Leaving Contaminated Trauma Laparotomy Wounds Open Reduces Wound Infections But Does Not Add Value

BACKGROUND

The incidence of surgical site infection (SSI) has become a key quality indicator following clean and clean/contaminated surgical procedures. In contrast, contaminated and dirty wounds have garnered little attention with this quality metric because of the expected higher complication incidence. We hypothesized that wound management strategies in this high-risk population vary significantly and might not add value to the overall care.

MATERIALS AND METHODS

This is a retrospective, observational study of trauma patients who underwent an exploratory laparotomy at an urban, academic, level 1 trauma center from 2014 to 2016. Deaths before hospital discharge were excluded. Wounds were classified using the Centers for Disease Control and Prevention definition on review of the operative reports. SSI was determined by review of the medical record, also per Centers for Disease Control and Prevention definition. Wound management strategies were categorized as either primary skin closure or closure by secondary intention. Outcomes were compared using Chi square or Kruskal-Wallis test.

RESULTS

There were 128 patients who met study criteria. Fifty-five (42.9%) wounds were left open to close by secondary intention. In the wounds that were closed primarily (n = 73), eight (10.9%) developed an SSI. There were significant differences in the average length of stay (25.0 versus 11.6 d, P = 0.032), number of office visits (3.0 versus 1.8, P = 0.008), and time from last laparotomy to the last wound care office visit (112.8 versus 57.4, P = 0.012) between patients who were treated with secondary intention closure compared to those closed primarily who did not suffer from SSI.

CONCLUSIONS

There is significant incidence of SSI in contaminated and dirty traumatic abdominal wounds; however, wound management strategies vary widely within this cohort. Closure by secondary intention requires significantly more resource utilization. Isolating risk factors for SSI may allow additional patients to undergo primary skin closure and avoid the morbidity of closure by secondary intention.

Pain, Agitation, and Delirium Guidelines: Interprofessional Perspectives to Translate the Evidence

BACKGROUND

Societal guidelines exist for the management of pain, agitation, and delirium (PAD) in critically ill patients. This contemporary practice aims for a more awake and interactive patient. Institutions are challenged to translate the interrelated multivariable concepts of PAD into daily clinical practice and to demonstrate improvement in quality outcomes. An interdisciplinary goal-directed approach shows outcomes in high-acuity surgical critical care during the early stages of implementation.

METHODS

This study was a prospective preintervention and postintervention design. A formal PAD clinical practice guideline targeting standardized assessment and "light" levels of sedation was instituted. All mechanically ventilated patients admitted to a 24-bed surgical intensive care unit (ICU) at an academic medical center during a 6-month period were included (3 months before and 3 months after implementation). Sedation and agitation were measured using the Richmond Agitation Sedation Scale (RASS), pain measured using a Behavioral or Numeric Pain Scale (NPS/BPS), and delirium using the Confusion Assessment Method for the Intensive Care Unit. Total ventilator days with exposure to continuous opioid or sedative infusions and total ICU days where the patient received a physical activity session exercising out of bed were recorded.

RESULTS

There were 106 patients (54 at preintervention and 52 at postintervention). Mean percentage of RASS scores between 0 to -1 increased from 38% to 50% postintervention (P < .02). Mean percentage of NPS/BPS scores within the goal range (<5 for BPS and <3 for NPS) remained stable, 86% to 83% (P = .16). There was a decrease in use of continuous narcotic infusions for mechanically ventilated patients. This was reported as mean percentage of total ventilator days with a continuous opioid infusing: 65% before implementation versus 47% after implementation (P < .01). Mean percentage of ICU days with physical activity sessions increased from 24% to 41% (P < .001). Overall mean ventilator-free days and ICU length of stay were 5.4 to 4.5 days (P = .29) and 11.75 to 9.5 days (P = .20), respectively.

CONCLUSION

Measureable patient outcomes are achievable in the early stages of PAD guideline initiatives and can inform future systems-level organizational change. Pain, agitation, and delirium assessment tools form the foundation for clinical implementation and evaluation. High-acuity surgical critical care patients can achieve more time at goal RASS, decreased ventilator days, and less exposure to continuous opioid infusions, all while maintaining stable analgesia.

Nighttime Trauma Fellow Care Is Associated with Improved Outcomes after Injury

Time of admission and surgeon experience may explain variations in trauma outcomes. We hypothesized that earlier admission time by a more experienced trauma surgeon leads to improved outcomes after injury. We conducted a retrospective cohort study using trauma registry and performance improvement data at our Level 1 trauma center. Consecutive patients presenting at night from 2013 to 2014 were dichotomized into early (6:00 pm-12:00 am) and late (12:01 am-7:00 am) cohorts. Second year trauma fellows acting as attendings and staff trauma surgeons were categorized as less and more experienced, respectively. The primary study outcome was any complication tracked by our state registry, missed injury, delay in diagnosis, or death. The influence of admission time and trauma surgeon experience on this endpoint was examined using multivariable logistic regression. A total of 2078 patients presented either during early (n = 1189) or late (n = 889) night. The cohorts were not different with respect to Deyo-Charlson index, systolic blood pressure, Glasgow Coma Scale, Injury Severity Core, admitting trauma surgeon age, experience, or unadjusted primary study outcome (early 14 vs late 16%; P = 0.206). Trauma surgeon experience was independently predictive of outcomes. Trauma patients admitted at night by fellows were 29 per cent less likely to sustain complications or death than those admitted by staff (adjusted odds ratio 0.71; 95% confidence interval: 0.54-0.92, P = 0.010). This protective effect of fellow care was found only in patients admitted after midnight (P = 0.03). In conclusion, nighttime initial trauma care by fellows was associated with improved outcomes. Possible explanations include more oversight of nighttime fellow care, variations in daytime responsibilities between fellows and staff, and differential effects of sleep loss by age.

Nighttime Trauma Fellow Care Is Associated with Improved Outcomes after Injury

Time of admission and surgeon experience may explain variations in trauma outcomes. We hypothesized that earlier admission time by a more experienced trauma surgeon leads to improved outcomes after injury. We conducted a retrospective cohort study using trauma registry and performance improvement data at our Level 1 trauma center. Consecutive patients presenting at night from 2013 to 2014 were dichotomized into early (6:00 PM–12:00 AM) and late (12:01 AM–7:00 AM) cohorts. Second year trauma fellows acting as attendings and staff trauma surgeons were categorized as less and more experienced, respectively. The primary study outcome was any complication tracked by our state registry, missed injury, delay in diagnosis, or death. The influence of admission time and trauma surgeon experience on this endpoint was examined using multivariable logistic regression. A total of 2078 patients presented either during early (n = 1189) or late (n = 889) night. The cohorts were not different with respect to Deyo–Charlson index, systolic blood pressure, Glasgow Coma Scale, Injury Severity Core, admitting trauma surgeon age, experience, or unadjusted primary study outcome (early 14 vs late 16%; P = 0.206). Trauma surgeon experience was independently predictive of outcomes. Trauma patients admitted at night by fellows were 29 per cent less likely to sustain complications or death than those admitted by staff (adjusted odds ratio 0.71; 95% confidence interval: 0.54–0.92, P = 0.010). This protective effect of fellow care was found only in patients admitted after midnight ( P = 0.03). In conclusion, nighttime initial trauma care by fellows was associated with improved outcomes. Possible explanations include more oversight of nighttime fellow care, variations in daytime responsibilities between fellows and staff, and differential effects of sleep loss by age.

Development and implementation of a risk identification tool to facilitate critical care transitions for high-risk surgical patients

Quality problem

Patients recently discharged from the intensive care unit (ICU) are at high risk for clinical deterioration.

Initial assessment

Unreliable and incomplete handoffs of complex patients contributed to preventable ICU readmissions. Respiratory decompensation was responsible for four times as many readmissions as other causes.

Choice of solution

Form a multidisciplinary team to address care coordination surrounding the transfer of patients from the ICU to the surgical ward.

Implementation

A quality improvement intervention incorporating verbal handoffs, time-sensitive patient evaluations and visual cues was piloted over a 1-year period in consecutive high-risk surgical patients discharged from the ICU. Process metrics and clinical outcomes were compared to historical controls.

Evaluation

The intervention brought the primary team and respiratory therapists to the bedside for a baseline examination within 60 min of ward arrival. Stakeholders viewed the intervention as such a valuable adjunct to patient care that the intervention has become a standard of care. While not significant, in a comparatively older and sicker intervention population, the rate of readmissions due to respiratory decompensation was 12.5%, while 35.0% in the control group (P = 0.28).

Lessons learned

The implementation of this ICU transition protocol is feasible and internationally applicable, and results in improved care coordination and communication for a high-risk group of patients.

Boarding ICU patients: Are our rounding practices subpar?

INTRODUCTION

Surgical Intensive Care Unit (SICU) patients "boarding" in ICUs other than the designated home unit have been shown to suffer increased rates of complications. We hypothesized that ICU rounding practices are different when SICU patients are housed in home vs. boarding ICUs.

MATERIAL AND METHODS

SICU rounds were observed at an academic quaternary medical center. Individual patient rounding time and order seen on rounds along with patient data and demographics were recorded. Multivariable regression analysis was used for comparison between patients.

RESULTS

Non-boarders were older, observed on a later post ICU admission day and were more likely to be mechanically ventilated. Boarded patients were often seen at the end of rounds and for less time. Not being a boarder, age, APACHE II score on admission, vasopressor use, and positive pressure ventilation all predicted increased rounding time.

CONCLUSIONS

Surgical ICU patients boarding in non-preferred units are often seen at the end of rounds, result in a greater reliance upon telephone communication, and receive less bedside attention from ICU provider teams.

Staying connected: Service-specific orientation can be successfully achieved using a mobile application for onboarding care providers

Communicating service-specific practice patterns, guidelines, and provider information to a new team of learners that rotate frequently can be challenging. Leveraging individual and healthcare electronic resources, a mobile device platform was implemented into a newly revised resident onboarding process. We hypothesized that offering an easy-to-use mobile application would improve communication across multiple disciplines as well as improve provider experiences when transitioning to a new rotation. A mobile platform was created and deployed to assist with enhancing communication within a trauma service and its resident onboarding process. The platform had resource materials such as: divisional policies, Clinical Practice Guidelines (CMGs), and onboarding manuals along with allowing for the posting of divisional events, a divisional directory that linked to direct dialing, text or email messaging, as well as on-call schedules. A mixed-methods study, including an anonymous survey, aimed at providing information on team member's impressions and usage of the mobile application was performed. Usage statistics over a 3-month period were analyzed on those providers who completed the survey. After rotation on the trauma service, trainees were asked to complete an anonymous, online survey addressing both the experience with, as well as the utility of, the mobile app. Thirty of the 37 (81%) residents and medical students completed the survey. Twenty-five (83%) trainees stated that this was their first experience rotating on the trauma service and 6 (20%) were from outside of the health system. According to those surveyed, the most useful function of the app were access to the directory (15, 50%), the divisional calendar (4, 13.3%), and the on-call schedules (3, 10%). Overall, the app was felt to be easy to use (27, 90%) and was accessed an average of 7 times per day (1-50, SD 9.67). Over half the survey respondents felt that the mobile app was helpful in completing their everyday tasks (16, 53.3%). Fifteen (50%) of the respondents stated that the app made the transition to the trauma service easier. Twenty-five (83.3%) stated it was valuable knowing about departmental events and announcements, and 17 (56.7%) felt more connected to the division. The evolution of mobile technology is rapidly becoming fundamental in medical education and training. We found that integrating a service-specific mobile application improved the learner's experience when transitioning to a new service and was a valuable onboarding instrument. Level of evidence IV.

Secondary extremity compartment syndrome after traumatic cardiac arrest

The objective of this case report is to investigate the pathophysiology, diagnosis, and surgical management of secondary extremity compartment syndrome. This case-based review documents the development of secondary extremity compartment syndrome in the setting of high-volume fluid resuscitation for a hemorrhagic cardiac arrest complicated by a global ischemia-reperfusion injury. A 21-year-old male presented with traumatic, hemorrhagic cardiac arrest. Following a resuscitative thoracotomy, massive transfusion and return of spontaneous circulation, the patient underwent damage control surgery. Over the first 48 h following the injury, the patient developed progressive diffuse interstitial edema ultimately culminating in compartment syndrome of the remaining three uninjured extremities as well as both uninjured gluteal compartments. The patient underwent bilateral lower extremity, thigh, gluteal, and right upper extremity compartment fasciotomies, with the left lower extremity being the single, traumatically injured extremity. To our knowledge, this is the only case of secondary extremity compartment syndrome in which bilateral gluteal compartments and bilateral thigh compartments were involved in addition to the bilateral upper and right lower extremities. The goal of this case report is to examine the pathophysiology of the development of secondary extremity compartment syndrome, with an emphasis on early recognition and surgical intervention.

Variation in intensive care unit utilization and mortality after blunt splenic injury

BACKGROUND

Although trauma patients are frequently cared for in the intensive care unit (ICU), admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients treated for blunt splenic injuries from 2011-2014 at 30 level I and II Pennsylvania trauma centers. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman's rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement between high and low-ICU-utilization centers.

RESULTS

Of 2587 patients with blunt splenic injuries, 63.9% (1654) were admitted to the ICU. Median injury severity score was 17 overall, 13 for non-ICU patients and 17 for ICU patients (P < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9%-87.3%. Risk-adjusted mortality rates ranged from 1.2%-9.6%. There was no correlation between observed-to-expected ratios for ICU utilization and mortality (Spearman's rho = -0.2595, P = 0.2103). Proportionately fewer ICU patients received critical care procedures at high-utilization centers than at low-utilization centers.

CONCLUSIONS

Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality.

Extracorporeal Membrane Oxygenation (ECMO)/Extracorporeal Carbon Dioxide Removal (ECCO2R)

Extracorporeal membrane oxygenation (ECMO) is a means of supporting severe pulmonary and cardiac dysfunction. It stabilizes critical derangements of oxygenation and ventilation, allowing time to diagnose, treat, and recover from the underlying cause of organ failure. The extracorporeal circuit has three main components: large-bore cannulae and circuit tubing to provide access to the native circulation, an artificial membrane lung to provide gas exchange, and an active pump to facilitate perfusion. Multiple clinical studies have evaluated this technology, the strongest evidence to date supporting its use being the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial, which showed survival advantage when patients were treated with a protocol that included ECMO. Extracorporeal carbon dioxide removal (ECCO₂R) is similar in concept to ECMO, but has a lower flow rate and does not significantly oxygenate the patient. It is a primary treatment for hypercarbic respiratory failure or is an adjunct to reduce potentially injurious levels of mechanical ventilator support in hypoxemic respiratory failure. Complications are common occurrences on both types of therapy. Strong institutional commitment and a team approach are critical to successful implementation. Additional randomized trials are needed to clarify the appropriate indications and best practices for these lifesaving therapies.

Care of the Surgical ICU Patient with Chronic Obstructive Pulmonary Disease and Pulmonary Hypertension

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease characterized by airflow limitation that is frequently progressive and associated with respiratory impairment. As the fourth leading cause of death in the United States and Europe, COPD results in a substantial and ever increasing economic and social burden [1]. Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are frequently encountered in the intensive care unit (ICU). Although there is no standardized definition, AECOPD are characterized by a significant change in patient symptoms from baseline accompanied by overall increased airway resistance [2]. These exacerbations carry a significant risk to patients, with 10 % in-hospital mortality and 1-year and 2-year all-cause mortality rates of 43 % and 49 %, respectively, in patients with hypercapnic exacerbations [3]. Other studies note in-hospital mortality rates as high as 30 % with worse outcomes associated with older age, severity of respiratory and non-respiratory organ dysfunction, and hospital length of stay [4]. Given that patients transferred to the ICU with AECOPD are at high risk for complications and adverse outcomes, early diagnosis and management are critical to improve patient outcomes and survival in this population.

Tracheostomy Complications as a Trigger for an Airway Rapid Response: Analysis and Quality Improvement Considerations

OBJECTIVE

To analyze the subset of airway rapid response (ARR) calls related to tracheostomy identified over a 46-month period from August 2011 to May 2015 to determine proximate cause, intervention, and outcome and to develop process improvement initiatives.

DESIGN

Single-institution multidisciplinary retrospective cohort study.

SETTING

Tertiary care academic medical center in a large urban setting.

SUBJECTS

Hospital inpatients with an in situ tracheostomy or laryngectomy who experienced an ARR.

METHODS

Detailed review of operator, hospital, and patient records related to ARR system activations over a 46-month period.

RESULTS

ARR was activated for 28 patients with existing tracheostomy. The cohort included open tracheostomy (n = 14), percutaneous tracheostomy (n = 8), laryngectomy stoma (n = 3), and indeterminate technique (n = 3). The most frequent triggers for emergency airway intervention were decannulation (n = 16), followed by mucus plugging (n = 4). The mean body mass index of ARR patients was higher than that of a comparator tracheostomy cohort (32.9 vs 26.3, P < .001). BMI was >40 in 9 ARR patients. There was 1 mortality in the series.

CONCLUSIONS

Tracheostomy is a major trigger for ARR with potential fatal outcome. Factors that may contribute to tracheostomy emergencies include high body mass index, surgical technique for open tracheostomy or percutaneous tracheostomy, tracheostomy tube size, and bedside tracheostomy management. Results have triggered a hospital-wide practice improvement plan focused on tracheostomy awareness and documentation, discrete process changes, and implementation of guidelines for emergency management.

A Simulation Curriculum for Management of Trauma and Surgical Critical Care Patients

BACKGROUND

Expectations continue to rise for residency programs to provide integrated simulation training to address clinical competence. How to implement such training sustainably remains a challenge. We developed a compact module for first-year surgery residents integrating theory with practice in high-fidelity simulations, to reinforce the preparedness and confidence of junior residents in their ability to manage common emergent patient care scenarios in trauma and critical care surgery.

METHODS

The 3-day module features a combination of simulated patient encounters using standardized patients and electronic manikins, didactic sessions, and hands-on training. Manikin-based scenarios developed in-house were used to teach trauma and critical care management concepts and skills. Separate scenarios in collaboration with the regional organ donation program addressed communication in difficult situations such as brain death. Didactic material based on contemporary evidence, as well as skills stations, was developed to complement the scenarios. Residents were surveyed before and after training on their confidence in meeting the 14 learning objectives of the curriculum on a 5-point Likert scale.

RESULTS

Data from 15 residents who underwent this training show an overall improvement in confidence across all learning objectives defined for the module, with confidence scores before to after training improving significantly from 2.8 (σ = 0.85, median = 3) to 3.9 (σ = 0.87, median = 4) of 5, p < 0.001. Although female residents reported higher posttraining confidence scores compared with male residents (average 4.2 female vs 3.8 male, p = 0.002), there were no other significant differences in confidence scores or changes to scores owing to resident sex or program status (categorical or preliminary).

CONCLUSION

We successfully implemented a multimodal simulation-based curriculum that provides skills training integrated with the clinical context of managing trauma and critical care patients, simultaneously addressing a range of clinical competencies. Results to date show consistent improvement in residents' confidence in meeting learning objectives. Development of the curriculum continues for sustainability, as well as measures to embed objective evaluations of resident competence.

Laparoscopy in trauma: An overview of complications and related topics

The introduction of laparoscopy has provided trauma surgeons with a valuable diagnostic and, at times, therapeutic option. The minimally invasive nature of laparoscopic surgery, combined with potentially quicker postoperative recovery, simplified wound care, as well as a growing number of viable intraoperative therapeutic modalities, presents an attractive alternative for many traumatologists when managing hemodynamically stable patients with selected penetrating and blunt traumatic abdominal injuries. At the same time, laparoscopy has its own unique complication profile. This article provides an overview of potential complications associated with diagnostic and therapeutic laparoscopy in trauma, focusing on practical aspects of identification and management of laparoscopy-related adverse events.

Arteriography for Lower Gastrointestinal Hemorrhage: Role of Preceding Abdominal Computed Tomographic Angiogram in Diagnosis and Localization

IMPORTANCE

Optimizing the nature and sequence of diagnostic imaging when managing lower gastrointestinal hemorrhage may reduce subsequent morbidity and mortality.

OBJECTIVES

To determine if preceding visceral arteriography with computed tomographic angiography (CTA) in acute lower gastrointestinal hemorrhage increases hemorrhage identification and localization and to determine if CTA was superior to nuclear scintigraphy when used as a pre-angiogram test.

DESIGN, SETTING, AND PARTICIPANTS

Analysis was conducted of prospectively acquired data from an interventional radiology database and of individual electronic medical records from an academic tertiary medical center. On January 1, 2009, a new, evidence-based, institutional protocol that formally incorporated CTA to manage acute lower gastrointestinal hemorrhage was launched after multidisciplinary consultation. All records of patients who underwent visceral angiography (VA) for acute lower gastrointestinal hemorrhage from January 1, 2005, to December 31, 2012, were evaluated.

EXPOSURES

Imaging, procedural, and operative details were abstracted from the medical records of all patients who underwent VA for lower gastrointestinal hemorrhage.

MAIN OUTCOMES AND MEASURES

Visceral angiography results and efficacy were compared in patients before and after protocol implementation and compared based on which imaging method was used prior to angiography.

RESULTS

A total of 161 angiographic procedures were performed during the study period (78 before and 83 after protocol implementation). Use of CTA increased from 3.8% to 56.6%, and use of nuclear scintigraphy decreased from 83.3% to 50.6% following protocol implementation (P < .001). Preceding angiography with CTA resulted in similar angiography contrast administration (mean [SD] amount for CTA prior to VA, 135 [63] vs 160 [77] mL; P = .18) and fluoroscopy time (mean [SD], 26.3 [16.8] vs 32.2 [34.9] minutes; P = .34). Although nuclear scintigraphy and CTA had similar sensitivity and specificity, localization of hemorrhage site by CTA was more precise and consistent with angiography findings. As a pre-angiography test, compared with nuclear scintigraphy, CTA reduced overall the number of imaging studies required (mean [SD] number per patient admission, 2.1 [0.3] vs 2.5 [0.8]; P = .005) and resulted in administration of more overall contrast (mean [SD], 220 [80] vs 130 [70] mL; P < .001) without worsening renal function.

CONCLUSIONS AND RELEVANCE

Preceding VA with a diagnostic study improves positive localization of the site of lower gastrointestinal hemorrhage compared with VA alone. Increasing the use of CTA for pre-angiography imaging may reduce overall imaging studies while appearing to increase positive yield at VA. Computed tomographic angiography can be used as part of a lower intestinal hemorrhage management algorithm and does not appear to worsen renal function despite the additional contrast load.

Increased mean arterial pressure goals after spinal cord injury and functional outcome

Introduction:

Acute spinal cord injury (SCI) is often treated with induced hypertension to enhance spinal cord perfusion. The optimal mean arterial pressure (MAP) likely varies between patients. Arbitrary goals are often set, frequently requiring vasopressors to achieve, with no clear evidence supporting this practice. We hypothesize that increased MAP goals and episodes of relative hypotension do not affect hospital outcome.

Materials and Methods:

All cervical and thoracic SCI patients treated at a level one trauma and regional SCI center over at 2.5-year period were retrospectively reviewed. Lowest and average hourly MAP was recorded for the first 72 h of hospitalization, allowing for quantification of mean MAP and the total number of episodic relative hypotensive events. These data were further compared to daily American spinal injury association motor score (AMS), which was used to determine the severity of SCI and improvement/decline during hospitalization. Patient's data were finally analyzed at theoretic MAP set points.

Results:

One hundred and five patients had complete data during the study period. At higher theoretic MAP set points (85 and 90), increased number of relative hypotensive episodes correlated with lower admission AMS (85 mmHg: <10 episodes, AMS 66.2; >50 episodes, 22.0; P < 0.001) and the need for vasopressors (P < 0.03) but showed no statistical change in AMS by hospital discharge. The need for vasopressors correlated with the number of hypotensive episodes and inversely related to admission AMS at all theoretic MAP goal set points but was not correlated with the change in AMS during the hospitalization.

Conclusions:

The frequency of relative hypotension and the need for vasopressors are progressively related to more severe SCI, as denoted by lower admission AMS. However, episodes of hypotension and the need for vasopressors did not affect the change in AMS during the acute hospitalization, regardless of theoretic MAP goal set-point. Arbitrarily elevated MAP goals may not be efficacious.