Does Scheduled Low-Dose Short-Term NSAID (Ketorolac) Modulate Cytokine Levels Following Orthopaedic Polytrauma? A Secondary Analysis of a Randomized Clinical Trial

OBJECTIVES

To determine whether scheduled low-dose, short-term ketorolac modulates cytokine concentrations in orthopaedic polytrauma patients.

METHODS

DESIGN

Secondary analysis of a double-blinded, randomized controlled trial.

SETTING

Single Level I trauma center from August 2018 to October 2022.

PATIENT SELECTION CRITERIA

Orthopaedic polytrauma patients between 18-75 years with a New Injury Severity Score greater than 9 were enrolled. Participants were randomized to receive 15 mg of intravenous (IV) ketorolac every 6 hours for up to 5 inpatient days or 2 mL of IV saline similarly.

OUTCOME MEASURES AND COMPARISONS

Daily concentrations of prostaglandin E2 (PGE2), interleukin (IL)-1a, IL-1b, IL-6, and IL-10. Clinical outcomes included hospital and intensive care unit (ICU) length of stay (LOS), pulmonary complications, and acute kidney injury (AKI).

RESULTS

Seventy orthopaedic polytrauma patients were enrolled, with 35 participants randomized to the ketorolac group and 35 to the placebo group. The overall IL-10 trend over time was significantly different in the ketorolac group (p = 0.043). IL-6 was 65.8% higher at enrollment compared to Day 3 (p < 0.001) when aggregated over both groups. There was no significant treatment effect for PGE2, IL-1a, or IL-1b (p > 0.05). There were no significant differences in clinical outcomes between groups (p > 0.05).

CONCLUSIONS

Scheduled low-dose, short-term, IV ketorolac was associated with significantly different mean trends in IL-10 concentration in orthopaedic polytrauma patients with no significant differences in PGE2, IL-1a, IL-1b, or IL-6 levels between groups. The treatment did not have an impact on clinical outcomes of hospital or ICU LOS, pulmonary complications, or AKI.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Optimal strategies for assessing and managing pain, agitation, and delirium in the critically ill surgical patient: What you need to know

ABSTRACT

Pain, agitation, and delirium (PAD) are primary drivers of outcome in the ICU, and expertise in managing these entities successfully is crucial to the intensivist's toolbox. In addition, there are unique aspects of surgical patients that impact assessment and management of PAD. In this review, we address the continuous spectrum of assessment, and management of critically ill surgical patients, with a focus on limiting PAD, particularly incorporating mobility as an anchor to ICU liberation. Finally, we touch on the impact of PAD in specific populations, including opioid use disorder, traumatic brain injury, pregnancy, obesity, alcohol withdrawal, and geriatric patients. The goal of the review is to provide rapid access to information regarding PAD and tools to assess and manage these important elements of critical care of surgical patients.

Prehospital shock index predicts outcomes after prolonged transport: A multicenter rural study

BACKGROUND

Shock index (SI) predicts outcomes after trauma. Prior single-center work demonstrated that emergency medical services (EMSs) initial SI was the most accurate predictor of hospital outcomes in a rural environment. This study aimed to evaluate the predictive ability of SI in multiple rural trauma systems with prolonged transport times to a definitive care facility.

METHODS

This retrospective review was performed at four American College of Surgeons-verified level 1 trauma centers with large rural catchment basins. Adult trauma patients who were transferred and arrived >60 minutes from scene during 2018 were included. Patients who sustained blunt chest or abdominal trauma were analyzed. Subjects with missing data or severe head trauma (Abbreviated Injury Scale score, >2) were excluded. Poisson and binomial logistic regression were used to study the effect of SI and delta shock index (∆SI) on outcomes.

RESULTS

After applying the criteria, 789 patients were considered for analysis (502 scene patients and 287 transfers). The mean Injury Severity Score was 8 (interquartile range, 6) for scene and 8.9 (interquartile range, 5) for transfers. Initial EMSs SI was a significant predictor of the need for blood transfusion and intensive care unit care in both scene and transferred patients. An increase in ∆SI was predictive of the need for operative intervention ( p < 0.05). There were increased odds for mortality for every 0.1 change in EMSs SI; those changes were not deemed significant among both scene and transfer patients ( p < 0.1).

CONCLUSION

Providers must maintain a high level of clinical suspicion for patients who had an initially elevated SI. Emergency medical services SI is a significant predictor for use of blood and intensive care unit care, as well as mortality for scene patients. This highlights the importance of SI and ∆SI in rural trauma care.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Timing of venous thromboembolism prophylaxis initiation after injury: Findings from the consensus conference to implement optimal VTE prophylaxis in trauma

ABSTRACT

Optimizing prophylaxis against venous thromboembolic events (VTEs) is a critical issue in the care of injured patients. Although these patients are at significant risk of developing VTE, they also present competing concerns related to exacerbation of bleeding from existing injuries. Especially after high-risk trauma, including injuries to the abdominal solid organs, brain, and spine, trauma providers must delineate the time period in which VTE prophylaxis successfully reduces VTE rates without encouraging bleeding. Although existing data are primarily retrospective in nature and further study is required, literature supports early VTE chemoprophylaxis initiation even for severely injured patients. Early initiation is most frequently defined as <48 hours from admission but varies from <24 hours to 72 hours and occasionally refers to time from initial trauma. Prior to chemical VTE prophylaxis initiation in patients at risk for bleeding, an observation period is necessary during which injuries must show themselves to be hemostatic, either clinically or radiographically. In the future, prospective examination of optimal timing of VTE prophylaxis is necessary. Further study of specific subsets of trauma patients will allow for development of effective VTE mitigation strategies based upon collective risks of VTE and hemorrhage progression.

A multicenter evaluation on the impact of non-therapeutic transfer in rural trauma

INTRODUCTION

Trauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia.

METHODS

This retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in <48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in <48 h, without major intervention, with an ISS< 15. Cost analysis was performed to describe the impact of NTT on EMS use.

RESULTS

4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9-26), and 48% had an AIS head ≥4. These were significantly greater (p<0.001) than non-futile transfers, median ISS 5 (IQR 2-9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care.

CONCLUSIONS

Non-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.

History of Equity, Diversity, and Inclusion in Trauma Surgery: for Our Patients, for Our Profession, and for Ourselves

Purpose of Review

Disparities exist in outcome after injury, particularly related to race, ethnicity, socioeconomics, geography, and age. The mechanisms for this outcome disparity continue to be investigated. As trauma care providers, we are challenged to be mindful of and mitigate the impact of these disparities so that all patients realize the same opportunities for recovery. As surgeons, we also have varied professional experiences and opportunities for achievement and advancement depending upon our gender, ethnicity, race, religion, and sexual orientation. Even within a profession associated with relative affluence, socioeconomic status conveys different professional opportunities for surgeons.

Recent Findings

Fortunately, the profession of trauma surgery has undergone significant progress in raising awareness of patient and professional inequity among trauma patients and surgeons and has implemented systematic changes to diminish these inequities. Herein we will discuss the history of equity and inclusion in trauma surgery as it has affected our patients, our profession, and our individual selves.

Summary

Our goal is to provide a historical context, a status report, and a list of key initiatives or objectives on which all of us must focus. In doing so, the best possible clinical outcomes can be achieved for patients and the best professional and personal “outcomes” can be achieved for practicing and future trauma surgeons.

Occupational vs. non-occupational equestrians: Differences in demographics and injury patterns

INTRODUCTION

Nineteen million people participate in horseback riding activities in the US, and the horse industry employs more than 460,000 full-time workers. Emergency department data suggest young female amateurs and male professionals are most at risk of death from horse-related injuries. However, there has been no investigation into factors that may increase severe injury and mortality risk in these populations. This study investigates demographics and injury pattern differences between occupational and non-occupational horse-related injuries in the US.

METHODS

The 2017 American College of Surgeons National Trauma Databank (ACS NTDB) was analyzed for horse-related injury using ICD 10 codes. Demographics, injury data, protective device use, and hospital procedures were analyzed. Occupational versus non-occupational injuries based on incident location (farm, sports, recreational, residential) were compared using ANOVA or Pearson's Chi-squared test.

RESULTS

Of 3911 incidents, the most common injury mechanism was falling from the horse, but occupational and non-occupational farm injuries showed higher incidence of being struck by a horse. One-third required surgery. Upper extremity injuries were most common. Occupational injuries more often affected upper extremities of working age, minority males with commercial insurance. Non-occupational injuries most often affected heads of women at the extremes of age. Helmet use was higher in occupational, non-occupational sports, and non-occupational recreation injuries, and severe head injury incidence was decreased in these groups. Complications and discharge dispositions were not different across groups.

CONCLUSIONS

In the largest trauma center study to date, we have shown equine-related trauma to be common and affect a predictable demographic that may permit injury prevention initiatives. Helmets may reduce severe head injury, but the efficacy of protective clothing remains to be validated.

Demonstration of a U.S. nationwide reduction in transfusion in general surgery and a review of published transfusion reduction methodologies

BACKGROUND

Red blood cell transfusions in surgical procedures can be lifesaving. However, recent studies show transfusions are associated with a dose-dependent increase in postoperative morbidity and mortality; hospitals and physicians have attempted to reduce them. We sought to determine the success of these efforts and review and summarize published reduction methods employed.

STUDY DESIGN/METHODS

An analysis of transfusion data from ACS-NSQIP public use files of general surgical procedures for 2012 and 2018; a retrospective review of the literature surrounding general surgical transfusion reduction from 2008 to 2018.

RESULTS

The rate of general surgical transfusion in the NSQIP dataset decreased from 5.5% in 2012 to 4.0% in 2018, a 27% relative reduction in transfusion. After extensive multivariable adjustment for patient risk and operative complexity, this effect remained (Odds ratio 0.65, 95% CI 0.63-0.67, p < .001). Furthermore, there was a positive correlation between specific procedure decreases in transfusion and decreases in 30-day morbidity (rho =0.41, p = .003) and mortality (rho = 0.37, p = .007). There were 866 published studies matching our search term "red blood cell transfusion reduction." Forty-four were relevant to general surgery. Seven dominant strategies for transfusion reduction by descending frequency of report included restrictive transfusion thresholds, management of preoperative anemia, perioperative interventions, educational programs, electronic clinical decision support, waste reduction, and audits of transfusion practices.

CONCLUSION

Our study demonstrates a 27% decrease in general surgery transfusion between 2012 and 2018 with associated reductions in morbidity and mortality, suggesting published employed strategies have been successful and safely implemented.

High Resource Utilization in Emergent Versus Elective General Surgery

BACKGROUND

In an era of pay for performance metrics, we sought to increase understanding of factors driving high resource utilization (HRU) in emergent (EGS) versus same-day elective (SDGS) general surgery patients.

METHODS

General surgery procedures from the 2016 ACS-NSQIP public use file were grouped according to the first four digits of the primary procedure CPT code. Groups having at least 100 of both elective and emergent cases were included (22 groups; 83,872 cases). HRU patients were defined as those in-hospital >7D, returned to the OR, readmitted, and/or had morbidity likely requiring an intensive care unit (ICU)stay. Independent NSQIP predictors of HRU were identified through forward regression; P for entry < 0.05, for exit > 0.10.

RESULTS

Of all patients, 33% were HRU. The three highest HRU procedures (total colectomy, enterolysis, and ileostomy) comprised a higher proportion of EGS than SDGS cases (10.3 versus 2.6%, P < 0.001). The duration of operation was 40 Min lower in EGS after adjustment. Thirty-nine of the remaining 40 HRU predictors were higher in EGS including preoperative SIRS/Sepsis (50 versus 2%), ASA classification IV-V (31 versus 5%), albumin <3.5 g/dL (40 versus 12%), transfers (26 versus 2%, P's < 0.001), septuagenarians (35 versus 25%) and disseminated cancer (6.3 versus 4.8%, P's < 0.001); while sex did not differ. After adjustment, EGS patients remained more likely to be HRU (odds ratio 2.5, 95% CI 2.4 - 2.6, P < 0.001).

CONCLUSIONS

EGS patients utilize significantly more resources than SDGS patients above what can be adjusted for in the clinically robust ACS-NSQIP dataset. Distinctive payment and value-based performance models are necessary for EGS.

An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

BACKGROUND

Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP.

METHODS

This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined.

RESULTS

Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables.

CONCLUSION

Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes.

LEVEL OF EVIDENCE

Prognostic, level III.

The Influence of the Opioid Epidemic on Firearm Violence in Kentucky Counties

BACKGROUND

The opioid crisis is a major public health emergency. Current data likely underestimate the full impact on mortality due to limitations in reporting and toxicology screening. We explored the relationship between opioid overdose and firearm-associated emergency department visits (ODED & FAED, respectively).

METHODS

For the years 2010 to 2017, we analyzed county-level ODED and FAED visits in Kentucky using Office of Health Policy and US Census Bureau data. Firearm death certificate data were analyzed along with high-dose prescriptions from the Kentucky All Schedule Prescription Electronic Reporting records. Socioeconomic variables analyzed included health insurance coverage, race, median household earnings, unemployment rate, and high-school graduation rate.

RESULTS

ODED and FAED visits were correlated (Rho = 0.29, P< 0.01) and both increased over the study period, remarkably so after 2013 (P < 0.001). FAED visits were higher in rural compared to metro counties (P < 0.001), while ODED visits were not. In multivariable analysis, FAED visits were associated with ODED visits (Std. B = 0.24, P= 0.001), high-dose prescriptions (0.21, P = 0.008), rural status (0.19, P = 0.012), percentage white race (-0.28, P = 0.012), and percentage high school graduates (-0.68, P < 0.001). Unemployment and earnings were bivariate correlates with FAED visits (Rho = 0.42, P < 0.001 and -0.32, P < 0.001, respectively) but were not significant in the multivariable model.

CONCLUSIONS

In addition to recognized nonfatal consequences of the opioid crisis, firearm violence appears to be a corollary impact, particularly in rural counties. Firearm injury prevention efforts should consider the contribution of opioid use and abuse.

Association of Prehospital Step 1 Vital Sign Criteria and Vital Sign Decline with Increased Emergency Department and Hospital Death

BACKGROUND

This study analyzed data from the 2017 American College of Surgeons National Trauma Data Bank to examine the effects of pre-hospital Field Triage Decision Scheme Step 1 vital sign criteria (S1C) and vital sign decline on subsequent emergency department (ED) and hospital death in emergency medical services (EMS) transported trauma victims.

STUDY DESIGN

Patient and injury characteristics, transport time, and ED and hospital disposition were collected. S1C (respiratory rate [RR]<10, RR>29 breaths/min, systolic blood pressure [SBP]<90 mmHg, Glasgow Coma Scale [GCS]<14) were recorded at the injury scene and hospital arrival. Decline was defined as a change ≥ 1 standard deviation (SD) into or within an S1C range. S1C and decline were analyzed relative to ED and hospital death using logistic regression.

RESULTS

Of 333,213 included patients, 54,849 (16.5%) met Step 1 criteria at the scene, and 21,566 (6.9%) declined en route. The ED death rate was 0.4% (n = 1,188), and the hospital death/hospice rate was 4.0% (11,624 of 287,675). Patients who met S1C at the scene or who declined were more likely to require longer hospital lengths of stay, ICU admission, and surgical intervention. S1C and decline patients had higher odds of death in both the ED (S1C odds ratio [OR] 15.1, decline OR 2.4, p values < 0.001) and hospital (S1C OR 4.8, decline OR 2.0, p values < 0.001) after adjusting for patient demographics, transport time and mode, injury severity, and injury mechanism. Each S1C and decline measure was independently predictive of death.

CONCLUSIONS

This study quantifies the mortality risks associated with individual S1C and validates their use as an indicator for injury severity and pre-hospital triage tool.

Intraoperative vasopressor use during emergency surgery on injured meth users

Background

Methamphetamine is a growing drug of abuse in America. Patients with recent methamphetamine use pose potential complications to general anesthesia due to changes in hemodynamics and arrhythmias. Limited data exists on the incidence of intraoperative complications on methamphetamine-intoxicated patients requiring urgent or emergent trauma surgery. This study aims to describe intraoperative complications observed in methamphetamine and amphetamine-intoxicated patients requiring emergent surgery.

Methods

Using the Trauma Registry at our ACS-verified level I trauma center, we completed a single-center, descriptive, retrospective cohort review between July 1, 2012 and June 30, 2016, of adult patients requiring emergent surgery with a positive urine-drug screen for methamphetamines or amphetamines. The objective was to evaluate vasopressor utilization during surgical operation.

Results

A total of 92 patients were identified with a positive UDS for amphetamine and/or methamphetamine who went to the operating room within 24 hours of admission. Thirty-two (34%) patients received one or more (≥1) doses of vasopressor, while 60 patients (66%) received no vasopressor. Changes in mean arterial pressure (MAP) were noted in 64%, while only 3% experienced an EKG change. A binomial logistic regression showed age, base deficit and change in MAP to be predictive of vasopressor use (p<0.002). No intraoperative cardiac events or anesthetic complications were seen.

Discussion

Hemodynamic instability in the amphetamine and methamphetamine-intoxicated population may be more directly related to degree of resuscitation required, than the presence of a positive UDS.

Level of evidence

IV

A Prospective, Controlled Evaluation of the Abdominal Reapproximation Anchor Abdominal Wall Closure System in Combination with VAC Therapy Compared with VAC Alone in the Management of an Open Abdomen

Dramatic increases in damage control and decompressive laparotomies and a significant increase in patients with open abdominal cavities have resulted in numerous techniques to facilitate fascial closure. We hypothesized addition of the abdominal reapproximation anchor system (ABRA) to the KCI Abdominal Wound Vac™ (VAC) or KCI ABThera™ would increase successful primary closure rates and reduce operative costs. Fourteen patients with open abdomens were prospectively randomized into a control group using VAC alone (control) or a study group using VAC plus ABRA (VAC-ABRA). All patients underwent regular VAC changes; patients receiving VAC-ABRA also underwent concomitant daily elastomer adjustment of the ABRA system. Primary end points included abdominal closure, number of operating room (OR) visits, and OR time use. Eight patients were included in the VAC-ABRA group and six patients in the control group. Primary closure rates between groups were not statistically different; however, the number of trips to the OR and OR time use were different. Despite higher Acute Physiology and Chronic Health Evaluation II scores, larger starting wound size, and higher rates of abdominal compartment syndrome, closure rates in the VAC-ABRA group were similar to VAC alone. Importantly, however, fewer OR trips and less OR time were required for the VAC-ABRA group.

Torso injuries after fall from standing-empiric abdominal or thoracic CT imaging is not indicated

PURPOSE

Falls from standing (FFS) have become the most common mechanism of injury at many trauma centers. Liberal imaging of low energy trauma has questionable value. We hypothesize that torso trauma intervention is rare in the FFS population, and physical examination sufficiently screens for torso injuries needing intervention.

METHODS

We queried our ACS-verified Level 1 trauma center registry for falls from standing from 1/1/14 to 12/31/16. Exclusion criteria were: falls from height, falls associated with penetrating trauma, lack of an abdominal or chest CT, a Glasgow Coma Scale Score (GCS) less than 15, and surgical intervention at another facility prior to arrival at our center. Demographics, historical details, hemodynamics, injuries, injury severity, procedures, initial vital signs, and outcome were recorded.

RESULTS

1,654 patients had a FFS during our study period. 728 had an abdominal or chest CT and a GCS of 15 and comprised the evaluable population. Mean age was 56.5 years. 55.8% were female. The mortality rate was 8%. There were 179 chest injuries in 121 patients, and 54 abdominal injuries in 43 patients. 379 patients had a GCS of 15 and underwent thoracic CT, yet only 11 (3%) underwent intervention. The negative predictive value for physical exam was 100% for chest intervention. 349 patients had a GCS of 15 and abdominal CT, yet only 13 (3.7%) underwent procedural intervention. Abdominal physical exam had a negative predictive value of 99.7% for intervention, but when combined with vital signs, the value was 100%.

CONCLUSION

Torso injuries in FFS are rare. Of our study population, 13 abdominal injuries underwent intervention, and 11 chest injuries underwent intervention. Screening patients by physical examination and vital signs is sufficient and safely allows for the use of selective abdominal and chest CT.

[Congenital heart disease : fistula from circumflex artery to coronary sinus]

Congenital coronary artery fistulas are infrequent but sometimes hemodynamically important anomalies depending on their magnitude and the cardiac chamber or vascular site involved. Fistula from left circumflex artery to coronary sinus are potentially curable causes of ischemic heart disease.

Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open-Label Randomized Trial

BACKGROUND

Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high-protein- and low-carbohydrate-facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol.

METHODS

This was a multicenter, randomized, open-label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high-protein (37%) and low-carbohydrate (29%) or control high-protein (25%) and conventional-carbohydrate (45%) EN formula.

RESULTS

A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1-5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (-SD 108, +SD 177) and 126 (-SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = -13%, P = .015), whereas that of 80-110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, -22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53).

CONCLUSIONS

A very high-protein and low-carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80-110 mg/dL.

Time is money: quantifying savings in outpatient appendectomy

Background

Laparoscopic appendectomy can be performed on a fast-track, short-stay, or outpatient basis with high success rates, low morbidity, low readmission rates, and shorter length of hospital stay. Cost savings from outpatient appendectomy have not been well described. We hypothesize that outpatient laparoscopic appendectomy is associated with cost savings.

Methods

We performed an original retrospective cohort analysis of patients undergoing laparoscopic appendectomy between June 2013 and April 2017 at our academic medical center before and after implementation of an outpatient protocol which began on January 1, 2016. We assessed appendicitis grade, length of stay (LOS), cost, net revenue, and profit margin.

Results

After protocol implementation, the percentage of patients discharged from the the postanesthesia care unit (PACU) increased from 3.7% to 29.7% (χ² p<0.001). The proportion of inpatient admissions and admissions to observation decreased by 5.7% and 20.3%, respectively. On average, PACU-to-home patients had a total hospital cost of $4734 compared with $5781 in patients admitted to observation, for an estimated savings of $1047 per patient (p<0.001). Comparing the time periods, the mean LOS decreased for all groups (p<0.001). Appendicitis grade was higher in those who required inpatient admission, but could not distinguish which patients required an observation bed.

Discussion

Outpatient appendectomy saves approximately $1000 per patient. Adoption of an outpatient appendectomy pathway is likely to be gradual, but will result in incremental improvement in resource utilization immediately. Grade does not predict which patients should be observed. Considering established safety, our data support widespread implementation of this protocol.

Level of evidence

III.

Patient-Surgeon Relationship Influences Outcomes in Bariatric Patients

Bariatric surgery is an important therapy in weight loss. However, adherence to follow-up is critical and may be influenced by the patient-surgeon relationship. To test this hypothesis, bariatric surgical patients were surveyed from March 2013 to March 2015 via the National Association for Weight Loss Surgery webpage and social media outlets. Surgical outcomes and adherence to follow-up were collected, and aspects of the patient-surgeon relationship were assessed via the Likert scale. Correlations between survey item responses were calculated using Fisher's exact test, Student's t test, and Spearman's rho rank correlation. Three hundred twenty patients responded (n = 287 completed in entirety and n = 33 partially completed); 48 months was the median time to survey from operation (interquartile range, 22-84 months). Eighty-six per cent (n = 276) of patients rated their relationship with their operative surgeon as "average" to "very good." Thirteen per cent (n = 43) rated their relationship as "poor" to "very poor." Positive relationship with the operative surgeon and lack of complication were associated with adherence to follow-up (P = 0.0001 and P = 0.002, respectively). The presence of complication did not affect the overall patient-surgeon relationship (P = 0.5), although aspects of the patient-surgeon relationship were correlated to complications. There was no association between weight loss at one year and patient-surgeon relationship (P = 0.6) or presence of complication (P = 0.1). The findings of this study support the role of a positive patient-surgeon relationship in achieving long-term follow-up in post-bariatric surgical patients.

Patient-Surgeon Relationship Influences Outcomes in Bariatric Patients

Bariatric surgery is an important therapy in weight loss. However, adherence to follow-up is critical and may be influenced by the patient-surgeon relationship. To test this hypothesis, bariatric surgical patients were surveyed from March 2013 to March 2015 via the National Association for Weight Loss Surgery webpage and social media outlets. Surgical outcomes and adherence to follow-up were collected, and aspects of the patient-surgeon relationship were assessed via the Likert scale. Correlations between survey item responses were calculated using Fisher's exact test, Student's t test, and Spearman's rho rank correlation. Three hundred twenty patients responded (n = 287 completed in entirety and n = 33 partially completed); 48 months was the median time to survey from operation (interquartile range, 22–84 months). Eighty-six per cent (n = 276) of patients rated their relationship with their operative surgeon as “average” to “very good.” Thirteen per cent (n = 43) rated their relationship as “poor” to “very poor.” Positive relationship with the operative surgeon and lack of complication were associated with adherence to follow-up ( P = 0.0001 and P = 0.002, respectively). The presence of complication did not affect the overall patient-surgeon relationship ( P = 0.5), although aspects of the patient-surgeon relationship were correlated to complications. There was no association between weight loss at one year and patient-surgeon relationship ( P = 0.6) or presence of complication ( P = 0.1). The findings of this study support the role of a positive patient-surgeon relationship in achieving long-term follow-up in post-bariatric surgical patients.

Minimizing opioid use after acute major trauma

PURPOSE

Results of an initiative at an academic medical center to reduce prescription opioid use in patients with acute traumatic injuries are reported.

METHODS

In 2014, the University of Kentucky Hospital trauma service implemented a pain management strategy consisting of patient and provider education emphasizing the use of nonopioid analgesics to minimize opioid use without compromising analgesia effectiveness. To assess the impact of the initiative, a retrospective analysis of data on cohorts of patients admitted with acute trauma before (n = 489) and after (n = 424) project implementation was conducted. The primary endpoint was opioid use (prescribed daily milligram morphine equivalents [MME]) at discharge. Secondary endpoints included inpatient opioid and alternative analgesic use, pain control, ileus development, length of stay, and discharge disposition.

RESULTS

Compared with the preintervention cohort, the postintervention cohort had a lower median daily discharge MME overall (45 MME versus 90 MME, p < 0.001); after stratification of MME data by baseline opioid use, this finding held true only for patients with no opioid prescription at admission. Although utilization of gabapentinoids, skeletal muscle relaxants, and clonidine increased during the postintervention period, inpatient opioid use did not differ significantly in the 2 cohorts. Utilization of both nonsteroidal antiinflammatory drugs and acetaminophen was lower in the postintervention cohort versus the preintervention cohort.

CONCLUSION

Targeted provider and patient education on minimizing opioid use was associated with a reduction in MME on discharge from the hospital after traumatic injury.

EAST Multicenter Trial on targeted temperature management for hanging-induced cardiac arrest

BACKGROUND

We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of Trauma (EAST) multicenter retrospective study.

METHODS

We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome.

RESULTS

A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy.

CONCLUSION

Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models.

LEVEL OF EVIDENCE

Therapeutic study, level IV; prognostic study, level III.

Variations in institutional review board processes and consent requirements for trauma research: an EAST multicenter survey

Oversight of human subject research has evolved considerably since its inception. However, previous studies identified a lack of consistency of institutional review board (IRB) determination for the type of review required and whether informed consent is necessary, especially for prospective observational studies, which pose minimal risk of harm. We hypothesized that there is significant inter-institution variation in IRB requirements for the type of review and necessity of informed consent, especially for prospective observational trials without blood/tissue utilization. We also sought to describe investigators' and IRB members' attitudes toward the type of review and need for consent. Eastern Association for the Surgery of Trauma (EAST) and IRB members were sent an electronic survey on IRB review and informed consent requirement. We performed descriptive analyses as well as Fisher's exact test to determine differences between EAST and IRB members' responses. The response rate for EAST members from 113 institutions was 13.5%, whereas a convenience sample of IRB members from 14 institutions had a response rate of 64.4%. Requirement for full IRB review for retrospective studies using patient identifiers was reported by zero IRB member compared with 13.1% of EAST members (p=0.05). Regarding prospective observational trials without blood/tissue collection, 48.1% of EAST members reported their institutions required a full IRB review compared with 9.5% of IRB members (p=0.01). For prospective observational trials with blood/tissue collection, 80% of EAST members indicated requirement to submit a full IRB review compared with only 13.6% of IRB members (p<0.001). Most EAST members (78.6%) stated that informed consent is not ethically necessary in prospective observational trials without blood/tissue collection, whereas most IRB members thought that informed consent was ethically necessary (63.6%, p<0.001). There is significant variation in perception and practice regarding the level of review for prospective observational studies and whether informed consent is necessary. We recommend future interdisciplinary efforts between researchers and IRBs should occur to better standardize local IRB efforts.

Level of evidence

IV.

Understanding Resident Performance, Mindfulness, and Communication in Critical Care Rotations

OBJECTIVE

Evidence from the medical literature suggests that surgical trainees can benefit from mindful practices. Surgical educators are challenged with the need to address resident core competencies, some of which may be facilitated by higher levels of mindfulness. This study explores whether mindful residents perform better than their peers as members of the health care team.

DESIGN

This study employed a multiphase, multimethod design to assess resident mindfulness, communication, and clinical performance.

SETTING

Academic, tertiary medical center.

PARTICIPANTS

Residents (N = 51) working in an intensive care unit. In phase I, medical residents completed a self-report survey of mindfulness, communication, emotional affect, and clinical decision-making. In phase II, resident performance was assessed using independent ratings of mindfulness and clinical decision-making by attending physicians and registered nurses.

RESULTS

In phase 1, a significant positive relationship was found between resident performance and mindfulness, positive affect (PA), and communication. In phase 2, attending physicians/registered nurses' perceptions of residents' mindfulness were positively correlated with communication and inversely related to negative affect (NA). The top quartile of residents for performance and mindfulness had the lowest NA. Higher-rated residents underestimated their performance/mindfulness, whereas those in the lowest quartile overestimated these factors.

CONCLUSIONS

This study offers a number of implications for medical resident education. First, mindfulness was perceived to be a significant contributor to self-assessments of competency and performance. Second, both PA and NA were important to mindfulness and performance. Third, communication was associated with resident performance, mindfulness, and PA. These implications suggest that individual characteristics of mindfulness, communication, and affect, all potentially modifiable, influence care quality and safety. To improve low performers, surgical educators could screen and identify residents with inaccurate self-assessments. Residents open to feedback will improve faster and develop awareness toward situations and interactions with patients, colleagues, attending physicians, and staff.

Defining and Assessing Tolerance in Enteral Nutrition

Nutrition support has become widely recognized as an essential component of optimal care for acutely ill patients. Enteral nutrition is preferred over parenteral routes when possible. However, prescribed enteral nutritional regimens are sometimes met with side effects and even complications. These adverse events have been collectively termed "intolerance," and forms of intolerance occur in a spectrum from bothersome at least to life threatening when most severe. Here we discuss nutritional access and its maintenance, introduce and define intolerance, and then review the current literature with regard to principal forms of enteral nutrition intolerance.

Enteral Nutrition and Drug Administration, Interactions, and Complications

The enteral route has become the standard of care to deliver nutrition support for hospitalized acute care and ambulatory care patients. The same access device is increasingly being used to deliver medications, which provides cost savings but also creates new challenges. Cost savings can be negated if the concomitant administration of nutrition elicits a decrease in bioavailability due to incompatibilities that alter drug or nutrition therapy. Feeding tubes can deliver nutrients and drugs to the stomach, small bowel, or both, with optimal efficacy of medications depending on delivery to the appropriate segment of the gastrointestinal tract. Liquid preparations are often the preferred formulation for enteral administration. Obstruction of the enteral access device may occur when specialized medication formulations are altered inappropriately. Occasionally, the enteral formula should be changed to modify the content of free water, fiber, electrolytes, or vitamins that may interfere with the drug therapy. Intolerance to enteral nutrition such as abdominal distention and diarrhea may be the result of the medication, and the causative agent should be identified to improve patient comfort. This article will address optimal drug delivery via enteral access devices and possible complications associated with therapy.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3-2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2-3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

On and off the horse: mechanisms and patterns of injury in mounted and unmounted equestrians

INTRODUCTION

The purpose of this study is to determine whether discrepant patterns of horse-related trauma exist in mounted vs. unmounted equestrians from a single Level I trauma center to guide awareness of injury prevention.

METHODS

Retrospective data were collected from the University of Kentucky Trauma Registry for patients admitted with horse-related injuries between January 2003 and December 2007 (n=284). Injuries incurred while mounted were compared with those incurred while unmounted.

RESULTS

Of 284 patients, 145 (51%) subjects were male with an average age of 37.2 years (S.D. 17.2). Most injuries occurred due to falling off while riding (54%) or kick (22%), resulting in extremity fracture (33%) and head injury (27%). Mounted equestrians more commonly incurred injury to the chest and lower extremity while unmounted equestrians incurred injury to the face and abdomen. Head trauma frequency was equal between mounted and unmounted equestrians. There were 3 deaths, 2 of which were due to severe head injury from a kick. Helmet use was confirmed in only 12 cases (6%).

CONCLUSION

This evaluation of trauma in mounted vs. unmounted equestrians indicates different patterns of injury, contributing to the growing body of literature in this field. We find interaction with horses to be dangerous to both mounted and unmounted equestrians. Intervention with increased safety equipment practice should include helmet usage while on and off the horse.

A prospective, controlled evaluation of the abdominal reapproximation anchor abdominal wall closure system in combination with VAC therapy compared with VAC alone in the management of an open abdomen

Dramatic increases in damage control and decompressive laparotomies and a significant increase in patients with open abdominal cavities have resulted in numerous techniques to facilitate fascial closure. We hypothesized addition of the abdominal reapproximation anchor system (ABRA) to the KCI Abdominal Wound Vac™ (VAC) or KCI ABThera™ would increase successful primary closure rates and reduce operative costs. Fourteen patients with open abdomens were prospectively randomized into a control group using VAC alone (control) or a study group using VAC plus ABRA (VAC-ABRA). All patients underwent regular VAC changes; patients receiving VAC-ABRA also underwent concomitant daily elastomer adjustment of the ABRA system. Primary end points included abdominal closure, number of operating room (OR) visits, and OR time use. Eight patients were included in the VAC-ABRA group and six patients in the control group. Primary closure rates between groups were not statistically different; however, the number of trips to the OR and OR time use were different. Despite higher Acute Physiology and Chronic Health Evaluation II scores, larger starting wound size, and higher rates of abdominal compartment syndrome, closure rates in the VAC-ABRA group were similar to VAC alone. Importantly, however, fewer OR trips and less OR time were required for the VAC-ABRA group.

Influence of in-house attending presence on trauma outcomes and hospital efficiency

BACKGROUND

The influence of in-house (IH) attendings on trauma patient survival and efficiency measures, such as emergency department length of stay (LOS), ICU LOS, and hospital LOS, has been debated for more than 20 years. No study has definitively shown improved outcomes with IH vs home-call attendings. This study examines trauma outcomes in a single, Level I trauma center before and after the institution of IH attending call.

STUDY DESIGN

Patient data were collected from the University of Kentucky's trauma registry. Based on the Trauma-Related Injury Severity Score, survival rates were compared between the IH and home-call groups. To evaluate efficiency, emergency department LOS, ICU LOS, and hospital LOS were compared. A separate subanalysis for the most severely injured patients (trauma alert red) was also performed.

RESULTS

The home-call group (n = 4,804) was younger (p = 0.018) and had a higher Injury Severity Score (p = 0.003) than the IH group (n = 5259), but there was no difference in Trauma-Related Injury Severity Score (p = 0.205) between groups. In-house attending presence did not reduce mortality. Emergency department LOS, ICU LOS, and hospital LOS were shorter during the IH period. Emergency department to operating room time was not different. There was no change in trauma alert red mortality with an attending present (20.7% vs 18.2%, p = 0.198).

CONCLUSIONS

In-house attending presence does not improve trauma patient survival. For the most severely injured patients, attendings presence does not reduce mortality. In-house coverage can improve hospital efficiency by decreasing emergency department LOS, hospital LOS, and ICU LOS.

An acute care surgery service generates a positive contribution margin in an appropriately staffed hospital

BACKGROUND

Acute care surgery (ACS) includes trauma, surgical critical care, and emergent general surgery. There is a national shortage of institutions that can provide for patients needing access to emergency surgical care. Inability to fund ACS surgeons can be a barrier. We hypothesize that an ACS service, in an appropriately staffed hospital, generates a positive contribution margin (CM).

STUDY DESIGN

Fiscal data for 2009 were retrospectively reviewed at the University of Kentucky, a Level I trauma center with an ACS service. Contribution margin (ie, net revenue minus direct costs) and mean length of stay were calculated for all patients admitted to the ACS service. Inpatient data were stratified by trauma vs general surgery, emergent vs elective, and by payor mix.

RESULTS

Annual CM associated with the 5 ACS faculty was $21,799,000. Trauma generated higher CM than general surgery. General surgery had a greater CM, more if emergent than if elective ($9,500 vs $5,500; p < 0.01). Self-payment was lower with emergent general surgery vs trauma (20% vs 25%; p = 0.02).

CONCLUSIONS

Acute care surgery generates a positive CM. Emergent general surgery generates a greater CM than elective general surgery because of increased case mix index. These data suggest that hospital subsidization of acute care surgeons is financially feasible and might address the surgical workforce shortage and the critical problem of access to emergency surgical services.

A placebo-controlled, double-blind, dose-escalation study to assess the safety, tolerability and pharmacokinetics/pharmacodynamics of single and multiple intravenous infusions of AZD9773 in patients with severe sepsis and septic shock

Introduction

Tumor necrosis factor-alpha (TNF-α), an early mediator in the systemic inflammatory response to infection, is a potential therapeutic target in sepsis. The primary objective of this study was to determine the safety and tolerability of AZD9773, an ovine, polyclonal, anti-human TNF-α Fab preparation, in patients with severe sepsis. Secondary outcomes related to pharmacokinetic (PK) and pharmacodynamic (PD) parameters.

Methods

In this double-blind, placebo-controlled, multicenter Phase IIa study, patients were sequentially enrolled into five escalating-dose cohorts (single doses of 50 or 250 units/kg; multiple doses of 250 units/kg loading and 50 units/kg maintenance, 500 units/kg loading and 100 units/kg maintenance, or 750 units/kg loading and 250 units/kg maintenance). In each cohort, patients were randomized 2:1 to receive AZD9773 or placebo.

Results

Seventy patients received AZD9773 (n = 47) or placebo (n = 23). Baseline characteristics were similar across cohorts. Mean baseline APACHE score was 25.9. PK data demonstrated an approximately proportional increase in concentration with increasing dose and a terminal half-life of 20 hours. For the multiple-dose cohorts, serum TNF-α concentrations decreased to near-undetectable levels within two hours of commencing AZD9773 infusion. This suppression was maintained in most patients for the duration of treatment. AZD9773 was well tolerated. Most adverse events were of mild-to-moderate intensity and considered by the reporting investigator as unrelated to study treatment.

Conclusions

The safety, PK and PD data support the continued evaluation of AZD9773 in larger Phase IIb/III studies.

As-needed antihypertensive therapy in surgical patients, why and how: challenging a paradigm

Hypertension is common in hospitalized patients and there are many causes. Some patients have no prior history of hypertension, few symptoms, and no apparent morbidity related to acute rises in blood pressure. Though there is no established guideline for therapy in these cases, patients often receive therapy directed at the abnormal vital sign. It is hypothesized that this practice is common and the associated costs are significant. Using the inpatient pharmacy database at the University of Kentucky Chandler Medical Center, a verified Level I trauma center and quaternary referral center, patients on the emergency general surgery or orthopedic surgery services receiving intravenous hydralazine, metoprolol, or labetalol were identified. Subjects were analyzed for indications, parameters, associated history of hypertension, and direct costs. Over the 4-month study period, 114 subjects received 522 drug doses. More than half (55%) of subjects had a prior history of hypertension but only 75 per cent were started on their home medication. Of those without hypertension before admission, 18 per cent required therapy at discharge. Labetalol was the most frequently used agent and total pharmacy costs for this cohort of patients was over $1200. Pro re nata (PRN), short-acting antihypertensive therapy has little evidence base in asymptomatic patients, but its prevalence is high on surgical services. The cost is significant, especially when extrapolated to the larger hospital population at this single institution. Further research is warranted to determine the prevalence of this practice in other centers or national regions, as well as its cost and benefit.

As-Needed Antihypertensive Therapy in Surgical Patients, Why and How: Challenging a Paradigm

Hypertension is common in hospitalized patients and there are many causes. Some patients have no prior history of hypertension, few symptoms, and no apparent morbidity related to acute rises in blood pressure. Though there is no established guideline for therapy in these cases, patients often receive therapy directed at the abnormal vital sign. It is hypothesized that this practice is common and the associated costs are significant. Using the inpatient pharmacy database at the University of Kentucky Chandler Medical Center, a verified Level I trauma center and quaternary referral center, patients on the emergency general surgery or orthopedic surgery services receiving intravenous hydralazine, metoprolol, or labetalol were identified. Subjects were analyzed for indications, parameters, associated history of hypertension, and direct costs. Over the 4-month study period, 114 subjects received 522 drug doses. More than half (55%) of subjects had a prior history of hypertension but only 75 per cent were started on their home medication. Of those without hypertension before admission, 18 per cent required therapy at discharge. Labetalol was the most frequently used agent and total pharmacy costs for this cohort of patients was over $1200. Pro re nata (PRN), short-acting antihypertensive therapy has little evidence base in asymptomatic patients, but its prevalence is high on surgical services. The cost is significant, especially when extrapolated to the larger hospital population at this single institution. Further research is warranted to determine the prevalence of this practice in other centers or national regions, as well as its cost and benefit.

Pediatric anthropometrics are inconsistent with current guidelines for assessing rider fit on all-terrain vehicles

BACKGROUND/PURPOSE

This study sought to establish objective anthropometric measures of fit or misfit for young riders on adult and youth-sized all-terrain vehicles and use these metrics to test the unproved historical reasoning that age alone is a sufficient measure of rider-ATV fit.

METHODS

Male children (6-11 years, n=8; and 12-15 years, n=11) were selected by convenience sampling. Rider-ATV fit was quantified by five measures adapted from published recommendations: (1) standing-seat clearance, (2) hand size, (3) foot vs. foot-brake position, (4) elbow angle, and (5) handlebar-to-knee distance.

RESULTS

Youths aged 12-15 years fit the adult-sized ATV better than the ATV Safety Institute recommended age-appropriate youth model (63% of subjects fit all 5 measures on adult-sized ATV vs. 20% on youth-sized ATV). Youths aged 6-11 years fit poorly on ATVs of both sizes (0% fit all 5 parameters on the adult-sized ATV vs 12% on the youth-sized ATV).

CONCLUSIONS

The ATV Safety Institute recommends rider-ATV fit according to age and engine displacement, but no objective data linking age or anthropometrics with ATV engine or frame size has been previously published. Age alone is a poor predictor of rider-ATV fit; the five metrics used offer an improvement compared to current recommendations.

Oxygen carriers: A selected review

The most common and widely transplanted tissue world wide is blood, which in 2000 resulted in the transfusion of 12.5 million units of blood in the US alone [Goodnough LT, Shander A, Brecher ME. Transfusion medicine: looking to the future. Lancet 2003;361:161-9]. The current use of donated blood products is relatively safe; however, there are inherent problems with allogeneic blood transfusions. The wide spread use of blood in procedures results in problems involving inadequate supply exacerbated in times of war and disasters and by the limited storage life of blood donations (30-42 days). Blood contamination due to patient pre-disposition, poor collection, sterilization, or storage is the second most common cause of death from transfusion in the US [Hillyer CD, Josephson CD, Blajchman MA, Vostal JG, Epstein JS, Goodman JL. Bacterial contamination of blood components: risks, strategies, and regulation: joint ASH and AABB educational session in transfusion medicine. Hematology (Am Soc Hematol Educ Program) 2003:575-89]. Blood is a complex tissue involved in a plethora of homeostatic roles, including immunity, wound healing and the transport of nourishment, electrolytes, hormones, vitamins, heat, oxygen and the removal of metabolic waste products. However, by far the principle role of blood transfusions is the replacement of red cell volume and the maintenance of oxygen levels within the circulation. Creation of investigational new drugs (INDs) which would function as oxygen carriers and prolong shelf life is now a very active arena of scientific research. Several such IND products are now in clinical trials. This article gives an easy to follow concise evaluation of major areas of focus and current testing for each type of blood substitution molecule.

Novel Spanish Translators for Acute Care Nurses and Physicians: Usefulness and Effect on Practitioners’ Stress

• Background Language barriers are significant impediments to providing quality healthcare, and increased stress levels among nurses and physicians are associated with these barriers. However, little evidence supports the usefulness of a translation tool specific to healthcare.

• Objectives To evaluate the effectiveness of a novel English-Spanish translator designed specifically for nurses and physicians. The hypothesis was that the translator would be useful and that use of the translator would decrease stress levels among nurses and physicians caring for Spanish-speaking patients.

• Methods Novel English-Spanish translators were developed entirely on the basis of input from critical care nurses and physicians. After 7 months of use, users completed surveys. Usefulness of the translator and stress levels among users were reported.

• Results A total of 60% of nurses (n = 32) and 71% (n = 25) of physicians responded to the survey. A total of 96% of physicians and 97% of nurses considered the language barrier an impediment to delivering quality care. Nurses reported significantly more stress reduction than did physicians (P = .01). Most nurses and physicians had used the translator during the survey period. Overall, 91% of nurses and 72% of physicians found that the translator met their needs at the bedside some, most, or all of the time. All nurses thought that they most likely would use the translator in the future.

• Conclusions The translator was useful for most critical care nurses and physicians surveyed. Healthcare providers, especially nurses, experienced decreased stress levels when they used the translator.

Novel spanish translators for acute care nurses and physicians: usefulness and effect on practitioners' stress

BACKGROUND

Language barriers are significant impediments to providing quality health care, and increased stress levels among nurses and physicians are associated with these barriers. However, little evidence supports the usefulness of a translation tool specific to health care.

OBJECTIVES

To evaluate the effectiveness of a novel English-Spanish translator designed specifically for nurses and physicians. The hypothesis was that the translator would be useful and that use of the translator would decrease stress levels among nurses and physicians caring for Spanish-speaking patients.

METHODS

Novel English-Spanish translators were developed entirely on the basis of input from critical care nurses and physicians. After 7 months of use, users completed surveys. Usefulness of the translator and stress levels among users were reported.

RESULTS

A total of 60% of nurses (n=32) and 71% (n=25) of physicians responded to the survey. A total of 96% of physicians and 97% of nurses considered the language barrier an impediment to delivering quality care. Nurses reported significantly more stress reduction than did physicians (P=.01). Most nurses and physicians had used the translator during the survey period. Overall, 91% of nurses and 72% of physicians found that the translator met their needs at the bedside some, most, or all of the time. All nurses thought that they most likely would use the translator in the future.

CONCLUSIONS

The translator was useful for most critical care nurses and physicians surveyed. Health care providers, especially nurses, experienced decreased stress levels when they used the translator.

Changing the paradigm for transfusing the anemic patient in an acute care environment

Blood is a precious and vital resource in medicine. Its importance in maintaining human life is second only to the oxygen it transports. Nearly 300,000 blood product transfusions occurred in Kentucky last year. While donor attrition from the pool is inevitable, recruiting efforts have resulted in an overall stable donor population in the state over the last five years. Roughly 5% of community members who are eligible to donate do so each year. Despite our effort to constantly recruit new donors, there is evidence to suggest that clinicians are less than rigorous in their efforts to conserve and to be accountable for this precious human product. For example, the indications for blood transfusions are often not documented in up to a third of the cases, and arbitrary transfusion "triggers" are often the criteria used to justify transfusion rather than the patient's clinical condition. Recent development of evidence-based criteria for prevention and treatment of anemia combined with technological advances suggest that a major paradigm shift in the clinical use of red cells is warranted.

Supplemental enteral arginine is metabolized to ornithine in injured patients1

BACKGROUND

Arginine has been added to immune enhancing diets that may improve patient outcomes, but little is known about the metabolic fate of supplemental arginine. We hypothesize that supplemental enteral arginine in injured patients is metabolized to ornithine by increased activity of the enzyme arginase.

MATERIALS AND METHODS

Twenty-five adult patients with injury severity scores > or =20 received up to 14 days of enteral nutrition supplemented with arginine (30 g/day) or placebo in a prospective, randomized, blinded study. Plasma arginine, citrulline, and ornithine concentrations and peripheral blood mononuclear cell (PBMC) arginase activity were measured at baseline and on days 1, 3, 5, 7, 10, and 14. Clinical data collected included demographics, injury patterns, lengths of stay, and infectious complications. Data were analyzed using ANOVA and t test.

RESULTS

PBMC arginase activity was elevated in all patients. In the supplemented group, plasma arginine concentrations increased at days 7, 10, and 14 when compared to baseline (P < 0.05) and were higher at day 14 when compared to those of controls (P < 0.05). Citrulline concentrations in both groups were unchanged over time. Ornithine concentration increased within 24 h of arginine supplementation and remained elevated when compared to baseline (P < 0.01). Ornithine concentration in the supplemented group was higher at days 1, 3, 5, and 7 when compared to that of controls (P < 0.05). There were no differences in clinical outcomes.

CONCLUSIONS

Supplemental enteral arginine is absorbed in injured patients and increases arginine levels. Supplemental arginine appears to be metabolized to ornithine. Increased arginase enzyme activity in peripheral blood mononuclear cells may be a contributor.

Laparoscopic Appendectomy after 30 Weeks Pregnancy: Report of Two Cases and Description of Technique

Appendicitis and pregnancy are both common conditions, and when they co-exist, both the general surgeon and obstetrician are presented with unique challenges. Acute appendicitis is the most common cause of the acute abdomen during pregnancy, effecting 0.1–0.3 per cent of pregnancies each year. With an estimated 4 million deliveries per year in the United States, there are potentially as many as 12,000 cases of acute appendicitis to be managed by the general surgeon during pregnancy (Eur J Surg 1992;158:603–6; Curr Surg 2003;60:164–73). Laparoscopic appendectomy has become a routine procedure and is now widely performed in North America. Although laparoscopic appendectomy has been discussed during pregnancy, limited data is available on the role of laparoscopic appendectomy in the third trimester of pregnancy. In fact, some authors have advocated a gestational age of 26–28 weeks to be the upper gestational limit for successful completion of laparoscopic surgery (Obstet Gynecol Surg 2001;56:50–9). In this paper, we present two recent cases of successful laparoscopic appendectomy during late pregnancy without immediate complication to mother or fetus and a description of our operative technique.