Matthew J. Wall

Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries

Background Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso. Methods We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure ≤ 90 mm Hg. The study setting was a city with a single centralized system of prehospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room. Results Among the 289 patients who received...

Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis

BACKGROUND Since the patients skin is a major source of pathogens that cause surgical-site infection, optimization of preoperative skin antisepsis may decrease postoperative infections. We hypothesized that preoperative skin cleansing with chlorhexidine-alcohol is more protective against infection than is povidone-iodine. METHODS We randomly assigned adults undergoing clean-contaminated surgery in six hospitals to preoperative skin preparation with either chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections. RESULTS A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in the povidone-iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs. 16.1%; P=0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine-alcohol was significantly more protective than povidone-iodine against both superficial incisional infections (4.2% vs. 8.6%, P=0.008) and deep incisional infections (1% vs. 3%, P=0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups. CONCLUSIONS Preoperative cleansing of the patients skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean-contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)

Prospective Study of Blunt Aortic Injury: Multicenter Trial of the American Association for the Surgery of Trauma

BACKGROUND Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.

Central Venous Catheters Coated with Minocycline and Rifampin for the Prevention of Catheter-Related Colonization and Bloodstream Infections: A Randomized, Double-Blind Trial

See related articles on pp 257-266 and 275-280 and editorial comment on pp 304-306. Central venous catheters are indispensable in the treatment of critically and chronically ill patients, but they are the leading cause of primary nosocomial bloodstream infection [1, 2]. A study of hospitals in the National Nosocomial Infection Surveillance System, conducted between 1986 and 1990, showed that rates of bloodstream infection were substantially higher in patients who were in intensive care units and had intravascular devices than in those who did not have such devices [3]. To decrease the risk for catheter colonization and infection, antiseptic and antibiotic agents have been applied topically at the insertion site [4-6]. More recently, the use of antimicrobial flush solutions has been proposed [7]. However, coating venous catheters with antiseptic or antimicrobial agents may have an even more pronounced protective effect against colonization and infection, particularly if both the external and internal surfaces of the device are coated. Since 1990, several types of antiseptic or antimicrobial vascular catheter coatings have been developed and studied [8, 9]. Maki and colleagues [9] investigated central venous catheters coated with chlorhexidine-silver sulfadiazine; the coated catheters seemed less likely than the uncoated catheters to be associated with bloodstream infections. We recently coated vascular catheters with a combination of minocycline and rifampin after treatment with the tridodecylmethyl-ammonium chloride surfactant. In vitro, these catheters were shown to have broad-spectrum antimicrobial inhibitory activity that was significantly superior to the activity of catheters coated with chlorhexidine-silver sulfadiazine [10, 11]. The catheters coated with minocycline and rifampin were also found to be highly efficacious in preventing catheter colonization and subcutaneous infection in a rabbit model [11]. In a double-blind, randomized clinical trial, we studied the efficacy of catheters that were treated with tridodecylmethyl-ammonium chloride and coated with minocycline and rifampin in preventing catheter colonization and bloodstream infection in hospitalized patients. Methods Study Sample Our study was conducted simultaneously at five university-based hospitals in the Texas Medical Center in Houston: The University of Texas M.D. Anderson Cancer Center (518 beds), Veterans Administration Medical Center (1050 beds), Hermann Hospital (600 beds), Ben Taub General Hospital (580 beds), and The Methodist Hospital (904 beds). The study began on 1 September 1994 and ended on 27 March 1995. Hospitalized patients 18 years of age or older who required a triple-lumen polyurethane central venous catheter at a new insertion site were asked to participate. We excluded pregnant women, patients who were allergic to rifampin or tetracycline, patients with dermatitis or a burn over the insertion site, and patients for whom the anticipated duration of catheterization was less than 3 days. All patients gave informed consent. Randomization All catheters were triple-lumen, polyurethane, 7 French, and 20 cm long (Cook Critical Care, Bloomington, Indiana). The coated catheters were pretreated with tridodecylmethyl-ammonium chloride and then coated, 18 hours later, with minocycline and rifampin. The levels of minocycline and rifampin on the external and internal surfaces of coated catheters before insertion, as determined by high-performance liquid chromatography, were 139.3 g/cm and 13.9 g/cm, respectively. Control catheters were untreated and uncoated. All catheters were gas sterilized and placed in identical trays, and each tray was assigned an identification number. The trays were then randomly assigned into blocks of six: three with coated catheters and three with control catheters. Each block of trays was placed in boxes by Cook Critical Care, and the boxes were shipped to the five hospitals. When a patient was determined to be eligible, a tray was removed from the box (trays were removed one at a time, in sequential order from top to bottom), and that catheter was used for the patient. The catheter identification number was recorded on a data entry form and on the patients medical chart; neither the patient nor the clinician who inserted the device knew which catheter (coated or uncoated) had been used. Catheter Insertion and Care Study catheters were inserted into the subclavian vein, internal jugular vein, or femoral vein of patients who had no other indwelling catheter. Study catheters were not exchanged over guidewires. Maximal sterile barrier precautions were taken, including use of a sterile gown, sterile gloves, full sterile drapes, a mask, and a cap. At the time of catheter insertion and at each dressing change, the insertion site was cleaned with chlorhexidine gluconate (at The Methodist Hospital) or 10% povidone-iodine scrub (at all other hospitals). In each case, the preparation was applied to the skin for 2 minutes before catheter insertion. The insertion site was then covered with sterile gauze and taped securely. The insertion site was inspected every 72 hours (during a dressing change) for evidence of infection, such as erythema, purulence, swelling, or tenderness over the catheter. During follow-up, the following information was obtained for all patients: site of catheter insertion; dates of catheter placement and removal; occurrence of difficulties and violations of aseptic technique during insertion or removal, if any; reason for using the catheter (chemotherapy, total parenteral nutrition, administration of blood products, or a combination of these reasons); type of dressing; and reason for catheter removal. In addition, clinical data were obtained on underlying disease, neutrophil and platelet counts, antibiotic therapy administration, other therapeutic interventions administered during the period of catheterization, and the presence or absence of fever and infection during catheterization. The catheter remained in place until it was no longer needed; until a specific event, such as catheter-related infection, necessitated its removal; or for 28 days, whichever occurred first. Microbiological Methods Quantitative Cultures of Central Venous Catheters The entire catheter was removed aseptically, and 4-cm segments were cut from the catheter tip and the subcutaneous section. These segments were semiquantitatively cultured by using the roll-plate method; the same segment was then quantitatively cultured by using the sonication method [12-14]. Organisms recovered by either method were fully identified according to standard microbiological methods. Coagulase-negative staphylococci were classified as gram-positive cocci in clusters that produced catalase but not coagulase and were categorized according to species by using the Staph-Ident System (Analytab Products, Plainview, New Jersey). All hospitals used the same methods for culture. Skin Cultures To determine whether bacteria became resistant to the antibiotics that coated the study catheters, skin samples obtained from the insertion site were cultured at the time of insertion and within 24 hours after catheter removal, as described elsewhere [15]. Organisms recovered from the insertion site were fully identified by using standard microbiological methods. Antimicrobial Resistance We used the modified Kirby-Bauer technique to test the antimicrobial activity of the catheters coated with minocycline and rifampin against all organisms isolated from indwelling coated catheters at the time of catheter removal [16]. The zones of inhibition against staphylococci cultured from coated catheters were compared with those of uncoated catheters. The minimal inhibitory concentration (MIC) of minocycline hydrochloride (Lederle Laboratories, Pearl River, New York) and rifampin (Ciba-Geigy Corp., Summit, New Jersey) against staphylococcal organisms that colonized the catheter tip, subcutaneous segments, and adjacent skin insertion sites of the coated catheters was determined. A microbroth dilution method was used to determine the MIC in accordance with guidelines established by the National Committee for Clinical Laboratory Standards [17]. Definitions The definitions adopted for our study were proposed by the Centers for Disease Control and Prevention [18]. Colonization of a central venous catheter was defined as 1) the isolation from either the tip or the subcutaneous segment of 15 or more colony-forming units of any organism by the rollplate technique or 2) isolation of more than 1000 colony-forming units of any organism by the sonication technique. Catheter-related bloodstream infection was defined as the isolation of microorganisms from the bloodstream (blood was obtained through venipuncture, not through the catheter) of a patient who had concurrent clinical manifestations of sepsis and no source for the bloodstream infection other than the vascular catheter. In addition, the catheter had to be colonized with the same organism (same species and same antibiogram). To confirm the diagnosis of catheter-related bloodstream infection, DNA molecular typing done using pulse-field gel electrophoresis was performed on organisms that were of the same species, had the same antibiogram, and were isolated from the catheter and blood during the period of catheterization. Patients were considered to have fever if the oral body temperature was greater than 38 C. Neutropenia was defined as a polymorphonuclear count of fewer than 1000 cells/mm3. Thrombocytopenia was defined as a platelet count of fewer than 100 000 cells/mm3. Molecular Typing Molecular typing was performed by using pulse-field gel electrophoresis. Identical organisms with similar DNA profiles that were isolated from a segment of the colonized catheter and from the bloodstream confirmed the diagnosis of catheter-related bloodstream infection. However, a mismatch did not rule out such a diagnosis because catheter coloniza

Hypotensive Resuscitation Strategy Reduces Transfusion Requirements and Severe Postoperative Coagulopathy in Trauma Patients With Hemorrhagic Shock: Preliminary Results of a Randomized Controlled Trial

BACKGROUND Trauma is a leading cause of death worldwide and is thus a major public health concern. Previous studies have shown that limiting the amount of fluids given by following a strategy of permissive hypotension during the initial resuscitation period may improve trauma outcomes. This study examines the clinical outcomes from the first 90 patients enrolled in a prospective, randomized controlled trial of hypotensive resuscitation, with the primary aim of assessing the effects of a limited transfusion and intravenous (IV) fluid strategy on 30-day morbidity and mortality. METHODS Patients in hemorrhagic shock who required emergent surgery were randomized to one of the two arms of the study for intraoperative resuscitation. Those in the experimental (low mean arterial pressure [LMAP]) arm were managed with a hypotensive resuscitation strategy in which the target mean arterial pressure (MAP) was 50 mm Hg. Those in the control (high MAP [HMAP]) arm were managed with standard fluid resuscitation to a target MAP of 65 mm Hg. Patients were followed up for 30 days. Intraoperative fluid requirements, mortality, postoperative complications, and other clinical data were prospectively gathered and analyzed. RESULTS Patients in the LMAP group received a significantly less blood products and total i.v. fluids during intraoperative resuscitation than those in the HMAP group. They had significantly lower mortality in the early postoperative period and a nonsignificant trend for lower mortality at 30 days. Patients in the LMAP group were significantly less likely to develop immediate postoperative coagulopathy and less likely to die from postoperatively bleeding associated with coagulopathy. Among those who developed coagulopathy in both groups, patients in the LMAP group had significantly lower international normalized ratio than those in the HMAP group, indicating a less severe coagulopathy. CONCLUSIONS Hypotensive resuscitation is a safe strategy for use in the trauma population and results in a significant reduction in blood product transfusions and overall IV fluid administration. Specifically, resuscitating patients with the intent of maintaining a target minimum MAP of 50 mm Hg, rather than 65 mm Hg, significantly decreases postoperative coagulopathy and lowers the risk of early postoperative death and coagulopathy. These preliminary results provide convincing evidence that support the continued investigation and use of hypotensive resuscitation in the trauma setting.

Emergency center thoracotomy: impact of prehospital resuscitation.

Emergency center thoracotomy was performed at our facility on 389 patients from 1984 through 1989. There were no patients excluded from the study, and survival for all patients was 8.3% with survival rates of 15.2% and 7.3% for stab and gunshot wounds, respectively. Emergency center thoracotomy was performed on 42 patients suffering from isolated extrathoracic injuries with 7% survival. There were no survivors of blunt trauma in this study. Fifty-three percent of the patients arrived with cardiopulmonary resuscitation (CPR) in progress. The average time of prehospital CPR for survivors was 5.1 minutes compared with 9.1 minutes for nonsurvivors. Of the survivors, prehospital endotracheal intubation prolonged successful toleration of CPR to 9.4 minutes compared with 4.2 minutes for nonintubated surviving patients (p less than 0.001). Emergency center thoracotomy is useful in the resuscitation of victims dying of penetrating truncal trauma. Prehospital endotracheal intubation significantly lengthened the time of successful CPR.

Planned reoperation for trauma: a two year experience with 124 consecutive patients.

Planned reoperation is a new approach to severe truncal trauma. A review of 124 patients treated over two years was undertaken. Penetrating injuries predominated (78%) involving primarily the abdomen or abdomen and chest. An abbreviated procedure was performed when direct hemostasis was impossible (102 patients), abrupt termination was required (56 patients), or the abdomen or chest could not be closed (20 patients). The techniques employed included packing, rapid skin closure, gastrointestinal interruption, rapid vascular control, temporary urinary diversion, stapled lung resection, and plastic bag closure. Seventy-three patients survived to undergo 101 operations. The first reoperation was planned in 52 patients and unplanned (either for bleeding or for abdominal compartment syndrome) in 21 patients. There were 14 missed injuries. The overall mortality rate was 58%. Survival was significantly better when the decision to abruptly terminate the initial procedure was made early and in patients undergoing planned reoperation. Wider adoption and better definition of the indications will result in more effective use of this approach.

Predicting the Need to Pack Early for Severe Intra-abdominal Hemorrhage

OBJECTIVE To determine if the decision to pack for hemorrhage could be refined. MATERIALS AND METHODS Seventy consecutive trauma patients for whom packing was used to control hemorrhage were studied. The patients had liver injuries, abdominal vascular injuries, and bleeding retroperitoneal hematomas. Preoperative variables were analyzed and survivors compared with nonsurvivors. RESULTS Packing controlled hemorrhage in 37 (53%) patients. Significant differences (p < 0.05) between survivors and nonsurvivors were Injury Severity Score (29 vs. 38), initial pH (7.3 vs. 7.1), platelet count (229,000 vs. 179,000/mm3), prothrombin time (14 vs. 22 seconds), partial thromboplastin time (42 vs. 69 seconds), and duration of hypotension (50 vs. 90 minutes). Nonsurvivors received 20 units of packed red blood cells before packing compared to 13 units for survivors. CONCLUSION Patients who suffer severe injury, hypothermia, refractory hypotension, coagulopathy, and acidosis need early packing if they are to survive. Failure to control hemorrhage is related to severity of injury and delay in the use of pack tamponade. A specific protocol that mandates packing when parameters reach a critical limit should be considered.

How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis

BACKGROUND The aim of this modeling study was to examine how casualty load affects the level of trauma care in multiple casualty incidents and to define the surge capacity of the hospital trauma assets. METHODS The disaster plan of a U.S. Level I trauma center was translated into a computer model and challenged with simulated casualties based on 223 patients from 22 bombing incidents treated at an Israeli hospital. The model assigns providers and facilities to casualties and computes the level of care for each critical casualty from six variables that reflect the composition of the trauma team and access to facilities. RESULTS The model predicts a sigmoid-shaped relationship between casualty load and the level of care, with the upper flat portion of the curve corresponding to the surge capacity of the trauma assets of the hospital. This capacity is 4.6 critical patients per hour using immediately available assets. A fully deployed disaster plan shifts the curve to the right, increasing the surge capacity to 7.1. Overtriage rates of 50% and 75% shift the curve to the left, decreasing the surge capacity to 3.8 and 2.7, respectively. CONCLUSION This model defines the quantitative relationship between an increasing casualty load and gradual degradation of the level of trauma care in multiple casualty incidents, and defines the surge capacity of the hospital trauma assets as a rate of casualty arrival rather than a number of beds. The study demonstrates the value of dynamic computer modeling as an important tool in disaster planning.

DAMAGE CONTROL FOR THORACIC INJURIES

Some of the earliest damage control techniques were applied to the chest during emergency center thoracotomy. It provided a paradigm that was adapted to other areas. Damage control of chest injuries has a different philosophy than that of abdominal injuries. Damage control in the abdomen primarily consists of multiple staged operations with abbreviated closures. Damage control in the chest consists of different technical maneuvers to use quicker and technically less demanding operations to accomplish the same goal. The philosophy of doing only enough to restore a survivable physiology is still a common theme. The following are the major principles of damage control for thoracic injuries: 1. Emergency center thoracotomy is a damage control prototype. 2. Anterolateral thoracotomy is the empiric incision of choice in the patient in extremis. 3. Nonanatomically stapled lung resections, pulmonary tractotomy, and en masse lobectomy/pneumonectomy are pulmonary damage control procedures. 4. The unique physiology of the chest may require en masse closure of muscles or patch closure of the wound. 5. Cardiopulmonary physiology can be affected by packing. Packing thus has a limited role in thoracic damage control. 6. Prosthetic grafts, intravascular shunts, and ligation are common thoracic vascular damage control techniques. 7. With new technology, an increased role for cardiopulmonary bypass and cardiac assistance may develop. 8. New technology must not overly complicate a procedure if it is to be a valuable damage control adjunct.