Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review

Reducing Systemic Risks in a Traumatic Panfacial Injury Patient

Panfacial trauma refers to injuries caused by high-energy mechanisms to two or more regions of the craniofacial skeleton, including the frontal bone, the midface, and the occlusal unit. As with any trauma, Advanced Trauma Life Support protocols should be followed in unstable patients. For the patient with panfacial traumatic injury, advanced perioperative care or critical care is frequently required. This article describes surgical critical care for panfacial injuries, a component of the acute-care surgery model, to reduce systemic risks, improve the patient's condition, and enable a successful surgical outcome.

A Flat Inferior Vena Cava on Computed Tomography Is Associated With Worse Outcomes in Emergency General Surgery

BACKGROUND

Several trauma studies have shown that a "flat" inferior vena cava (IVC) is associated with poor clinical outcomes, including hypovolemic shock, major bleeding, transfusions and mortality. These studies utilize IVC measurements on computed tomography (CT) scans, and rarely include emergency general surgery patients. We examine the association between IVC flatness and clinical outcomes in a series of patients with perforated viscus.

MATERIALS AND METHODS

Medical records at an academic hospital were reviewed of adults with perforated viscus. Patients who underwent laparotomy or laparoscopy were included if they underwent CT within 12 h prior to incision time. Perforated appendicitis was excluded. A ratio was calculated of the transverse to anterior-posterior diameter of the IVC at 3 locations, then averaged. Clinical outcomes were analyzed by the average IVC ratio.

RESULTS

A total of 83 patients were included. Using binomial regression, the average IVC ratio significantly correlated with ICU admission (OR 3.6, 95% CI 1.2 to 11) and acute kidney injury (OR 2.3, 95% CI 1.0 to 5.3), but not postoperative shock (OR 1.2, 95% CI 0.56 to 2.6).

CONCLUSIONS

A flat IVC on CT prior to an operation for perforated viscus was associated with worse outcomes, including increased rate of ICU admission and acute kidney injury. More outcomes research is needed to assess the potential role of IVC assessment in preoperative resuscitation.

Exaggerated Interventricular Dependence among Trauma and Burn Patients: A Relationship with Kidney Function—An Exploratory Study

Acute kidney injury (AKI) is a serious condition that affects critically ill patients admitted to the ICU. In this study, we report the association between right ventricle shape and AKI in a cohort of burn and trauma patients. This study is a retrospective review of trauma and burn patients who were admitted to our ICU between 2013 and 2016 who underwent hemodynamic transesophageal echocardiography. Left ventricular eccentricity index (LVEI) measurements were performed on still images obtained from transgastric short-axis view clips at end diastole. LVEI was used as a surrogate of right ventricular volume loading. There were 132 patients, the mean age was 50.8 years, and they were predominantly white and males. Using logistic regression and adjusting for age, race, gender, injury mechanism, and injury severity, higher LVEI was independently significantly associated with lower incidence of AKI (odds ratio 0.03, confidence interval 0.00–0.69). Higher LVEI is associated with a lower incidence of AKI in critically injured trauma and burn patients.

Ultrasound Training in Surgical Critical Care Fellowship: A Survey of Program Directors

OBJECTIVE

Surgical critical care (SCC) fellows are expected to receive training in critical care ultrasound (CCUS) but training is sporadic and there is no standardized curriculum to guide educators. Previous studies show wide variation in CCUS training during fellowship across specialties but SCC has been underrepresented. This study was performed to assess SCC program directors' views regarding CCUS during fellowship training.

DESIGN

Adult SCC program directors were surveyed regarding the role of CCUS in fellowship training. This survey assessed how CCUS training was performed, perceived barriers to education, and importance of specific studies. Survey responses were measured using a Likert scale ranging from 5 (strongly agree) to 1 (strongly disagree).

SETTING

Web-based survey.

PARTICIPANTS

Adult Surgical Critical Care Fellowship Program Directors.

RESULTS

A total 67 of 108 (62%) SCC program directors responded to the survey. Over 75% felt that CCUS during training should be a priority. Fifteen (24.6%) programs required a specific number of ultrasounds to be performed. Five programs (7.5%) provided no CCUS training at all. Over 75% felt that training in FAST, transthoracic echocardiography, inferior vena cava assessment, and US for procedures (line placement, thoracentesis, and paracentesis) were either important or very important but experience in transesophageal echocardiography, assessment for deep vein thrombosis, and pulmonary US were not important. Lack of time (63.8%) and trained faculty (51.2%) were the most cited barriers to training.

CONCLUSIONS

There is a wide variation in how CCUS training is performed during SCC fellowship. SCC programs will need trained faculty, appropriate time allocation, and implementation of a standardized curriculum to provide consistent and high-quality CCUS education during fellowship.

Right ventricular fractional area of change is predictive of ventilator support days in trauma and burn patients

Echocardiography has contributed to the care of critically ill patients but there remains a need for more publications about its association with outcomes to confirm its role. We conducted a retrospective review of trauma and burn patients that were admitted to our intensive care unit between 2015 and 2017 that underwent hemodynamic transesophageal echocardiography. Data collected included demographics, clinical and laboratory data. Right ventricle fractional area of change (RVFAC) measurements were performed on still mages obtained from mid-esophageal four-chamber-view clips. There were 74 patients, mean age was 51 years, and were predominantly white and male. Linear regression was used to test for the association between RVFAC and clinical outcomes. Adjusting for age, injury mechanism and injury severity, higher RVFAC was significantly associated with lower ventilator days (p = 0.03). Conclusion, higher right ventricle systolic function is associated with a lower number of ventilator support days in critically injured trauma and burn patients.

Ultrasound and Other Innovations for Fluid Management in the ICU

Ultrasound is a user-dependent tool that can help guide therapy. The use of ultrasound to guide central line placement decreases complication rates. Cardiac ultrasound can help with the diagnosis of cases of hypotension. Lung and pleura ultrasound is a useful adjunct for diagnosis causes of desaturation. Abdominal ultrasound can help in rapid visitation of fluid and intra-abdominal structures.

Variation in training and use of the focused assessment with sonography in trauma (FAST)

BACKGROUND

Training in ultrasound is variable among residents and practicing traumatologists. Focused Assessment with Sonography in Trauma (FAST) may be underused in non-urbanized areas, possibly due to lack of training.

METHODS

State trauma registry data from January 2014-June 2016 were reviewed for FAST results. Trauma practitioners were surveyed querying training, confidence, and obstacles to performing FAST.

RESULTS

12,855 records revealed highest FAST use at the urban Level II center (39%, p < 0.0001). Despite similar injury patterns, non-urban/Level III centers' frequency of FAST was only 1-28%. 39 practitioners were surveyed, those with training (54%) were more likely to use FAST (p < 0.05). 61% of practitioners outside the Level II center cited lack of confidence in their ability to perform FAST as the primary reason for omitting the exam.

CONCLUSIONS

FAST is relatively underused in non-urbanized areas of the state. Lack of confidence in ability to perform FAST was cited as the primary barrier.