Withdrawal of Care in a Trauma Intensive Care Unit: The Impact on Mortality Rate

Withdrawal of care has increased in recent years as the population older than 65 years of age has increased. We sought to investigate the impact of this decision on our mortality rate. We retrospectively reviewed a prospectively collected database to determine the percentage of cases in which care was actively withdrawn. Neurologic injury as the cause for withdrawal, age of the patient, number of days to death, number of cases thought to be treatment failures, and the reason for failure were analyzed. Between January 2008 and December 2012, there were 536 trauma service deaths; 158 (29.5%) had care withdrawn. These patients were 67 (6 18.5) years old and neurologic injury was responsible in 63 per cent (6 5.29%). Fifty-two per cent of the patients died by Day 3; 65 per cent by Day 5; and 74 per cent Day 7. A total of 22.7 per cent (6 7.9%) could be considered a treatment failure. Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent. Trauma center mortality calculation does not account for care withdrawn. Treating an active, aging population, with advance directives, requires methodologies that account for such decision-making when determining mortality rates.

Basic Ultrasound Training Can Replace Chest Radiography for Safe Tube Thoracostomy Removal

An ultrasound (US) examination can be easily and rapidly performed at the bedside to aide in clinical decisions. Previously we demonstrated that US was safe and as effective as a chest x-ray (CXR) for removal of tube thoracostomy (TT) when performed by experienced sonographers. This study sought to examine if US was as safe and accurate for the evaluation of pneumothorax (PTX) associated with TT removal after basic US training. Patients included had TT managed by the surgical team between October 2012 and May 2013. Bedside US was performed by a variety of members of the trauma team before and after removal. All residents received, at minimum, a 1-hour formal training class in the use of ultrasound. Data were collected from the electronic medical records. We evaluated 61 TTs in 61 patients during the study period. Exclusion of 12 tubes occurred secondary to having incomplete imaging, charting, or death before having TT removed. Of the 49 remaining TT, all were managed with US imaging. Average age of the patients was 40 years and 30 (61%) were male. TT was placed for PTX in 37 (76%), hemothorax in seven (14%), hemopneumothorax in four (8%), or a pleural effusion in one (2%). Two post pull PTXs were correctly identified by residents using US. This was confirmed on CXR with appropriate changes made. US was able to successfully predict the safe TT removal and patient discharge at all residency levels after receiving a basic US training program.

Transitioning to Thoracic Endovascular Repair: A Single Institution's Analysis of the Management of Blunt Aortic Injury

Over the past 15 years, there has been a rapid transformation in the way blunt aortic injuries (BAIs) are managed shifting from open thoracotomies to thoracic endovascular repairs (TEVAR). As a result of this change, we sought to describe our experience with open and endovascular repairs through a retrospective analysis of all trauma patients admitted with BAI to our Level I trauma center from 2002 to 2011. Demographic data, type of repair, complications, length of stay (LOS) data, and mortality were identified. No difference was noted in age, sex, Injury Severity Score, or Glasgow Coma Scale score between the two groups. There were also no differences in the number of acute complications or mortality. Intensive care unit (ICU) LOS was significantly shorter in the TEVAR group (20 vs 9 days, P < 0.05). Additionally, there was a trend toward shorter hospital LOS (28 vs 18 days, P = 0.07) and ventilator length of stay (12 vs 5 days, P = 0.171). In summary, endovascular repair of BAI is safe and has no increased rate of acute complications or mortality. ICU LOS is much shorter with TEVAR, and there was a trend toward shorter ventilator and hospital LOS, all of which may result in decreased cost. Still, more needs to be learned about potential long-term complications.

Mass Casualty Incident Management Preparedness: A Survey of the American College of Surgeons Committee on Trauma

Mass casualty incidents (MCIs) are events resulting in more injured patients than hospital systems can handle with standard protocols. Several studies have assessed hospital preparedness during MCIs. However, physicians and trauma surgeons need to be familiar with their hospital's MCI Plan. The purpose of this survey was to assess hospitals' and trauma surgeon's preparedness for MCIs. Online surveys were e-mailed to members of the American College of Surgeons committee on Trauma Ad Hoc Committee on Disaster and Mass Casualty Management before the March 2012 meeting. Eighty surveys were analyzed (of 258). About 76 per cent were American College of Surgeons Level I trauma centers, 18 per cent were Level II trauma centers. Fifty-seven per cent of Level I and 21 per cent of Level II trauma centers had experienced an MCI. A total of 98 per cent of respondents thought it was likely their hospital would see a future MCI. Severe weather storm was the most likely event (95%), followed by public transportation incident (86%), then explosion (85%). About 83 per cent of hospitals had mechanisms to request additional physician/surgeons, and 80 per cent reported plans for operative triage. The majority of trauma surgeons felt prepared for an MCI and believed an event was likely to occur in the future. The survey was limited by the highly select group of respondents and future surveys will be necessary.

Mass Casualty Incident Management Preparedness: A Survey of the American College of Surgeons Committee on Trauma

Mass casualty incidents (MCIs) are events resulting in more injured patients than hospital systems can handle with standard protocols. Several studies have assessed hospital preparedness during MCIs. However, physicians and trauma surgeons need to be familiar with their hospital's MCI Plan. The purpose of this survey was to assess hospitals’ and trauma surgeon's preparedness for MCIs. Online surveys were e-mailed to members of the American College of Surgeons committee on Trauma Ad Hoc Committee on Disaster and Mass Casualty Management before the March 2012 meeting. Eighty surveys were analyzed (of 258). About 76 per cent were American College of Surgeons Level I trauma centers, 18 per cent were Level II trauma centers. Fifty-seven per cent of Level I and 21 per cent of Level II trauma centers had experienced an MCI. A total of 98 per cent of respondents thought it was likely their hospital would see a future MCI. Severe weather storm was the most likely event (95%), followed by public transportation incident (86%), then explosion (85%). About 83 per cent of hospitals had mechanisms to request additional physician/surgeons, and 80 per cent reported plans for operative triage. The majority of trauma surgeons felt prepared for an MCI and believed an event was likely to occur in the future. The survey was limited by the highly select group of respondents and future surveys will be necessary.

Surgical Skill Performance Under Combat Conditions in a Virtual Environment

A group of medical students were taught to perform a tube thoracostomy on a mannequin simulator in a traditional medical school setting and demonstrate competency in that environment. Immediately afterward and again four months later, they performed the procedure in a CAVE virtual environment running a combat simulation under day and nighttime lighting conditions. The results showed that accuracy suffered in the simulation. Participants also needed more time to perform the procedures under the nighttime conditions. Further, performance did not change over the retention interval. The results suggest that although the surgical skills acquired by students in a traditional medical school setting are robust, they may still be compromised under hazardous conditions. More important, these findings show that virtual environments can provide a safe and effective venue for military medical personnel to train for dangerous duty.

Torso Computed Tomography Can be Bypassed after Thorough Trauma Bay Examination of Patients who Fall from Standing

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.

Can Routine Trauma Bay Chest X-ray be Bypassed with an Extended Focused Assessment with Sonography for Trauma Examination?

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.

Can routine trauma bay chest x-ray be bypassed with an extended focused assessment with sonography for trauma examination?

The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.

The trauma pan scan: what else do you find?

The objective of this study was to investigate the prevalence of incidental findings in pan-computed tomography (CT) scans of trauma patients and the communication of significant findings requiring follow-up to the patient. A retrospective chart review of adult trauma patients was performed during the period of January 1, 2011, to August 31, 2011. During that period, 990 patient charts were examined and 555 charts were selected based on the inclusion criteria of a pan-CT scan including the head, neck, abdomen/pelvis, and chest. Patient demographics such as age, gender, mechanism of injury, and Injury Severity Score were collected. Nontraumatic incidental findings were analyzed to establish the prevalence of incidental findings among trauma patients. Discharge summaries were also examined for follow-up instructions to determine the effectiveness of communication of the significant findings. Between the 555 pan-CT scans (1759 total scans), 1706 incidental findings were identified with an incidence of 3.1 incidental findings per patient and with the highest concentration of findings occurring in the abdomen/pelvis. The majority of findings were benign including simple renal cysts with a prevalence of 7.7 per cent. However, 282 significant findings were identified that were concerning for possible malignancy or those requiring further evaluation, the most common of which were lung nodules, which accounted for 21.6 per cent of significant findings. However, only 32.6 per cent of significant findings were documented as reported to the patient. With the use of pan scans on trauma patients, many incidental findings have been identified to the benefit of the patient. The majority of these are clinically insignificant; however, only 32.6 per cent of potentially significant findings were communicated to the patient. The advantage of early detection comes from proper communication and this study demonstrates that there could be improvement in conveying findings to the patient.

Do postoperative antibiotics prevent abscess formation in complicated appendicitis?

Recent studies have shown that postoperative antibiotics in nonperforated appendicitis do not reduce infectious complications; however, there is no consensus on patients with complicated appendicitis. The aim of this study is to determine whether postoperative antibiotic administration in complicated appendicitis prevents intra-abdominal abscess formation. We conducted a retrospective chart review of all patients undergoing appendectomy from 2007 to 2012 at our institution. Patients with complicated appendicitis (perforated, gangrenous, or periappendiceal abscess) were identified and data collected including details of postoperative antibiotic administration and rates of postoperative abscess development. Of 444 charts reviewed, 52 patients were included. Forty-four patients received greater than 24 hours and eight patients received 24 hours or less of postoperative antibiotics. In those receiving greater than 24 hours of antibiotics, nine of 44 (20.5%) developed a postoperative abscess, and in those receiving 24 hours or less of antibiotics, two of eight (25.0%) developed a postoperative abscess (P = 1.0000). There is no significant difference in postoperative abscess development among those with complicated appendicitis who received greater than 24 hours of postoperative antibiotics compared with those who did not. Postoperative antibiotics may not provide an appreciable clinical benefit for preventing intra-abdominal abscesses; however, larger sample sizes and prospective studies are needed to confirm these findings.

Do Postoperative Antibiotics Prevent Abscess Formation in Complicated Appendicitis?

Recent studies have shown that postoperative antibiotics in nonperforated appendicitis do not reduce infectious complications; however, there is no consensus on patients with complicated appendicitis. The aim of this study is to determine whether postoperative antibiotic administration in complicated appendicitis prevents intra-abdominal abscess formation. We conducted a retrospective chart review of all patients undergoing appendectomy from 2007 to 2012 at our institution. Patients with complicated appendicitis (perforated, gangrenous, or periappendiceal abscess) were identified and data collected including details of postoperative antibiotic administration and rates of postoperative abscess development. Of 444 charts reviewed, 52 patients were included. Forty-four patients received greater than 24 hours and eight patients received 24 hours or less of postoperative antibiotics. In those receiving greater than 24 hours of antibiotics, nine of 44 (20.5%) developed a postoperative abscess, and in those receiving 24 hours or less of antibiotics, two of eight (25.0%) developed a postoperative abscess ( P = 1.0000). There is no significant difference in postoperative abscess development among those with complicated appendicitis who received greater than 24 hours of postoperative antibiotics compared with those who did not. Postoperative antibiotics may not provide an appreciable clinical benefit for preventing intra-abdominal abscesses; however, larger sample sizes and prospective studies are needed to confirm these findings.

The Trauma Pan Scan: What Else Do you Find?

The objective of this study was to investigate the prevalence of incidental findings in pan-computed tomography (CT) scans of trauma patients and the communication of significant findings requiring follow-up to the patient. A retrospective chart review of adult trauma patients was performed during the period of January 1, 2011, to August 31, 2011. During that period, 990 patient charts were examined and 555 charts were selected based on the inclusion criteria of a pan-CT scan including the head, neck, abdomen/pelvis, and chest. Patient demographics such as age, gender, mechanism of injury, and Injury Severity Score were collected. Nontraumatic incidental findings were analyzed to establish the prevalence of incidental findings among trauma patients. Discharge summaries were also examined for follow-up instructions to determine the effectiveness of communication of the significant findings. Between the 555 pan-CT scans (1759 total scans), 1706 incidental findings were identified with an incidence of 3.1 incidental findings per patient and with the highest concentration of findings occurring in the abdomen/pelvis. The majority of findings were benign including simple renal cysts with a prevalence of 7.7 per cent. However, 282 significant findings were identified that were concerning for possible malignancy or those requiring further evaluation, the most common of which were lung nodules, which accounted for 21.6 per cent of significant findings. However, only 32.6 per cent of significant findings were documented as reported to the patient. With the use of pan scans on trauma patients, many incidental findings have been identified to the benefit of the patient. The majority of these are clinically insignificant; however, only 32.6 per cent of potentially significant findings were communicated to the patient. The advantage of early detection comes from proper communication and this study demonstrates that there could be improvement in conveying findings to the patient.

Basic ultrasound training can replace chest radiography for safe tube thoracostomy removal

An ultrasound (US) examination can be easily and rapidly performed at the bedside to aide in clinical decisions. Previously we demonstrated that US was safe and as effective as a chest x-ray (CXR) for removal of tube thoracostomy (TT) when performed by experienced sonographers. This study sought to examine if US was as safe and accurate for the evaluation of pneumothorax (PTX) associated with TT removal after basic US training. Patients included had TT managed by the surgical team between October 2012 and May 2013. Bedside US was performed by a variety of members of the trauma team before and after removal. All residents received, at minimum, a 1-hour formal training class in the use of ultrasound. Data were collected from the electronic medical records. We evaluated 61 TTs in 61 patients during the study period. Exclusion of 12 tubes occurred secondary to having incomplete imaging, charting, or death before having TT removed. Of the 49 remaining TT, all were managed with US imaging. Average age of the patients was 40 years and 30 (61%) were male. TT was placed for PTX in 37 (76%), hemothorax in seven (14%), hemopneumothorax in four (8%), or a pleural effusion in one (2%). Two post pull PTXs were correctly identified by residents using US. This was confirmed on CXR with appropriate changes made. US was able to successfully predict the safe TT removal and patient discharge at all residency levels after receiving a basic US training program.

Withdrawal of care in a trauma intensive care unit: the impact on mortality rate

Withdrawal of care has increased in recent years as the population older than 65 years of age has increased. We sought to investigate the impact of this decision on our mortality rate. We retrospectively reviewed a prospectively collected database to determine the percentage of cases in which care was actively withdrawn. Neurologic injury as the cause for withdrawal, age of the patient, number of days to death, number of cases thought to be treatment failures, and the reason for failure were analyzed. Between January 2008 and December 2012, there were 536 trauma service deaths; 158 (29.5%) had care withdrawn. These patients were 67 (± 18.5) years old and neurologic injury was responsible in 63 per cent (± 5.29%). Fifty-two per cent of the patients died by Day 3; 65 per cent by Day 5; and 74 per cent Day 7. A total of 22.7 per cent (± 7.9%) could be considered a treatment failure. Accounting for cases in which care was withdrawn for futility would decrease the overall mortality rate by approximately 23 per cent. Trauma center mortality calculation does not account for care withdrawn. Treating an active, aging population, with advance directives, requires methodologies that account for such decision-making when determining mortality rates.

Transitioning to thoracic endovascular repair: a single institution's analysis of the management of blunt aortic injury

Over the past 15 years, there has been a rapid transformation in the way blunt aortic injuries (BAIs) are managed shifting from open thoracotomies to thoracic endovascular repairs (TEVAR). As a result of this change, we sought to describe our experience with open and endovascular repairs through a retrospective analysis of all trauma patients admitted with BAI to our Level I trauma center from 2002 to 2011. Demographic data, type of repair, complications, length of stay (LOS) data, and mortality were identified. No difference was noted in age, sex, Injury Severity Score, or Glasgow Coma Scale score between the two groups. There were also no differences in the number of acute complications or mortality. Intensive care unit (ICU) LOS was significantly shorter in the TEVAR group (20 vs 9 days, P < 0.05). Additionally, there was a trend toward shorter hospital LOS (28 vs 18 days, P = 0.07) and ventilator length of stay (12 vs 5 days, P = 0.171). In summary, endovascular repair of BAI is safe and has no increased rate of acute complications or mortality. ICU LOS is much shorter with TEVAR, and there was a trend toward shorter ventilator and hospital LOS, all of which may result in decreased cost. Still, more needs to be learned about potential long-term complications.

Mass Casualty Triage: An Evaluation of the Science and Refinement of a National Guideline

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

(Disaster Med Public Health Preparedness. 2011;5:129-137)

Ventilator-Associated Pneumonia: Depends on Your Definition

Reduction of hospital-acquired infections is a patient safety goal and regularly monitored by Performance Improvement committees. There is discordance between the ventilator-associated pneumonia (VAP) rate reported by the Infection Control Committee (ICC) and that observed by our Trauma Service. To investigate this difference, a retrospective evaluation of cases of VAP diagnosed on a single service was undertaken. A prospectively collected database was queried for VAP in intensive care unit patients between January 2010 and June 2011. This was compared with the list of mechanically ventilated patients provided by the ICC. Comparison for criteria used to diagnose pneumonia, ventilator day of the diagnosis, was recorded. The ICC identified two VAPs from 136 potential patients compared with the Trauma Service identifying 36 VAPs. A difference in diagnostic criteria between the ICC and the Trauma Service focused on use of the National Nosocomial Infection Survey (NNIS) algorithm versus quantitative microbiology from bronchoalveolar lavage specimens. Thirty-five of 36 Trauma Service VAPs were not identified as VAPs by the NNIS algorithm as a result of the chest radiographs. Application of differing definitions of VAP results in markedly different VAP rates. The difference has significant implications as infection rates are increasingly reported as a quality metric.

Ventilator-associated pneumonia: depends on your definition

Reduction of hospital-acquired infections is a patient safety goal and regularly monitored by Performance Improvement committees. There is discordance between the ventilator-associated pneumonia (VAP) rate reported by the Infection Control Committee (ICC) and that observed by our Trauma Service. To investigate this difference, a retrospective evaluation of cases of VAP diagnosed on a single service was undertaken. A prospectively collected database was queried for VAP in intensive care unit patients between January 2010 and June 2011. This was compared with the list of mechanically ventilated patients provided by the ICC. Comparison for criteria used to diagnose pneumonia, ventilator day of the diagnosis, was recorded. The ICC identified two VAPs from 136 potential patients compared with the Trauma Service identifying 36 VAPs. A difference in diagnostic criteria between the ICC and the Trauma Service focused on use of the National Nosocomial Infection Survey (NNIS) algorithm versus quantitative microbiology from bronchoalveolar lavage specimens. Thirty-five of 36 Trauma Service VAPs were not identified as VAPs by the NNIS algorithm as a result of the chest radiographs. Application of differing definitions of VAP results in markedly different VAP rates. The difference has significant implications as infection rates are increasingly reported as a quality metric.

Screening Human Immunodeficiency Virus-Positive Men for Anal Intraepithelial Neoplasia

Squamous cell carcinoma of the anus is rare, but more common in men with human immunodeficiency virus (HIV). We describe our findings in 50 biopsies done on 37 HIV-positive men over 5 years. The men were referred from our HIV clinic for abnormal cytology on anal pap or anal condyloma. Thirty-seven patients were referred from the HIV clinic for abnormal cytology on anal pap or the presence of anal condyloma. Biopsies were done in the operating room using acetic acid to visually localize areas of dysplasia. If no abnormalities were seen, biopsies were taken from each quadrant of the anus. A retrospective review was done for biopsy indication, pathology, recurrence, and correlation with anal pap results. On initial biopsy, anal condyloma conferred the presence of anal intraepithelial neoplasia (AIN) in 64.7 per cent (11 of 17), abnormal paps in 83.3 per cent (10 of 12), and both in 50 per cent (3 of 6). Patients with anal condyloma had AIN in an average of 2.5 quadrants whereas those with abnormal cytology had AIN in 2.3 quadrants. Thirty-four of 50 biopsies showed abnormalities (68%), with AIN present in 32 cases, one case of carcinoma in situ, and one case of invasive carcinoma. Aldara was used nine times with improvement in four cases. In HIV-positive men, the presence of condyloma warrants surgical biopsy. Performing anal cytology on patients with anal condyloma did not increase the rate of positive results. Patients with AIN often had disease in more than two quadrants, making surgical excision problematic.

Screening human immunodeficiency virus-positive men for anal intraepithelial neoplasia

Squamous cell carcinoma of the anus is rare, but more common in men with human immunodeficiency virus (HIV). We describe our findings in 50 biopsies done on 37 HIV-positive men over 5 years. The men were referred from our HIV clinic for abnormal cytology on anal pap or anal condyloma. Thirty-seven patients were referred from the HIV clinic for abnormal cytology on anal pap or the presence of anal condyloma. Biopsies were done in the operating room using acetic acid to visually localize areas of dysplasia. If no abnormalities were seen, biopsies were taken from each quadrant of the anus. A retrospective review was done for biopsy indication, pathology, recurrence, and correlation with anal pap results. On initial biopsy, anal condyloma conferred the presence of anal intraepithelial neoplasia (AIN) in 64.7 per cent (11 of 17), abnormal paps in 83.3 per cent (10 of 12), and both in 50 per cent (3 of 6). Patients with anal condyloma had AIN in an average of 2.5 quadrants whereas those with abnormal cytology had AIN in 2.3 quadrants. Thirty-four of 50 biopsies showed abnormalities (68%), with AIN present in 32 cases, one case of carcinoma in situ, and one case of invasive carcinoma. Aldara was used nine times with improvement in four cases. In HIV-positive men, the presence of condyloma warrants surgical biopsy. Performing anal cytology on patients with anal condyloma did not increase the rate of positive results. Patients with AIN often had disease in more than two quadrants, making surgical excision problematic.

MRI as an adjunct to cervical spine clearance: a utility analysis

Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.

MRI as an Adjunct to Cervical Spine Clearance: A Utility Analysis

Cervical spine (CS) injury occurs in 1 to 3 per cent of blunt trauma patients. The goal of this study is to evaluate the use of magnetic resonance imaging (MRI) as an adjunct to CS computed tomography (CT) in the presence of persistent pain with a normal physical examination or obtundation. A retrospective chart review was performed on 389 blunt trauma patients undergoing both CS CT and MRI between 2007 and 2010. Abnormal CT findings were found in 199. The remaining 190 patients with normal CT scans underwent MRI for persistent pain (109), neurologic symptoms (57), or obtundation (24). Motor vehicle crashes predominated (50%) followed by falls (19%) and motorcycle crashes (12%). In the patients with persistent pain, CT showed no acute injury (89%) with subsequent MRI demonstrating ligamentous edema or injury not seen on CT in 12 per cent of patients. No patient required an operation for CS instability. All the obtunded patients demonstrated localizing motion of four extremities. MRI of these patients demonstrated ligamentous edema or injury not seen on CT in 20 per cent of patients. No obtunded patient had CS instability or needed operative intervention. A localizing physical examination in conjunction with normal CS CT safely precludes a CS injury requiring cervical fixation. MRI does not add substantially to this decision-making and the cervical collar can be safely removed.

Cervical spinal cord injury associated with near-drowning does not increase pneumonia risk or mortality

Body surfing accidents (BSA) can cause cervical spinal cord injuries (CSCIs) that are associated with near-drowning (ND). The submersion injury from a ND can result in aspiration and predispose to pulmonary complications. We predicted a worse outcome (particularly the development of pneumonia) in patients with CSCIs associated with ND. A retrospective review was performed of patients who were treated at Eastern Virginia Medical School for a CSCI resulting from a blunt mechanism. Data collected included basic demographic data, data regarding injury and in-hospital outcomes, and discharge data, including discharge disposition. Statistics were performed using χ(2) and Student t test. In 2003 to 2008, 141 patients were treated for CSCIs with inclusion criteria. Thirty patients (21%) had an associated ND (BSA) and 111 patients (79%) did not (BLT). The cohorts were similar in mean age (BSA, 45 years; BLT, 50 years; P = 0.16) and male gender distribution (BSA, 93%; BLT, 79%; P = 0.13). The cohorts were similar in injury severity using Injury Severity Score (BSA, 22; BLT, 24; P = 0.65). The cohorts were similar in rates of developing pneumonia (BSA, 3%; BLT, 12%; P = 0.31). The rate of infection was significantly higher in the cohort without an associated near-drowning (BSA, 10%; BLT, 32%; P = 0.033). The mean intensive care unit stay (BSA, 3.5 days; BLT, 11.3 days; P = 0.057) and the rate of mortality were similar (BSA, 10%; BLT, 10% P = 0.99). Those patients with an associated ND had a shorter hospital stay (BSA, 5.7 days; BLT, 22.2 days; P = 0.007) and a better chance of being discharged home (BSA, 57%; BLT, 27%; P = 0.004). CSCIs after a BSA do better than their counterparts without an associated ND. CSCIs associated with ND appear to be isolated injuries with minimal pulmonary involvement despite submersion injuries.

Cervical Spinal Cord Injury Associated with Near-Drowning Does Not Increase Pneumonia Risk or Mortality

Body surfing accidents (BSA) can cause cervical spinal cord injuries (CSCIs) that are associated with near-drowning (ND). The submersion injury from a ND can result in aspiration and predispose to pulmonary complications. We predicted a worse outcome (particularly the development of pneumonia) in patients with CSCIs associated with ND. A retrospective review was performed of patients who were treated at Eastern Virginia Medical School for a CSCI resulting from a blunt mechanism. Data collected included basic demographic data, data regarding injury and in-hospital outcomes, and discharge data, including discharge disposition. Statistics were performed using χ2 and Student t test. In 2003 to 2008, 141 patients were treated for CSCIs with inclusion criteria. Thirty patients (21%) had an associated ND (BSA) and 111 patients (79%) did not (BLT). The cohorts were similar in mean age (BSA, 45 years; BLT, 50 years; P = 0.16) and male gender distribution (BSA, 93%; BLT, 79%; P = 0.13). The cohorts were similar in injury severity using Injury Severity Score (BSA, 22; BLT, 24; P = 0.65). The cohorts were similar in rates of developing pneumonia (BSA, 3%; BLT, 12%; P = 0.31). The rate of infection was significantly higher in the cohort without an associated near-drowning (BSA, 10%; BLT, 32%; P = 0.033). The mean intensive care unit stay (BSA, 3.5 days; BLT, 11.3 days; P = 0.057) and the rate of mortality were similar (BSA, 10%; BLT, 10% P = 0.99). Those patients with an associated ND had a shorter hospital stay (BSA, 5.7 days; BLT, 22.2 days; P = 0.007) and a better chance of being discharged home (BSA, 57%; BLT, 27%; P = 0.004). CSCIs after a BSA do better than their counterparts without an associated ND. CSCIs associated with ND appear to be isolated injuries with minimal pulmonary involvement despite submersion injuries.

The Incidence of Benign and Malignant Neoplasia Presenting as Acute Appendicitis

Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.

The incidence of benign and malignant neoplasia presenting as acute appendicitis

Acute appendicitis remains the most common surgical emergency encountered by the general surgeon. It is most often secondary to lymphoid hyperplasia, however it can also result from obstruction of the appendiceal lumen by a mass. We sought to review our experience with neoplasia presenting as appendicitis. We retrospectively reviewed all patients admitted with the diagnosis of appendicitis to our Acute Care Surgery Service from July 1, 2007 to June 30, 2009. Patient demographics, duration of symptoms, lab findings, computed tomography findings, and pathology were all analyzed. Over the 2-year period, 141 patients underwent urgent appendectomy. Ten patients (7.1%) were diagnosed with neoplasia on final pathology, including four women and six men with a mean age of 46.9 years and mean duration of symptoms of 12.6 days. Final pathology revealed four colonic adenocarcinoma; three mucinous tumors; one carcinoid; one endometrioma; and one patient had a combination of a mucinous cystadenoma, a carcinoid tumor, and endometriosis of the appendix. Six patients had concurrent appendicitis. Colonic and appendiceal neoplasia are not unusual etiologies of appendicitis. These patients tend to present at an older age and with longer duration of symptoms.

Initial implementation of an acute care surgery model: implications for timeliness of care

BACKGROUND

In July 2007, we introduced an acute care surgery service to an academic department of surgery staffed in a prearranged, dedicated rotation by critical care-trained surgeons to address all emergency department, inpatient, and transfer consultations. This study is designed to evaluate the impact on patient care and describe the case-mix experienced.

STUDY DESIGN

A retrospective review was done of a prospectively collected database encompassing all patients evaluated. Diagnosis, operations performed, and times of operations were recorded.

RESULTS

Eight hundred sixty-one patients were evaluated. Four hundred ten patients (47.6%) had 500 operations; 368 (72.8%) were performed in the operating room and 132 (26.2%) at the bedside. Respiratory failure and malnutrition (n = 130), soft-tissue infection (n = 115), abdominal pain (n = 97), biliary (n = 94), bowel obstruction (n = 78), diseases of the colon (n = 49), and appendicitis (n = 46) were the most common diseases seen. The most common operations performed included incision and drainage (n = 61); tracheostomy or percutaneous gastrostomy, or both (n = 125); cholecystectomy (n = 53); appendectomy (n = 41); colectomy (n = 34); and complex abdominal wound care (n = 43). In the year before implementation, 55.4% of emergent procedures were performed between 7:30 am and 5:30 pm, compared with 70% after implementation (p = 0.0002). Procedures performed after 5:30 pm decreased from 44.6% to 30%.

CONCLUSIONS

Implementation of an acute care surgery service has been positive in terms of facilitating the ability to provide more timely care by increasingly using the daytime operating room and providing a breadth of consultative and operative experience to the participating academic surgeons and trainees.

Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a longterm performance-improvement project

BACKGROUND

Ventilator-associated pneumonia (VAP) remains a major source of morbidity, mortality, and expense in the ICU despite therapies directed against it.

STUDY DESIGN

A retrospective review of a prospectively developed performance-improvement project monitoring the incidence of VAP in two adjacent ICUs was conducted. In response to an excessive VAP rate, weekly multidisciplinary team meetings were instituted to review data, develop care protocols, and modify care routines. Protocol compliance was monitored daily and feedback provided weekly to the care teams. VAP rates were determined by the institutional Infection Control Committee and reviewed monthly with the ICU multidisciplinary team. Duration of the investigational period was 10 years.

RESULTS

A standardized ventilator-weaning protocol was instituted with confirmed 95% use. Additional modifications of care, such as patient positioning, use of specific endotracheal tubes to minimize aspiration of supraglottic secretions, an oral-care regimen, and aggressive antibiotic stewardship were standardized, with a compliance rate >90%. VAP rates dropped from 12.8 per 1,000 patient-days in 1998 to 1.1 in 2007 in the burn trauma ICU and from 21.2 to <1 in the neurotrauma ICU in the same time frame. Also, mean ventilator length of stay decreased from 6 days to 4.2 and from 5.8 days to 4.75 simultaneously in the respective ICUs. Such performance improvement has been sustained since implementation of the program.

CONCLUSION

A systematic, monitored program of standardized care protocols can markedly reduce VAP rate in the ICU.

The cuff leak test is not predictive of successful extubation

In intubated patients the presence of a cuff leak (CL) is used as a predictor of successful extubation. CL is proposed to indicate laryngeal edema and predict which patients may develop complications such as postextubation stridor and eventual reintubation. Our objective was to evaluate the reliability of CL in our population of critically ill trauma patients. A retrospective chart review was performed of patients admitted to the trauma service who required mechanical ventilation. All patients undergo the CL test by a single respiratory therapist team before attempted extubation. Data collected included body mass index (BMI), endotracheal tube (ETT) size, length of time of mechanical ventilation, tidal volumes (Vt), and the size of the patient's trachea based on CT scan. The test is performed by the respiratory therapists and involves measuring expired Vt before and after the ETT cuff has been deflated and listening for an audible leak. A positive test result is defined as a CL greater than 10 per cent of Vt or, when volumes are not available, as audible air expired. From October 2005 to May 2006, 150 mechanically ventilated patients were identified and 49 charts were available for review. Forty-one patients had a cuff leak (+CL), whereas eight did not (-CL). The two cohorts were similar in age (+CL = 36.5 years, -CL = 38.1 years, P = 0.82), male gender (+CL = 70%, -CL = 50%, P = 0.25) ETT size (+CL = 7.4, -CL = 7.4, P = 0.57), and BMI (+CL = 28 kg/m2, -CL = 27 kg/m2, P = 0.71). The average tracheal diameter (+CL = 17.4 mm, -CL = 17.5 mm, P = 0.90) as well as the ratio of ETT and tracheal diameter was similar for the two cohorts (+CL = 0.65, -CL = 0.64, P = 0.73). Four patients (10%) in the +CL cohort failed extubation, whereas none of the -CL cohort failed (0%) (P = 0.40). The CL test does not reliably identify those patients who will require reintubation in our trauma population. In addition, the ratio of ETT and tracheal diameter is not predictive of successful extubation.

Insulin requirements in the intensive care unit in response to infection

Infectious complications in the intensive care unit (ICU) are classically identified when an elevated temperature triggers obtaining cultures. Elevated temperature, however, is a nonspecific marker of infection and may occur well into the course of the infection. The goal of this study was to evaluate whether escalating insulin demands may serve as an earlier marker for infection. A retrospective review of a prospective database from a trauma ICU over a 6-month period was done for all patients who developed infection while in the ICU. All patients in the ICU are placed at admission on an intensive insulin protocol with target blood glucose levels between 80 and 110 mg/dL. Data were collected on infection, insulin needs, blood glucose levels, temperature, white blood cell count, and antibiotic use. Twenty-four infections were identified, with 16 pneumonias, four bloodstream infections, and four urinary tract infections. Twelve of the 24 patients had increasing insulin needs in the 3 days preceding their infection diagnosis, with nine of the 12 requiring continued escalation of insulin needs from preinfection Day 3 to 2 to 1 (D3, D2, D1). In five of the 12 patients, the escalation of insulin dose preceded the elevated temperature, and in three of the 12 patients, the escalation preceded elevation of the white blood cell count above 12. For all 24 patients, the average insulin dose increased steadily, from 1.8 U/hr on D3 preinfection to 2.5 U/hr D2 and 3.1 U/hr D1. Infection does seem to be preceded by escalating insulin demands in many patients. A prospective study to evaluate the value of increased insulin demand as a marker for developing infection is warranted.

Early Glucose Normalization Does Not Improve Outcome in the Critically Ill Trauma Population

Strict control of serum glucose in critically ill patients decreases morbidity and mortality. The objective of this study was to evaluate the effect of early normalization of glucose in our burn and trauma intensive care unit. From January 2002 to June 2005, 290 patients were admitted with serum glucose 150 mg/dL or greater and 319 patients with serum glucose less than 150 mg/dL. The patients with hyperglycemia were more severely injured and more often required operative intervention within the first 48 hours. The patients with hyperglycemia were at increased risk for infection and mortality. Of those 290 patients in the hyperglycemic cohort, 125 patients had early normalization of serum glucose, whereas 165 patients required more than 24 hours to normalize. The early normalization cohort was younger in mean age than the late group, but these 2 groups were similar in injury severity. Correspondingly, there was no difference in the rate of infection. Although hyperglycemia on admission appears to correlate with a worse outcome, early glucose normalization did not affect morbidity and mortality in our critically ill population.

Early glucose normalization does not improve outcome in the critically ill trauma population

Strict control of serum glucose in critically ill patients decreases morbidity and mortality. The objective of this study was to evaluate the effect of early normalization of glucose in our burn and trauma intensive care unit. From January 2002 to June 2005, 290 patients were admitted with serum glucose 150 mg/dL or greater and 319 patients with serum glucose less than 150 mg/dL. The patients with hyperglycemia were more severely injured and more often required operative intervention within the first 48 hours. The patients with hyperglycemia were at increased risk for infection and mortality. Of those 290 patients in the hyperglycemic cohort, 125 patients had early normalization of serum glucose, whereas 165 patients required more than 24 hours to normalize. The early normalization cohort was younger in mean age than the late group, but these 2 groups were similar in injury severity. Correspondingly, there was no difference in the rate of infection. Although hyperglycemia on admission appears to correlate with a worse outcome, early glucose normalization did not affect morbidity and mortality in our critically ill population.

Lung protective ventilation strategies: have we applied them in trauma patients at risk for acute lung injury and acute respiratory distress syndrome?

Lung protective ventilation strategies for patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are well documented, and many medical centers fail to apply these strategies in ALI/ARDS. The objective of this study was to determine if we apply these strategies in trauma patients at risk for ALI/ARDS. We undertook a retrospective review of trauma patients mechanically ventilated for > or = 4 days with an ICD-9 for traumatic pneumothorax, hemothorax, lung contusion, and/or fractured ribs admitted from May 1, 1999 through April 30, 2000 (Group 1), the pre-ARDS Network study, and from May 1, 2003 through April 30, 2004 (Group 2), the post-ARDS Network study. Tidal volume (VT)/kg admission body weight, VT/kg ideal body weight (IBW), and plateau and peak pressures were analyzed with respect to mortality. VT/Kg admission body weight and IBW were significantly reduced when comparing Group 1 with Group 2 (9.27 to 8.03 and 11.67 to 10.04, respectively). VT/kg IBW was greater (P < 0.01) for patients who died in Group 1 (13.81) compared with patients who lived (10.29) or died (9.89) in Group 2. Peak and plateau pressures were greater (P < 0.01) in patients who died in Group 1 than patients who lived or died in Group 2. A strict ARDS Network ventilation strategy (VT < 6 mL/kg) is not followed, rather a low plateau/peak pressure strategy is used, which is a form of lung protective ventilation.

Lung Protective Ventilation Strategies: Have We Applied Them in Trauma Patients at Risk for Acute Lung Injury and Acute Respiratory Distress Syndrome?

Lung protective ventilation strategies for patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are well documented, and many medical centers fail to apply these strategies in ALI/ARDS. The objective of this study was to determine if we apply these strategies in trauma patients at risk for ALI/ARDS. We undertook a retrospective review of trauma patients mechanically ventilated for ≥4 days with an ICD-9 for traumatic pneumothorax, hemothorax, lung contusion, and/or fractured ribs admitted from May 1, 1999 through April 30, 2000 (Group 1), the pre-ARDS Network study, and from May 1, 2003 through April 30, 2004 (Group 2), the post-ARDS Network study. Tidal volume (VT)/kg admission body weight, VT/kg ideal body weight (IBW), and plateau and peak pressures were analyzed with respect to mortality. VT/Kg admission body weight and IBW were significantly reduced when comparing Group 1 with Group 2 (9.27 to 8.03 and 11.67 to 10.04, respectively). VT/kg IBW was greater ( P < 0.01) for patients who died in Group 1 (13.81) compared with patients who lived (10.29) or died (9.89) in Group 2. Peak and plateau pressures were greater ( P < 0.01) in patients who died in Group 1 than patients who lived or died in Group 2. A strict ARDS Network ventilation strategy (VT < 6 mL/kg) is not followed, rather a low plateau/peak pressure strategy is used, which is a form of lung protective ventilation.

Adrenal insufficiency in hemorrhagic shock

Adrenal insufficiency during sepsis is well documented. The association between hemorrhagic shock and adrenal insufficiency is unclear and may be related to ischemia, necrosis, or resuscitation. This study was designed to determine the incidence of relative adrenal insufficiency in hemorrhagic shock. A retrospective review of a prospectively gathered database for patients admitted to the trauma intensive care unit with hemorrhagic shock was undertaken. A random serum cortisol of <25 mcg/dL defined relative adrenal insufficiency. All of the cortisol levels were drawn within the first 24 hours of admission. Data analyzed included demographics, length of stay, injury mechanism, infections, and mortality. Fifteen patients presented with hemorrhagic shock, with 14 of 15 meeting the criteria for relative adrenal insufficiency. The average serum cortisol level was 15.8 (9-26.8). The average APACHE II score was 18.3 (4-33), and the average Injury Severity Score was 22.5 (8-41). The mechanism was blunt trauma in 10 patients and penetrating trauma in 5. The average intensive care unit and hospital length of stay were 13.2 and 27.4 days, respectively. There were five urinary tract infections, four blood stream infections, and two wound infections. Two of the 15 patients died. Relative adrenal insufficiency appears to be common in hemorrhagic shock. Future research is warranted to elucidate the pathophysiology, as well as to prospectively determine which patients may benefit from steroid replacement.

Adrenal insufficiency in the critically III trauma population

Acute adrenal insufficiency has been demonstrated in a number of patients with shock. This study was designed to evaluate the rate of occult adrenal insufficiency in the critically ill trauma population and to determine the impact of hypoproteinemia on the use of random cortisol levels as a marker for adrenal insufficiency. Forty-four patients were prospectively enrolled on admission to the trauma intensive care unit, with three excluded, for a total n of 41. Random total serum cortisol and albumin levels were drawn on hospital Days 1, 4, 8, and 14. Occult adrenal insufficiency was defined as a cortisol less than 25 mcg/dL in the setting of an albumin greater than 2.5 g/dL. The prevalence of cortisol less than 25 mcg/dL ranged from 51 to 81 per cent during the study period, and peaked on Days 4 and 8. Albumin 2.5 g/dL or less ranged from 37 to 60 per cent, and this prevalence also peaked on Days 4 and 8. The patients with a low albumin had a high prevalence of low cortisol, ranging from 67 to 100 per cent. The prevalence of adrenal insufficiency, with low cortisol and normal albumin, ranged from 41 to 82 per cent during the study period. None of our patients with occult adrenal insufficiency were treated with steroids, which was a decision made by the treating physicians. Among the patients with occult adrenal insufficiency, survival was 100 per cent. Occult adrenal insufficiency is common in critically ill trauma patients, and is a dynamic entity that can be acquired and even resolved during critical illness. Random cortisol of 25 mcg/dL may actually not be an adequate marker of occult adrenal insufficiency. Low albumin predicts a low cortisol. Hemodynamically stable occult adrenal insufficiency should not be treated with steroid replacement in the critically ill trauma patient, as survival in our series was 100 per cent without replacement.

Corticosteroid use in the intensive care unit: at what cost?

HYPOTHESIS

Corticosteroid use has a significant effect on morbidity and mortality in the intensive care unit (ICU).

DESIGN

Case-control study.

SETTING

Burn-trauma ICU in a level 1 trauma center.

PATIENTS

All patients who received corticosteroids while in the ICU from January 1, 2002, to December 31, 2003 (n = 100), matched by age and Injury Severity Score with a control group (n = 100).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

We considered the following 7 outcomes: pneumonia, bloodstream infection, urinary tract infection, other infections, ICU length of stay (LOS), ventilator LOS, and mortality.

RESULTS

Cases and controls had similar APACHE II (Acute Physiology and Chronic Health Evaluation II) scores and medical history. In univariate analysis, the corticosteroid group had a significant increase in pneumonia (26% vs 12%; P<.01), bloodstream infection (19% vs 7%; P<.01), and urinary tract infection (17% vs 8%; P<.05). In multivariate models, corticosteroid use was associated with an increased rate of pneumonia (odds ratio [OR], 2.64; 95% confidence interval [CI], 1.21-5.75) and bloodstream infection (OR, 3.25; 95% CI, 1.26-8.37). There was a trend toward increased urinary tract infection (OR, 2.31; 95% CI, 0.94-5.69), other infections (OR, 2.57; 95% CI, 0.87-7.67), and mortality (OR, 1.89; 95% CI, 0.81-4.40). Patients in the ICU who received corticosteroids had a longer ICU LOS by 7 days (P<.01) and longer ventilator LOS by 5 days (P<.01).

CONCLUSIONS

Corticosteroid use is associated with increased rate of infection, increased ICU and ventilator LOS, and a trend toward increased mortality. Caution must be taken to carefully consider the indications, risks, and benefits of corticosteroids when deciding on their use.

A simulation-based training system for surgical wound debridement

A simulation-based training system for surgical wound debridement was developed and comprises a multimedia introduction, a surgical simulator (tutorial component), and an assessment component. The simulator includes two PCs, a haptic device, and mirrored display. Debridement is performed on a virtual leg model with a shallow laceration wound superimposed. Trainees are instructed to remove debris with forceps, scrub with a brush, and rinse with saline solution to maintain sterility. Research and development issues currently under investigation include tissue deformation models using mass-spring system and finite element methods; tissue cutting using a high-resolution volumetric mesh and dynamic topology; and accurate collision detection, cutting, and soft-body haptic rendering for two devices within the same haptic space.