The Benefit of Benzodiazepine Reduction: Improving Sedation in Surgical Intensive Care

Aims:

Sedation, as it is often required in critical care, is associated with immobilization, prolonged ventilation, and increased morbidity. Most sedation protocols are based on benzodiazepines. The presented study analyzes the benefit of benzodiazepine-free sedation.

Methods:

In 2008, 134 patients were treated according to a protocol using benzodiazepine and propofol (Group 1). In 2009, we introduced a new sedation strategy based on sufentanil, nonsteroidal anti-inflammatory drugs, neuroleptics, and antidepressants, which was applied in 140 consecutive patients (Group 2). Depth of sedation, duration of mechanical ventilation, duration of Intensive Care Unit, and hospital stay were analyzed.

Results:

Group 1 had both a longer duration of deep sedation (18.7 ± 2.5 days vs. 12.6 ± 1.85 days, P = 0.031) and a longer duration of controlled ventilation (311, 35 ± 32.69 vs. 143, 96 ± 20.76 h, P < 0.0001) than Group 2. Ventilator days were more frequent in Group 1 (653, 66 ± 98.37 h vs. 478, 89 ± 68.92 h, P = 0.128).

Conclusions:

The benzodiazepine-free sedation protocol has been shown to significantly reduce depth of sedation and controlled ventilation. Additional evidence is needed to ascertain reduction of ventilator days which would not only be of benefit for the patient but also for the hospital Management.

TraumaNetzwerk DGU(®): optimizing patient flow and management

PURPOSE

Caring for severely injured trauma patients is challenging for all medical professionals involved both in the preclinical and in the clinical course of treatment. While the overall quality of care in Germany is high there still are significant regional differences remaining. Reasons are geographical and infrastructural differences as well as variations in personnel and equipment of the hospitals.

METHODS

To improve state-wide trauma care the German Trauma Society (DGU) initiated the TraumaNetzwerk DGU(®) (TNW) project. The TNW is based on five major components: (a) Whitebook for the treatment of severely injured patients; (b) evidence-based guidelines for the medical care of severe injury; (c) local auditing of participating hospitals; (d) contract of interhospital cooperation; (d) TraumaRegister DGU(®) documentation.

RESULTS

By the end of 2013, 644 German Trauma Centres (TC) had successfully passed the audit. To that date 44 regional TNWs with a mean of 13.5 TCs had been established and certified. The TNWs cover approximately 90% of the country's surface. Of those hospitals, 2.3 were acknowledged as Supraregional TC, 5.4 as Regional TC and 6.7 as Lokal TC. Moreover, cross border TNW in cooperation with hospitals in The Netherlands, Luxembourg, Switzerland and Austria have been established. Preparing for the audit 66% of the hospitals implemented organizational changes (e.g. TraumaRegister DGU(®) documentation and interdisciplinary guidelines), while 60% introduced personnel and 21% structural (e.g. X-ray in the ER) changes.

CONCLUSIONS

The TraumaNetzwerk DGU(®) project combines the control of common defined standards of care for all participating hospitals (top down) and the possibility of integrating regional cooperation by forming a regional TNW (bottom up). Based on the joint approach of healthcare professionals, it is possible to structure and influence the care of severely injured patients within a nationwide trauma system.

Less invasive polyaxial locking plate fixation in periprosthetic and peri-implant fractures of the femur--a prospective study of 41 patients

BACKGROUND

A great variety of methods for the stabilisation of periprosthetic fractures around total hip (THA) or total knee arthroplasty (TKA) have been described. We present the data of our experience in combining a polyaxial, anatomical locking plate with a standardised less invasive technique in the treatment of periprosthetic and peri-implant (femoral nail) femur fractures in this prospective study.

PATIENTS AND METHODS

A consecutive series of 41 patients (33 women; age 79.8±11 years) with 41 fractures (n=17 periprosthetic THA, n=10 periprosthetic TKA, n=3 interprosthetic, n=11 perinail) was treated in a 'mini-open' (MO; direct reduction of the fracture and percutaneous plate fixation in two-part fractures; n=22) or a 'minimally invasive' (MI; indirect reduction and percutaneous fixation; n=19) technique. All patients were followed up for 12 months postoperatively.

RESULTS

The polyaxial locking mechanism allowed for the setting of a mean of 5.3 screws around an intramedullary implant. Supported by the less invasive strategy, mainly long plates (n=36; 88% were longer than 24cm) were applied without relevant soft-tissue complication. Five surgical revisions (12.1%) had to be performed. During the first postoperative stay, one seroma was evacuated and in two cases the plate broke due to failed biological healing 6 months after the MO technique. In one case, a revision prosthesis had to be implanted due to ligamentous instability, and in another case, soft-tissue balancing of the patella was performed. In the MO group, four of the five complications requiring surgical revision were seen. There was no infection. No statistical difference was seen between the MO and the MI groups for operating room (OR) time and perioperative need for transfusion. In patients with a poor state of health (n=8; immobile and Glasgow Coma Outcome Scale=3), no local complications were seen. All fractures in the peri-implant fracture group (n=11) healed uneventfully.

CONCLUSION

Periprosthetic fracture fixation can be performed as part of a standardised less invasive strategy, but the MI technique should be the preferred treatment. The NCB(®) system allows for a stable plate fixation around an intramedullary implant. With the less invasive technique, long plates can be applied with low rates of soft-tissue complication and implant failure.

Monoaxial versus polyaxial locking systems: a biomechanical analysis of different locking systems for the fixation of proximal humeral fractures

OBJECTIVE

The development of locking plate systems has led to polyaxial screws and new plate designs. This study compares monoaxial head locking screws (PHILOS© by Synthes) and a new generation of polyaxial locking screws (NCB-LE© by Zimmer) with respect to biomechanical stability.

METHODS

On nine pairs of randomised formalin fixed humerus specimens, standardised osteotomies and osteosyntheses with nine monoaxial (group A) und nine polyaxial (group B) plate/screw systems were performed. A material testing machine by Instron (M-10 14961-DE) was used for cyclic stress tests and crash tests until defined breakup criteria as endpoints were reached.

RESULTS

After axial cyclic stress 200 times at 90 N, plastic deformation was 1.02 mm in group A and 1.25 mm in group B. After the next cycle using 180 N the additional deformation averaged 0.23 mm in group A and 0.39 mm in group B. The deformation using 450 N was 0.72 mm in group A compared to 0.92 mm in group B. The final full power test resulted in a deformation average of 0.49 mm in group A and 0.63 mm in group B after 2,000 cycles using 450 N. When reaching the breakup criteria the plastic deformation of the NCB plate was 9.04 mm on average. The PHILOS plate was similarly deformed by 9.00 mm. As a result of the crash test, in group A the screws pulled out of the humeral head four times whereas the shaft broke one time and another time the implant was ripped out. The gap was closed four times. In group B, there were three cases of screw cut-through, four shaft fractures/screw avulsions from the shaft and two cases of gap closure.

CONCLUSION

The two systems resist the cyclic duration tests and the increasing force tests in a similar manner. The considerable clinical benefits of the polyaxial system are enhanced by equal biomechanical performance.

The emergency room transfusion score (ETS): prediction of blood transfusion requirement in initial resuscitation after severe trauma

The presented study was initiated to develop a scoring system for the prediction of red blood cell transfusion requirement in the early care of trauma patients. All trauma patients admitted to our institution who needed trauma team activation were evaluated during a 4-year period. A set of nine parameters with possible predictive value for the need of blood transfusion was recorded. All relevant data can be acquired during the first 10 min in the emergency room (ER). The data underwent multivariate logistic regression analysis for correlation and the calculation of predictive power. To transform the model into a practical score, we rounded all coefficients. The predictive power of the score was evaluated based on a linear regression equation. Of the 1103 patients (Injury Severity Score [ISS] 21 +/- 16) included in the study, 116 (10.5%; ISS 39 +/- 18) received blood in the ER. Early transfusion need was significantly correlated with systolic blood pressure (SBP) <90 mmHg (coefficient 2.5), SBP 90-120 mmHg (1.5), free fluid in abdominal ultrasound (2.0), clinically unstable pelvic ring fracture (1.5), age 20-60 years (0.5), age >60 years (1.5), admission from scene (1.0), traffic accident (1.0) and fall from >3 m (1.0). The probability for transfusion exponentially increased with the sum of points in the ER transfusion score, i.e. from 0.7% at one point to 5% at three points and 97% at 9.5 points maximum. To establish a practical cutoff point (risk <5%) a low-risk group was defined at <points (64% of the whole study group). The presented ER transfusion score is based on rapidly assessable parameters. The score identifies patients in need for immediate red blood cell substitution. Cost effectiveness appears to be a further advantage of the score. For patients not in need of urgent transfusion (low-risk group), the costs for transportation, cross-matching and loss by maltreatment of blood products may be avoided.

Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe

BACKGROUND

Although early fracture fixation is expedient in patients with multiple injuries, early total care (ETC) may be associated with posttraumatic systemic complications. This study was conducted to prospectively evaluate the concept of damage control by immediate external fracture fixation (damage control orthopedics [DCO]) and consecutive conversion osteosynthesis with regard to time savings, effectiveness, and safety.

METHODS

In a prospective controlled trial, a cohort of 1,070 patients with an Injury Severity Score (ISS) of 20.7 were admitted to a Level I trauma center over a 3.5-year period. Patients with an ISS > 15, survival of more than 24 hours, and without interhospital transfer were included. In all patients with major fractures requiring immediate stabilization, external fixation was performed (DCO). Conversion was executed at the earliest possible time as a one-stage procedure after stabilization of organ functions. TRISS was calculated for patients requiring DCO (DCO group) and for patients without major fractures (control group). Time spent on particular and all surgical procedures, blood loss, and complications of DCO were compared with data of consecutive conversion osteosyntheses which were considered as hypothetical ETC procedures (h-ETC) in identical patients.

RESULTS

Four hundred nine patients fulfilled the inclusion criteria. Seventy-five (ISS of 37.3) required DCO for 135 fractures, whereas 334 patients (ISS of 30.4) did not require immediate fracture fixation. Mean surgical time was 62 +/- 30 minutes (SEM, 3.5) for DCO. Because of fracture consolidation with external fixation (n = 3) and injury-related death (n = 15), conversion (h-ETC) was performed in 57 patients for 101 fractures. Duration of external fixation averaged 13.7 days (range, 3-46 days). Fifty-five patients (96.5%) required intensive care treatment and 42 patients (73.7%) required mechanical ventilation at the time of conversion. Mean operation time for conversion was 233 +/- 19 minutes (SEM, 18.7) with a value of p < 0.001. Also, blood loss was significantly (p < 0.001) different for DCO (<50 mL) and h-ETC (472 mL; SEM, 63). Pin-track infections were identified in five patients, two patients with acetabular plate osteosynthesis had deep wound infection, and one patient died related to bacterial sepsis with infections of all wound sites. Overall mortality in DCO patients was significantly lower than predicted by TRISS (20% vs. 39.3%), as it was in the 334 patients without immediate fracture fixation (29.5% vs. 24.3%).

CONCLUSION

DCO appears to provide a major reduction of operation time and blood loss in the primary treatment period in severely injured patients compared with h-ETC. In addition, we found that DCO is not associated with an increased rate of procedure-related complications. So far, DCO with early and one-stage conversion seems to be a safe strategy of primary fracture treatment in patients with multiple injuries.

Free Abdominal Fluid on Ultrasound in Unstable Pelvic Ring Fracture: Is Laparotomy Always Necessary?

BACKGROUND

In unstable pelvic ring fractures free abdominal fluid on ultrasound (US) may be caused by retroperitoneal hematoma that passes into the abdominal cavity or by an additional intraabdominal lesion. In this study a clinical pathway for the therapy of potentially combined lesions was analyzed.

PATIENTS AND METHODS

All patients treated in the ED for severe trauma underwent basic sonographical and radiologic diagnostics within 15 minutes. of admission. Data were prospectively documented. According to the treatment protocol unstable pelvic ring fractures with initial free fluid on US received laparotomy. Patients with stable vital conditions had abdominal CT-Scan before surgery.

RESULTS

1472 consecutive severely injured patients (ISS 20, age: 39 years) were included. Eighty subjects had sustained type B (47) or C (33) pelvic ring fracture. Early free abdominal fluid on US was absent in 49 cases. Three patients in this group required celiotomy later on, during ICU treatment. In 31 patients free fluid was present. All of them had laparotomy. Only one patient showed retroperitoneal hematoma alone, while all others had one or more significant lesions (rupture) that required surgical repair. Simultaneously with laparotomy pelvic stabilization was performed by external (19) or internal (6) fixation. In all cases with massive pelvic hemorrhage and free fluid in US bleeding was controlled by internal tamponade and external fixation.

CONCLUSION

The finding of intraperitoneal fluid on US in the emergency department strongly correlates with significant intraabdominal lesions requiring surgical intervention. Early laparotomy appears indicated in these cases. Shock control in pelvic bleeding can be sufficiently achieved by internal tamponade and external fixation.

A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers

OBJECTIVE

The impact of a multidisciplinary quality management system (MQMS) on the early treatment of severely injured patients was tested.

DESIGN AND SETTING

Prospective clinical study in two level 1 trauma centers.

METHODS AND MATERIALS

MQMS comprised a protocol for documentation, 20 assessment criteria, and the judgement of data by a quality circle. After implementation in Munich (1st period, n=90; 2nd period, n=77) the validation took place in Essen (1st period, n=175; 2nd period, n=150).

RESULTS

Improvements in diagnostics were shown by significant time savings in radiological diagnostics and before computed tomography in severe traumatic brain injury. In patients with hemorrhagic shock there was a reduction in time before transfusion (49 to 14 min in Munich; 31 to 22 min in Essen) and before emergency operation (74 to 43 min in Munich; 69 to 45 min in Essen). The time before craniotomy was reduced from 97 to 67 min in Munich. The incidence of delayed diagnosis of life-threatening lesions was diminished from 6% to 3% in Munich (not found in Essen). The TRISS technique showed a reduction in mortality in both hospitals in the second period (Munich: 15.4% TRISS vs. 9.1% observed mortality; Essen: 17.8% vs. 11.3%).

CONCLUSIONS

MQMS improved early clinical treatment in severe injury with respect to therapeutic effectiveness and outcome. The effectiveness of the MQMS was shown at two different hospitals

Prehospital intubation in severe thoracic trauma without respiratory insufficiency: a matched-pair analysis based on the Trauma Registry of the German Trauma Society

OBJECTIVE

On the basis of the data of a multicenter study, the impact of prehospital intubation and ventilation in the therapy of severe thoracic trauma without manifest respiratory insufficiency was analyzed.

METHODS

Data were collected prospectively in the Trauma Registry of the German Trauma Society. In a matched-pair analysis, patients with severe thoracic trauma (Abbreviated Injury Scale score of 4) with and without prehospital intubation were compared. Patients were paired with respect to age, injury severity, and prognosis (according to the TRISS method).

RESULTS

From a total of 3,814 patients, two groups (with/without prehospital intubation) of 44 matched patients each with comparable average age (36 vs. 36 years), Injury Severity Score (29 vs. 29), and TRISS (95.2 vs. 95.3) were identified. No patient was unconscious at the scene (all Glasgow Coma Scale scores > or = 8) or presented with severe respiratory insufficiency (all > or = 10 breaths/min). Time between injury and hospital admission was significantly longer (73 minutes; p < 0.05) in the group with prehospital intubation compared with the nonintubated group (47 minutes). Furthermore, fluid requirements in the prehospital period were significantly higher in the intubated patients (3,000 mL vs. 1,000 mL). In the prehospital intubation group, the number of patients with mass transfusion (9 vs. 4) as well as with emergency operations (10 vs. 4) were not significantly different from the nonintubated group. The prehospital intubation group showed a similar incidence of lung failure (17 vs. 14), kidney failure (6 vs. 2), and circulation failure (13 vs. 5). Except for two of the primarily nonintubated patients, all were intubated during their stay in the emergency room or on the intensive care unit. Days of ventilation (median, 7 days) as well as the length of stay on the ICU (median, 11 days) were comparable in both groups. Mortality in the prehospital intubation group was not significantly different between groups (six vs. two deceased).

CONCLUSION

Prognosis with respect to organ failure, treatment time, and mortality is not adversely affected in the German trauma system, if patients with severe thoracic trauma without manifest respiratory insufficiency and without other indications for intubation are not treated with prehospital intubation.

Long-term results and quality of life after parasuicidal multiple blunt trauma

OBJECTIVE

This study evaluates the somatic, socioeconomic, and psychiatric long-term results, as well as the factors for adverse outcome, in a significant subset of patients with severe multiple injuries resulting from attempted suicide.

DESIGN

The follow-up study 6.1 +/- 3 (SD) yrs after trauma was based on prospectively documented data of patients with multiple injuries.

SETTING

Level I university trauma center in a major German city.

MEASUREMENTS AND MAIN RESULTS

Data derived from thorough physical and psychiatric evaluations. The Brief Psychiatric Rating Scale and the Global Assessment of Functioning Scale served to describe psychiatric outcome.

PATIENTS

In a series of 539 severely injured patients (Abbreviated Injury Score in two regions > or = 3), 65 (12%) attempted suicides were reported (Injury Severity Score, 40 +/- 15; age, 38 +/- 18 yrs). Twenty-one patients of the study cohort died during the hospital stay, and six subjects died thereafter, none because of suicide. Three patients were lost to follow-up, resulting in 35 individuals eligible for examination. None of the latter had reattempted suicide. Seventeen (48%) had good or satisfactory outcomes reflected by absent or ambulatory psychiatric treatment, employment, normal psychiatric findings (Brief Psychiatric Rating Scale), and good psychosocial ability (Global Assessment of Functioning Scale). For eight patients (24%), the result was indeterminate. The adverse outcomes in ten patients (28%) were mainly influenced by the presence of chronic schizophrenia (n = 4), affective disorder (n = 2), or severe traumatic brain injury (n = 3).

CONCLUSIONS

Despite the parasuicidal origin, the long-term results after severe trauma were good or satisfactory in approximately half the cases and without further suicide attempts in any of the patients. Good recovery of the parasuicidal patients in our study is approximately 20% lower than in an unselected group of patients with multiple injuries and may be attributed mainly to the underlying chronic psychiatric disease.

Nonsurgical treatment of a severe tracheal rupture after endotracheal intubation

OBJECTIVE

We report the case of an 82-yr-old woman with a large complete longitudinal tracheal rupture, following endotracheal intubation. The patient was treated nonoperatively with excellent outcome. The diagnostic and therapeutic course as well as other therapeutic options are discussed.

[Shock room management in severe craniocerebral trauma]

Early clinical management of severe head injury should take place in an emergency resuscitation room and be conducted according to the guidelines of the treatment of severely injured patients with attention given to time. The first phase (with a maximum duration of 30 min) comprises physical examination, stabilisation of vital functions and basic technical diagnostics. With pulmonary and circulatory functions stabilized, the second phase begins with a craniol computed tomography examination followed by adequate therapeutic measures, including, if necessary, the CT-controlled implantation of an intracranial pressure catheter.

Improvement in the therapy of multiply injured patients by introduction of clinical management guidelines

A trauma algorithm representing the guidelines for the management of emergency treatment of severe blunt trauma was implemented at our institution in 1994. By comparison of two prospectively recorded cohorts of multiply injured patients, the clinical efficacy of these guidelines was analysed. The algorithm cohort comprised 74 patients over the period January 1994 to June 1996, and the Control cohort 126 patients over the period April 1988 to December 1993. To evaluate procedural quality of early clinical trauma management, nine criteria were applied. After implementation of the algorithm there was an improvement in all parameters reflected by a significant reduction of missed injuries and important time savings. Mortality rates in the cohorts were calculated after subdivision into three groups (I-III) with moderate (ISS: 18-24), high (ISS: 25-49) and very high (ISS: 50-75) injury severity. All cohort subgroups were comparable with respect to ISS values, age, initial loss of consciousness (GCS) and shock rate. In all subgroups of the algorithm cohort mortality rates were reduced: group I: 0 versus 20 per cent (p < 0.05); group II: 8 versus 24 per cent (p < 0.05); group III: 40 versus 71 per cent. Improvements in both therapeutic process and outcome were observed after implementation of the trauma algorithm.

[Long-term outcome of the donor site after free, microvascular pedicled iliac crest transplantation: experiences with 95 cases]

Using the anterior iliac crest as donor-site for free osseous, osseomuscular, and osseomyocutaneous flaps has proven itself an important reconstructive instrument both in maxillofacial and in orthopaedic surgery. We present a long-term retrospective evaluation of the donor-site situation after vascularized free anterior iliac crest transfer. The study is based in 95 cases from the years 1985 to 1993 including 11 cases from Switzerland (Kantonsspital Aarau). The patients were examined, looking for objective complications and asked questions about their subjective symptoms at the donor site. These objective and subjective results were then correlated. Herniation developed in 3% of cases, loss of sensibility in the region of the N. cutaneous femoris lateralis occurred in 9.5% and was in 6% reversible. Scars were in 7% aesthetically not satisfying with no keloids or hypertrophic scarring after all wounds healed per primam intentionem. Mostly minor alteration of the outer surface of the donor site was notable in 20 to 25% of the patients. Pain was a problem for an average of 7% of cases. Impairment in private life was named in 3.5%, in professional life in 4.7%, and in daily life in 11.9% of cases. Not content with the donor-site situation were 13.5%, not content with the preoperative information were 12% of the patients. Nonetheless were 98.8% of the patients willing to, if necessary, undergo the same operation again. Surprisingly, there is a negative correlation between objective and subjective results: Merely 25% of the patients with sensibility loss were not content with the donor-site result of the operation and vice versa only 1% of the dissatisfied patients had objectively measurable minor complications.

[Cost analysis of clinical treatment of polytrauma patients]

In order to assess the costs arising from the treatment of polytraumatized patients we analysed the data of 100 prospectively studied multiple trauma patients (ISS 38) calculating all medical expenses during their clinical stay. The average cost per patient in the studied group (n = 100) amounted to 63989.- DM. About 65% of this sum derived from the costs of intensive care, while the expenses for operations covered 19%. The group of primarily deceased patients (n = 25) generated the lowest costs of 8468.- DM (per pat.). The highest costs of 95626.- DM were caused by the treatment of patients (n = 32) that developed one or more complications (organ failure) during their stay in the intensive care unit or died (n = 10) during this therapy (101940.- DM). Since the data concerning medical equipment (i.e. surgical devices, radiological equipment) were not centrally registered in the administration department of our clinic, it was not possible to include these costs into this calculation. Thus the total costs must be presumed higher. A relationship between costs of treatment and injury severity (ISS) appeared in polytrauma only by a cost reduction in early deceased very severely injured patients (ISS > 70). The primary diagnosis (injury pattern and severity) cannot predict the incidence of complications increasing the costs of treatment. In the presented study we did not find a correlation between age and treatment costs.(ABSTRACT TRUNCATED AT 250 WORDS)

[Plastic surgery in soft tissue reconstruction in large extremity defects]

Soft-tissue defects in the extremities vary greatly, depending on the trauma mechanism, localization and a number of factors related to the patient's physical condition. We offer an overview of the plastic surgery methods in reconstruction of different soft-tissue defects in the extremities, beginning with the diagnostic, clinical and radiological measures that make classification of soft-tissue defects possible, and then giving a concentrated view of the appropriate reconstruction methods. Collaboration between traumatology and plastic surgery seems to be especially important in lesions in the extremities.