Tyler Ewing

Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically Ill trauma and surgical patients

BACKGROUND Deep venous thromboses (DVT) continue to cause significant morbidity in critically ill patients. Standard prophylaxis for high risk patients includes twice-daily dosing with 30 mg enoxaparin. Despite prophylaxis, DVT rates still exceed 10% to 15%. Anti-Xa levels are used to measure the activity of enoxaparin and 12-hour trough levels <or=0.1 IU/mL have been associated with higher rates of DVT in orthopedic patients. We hypothesized that low Anti-Xa levels would be found in critically ill trauma and surgical patients and that low levels would be associated with higher rates of DVT. METHODS All patients on the surgical intensive care unit (ICU) service were prospectively followed. In the absence of contraindications, patients were given prophylactic enoxaparin and anti-Xa levels were drawn after the third dose. Trough levels <or=0.1 IU/mL were considered low. Screening duplex exams were obtained within 48 hours of admission and then weekly. Patients were excluded if they did not receive a duplex, if they had a prior DVT, or if they lacked correctly timed anti-Xa levels. DVT rates and demographic data were compared between patients with low and normal anti-Xa levels. RESULTS Data were complete for 54 patients. Eighty-five percent suffered trauma (Injury Severity Score of 25 +/- 12) and 74% were male. Overall, 27 patients (50%) had low anti-Xa levels. Patients with low anti-Xa levels had significantly more DVTs than those with normal levels (37% vs. 11%, p = 0.026), despite similar age, body mass index, Injury Severity Score, creatinine clearance, high risk injuries, and ICU/ventilator days. CONCLUSION Standard dosing of enoxaparin leads to low anti-Xa levels in half of surgical ICU patients. Low levels are associated with a significant increase in the risk of DVT. These data support future studies using adjusted-dose enoxaparin.

The Impact of Meeting Donor Management Goals on the Number of Organs Transplanted per Expanded Criteria Donor: A Prospective Study From the UNOS Region 5 Donor Management Goals Workgroup

IMPORTANCE The shortage of organs available for transplant has led to the use of expanded criteria donors (ECDs) to extend the donor pool. These donors are older and have more comorbidities and efforts to optimize the quality of their organs are needed. OBJECTIVE To determine the impact of meeting a standardized set of critical care end points, or donor management goals (DMGs), on the number of organs transplanted per donor in ECDs. DESIGN, SETTING, AND PARTICIPANTS Prospective interventional study from February 2010 to July 2013 of all ECDs managed by the 8 organ procurement organizations in the southwestern United States (United Network for Organ Sharing Region 5). INTERVENTIONS Implementation of 9 DMGs as a checklist to guide the management of every ECD. The DMGs represented normal cardiovascular, pulmonary, renal, and endocrine end points. Meeting the DMG bundle was defined a priori as achieving any 7 of the 9 end points and was recorded at the time of referral to the organ procurement organization, at the time of authorization for donation, 12 to 18 hours later, and prior to organ recovery. MAIN OUTCOMES AND MEASURES The primary outcome measure was 3 or more organs transplanted per donor and binary logistic regression was used to identify independent predictors with P < .05. RESULTS There were 671 ECDs with a mean (SD) number of 2.1 (1.3) organs transplanted per donor. Ten percent of the ECDs had met the DMG bundle at referral, 15% at the time of authorization, 33% at 12 to 18 hours, and 45% prior to recovery. Forty-three percent had 3 or more organs transplanted per donor. Independent predictors of 3 or more organs transplanted per donor were older age (odds ratio [OR] = 0.95 per year [95% CI, 0.93-0.97]), increased creatinine level (OR = 0.73 per mg/dL [95% CI, 0.63-0.85]), DMGs met prior to organ recovery (OR = 1.90 [95% CI, 1.35-2.68]), and a change in the number of DMGs achieved from referral to organ recovery (OR = 1.11 per additional DMG [95% CI, 1.00-1.23]). CONCLUSIONS AND RELEVANCE Meeting DMGs prior to organ recovery with ECDs is associated with achieving 3 or more organs transplanted per donor. An increase in the number of critical care end points achieved throughout the care of a potential donor by both donor hospital and organ procurement organization is also associated with an increase in organ yield.

Which central venous catheters have the highest rate of catheter-associated deep venous thrombosis: a prospective analysis of 2,128 catheter days in the surgical intensive care unit.

BACKGROUND Catheter-associated deep venous thromboses (CADVTs) are a common occurrence in the surgical intensive care unit (SICU), necessitating central venous catheter (CVC) removal and replacement. Previous studies evaluating risk factors for CADVT in SICU patients are limited, and most lack a true denominator of all CVC days. We sought to determine the true incidence of and risk factors for CADVT based on patient characteristics as well as CVC site, type, and duration of insertion. METHODS The following data from all SICU patients in two urban Level I trauma centers were prospectively collected from 2009 to 2012: demographics, risk factors for DVT, CVC site/type/duration, and duplex results. Sites included the subclavian (SC), internal jugular (IJ), arm (for peripherally inserted central catheter [PICC] lines), and femoral. Types included multilumen (ML), introducer/hemodialysis (I/HD), and PICC. High-risk patients received weekly screening duplex examinations and a CADVT was defined as a DVT being detected on duplex with a CVC in place or within 7 days of removal. Rates of CADVT were normalized per 1,000 CVC days, and independent predictors of CADVT were determined using logistic regression. RESULTS Data were complete for 184 patients, 354 CVCs, and 2,128 CVC days. Fifty-nine CADVTs were diagnosed in 28% of patients. Rates of CADVT were 9 per 1,000 catheter days for SC, 61 for IJ (p < 0.01 vs. SC), 27 for arm (p < 0.01), 36 for femoral (p < 0.01), 22 for ML, 57 for I/HD (p < 0.01 vs. ML), and 27 for PICC (p = 0.24). After adjusting for patient risk factors, predictors of CADVT included the IJ and arm sites (odds ratio, 6.0 and 3.0 compared with SC) and the I/HD type (odds ratio, 2.6 compared with ML, all p < 0.05). CONCLUSION The IJ and arm sites and I/HD type are associated with increased CADVT. These data may be used to determine the optimal site and type of CVC for insertion. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Risk factors for venous thromboembolism in critically ill trauma patients who cannot receive chemical prophylaxis

BACKGROUND Standard venous thromboembolism (VTE) prevention for critically ill trauma patients includes sequential compression devices and chemical prophylaxis. When contraindications to anticoagulation are present, prophylactic inferior vena cava filters (IVCF) may be used to prevent pulmonary emboli (PE) in high-risk patients, but specific indications are lacking. We sought to identify independent predictors of VTE in critically-ill trauma patients who cannot receive chemical prophylaxis in order to identify a subset of patients who may benefit from aggressive screening and/or prophylactic IVCF placement. METHODS All trauma patients in the surgical ICU from 2008 to 2009 were prospectively followed. Patients with an ICU length of stay ≥2 days who had contraindications to prophylactic anticoagulation were included. Screening duplex exams were obtained within 48 h of admission and then weekly. CT-angiography for PE was obtained if clinically indicated. Patients were excluded if they did not receive a duplex or if they had a post-injury VTE prior to ICU admission. Data regarding VTE rates (lower extremity [LE] DVT or PE), demographics, past medical history (PMH), injuries, and surgeries were collected. Univariate and multivariable analyses were performed to identify independent predictors of VTE with a p<0.05. RESULTS 411 trauma patients with a mean age of 48 (SD 22) years and 8 (SD 9) ICU days were included. 72% were male and the mean ISS was 22 (SD 13). 30 (7.3%) patients developed VTE: 28 (6.8%) with LEDVT and 2 (0.5%) with PE. Risk factors for VTE with a p<0.2 on univariate analysis included: PMH of DVT, injury severity score (ISS), extremity fractures (Fx), and a pelvis or LE extremity Fx repair. After logistic regression, only PMH of DVT (OR=22.6) and any extremity Fx (OR=2.4) remained as independent predictors. CONCLUSION VTE occur in 7% of critically injured trauma patients who cannot receive chemical prophylaxis. Aggressive screening and/or prophylactic IVCF placement may be considered in patients with a PMH of DVT or extremity fractures when anticoagulation is prohibited.

The impact of implementing a 24/7 open trauma bed protocol in the surgical intensive care unit on throughput and outcomes.

BACKGROUND Increased emergency department (ED) length of stay (LOS) has been associated with increased mortality in trauma patients. In 2010, we implemented a 24/7 open trauma bed protocol in our designated trauma intensive care units (TICUs) to facilitate rapid admission from the ED. This required maintenance of a daily bump list and timely transferring of patients out of the TICU. We hypothesized that ED LOS and mortality would decrease after implementation. METHODS The following data from patients admitted directly from the ED to any ICU were retrospectively compared before (2009) and after (2011) the implementation of a trauma bed protocol at a Level I trauma center: age, sex, Glasgow Coma Scale (GCS) score, shock on admission (systolic blood pressure < 90 mm Hg), mechanism, injury severity scores (Injury Severity Score [ISS] and Abbreviated Injury Scale [AIS] score), ED LOS, ICU readmission rates, and mortality. RESULTS Of the patients, 267 (17%) of 1,611 before and 262 (21%) of 1,266 (p < 0.01) after the protocol were admitted directly to the ICU, despite similar characteristics. ED LOS decreased from 4.2 ± 4.0 hours to 3.1 ± 2.1 hours (p < 0.01) in all patients as well as patients with an ISS of greater than 24 (3.1 ± 2.5 vs. 2.2 ± 1.6, p < 0.05) and a head AIS score of greater than 2 (4.2 ± 4.9 vs. 3.1 ± 2.0, p = 0.01). Mortality was unchanged for all patients (9% vs. 8%, p = 0.58) but trends toward improved mortality were found after protocol implementation inpatients with an ISS of greater than 24 (30% vs. 13%, p = 0.07) and in patients with a head AIS score of greater than 2 (12% vs. 6%, p = 0.08). A greater proportion of total patients were admitted to a designated TICU after implementation (83% vs. 93%, p < 0.01). ICU readmissions were unchanged (0.3% vs. 1.5%, p = 0.21). CONCLUSION The implementation of a 24/7 open trauma bed protocol in the surgery ICU was associated with a decreased ED LOS and increased admissions to designated TICUs in all patients. Improved throughput was achieved without increases in ICU readmissions. LEVEL OF EVIDENCE Therapeutic study, level IV.

Determining optimal threshold for glucose control in organ donors after neurologic determination of death: a United Network for Organ Sharing Region 5 Donor Management Goals Workgroup prospective analysis.

BACKGROUND The appropriate level of glucose control in organ donors after neurologic determination of death (DNDD) remains uncertain. We hypothesized that a glucose target of 180 mg/dL would be appropriate for optimizing organ transplantation rates and outcomes. METHODS Demographic, critical care, organ transplantation, and graft outcome data were prospectively collected on all DNDDs in United Network for Organ Sharing (UNOS) Region 5 from 2010 to 2012. Glucose levels were assessed at four time points in the organ donation process. The primary outcome measure was having four or more organs transplanted per donor (OTPD). Univariate analyses were conducted to determine the relationship between glucose levels and OTPD, organ transplantation rates, and graft function. Multivariate analyses were performed to determine independent predictors of four or more OTPDs. Glucose levels were analyzed at the following cutoff points: 150 or less, 180, and 200 mg/dL. Results with a p < 0.05 are listed. RESULTS A total of 1,611 DNDDs had a mean (SD) age of 38 (17) years and 3.4 (1.7) OTPDs. Forty-one percent had four or more OTPDs. Glucose levels of 150 mg/dL or less were not associated with differences in organ use. Levels of 180 mg/dL or less were associated with more OTPDs (3.5 vs. 3.2), a higher rate of four or more OTPDs (42% vs. 34%), and more heart (34% vs. 28%), pancreas (18% vs. 11%), and kidney (85% vs. 81%) use. Levels of 200 mg/dL or less revealed similar results. However, only a level of 180 mg/dL or less was an independent predictor of four or more OTPDs (odds ratio, 1.4). All three levels were associated with higher kidney graft survival after a mean (SD) of 10 (6.0) months of follow-up (97% vs. 95%). CONCLUSION Hyperglycemia is common in DNDDs and is associated with lower organ transplantation rates and worse graft outcomes. Targeting a glucose level of 180 mg/dL or less seems to preserve outcomes and is consistent with general critical care guidelines. LEVEL OF EVIDENCE Therapeutic study, level II.

Predictors of Hazardous Drinking Behavior in 1,340 Adult Trauma Patients: A Computerized Alcohol Screening and Intervention Study

BACKGROUND Alcohol screening and brief intervention (SBI) is used to decrease alcohol consumption, health care costs, and injury recidivism in trauma patients. Despite SBI being mandated for trauma centers, various concerns have led many centers to conduct SBI only on patients with a detectable blood alcohol concentration (BAC). We sought to determine the predictive nature of BAC on hazardous drinking behavior. STUDY DESIGN Adult trauma patients were included if they received an SBI before discharge. SBI was administered using a computerized alcohol screening and intervention (CASI) system with the Alcohol Use Disorder Identification Test (AUDIT). Data regarding demographics, injuries, and BAC were prospectively collected. Multivariate analyses were performed to identify independent predictors of hazardous drinking behavior. RESULTS Data were complete for 1,340 patients, with a mean age of 43 years (SD 20 years). Sixty-eight percent were male, 33% had detectable BAC, and 19% had hazardous drinking behavior. Multivariate analysis identified age (odds ratio [OR] 0.97 per year), male sex (OR 3.1), BAC (OR 1.009 per mg/dL), detectable BAC (OR 3.9), and legal intoxication (OR 7.8) as independent predictors of hazardous drinking behavior. Asian/Pacific Islander ethnicity was a significant negative predictor (OR 0.53) compared with white. Thirty-eight percent of patients with hazardous drinking behavior had no detectable BAC. CONCLUSIONS Younger age, male sex, and higher BAC are early predictors of hazardous drinking behavior in adult trauma patients. Asian/Pacific Islander patients are half as likely to report hazardous drinking behavior compared with white patients. More than one-third of patients with hazardous drinking behavior do not have detectable BAC on admission and are not receiving interventions in centers that screen solely based on BAC.

The natural history of upper extremity deep venous thromboses in critically ill surgical and trauma patients: what is the role of anticoagulation?

BACKGROUND The natural history and optimal treatment of upper extremity (UE) deep venous thromboses (DVTs) remains uncertain as does the clinical significance of catheter-associated (CA) UE DVTs. We sought to analyze predictors of UE DVT resolution and hypothesized that anticoagulation will be associated with quicker UE DVT clot resolution and that CA UE DVTs whose catheters are removed will resolve more often than non-CA UE DVTs. METHODS All patients on the surgical intensive care unit service were prospectively followed from January 2008 to May 2010. A standardized DVT prevention protocol was used and screening bilateral UE and lower extremity duplex examinations were obtained within 48 hours of admission and then weekly. Computed tomography angiography for pulmonary embolism was obtained if clinically indicated. Patients with UE DVT were treated according to attending discretion. Data regarding patient demographics and UE DVT characteristics were recorded: DVT location, catheter association, occlusive status, treatment, and resolution. The primary outcome measure was UE DVT resolution before hospital discharge. Interval decrease in size on the subsequent duplex after UE DVT detection was also noted. UE DVTs without a follow-up duplex were excluded from the final analysis. Univariate and multivariate analyses were used to identify independent predictors of UE DVT resolution. RESULTS There were 201 UE DVTs in 129 patients; 123 DVTs had a follow-up duplex and were included. Fifty-four percent of UEDVTs improved on the next duplex, 60% resolved before discharge, and 2% embolized. The internal jugular was the most common site (52%) and 72% were nonocclusive. Sixty-four percent were CAUEDVTs and line removal was associated with more frequent improvement on the next duplex (55% vs. 17%, p = 0.047, mid-P exact). Sixty-eight percent of UEDVTs were treated with some form of anticoagulation, but this was not associated with improved UE DVT resolution (61% vs. 60%). Independent predictors of clot resolution were location in the arm (odds ratio = 4.1 compared with the internal jugular, p = 0.031) and time from clot detection until final duplex (odds ratio =1.052 per day, p = 0.032). CONCLUSION A majority of UE DVTs are CA, more than half resolve before discharge, and 2% embolize. Anticoagulation does not appear to affect outcomes, but line removal does result in a quicker decrease in clot size.

The Impact of Hydroxyethyl Starch Use in Deceased Organ Donors on the Development of Delayed Graft Function in Kidney Transplant Recipients: A Propensity-Adjusted Analysis

Our objective was to evaluate the impact of hydroxyethyl starch (HES) use in organ donors after neurologic determination of death (DNDD) on recipient renal graft outcomes. The following data elements were prospectively collected for every DNDD managed by a single organ procurement organization from June 2011 to July 2013: demographics; critical care endpoints; treatments, including the use of HES; graft cold ischemia time (CIT); and the occurrence of recipient delayed graft function (DGF, dialysis in the first week after transplantation). Logistic regression was performed to identify independent predictors of DGF with a p‐value <0.05. The results were then adjusted for each donors calculated propensity to receive HES. Nine hundred eighty‐six kidneys were transplanted from 529 donors. Forty‐two percent received HES (1217 ± 528 mL) and 35% developed DGF. Kidneys from DNDDs who received HES had a higher crude rate of DGF (41% vs. 31%, p < 0.001). After accounting for the propensity to receive HES, independent predictors of DGF were age (OR 1.02 [1.01–1.04] per year), CIT (OR 1.04[1.02–1.06] per hour), creatinine (OR 1.5 [1.32–1.72] per mg/dL) and HES use (OR 1.41 [1.02–1.95]). HES use during donor management was independently associated with a 41% increase in the risk of DGF in kidney transplant recipients.

Patients on state organ donor registries receive similar levels of intensive care compared to those who are not: An opportunity to increase public intent to donate

The intent to donate organs is affected by the public perception that patients on state registries receive less aggressive life‐saving care in order to allow organ donation to proceed. However, the association between first person authorization to donate organs and the actual care received by eventual organ donors in hospitals is unknown. From August 2010 to April 2011, all eight organ procurement organizations in United Network for Organ Sharing Region 5 prospectively recorded demographic data and organ utilization rates on all donors after neurologic determination of death (DNDDs). Critical care and physiologic parameters were also recorded at referral for imminent neurologic death and prior to authorization for donation to reflect the aggressiveness of provided care. There were 586 DNDDs and 23% were on a state registry. Compared to non‐registered DNDDs, those on state registries were older but were noted to have similar critical care parameters at both referral and authorization. Furthermore, there was no significant difference in organs procured per donor or organs transplanted per donor between registered and non‐registered DNDDs. Thus, DNDDs who are on state donor registries receive similar levels of intensive care compared to non‐registered donors. The association noted in this study may therefore help to dispel a common misperception that decreases the intent to donate.