Scott R. Gunn

An FFP: PRBC transfusion ratio >/=1:1.5 is associated with a lower risk of mortality after massive transfusion.

OBJECTIVE The detrimental effects of coagulopathy, hypothermia, and acidosis are well described as markers for mortality after traumatic hemorrhage. Recent military experience suggests that a high fresh frozen plasma (FFP):packed red blood cell (PRBC) transfusion ratio improves outcome; however, the appropriate ratio these transfusion products should be given remains to be established in a civilian trauma population. METHODS Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in blunt injured adults with hemorrhagic shock. Those patients who required >/=8 units PRBCs within the first 12 hours postinjury were analyzed (n = 415). RESULTS Patients who received transfusion products in >/=1:1.50 FFP:PRBC ratio (high F:P ratio, n = 102) versus <1:1.50 FFP:PRBC ratio (low F:P, n = 313) required significantly less blood transfusion at 24 hours (16 +/- 9 units vs. 22 +/- 17 units, p = 0.001). Crude mortality differences between the groups did not reach statistical significance (high F:P 28% vs. low F:P 35%, p = 0.202); however, there was a significant difference in early (24 hour) mortality (high F:P 3.9% vs. low F:P 12.8%, p = 0.012). Cox proportional hazard regression revealed that receiving a high F:P ratio was independently associated with 52% lower risk of mortality after adjusting for important confounders (HR 0.48, p = 0.002, 95% CI 0.3-0.8). A high F:P ratio was not associated with a higher risk of organ failure or nosocomial infection, however, was associated with almost a twofold higher risk of acute respiratory distress syndrome, after controlling for important confounders. CONCLUSIONS In patients requiring >/=8 units of blood after serious blunt injury, an FFP:PRBC transfusion ratio >/=1:1.5 was associated with a significant lower risk of mortality but a higher risk of acute respiratory distress syndrome. The mortality risk reduction was most relevant to mortality within the first 48 hours from the time of injury. These results suggest that the mortality risk associated with an FFP:PRBC ratio <1:1.5 may occur early, possibly secondary to ongoing coagulopathy and hemorrhage. This analysis provides further justification for the prospective trial investigation into the optimal FFP:PRBC ratio required in massive transfusion practice.

MRI Is Unnecessary to Clear the Cervical Spine in Obtunded/Comatose Trauma Patients: The Four-Year Experience of a Level I Trauma Center

BACKGROUND Cervical (C)-spine clearance protocols exist both to identify traumatic injury and to expedite rigid collar removal. Computed tomography (CT) of the C-spine in trauma patients facilitates the removal of immobilization collars in patients who are neurologically intact, and magnetic resonance imaging (MRI) has become an indispensable adjunct for evaluating trauma patients with neurologic deficits. Yet, the management of patients with impaired mental status who lack neurologic deficits attributable to the spinal cord remains controversial. C-spine MRI has been suggested and employed as an imaging modality to exclude occult C-spine instability in this population of patients. However, currently available data are inconclusive as to the necessity of MRI in the C-spine clearance of obtunded or comatose trauma patients with a normal CT. METHODS The records of patients undergoing contemporaneous CT and MRI of the C-spine in a level I trauma center from January 2003 to December 2006 were retrospectively analyzed. From this group, patients admitted with a Glasgow Coma Scale score </=13 and a normal C-spine CT with sagittal and coronal reconstructions were identified. Patients were excluded if a neurologic deficit potentially referable to the spinal cord was identified. The results of C-spine MRI in this group were tabulated and analyzed. RESULTS A total of 690 patients were identified who had undergone contemporaneous C-spine CT and MRI. Of this group, 180 patients (26.2%) were identified as having a normal CT with sagittal and coronal reconstructions, no neurologic deficit, and Glasgow Coma Scale score </=13. Within this group, the average time interval between CT and MRI was 4.6 days (median, 4 days). Among these 180 patients, C-spine MRI identified 38 patients (21.1%) with acute traumatic findings in the cervical spine. However, none of these patients had a missed unstable injury and no patient required surgery or developed evidence of delayed instability. CONCLUSION Our data suggests that, outside of its appropriate application to patients with a neurologic deficit, MRI is unlikely to uncover unstable C-spine injuries in patients who are obtunded or comatose when C-spine CT using modern imaging protocols is normal.

Implications of arterial pressure variation in patients in the intensive care unit

Positive-pressure ventilation alters stroke volume by transiently increasing intrathoracic pressure and thereby decreasing preload. This phasic variation in stroke volume results in a cyclic fluctuation in arterial pressure with a phase length equal to the respiratory rate. Measuring ventilation-induced arterial pressure variation allows the clinician to predict the cardiovascular response to changes in intravascular volume status. Thus, one may predict preload responsiveness because the greater the amount of ventilation-associated arterial pressure variation, the greater the patient’s preload responsiveness. This variation in arterial pressure can been defined as a variation in either systolic pressure or pulse pressure. Although pulse pressure gives a clearer signal, systolic pressure variation may be easier to measure bedside without invasive hemodynamic monitoring. Newer methods of quantifying this arterial pressure variation include the respiratory systolic variation test, which can performed without an apneic baseline, and the pulse pressure variation, a potentially more accurate measure of preload responsiveness.

Critical care medicine training and certification for emergency physicians.

Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine (EM) and critical care medicine (CCM). Critical care is a continuum that includes prehospital, emergency department (ED), and intensive care unit (ICU) care teams. Both EM and CCM require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of CCM fellowships do not accept EM residents, and those who successfully complete a fellowship do not have access to a U.S. certification exam in CCM. Despite these barriers, interest in CCM training among EM physicians is increasing. Dual EM/CCM-trained physicians not only will help alleviate the intensivist shortage but also will strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to CCM certification for emergency physicians who complete a critical care fellowship.

Equipment review: The success of early goal-directed therapy for septic shock prompts evaluation of current approaches for monitoring the adequacy of resuscitation

A recent trial utilizing central venous oxygen saturation (SCVO2) as a resuscitation marker in patients with sepsis has resulted in its inclusion in the Surviving Sepsis Campaign guidelines. We review the evidence behind SCVO2 and its relationship to previous trials of goal-directed therapy. We compare SCVO2 to other tools for assessing the adequacy of resuscitation including physical examination, biochemical markers, pulmonary artery catheterization, esophageal Doppler, pulse contour analysis, echocardiography, pulse pressure variation, and tissue capnometry. It is unlikely that any single technology can improve outcome if isolated from an organized pattern of early recognition, algorithmic resuscitation, and frequent reassessment. This article includes a response to the journals Health Technology Assessment questionnaire by the manufacturer of the SCVO2 catheter.

Use of a Nasal Bridle Prevents Accidental Nasoenteral Feeding Tube Removal

Reinserting feeding tubes that are accidentally removed exposes patients to risk and consumes hospital resources. We were interested to know if using a bridle to secure tubes would be more effective than tape at preventing accidental tube removal. This was a quality improvement project with a before-and-after design. Between May 2007 and August 2007, we prospectively followed 90 tubes (50 tape, 40 bridle). Tubes were followed up daily until accidental tube removal, ICU discharge, or planned tube removal. Our primary endpoint was accidental tube removal. We compared the 2 groups on the following: (1) proportion of tubes accidentally removed; (2) rate of accidental tube removal (per 100 tube-days); and (3) Kaplan-Meier survival analysis. Survival analysis data were right-censored at ICU discharge or planned tube removal. There were no significant differences between groups in any demographics. The proportion of tubes accidentally removed was 36% (18 of 50) in the tape group and 10% (4 of 40) in the bridle group; P<.05. The rate of accidental tube removal (per 100 tube-days) was 6.4 (18 in 281 tube-days) in the tape group and 1.6 (4 in 248 tube-days) in the bridle group; P<.05. Survival analysis showed a significant difference between the groups with a log-rank test for equality of survivor function of P<.05. Using a bridle to secure feeding tubes significantly reduces the proportion and rate of accidental tube removal and results in increased tube survival by Kaplan-Meier analysis.

Impact of nurse-led remote screening and prompting for evidence-based practices in the ICU*.

Objectives:Evidence-based practices are not consistently applied in the ICU. We sought to determine if nurse-led remote screening and prompting for evidence-based practices using an electronic health record could impact ICU care delivery and outcomes in an academic medical center. Design:Single-center, before-after evaluation of a quality improvement project. Setting:Urban, academic medical center in the mid-Atlantic United States with eight subspecialty ICUs and 156 ICU beds. Patients:Adult patients admitted to the ICU between January 1, 2011, and August 31, 2012. Interventions:Beginning on July 25, 2011, trained ICU nurses screened all ICU patients for selected evidence-based practices on a daily basis. The screening was conducted from a remote office, facilitated by the electronic health record. Selected practices included compliance with a ventilator care bundle, assessment of appropriateness of indwelling venous and urinary catheters, and concordance between sedation orders and documented level of sedation. When gaps were observed, they were communicated to the point-of-care bedside nurse via telephone, page, or facsimile. Measurements and Main Results:Fourteen thousand eight hundred twenty-three unique patients were admitted during the study period. We excluded 1,546 patients during a 2-month run-in period from July 1, 2011, to August 31, 2011, resulting in 4,339 patients in the 6-month preintervention period and 8,938 patients in the 12-month postintervention period. Compared with patients admitted in the preintervention period, patients admitted in the postintervention period were more likely to receive sedation interruption (incidence rate ratio, 1.57; 95% CI, 1.45–1.71) and a spontaneous breathing trial (incidence rate ratio, 1.24; 95% CI, 1.20–1.29). Hospital-acquired infection rates were not different between the two periods. Adjusting for patient characteristics and illness severity, patients in the postintervention period experienced shorter duration of mechanical ventilation (adjusted reduction, 0.61 d; 95% CI, 0.27–0.96; p < 0.001), shorter ICU length of stay (adjusted reduction, 0.22 d; 95% CI, 0.04–0.41; p = 0.02), and shorter hospital length of stay (adjusted reduction, 0.55 d; 95% CI, 0.15–0.93; p = 0.006). In-hospital mortality was unchanged (adjusted odds ratio, 0.96; 95% CI, 0.84–1.09; p = 0.54). The results were robust to tests for concurrent temporal trends and coincident interventions. Conclusions:A program by which nurses screened ICU patients for best practices from a remote location was associated with improvements in the quality of care and reductions in duration of mechanical ventilation and length of stay, but had no impact on mortality.

Incidence and Etiology of Potentially Preventable Icu Readmissions

Objectives: The rate of unplanned ICU readmissions is often considered a measure of hospital performance. However, the degree to which these readmissions are preventable and the causes of preventable readmissions are unknown, creating uncertainty about the feasibility and value of reducing ICU readmission rates. To inform this issue, we sought to determine the frequency and underlying causes of potentially preventable ICU readmissions. Design: Retrospective cohort study. Setting: Urban, academic medical center in the mid-Atlantic United States. Patients: Adult patients discharged alive from their first ICU admission with an unplanned readmission within 48 hours of discharge. Measurements and Main Results: Each patient’s medical chart was reviewed by two independent investigators who rated each readmission’s preventability according to standardized scale and assessed the etiology of both preventable and nonpreventable readmissions. We assessed concordance between raters using the &kgr; statistic and resolved disagreements through iterative discussion. Of 136 readmissions in the final analysis, 16 (11.8%; 95% CI, 6.9–18.4) were considered preventable and 120 (88.2%; 95% CI, 81.5–93.1) were considered nonpreventable. Of nonpreventable readmissions, 67 were due to a new clinical problem and 53 were due to an existing clinical problem. Among preventable readmissions, six were attributable to system errors, six were attributable to management errors, two were attributable to procedural events, one was attributable to a diagnostic error, and one was attributable to a medication error. Compared to nonpreventable readmissions, preventable readmissions tended to have shorter index ICU lengths of stay (2 vs 3 d; p = 0.05) and a shorter duration of time on the ward prior to readmission (16.6 vs 23.6 hr; p = 0.05). Conclusions: The majority of early ICU readmissions are nonpreventable, raising important concerns about ICU readmission rates as a measure of hospital performance.

Interleukin 6 and Apolipoprotein E as Predictors of Acute Brain Dysfunction and Survival in Critical Care Patients

BACKGROUND Delirium occurs in up to 80% of intensive care patients and is associated with poor outcomes. The biological cause of delirium remains elusive. OBJECTIVES To determine if delirium and recovery are associated with serum levels of interleukins and apolipoprotein E over time and with apolipoprotein E genotype. METHODS The sample consisted of 77 patients with no previous cognitive deficits who required mechanical ventilation for 24 to 96 hours. Daily serum samples were obtained for enzyme-linked immunosorbent assay measurements of interleukins 6, 8, and 10 and apolipoprotein E. DNA extracted from blood was analyzed for apolipoprotein E genotyping. The Confusion Assessment Method for the Intensive Care Unit was administered daily on days 2 through 9. RESULTS Among the 77 patients, 23% had no delirium, 46% experienced delirium, and 31% experienced coma. Additionally, 77% had delirium or coma (acute brain dysfunction), and compared with other patients, had fewer ventilator-free days (P = .03), longer stay (P = .04), higher care needs at discharge (P = .001), higher mortality (P = .02), and higher levels of interleukin 6 (P = .03), and the APOE*3/*3 apolipoprotein E genotype (P = .05). Serum levels of apolipoprotein E correlated with levels of interleukins 8 and 10. Patients with the E4 allele of apolipoprotein E had shorter duration of delirium (P = .02) and lower mortality (P = .03) than did patients without this allele. CONCLUSIONS Apolipoprotein E plays a complex role in illness response and recovery in critically ill patients. The relationship between apolipoprotein E genotype and brain dysfunction and survival is unclear.

Effect of ganciclovir on IL-6 levels among cytomegalovirus-seropositive adults with critical illness: A randomized clinical trial

Importance The role of cytomegalovirus (CMV) reactivation in mediating adverse clinical outcomes in nonimmunosuppressed adults with critical illness is unknown. Objective To determine whether ganciclovir prophylaxis reduces plasma interleukin 6 (IL-6) levels in CMV-seropositive adults who are critically ill. Design, Setting, and Participants Double-blind, placebo-controlled, randomized clinical trial (conducted March 10, 2011-April 29, 2016) with a follow-up of 180 days (November 10, 2016) that included 160 CMV-seropositive adults with either sepsis or trauma and respiratory failure at 14 university intensive care units (ICUs) across the United States. Interventions Patients were randomized (1:1) to receive either intravenous ganciclovir (5 mg/kg twice daily for 5 days), followed by either intravenous ganciclovir or oral valganciclovir once daily until hospital discharge (n = 84) or to receive matching placebo (n = 76). Main Outcomes and Measures The primary outcome was change in IL-6 level from day 1 to 14. Secondary outcomes were incidence of CMV reactivation in plasma, mechanical ventilation days, incidence of secondary bacteremia or fungemia, ICU length of stay, mortality, and ventilator-free days (VFDs) at 28 days. Results Among 160 randomized patients (mean age, 57 years; women, 43%), 156 patients received 1or more dose(s) of study medication, and 132 patients (85%) completed the study. The mean change in plasma IL-6 levels between groups was −0.79 log10 units (−2.06 to 0.48) in the ganciclovir group and −0.79 log10 units (−2.14 to 0.56) in the placebo group (point estimate of difference, 0 [95% CI, −0.3 to 0.3]; P > .99). Among secondary outcomes, CMV reactivation in plasma was significantly lower in the ganciclovir group (12% [10 of 84 patients] vs 39% [28 of 72 patients]); absolute risk difference, −27 (95% CI, −40 to −14), P < .001. The ganciclovir group had more median VFDs in both the intention-to-treat (ITT) group and in the prespecified sepsis subgroup (ITT group: 23 days in ganciclovir group vs 20 days in the placebo group, P = .05; sepsis subgroup, 23 days in the ganciclovir group vs 20 days in the placebo group, P = .03). There were no significant differences between the ganciclovir and placebo groups in duration of mechanical ventilation (5 days for the ganciclovir group vs 6 days for the placebo group, P = .16), incidence of secondary bacteremia or fungemia (15% for the ganciclovir group vs 15% for the placebo group, P = .67), ICU length of stay (8 days for the ganciclovir group vs 8 days for the placebo group, P = .76), or mortality (12% for the ganciclovir group vs 15% for the placebo group, P = .54). Conclusions and Relevance Among CMV-seropositive adults with critical illness due to sepsis or trauma, ganciclovir did not reduce IL-6 levels and the current study does not support routine clinical use of ganciclovir as a prophylactic agent in patients with sepsis. Additional research is necessary to determine the clinical efficacy and safety of CMV suppression in this setting. Trial Registration clinicaltrials.gov Identifier: NCT01335932