Krishnamurti A. Rao

Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study

BACKGROUND Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers. METHODS The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration. RESULTS From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003). CONCLUSION Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial. LEVEL OF EVIDENCE Therapeutic/care management, level III.

Incidence and operative factors associated with discretional postoperative mechanical ventilation after general surgery

BACKGROUND: Mechanical ventilation after general surgery is associated with worse outcomes, prolonged hospital stay, and increased health care cost. Postoperatively, patients admitted to the intensive care unit (ICU) may be categorized into 1 of 3 groups: extubated patients (EXT), patients with objective medical indications to remain ventilated (MED), and patients not meeting these criteria, called “discretional postoperative mechanical ventilation” (DPMV). The objectives of this study were to determine the incidence of DPMV in general surgery patients and identify the associated operative factors. METHODS: At a large, tertiary medical center, we reviewed all surgical cases performed under general anesthesia from April 1, 2008 to February 28, 2015 and admitted to the ICU postoperatively. Patients were categorized into 1 of 3 cohorts: EXT, MED, or DPMV. Operative factors related to the American Society of Anesthesiologists Physical Status (ASA PS), duration of surgery, surgery end time, difficult airway management, intraoperative blood and fluid administration, vasopressor infusions, intraoperative arterial blood gasses, and ventilation data were collected. Additionally, anesthesia records were reviewed for notes indicating a reason or rationale for postoperative ventilation. Categorical variables were compared by &khgr;2 test, and continuous variables by analysis of variance or Kruskal-Wallis H test. Categorical variables are presented as n (%), and continuous variables as mean ± standard deviation or median (interquartile range) as appropriate. Significance level was set at P⩽ .05. RESULTS: Sixteen percent of the 3555 patients were categorized as DPMV and 12.2% as MED. Compared to EXT patients, those classified as DPMV had received significantly less fluid (2757 ± 2728 mL vs 3868 ± 1885 mL; P < .001), lost less blood during surgery (150 [20–625] mL vs 300 [150–600] mL; P< .001), underwent a shorter surgery (199 ± 215 minutes vs 276 ± 143 minutes; P< .001), but received more blood products, 900 (600–1800) mL vs 600 (300–900) mL. The DPMV group had more patients with high ASA PS (ASA III–V) than the EXT group: 508 (90.4%) vs 1934 (75.6%); P< .001. Emergency surgery (ASA E modifier) was more common in the DPMV group than the EXT group: 145 (25.8%) vs 306 (12%), P< .001, respectively. Surgery end after regular working hours was not significantly higher with DPMV status compared to EXT. DPMV cohort had fewer cases with difficult airway when compared to EXT or MED. When compared to MED patients, those classified as DPMV received less fluid (2757 ± 2728 mL vs 4499 ± 2830 mL; P< .001), lost less blood (150 [20–625] mL vs 500 [200–1350] mL; P < .001), but did not differ in blood products transfused or duration of surgery. CONCLUSIONS: In our tertiary medical center, patients often admitted to the ICU on mechanical ventilation without an objective medical indication. When compared to patients admitted to the ICU extubated, those mechanically ventilated but without an objective indication had a higher ASA PS class and were more likely to have an ASA E modifier. A surgery end time after regular working hours or difficult airway management was not associated with higher incidence of DPMV.

Gastroduodenal artery coiling to curb upper gastrointestinal bleeding

BACKGROUND Peptic ulcers in pediatric populations are uncommon and can present with upper gastrointestinal bleeding and shock on presentation. An endoscopy is done initially to identify bleeding source. However, definitive treatment is achieved with angiography. The use of coiling is effective in achieving hemorrhagic control in duodenal ulcers or gastric ulcers, particularly in adults. However, the use in pediatric populations is unknown. We present a case of peptic ulcer disease treated with a gastroduodenal artery coil in a pediatric patient that has never been reported in the literature. CASE PRESENTATION A 15-year-old male with a five-year history of peptic ulcer disease was admitted with an upper gastrointestinal bleed. Angiographic imaging was done to isolate and locate the bleeding, and coil embolization of the gastroduodenal artery was performed. Coils eroded into intestinal lumen but bleeding was controlled. CONCLUSION Peptic ulcers in pediatric populations are rare and complex in nature. Besides aggressive resuscitation and endoscopy, other methods to control bleeding such as coil embolization can be performed. Further investigations are needed to understand long-term effects of coil embolization in pediatric peptic ulcer patients. LEVEL OF EVIDENCE 5/Case Report/.

1569: INCIDENCE, OPERATIVE FACTORS, AND OUTCOMES ASSOCIATED WITH DISCRETIONAL POSTOPERATIVE VENTILATION

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) bead. The effects of the alginate encapsulation was measured by assessing BBB integrity, by measuring TNF–α and IFN–γ and the number of microglia based on immunohistochemistry. Each treatment group had all microglia (inactive, semi-activated and fully-activated microglia) counted. We used a 20x objective to obtain images from both contralateral and ipsilateral sides of injured and sham animals. Results: The BBB permeability measurements did not result in statistically significant changes. However, there was statistical significance on the ipsilateral side when measuring the number of microglial cells, active, total active and percent active, as compared to control (p<0.05). Statistical analysis was done with ANOVA followed by the Dunnett multivariant test. Conclusions: Our early data shows that MSC + cord blood co-encapsulation provides increased protection against secondary injury, however, further evaluation is necessary. In vivo experiments to assess the mechanism of the inhibition of inflammation are currently being performed. Immune cell activation supports our hypothesis that co-encapsulation reduces inflammatory cytokines involved in inflammation and edema.