Richard S. Miller

Infant survival after cesarean section for trauma

HYPOTHESIS Emergency cesarean sections in trauma patients are not justified and should be abandoned. SETTING AND DESIGN A multi-institutional, retrospective cohort study was conducted of level 1 trauma centers. METHODS Trauma admissions from nine level 1 trauma centers from January 1986 through December 1994 were reviewed. Pregnant women who underwent emergency cesarean sections were identified. Demographic and clinical data were obtained on all patients undergoing a cesarean section. Fetal distress was defined by bradycardia, deceleration, or lack of fetal heart tones (FHTs). Maternal distress was defined by shock (systolic blood pressure < 90) or acute decompensation. Statistical analyses were performed. RESULTS Of the 114,952 consecutive trauma admissions, more than 441 pregnant women required 32 emergency cesarean sections. All were performed for fetal distress, maternal distress, or both. Overall, 15 (45%) of the fetuses and 23 (72%) of the mothers survived. Of 33 fetuses delivered, 13 had no FHTs and none survived. Twenty infants (potential survivors) had FHTs and an estimated gestational age (EGA) of greater than or equal to 26 weeks, and 75% survived. Infant survival was independent of maternal distress or maternal Injury Severity Score. The five infant deaths in the group of potential survivors resulted from delayed recognition of fetal distress, and 60% of these deaths were in mothers with mild to moderate injuries (Injury Severity Score < 16). CONCLUSIONS In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.

Feeding the Open Abdomen

BACKGROUND The purpose of this study was to determine if early enteral nutrition improves outcome for trauma patients with an open abdomen (OA). METHODS Retrospective review was used to identify 78 patients who required an OA for >or=4 hospital days, survived, and had available nutrition data. Demographic data and nutrition data comprising enteral nutrition initiation day and daily % target goal were collected. Patients were divided into 2 groups: early enteral feeding (EEN), initiated <or=4 days within celiotomy; and late enteral feeding (LEN; >4 days). Outcomes included infectious complications, early closure of the abdominal cavity (<8 days from original celiotomy), and fistula formation. RESULTS Fifty-three of 78 (68%) patients were men, with a mean age of 35 years; 74% had blunt trauma. Forty-three of 78 (55%) patients had EEN, whereas 35 of 78 (45%) had LEN. There was no difference with respect to demographics, injury severity, or infectious complication rates. Thirty-two of 43 (74%) patients with EEN had early closure of the abdominal cavity, whereas 17 of 35 (49%) patients with late feeding had early closure (p = .02). Four of 43 (9%) patients with EEN demonstrated fistula formation, whereas 9 of 35 (26%) patients with late feeding formed fistulae (p = .05). The EEN group had lower hospital charges (p = .04) by more than

The impact of a normoglycemic management protocol on clinical outcomes in the trauma intensive care unit.

50,000. CONCLUSIONS EEN in the OA was associated with (1) earlier primary abdominal closure, (2) lower fistula rate, (3) lower hospital charges.

Survival in patients with severe adult respiratory distress syndrome treated with high-level positive end-expiratory pressure.

BACKGROUND The purpose of this study was to determine if protocol-driven normoglycemic management in trauma patients affected glucose control, ventilator-associated pneumonia, surgical-site infection, and inpatient mortality. METHODS A prospective, consecutive-series, historically controlled study design evaluated protocol-driven normoglycemic management among trauma patients at Vanderbilt University Medical Center. Those mechanically ventilated > or =24 hours and > or =15 years of age were included. A glycemic-control protocol required insulin infusion therapy for glucose >110 mg/dL. Control patients included those who met criteria, were admitted the year preceding protocol implementation, and had hyperglycemia treated at the physicians discretion. RESULTS Eight hundred eighteen patients met study criteria; 383 were managed without protocol; 435 underwent protocol. The protocol group had lower glucose levels 7 of 14 days measured. After admission, both groups had mean daily glucose levels <150 mg/dL. No difference in pneumonia (31.6% vs 34.5%; p = .413), surgical infection (5.0% vs 5.7%; p = .645) or mortality (12.3% vs 13.1%; p = .722) occurred between groups. If one episode of blood glucose level was > or =150 mg/dL (n = 638; 78.0%), outcomes were worse: higher daily glucose levels for 14 days after admission (p < .001), pneumonia rates (35.9% vs 23.3%; p = .002), and mortality (14.6% vs 6.1%; p = .002). One or more days of glucose > or =150 mg/dL had a 2- to 3-fold increase in the odds of death. Protocol use in these patients was not associated with outcome improvement. CONCLUSIONS Protocol-driven management decreased glucose levels 7 of 14 days after admission without outcome change. One or more glucose levels > or =150 mg/dL were associated with worse outcome.

Blunt colonic injury : a multicenter review

OBJECTIVE To assess the mortality rate and complications in a population of surgical patients with severe adult respiratory distress syndrome (ARDS) treated with positive end-expiratory pressure (PEEP) of > 15 cm H2O in an attempt to reduce intrapulmonary shunt to approximately 0.20 and reduce FIO2 to < 0.50. DESIGN Retrospective review of patients treated by a standardized ventilatory support protocol at the time of their illness. SETTING A 24-bed surgical intensive care unit in a university medical center. PATIENTS All patients admitted to the surgical intensive care unit during a 34-month period who met the criteria for severe ARDS (Pao2 of < or = 70 torr [< or = 9.3 kPa] on an FIO2 of > or = 0.50, diffuse interstitial and/or alveolar infiltrates on chest radiograph, decreased lung compliance, no evidence of congestive heart failure, and a likely predisposing etiology) were evaluated. Patients treated with PEEP of > 15 cm H2O were selected for this review. INTERVENTIONS Patients were treated by a protocol to achieve oxygenation end points, which consisted of maintaining arterial oxyhemoglobin saturation (as determined by pulse oximetry of > or = 0.92), while reducing FIO2 to < 0.50 and decreasing intrapulmonary shunt fraction to < or = 0.20 by adding PEEP. With the exception of patients with suspected intracranial hypertension related to closed-head injury, low-rate intermittent mandatory ventilation was the primary mode of ventilation. Pressure-support ventilation was added, when needed, to improve patient comfort, enhance spontaneous tidal volume, or improve CO2 excretion. MEASUREMENTS AND MAIN RESULTS Eighty-six patients with severe ARDS were treated with a PEEP of > 15 cm H2O. Nineteen of these patients died early of severe closed-head injury or massive uncontrollable hemorrhage and were excluded from the evaluation. The remaining 67 patients had a mean Lung Injury Score of 3.3 during their treatment with high PEEP. Twenty (30%) of 67 patients died. Eight of the deaths occurred after decrease of ventilatory support and with acceptable blood gases. The other 12 patients who died had continued oxygenation deficits and received increased levels of ventilatory support at the time of death. Twenty-six (39%) of 67 patients had radiographic manifestations of barotrauma (pneumothorax, subcutaneous emphysema, etc.) related to their primary injuries or to complications related to central venous catheter placement. Seven (17%) of 41 patients developed clinical or radiographic signs of barotrauma while receiving high-level PEEP. The hemodynamic effects of increased airway pressure were managed with fluids and inotropic agents, when necessary, and did not limit the application of PEEP to reach the defined end point of treatment. CONCLUSIONS This subset of patients with severe ARDS treated with high-level PEEP had a mortality rate lower than those rates previously reported by other researchers using more conventional ventilatory support and resuscitation techniques. FIO2 may be significantly reduced and PaO2 may be maintained at acceptable values by decreasing intrapulmonary shunt fraction using high-level PEEP.

Morbid Obesity is Not a Risk Factor for Mortality in Critically Ill Trauma Patients

During the past decade there has been a shift in the management of injuries of the colon to primary repair without a protective diverting colostomy. Unfortunately, reports concerning this practice contain relatively few patients with blunt trauma and it is unclear whether the principles established for penetrating injury should be applied in the setting of blunt colon injury. A retrospective review of 54,361 major blunt trauma patients admitted to nine regional trauma centers from January 1, 1986, through December 31, 1990, was conducted. Statistical analysis of the data collected regarding 286 (0.5%) of these patients who suffered colonic injury revealed: (1) injury to the colon is found in more than 10% of patients undergoing laparotomy following blunt trauma; (2) available diagnostic modalities are unreliable in detecting isolated colonic pathology; (3) primary repair of full-thickness injuries or resection and anastomosis may be safely performed without diversion; (4) gross fecal contamination is the strongest contraindication to primary repair. Further, delay of surgery, shock, and the timing of antibiotic administration were not associated with significantly increased morbidity.

Feasibility of Implementing a Reduced Fasting Protocol for Critically Ill Trauma Patients Undergoing Operative and Nonoperative Procedures

BACKGROUND Age, Injury severity score (ISS), hyperglycemia (HGL) at admission, and morbid obesity are known risk factors of poor outcome in trauma patients. Our aim was to which risk factors had the highest risk of death in the critically ill trauma patient. METHODS A Trauma Registry of the American College of Surgeons database retrospective study was performed at our Level I trauma center from January 2000 to October 2004. Inclusion criteria were age >15 years and >or=3 days hospital stay. Data collected included age, gender, and ISS. Groups were divided into nonobese and morbidly obese (MO) (body mass index, BMI >or=40 kg/m2) and into HGL (mean >or=150 mg/dL on initial hospital day) and non-HGL. Primary outcome was 30-day mortality. Differences in mortality and demographic variables between groups were compared using Fishers exact and Wilcoxons rank sum tests. Univariate and multivariate logistic regression was used to assess the relationship of HGL, morbid obesity, age, and injury severity to risk of death. Relationships were assessed using odds ratios (OR) and area under the receiver operator characteristic curve (AUC). RESULTS A total of 1,334 patients met study criteria and 70.5% were male. Demographic means were age 40.3, ISS 25.7, length of stay 13.4, and BMI 27.5. The most common mechanism of injury was motor vehicle collision 55.1%. Overall mortality was 4.7%. Mortality was higher in HGL versus non-HGL (8.7% vs. 3.5%; p < 0.001). Mortality was higher in MO versus nonobese, but not significantly (7.8 vs. 4.6%; not significant [NS] p = 0.222). Univariate logistic regression relationships of death to age OR: 1.031, p < 0.001, AUC +/- SE: 0.639 +/- 0.042; ISS OR: 1.044, p < 0.001, AUC +/- SE: 0.649 +/- 0.039; HGL OR: 2.765, p < 0.001; MO: OR: NS, p = NS, AUC +/- SE: NS. Relationships were similar in a combined multivariate model. CONCLUSION HGL >150 mg/dL on the day of admission is associated with twofold increase in mortality, and an outcome measure should be followed. Morbid obesity (BMI >or=40) is not an independent risk factor for mortality in the critically ill trauma patient.

Antithrombin III and trauma patients : factors that determine low levels

BACKGROUND This prospective, observational cohort study was designed to determine the feasibility of implementing a reduced enteral fasting protocol in mechanically ventilated trauma patients undergoing selected operative and nonoperative procedures. METHODS Critically ill, mechanically ventilated trauma patients undergoing selected operative and nonoperative procedures received enteral nutrition up until the time of the procedure, if receiving small bowel feeds, or received enteral nutrition that was discontinued 45 minutes before the procedure, if receiving gastric feeds. RESULTS Measures of delivery of nutrition such as total enteral nutrition delivered and days required to reach nutrition goal were collected. Complications measured were death, incidence of ventilator-associated pneumonia, urinary tract infection, catheter-related bloodstream infection, wound infection, hypoglycemia, and emesis during procedures. No significant demographic differences were observed between the 2 groups. Patients in the intervention group showed trends toward greater total enteral nutrition delivered and faster attainment of target nutrition goals, although these measures were not statistically significant. Patients in the intervention group had rates of infective complications similar to those in the standard group. The median (interquartile range) for intensive care unit length of stay in the intervention group vs standard group was 7 (5, 15) vs 7 (5, 12) (P = 0.94), and the ventilator days were 8 (4.2, 14) vs 7 (3, 11) (P = 0.37). CONCLUSIONS A reduced fasting protocol was feasible for selected operative procedures, with trends toward improving nutrition delivery and no increase in adverse outcomes. A larger randomized study of this approach is warranted before adoption of this practice can be advocated.

Long-term follow-up of unsuccessful violent suicide attempts: Risk factors for subsequent attempts

A prospective (cohort) study was conducted to determine the incidence of low antithrombin III (AT III) levels and the association with selected clinical variables in adult trauma patients. One hundred sixty AT III levels were obtained on 50 consecutive trauma admissions to a community-based level I trauma center. Antithrombin III levels were drawn as soon after admission as possible and every other day thereafter. Thirty-one patients (62%) had at least one low AT III level (< 80%), whereas 15 concurrently drawn control levels were all > or = 90%. Low AT III levels were more common in patients with one or more of the following: base deficit less than -4 (39% vs. 0, p = 0.002); Injury Severity Score > 15 (48% vs. 16%, p = 0.04); and blood transfusion (32% vs. 5%, p = 0.04). All other variables (shock, surgical intervention, subcutaneous heparin, and sequential compression devices) were not statistically significant, although all six patients with shock had low levels. In conclusion, over 60% of adult trauma patients had low AT III levels at some time during hospitalization and these patients were clearly more severely injured. Further studies are required to determine if these patients are more susceptible to thromboembolic phenomena.

High-level positive end-expiratory pressure management in trauma-associated adult respiratory distress syndrome.

STUDY POPULATION Of 9046 consecutive trauma admissions, all suicide attempts (n = 156) were identified: 38 patients (24%) died in hospital; 118 (76%) were discharged and received long-term follow-up (mean = 2.8 years). Factors assessed included suicidal ideation and planning, reason for attempt; number of attempts, methods, dates of prior and subsequent attempts; psychiatric diagnoses, substance abuse history, treatment and medication compliance, hospitalizations, incidence of family depression and suicide; education level, job history, and living conditions. RESULTS 104 (88%) patients were interviewed and 14 (12%) were lost to follow-up. Seventy-seven of the patients (74%) used guns in their attempt; their mean ISS was 14.2. Seven (6.7%) made repeat suicide attempts (all unsuccessful). Late mortality was 7% (one related to index suicide, five to chronic illness, one to motor vehicle crash). Most patients (96%) had psychiatric diagnoses at discharge, 77 of 93 (83%) had diagnosed depression. Sixty-six percent (69 of 104) had histories of alcohol abuse, 42% (42 of 101) histories of drug abuse. Thirty-five percent (34 of 96) were noncompliant with psychiatric follow-up and 70% (16 of 23) were noncompliant with alcohol abuse treatment. CONCLUSIONS (1) Repeat attempts were rare (7%) after failed suicide attempts. (2) No late deaths resulted from repeat suicide attempts. (3) Risk factors associated with repeat attempts were younger age (p = 0.002), prior attempts (p = 0.02), family history of suicide (p = 0.03), schizophrenia (p = 0.005), and not living at home (p = 0.04). (4) Identifying patients with these risk factors, ensuring that they receive inpatient alcohol abuse treatment, along with sustained psychiatric treatment and help in maintaining home environments, may prevent repeat suicide attempts.