate, all high, improving, worsening, highly variable. Outcome was measured by ventilator days, infection, hospital and intensive care unit length of stay, and mortality. Multiple variable logistic and linear regression models were used to determine level of significance. RESULTS Eighty-three percent were victims of blunt trauma. The majority (74%) were male, with a mean ISS of 26 +/- 12. Hyperglycemia (moderate, worsening, and highly variable) in the first week was associated with significantly greater hospital and intensive care unit length of stay, ventilator time, infection, and mortality when controlling for age, race, gender, ISS, mechanism of injury, obesity, and insulin dependent diabetes (p < 0.03). However, hyperglycemia in later weeks was not associated with infection and only weakly associated with mortality when analyzed by the same model. When controlling for glucose levels in subsequent weeks, patients who were normoglycemic in the first week had a lower infection rate and were less likely to die even when controlling for age, ISS, and obesity (p < 0.05). CONCLUSIONS Early euglycemia is associated with improved outcome and appears to be protective regardless of glucose levels in subsequent weeks. Further studies are warranted to determine the etiology of this protective effect.

A time-dependent analysis of intensive care unit pneumonia in trauma patients.

BACKGROUND Appropriate and timely antibiotic therapy to treat pneumonia in trauma patients is extremely important. We evaluated the incidence and microbiology of pneumonia stratified by days postadmission and risk factors. METHODS Prospective data were collected on 714 trauma patients admitted to the intensive care unit over a 1-year period. Pneumonia was classified as community acquired (CAP) (< or = 3 days), early nosocomial (ENP) (4-6 days), or late nosocomial (LNP) (> or = 7 days). In addition, pneumonia was classified as CAP only, nosocomial only (NI), or combination (CAP and NI, or ENP and LNP) pneumonia. Strict institutional guidelines were followed for diagnosis. RESULTS One hundred eighty-two patients (25%) were diagnosed with 204 pneumonias over the study period. One hundred twenty-five (61%) of these pneumonias were ventilator associated. Staphylococcus aureus and Haemophilus influenzae were the most common pathogens isolated. Twenty-one percent of patients with CAP acquired an LNP (p < 0.025), in which Pseudomonas was the most common organism. Haemophilus caused LNP in 12% of patients. Cancer (p < 0.01), liver failure (p < 0.05), and age (p < 0.01) were predictive of nontypical pathogens in patients with CAP and ENP (p < 0.05). Obesity was most predictive of increased ventilator days (p < 0.001) and intensive care unit length of stay (p < 0.001). Increased age, alcohol abuse, and field airway were most predictive of mortality. CONCLUSION Unanticipated pathogens were isolated in each class of pneumonia. The clinician must be aware of significant risk factors that may predispose patients to pathogens that are not ordinarily covered with standard antibiotic therapy.

Blood Product Transfusion and Ventilator-Associated Pneumonia in Trauma Patients

BACKGROUND Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in trauma patients, with a high mortality rate. Blood transfusion has been identified as an independent risk factor for VAP in critically ill patients. Prior studies in trauma are limited by retrospective design, lack of multivariable analyses, and scant data on the timing of transfusion. We examined critically the relation between blood product transfusion and VAP in trauma patients. METHODS Prospective observational cohort study of 766 trauma patients admitted to the intensive care unit (ICU), who received mechanical ventilation (MV) for >or= 48 h, and who did not have pneumonia on admission. Late-onset VAP was defined as that occurring >or= 72 h after MV. Only transfusions of red blood cell (RBC) concentrate, fresh-frozen plasma (FFP), or platelets before the onset of VAP were considered. Logistic regression analyses controlled for all variables related significantly to VAP by univariate analysis (sex, Injury Severity Score, and ventilator days and ICU length of stay prior to VAP). RESULTS A significantly greater proportion of male patients developed VAP. Patients with VAP had a longer duration of MV: The mean number ventilator days prior to VAP was 11.1 +/- 8.0. Transfusion of blood products was an independent risk factor for VAP, and the risk increased with more units transfused. All blood products were associated with a higher risk of VAP (RBC: odds ratio [OR] 4.41; 95% confidence interval [CI] 1.00, 19.54; p = 0.05; FFP: OR 3.34; 95% CI 1.18, 9.43; p = 0.023; platelets: OR 4.19; 95% CI 1.37, 12.83; p = 0.012). CONCLUSION Blood product transfusion is an independent risk factor for VAP in trauma, and the odds ratio is significantly higher (3.34-4.41) than in published studies of other types of ICU patients (1.89). To reduce the incidence of VAP, all efforts to reduce the transfusion of blood products to trauma patients should be implemented.

Acute glucose elevation is highly predictive of infection and outcome in critically injured trauma patients.

Objective(s):To evaluate whether acute glucose elevation (AGE) is predictive of infection and outcome in critically injured trauma patients during the first 14 days of ICU admission. Methods:A prospective study was conducted on 2200 patients admitted to the ICU over a 2 1/2 year period. The diagnosis of infection was made via a multidisciplinary fashion utilizing CDC criteria. After early glucose stabilization occurred (no significant change for 48 hours after admission) monitoring for AGE was performed utilizing a computational and graded algorithmic model. Iatrogenic causes of AGE were excluded. Stepwise regression models were performed controlling for age, gender, mechanism of injury, diabetes, injury severity, and APACHE 2 score. ROC curves were used to evaluate the positive predictive value of the test. Results:Seventy-seven percent of the patients in the cohort were males, and were admitted for blunt injuries (n = 1870 or 85%). The mean age, Injury Severity Score, and APACHE score were 44 ± 20 years, 29 ± 13, and 13 ± 7, respectively. The mean admission serum glucose value was 141 ± 36 mg/dL (range, 64–418 mg/dL). A total of 616 (28%) patients were diagnosed with an infection during the first 14 days of admission. AGE had a 91% positive predictive value for infection diagnosis. In addition, AGE was associated with a significant increase in ventilator, ICU, and hospital days as well as mortality even when adjusted for age, injury severity, APACHE score, and diabetes (P < 0.001). Conclusions:AGE is a highly accurate predictor of infection and should stimulate clinicians to identify a new source of infection.

Tolerance and Efficacy of Enteral Nutrition in Traumatic Brain–Injured Patients Induced Into Barbiturate Coma

BACKGROUND There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. METHODS Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with <150 mL of gastric residuals every 6 hours for >72 hours. RESULTS Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37+/-12 years and a mean injury severity score of 24+/-10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. CONCLUSIONS Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population.

Incidence and Impact of Risk Factors in Critically Ill Trauma Patients

There is a paucity of data describing the incidence of pre-existing diseases or risk factors and their effects in trauma patients. We conducted a prospective study to determine the incidence of such factors in critically ill trauma patients and to evaluate their impact on outcome. The study, performed over a 2-year period, examined the hospital course of all trauma patients admitted to the ICU. Multiple risk factors were evaluated and analyzed via multivariate regression analysis. Outcome was evaluated by infection rate, hospital length of stay, ventilator days, and mortality matched for age and Injury Severity Score (ISS). A total of 1172 patients (73% blunt injury) were enrolled over the study period. Of these, 873 (74.5%) were male. The mean age was 42.5 years with an ISS of 19.8. Tobacco use (24%) was the most common risk factor identified, followed by hypertension (HTN, 17%), coronary artery disease (9%), chronic obstructive pulmonary disease (COPD)/reactive airway disease (4%), non-insulin-dependent diabetes (NIDDM) (4%), insulin-dependent diabetes (IDDM) (3.2%), cancer (3%), liver disease (2%), and HIV/AIDS (1.4%). Of these risk factors, IDDM was found to be an independent risk factor for infection (0.004) and ventilator days (0.047), increasing age was found to be an independent risk factor for hospital length of stay (0.023) and mortality (<0.001), and HTN was found to be an independent risk factor for increased ventilator days (0.04). In addition, COPD/reactive airway disease was found to be an independent predictor of ventilator days, infection, and ICU days (P < 0.05). Thus, increased age, IDDM, COPD, and HTN are most predictive of outcome in critically ill trauma patients. With our aging population it is becoming increasingly important to identify pre-existing risk factors on admission in order to minimize their effects on outcome.

Reclassification of urinary tract infections in critically ill trauma patients: a time-dependent analysis.

BACKGROUND Successful treatment of urinary tract infections (UTIs) in the trauma ICU requires early recognition and timely, appropriate antibiotic therapy. We evaluated the incidence and microbiology of UTIs stratified by days post-admission and risk factors. METHODS Prospective data were collected on 1,172 trauma patients admitted to the ICU over a two-year period. Infections were classified as Community Acquired (CA, < or = 3 days), Early Nosocomial (EN, 4-6 days), Mid-Nosocomial (MN, 7-10 days) and Late Nosocomial (LN > 10 days). Criteria of the U.S. Centers for Disease Control and Prevention (CDC) were used for diagnosis. RESULTS Two hundred twenty patients (19%) were diagnosed with a total of 235 UTIs. Thirtysix patients were diagnosed with multiple UTIs. Escherichia coli, Enterococcus sp. and Candida sp. were the most common pathogens isolated. One thousand one hundred fifty-one patients had a Foley catheter placed (mean duration, 1 +/- 11 days) with a CDC device-related infection rate (no. of catheter-associated UTIs/1000 catheter days) of 18. Patients admitted with a CA infection were significantly older (p < 0.001) and had a higher mortality rate (39% vs. 15%, p = 0.001). Unanticipated pathogens in this group included Enterococcus, Candida, and Pseudomonas. Women were more likely to be admitted with a CA infection (5% vs. 1%, p < 0.001) or acquire an NI infection (23% vs. 15%, p < 0.001). Obesity was highly predictive of increased Foley catheter days, and thus UTI, by multivariate analysis (p < 0.001). CONCLUSIONS Escherichia coli was the most common pathogen in all nosocomial infection categories. Increased age, gender, and obesity, in addition to catheter-days, were significant risk factors for UTI in trauma patients. Specific risk factors may predispose patients to pathogens that are not ordinarily covered by usually-chosen antibiotic therapy.