Organ Donation, an Unexpected Benefit of Aggressive Resuscitation of Trauma Patients Presenting Dead on Arrival

BACKGROUND

We sought to determine whether aggressive resuscitation in trauma patients presenting without vital signs, or "dead on arrival," was futile. We also sought to determine whether organ donation was an unexpected benefit of aggressive resuscitation.

STUDY DESIGN

We conducted a review of adults presenting to our Level I trauma center with no signs of life (pulse = 0 beats/min; systolic blood pressure = 0 mmHg; and no evidence of neurologic activity, Glasgow Coma Scale score = 3). Primary end point was survival to hospital discharge or major organ donation (ie heart, lung, kidney, liver, or pancreas were harvested). We compared our survival rates with those of the National Trauma Data Bank in 2012. Patient demographics, emergency department vital signs, and outcomes were analyzed.

RESULTS

Three hundred and forty patients presented with no signs of life to our emergency department after injury (median Injury Severity Score = 40). There were 7 survivors to discharge, but only 5 (1.5%) were functionally independent (4 were victims of penetrating trauma). Of the 333 nonsurvivors, 12 patients (3.6%) donated major organs (16 kidneys, 2 hearts, 4 livers, and 2 lungs). An analysis of the National Trauma Data Bank yielded a comparable survival rate for those presenting dead on arrival, with an overall survival rate of 1.8% (100 of 5,384); 2.3% for blunt trauma and 1.4% for penetrating trauma.

CONCLUSIONS

Trauma patients presenting dead on arrival rarely (1.5%) achieve functional independence. However, organ donation appears to be an under-recognized outcomes benefit (3.6%) of the resuscitation of injury victims arriving without vital signs.

Elevations in growth hormone and glucagon-like peptide-2 levels on admission are associated with increased mortality in trauma patients

BACKGROUND

Burn and trauma patients present a clinical challenge due to metabolic derangements and hypermetabolism that result in a prolonged catabolic state with impaired healing and secondary complications, including ventilator dependence. Previous work has shown that circulating levels of growth hormone (GH) are predictive of mortality in critically ill adults, but few studies have examined the prognostic potential of GH levels in adult trauma patients.

METHODS

To investigate the utility of GH and other endocrine responses in the prediction of outcomes, we conducted a prospective, observational study of adult burn and trauma patients. We evaluated the serum concentration of GH, insulin-like growth factor 1 (IGF-1), IGF binding protein 3 (IGFBP-3), and glucagon-like peptide-2 (GLP-2) weekly for up to 6 weeks in 36 adult burn and trauma patients admitted between 2010 and 2013.

RESULTS

Non-survivors had significantly higher levels of GH and GLP-2 on admission than survivors.

DISCUSSION

This study demonstrates that GH has potential as a predictor of mortality in critically ill trauma and burn patients. Future studies will focus on not only the role of GH, but also GLP-2, which was shown to correlate with mortality in this study with a goal of offering early, targeted therapeutic interventions aimed at decreasing mortality in the critically injured.

CONCLUSIONS

GH and GLP-2 may have clinical utility for outcome prediction in adult trauma patients.

Prospective Trial of Low-Molecular-Weight Heparin Versus Unfractionated Heparin in Moderately Injured Patients

The safety and efficacy of low-molecular-weight heparin (LMWH) was compared with those of conventional unfractionated heparin (UH) in preventing deep venous thrombosis (DVT) in trauma patients with moderate injuries in a prospective double-blind, randomized trial at a level I trauma center. After informed consent, trauma patients meeting inclusion criteria (age > 45 or requiring > 2 days' bedrest) received LMWH or UH twice daily in a double-blind, randomized trial. Patients were excluded if they had severe brain injuries or bleeding injuries not accessible to hemostatic control (eg, severe visceral contusions). Clinical examination and weekly venous duplex ultrasound evaluations were performed to identify DVT. One hundred four patients were randomized, 53 to receive UH and 51 to receive LMWH; 32 UH and 34 LMWH patients completed the study (mean injury severity score [ISS] = 12). There were no significant differences between groups with regard to age, sex, ISS, mechanism of injury, or doses of drug given. Outcome measures such as length of stay in the surgical intensive care unit and hospital days were similar. There were two patients with DVT in the UH group, none in the LMWH group (p = 0.493 by Fisher's exact test). This was not a statistically significant difference. There were five major bleeding complications in each group. The incidence of DVT in injured patients receiving prophylaxis appears to be quite low if individuals such as those with severe head injury or visceral contusions are excluded. LMWH is not clearly beneficial when compared with UH in this moderate-risk trauma population.

Appendectomy and Pregnancy: Gestational Age Does Not Affect the Position of the Incision

The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.

Appendectomy and pregnancy: gestational age does not affect the position of the incision

The position of the base of the appendix during advancing gestational age is based on inadequate data. Therefore, the proper location for an appendectomy incision during pregnancy is highly unclear. This study investigated the location of the appendix during pregnancy to determine the optimal location for an incision in pregnant patients with appendicitis relative to McBurney's point. Magnetic resonance images (MRIs) were reviewed independently by two fellowship-trained abdominal MRI radiologists blinded to the imaging report. The distance of the appendix from anatomic landmarks was measured in a total of 114 pregnant women with an abdominal or pelvic MRI who were admitted between 2001 and 2011 at a Level I trauma center. Patients with a history of appendectomy were excluded. The distance from the base of the appendix to McBurney's point changed over the course of the gestation by only 1.2 cm and which did not amount to a clinically or statistically significant change in position. Our data provide evidence that there is minimal upward or lateral displacement of the appendix during pregnancy, and therefore its distance from the McBurney's point remains essentially unchanged. These findings justify the use of the McBurney's incision for appendectomy during pregnancy regardless of the trimester.

Venous thromboembolism during combat operations: a 10-y review

BACKGROUND

This article examines the incidence of venous thromboembolism (VTE) in combat wounded, identifies risk factors for pulmonary embolism (PE), and compares the rate of PE in combat with previously reported civilian data.

METHODS

A retrospective review was performed of all U.S. military combat casualties in Operation Enduring Freedom and Operation Iraqi Freedom with a VTE recorded in the Department of Defense Trauma Registry from September 2001 to July 2011. The Military Amputation Database of all U.S. military amputations during the same 10-y period was also reviewed. Demographic data, injury characteristics, and outcomes were evaluated.

RESULTS

Among 26,634 subjects, 587 (2.2%) had a VTE. This number included 270 subjects (1.0%) with deep venous thrombosis (DVT), 223 (0.8%) with PE, and 94 (0.4%) with both DVT and PE. Lower extremity amputation was independently associated with PE (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.07-2.69). A total of 1003 subjects suffered a lower extremity amputation, with 174 (17%) having a VTE. Of these, 75 subjects (7.5%) were having DVT, 70 (7.0%) were having PE, and 29 (2.9%) were found to have both a DVT and a PE. Risk factors found to be independently associated with VTE in amputees were multiple amputations (OR, 2; 95% CI, 1.35-3.42) and above the knee amputation (OR, 2.11; 95% CI, 1.3-3.32).

CONCLUSIONS

Combat wounded are at a high risk for thromboembolic complications with the highest risk associated with multiple or above the knee amputations.

Development of an animal model to investigate optimal laparoscopic trocar site fascial closure

BACKGROUND

The rate of hernia formation after closure of 10-12 mm laparoscopic trocar sites is grossly under-reported. Using an animal model, we have developed a method to assess trocar site fascial dehiscence and the strength of different methods of fascial closure.

MATERIALS AND METHODS

Pigs (n = 9; 17 ± 2.5 lbs) underwent placement of 12 mm Hasson trocars with pneumoperitoneum maintained for 1 h. Three closure techniques (Figure-of-eight; simple interrupted; pulley) were compared with no fascial closure and to native fascia at five randomly allocated abdominal wall midline locations. Necropsy was performed on the fourth postoperative d. Statistical comparisons of tensile strength and breaking strength based on closure type and trocar location were made using ANOVA with Tukey's tests.

RESULTS

The mean (SD) force (Newtons) required for fascial disruption varied significantly with closure type [Native Fascia 170 (39), Figure-of-eight 169 (31), Pulley 167 (59), Simple Interrupted 151 (27), No Closure 108 (28)]; P = 0.007. The mean force required for fascial disruption was significantly increased for Native Fascia, Figure-of-eight, and Pulley relative to No Closure (P = 0.013, P = 0.015, P = 0.023, respectively). The mean (SD) force (in Newtons) required for fascial disruption also varied significantly with location of trocar [subxiphoid 181 (43), supraumbilical 151 (23), Umbilical 146 (23), infraumbilical 168 (62), suprapubic 120 (38)]; P = 0.03. The mean force for subxiphoid location was significantly increased relative to the suprapubic location (P = 0.021).

CONCLUSIONS

We have developed a novel assessment model that reliably detects differences in fascial integrity after laparoscopic trocar placement and closure. This model will allow for further testing of various trocars and closure techniques, and facilitate hernia prevention strategies.

The need for early angiography in patients with penetrating renal injuries

BACKGROUND

Renal injuries occur in as many as 10% of penetrating abdominal wounds. Today, these wounds are often managed selectively, but there is little contemporary information on the natural history of kidney injuries after penetrating trauma. The purpose of this study was to examine the clinical outcomes of penetrating injuries to the kidney, and to determine if these patients may benefit from routine early angiography.

METHODS

All trauma patients admitted to three Level I Trauma Centers with penetrating renal injuries over a 10 year study period were retrospectively reviewed.

RESULTS

We identified 237 patients with a penetrating renal injury, of whom 39 died within the first 24 h and were excluded from analysis. Among the remaining 198 individuals, 130 (66%) underwent immediate exploratory laparotomy. Of the 68 subjects not undergoing immediate surgery, seven had early angiography. The remaining 61 patients (31%) were observed, with 12 (20%) ultimately requiring an intervention to treat the renal injury. Those subjects who failed nonoperative management had significantly fewer hospital-free days compared to those who did not need a procedure (19.2 ± 8.1 vs. 25.7 ± 4.5, p = 0.002).

CONCLUSIONS

Nearly one in three patients with penetrating renal injuries are currently managed with serial observation, although one in five of these subjects ultimately require either angiographic or surgical treatment. We feel that routine use of early angiography may reduce the failure rate and improve outcomes for patients whose penetrating renal injuries are managed nonoperatively.

A Prospective Randomized Pilot Study of Near-Infrared Spectroscopy-Directed Restricted Fluid Therapy versus Standard Fluid Therapy in Patients Undergoing Elective Colorectal Surgery

There are substantial data supporting the concept that algorithms that effectively limit fluid volumes to patients undergoing elective surgery, particularly intraoperatively, significantly reduce perioperative morbidity. We hypothesized that intraoperative fluid limitation could be safely accomplished when guided by near-infrared spectroscopy (NIRS) monitoring, and that this fluid restriction regimen would result in a reduction in postoperative morbidity when compared with standard monitoring and fluid therapy. The intent of this pilot study was to demonstrate the feasibility and ease of conduct of this study protocol before expanding to the multicenter pivotal trial. We performed a prospective, (2:1) randomized, pilot study at two centers. A total enrollment of 24 fully evaluable patients undergoing elective open colorectal surgery (16 restricted, 8 standard) was planned. After providing informed consent, patients were randomized to standard fluid resuscitation (500 LR induction bolus, then LR 7 mL/kg/h X 1 h, then 5 mL/kg/h) or restricted fluid resuscitation (no induction bolus, then LR 2 mL/kg/h). Subsequent fluid bolus infusions were guided by physiologic parameters (systolic blood pressure < 90 mm Hg, heart rate > 100 bpm, or oliguria) in the standard group, and by tissue oxygen saturation from NIRS (tissue oxygen saturation (StO2) < 75%, or 20% below baseline; or the same physiologic parameters) in the restricted group. Primary endpoints were major postoperative complications. A total of 27 patients were randomized (18 restricted, 9 standard). Age, gender, ethnicity, past medical history, and body mass index were similar. American Society of Anesthesiologists class was somewhat higher in the restricted group (American Society of Anesthesiologists class 3 in 77% of restricted vs 44% of standard patients; P = 0.194). Median total intraoperative fluids were less in the restricted group (1300 mL) when compared with the standard group (3014 mL) ( P = 0.021). Total fluids for the hospitalization were also statistically significantly decreased in the restricted group. Complications occurred in about two-thirds of patients, and complication rates were not statistically different between groups (1.6/restricted patient vs 2.1/standard patient; P = 0.333). Primary indications for boluses (n = 93) given to study patients were: hypotension (69%); oliguria (15%); and tachycardia (14%), with multiple indications per bolus. In only two instances did the StO2 drop to less than 75 per cent, or decrease by 20 per cent from baseline in the 3 minutes before bolus as an indication for fluid administration. Patients undergoing elective colorectal surgery with a fluid restricted strategy had only rare episodes of decreased StO2, suggesting that adequate tissue perfusion was maintained in this group. As a result, NIRS monitoring did not significantly influence intraoperative fluid management of patients undergoing colorectal surgery.

A prospective randomized pilot study of near-infrared spectroscopy-directed restricted fluid therapy versus standard fluid therapy in patients undergoing elective colorectal surgery

There are substantial data supporting the concept that algorithms that effectively limit fluid volumes to patients undergoing elective surgery, particularly intraoperatively, significantly reduce perioperative morbidity. We hypothesized that intraoperative fluid limitation could be safely accomplished when guided by near-infrared spectroscopy (NIRS) monitoring, and that this fluid restriction regimen would result in a reduction in postoperative morbidity when compared with standard monitoring and fluid therapy. The intent of this pilot study was to demonstrate the feasibility and ease of conduct of this study protocol before expanding to the multicenter pivotal trial. We performed a prospective, (2:1) randomized, pilot study at two centers. A total enrollment of 24 fully evaluable patients undergoing elective open colorectal surgery (16 restricted, 8 standard) was planned. After providing informed consent, patients were randomized to standard fluid resuscitation (500 LR induction bolus, then LR 7 mL/kg/h x 1 h, then 5 mL/kg/h) or restricted fluid resuscitation (no induction bolus, then LR 2 mL/kg/h). Subsequent fluid bolus infusions were guided by physiologic parameters (systolic blood pressure < 90 mm Hg, heart rate > 100 bpm, or oliguria) in the standard group, and by tissue oxygen saturation from NIRS (tissue oxygen saturation (StO2) < 75%, or 20% below baseline; or the same physiologic parameters) in the restricted group. Primary endpoints were major postoperative complications. A total of 27 patients were randomized (18 restricted, 9 standard). Age, gender, ethnicity, past medical history, and body mass index were similar. American Society of Anesthesiologists class was somewhat higher in the restricted group (American Society of Anesthesiologists class 3 in 77% of restricted vs 44% of standard patients; P = 0.194). Median total intraoperative fluids were less in the restricted group (1300 mL) when compared with the standard group (3014 mL) (P = 0.021). Total fluids for the hospitalization were also statistically significantly decreased in the restricted group. Complications occurred in about two-thirds of patients, and complication rates were not statistically different between groups (1.6/restricted patient vs 2.1/standard patient; P = 0.333). Primary indications for boluses (n = 93) given to study patients were: hypotension (69%); oliguria (15%); and tachycardia (14%), with multiple indications per bolus. In only two instances did the StO2 drop to less than 75 per cent, or decrease by 20 per cent from baseline in the 3 minutes before bolus as an indication for fluid administration. Patients undergoing elective colorectal surgery with a fluid restricted strategy had only rare episodes of decreased StO2, suggesting that adequate tissue perfusion was maintained in this group. As a result, NIRS monitoring did not significantly influence intraoperative fluid management of patients undergoing colorectal surgery.

Pulmonary contusion: an update on recent advances in clinical management

Pulmonary contusion is a common finding after blunt chest trauma. The physiologic consequences of alveolar hemorrhage and pulmonary parenchymal destruction typically manifest themselves within hours of injury and usually resolve within approximately 7 days. Clinical symptoms, including respiratory distress with hypoxemia and hypercarbia, peak at about 72 h after injury. The timely diagnosis of pulmonary contusion requires a high degree of clinical suspicion when a patient presents with trauma caused by an appropriate mechanism of injury. The clinical diagnosis of acute parenchymal lung injury is usually confirmed by thoracic computed tomography, which is both highly sensitive in identifying pulmonary contusion and highly predictive of the need for subsequent mechanical ventilation. Management of pulmonary contusion is primarily supportive. Associated complications such as pneumonia, acute respiratory distress syndrome, and long-term pulmonary disability, however, are frequent sequelae of these injuries.

Novel toxin assays implicate Mycoplasma pneumoniae in prolonged ventilator course and hypoxemia

BACKGROUND

Community-acquired respiratory distress syndrome (CARDS) toxin is a unique Mycoplasma pneumoniae virulence factor. Molecular assays targeting this toxin are more sensitive than existing diagnostics, but these assays have not been used to investigate the role of M pneumoniae as a nosocomial infection in critical illness. We sought to determine the incidence of M pneumoniae among mechanically ventilated subjects using these novel assays and to investigate the impact of this pathogen on pulmonary outcomes.

METHODS

We conducted a prospective observational study enrolling subjects with suspected ventilator-associated pneumonia (VAP) undergoing BAL in the surgical trauma ICU at a level I trauma center. Lavage fluid and serum samples were tested for M pneumoniae using assays to detect CARDS toxin gene sequences, protein, or antitoxin antibodies.

RESULTS

We collected samples from 37 subjects, with 41% (15 of 37) testing positive using these assays. The positive and negative groups did not differ significantly in baseline demographic characteristics, including age, sex, injury severity, or number of ventilator days before bronchoscopy. The positive group had significantly fewer ventilator-free days (P = .04) and lower average oxygenation (P = .02). These differences were most pronounced among subjects with ARDS.

CONCLUSIONS

Evidence is provided that M pneumoniae is present in a substantial number of subjects with suspected VAP. Subjects testing positive experience a significantly longer ventilator course and worse oxygenation compared with subjects testing negative.

Diaphragmatic Injuries: What Has Changed over a 20-Year Period?

Traumatic diaphragmatic injuries are uncommon events but are associated with a high mortality. We hypothesize that injury pattern has changed over time with increasing prevalence of blunt injuries. A retrospective chart review was performed of 124 patients who sustained traumatic diaphragmatic injuries over the 20-year period between January 1,1986 and December 31, 2005. Penetrating trauma accounted for 65 per cent (80/124) of all diaphragm injuries, and blunt trauma for 35 per cent (44/124). Mean Injury Severity Scores of 19 ± 9 and 34 ± 13 were observed for the penetrating and blunt trauma groups, respectively ( P = 0.001). Blunt traumatic diaphragm injuries increased from 13 per cent in the first 10-year period to 66 per cent in the second 10-year period ( P = 0.001). The overall mortality was 9 per cent (11/124) with 10 deaths resulting from blunt trauma and one resulting from penetrating trauma ( P < 0.001). The mortality rate increased from 3 to 17 per cent over the two decades ( P = 0.007). Our data suggests that over the last 20 years, the increase in mortality associated with traumatic diaphragmatic injury is primarily related to an increase in the proportion of patients with blunt trauma as a cause of their diaphragmatic injury and associated injuries.