Rajesh R. Gandhi

Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation.

OBJECTIVE Unplanned endotracheal extubation (UEE) is a common complication in medical intensive care units but very little data about UEE in surgical populations are available. Our hypothesis is that the surgical intensive care unit (SICU) population requires reintubation less frequently compared with the medical intensive care unit population. We prospectively gathered data on patients in a SICU in an attempt to identify the incidence of UEE and to study the need for reintubation after UEE. METHODS During an 18-month period, we prospectively identified SICU patients from a quality improvement database who required ventilatory support. All patients who self-extubated were included in the study. RESULTS Fifty-eight of 1,178 intubated patients experienced unplanned extubation 61 times during the 18-month period. A total of 22 patients (36%) required reintubation, whereas 39 patients (64%) did not. Thirty-three patients self-extubated while being actively weaned from ventilatory support. Of these, only 5 patients (15%) required reintubation and 28 patients (85%) did not (p < 0.01). CONCLUSION A total of 85% of patients who self-extubate during the weaning process did not require reintubation in our study. Those who have an FiO2 >50%, a lower PaO2/FiO2 ratio, had UEE occur by accident, or were not being weaned when UEE occurred required reintubation more frequently. These data suggest that some of our SICU patients are intubated longer than necessary, which may translate into more ventilator related complications, longer ICU stays and increased cost.

What is taught, what is tested: Findings and competency-based recommendations of the Undergraduate Medical Education Committee of the Society of Critical Care Medicine

Introduction:Addressing an unexpected shortfall of intensivists requires early identification and training of appropriate personnel. The purpose of this study was to determine how U.S. medical students are currently educated and tested on acute care health principles. Hypothesis/Methods:A survey of critical care education with telephone follow-up was mailed to the deans of all 126 medical schools. Web site review of medical school curricula for critical care education was performed. Upon invited request, four members of the Undergraduate Medical Education Committee (UGMEC) reviewed 1,200 pool questions of step II of the U.S. Medical Licensing Examination (USMLE) given to graduating medical students for critical care content. Descriptive statistics are employed. Results:Survey response rate was 49% and 88% by the second mailing with Web site review. Forty-five percent of U.S. medical schools responding had formal undergraduate critical care didactic curricula averaging 12 ± 3 hrs: 60% were elective, 60% taught in the 4th year. Eighty percent of clinical ICU rotations offered were elective. Sixty percent of schools taught 11 key critical care procedures in the 3rd or 4th year; 17% required them to graduate. Nineteen percent of Step II USMLE questions had critical care content; 58% dealt with pulmonary or cardiac disease. Conclusions:Graduating medical students are tested (and licensed accordingly) on critical care knowledge, despite an inconsistent exposure to the discipline in medical school. The UGMEC has drafted competency-based recommendations for acute health care delivery that encourage mandatory didactic and procedural critical care training. The UGMEC recommends that critical care rotations with didactic curricula be required for undergraduate education and that acute care procedural skills be an important component of these curricula.

Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (<24 hours) versus late (>24 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. METHODS A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50–1.08). The quality of evidence was rated as “low.” No significant reduction in infection (RR, 0.4; 95% CI, 0.10–1.6) or VTE (RR, 0.63; 95% CI, 0.37–1.07) was associated with early stabilization. The quality of evidence was rated “low.” CONCLUSION In trauma patients with open or closed femur fractures, we suggest early (<24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

Traumatic internal carotid artery injury treated with overlapping bare metal stents under intravascular ultrasound guidance

We report a case of traumatic internal carotid artery pseudoaneurysm near the skull base that was successfully treated with anticoagulation and antiplatelet therapy and two overlapping bare stents placed under intravascular ultrasound guidance. Although incomplete exclusion of the pseudoaneurysm was seen on completion angiography, follow-up computed tomography angiography revealed complete resolution of the treated lesion. The patient remains asymptomatic at the 18-month clinical follow-up. This case report illustrates a successful endovascular treatment of a complex traumatic pseudoaneurysm with bare metal stenting using intravascular ultrasound guidance.

Traumatic colon injury in damage control laparotomy - A multicenter trial: Is it safe to do a delayed anastomosis?

Background Delayed colonic anastomosis after damage control laparotomy (DCL) is an alternative to colostomies during a single laparotomy (SL) in high-risk patients. However, literature suggests increased colonic leak rates up to 27% with DCL, and various reported risk factors. We evaluated our regional experience to determine if delayed colonic anastomosis was associated with worse outcomes. Methods A multicenter retrospective cohort study was performed across three Level I trauma centers encompassing traumatic colon injuries from January 2006 through June 2014. Patients with rectal injuries or mortality within 24 hours were excluded. Patient and injury characteristics, complications, and interventions were compared between SL and DCL groups. Regional readmission data were utilized to capture complications within 6 months of index trauma. Results Of 267 patients, 69% had penetrating injuries, 21% underwent DCL, and the mortality rate was 4.9%. Overall, 176 received primary repair (26 in DCL), 90 had resection and anastomosis (28 in DCL), and 26 had a stoma created (10 end colostomies and 2 loop ileostomies in DCL). Thirty-five of 56 DCL patients had definitive colonic repair subsequent to their index operation. DCL patients were more likely to be hypotensive; require more resuscitation; and suffer acute kidney injury, pneumonia, adult respiratory distress syndrome, and death. Five enteric leaks (1.9%) and three enterocutaneous fistulas (ECF, 1.1%) were identified, proportionately distributed between DCL and SL (p = 1.00, p = 0.51). No difference was seen in intraperitoneal abscesses (p = 0.13) or surgical site infections (SSI, p = 0.70) between cohorts. Among SL patients, pancreas injuries portended an increased risk of intraperitoneal abscesses (p = 0.0002), as did liver injuries in DCL patients (p = 0.06). Conclusions DCL was not associated with increased enteric leaks, ECF, SSI, or intraperitoneal abscesses despite nearly two-thirds having delayed repair. Despite this being a multicenter study, it is underpowered, and a prospective trial would better demonstrate risks of DCL in colon trauma. Level of Evidence Therapeutic study, level IV.

Nursing Considerations for Traumatic Geriatric Orthopedic Injuries

Traumatic orthopedic fractures in the elderly population can cause significant morbidity and mortality. The most common mechanism of injury for elderly patients with orthopedic fracture is a fall from standing. According to the Centers for Disease Control and Prevention (CDC), one out of five falls results in serious injury including fracture or traumatic brain injury. In the elderly population, over 250,000 patients are hospitalized each year because of hip fractures (Centers for Disease Control and Prevention. 2015. Important facts about falls. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Accessed 9 Apr 2016; Centers for Disease Control and Prevention. 2015. Costs of falls among older adults. http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html. Accessed 9 Apr 2016; Centers for Disease Control and Prevention. 2015. Stopping elderly accidents, deaths and injuries. http://www.cdc.gov/steadi/materials.html. Accessed 9 Apr 2016). In 2013, direct medical cost for treatment of hip fractures was approximately

Role of ED crowding relative to trauma quality care in a Level 1 Trauma Center

34 billion dollars (Centers for Disease Control and Prevention. 2015. Important facts about falls. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Accessed 9 Apr 2016; Centers for Disease Control and Prevention. 2015. Costs of falls among older adults. http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html. Accessed 9 Apr 2016; Centers for Disease Control and Prevention. 2015. Stopping elderly accidents, deaths and injuries. http://www.cdc.gov/steadi/materials.html. Accessed 9 Apr 2016). In this injured population, it is important to provide evidence-based, expedited care to decrease complications and lengthy hospital stays which can ultimately cause severe functional decline and possibly death. Nursing measures to decrease the incidence of complications and shorten hospital length of stay should be implemented in all geriatric trauma fractures, whether operative or nonoperative.

Utilization of Pastoral Care Services for a Screening, Brief Intervention, and Referral-to-Treatment Program at an Urban Level I Trauma Center

Objective: Trauma Quality Improvement Program participation among all trauma centers has shown to improve patient outcomes. We aim to identify trauma quality events occurring during the Emergency Department (ED) phase of care. Methods: This is a single‐center observational study using consecutively registered data in local trauma registry (Jan 1, 2016–Jun 30, 2017). Four ED crowding scores as determined by four different crowding estimation tools were assigned to each enrolled patient upon arrival to the ED. Patient related (age, gender, race, severity of illness, ED disposition), system related (crowding, night shift, ED LOS), and provider related risk factors were analyzed in a multivariate logistic regression model to determine associations relative to ED quality events. Results: Total 5160 cases were enrolled among which, 605 cases were deemed ED quality improvement (QI) cases and 457 cases were ED provider related. Similar percentages of ED QI cases (10–12%) occurred across the ED crowding status range. No significant difference was appreciated in terms of predictability of ED QI cases relative to different crowding status after adjustment for potential confounders. However, an adjusted odds ratio of 1.64 (95% CI, 1.17–2.30, p < 0.01) regarding ED LOS ≥2 h predictive of ED related quality issues was noted when analyzed using multivariate logistic regression. Conclusion: Provider related issues are a common contributor to undesirable outcomes in trauma care. ED crowding lacks significant association with poor trauma quality care. Prolonged ED LOS (≥2 h) appears to be linked with unfavorable outcomes in ED trauma care.

Abdominal compartment syndrome in the pediatric blunt trauma patient treated with paracentesis: report of two cases.

to identify at-risk individuals while continually monitoring their progress. The CAGE and AUDIT questionnaires have shown more efficacy in the identification of alcohol use problems than other screening methods, even the use of direct questions about the quantity and frequency of use, 15 with the AUDIT slightly more effective than the CAGE questionnaire. 16 For the first step in the SBIRT process, the previously mentioned screening procedures (CAGE and AUDIT questionnaires) are commonly used to assess alcohol consumption behaviors in patients with an elevated blood alcohol content. Brief intervention can range from brief motivational conversations to more extensive interventions, with the ultimate goal of motivating individuals to change their substance use behaviors. The last step of the SBIRT program, referral to treatment, consists of helping clients identify resources to assist with alcohol or substance abuse recovery. 6 Research has shown that the implementation of SBIRT programs is associated with reductions in excessive alcohol consumption. The implementation of SBIRT programs has shown reductions in negative consequences associated with drinking, 7–10 as well as reduced consumption after 3 months. 17 Given their efficacy, SBIRT programs are recommended by several national organizations to reduce alcohol misuse among injured patients. 11,18,19