Matthew C. Byrnes

A systematic method for follow-up improves removal rates for retrievable inferior vena cava filters in a trauma patient population.

BACKGROUND Retrievable inferior vena cava filters (rIVCF) reduce the short-term risk of pulmonary embolism without the filter and inferior vena cava (IVC) thrombosis that have been reported with the use of permanent filters. Studies have shown that most rIVCFs are not removed, leaving patients at risk for thrombotic complications of rIVCF retention. We hypothesize that the application of a systematic follow-up for rIVCF will improve filter removal rates, providing patients short-term prophylaxis from pulmonary embolism whereas avoiding complications of permanent filter retention. METHODS The trauma registry of a Level I trauma center was queried to identify patients who underwent placement of IVCFs between January 1, 2003, and June 30, 2008. The medical records were reviewed and details of the patients injuries, indications for filter placement, repositioning, and retrieval were collected. Radiographic images were reviewed to confirm ultimate filter retention or removal. RESULTS Between January 1, 2003, and June 30, 2008, rIVCFs were placed in 118 patients, 44% had known venous thromboembolic event. Three patients died before rIVCFs could be considered for extraction, leaving 115 patients for evaluation. Filters were removed in 80 patients (70%) overall. Of the 35 patients in whom filters were not removed, 11 were lost to follow-up, 4 failed removal attempts, and 20 had indications for filter retention. The rIVCFs were retrieved in 75% of patients not lost to follow-up and 92% of patients who did not have contraindications for filter removal. CONCLUSION A dedicated system for following-up patients with rIVCFs markedly improves removal rates of retrievable filters.

Providing Care for Critically Ill Surgical Patients: Challenges and Recommendations

Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed.

Nasal Swabs Collected Routinely To Screen for Colonization by Methicillin-Resistant Staphylococcus aureus in Intensive Care Units Are a Sensitive Screening Test for the Organism in Clinical Cultures

BACKGROUND Many hospitals screen patients for methicillin-resistant Staphylococcus aureus (MRSA) on admission to the intensive care unit (ICU). We hypothesized that this screening information could be used to assist with empiric antibiotic decisions. METHODS The medical records of patients admitted to a university-affiliated community hospital as well as a tertiary-care university hospital were reviewed. Patients admitted to the ICU were screened for MRSA colonization with a nasal swab that was analyzed with either chromogenic medium (hospital 1) or polymerase chain reaction (PCR) (hospital 2). The results of the nasal swab were compared with clinical culture results. RESULTS There were 141 patients, and 167 cultures were obtained. The majority of the cultures (70%) were performed on sputum specimens in an effort to diagnose pneumonia. The remaining cultures were performed on blood (10.1%), incisions (21.5%), and urine (3.4%). The overall sensitivity of nasal swab results was 69.5%. However, the sensitivity was significantly higher for nasal swab screening performed within six days of clinical cultures compared with screening performed seven days or more before cultures were obtained. (79% vs. 46%; p < 0.0001). Sensitivity also differed significantly depending on the surveillance method, being significantly higher among patients screened with PCR within six days of developing an infection than in patients screened with chromogenic medium (88% vs. 65.5%; p = 0.006). CONCLUSION Screening with PCR analysis of nasal swab specimens is a highly sensitive test for MRSA in clinical cultures. Clinicians may be able to use the swab results to tailor more appropriate empiric antimicrobial regimens. The results with chromogenic medium screening are markedly poorer, which suggests that clinicians should view them with caution.

Therapeutic anticoagulation can be safely accomplished in selected patients with traumatic intracranial hemorrhage

IntroductionTherapeutic anticoagulation is an important treatment of thromboembolic complications, such as DVT, PE, and blunt cerebrovascular injury. Traumatic intracranial hemorrhage has traditionally been considered to be a contraindication to anticoagulation.HypothesisTherapeutic anticoagulation can be safely accomplished in select patients with traumatic intracranial hemorrhage.MethodsPatients who developed thromboembolic complications of DVT, PE, or blunt cerebrovascular injury were stratified according to mode of treatment. Patients who underwent therapeutic anticoagulation with a heparin infusion or enoxaparin (1 mg/kg BID) were evaluated for neurologic deterioration or hemorrhage extension by CT scan.ResultsThere were 42 patients with a traumatic intracranial hemorrhage that subsequently developed a thrombotic complication. Thirty-five patients developed a DVT or PE. Blunt cerebrovascular injury was diagnosed in four patients. 26 patients received therapeutic anticoagulation, which was initiated an average of 13 days after injury. 96% of patients had no extension of the hemorrhage after anticoagulation was started. The degree of hemorrhagic extension in the remaining patient was minimal and was not felt to affect the clinical course.ConclusionTherapeutic anticoagulation can be accomplished in select patients with intracranial hemorrhage, although close monitoring with serial CT scans is necessary to demonstrate stability of the hemorrhagic focus.

Reducing complications in trauma patients: use of a standardized quality improvement approach.

Injured patients are especially prone to developing complications. Using a multidisciplinary standardized approach to complication review is an effective method of evaluating quality improvement in patients on the trauma service. Collaboration between trauma surgeons and nurse clinicians is instrumental in improving the care of patients in each of the areas we identified. Using this consistently, quality improvement strategies can be put in place and tracked for outcomes. This has allowed for better quantification of the problem as well as any change that may result from applying this formal review process and subsequent intervention.

Adjunctive Measures for Treating Surgical Infections and Sepsis

The history of adjunctive treatments for severe sepsis has been fraught with more failures than successes. To date, there have been few interventions that have been demonstrated to be efficacious by multiple large, well-designed, multicenter randomized clinical trials. However, recent research into treatment strategies using drotrecogin alfa (activated), effective blood glucose management, early goal-directed therapy, protocolization of care, and intensivist management has demonstrated positive results. Further research is being conducted to verify the success of these initial trials. This article summarizes some of the available adjunctive treatments for severe sepsis.

Ostomies in Trauma

Injuries to the colon represent a challenging and controversial facet of trauma surgery. Historically, diversion was considered to be the standard of care for all colon injuries. Recently, however, significant data have emerged that has demonstrated the safety of performing primary anastomoses after colonic injuries. This chapter reviews indications for performing a colostomy in injured patients. There are also unique anatomic and physiologic issues that surgeons must consider when performing a colostomy for trauma. Injured patients are more likely to require an “open abdomen” and are more likely to have devascularization secondary to blast effects or vessel trauma. These situations require special attention to diversion of fecal contents away from the open wound as well as accurate appreciation of the extent of devascularization. This chapter reviews the techniques for performing a colostomy that are germane to injured patients.