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How to Feed the Open Abdomen

Patients treated with damage control surgery develop a severe systemic inflammatory response associated with a catabolic state compounded by protein losses through the open abdomen. Diligence regarding nutrition provision is essential for optimal outcomes in these patients. Enteral nutrition (EN) should be initiated within 24–36 h of admission, or as soon as gastrointestinal continuity is restored, regardless of resuscitation status. Avoiding hypervolemia and closing the abdomen as soon as possible help to minimize protein losses. Direct peritoneal resuscitation can be useful as an adjunct therapy, facilitating earlier closure of the abdomen. Post-pyloric feeding is preferred, but there is no reason to withhold pre-pyloric feeding if this cannot be achieved. Planning for definitive surgical therapy includes consideration for surgical feeding access as early as postoperative day 1. Keeping an intubated patient “nil per os,” or EN turned off for operative procedures is an archaic practice and potentially detrimental. There are benefits to EN even if administered in amounts that provide less than goal caloric requirements. Suboptimal nutrition due to interruptions in delivery can be mitigated through the use of feeding protocols. EN is superior to parenteral nutrition (PN); but if EN is not providing at least 60–70 % of the calories and protein needed by day 5–7, PN must then be considered. Provision of appropriate and early goal-directed protein and caloric support should be considered an essential component in the management of the patient with an open abdomen.

Organ donation as an outcome of traumatic cardiopulmonary arrest: A cost evaluation.

BACKGROUND Survival after traumatic cardiopulmonary arrest (TCPA) is rare and requires significant resource expenditure. Organ donation as an outcome of TCPA resuscitation has not yet been included in a cost analysis. The aims of this study were to identify variables associated with survival and organ donation after TCPA, and to estimate the cost of achieving these outcomes. We hypothesized that the inclusion of organ donation as a potential outcome would make TCPA resuscitation more cost-effective. METHODS Adult patients who required resuscitation for TCPA at a level I trauma center were retrospectively reviewed over 36 months. Data were obtained from medical records, hospital accounting records, and the local organ procurement agency. Outcomes included survival to discharge, neurologic function, and organ donor eligibility. An individual-level state-transition cost-effectiveness model was used to evaluate the cost of TCPA resuscitation with and without organ donation included as an outcome. Incremental cost-effectiveness ratio was calculated to determine additional cost per life saved when organ donation is included. RESULTS Over the study period, 8,932 subjects were evaluated. Traumatic cardiopulmonary arrest occurred in 237 patients (3%). The mortality rate was 97%. Variables associated with survival included emergency department disposition to the operating room (p < 0.01) and reactive pupils (p < 0.001). Of seven survivors, four were discharged neurologically intact. Of the patients with TCPA, 5% were eligible for organ donation with a procurement rate of 2%. Organ donor eligibility was associated with arrest after arrival to the emergency department (p < 0.01) and transfusion of fresh frozen plasma (p = 0.01). The cost of TCPA resuscitation per survivor was

A natural immune modulator attenuates stress hormone and catecholamine concentrations in polymicrobial peritonitis.

1.8 million; cost per survivor or life saved by donation was

1556: TRACHEOSTOMY AND GASTROSTOMY IN GERIATRIC TRAUMA ASSOCIATED WITH HIGH POST-DISCHARGE MORTALITY

538,000. The incremental cost-effectiveness ratio was

Parathyroid hormone as a marker for hypoperfusion in trauma: a prospective observational study.

76,816 per additional life saved including donation as an outcome. CONCLUSION The decision to pursue resuscitation should continue to be based on the presence of signs of life, especially pupil reactivity and duration of arrest. If the primary objective is survival, organ procurement will be maximized without conflict of interest. Early fresh frozen plasma transfusion may increase successful organ donation. The financial burden of TCPA resuscitation can be mitigated by expanding end points to include organ donation. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III; cost analysis, level V.

Small bowel trauma: current approach to diagnosis and management.

BACKGROUND Activated hexose correlated compound (AHCC), derived from shiitake mushrooms, increases resistance to infection in immunocompromised hosts with positive effects on dendritic cells, natural killer cell function and interleukin 12 production. It may also be attenuating the systemic inflammatory response by regulating the secretion of cortisol and norepinephrine (NE). METHODS Female Swiss-Weber mice were pretreated with AHCC (Amino Up Chemical Co., Sapporo, Japan) or water by gavage for 10 days before undergoing cecal ligation and puncture (CLP). Peritoneal exudate cells and blood samples were harvested at 4 hours and 24 hours following CLP. Plasma and peritoneal concentrations of cortisol and NE were obtained using enzyme-linked immunosorbent assay. Peritoneal bacteria were quantified by colony counts after 4 hours and 24 hours. Significance was denoted by a p < 0.05. RESULTS Plasma and peritoneal cortisol concentrations were increased 4 hours after CLP compared with normal controls, with no difference between the pretreated groups. Concentrations of cortisol decreased from 4 hours to 24 hours after CLP with AHCC (plasma, p = 0.009; peritoneal, p < 0.001), and peritoneal cortisol at 24 hours was lower with AHCC as compared with water (p = 0.028). There was no change in plasma or peritoneal NE concentrations at 4 hours. At 24 hours, higher concentrations of NE were detected in both plasma and peritoneal fluid, with lower plasma concentrations in those gavaged with AHCC (p = 0.015). There was no significant difference in peritoneal bacteria counts. CONCLUSION Enhanced immune function observed with AHCC could be caused by attenuated concentrations of stress hormones and catecholamines.

Vital Signs Strongly Predict Massive Transfusion Need in Geriatric Trauma Patients.

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: A link has been established between psychiatric illness and burn injury, however there are few studies which evaluate this link at a national level. This study aims to explore psychiatric morbidity in the Scottish burns population. Methods: This retrospective population-based cohort study included 903 adult patients admitted to Scottish Burns Units from 2012–2015. Burn injury data was prospectively collected by the Managed Clinical Network Care of Burns in Scotland (COBIS). COBIS data was joined to Scottish Morbidity Record 04 (SMR04); the national Mental Health Inpatient and Day Case database. SMR04 provided information on psychiatric admissions to hospital from 2007–2015. Psychiatric conditions were recorded as World Health Organisation (WHO) International Classification of Disease (ICD) Codes. Data analysis was conducted using the statistical package R and descriptive statistics were performed. Results: For the 903 patients included in the study mean age was 45 years, mean total body surface area (TBSA) burned was 5.5% and mean length of hospital stay was 8.6 days. Ninety-three burns patients were on the SMR04 database meaning they had a psychiatric admission to hospital around the time of the burn injury. There were 402 distinct admissions. Mean TBSA of this subgroup was > 2% higher than that of the full cohort. Despite being only 34.1% of all burns patients, females made up 60.8% of psychiatric admissions. The mean psychiatric admission length of stay was 10 days. The most common psychiatric condition, recorded for 91 admissions, was “mental and behavioural disorders due to use of alcohol” followed by “emotionally unstable personality disorder” for 56 admissions. Thirty-nine admissions had “schizophrenia” and 28 had “depressive episode”. All other conditions had < 10 admissions each. Conclusions: There is currently no standard format for delivering psychological support to burns patients in Scotland. By establishing a link between burn injury and psychopathology, it is recommended that psychological support be formally included in the long-term package of care offered to these patients.

Alternatives to Indwelling Catheters Cause Unintended Complications.

BACKGROUND Hyperparathyroidism is common in critical illness. Intact parathyroid hormone has a half-life of 3 minutes to 5 minutes due to rapid clearance by the liver, kidneys, and bone. In hemorrhagic shock, decreased clearance may occur, thus making parathyroid hormone a potential early marker for hypoperfusion. We hypothesized that early hyperparathyroidism predicts mortality and transfusion in trauma patients. METHODS A prospective observational study was performed at a Level I trauma center in consecutive adult patients receiving the highest level of trauma team activation. Parathyroid hormone and lactic acid were added to the standard laboratory panel drawn in the trauma bay on arrival, before the administration of any blood products. The primary outcomes assessed were transfusion in 24 hours and mortality. RESULTS Forty-six patients were included. Median age was 47 years, 82.6% were men, 15.2% suffered penetrating trauma, and 21.7% died. Patients who were transfused in the first 24 hours (n = 17) had higher parathyroid hormone (182.0 pg/mL vs. 73.5 pg/mL, p < 0.001) and lactic acid (4.6 pg/mL vs. 2.3 pg/mL, p = 0.001). Patients who did not survive to discharge (n = 10) also had higher parathyroid hormone (180.3 pg/mL vs. 79.3 pg/mL, p < 0.001) and lactic acid (5.5 mmol/L vs. 2.5 mmol/L, p = 0.001). For predicting transfusion in the first 24 hours, parathyroid hormone has an area under the receiver operating characteristic curve of 0.876 compared with 0.793 for lactic acid and 0.734 for systolic blood pressure. Parathyroid hormone has an area under the receiver operating characteristic curve of 0.875 for predicting mortality compared with 0.835 for lactic acid and 0.732 for systolic blood pressure. CONCLUSION Hyperparathyroidism on hospital arrival in trauma patients predicts mortality and transfusion in the first 24 hours. Further research should investigate the value of parathyroid hormone as an endpoint for resuscitation. LEVEL OF EVIDENCE Prognostic, level II.