Surgical critical care and private practice surgeons: a different world out there!

Use of extracorporeal membranous oxygenation in the management of refractory trauma-related severe acute respiratory distress syndrome: a national survey of the Eastern Association for the Surgery of Trauma

Objective

To report results of a national survey of provider attitudes, observations, and opinions regarding the use of extracorporeal membranous oxygenation (ECMO) to manage severe acute respiratory distress syndrome (ARDS) in trauma patients.

Design

A survey was created to query providers on the use of ECMO in trauma, as well as general management principals related to care of the patient with refractory hypoxic respiratory failure. The survey was sent to all members of Eastern Association for the Surgery of Trauma (EAST). Once completed, the survey was returned to the University of Alabama at Birmingham and results were analyzed.

Setting/patients

Trauma patients with refractory ARDS.

Interventions

None.

Measurements and main results

Respondents were from 37 states, the District of Columbia, and Puerto Rico. 56.9% reported institutional ECMO capabilities, but only 45.2% reported using ECMO for trauma patients. Most respondents (90.2%) reported ECMO use in less than or equal to five trauma patients per year. 20.9% think there is not enough data to support its use in trauma but only 4.7% would absolutely not consider ECMO use for trauma patients. Ranking the preferred modality of treatments for refractory ARDS from most to least preferable is as follows: airway pressure release ventilation, bilevel ventilation, paralysis, prone positioning, inhaled nitric oxide, epoprostenol, high-frequency oscillatory ventilation, corticosteroids, surfactant.

Conclusions

ARDS has a high mortality among trauma patients. Despite its utility in treating severe ARDS and other pulmonary disease processes, ECMO has not been universally embraced by the trauma community. There are an increasing number of studies that suggest that ECMO is a safe and viable treatment option for trauma patients with ARDS. Based on the results of this survey, ECMO use remains limited by trauma providers that care for patients with refractory hypoxic respiratory failure and ARDS, likely due to a combination of knowledge gaps and lack of access to ECMO.

Level of evidence

Level V.

Use of ECMO in the Management of Severe Acute Respiratory Distress Syndrome: A Survey of Academic Medical Centers in the United States

Mortality of severe acute respiratory distress syndrome (ARDS) remains high. Once conventional mechanical ventilation fails, alternative modes of therapy are used; most of which have limited evidence to support their use. No definitive guidelines exist for the management of these patients with alternate modalities of treatment. We conducted a cross-sectional national survey of 302 adult critical care training programs in the United States to understand the current preferences of intensivists regarding the use of different therapies for severe ARDS, including the use of extracorporeal membrane oxygenation (ECMO). A total of 381 responses were received: 203 critical care faculty and 174 critical care trainees. Airway pressure release ventilation was the initial choice of treatment reported by most when conventional mechanical ventilation strategy failed followed by inhaled nitric oxide and prone positioning. Extracorporeal membrane oxygenation availability was reported by 80% of the respondents at their institutions. Most respondents (83%) would consider ECMO in patients who fail optimal mechanical ventilation strategies, and the majority (60%) believed that ECMO use can facilitate lung protective ventilation, but few favored its use as a first-line modality. The majority of respondents reported limited knowledge of ECMO and desired specific ECMO education during training.

Is There a Benefit to Multidisciplinary Rounds in an Open Trauma Intensive Care Unit regarding Ventilator-Associated Pneumonia?

Multidisciplinary rounds (MDRs) have been instituted for patient care since June 2005. Before June 2005, all care was provided by individual practitioners. MDRs include the surgical intensivist, surgical resident, patient's nurse, case manager, pharmacist, chaplain, nutritionist, and respiratory therapist. Our study examined the effect of MDRs on ventilator-associated pneumonia in trauma patients in open intensive care units (ICUs). Group 1 included patients from June 2003 to May 2005 before the implementation of MDRs, and Group 2 included patients after the institution of MDRs from June 2005 to May 2007. In Group 1, there were 83 ventilator-associated pneumonias (VAPs) during 2414 ventilator days. In Group 2, there were 49 VAPs during 2094 ventilator days. The ratio of VAPs per thousand ventilator days decreased from 34.4 to 23.4 between the two groups ( P = 0.04). When comparing trauma patients in our open ICU with similar mean Injury Severity Score and mean Abbreviated Injury Score for chest and for head and neck, implementing MDRs significantly decreased our incidence of VAP.

Trauma and surgical critical care workforce in the United States: a severe surgeon shortage appears imminent

BACKGROUND

We conducted a survey to determine the state of the trauma and critical care workforce and compensation for such surgeons.

STUDY DESIGN

We sent questionnaires to 460 directors of Level I and Level II trauma centers in the US to gather information about their current and expected resource needs and compensation packages.

RESULTS

We received responses from 117 directors (25%). Midlevel faculty mean salary was $282,000 +/- $85,000; with a mean bonus of $33,000 +/- $34,000; and a mean trauma call stipend of $1,690 +/- $900. Mean of the yearly representative value units of work was 7,845 +/- 3,154. An average of 1.7 +/- 1.4 trauma surgeon positions per center are currently unfilled (mean vacancy duration of 19 +/- 20 months), with another 1.2 +/- 0.5 full-time equivalents expected to retire within 3 years. A mean of 0.9 +/- 0.9 additional positions are expected to be added within the next 3 years because of the growing workload. By 2012, the US might have 1,500 unfilled trauma surgeon positions (with 2,250 occupied).

CONCLUSIONS

Trauma and critical care surgeons in the US are clinically busy and well compensated for their efforts, but a severe shortage of surgeons in this specialty appears imminent.