Linda L. Maerz

The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion?

BACKGROUND: Massive transfusion protocol (MTP) utilization and makeup is unknown.

Contrast-induced nephropathy in elderly trauma patients.

BACKGROUND Computed tomography (CT) is the gold standard for the identification of occult injuries, but the intravenous (IV) contrast used in CT scans is potentially nephrotoxic. Because elderly patients have decreased renal function secondary to aging and chronic disease, we sought to determine the rate of acute kidney injury (AKI) in elderly trauma patients exposed to IV contrast. METHODS Medical records of patients older than 55 years evaluated at a level-one trauma center between January 2003 and July 2008 were reviewed. Contrast was nonionic, isosmolar, and administered in standard volumes. Groups were based on administration of contrast. AKI was defined as a 25% relative or 0.5 mg/dL absolute increase in serum creatinine within 72 hours of presentation [corrected]. RESULTS During the study period 1,371 patients older than 55 years were evaluated, and 1,152 met the inclusion criteria. CT was performed on 1,071 patients (96%); 71% of this group received IV contrast. There was no significant difference between the contrast and noncontrast groups in terms of baseline characteristics. Criteria for AKI were satisfied in 2.1% of all patients, including 1.9% the contrast group versus 2.4% in the noncontrast group. AKI diagnosed within 72 hours of patient presentation was an independent risk factor for in-hospital mortality and prolonged length of stay. CONCLUSIONS IV contrast media in elderly trauma patients is not associated with an increased risk of AKI. Development of AKI within 72 hours of admission is associated with mortality and increased length of stay.

Risk of venous thromboembolism after spinal cord injury: not all levels are the same.

BACKGROUND Venous thromboembolism (VTE), a diagnosis that includes both deep vein thrombosis and pulmonary embolism, is a well-recognized complication following injury. Previous studies have identified multiple risk factors including spinal cord injury (SCI). We hypothesized that the level of SCI also influences the likelihood of VTE. METHODS The National Trauma Data Bank was queried to identify all patients with SCI admitted in 2007 and 2008. Rates of VTE, demographics, admitting comorbidities, in-hospital complications, level of SCI (divided by National Trauma Data Bank into five groups), associated injuries, and outcome variables were abstracted. Multiple regression was used to identify independent risk factors for VTE. RESULTS During the 2-year period, 18,302 patients were admitted with SCI. The overall rate of VTE was 4.3% but varied significantly depending on the level of SCI injury (χ(2), 44.8; p < 0.05). Patients with high cervical spine (C1-4) injury had a rate VTE of 3.4%, whereas patients with high thoracic spine (T1-6) injury had the highest rate of VTE at 6.3%. The lowest rate of VTE was in patients with lumbar injury (3.2%). There were no significant differences in the preexisting comorbidities or in-hospital complications among the five SCI groups with the exception of pneumonia. In a multiple logistic regression model, the level of SCI was an independent risk factor for VTE as was increasing age, increasing Injury Severity Score, male gender, traumatic brain injury, and chest trauma. CONCLUSIONS The rate of VTE differs with various SCI levels. Patients with high thoracic (T1-6) injury seem to be at the highest risk and patients with high cervical (C1-4) injury at one of the lowest. A higher index of suspicion for VTE should therefore be maintained in patients with a high thoracic SCI. Further studies are required to elucidate the underlying mechanisms.

Compared to conventional ventilation, airway pressure release ventilation may increase ventilator days in trauma patients.

BACKGROUND Airway pressure release ventilation (APRV) is used both as a rescue therapy for patients with acute lung injury and as a primary mode of ventilation. Unlike assist-control volume (ACV) ventilation that uses spontaneous breathing trials, APRV weaning consists of gradual decreases in supporting pressure. We hypothesized that the APRV weaning process increases total ventilator days compared with those of spontaneous breathing trials–based weaning. METHODS A retrospective review of a Level I trauma center’s database identified trauma admissions from January 1, 2007, to December 31, 2010, which required mechanical ventilation for more than 24 hours and survived. Demographics, injuries, in-hospital complications, ventilation mode(s), and total ventilator days were abstracted. RESULTS A total of 362 patients fulfilled study entry criteria; 53 patients with more than one ventilator mode change were excluded. Seventy-five patients were successfully liberated from mechanical ventilation on APRV and 234 on ACV. The APRV and ACV groups, respectively, were similar in age (46.1 vs. 44.6 years) and sex (72% vs. 73% male) but differed in Injury Severity Score (20.8 vs. 17.5; p = 0.03). Patients on APRV had higher rates of abdominal compartment syndrome (6.7% vs. 0.8%, p = 0.003) and were more likely to have a higher chest Abbreviated Injury Scale (AIS) score ≥3 (57.3% vs. 30.8%, p < 0.001). Ventilator days were significantly greater in the APRV group (19.6 vs. 10.7 days, p < 0.001). Multiple regression was performed to adjust for the clinical differences between the two groups, identifying APRV as an independent predictor for increased number of ventilator days (B = 6.2 ± 1.5, p < 0.001) in addition to male sex, abdomen AIS score of 3 or higher, spine AIS score of 3 or higher, acute renal failure, and sepsis. CONCLUSION APRV is frequently used for patients who are more severely injured or who develop in-hospital complications such as pneumonia. However, after controlling for potential confounding factors in a multiple regression model, the APRV mode itself seems to increase ventilator days. LEVEL OF EVIDENCE Therapeutic study, level IV.

A physicochemical approach to acid-base balance in critically ill trauma patients minimizes errors and reduces inappropriate plasma volume expansion

BACKGROUND This study assesses if a physicochemical (PC) approach to acid-base balance improves the accuracy of acid-base diagnosis, and reduces inappropriate fluid loading. METHODS Hundred consecutive patients with trauma admitted to a surgical intensive care unit at a level I trauma center were prospectively analyzed. Demographics, acid-base data and diagnoses, and interventions were collected. Patients were cared for by one physician using a PC approach, or four using conventional (CONV) acid-base balance techniques. The diagnoses and interventions made by CONV physicians were reviewed by the PC physician for accuracy and appropriateness using PC techniques. Data are mean +/- SD or percents; p values reflect PC evaluation of CONV analysis. RESULTS There were 50 PC patients and 50 CONV. There were no differences in age (p = 0.13), injury severity score (p = 0.21), number of operations (p = 0.87), transfusions (p = 0.87), or survival (p = 0.15). CONV missed 12 diagnoses of metabolic acidosis (p = 0.03), 10 of hyperchloremic metabolic acidosis (p = 0.003), 11 metabolic alkalosis (p = 0.02), and 19 tertiary disorders (p < 0.001). CONV missed 38 diagnoses of increased unmeasured ions (p < 0.001). PC normalized their acid-base balance sooner than CONV (3.3 days +/- 3.4 days vs. 8.3 days +/- 7.4 days, p < 0.01). CONCLUSIONS A PC approach improves acid-base diagnosis accuracy. CONV often miss acidosis (particularly those because of hyperchloremia), alkalosis, and tertiary disorders. Inappropriate volume loading follows in the wake of misinterpretation of increased base deficit using CONV and is avoided using PC. PC-directed therapy normalizes acid-base balance more rapidly than CONV.

Uncovering System Errors Using a Rapid Response Team: Cross-coverage Caught in the Crossfire

BACKGROUND Because of the 80-hour work week, extensive service cross-coverage creates great potential for patient care errors. These patient care emergencies are increasingly managed using a rapid response team (RRT) to reduce patient morbidity. We examine the proximate causes of a surgical RRT activation. We hypothesize that most RRTs would occur during cross-coverage hours and be preventable or potentially preventable. METHODS All surgical RRTs more than a 15-month period were captured using a nursing database and the note from the staffing intensivist/fellow. RRTs were reviewed for appropriateness (pre-existing criteria) and proximate cause. Proximate causes were further classified as patient disease, team error, nursing error, or system error as well as preventable, potentially preventable, or nonpreventable. RESULTS Of 98 RRT activations, complete data were available for 82 (84%); 100% met activation criteria; and 76 (93%) occurred between 2100 and 0600. Seventy-six patients were 48 hours to 72 hours postoperative; six had nonoperatively managed injuries. The most common reason for activation was impending respiratory failure and acute volume overload (n = 72; 88%). RRT therapies included diuretics (n = 72), antiarrhythmics (n = 48), oxygen (n = 82), and bronchodilators (n = 36); only 2 received blood component therapy. Seventy-eight patients (95%) were transferred to higher level of care (61, surgical intensive care unit; 17, SSDU). Only 46% of patients required intubation. Performance improvement review identified 90% of physician related RRTs as preventable/potentially preventable because of errors in judgment or omission. Four RRTs because of patient disease were unpreventable. Two potentially preventable errors were each ascribed to RN or system concerns. CONCLUSION RRT activations principally result from team-based errors of omission, more often occur between 2100 and 0600, and are more often preventable or potentially preventable. Careful attention to fluid balance and medications for comorbid diseases would reduce RRT needs.

Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors☆ , ☆☆ ,★

BACKGROUND Non-physician advanced practice providers (APPs) such as nurse practitioners and physician assistants are being increasingly utilized as critical care providers in the United States. The objectives of this study were to determine the utilization of APPs in the intensive care units (ICU)s of academic medical centers (AMCs) and to assess the perceptions of critical care fellowship program directors (PDs) regarding the impact of these APPs on fellowship training. METHODS A cross-sectional national survey questionnaire was distributed to program directors of 331 adult Accreditation Council for Graduate Medical Education-approved critical care fellowship training programs (internal medicine, anesthesiology and surgery) in US AMCs. RESULTS We received 124 (37.5%) PD responses. Of these, 81 (65%) respondents indicated that an APP was part of the care team in either the primary ICU or any ICU in which the fellow trained. The majority of respondents reported that patient care was positively affected by APPs with nearly two-thirds of PDs reporting that fellowship training was also positively impacted. CONCLUSIONS Our survey revealed that APPs are utilized in a large number of US AMCs with critical care training programs. Program director respondents believed that patient care and fellowship training were positively impacted by APPs.

When the ICU is the operating room.

BACKGROUND The surgical intensive care unit (SICU) is increasingly used as a surrogate operating room (OR). This study seeks to characterize a Level I trauma center’s operative undertakings in the SICU versus OR for trauma and emergency general surgery patients. METHODS Operative and ICU databases were queried for all operative procedures as a function of procedure type (CPT code) and location (OR, ICU) from August 2002 through June 2009. Mode of ventilation, type of anesthesia used, and adverse outcomes were recorded. Data were divided into 2002–2006 versus 2007–2009 because of MD staffing and service structure changes. Time frames were compared via Student’s t-test or &khgr;2 as appropriate; significance for p < 0.05 (*) versus 2002–2006. RESULTS Trauma service–admitted patient volume increased from 2002–2003 (n = 1,293) to 2006–2007 (n = 1,577) and again in 2008–2009 (n = 1,825). Emergency general surgery total operative cases increased from 2002–2003 (n = 246) to 2005–2006 (n = 468). Case volume further increased in 2006–2007 (n = 767*), 2007–2008 (n = 1,071*), and 2008–2009 (n = 875*) compared with 2002–2003 or 2005–2006. Relaparotomy and temporary abdominal closure procedures were significantly increased in 2007–2008 (n = 109*) and 2008–2009 (n = 128*) versus 2002–2006 (n = 6) and 2006–2007 (n = 10). ICU cases were 11.5% of total cases (OR + ICU) spanning 2002–2006 and significantly increased to 24.3%* in 2007–2008 and 36%* in 2008–2009. Advanced ventilation was used in 15% of ICU cases in 2002–2003 and significantly increased to 40% in 2006–2007 and 78%* in 2008–2009. Neuromuscular blockade was rare; most cases (93.9%) were performed under deep sedation. CONCLUSION Our ICU is increasingly used for surgical procedures traditionally reserved for the OR. Advanced ventilation management may influence the choice of operative location. The ICU may be safely used as an operative location for the critically ill and injured. LEVEL OF EVIDENCE Epidemiologic study, level III.

Futility and the acute care surgeon.

Managing medical and surgical futility is a challenging aspect of the practice of the acute care surgeon. Analysis of futility and application of multidisciplinary and interprofessional patient care have the potential to optimize clinical management of patients at the end of life. Review of the vast literature on the topic reveals evolving practices for the management of futility. TheCritical CareCommittee of theAmericanAssociation for the Surgery of Trauma (AAST) was charged with addressing this topic in a luncheon session at the 73rd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery on September 12, 2014, in Philadelphia, Pennsylvania.We surmised that querying surgeons engaged in the management of trauma and emergency general surgery patients nationally would provide a practical context and framework useful for the individual acute care surgeon. To this end, we created a survey defining the attitudes and practices of acute care surgeons related to medical and surgical futility and end-of-life care in the trauma and emergency general surgery patient populations. The survey was distributed to the membership of the AAST on June 10, 2014, and again on June 30, 2014.Responseswere not linked to individuals, and participation was anonymous and confidential. The results of the survey were the focal point of discussion for the aforementioned luncheon session entitled, ‘‘Death, Dying and Futile Care in the ICU, ED and ORVWhat Have We Learned?’’

Disseminated enteroinvasive aspergillosis in a critically ill patient without severe immunocompromise

Invasive aspergillosis (IA) is a rapidly progressive and often fatal infectious disease described classically in patients who are highly immunocompromised. However, there has been increasing evidence that IA may affect critically ill patients without traditional risk factors. We present a case of a 47-year-old man without conventional risk factors for IA who presented with impending sepsis and proceeded to have a complicated hospital course with a postmortem diagnosis of invasive gastrointestinal aspergillosis of the small bowel.