Changing paradigms in surgical resuscitation

Frequency of Operative Anesthesia Care After Traumatic Injury

BACKGROUND

Virtually all anesthesiologists care for patients who sustain traumatic injuries; however, the frequency with which operative anesthesia care is provided to this specific patient population is unclear. We sought to better understand the degree to which anesthesia providers participate in operative trauma care and how this differs by trauma center designation (levels I-V), using data from a comprehensive, regional database-the Washington State Trauma Registry (WSTR). We also sought to specifically assess operative anesthesia care frequency vis a vis the American College of Surgeons guidelines for continuous anesthesiology coverage for Level II trauma center accreditation.

METHODS

We conducted a retrospective analysis measuring the frequency of operative anesthesia care among patients enrolled in the WSTR. Univariate comparisons were made between trauma patients who had surgery during their admission and those who did not (medical management only). In addition, clinical factors associated with surgical intervention were measured. We also measured the average times from hospital admission to surgery and compared these times across trauma centers, grouped level I, II, and III-V.

RESULTS

From 2004 to 2014, there were approximately 176,000 encounters meeting WSTR inclusion criteria. Approximately 60% of these trauma encounters included exposure to operative anesthesia during the admission. Among all surgical procedures during the trauma admission, approximately 33% occurred within a level I trauma center, 23% occurred within a level II trauma center, and 44% occurred in a trauma center with a III, IV, or V designation. The predominant procedure category during a trauma admission was orthopedic. The presence of hypotension on admission (P < .01), increasing injury severity score (P < .01) and higher emergency department Glasgow Coma Score (P < .01) were all associated with surgical intervention during the trauma hospitalization, after adjustment for potential confounders. In level I trauma centers, for general surgical procedures, the median time to surgery was 2.5 hours; in level II trauma centers, the median time was 1.7 hours.

CONCLUSIONS

This study highlights the frequent role anesthesiologists play in caring for patients who sustain traumatic injuries, in trauma centers levels I-V. In level II trauma centers, in-house anesthesiology coverage might have benefit for those patients requiring surgery within 1 hour, whereas the former American College of Surgeons requirement of 30-minute response time for out-of-hospital anesthesiology coverage is likely sufficient to provide satisfactory care to patients requiring surgery within 3 hours. Whether the increased cost of such in-house anesthesiology coverage at level II trauma centers is justified by its clinical benefit remains an unanswered question.

A preliminary prospective study of patients who underwent vacuum-assisted and mesh-mediated fascial traction techniques for open abdomen management with negative fluid therapy: An observational study

It is unclear whether strategies targeting negative fluid balance are associated with facilitated early fascial closure. The present study investigated the effects of fluid removal therapy on early facial closure of open abdomen patients.A prospective study was conducted in patients who underwent open abdomen management with vacuum-assisted and mesh-mediated fascial traction technique. Therapeutic diuresis with torasemide was applied to cause negative fluid balance in the treatment group. The study and follow-up periods were 7 and 180 days, respectively. The observational indices included the intra-abdominal pressure, the number of days to closure, the type of closure, the septic complications, the duration of ventilation support, the duration of initial hospital stay, and the duration of intensive care unit (ICU) stay.A total of 27 patients were divided into the treatment (16 patients) and control (11 patients) groups. The median intra-abdominal pressure (IAP) of the patients of the control and the treatment groups was significantly lower at day 7 compared with the baseline value (P < .0001). IAP was lower in the treatment group compared with that noted in the control group, following day 4 of the fluid removal therapy (P < .05). The percentage weight loss in the treatment group was between 4.80% and 10.88%. The early closure rates were significantly higher in the treatment group compared with those in the control group (75.0% vs 18.2%, P = .0063).Fluid removal therapy combined with vacuum-assisted and mesh-mediated fascial traction provided a high early fascial closure rate for open abdomen patients.

The Use of Internal Jugular Vein Ultrasonography to Anticipate Low or High Central Venous Pressure During Mechanical Ventilation

BACKGROUND

Critically low or high central venous pressure (CVP) values, together with systemic hypotension, can indicate hypovolemia or acute heart failure. However, measuring CVP requires the insertion of a central venous catheter, a time-consuming procedure that can be associated with severe complications.

OBJECTIVE

We sought to evaluate the use of ultrasonography of the internal jugular vein (IJV) to estimate low or high CVP values in patients who were on ventilation.

METHODS

Ultrasonography of IJV dimensions and the collection of hemodynamic data was performed in 47 patients, and the ratio between IJV diameter in the 30° and 0° position was calculated (ratio(30/0)). The predictive value of ratio(30/0) for estimating low and high CVP levels was analyzed using receiver operating characteristic curves.

RESULTS

The median IJV diameter ratio(30/0) was 0.49. CVP ranged from 1 to 13 mm Hg (median 7 mm Hg). Seventeen patients had a CVP ≤ 5 mm Hg or lower (defined as "low"), and in 11 patients, values of ≥ 10 mm Hg were measured (defined as "high"). The corresponding IJV diameter ratios increased significantly from 0.34 (in the low CVP group) to 0.9 (in the high CVP group). Receiver operating characteristic analysis revealed a good predictive value of the ratio(30/0) for the prediction of low or high CVP values, respectively. A ratio(30/0) of < 0.45 optimally indicated a low CVP, while > 0.65 was the cutoff value to detect a CVP ≥ 10 mm Hg.

CONCLUSION

The estimation of low or high CVP values by IJV ultrasonography in different patient positions can be a helpful instrument for the rapid hemodynamic assessment of the critically ill patient.

Impact of early haemodynamic goal-directed therapy in patients undergoing emergency surgery: an open prospective, randomised trial

Haemodynamic goal-directed therapies (GDT) may improve outcome following elective major surgery. So far, few data exist regarding haemodynamic optimization during emergency surgery. In this randomized, controlled trial, 50 surgical patients with hypovolemic or septic conditions were enrolled and we compared two algorithms of GDTs based either on conventional parameters and pressure pulse variation (control group) or on cardiac index, global end-diastolic volume index and stroke volume variation as derived from the PiCCO monitoring system (optimized group). Postoperative outcome was estimated by a composite index including major complications and by the Sequential Organ Failure Assessment (SOFA) Score within the first 3 days after surgery (POD1, POD2 and POD3). Data from 43 patients were analyzed (control group, N = 23; optimized group, N = 20). Similar amounts of fluid were given in the two groups. Intraoperatively, dobutamine was given in 45 % optimized patients but in no control patients. Major complications occurred more frequently in the optimized group [19 (95 %) versus 10 (40 %) in the control group, P < 0.001]. Likewise, SOFA scores were higher in the optimized group on POD1 (10.2 ± 2.5 versus 6.6 ± 2.2 in the control group, P = 0.001), POD2 (8.4 ± 2.6 vs 5.0 ± 2.4 in the control group, P = 0.002) and POD 3 (5.2 ± 3.6 and 2.2 ± 1.3 in the control group, P = 0.01). There was no significant difference in hospital mortality (13 % in the control group and 25 % in the optimized group). Haemodynamic optimization based on volumetric and flow PiCCO-derived parameters was associated with a less favorable postoperative outcome compared with a conventional GDT protocol during emergency surgery.

VAWCM-Instillation Improves Delayed Primary Fascial Closure of Open Septic Abdomen

Background. Failure to achieve delayed primary fascial closure (DPFC) is one of the main complications of open abdomen (OA), certainly when abdominal sepsis is present. This retrospective cohort study aims to evaluate the effect of combined therapy of vacuum-assisted mesh-mediated fascial traction and topical instillation (VAWCM-instillation) on DPFC in the open septic abdomen. Methods. The patients with abdominal sepsis who underwent OA using VAWCM were included and divided into the instillation and noninstillation (control) groups. The DPFC rate and other outcomes were compared between the two groups. Results. Between 2007 and 2013, 73 patients with open septic abdomen were treated with VAWCM-instillation and 61 cases with VAWCM-only. The DPFC rate in the instillation group was significantly increased (63% versus 41%, P = 0.011). The mortality with OA was similar (24.6% versus 23%, P = 0.817) between the two groups. However, time to DPFC (P = 0.003) and length of stay in hospital (P = 0.022) of the survivals were significantly decreased in the instillation group. In addition, VAWCM-instillation (OR 1.453, 95% CI 1.222–4.927, P = 0.011) was an independent influencing factor related to successful DPFC. Conclusions. VAWCM-instillation could improve the DPFC rate but could not decrease the mortality in the patients with open septic abdomen.

Severe postpartum hemorrhage from uterine atony: a multicentric study

Objective. Postpartum hemorrhage (PPH) is an important cause of maternal mortality (MM) around the world. Seventy percent of the PPH corresponds to uterine atony. The objective of our study was to evaluate multicenter PPH cases during a 10-month period, and evaluate severe postpartum hemorrhage management. Study Design. The study population is a cohort of vaginal delivery and cesarean section patients with severe postpartum hemorrhage secondary to uterine atony. The study was designed as a descriptive, prospective, longitudinal, and multicenter study, during 10 months in 13 teaching hospitals. Results. Total live births during the study period were 124,019 with 218 patients (0.17%) with severe postpartum hemorrhage (SPHH). Total maternal deaths were 8, for mortality rate of 3.6% and a MM rate of 6.45/100,000 live births (LB). Maternal deaths were associated with inadequate transfusion therapy. Conclusions. In all patients with severe hemorrhage and subsequent hypovolemic shock, the most important therapy is intravascular volume resuscitation, to reduce the possibility of target organ damage and death. Similarly, the current proposals of transfusion therapy in severe or massive hemorrhage point to early transfusion of blood products and use of fresh frozen plasma, in addition to packed red blood cells, to prevent maternal deaths.

Fluid volume overload negatively influences delayed primary facial closure in open abdomen management

BACKGROUND AND AIM

The open abdomen (OA) is associated with significant morbidity and mortality, and its management poses a formidable challenge. Inability to achieve primary closure of the abdominal wall is one of the most severe complications of this technique. Factors influencing primary fascial closure, however, are unknown. This study aims to explore the influence of fluid volume overload on the application of vacuum-assisted and mesh-mediated fascial traction (VAWCM) in OA treatment.

METHODS

A review of patients undergoing OA management using VAWCM technique from January 2006 to November 2011 was performed. Patients with aged <18 y OA treatment for fewer than 5 d and abdominal wall hernia before OA treatment were excluded.

RESULTS

Average age was 45 ± 10.1 y and average OA treatment time was 31 ± 6.8 d. The complete fascial closure rate was 60%. The overall mean bodyweight-based fluid overload was 7.2 kg (range: -8.0 to +21.6 kg), representing a mean percent weight gain of 11.5% (range: -9.5% to +27%). Patients with fluid-related weight gain ≥10% had a lower primary facial closure rate than those with <10% (39% versus 77%). And primary facial closure rate seems to further decrease with fluid-related weight gain ≥20%, suggesting a dose-response effect of progressive fluid accumulation.

CONCLUSIONS

The VAWCM method provided a high primary fascial closure rate after long-term treatment of OA. Fluid volume overload negatively influences delayed primary facial closure. Judicious intravenous fluid resuscitation should be advocated in the therapy of critically ill patients.

Organisation and planning of anaesthesia for emergency surgery

Patients presenting for emergency surgery represent a category at high risk of complications, with substantial morbidity and mortality, whose management may be extremely challenging. In this first of two articles we consider the identification and evaluation of high risk emergency patients, the provision of critical care support, the management of sepsis, common postoperative complications and in-theatre death.

Critical care considerations in the management of the trauma patient following initial resuscitation

Background

Care of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented.

Methods

A non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012.

Results and conclusion

Polytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.

Surgical strategies for management of the open abdomen

Since the mid-1990s the surgical community has seen a surge in the prevalence of open abdomens (OAs) reported in the surgical literature and in clinical practice. The OA has proven to be effective in decreasing mortality and immediate postoperative complications; however, it may come at the cost of delayed morbidity and the need for further surgical procedures. Indications for leaving the abdomen open have broadened to include damage control surgery, abdominal compartment syndrome, and abdominal sepsis. The surgical options for management of the OA are now more diverse and sophisticated, but there is a lack of prospective randomized controlled trials demonstrating the superiority of any particular method. Additionally, critical care strategies for optimization of the patient with an OA are still being developed. Review of the literature suggests a bimodal distribution of primary closure rates, with early closure dependent on postoperative intensive care management and delayed closure more affected by the choice of the temporary abdominal closure technique. Invariably, a small fraction of patients requiring OA management fail to have primary fascial closure and require some form of biologic fascial bridge with delayed ventral hernia repair in the future.

Hypercoagulability in porcine hemorrhagic shock is present early after trauma and resuscitation

INTRODUCTION

The understanding of coagulopathy associated with trauma continues to evolve. Trauma patients are frequently coagulopathic early after injury and become hypercoagulable within days of injury. Thrombelastography (TEG) allows real-time evaluation of the coagulation status of patients. We hypothesized that TEG will identify post-traumatic hypercoagulable state in our porcine model of hemorrhagic shock and resuscitation.

METHODS

Fourteen male Yorkshire pigs were sedated, instrumented, and splenectomized via laparotomy. Eight of these animals underwent a shock protocol consisting of a pulmonary contusion via captive bolt gun, 35% hemorrhage and two liver fractures. Vitals, hemodynamics, physiologic parameters and TEG were measured at baseline, after shock and at intervals after injury thru 72 h post-injury.

RESULTS

Animals undergoing surgery and instrumentation demonstrated the same hypercoagulable patterns as animals that received shock, injury, and resuscitation. In this model, hypercoagulability was present in both groups at 4 h after injury and continued for 72 h post-injury (increased angle and maximum amplitude, P < 0.05, compared to baseline). Statistically significant differences between the groups were noted at both 16 and 48 h post-injury.

CONCLUSIONS

Hypercoagulability is present early after surgical intervention and trauma. This finding has implications for use of deep venous thrombosis (DVT) prophylaxis in trauma patients.

Resuscitation and monitoring in gastrointestinal bleeding

INTRODUCTION

Gastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately.

MATERIALS AND METHODS

Articles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards.

RESULTS

Decisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. "Functional hemodynamic monitoring" requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding.

CONCLUSIONS

Management of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.