Deleterious effects of plasma-derived cellular debris in a porcine model of hemorrhagic shock

BACKGROUND

Recent studies identify large quantities of inflammatory cellular debris within Fresh Frozen Plasma (FFP). As FFP is a mainstay of hemorrhagic shock resuscitation, we used a porcine model of hemorrhagic shock and ischemia/reperfusion to investigate the inflammatory potential of plasma-derived cellular debris administered during resuscitation.

METHODS

The porcine model of hemorrhagic shock included laparotomy with 35 % hemorrhage (Hem), 45 min of ischemia from supraceliac aortic occlusion with subsequent clamp release (IR), followed by protocolized resuscitation for 6 h. Cellular debris (Debris) was added to the resuscitation phase in three groups. The four groups consisted of Hem + IR (n = 4), Hem + IR + Debris (n = 3), Hem + Debris (n = 3), and IR + Debris (n = 3). A battery of laboratory, physiologic, cytokine, and outcome data were compared between groups.

RESULTS

As expected, the Hem + IR group showed severe time dependent decrements in organ function and physiologic parameters. All animals that included both IR and Debris (Hem + IR + Debris or IR + Debris) died prior to the six-hour end point, while all animals in the Hem + IR and Hem + Debris survived. Cytokines measured at 30-60 min after initiation of resuscitation revealed significant differences in IL-18 and IL-1β between all groups.

CONCLUSIONS

Ischemia and reperfusion appear to prime the immune system to the deleterious effects of plasma-derived cellular debris. In the presence of ischemia and reperfusion, this model showed the equivalency of 100 % lethality when resuscitation included quantities of cellular debris at levels routinely administered to trauma patients during transfusion of FFP. A deeper understanding of the immunobiology of FFP-derived cellular debris is critical to optimize resuscitation for hemorrhagic shock.

A Single Hospital-Wide Antibiogram is Insufficient to Account for Differences in Antibiotic Resistance Patterns Across Multiple ICUs

BACKGROUND

Infection is a common cause of mortality within intensive care units (ICUs). Antibiotic resistance patterns and culture data are used to create antibiograms. Knowledge of antibiograms facilitates guiding empiric therapies and reduces mortality. Most major hospitals utilize data collection to create hospital-wide antibiograms. Previous studies have shown significant differences in susceptibility patterns between hospital wards and ICUs. We hypothesize that institutional or combined ICU antibiograms are inadequate to account for differences in susceptibility for patients in individual ICUs.

METHODS

Culture and susceptibility data were reviewed over a 1-year period for 13 bacteria in the following ICUs: Surgical/Trauma, Medical, Neuroscience, Burn, and Emergency department. Antibiotic management decisions are made by individual teams.

RESULTS

Nine species had sufficient data for inclusion into an All-ICU antibiogram. E coli and S aureus were the most common isolates. Seven species had significant differences in susceptibility patterns between ICUs. E cloacae showed higher rates of resistance to multiple antibiotics in the STICU than other ICUs. P aeruginosa susceptibility rates in the NSICU and BICU were 88% and 92%, respectively, compared to 60% and 55% in the STICU and MICU. Cephalosporins and Aztreonam had reduced efficacy against E coli in the NSICU, however remain effective in other ICUs.

CONCLUSIONS

The results of this study show that different ICUs do have variability in antibiotic susceptibility patterns within a single hospital. While this only represents a single institution, it shows that the use of hospital-wide antibiograms is inadequate for creating empiric antibiotic protocols within individual ICUs.

Time to Mobility Is Associated With Pulmonary Complications in Patients With Spine Fractures

INTRODUCTION

Treatment of spine fractures may require periods of prolonged immobilization which prevents effective pulmonary toileting. We hypothesized that patients with longer time to mobilization, as measured by time to first physical therapy (PT) session, would have higher pulmonary complications.

METHODS

We performed a retrospective review of all trauma patients with cervical and thoracolumbar spinal fractures admitted to a level 1 trauma center over a 12-month period. Demographic data collection included age, gender, BMI, pulmonary comorbidities, concomitant rib fractures, admission GCS, Injury Severity Score (ISS), GCS at 24 h, treatment with cervical or thoracolumbar immobilization, and time to first PT evaluation. The primary outcome was the presence of any one of the following complications: unplanned intubation, pneumonia, or mortality at 30 days. Multivariable logistic regression analysis was used to assess significant predictors of pulmonary complication.

RESULTS

In total, 491 patients were identified. In terms of overall pulmonary complications, 10% developed pneumonia, 13% had unplanned intubation, and 6% died within 30 days. In total, 19% developed one or more complication. Overall, 25% of patients were seen by PT <48 h, 33% between 48 and 96 h, 19% at 96 h to 1 week, and 7% > 1 week. Multivariable logistic regression analysis showed that time to PT session (OR 1.010, 95% CI 1.005-1.016) and ISS (OR 1.063, 95% CI 1.026-1.102) were independently associated with pulmonary complication.

CONCLUSION

Time to mobility is independently associated with pulmonary complications in patients with spine fractures.

Admission Medication Reconciliation Discrepancies in Trauma Patients: Consistent Nursing Care May Not Be the Answer

Inadvertent medication reconciliation discrepancies are common among trauma patient populations. We conducted a prospective study at a level 1 trauma center to assess incidence of inadvertent medication reconciliation discrepancies following decreased reliance on short-term nursing staff. Patients and independent sources were interviewed for home medication lists and compared to admission medication reconciliation (AMR) lists. Of the 108 patients included, 37 patients (34%) never received an AMR. Of the 71 patients that had a completed AMR, 42 patients (59%) had one or more errors, with total 154 errors across all patients, for a rate of 3.7 per patient with any discrepancy. Patients taking ≥ 5 medications were significantly more likely to have an incomplete or inaccurate AMR than those taking <5 medications (89% vs 41%, P < .0001). Decreased reliance on short-term nursing staff did not decrease inadvertent admission medication reconciliation discrepancies. Additional interventions to decrease risk of medication administration errors are needed.

Diabetes in Trauma Patients: A Potential Gateway to a Medical Home

BACKGROUND

Diabetes is a major determinant of health outcomes. Trauma patients are disproportionately from lower socioeconomic status, where lack of access to health care prevents timely treatment. Trauma centers could play a role in identifying patients in need of improved glucose management, but the current burden of disease is not known. We assessed the incidence of patients in need of intervention that presented to a level 1 trauma center over a 6-month period.

METHODS

A retrospective chart review over 6 months of all trauma patients admitted to a level 1 trauma center was performed. Patients' past medical history (PMH), medication reconciliation, and hemoglobin A1c (HbA1c) were recorded on initial assessment; patients <18 years old, lacking an HbA1c, or missing PMH were excluded. Patients with PMH of diabetes or antihyperglycemic use were classified by HbA1c: well-controlled ≤8.0% or poorly controlled >8.0%. Patients with no history of diabetes or antihyperglycemic use were classified based on their HbA1c: non-diabetic <5.7%, pre-diabetic 5.7-6.4%, and undiagnosed diabetic ≥6.5%.

RESULTS

Overall, 1377 patients were identified. After exclusion criteria, 903 patients were classified as follows: 593 (66%) non-diabetics, 160 (18%) pre-diabetics, and 150 (17%) diabetics. Fifteen diabetics were undiagnosed; 39 of the diagnosed diabetics were poorly controlled. Including pre-diabetics, a total of 214 (24%) trauma patients were in need of improved glycemic control.

DISCUSSION

One in four trauma patients would benefit from improved outpatient glycemic management, representing a missed opportunity for preventative health care. Trauma centers should develop strategies to meet this need as part of their post-discharge care.

Amyloid-β and caspase-1 are indicators of sepsis and organ injury

Background

Sepsis is a life-threatening condition that results from a dysregulated host response to infection, leading to organ dysfunction. Despite the prevalence and associated socioeconomic costs, treatment of sepsis remains limited to antibiotics and supportive care, and a majority of intensive care unit (ICU) survivors develop long-term cognitive complications post-discharge. The present study identifies a novel regulatory relationship between amyloid-β (Aβ) and the inflammasome-caspase-1 axis as key innate immune mediators that define sepsis outcomes.

Methods

Medical ICU patients and healthy individuals were consented for blood and clinical data collection. Plasma cytokine, caspase-1 and Aβ levels were measured. Data were compared against indices of multiorgan injury and other clinical parameters. Additionally, recombinant proteins were tested in vitro to examine the effect of caspase-1 on a functional hallmark of Aβ, namely aggregation.

Results

Plasma caspase-1 levels displayed the best predictive value in discriminating ICU patients with sepsis from non-infected ICU patients (area under the receiver operating characteristic curve=0.7080). Plasma caspase-1 and the Aβ isoform Aβx-40 showed a significant positive correlation and Aβx-40 associated with organ injury. Additionally, Aβ plasma levels continued to rise from time of ICU admission to 7 days post-admission. In silico, Aβ harbours a predicted caspase-1 cleavage site, and in vitro studies demonstrated that caspase-1 cleaved Aβ to inhibit its auto-aggregation, suggesting a novel regulatory relationship.

Conclusions

Aβx-40 and caspase-1 are potentially useful early indicators of sepsis and its attendant organ injury. Additionally, Aβx-40 has emerged as a potential culprit in the ensuing development of post-ICU syndrome.

Defining Pathogen and Susceptibility Patterns for Early Versus Late Ventilator Associated Pneumonia in Trauma Patients to Guide Empiric Treatment Decisions

INTRODUCTION

Studies have demonstrated that trauma patients with early-ventilator associated pneumonia (early-VAP, < 7 days) have decreased risk of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa infections. We hypothesize that routinely using broad-spectrum antibiotics is unnecessary to treat trauma patients with the diagnosis of early-VAP.

METHODS

This retrospective cohort study included adult trauma patients with the diagnosis of VAP. The primary outcome was the presence of MRSA and/or P. aeruginosa in patients with early- and late-VAP. Secondary outcomes included the bacterial susceptibility of pathogens to methicillin, ampicillin/sulbactam, ceftriaxone, piperacillin/tazobactam, and cefepime. Intensive care unit (ICU) and hospital length of stay (LOS), ventilator-free days, and in-hospital mortality were also collected.

RESULTS

164 patients met inclusion criteria, and 208 organisms (n = 90 early vs n = 118 late) were identified by respiratory culture. The incidence of MRSA and P. aeruginosa in early-VAP was 7.7% (7/90) and 5.6% (5/90), respectively. The susceptibility of bacteria causing early-VAP to ampicillin/sulbactam and ceftriaxone was 73.3% (66/90) and 83.3% (75/90), respectively. Ventilator-free days at 30 days was similar between groups (P = .649). Patients with late-VAP spent more time in the ICU (P = .040); however, in-hospital mortality was higher in the early-VAP group (P = .012).

CONCLUSIONS

Ampicillin/sulbactam or ceftriaxone monotherapy did not provide reliable broad-spectrum coverage for early-VAP in our cohort. These findings highlight the importance of each institution performing a similar analysis to ensure adequate initial treatment of VAP.

Implementing a Discharge Opioid Bundle in Adult Trauma Patients Decreases the Amount of Opioids Prescribed at Discharge

BACKGROUND

Opioids remain the mainstay treatment of acute pain caused by trauma. The lack of evidence driven prescribing creates a challenging situation for providers. We hypothesized that the implementation of a trauma discharge opioid bundle (TDOB) would decrease the total morphine milligram equivalents (MME) prescribed at discharge while maintaining pain control.

METHODS

This was a pre-post study of adult trauma patients before and after implementation of a TDOB to guide the prescription of opioids and discharge prescription education in patients discharged from a level one trauma center. The pre-group and post-group, included consecutively discharged patients from September through November in 2018 and 2019. The primary outcome was the total MME prescribed at discharge.

RESULTS

A total of 377 patients met inclusion criteria. One hundred and fifty-one patients were included in the pre-group and 226 in the post-group. The total MME prescribed at discharge (225 ± [150-300] pre vs 200 ± [100-225] post, P = < .001) and maximum MME/day (45 ± [30-45] vs 30 ± [20-45], P = .004) were significantly less in the post-group. Incidence of outpatient refills within fourteen days were similar. More non-opioid pain adjuncts were prescribed post-intervention and discharge pain education was provided more frequently.

CONCLUSION

The implementation of a TDOB significantly reduced the MME prescribed at discharge without increasing the number of opioid refills.

Effects of the COVID-19 Pandemic on the Trauma Population in a Level 1 Trauma Center

In this study, we evaluated the effects of the pandemic on our trauma population. We performed a retrospective review of the trauma registry in the 2 years prior, and then 2 years during the pandemic. We evaluated age, race, gender, injury severity score (ISS), mechanism of trauma, rate of self-inflicted injury, rate of gunshot wounds (GSW), presence of EtOH, drug screen results, mortality, rate of burn traumas, and zip code of residence. Our query captured 5 054 patients before, and 5 731 during the pandemic. We found no statistical difference in age, gender, mechanism of trauma, rate of self-inflicted injuries, and mortality during the pandemic when compared to before. There were statistically significant differences in race, ISS, rate of GSWs, EtOH use, drug screen results, and burn traumas. Geospatial mapping found a rise in GSWs for zip code 36606. Gun violence and substance use rose in our trauma population during COVID-19.

Project Inspire pilot study: A hospital-led comprehensive intervention reduces gun violence among juveniles delinquent of gun crimes

BACKGROUND

Gun violence disproportionately affects young Black men, but the impact extends to families and communities. Those at highest risk are teens delinquent of gun crimes. While there is no nationally accepted juvenile rate of recidivism, previous literature reveals rearrest rates from 50% to 80% in high-risk youth, and some reports show that up to 40% of delinquent juveniles are incarcerated in adult prisons before the age of 25 years. We hypothesize that Project Inspire, a hospital-led comprehensive intervention, reduces recidivism among high-risk teens.

METHODS

Led by a level 1 trauma center, key community stakeholders including the juvenile court, city, and city police department joined forces to create a community-wide program aimed at curbing gun violence in high-risk individuals. Participants, aged 13 to 18 years, are selected by the juvenile gun court. They underwent a rigorous 3-week program with a curriculum incorporating the following: trauma-informed training and confidence building, educational/professional development, financial literacy, entrepreneurship, and career-specific job shadowing and mentorship. Rates of recidivism were measured annually.

RESULTS

Project Inspire has hosted two classes in 2018 and 2019, graduating nine participants aged 14 to 17 years. Sixty-seven percent were Black. All were males. At 1 year, none of the graduates reoffended. At 2 years, one participant reoffended. At 3 years, no additional participants reoffended. No graduate reoffended as a juvenile. Thus, the overall rate of recidivism for Project Inspire is 11% to date. Eighty-nine percent of graduates received a diploma, general educational development, or obtained employment.

CONCLUSION

Project Inspire is a hospital-led initiative that effectively reduces recidivism among juveniles delinquent of gun crimes. This sets the framework for trauma centers nationwide to lead in establishing impactful, comprehensive, gun-violence intervention strategies.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level V.

Treatment of Chronic Hypertrophic Burn Scars With a Fractional CO 2 Laser Is Well Tolerated in an Outpatient Clinic Setting

INTRODUCTION

The necessity of treating hypertrophic burn scars has expanded significantly with increased burn survivorship. Ablative lasers, such as carbon dioxide (CO 2 ) lasers, have been the most common nonoperative option for improving functional outcomes in severe recalcitrant hypertrophic burn scars. However, the overwhelming majority of ablative lasers used for this indication require a combination of systemic analgesia, sedation, and/or general anesthesia due to the painful nature of the procedure. More recently, the technology of ablative lasers has advanced and is more tolerable than their first-generation counterparts. Herein, we hypothesized that refractory hypertrophic burn scars can be treated by a CO 2 laser in an outpatient clinic.

METHODS

We enrolled 17 consecutive patients with chronic hypertrophic burn scars that were treated with a CO 2 laser. All patients were treated in the outpatient clinic with a combination of a topical solution (23% lidocaine and 7% tetracaine) applied to the scar 30 minutes before the procedure, Cryo 6 air chiller by Zimmer, and some patients received a mixture of N 2 O/O 2 . Laser treatments were repeated every 4 to 8 weeks until the patient's goals were met. Each patient completed a standardized questionnaire to assess tolerability and patient satisfaction of functional results.

RESULTS

All patients tolerated the laser well in the outpatient clinic setting, with 0% indicating "not tolerable," 70.6% "tolerable," and 29.4% "very tolerable." Each patient received more than 1 laser treatment for the following complaints: decreased range of motion (n = 16, 94.1%), pain (n = 11, 64.7%), or pruritis (n = 12, 70.6%). Patients were also satisfied with the results of the laser treatments ("no improvement or worsened" = 0%, "improved" = 47.1%, and "significant improvement" = 52.9%). The age of patient, type of burn, location of burn, presence of skin graft, or age of scar did not significantly affect the tolerability of treatment or satisfaction of outcome.

CONCLUSIONS

The treatment of chronic hypertrophic burn scars with a CO 2 laser is well tolerated in an outpatient clinic setting in select patients. Patients reported a high level of satisfaction with notable improvement in functional and cosmetic outcomes.

Identifying Radiographic and Clinical Indicators to Reduce the Occurrence of Nontherapeutic Laparotomy for Blunt Bowel and Mesenteric Injury

BACKGROUND

Roughly 5% of patients with blunt abdominal trauma (BAT) have a blunt bowel and/or mesenteric injury (BBMI). Determining the need for operative management in these patients can be challenging when hemodynamically stable. Single center studies have proposed scoring systems based on CT findings to guide management. Our study aimed to determine the predictability of abdominopelvic CT scan (CT A/P) findings in conjunction with clinical exam to determine the necessity of operative intervention for BBMI.

METHODS

Patients presenting from 2017 to 2022 to the University of South Alabama Level 1 Trauma Center after motor vehicle collision were retrospectively reviewed. Patients with CT findings suggestive of BBMI were further analyzed, noting CT findings, Glasgow coma scale (GCS), shock index, abdominal exam, operative or nonoperative management, and intraoperative intervention.

RESULTS

1098 patients with BAT underwent CT A/P. 139 patients had ≥1 finding suggestive of BBMI. 38 patients underwent surgical exploration and 30 had surgically confirmed BBMI. 27 patients required intervention for BBMI. Univariate analysis indicated that pneumoperitoneum (p < 0.0001), active extravasation of contrast (p = 0.0001), hemoperitoneum without solid organ injury (SOI) (p < 0.0001), peritonitis (p < 0.0001), and mesenteric stranding(p < 0.05) were significantly associated with intervention.

CONCLUSION

In total, 30 patients had surgically confirmed BBMI. Active extravasation, pneumoperitoneum, hemoperitoneum without SOI, mesenteric stranding, and peritonitis were significant indicators of BBMI requiring intervention. CT and clinical findings cannot reliably predict the need for surgical intervention without ≥1 of these findings. Initial nonoperative management with serial clinical exams should be strongly considered to reduce incidence of nontherapeutic laparotomies.

Blunt Cerebrovascular Injury (BCVI) Management: Is There a Right Answer?

Blunt cerebrovascular injury (BCVI) results from blunt trauma causing injury to the carotid and/or vertebral arteries. Its most severe manifestation is stroke. The purpose of this study was to evaluate the incidence, management, and outcomes of BCVI at a level one trauma/stroke center. Data on patients diagnosed with BCVI from 2016 to 2021 were extracted from the USA Health trauma registry with associated intervention performed and patient outcomes. Of the 97 patients identified, 16.5% presented with stroke-like symptoms (SS). Medical management was employed for 75%. Intravascular stent alone was utilized for 18.8%. The mean age of symptomatic BCVI patients was 37.6 with a mean injury severity score (ISS) of 38.2. Within the asymptomatic population, 58% received medical management and 3.7% underwent combination therapy. The mean age of asymptomatic BCVI patients was 46.9 with a mean ISS of 20.3. There were 6 mortalities, only one BCVI related.

Social Determinants of Health Impact Physical Recovery After Blunt Injury

As defined by the United States Department of Health and Human Services, the Social Determinants of Health (SDOH) are conditions in the environment that affect health function and outcomes. The SDOH are divided into the following categories: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community content. It is known that SDOH impact long-term health outcomes. The influence that SDOH have on physical recovery after acute injury is less understood, however. In this study, patients who suffered a traumatic blunt injury completed a survey 12-14 months post-injury to assess their SDOH and physical health before and after their injury. The results showed that for the cohort of patients studied SDOH was the greatest predictor of long-term recovery, having a stronger correlation with recovery than injury severity score (ISS) or hospital length of stay (HLOS).

Incidence and Severity of Medication Reconciliation Discrepancies in Trauma Patients

Trauma patients are especially vulnerable to inadvertent medication reconciliation discrepancies. We conducted a prospective study to evaluate the USA Health University Hospital's incidence and type of inadvertent medication reconciliation discrepancies among trauma patients. Patients were interviewed for accuracy of their admission medication reconciliation (AMR). Eighty-nine patients were included in this study. Twenty-six patients (29%) never received an AMR. There were 107 inadvertent medication reconciliation errors identified from 30 separate patients (48%), for a rate of 3.6 errors per patient with any error. There was a significant difference in the frequency of inadvertent medication reconciliation discrepancies for patients with >5 medication compared to those with fewer (P = .00029). In conclusion, trauma centers must be adequately staffed to provide timely, accurate, and available medication lists so that patients can be appropriately cared for.

Incidence and Outcomes of Undiagnosed and Untreated Diabetes Mellitus in Trauma Patients

Diabetes is a major determinate for mortality in trauma patients. Many diabetics are undiagnosed or poorly controlled. Trauma patients disproportionately come from lower socioeconomic status, making missed diagnoses more likely. We aimed to quantify the incidence of undiagnosed or poorly controlled diabetics assessed at a Level 1 Trauma Center. We did a retrospective chart review of admitted trauma patients over a one-month period. Past Medical History, home medication lists, and Hemoglobin A1c on admission were recorded for each patient. We determined that 30 of 173 trauma patients qualifying for the study were diabetic. Furthermore, 30% of these diabetics were undiagnosed or had poorly controlled diabetes. Undiagnosed pre-diabetics made up 20% of the entire study group. Our data show that 26% of trauma patients would benefit from an intervention for improved glucose control. Trauma centers should consider creating routine clinical practice guidelines to identify at-risk patients and provide intervention for long-term management.

Survey of venous thromboembolism prophylaxis in trauma patients: current prescribing practices and concordance with clinical practice guidelines

Objectives

Pharmacological venous thromboembolism (VTE) prophylaxis is recommended in the vast majority of trauma patients. The purpose of this study was to characterize current dosing practices and timing of initiation of pharmacological VTE chemoprophylaxis at trauma centers.

Methods

This was an international, cross-sectional survey of trauma providers. The survey was sponsored by the American Association for the Surgery of Trauma (AAST) and distributed to AAST members. The survey included 38 questions about practitioner demographics, experience, level and location of trauma center, and individual/site-specific practices regarding the dosing, selection, and timing of initiation of pharmacological VTE chemoprophylaxis in trauma patients.

Results

One hundred eighteen trauma providers responded (estimated response rate 6.9%). Most respondents were at level 1 trauma centers (100/118; 84.7%) and had >10 years of experience (73/118; 61.9%). While multiple dosing regimens were used, the most common dose reported was enoxaparin 30 mg every 12 hours (80/118; 67.8%). The majority of respondents (88/118; 74.6%) indicated adjusting the dose in patients with obesity. Seventy-eight (66.1%) routinely use antifactor Xa levels to guide dosing. Respondents at academic institutions were more likely to use guideline-directed dosing (based on the Eastern Association of the Surgery of Trauma and the Western Trauma Association guidelines) of VTE chemoprophylaxis compared with those at non-academic centers (86.2% vs 62.5%; p=0.0158) and guideline-directed dosing was reported more often if the trauma team included a clinical pharmacist (88.2% vs 69.0%; p=0.0142). Wide variability in initial timing of VTE chemoprophylaxis after traumatic brain injury, solid organ injury, and spinal cord injuries was found.

Conclusions

A high degree of variability exists in prescribing and monitoring practices for the prevention of VTE in trauma patients. Clinical pharmacists may be helpful on trauma teams to optimize dosing and increase prescribing of guideline-concordant VTE chemoprophylaxis.

Association Between Adverse Childhood Experiences and Posttraumatic Stress Disorder Symptoms in Adults With Injury

This case-control study examines the risk factors associated with acute stress disorder in patients with severe injury.

601 Bromelain Based Enzymatic Debridement Followed by Application of Autologous Cell Suspension for Treatment of Burns

Introduction

Bromelain based enzymatic debridement has been shown to have a unique selectivity for nonviable tissue and is being evaluated for its use in the treatment of select burn wounds. The treatment has potential to augment more traditional operative eschar excision. Herein, we retrospectively review our tertiary burn center’s early experiences in cases in which bromelain based enzymatic debridement (BBED) is paired with autologous cell suspension (ACS).

Methods

Patients whose burn wounds were deemed eligible for BBED at our institution from July 2020 to June 2021 were queried for concurrent treatment with ACS. Inclusion criteria by study design consisted of 18 years of age or older, non-electrical and non-chemical burns, predominance of deep partial and/or full thickness burn, and less than 30% total body surface area. Success of escharotomy by BBED, grafting methods, infections, transfusions, inflammatory response, and response to grafting were analyzed.

Results

Seven patients met inclusions criteria from July 2020 to June 2021. The mean age was 44 (IQR: 39-53). The mean TBSA was 13.7% (IQR 8-20). The mean time from injury to BBED was 2.1 days (IQR 1.5-2.0). The mean time to ACS after BBED was 1.3 days (IQR 1.0-1.5). The mean area debrided with BBED was 2347 sq cm (IQR 1367-3534). All patients were determined to have complete eschar removal on the day of application by the multidisciplinary burn team. All seven cases had deep partial thickness areas treated with ACS alone, with a mean area of 1574sq cm (IQR 877-2327). The total area treated was 11,016 sq cm. Only two patients required delayed grafting, a combined total of 1573 sq cm, meaning that 86% of the total burn area treated with ACS alone was recovered. Five patients had ACS paired with split thickness autografts, with a mean area of 867 sq cm (IQR 519-1328). Graft imbibition was noted to be rapid with >95% wound closure by postoperative day eight. There were no graft infections, and no transfusions required. White blood cell (WBC) counts decreased after BBED, then increased marginally after grafting. Only two patients had WBC >20,000 and this aided in diagnosis of one donor site infection and one pneumonia.

Conclusions

In our series, BBED within three days of injury paired with ACS within two days of BBED resulted in excellent split thickness graft take and recovery of 86% of the burn wounds treated with ACS alone.

ExoU Induces Lung Endothelial Cell Damage and Activates Pro-Inflammatory Caspase-1 during Pseudomonas aeruginosa Infection

The Gram-negative, opportunistic pathogen Pseudomonas aeruginosa utilizes a type III secretion system to inject exoenzyme effectors into a target host cell. Of the four best-studied exoenzymes, ExoU causes rapid cell damage and death. ExoU is a phospholipase A₂ (PLA₂) that hydrolyses host cell membranes, and P. aeruginosa strains expressing ExoU are associated with poor outcomes in critically ill patients with pneumonia. While the effects of ExoU on lung epithelial and immune cells are well studied, a role for ExoU in disrupting lung endothelial cell function has only recently emerged. Lung endothelial cells maintain a barrier to fluid and protein flux into tissue and airspaces and regulate inflammation. Herein, we describe a pulmonary microvascular endothelial cell (PMVEC) culture infection model to examine the effects of ExoU. Using characterized P. aeruginosa strains and primary clinical isolates, we show that strains expressing ExoU disrupt PMVEC barrier function by causing substantial PMVEC damage and lysis, in a PLA₂-dependent manner. In addition, we show that strains expressing ExoU activate the pro-inflammatory caspase-1, in a PLA₂-dependent manner. Considering the important roles for mitochondria and oxidative stress in regulating inflammatory responses, we next examined the effects of ExoU on reactive oxygen species production. Infection of PMVECs with P. aeruginosa strains expressing ExoU triggered a robust oxidative stress compared to strains expressing other exoenzyme effectors. We also provide evidence that, intriguingly, ExoU PLA₂ activity was detectable in mitochondria and mitochondria-associated membrane fractions isolated from P. aeruginosa-infected PMVECs. Interestingly, ExoU-mediated activation of caspase-1 was partially inhibited by reactive oxygen species scavengers. Together, these data suggest ExoU exerts pleiotropic effects on PMVEC function during P. aeruginosa infection that may inhibit endothelial barrier and inflammatory functions.

Cryoablation for Chest Wall Trauma: A Brief Report

Respiratory failure secondary to rib fractures is a major source of morbidity and mortality in trauma patients, particularly in older populations. Management of pain in these patients is complex due to the nature of the injuries. We present 3 patients who underwent a video-assisted thoracoscopic cryoablation of intercostal nerves for pain control after chest trauma. None of the patients developed post-operative complications related to poor respiratory status such as pneumonia or atelectasis. At one-month clinic follow-up, all patients reported no chest pain and were not using opiate analgesics. In patients for whom there is a contraindication to rib fixation in the setting of unstable rib fractures, cryoablation may be a method by which to improve respiratory status and decrease ventilator dependency due to pain. Cryoablation of intercostal nerves may provide a more durable and clinically feasible solution to aid in the healing process of these patients.

The Relationship between Serum Sodium, Serum Osmolality, and Intracranial Pressure in Patients with Traumatic Brain Injury Treated with Hyperosmolar Therapy

BACKGROUND

Treatment of elevated intracranial pressure (ICP) in traumatic brain injury (TBI) is controversial. Hyperosmolar therapy is used to prevent cerebral edema in these patients. Many intensivists measure direct correlates of these agents-serum sodium and osmolality. We seek to provide context on the utility of using these measures to estimate ICP in TBI patients.

MATERIALS AND METHODS

Patients admitted with TBI who required ICP monitoring from 2008 to 2012 were included. Intracranial pressure, serum sodium, and serum osmolality were assessed prior to hyperosmotic therapy then at 6, 12, 18, 24, 48, and 72 hours after admission. A linear regression was performed on sodium, osmolality, and ICP at baseline and serum sodium and osmolality that corresponded with ICP for 6-72-hour time points.

RESULTS

136 patients were identified. Patients with initial measures were included in the baseline analysis (n = 29). Patients who underwent a craniectomy were excluded from the 6-72-hour analysis (n = 53). Initial ICP and serum sodium were not significantly correlated (R2 .00367, P = .696). Initial ICP and serum osmolality were not significantly correlated (R2 .00734, P = .665). Intracranial pressure and serum sodium 6-72 hours after presentation were poorly correlated (R2 .104, P < .0001), as were ICP and serum osmolality at 6-72 hours after presentation (R2 .116, P < .0001).

DISCUSSION

Our results indicate initial ICP is not correlated with serum sodium or osmolality suggesting these are not useful initial clinical markers for ICP estimation. The association between ICP and serum sodium and osmolality after hyperosmolar therapy was poor, thus may not be useful as surrogates for direct ICP measurements.

Reducing Health Care Burden of Emergency General Surgery with a 24-Hour Dedicated Emergency General Surgery Service

BACKGROUND

Emergency general surgery (EGS) diagnoses account for 11% of surgical admissions and 50% of surgical mortality. In this population, 7 specific operations are associated with 80.3% of deaths, 78.9% of complications, and 80.2% of hospital costs. In 2016, our institution established a comprehensive in-house EGS service. Herein, we hypothesize that formation of a dedicated EGS service is associated with a significant reduction in morbidity for patients undergoing the most common EGS procedures.

METHODS

All patients undergoing one of the most common EGS procedures within 2 days of admission were identified from 1/1/2013 to 5/9/2019 via a retrospective chart review. Patients were cohorted as pre- and post-EGS implementation. The primary outcome measure was the overall complication rate. Secondary endpoints included mortality, individual complication rate, time to operation, overnight operation, and length of stay. Finally, both cohorts were benchmarked to national outcomes.

RESULTS

718 patients met inclusion criteria (pre-EGS = 409 and post-EGS = 309). Overall complication rate decreased significantly (19.8% vs 13.9%, P = .0387) and overnight operations increased significantly in the post-EGS group (7.8%-16.5%, P = .0003). Pre-EGS complications were higher than national data in all but 1 procedure group, whereas post-EGS complications rates were lower in all but 2 categories.

DISCUSSION

Implementation of a dedicated EGS service line was associated with a significant decrease in complication rate among the most complication-prone EGS procedures. Number of operations within 24 hours did not increase significantly; however, overnight operations did increase. Our results indicate that establishing a service-specific EGS line is reasonable and beneficial.

Unexpected Diaphragmatic Hernia Among Patients Undergoing Video-Assisted Thoracic Surgery for Internal Fixation of Rib Fractures

Traumatic blunt diaphragm injuries are a diagnostic challenge in trauma. They may be missed due to the increasing trend of non-operative management of patients. The purpose of this study was to review the rate of occult blunt diaphragm injuries in patients who underwent video assisted thoracic surgery (VATS) for rib fixation. This retrospective study included patients that received VATS as part of our institutional protocol for rib fracture management. This includes utilizing incentive spirometry, multimodal analgesia, and early consideration for VATS. Data was abstracted from the electronic medical record and included demographics, operative findings, and outcomes. Thirty patients received VATS per our rib fracture protocol. No patients had any identified diaphragm injury on pre-operative imaging. A concomitant diaphragm injury was identified in 20% (6/30) of the study population. All patients were alive at 30 days. For all patients, total hospital length of stay was 14.5 days, ICU length of stay was 8.9 days, and average ventilator days was 4.2 days. When comparing patients with and without concomitant diaphragm injuries, hospital length of stay was 16.8 days vs. 14.5 (P = 0.59), ICU length of stay was 11.8 days vs. 8.2 (P = 0.54), and ventilator days was 4.5 days vs. 4.2 (P = 0.93). This study revealed that 20% of patients undergoing VATS for rib fracture fixation had a concomitant diaphragm injury. This higher-than-expected prevalence suggests that groups of patients sustaining blunt trauma may have occult diaphragmatic injuries that are otherwise unidentified. This raises the need for improved diagnostic modalities to identify these injuries.

Analysis of Plasma Products for Cellular Contaminants: Comparing Standard Preparation Methods

BACKGROUND

Recent reports suggest that component plasma products contain significant quantities of cellular contamination. We hypothesized that leukoreduction of whole blood before preparation of derived plasma is an effective method to prevent cellular contamination of stored plasma.

STUDY DESIGN

Samples of never-frozen liquid plasma prepared by standard methods (n = 25) were obtained from 3 regional blood centers that supply 3 major trauma centers. Samples were analyzed for leukocyte and platelet contamination by flow cytometry. To determine if leukoreduction of whole blood before centrifugation and expression of plasma prevents cellular contamination of liquid plasma, 1 site generated 6 additional units of liquid plasma from leukoreduced whole blood, which were then compared with units of liquid plasma derived by standard processing.

RESULTS

Across all centers, each unit of never-frozen liquid plasma contained a mean of 12.8 ± 3.0 million leukocytes and a mean of 4.6 ± 2 billion platelets. Introduction of whole blood leukoreduction (LR) before centrifugation and plasma extraction essentially eliminated all contaminating leukocytes (Non-LR: 12.3 ± 2.9 million vs LR: 0.05 ± 0.05 million leukocytes) and platelets (Non-LR: 4.2 ± 0.3 billion platelets vs LR: 0.00 ± 0.00 billion platelets).

CONCLUSIONS

Despite widespread belief that stored plasma is functionally acellular, testing of liquid plasma from 3 regional blood banks revealed a significant amount of previously unrecognized cellular contamination. Introduction of a leukoreduction step before whole blood centrifugation essentially eliminated detectable leukocyte and platelet contaminants from plasma. Therefore, our study highlights a straightforward and cost-effective method to eliminate cellular contamination of stored plasma.

Do Internal or External Characteristics More Reliably Predict Burnout in Resident Physicians: A Multi-institutional Study

INTRODUCTION

Surgical residents have been shown to experience high rates of burnout. Whether this is influenced predominately by intrinsic characteristics, external factors, or is multifactorial has not been well studied. The aim of this study was to explore the relationship between these elements and burnout. We hypothesized that residents with higher emotional intelligence scores, greater resilience and mindfulness, and better work environments would experience lower rates of burnout.

METHODS

General surgery residents at 7 sites in the US were invited to complete an electronic survey in 2019 that included the 2-item Maslach Burnout Inventory, Brief Emotional Intelligence Scale, Revised Cognitive and Affective Mindfulness Scale, 2-Item Connor-Davidson Resilience Scale, Utrecht Work Engagement Scale, and Job Resources scale of the Job Demands-Resources Questionnaire. Individual constructs were assessed for association with burnout, using multivariable logistic regression models. Residents' scores were evaluated in aggregate, in groups according to demographic characteristics, and by site.

RESULTS

Of 284 residents, 164 completed the survey (response rate 58%). A total of 71% of respondents were at high risk for burnout, with sites ranging from 57% to 85% (p = 0.49). Burnout rates demonstrated no significant difference across gender, PGY level, and respondent age. On bivariate model, no demographic variables were found to be associated with burnout, but the internal characteristics of emotional intelligence, resilience and mindfulness, and the external characteristics of work engagement and job resources were each found to be protective against burnout (p < 0.001 for all). However, multivariable models examining internal and external characteristics found that no internal characteristics were associated with burnout, while job resources (coeff. -1.0, p-value <0.001) and work engagement (coeff. -0.76, p-value 0.032) were significantly protective factors. Rates of engagement overall were high, particularly with respect to work "dedication."

CONCLUSIONS

A majority of residents at multiple institutions were at high risk for burnout during the study period. Improved work engagement and job resources were found to be more strongly associated with decreased burnout rates when compared to internal characteristics. Although surgical residents appear to already be highly engaged in their work, programs should continue to explore ways to increase job resources, and further research should be aimed at elucidating the mediating effect of internal characteristics on these external factors.

Neuroleptic Malignant Syndrome: A Potential Etiology of Multisystem Organ Failure in a Burn Patient

Neuroleptic malignant syndrome (NMS) is described in the medical literature but rarely seen among acutely ill trauma patients. A 44-year-old man with burns to the hands and back after a chemical explosion was transported to an outside facility where he received treatment for presumed acute coronary syndrome after developing ventricular tachycardia and elevated serum troponins after the exposure. His cardiac catheterization was unremarkable, but an echocardiogram revealed severe cardiomyopathy, and he was also in multisystem organ failure. He was transferred to our facility after hospital day 2 for treatment of his multisystem organ failure and 2% total body surface area burns. His laboratory results were remarkable for a creatine kinase of >100 000 units/L, and he required 14 g of intravenous calcium. Upon further investigation, the patient reported taking ziprasidone for his bipolar disorder, and he had a core temperature of 103.5 °F on his initial presentation to the outside facility. As he convalesced, the unifying diagnosis was NMS. NMS is a side effect of antipsychotic therapy and is manifested by hyperpyrexia, rigidity, autonomic instability, and altered consciousness. An elevated creatine kinase >100 000 units/L is almost pathognomonic for NMS. Patients can also present with leukocytosis, organ failure, and electrolyte disturbances including hypocalcemia. We hypothesized that dehydration, the warm environmental conditions at our patient's job, and immense stress resulting in a catecholamine surge following his trauma were inciting triggers to this event. This case highlights the importance of considering alternate diagnoses in patients whose clinical presentation does not fit the most "obvious cause."

The Treatment of Rib Fractures : A Single-Center Comparison

BACKGROUND

Rib fractures are a major problem characterized by pain, increased length of stay, and respiratory complications. Treatments include fixation, management with opiates, paraspinous local anesthetic pumps, and intercostal nerve blocks. The aim of this study was to evaluate the use of treatment options and compare clinically relevant outcomes.

METHODS

Patients admitted to a Level 1 trauma center with multiple rib fractures between 2015 and 2019 were screened. We included all participants treated with surgical fixation and/or intercostal nerve block or local anesthetic pump. Patients were case-matched 1:2 by Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) Chest and Head, age, and number of rib fractures. Outcomes assessed were hospital length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, pneumonia, and tracheostomy rates.

RESULTS

We identified 25 patients who received rib fixation and intercostal analgesia. Of these, 14 cases were treated with liposomal bupivaicaine nerve block and 11 by paraspinous catheter block. Fifty control cases treated with opiates were identified. All patients survived to discharge. Cases and controls were approximately equivalent in age, ISS, number of fractured ribs, chest AIS, and head AIS. Rib-plated patients had a lower rate of pneumonia (OR 0.2029, 95% CI 0.0242, 0.09718), decreased average ICU LOS (10.62 vs 6.64, P = .018), and decreased average ventilator days (5.44 vs 1.68, P = .003).

DISCUSSION

Findings suggest more aggressive treatment of rib fractures may decrease ICU LOS, ventilator days, and pneumonia in patients with multiple rib fractures. These findings are in line with current literature; however, more research is needed in this area.

Plasma mitochondrial DNA is elevated in obese type 2 diabetes mellitus patients and correlates positively with insulin resistance

Cells damaged by mechanical or infectious injury release proinflammatory mitochondrial DNA (mtDNA) fragments into the circulation. We evaluated the relation between plasma levels of mtDNA fragments in obese type 2 diabetes mellitus (T2DM) patients and measures of chronic inflammation and insulin resistance. In 10 obese T2DM patients and 12 healthy control (HC) subjects, we measured levels of plasma cell-free mtDNA with quantitative real-time polymerase chain reaction, and mtDNA damage in skeletal muscle with quantitative alkaline Southern blot. Also, markers of systemic inflammation and oxidative stress in skeletal muscle were measured. Plasma levels of mtDNA fragments, mtDNA damage in skeletal muscle and plasma tumor necrosis factor α levels were greater in obese T2DM patients than HC subjects. Also, the abundance of plasma mtDNA fragments in obese T2DM patients levels positively correlated with insulin resistance. To the best of our knowledge, this is the first published evidence that elevated level of plasma mtDNA fragments is associated with mtDNA damage and oxidative stress in skeletal muscle and correlates with insulin resistance in obese T2DM patients. Plasma mtDNA may be a useful biomarker for predicting and monitoring insulin resistance in obese patients.

Enhanced Mitochondrial DNA Repair Resuscitates Transplantable Lungs Donated After Circulatory Death

BACKGROUND

Transplantation of lungs procured after donation after circulatory death (DCD) is challenging because postmortem metabolic degradation may engender susceptibility to ischemia-reperfusion (IR) injury. Because oxidative mitochondrial DNA (mtDNA) damage has been linked to endothelial barrier disruption in other models of IR injury, here we used a fusion protein construct targeting the DNA repair 8-oxoguanine DNA glycosylase-1 (OGG1) to mitochondria (mtOGG1) to determine if enhanced repair of mtDNA damage attenuates endothelial barrier dysfunction after IR injury in a rat model of lung procurement after DCD.

MATERIALS AND METHODS

Lungs excised from donor rats 1 h after cardiac death were cold stored for 2 h after which they were perfused ex vivo in the absence and presence of mt-OGG1 or an inactive mt-OGG1 mutant. Lung endothelial barrier function and mtDNA integrity were determined during and at the end of perfusion, respectively.

RESULTS AND CONCLUSIONS

Mitochondria-targeted OGG1 attenuated indices of lung endothelial dysfunction incurred after a 1h post-mortem period. Oxidative lung tissue mtDNA damage as well as accumulation of proinflammatory mtDNA fragments in lung perfusate, but not nuclear DNA fragments, also were reduced by mitochondria-targeted OGG1. A repair-deficient mt-OGG1 mutant failed to protect lungs from the adverse effects of DCD procurement.

CONCLUSIONS

These findings suggest that endothelial barrier dysfunction in lungs procured after DCD is driven by mtDNA damage and point to strategies to enhance mtDNA repair in concert with EVLP as a means of alleviating DCD-related lung IR injury.

Plasma Transfusion Products and Contamination with Cellular and Associated Pro-Inflammatory Debris

BACKGROUND

Stored plasma products are widely regarded as being functionally acellular, obviating the need for leukoreduction. We tested the hypothesis that donor plasma is contaminated by leukocytes and platelets, which, after frozen storage, would release cellular debris in quantities sufficient to elicit significant pro-inflammatory responses.

STUDY DESIGN

Samples of never-frozen liquid plasma from 2 regional Level I trauma centers were analyzed for leukocyte and platelet contamination. To determine if the cellular contamination and associated debris found in liquid plasma were at levels sufficient to evoke an innate immune response, known quantities of leukocytes were subjected to a freeze-thaw cycle, added to whole blood, and the magnitude of the inflammatory response was determined by induction of interleukin-6.

RESULTS

Units of never-frozen plasma from 2 regional Level I trauma centers located in Alabama and Louisiana contained significant amounts of leukocyte contamination (Louisiana, n = 22; 17.3 ± 4.5 million vs Alabama, n = 22; 11.3 ± 2.2 million) and platelet contamination (Louisiana, n = 21; 0.86 ± 0.20 billion vs Alabama, n = 22; 1.0 ± 0.3 billion). Cellular debris from as few as 1 million leukocytes induced significant increases in interleukin-6 levels (R² = 0.74; p < 0.0001).

CONCLUSIONS

Stored plasma units from trauma center blood banks were highly contaminated with leukocytes and platelets, at levels more than 15-fold higher than sufficient to elicit ex vivo inflammatory responses. In light of paradigm shifts toward the use of more empiric plasma for treatment of hypovolemia, this study suggests that new manufacturing and quality-control processes are needed to eliminate previously unrecognized cellular contamination present in stored plasma products.

Early Assessment of Burn Depth with Far Infrared Time-Lapse Thermography

BACKGROUND

Diagnosing the extremes of superficial burns and full-thickness burns is straightforward. It is in the middle ground of partial-thickness burns where the diagnostic difficulties emerge; it can take up to 3 to 5 days for signs of healing to appear. We hypothesize that cooling partial-thickness burns and tracking the rate of rewarming will immediately reflect the condition of the burn: shallow partial-thickness burns that retain cell health and blood flow will rewarm rapidly, and deeper burns with damaged microvessels will rewarm slowly.

STUDY DESIGN

We enrolled 16 patients with isolated, partial-thickness burns on their extremities who were diagnosed as indeterminate by our burn surgeon. Within 24 hours after presentation, room-temperature saline was poured over the burn as a cooling challenge. An infrared camera that was sensitive to body temperature produced false-color images showing pixel-by-pixel temperatures. A time-lapse recording from the infrared camera images taken as the burn rewarmed produced a time-temperature curve that reflected the kinetics of rewarming. The outcomes variable was whether or not the patient received a skin graft, which was determined 72 hours after presentation.

RESULTS

The method correctly predicted whether or not the patient required a skin graft.

CONCLUSIONS

Here we report a new technique that permits determination of wound viability much earlier than clinical examination. Due to the simplicity of the method, non-experts can successfully perform the technique on the first day of the burn and make the correct diagnosis and decision to graft or not to graft.

Impact of a novel phosphoinositol-3 kinase inhibitor in preventing mitochondrial DNA damage and damage-associated molecular pattern accumulation: Results from the Biochronicity Project

BACKGROUND

Despite improvements in the management of severely injured patients, development of multiple organ dysfunction syndrome (MODS) remains a morbid complication of traumatic shock. One of the key attributes of MODS is a profound bioenergetics crisis, for which the mediators and mechanisms are poorly understood. We hypothesized that metabolic uncoupling using an experimental phosphoinositol-3 kinase (PI3-K) inhibitor, LY294002 (LY), may prevent mitochondrial abnormalities that lead to the generation of mitochondrial DNA (mtDNA) damage and the release of mtDNA damage-associated molecular patterns (DAMPs).

METHODS

Sixteen swine were studied using LY, a nonselective PI3-K inhibitor. Animals were assigned to trauma only (TO, n = 3), LY drug only (LYO, n = 3), and experimental (n = 10), trauma + drug (LY + T) groups. Both trauma groups underwent laparotomy, 35% hemorrhage, severe ischemia-reperfusion injury, and protocolized resuscitation. A battery of hemodynamic, laboratory, histological, and bioenergetics parameters were monitored. Mitochondrial DNA damage was determined in lung, liver, and kidney using Southern blot analyses, whereas plasma mtDNA DAMP analysis used polymerase chain reaction amplification of a 200-bp sequence of the mtDNA D-loop region.

RESULTS

Relative to control animals, H + I/R (hemorrhage and ischemia/reperfusion) produced severe, time-dependent decrements in hepatic, renal, cardiovascular, and pulmonary function accompanied by severe acidosis and lactate accumulation indicative of bioenergetics insufficiency. The H-I/R animals displayed prominent oxidative mtDNA damage in all organs studied, with the most prominent damage in the liver. Mitochondrial DNA damage was accompanied by accumulation of mtDNA DAMPs in plasma. Pretreatment of H + I/R animals with LY resulted in profound metabolic suppression, with approximately 50% decreases in O2 consumption and CO2 production. In addition, it prevented organ and bioenergetics dysfunction and was associated with a significant decrease in plasma mtDNA DAMPs to the levels of control animals.

CONCLUSIONS

These findings show that H + I/R injury in anesthetized swine is accompanied by MODS and by significant mitochondrial bioenergetics dysfunction, including oxidative mtDNA damage and accumulation in plasma of mtDNA DAMPs. Suppression of these changes with the PI3-K inhibitor LY indicates that pharmacologically induced metabolic uncoupling may comprise a new pharmacologic strategy to prevent mtDNA damage and DAMP release and prevent or treat trauma-related MODS.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Intraoperative management of renal gunshot injuries: is mandatory exploration of Gerota's fascia necessary?

BACKGROUND

Many trauma surgeons and trauma centers use routine exploration of Gerota's fascia (GE) for renal gunshot wounds (RGSW). The purpose of this study was to assess whether RGSW can be selectively explored for patients who undergo exploratory laparotomy.

METHODS

Retrospective 10-year review of all patients who underwent exploratory laparotomy for abdominal gunshot wounds and had RGSW selectively explored.

RESULTS

Sixty-three patients with RGSW underwent exploratory laparotomy. Twenty-eight (44%) underwent GE vs 35 (56%) who did not. Eight (29%) mortalities occurred with GE and 5 (14%) without GE (P < .05). Of GE patients, 14 (50%) had nephrectomy and 14 (50%) had renorrhaphy. Average hospital length of stay with GE was 16.7 days vs 17.9 without GE. Three (9%) renal-associated complications occurred without GE and 1 (4%) with GE.

CONCLUSIONS

Most patients who suffer RGSW do not require exploration of GE during abdominal exploration. Complication rates due to nonexploration of RGSW are very low with infrequent need for surgical intervention due to renal-associated complications. High nephrectomy rates may be avoided when GE is averted.

Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R(2) = 0.525, De Backer R(2) = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of microcirculatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.