Stathis Poulakidas

Ventilator-associated pneumonia in injured patients: Do you trust your Gram's stain?

BACKGROUND The results of sputum or bronchoalveolar lavage (BAL) fluid Grams stain have been used to guide presumptive antibiotic therapy for ventilator-associated pneumonia (VAP) in injured patients, despite reported variability in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Our aim was to evaluate the utility of Grams stain of BAL fluid in the diagnosis of VAP. METHODS We conducted a retrospective chart review of all mechanically ventilated trauma patients who developed pneumonia over a 5-year period in whom Grams stain and final culture data were available. RESULTS One hundred fifty-five records with complete data sets were reviewed. VAP was diagnosed by Centers for Disease Control and Prevention criteria and confirmed by BAL and quantitative culture in all patients. Overall accuracy of Grams stain in diagnosing VAP for any organism was 88% (137 true-positives). When assessed for the ability to predict pneumonia caused by a specific organism, the accuracy decreased significantly, with only 63% of Gram-negative VAPs and 72% of Gram-positive VAPs accurately identified by Grams stain. However, the absence of Gram-positive organism of Grams stain excludes Gram-positive VAP in 80% of patients. CONCLUSION All trauma patients should be covered presumptively for gram-negative organisms, as they encompass 70% of infections, but are not reliably identified by Grams stain. As 88% of VAP can be identified by the presence of any organism on Grams stain, it may be useful in the early diagnosis of VAP but cannot reliably be used to guide presumptive therapy.

Urgent airways after trauma: Who gets pneumonia?

BACKGROUND Several risk factors, including emergent intubation, severe head injury, shock, blunt trauma, and high severity of injury, have been identified as risk factors for the development of pneumonia after trauma. This study assesses the contribution of emergent intubation to the development of pneumonia after injury. METHODS A retrospective review of all trauma patients requiring intubation or cricothyroidotomy in the Emergency Department (ED) or in the pre-hospital area (field) over a 41/2 year period. RESULTS 571 patients comprised the study population. Of these, 80% had airways established in the ED, while 20% were intubated in the field. Field intubation was associated with a lower Glasgow Coma Scale (GCS) score (p <0.0001) and more severe injury (p <0.0001), particularly to the chest and extremities.Twenty-five percent of the population developed pneumonia. Patients diagnosed with pneumonia were older (p=0.009), and had a higher ISS (p <0.0001), lower GCS score, (p <0.008), longer ICU and hospital length of stay (p < 0.0001). Injuries to the head, thorax and extremities were more common (p < 0.05) and more severe (p <0.05) in patients developing pneumonia. The incidence of pneumonia after field airway was significantly higher (35% versus 23%, p=0.048).Multiple logistic regression analysis identified field intubation, age, AIS-head, and AIS-extremity as independent risk factors for pneumonia. CONCLUSION Pre-hospital but not ED intubation is an independent risk factor for the development of post-traumatic pneumonia. Other predictors include the severity of injury, specifically head and extremity injuries.

Not so fast to skin graft: Transabdominal wall traction closes most ''domain loss'' abdomens in the acute setting

BACKGROUND Damage-control laparotomy (DCL) has revolutionized the surgery of injury. However, this has led to the dilemma of the nonclosable abdomen. Subsequently, there exists a subgroup of patients who after resuscitation and diuresis, remain nonclosable. Before the adoption of our open abdomen protocol (OAP) and use of transabdominal wall traction (TAWT), these patients required skin grafting and a planned ventral hernia. We hypothesize that our OAP and TAWT device, which use full abdominal wall thickness sutures to dynamically distribute midline traction, achieve an improved method of fascial reapproximation. METHODS From 2008 to 2011, all DCL and decompressive laparotomy patients in our urban trauma center were managed by our OAP. Thirty two were noncloseable “domain loss abdomens” after achieving physiologic steady state and near dry weight. All patients received the TAWT device when near dry weight was achieved. Wound size, days to closure, days to TAWT, and TAWT to closure were tracked. RESULTS During this 36-month period, OAP/TAWT was applied to 32 patients. All patients demonstrated domain loss precluding fascial closure. Average wound size was 18.5-cm width by 30.5-cm length. Mean time DCL surgery to TAWT was 9.5 days. At time of placement, TAWT decreased initial wound width by an average of 9.8 cm (51.4%). Patients returned to the operating room for tightening/washout an average of 2.2 times (excluding TAWT insertion and final closure operations). Mean time TAWT to closure was 8.7 days. Mean time from admission surgery to primary closure was 18.2 days. All patients achieved primary fascial closure using this method without components separation or biologic bridge operations. CONCLUSION OAP/TAWT has revolutionized the way we manage “domain loss” open abdomen patients and has virtually eliminated the acceptance of planned ventral hernia. TAWT consistently recaptures lost domain, preserves the leading fascial edge, and eliminates the need for biologic bridges, components separation, or skin grafting. LEVEL OF EVIDENCE Therapeutic study, level III.

Component separation technique for abdominal wall reconstruction in burn patients with decompressive laparotomies.

BACKGROUND Component separation technique has been used successfully in ventral hernia repair occurring after damage control surgery. Abdominal compartment syndrome, seen in severely injured burn patients, frequently requires decompressive laparotomy. The patient is at risk during this time not only for burn injury complications but also for those from an open abdomen. METHODS This report presents the successful application of the component separation technique for early closure of decompressive laparotomies in patients with >75% total body surface area burn, which included the abdominal wall. RESULTS Skin flaps (necrotic/burned skin) overlying the abdominal wall fascia were raised bilaterally at the costal margin, from the anterior superior iliac spine inferiorly to the ribs superiorly. An incision was made just lateral to the rectus sheath through the aponeurosis of the external oblique muscle. With this, the fascia was mobilized to the middle with no tension. With no elevation of the patients intrathoracic pressure on closure of the abdomen, multiple no. 2 Ethibond fascial figure of eight sutures closed the abdomen. Skin flaps were excised, so that grafting of the abdominal wall could occur. CONCLUSION Burn patients, who required decompressive laparotomies for abdominal compartment syndrome in response to massive fluid resuscitation, tolerated early closure by the modified component separation technique. This markedly improved the care of these critically burned individuals, allowing for less third space fluid loss, less difficulty in management of the open abdominal wound, along with decreased risk of potential enterocutaneous fistula and intraabdominal abscess formation.

Ventilator-associated pneumonia after combined burn and trauma is caused by associated injuries and not the burn wound.

An increased risk of ventilator-associated pneumonia (VAP) has previously been demonstrated in trauma patients urgently intubated in the prehospital (ie, field) and emergency department (ED) settings. This study investigated the impact of urgent intubation on subsequent VAP in patients who sustained both a burn injury and a traumatic injury. We undertook a retrospective review of both trauma registry data and medical records for all patients with combined thermal and traumatic injuries admitted to a single verified burn center and level I trauma center. Patients undergoing field or ED intubation during the 5-year period ending December 2002 were identified and studied. Data abstracted included admission demographics and vital signs, presence of inhalation injury, location at the time of intubation, presence of associated injury, percentage TBSA burn, hospital and intensive care unit length of stay, and hospital day of VAP diagnosis. Seventy-eight of the 3388 patients (2.3%) admitted during the study period sustained a combination of burn wounds and trauma and underwent urgent field or ED intubation. The majority of patients were men (71%), with a mean age of 46 ± 24 years. There was one failed oral intubation, which required cricothyroidotomy. The location of the patient at the time of intubation was ED, 66%; burn center ED, 17%; and field, 17%. Eighty percent of all patients were diagnosed with an inhalation injury. VAP was diagnosed in 39 patients (50%), with a mean time to diagnosis of 10 ± 9 days. TBSA burn, smoke inhalation, and time (in days) to diagnosis of VAP were not independent risk factors for the occurrence of pneumonia in any of the 3 groups. However, those intubated at the initial ED were more likely to develop VAP (P = .028) compared to those intubated in the field or in the burn center. The incidence of associated injuries was significantly greater (P < .0001) in the initial ED group. Only a small percentage of burn patients also sustain blunt trauma. VAP occurs in 50% of the patients requiring urgent intubation. Independent risk factors appear to be intubation at an initial ED before transfer and associated injuries.

Facilitating residual wound closure after partial graft loss with vacuum assisted closure therapy.

Third degree burns require skin grafting. In most instances, if the graft becomes infected, it requires debridement of the site and re-grafting. The purpose of this report is to illustrate the successful healing of a skin graft using negative pressure wound therapy with silver impregnated foam and soft silicone wound contact layer in a 4% total body surface area burn of a lower extremity skin graft infected with Pseudomonas aerugenosa without regrafting. A 27-year-old Hispanic male sustained a gasoline flame burn and presented 72 hours postincident with right lower extremity cellulitis. After intravenous antibiotics, the area was grafted with a partial thickness sheet graft. At 9 days postoperatively, the patient developed a wound infection, with an eventual 40% graft loss and was started on a course of antibiotics. With continued graft loss, on the 22nd postoperative day, negative pressure wound therapy V.A.C.™ (Vacuum Assisted Closure-KCI, San Antonio, TX) with silver impregnated foam and soft silicone wound contact layer (Mepitel™, Molnlycke Health Care, Gothenburg, Sweden) were applied. The wound was completely re-epithelialized by 9 days. In combination with antibiotics, it was possible to treat a residual open wound and prevent the need for regrafting.

Trephination and subatmospheric pressure therapy in the management of extremity exposed bone.

BACKGROUND Distal lower and upper extremity wounds with bone and tendon exposure present unique challenges to reconstructive surgeons. The limitations of the local anatomy usually make simpler reconstructive modalities such as primary closure and skin grafting difficult. As a result, wounds in this area, especially ones with bone or tendon exposures, are classically treated with free tissue transfer. METHODS Limb preservation using the combination of bone trephination and subatmospheric pressure therapy is described. RESULTS Six cases with preserved extremities are presented. Three cases illustrate extremity wound with bone and tendon exposure healing through pregrafting wound optimization (bone trephination) with the use of subatmospheric pressure therapy. CONCLUSIONS This treatment may offer an alternative method of limb salvage, in cases where flaps or free tissue transfer are not possible or optimal.

Trans-abdominal wall traction as a universal solution to the management of giant ventral hernias.

Background: Domain loss following damage-control laparotomy is a challenging problem many surgeons face. The authors recently developed trans–abdominal wall traction, which closed 100 percent of domain loss abdomens in the acute setting. They hypothesized that it can be used successfully in patients with chronic giant ventral defects. Methods: From 2008 to 2013, 44 patients with acute loss of domain and 10 with chronically giant ventral defects were enrolled in the open abdomen protocol with subsequent placement of the trans–abdominal wall traction device. Results: Patients’ average age in the acute and chronic groups was 28.2 and 35.3 years and average body mass index was 26.4 and 32.4 kg/m2, respectively. Ventral hernia size was reduced with the first trans–abdominal wall traction insertion from 610.5 cm2 to 274.6 cm2 in the acute setting and from 598 cm2 to 236.9 cm2 in the chronic setting. Average time from damage-control laparotomy to device insertion was 12.9 days in the acute group and more than 3 years in the chronic group. Lost domain was achieved with an average of less than 2.5 trans–abdominal wall traction tightenings, correlating to 9.2 and 8.2 days in the acute and chronic groups, respectively. Enterocutaneous fistula occurrence was 9 percent in the acute group and 0 percent in the chronic group. Conclusions: All patients were successfully closed after reestablishment of the lost domain. Trans–abdominal wall traction is an effective means of reestablishing abdominal domain and achieving primary abdominal wall closure in all patients with giant ventral defects, both acute and chronic. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Placenta to the Rescue: Limb Salvage Using Dehydrated Human Amnion/Chorion Membrane

Reconstruction of skin and soft tissue wounds can pose a unique surgical challenge. This is especially true for cases of exposed bone and tendon where soft tissue loss is extensive and opportunities for tissue advancement or rotation are limited. A clinical case is presented describing an experience with dehydrated human amnion/chorion membrane (dHACM, EpiFix®/AmnioFix®, MiMedx Group, Marietta, GA) graft to obtain granulation over an open fracture with desiccated bone. The 22-year-old female trauma patient presented with high-grade bilateral lower extremity soft tissue loss after being run over and dragged by a semitruck. Despite several weeks of serial debridemonts, the right distal fibula and left medial femur remained desiccated and infected. Both extremities had cavernous tissue landscapes with minimal granulation tissue and neither was hospitable for split thickness skin grafting. Four separate applications of dHACM (combination of EpiFix® and AmnioFix®) to the affected areas of exposed bone were successful at stimulating a robust granulation bed. On hospital days 44 and 61, the wounds were successfully skin grafted. The authors suspect that the dHACM applications contributed to successful granulation coverage to the affected bones that were otherwise not amendable to other coverage options. This contributed to limb salvage and a successful outcome.

The Open Abdomen: Management from Initial Laparotomy to Definitive Closure

A 67-year-old patient has undergone a prolonged and complicated operation for mesenteric ischemic (embolic etiology). Circulation has just been restored to the ischemic bowel; however, the patient is hypothermic (34°C), acidotic, and coagulopathic. Which of the following is the appropriate management at this time? (A) Wood’s lamp assessment of bowel viability (B) Repeated on-table angiography after 45 minutes (C) Administration of mannitol (D) Immediate fascial closure of the abdomen (E) Creative abdominal closure