Optimal initial diet in mild acute pancreatitis: A comprehensive meta-analysis of randomized control trials.

OBJECTIVE: We performed a comprehensive systematic review and meta-analysis comparing initiation of full solid diet (FSD) versus stepwise diet to better define the management of patients with mild acute pancreatitis (AP). METHODS: Electronic databases were searched through August 2, 2021 for trials comparing initial FSD versus stepwise advancement in patients with mild AP on length of hospital stay (LOHS). We stratified by whether diet was initiated early (within 24 h or immediately upon presence of bowel sounds). RESULTS: We identified seven RCTs that compared LOHS in AP patients who received initial oral intake with solid diet versus stepwise diet. Across the studies a total of 305 patients were randomized to immediate FSD and 308 patients to sequential advancement. Patients who were initiated on a FSD had a significant reduction in total LOHS (Standardized Mean Difference (SMD) -0.52 [95% CI -0.69, -0.36]). There was no difference in post refeeding abdominal pain, tolerance of diet, or necessity to cease diet between the two groups. Sub-analysis of three studies that initiated FSD early reduced total LOHS (OR -0.95 [95% CI -1.26, -0.65]) compared to those who received graded diet advancement as well as higher likelihood of tolerating the assigned diet (OR 6.8 [95% CI 1.2, 39.2]). CONCLUSIONS: Our meta-analysis shows that initiation of FSD reduces total LOHS in patients with mild AP and does not increase post refeeding abdominal pain. Though additional high-quality studies are needed, these findings support initial solid diet for AP and consideration of feeding within the first 24 h.

Transfusion-Related Hypocalcemia After Trauma.

BACKGROUND: Hypocalcemia is cited as a complication of massive transfusion. However, this is not well studied as a primary outcome in trauma patients. Our primary outcome was to determine if transfusion of packed red blood cells (pRBC) was an independent predictor of severe hypocalcemia (ionized calcium ≤ 3.6 mg/dL). METHODS: Retrospective, single-center study (01/2004-12/2014) including all trauma patients ≥ 18 yo presenting to the ED with an ionized calcium (iCa) level drawn. Variables extracted included demographics, interventions, outcomes, and iCa. Regression models identified independent risk factors for severe hypocalcemia (SH). RESULTS: Seven thousand four hundred and thirty-one included subjects, 716 (9.8%) developed SH within 48 h of admission. Median age: 39 (Range: 18-102), systolic blood pressure: 131 (IQR: 114-150), median Glasgow Coma Scale (GCS): 15 (IQR: 10-15), Injury Severity Score (ISS): 14 (IQR: 9-24). SH patients were more likely to have depressed GCS (13 vs 15, p < 0.0001), hypotension (23.2% vs 5.1%, p < 0.0001) and tachycardia (57.0% vs 41.9%, p < 0.0001) compared to non-SH patients. They also had higher emergency operative rate (71.8% vs 29%, p < 0.0001) and higher blood administration prior to minimum iCa [pRBC: (8 vs 0, p < 0.0001), FFP: (4 vs 0, p < 0.0001), platelet: (1 vs 0, p < 0.0001)]. Multivariable analysis revealed penetrating mechanism (AOR: 1.706), increased ISS (AOR: 1.029), and higher pRBC (AOR: 1.343) or FFP administered (AOR: 1.097) were independent predictors of SH. SH was an independent predictor of mortality (AOR: 2.658). Regression analysis identified a significantly higher risk of SH at pRBC + FFP administration of 4 units (AOR: 18.706, AUC:. 897 (0.884-0.909). CONCLUSION: Transfusion of pRBC is an independent predictor of SH and is associated with increased mortality. The predicted probability of SH increases as pRBC + FFP administration increases.

The Pancreatitis Activity Scoring System predicts clinical outcomes in acute pancreatitis: findings from a prospective cohort study.

OBJECTIVES: The Pancreatitis Activity Scoring System (PASS) has been derived by an international group of experts via a modified Delphi process. Our aim was to perform an external validation study to assess for concordance of the PASS score with high face validity clinical outcomes and determine specific meaningful thresholds to assist in application of this scoring system in a large prospectively ascertained cohort. METHODS: We analyzed data from a prospective cohort study of consecutive patients admitted to the Los Angeles County Hospital between March 2015 and March 2017. Patients were identified using an emergency department paging system and electronic alert system. Comprehensive characterization included substance use history, pancreatitis etiology, biochemical profile, and detailed clinical course. We calculated the PASS score at admission, discharge, and at 12 h increments during the hospitalization. We performed several analyses to assess the relationship between the PASS score and outcomes at various points during hospitalization as well as following discharge. Using multivariable logistic regression analysis, we assessed the relationship between admission PASS score and risk of severe pancreatitis. PASS score performance was compared to established systems used to predict severe pancreatitis. Additional inpatient outcomes assessed included local complications, length of stay, development of systemic inflammatory response syndrome (SIRS), and intensive care unit (ICU) admission. We also assessed whether the PASS score at discharge was associated with early readmission (re-hospitalization for pancreatitis symptoms and complications within 30 days of discharge). RESULTS: A total of 439 patients were enrolled, their mean age was 42 (±15) years, and 53% were male. Admission PASS score >140 was associated with moderately severe and severe pancreatitis (OR 3.5 [95% CI 2.0, 6.3]), ICU admission (OR 4.9 [2.5, 9.4]), local complications (3.0 [1.6, 5.7]), and development of SIRS (OR 2.9 [1.8, 4.5]) as well as prolongation of hospitalization by a mean of 1.5 (1.3-1.7) days. For the prediction of moderately severe/severe pancreatitis, the PASS score (AUC = 0.71) was comparable to the more established Ranson's (AUC = 0.63), Glasgow (AUC = 0.72), Panc3 (AUC = 0.57), and HAPS (AUC = 0.54) scoring systems. Discharge PASS score >60 was associated with early readmission (OR 5.0 [2.4, 10.7]). CONCLUSIONS: The PASS score is associated with important clinical outcomes in acute pancreatitis. The ability of the score to forecast important clinical events at different points in the disease course suggests that it is a valid measure of activity in patients with acute pancreatitis.

Inventory management strategies that reduce the age of red blood cell components at the time of transfusion.

BACKGROUND: There has been interest concerning patient outcomes when older red blood cell (RBC) components are utilized. Inventory management is key to maintaining a stock of fresher RBCs for general transfusion needs. We have altered our practice for RBC management to reduce RBC age at the time of transfusion. STUDY DESIGN AND METHODS: Retrospective review of RBC age at time of transfusion at a tertiary care hospital with active trauma service was performed. The baseline nonirradiated RBC inventory was decreased from 12 to 15 days of stock to 7 to 10 days of stock, with request made to the blood supplier for fresher RBCs, specified at 75% of RBCs less than 14 days old. The age of RBCs at time of receipt and at time of transfusion was tracked on a monthly basis for the next 12 months. RESULTS: The mean age of RBCs at transfusion was decreased by 9 days on average for the year. Significant decreases in the mean age of RBCs at transfusion were seen in the second half of the year, with 4 of 6 months seeing a mean age of less than 20 days. There were no documented incidences of hospital blood shortages after the reduction in inventory; no surgery was canceled or delayed because of inventory. CONCLUSION: Inventory age depends on active management, combined with vendor cooperation to receive fresher components. Reducing the age of RBC components transfused is possible without experiencing blood component shortages. Longer periods of observation may allow for further adjustment of stocking levels on a seasonal basis.

Anti-Jka that are detected by solid-phase red blood cell adherence but missed by gel testing can cause hemolytic transfusion reactions.

BACKGROUND: Kidd blood group antibodies are notorious for transient detection and hemolytic transfusion reactions. This report compares the rate of detection of anti-Jka when using gel column agglutination versus solid-phase red blood cell adherence (SPRCA) testing and documents the occurrence of hemolytic transfusion reactions in 17 recently transfused patients who developed anti-Jka that were detectable by SPRCA but were undetectable by gel. STUDY DESIGN AND METHODS: Before April 20, 2011, the laboratory used gel column agglutination as the primary method for antibody screening and identification. From April 20, 2011, to August 12, 2013, SPRCA was adopted as the primary method for antibody screen with gel remaining the primary method for identification. SPRCA identification was also performed if sufficient sample was available. Medical records were reviewed for evidence of hemolytic reaction in patients whose anti-Jka was negative or inconclusive by gel, but clearly identifiable by SPRCA at the time the anti-Jka was first identified. RESULTS: A total of 105 patients were discovered with anti-Jka from 88,478 SPRCA screens performed. In 32 patients, anti-Jka was initially discovered by SPRCA testing and concurrent gel testing was completely negative (n = 26) or inconclusive (n = 6). Seventeen of the 32 patients were recently transfused and of these six met criteria for delayed hemolytic transfusion reaction (DHTR), three had possible DHTRs, and eight had delayed serologic reactions; 13 of the transfused patients received Jk(a-) RBCs to avoid potential hemolysis. CONCLUSION: SPRCA testing significantly increased the discovery of clinically significant anti-Jka and facilitated the earlier use of Jk(a-) RBCs to avoid hemolytic transfusion reactions.

Microbial keratitis in los angeles: the doheny eye institute and the los angeles county hospital experience.

OBJECTIVE: To evaluate the spectrum and antibiotic susceptibility panel of infectious keratitis at a major tertiary care referral eye center and a major county hospital in Southern California. DESIGN: Retrospective case series. PARTICIPANTS: All cultured infectious keratitis cases from July 1, 2008, through December 31, 2012, from the Doheny Eye Institute (DEI) and the Los Angeles County + University of Southern California Medical Center (LAC+USC) were evaluated. METHODS: Microbiology records were reviewed retrospectively. MAIN OUTCOME MEASURES: Microbial isolates as well as antibiotic susceptibility patterns were analyzed. RESULTS: One hundred eighty-four (63%) of 290 cases showed positive culture results at DEI and 152 (82%) of 186 cases showed positive culture results at LAC+USC. Gram-positive pathogens were found to be the most common at both DEI (70%) and LAC+USC (68%), with coagulase-negative Staphylococcus being the most common gram-positive organism (58% at DEI and 44% at LAC+USC). Pseudomonas aeruginosa was the most common gram-negative organism (57% at DEI and 43% at LAC+USC). Ciprofloxacin and levofloxacin susceptibility for all tested pathogens was 73% at DEI and 81% at LAC+USC (P = 0.16). Oxacillin-resistant Staphylococcus aureus (ORSA) was found in 42% of cases at DEI and in 45% of cases at LAC+USC (P = 1.00). CONCLUSIONS: There is no significant difference in the spectrum of pathogens or antibiotic susceptibility of pathogens at DEI versus LAC+USC, and ORSA was found in approximately half of all S. aureus samples.

Life-threatening delayed hyperhemolytic transfusion reaction in a patient with sickle cell disease: effective treatment with eculizumab followed by rituximab.

BACKGROUND: Hyperhemolysis in sickle cell disease is a rare and potentially life-threatening complication of transfusion. STUDY DESIGN AND METHODS: In this article we report a case of delayed hemolytic transfusion reaction with resultant hyperhemolysis triggered by an anti-IH autoantibody with alloantibody behavior. RESULTS: The anti-IH was reactive at room temperature as well as 37 °C, but only weakly reactive with autologous red blood cells. Initial cold agglutinin titer was 512. The profound, life-threatening, intravascular hemolysis was rapidly and dramatically reduced with the Complement 5 (C5) inhibitory antibody, eculizumab. The auto/allo cold agglutinin was subsequently suppressed with rituximab treatment. CONCLUSIONS: Eculizumab, a potent C5 inhibitory antibody, can be a rapid and effective therapy for hyperhemolytic transfusion reactions when given in a sufficient dose to fully block the activation of complement C5.

Making thawed universal donor plasma available rapidly for massively bleeding trauma patients: experience from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial.

BACKGROUND: The Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial was a randomized clinical trial comparing survival after transfusion of two different blood component ratios for emergency resuscitation of traumatic massive hemorrhage. Transfusion services supporting the study were expected to provide thawed plasma, platelets, and red blood cells within 10 minutes of request. STUDY DESIGN AND METHODS: At the 12 Level 1 trauma centers participating in PROPPR, blood components transfused and delivery times were tabulated, with a focus on universal donor (UD) plasma management. The adequacy of site plans was assessed by comparing the bedside blood availability times to study goals and the new American College of Surgeons guidelines. RESULTS: Eleven of 12 sites were able to consistently deliver 6 units of thawed UD plasma to their trauma-receiving unit within 10 minutes and 12 units in 20 minutes. Three sites used blood group A plasma instead of AB for massive transfusion without complications. Approximately 4700 units of plasma were given to the 680 patients enrolled in the trial. No site experienced shortages of AB plasma that limited enrollment. Two of 12 sites reported wastage of thawed AB plasma approaching 25% of AB plasma prepared. CONCLUSION: Delivering UD plasma to massively hemorrhaging patients was accomplished consistently and rapidly and without excessive wastage in high-volume trauma centers. The American College of Surgeons Trauma Quality Improvement Program guidelines for massive transfusion protocol UD plasma availability are practicable in large academic trauma centers. Use of group A plasma in trauma resuscitation needs further study.

Comprehensive Training of Community Diagnosis and the Community-Oriented Primary Health Care Model in Nursing Education: An Evidence-Based Project.

BACKGROUND: Community-oriented primary health care is a health promotion model that includes community diagnosis of a targeted community. PURPOSE: This educational project aimed to develop and implement an innovative approach of applying the principles of evidence-based practice in the teaching of community diagnosis, where the class of nursing students serves as an example of community. METHODS: The method consisted of a lecture and an evidence-based simulation of community diagnosis based on data collection regarding the lifestyle and health behaviors of third-year nursing students from a 4-year academic nursing program (200 students; 90% response rate). RESULTS: The data analysis revealed insufficient consumption of fruits, vegetables, and unsweetened fluids; excessive consumption of red and processed meat; insufficient engagement in physical activity; high anxiety level; and sleep deprivation. CONCLUSIONS: This educational approach allowed an interactive presentation of community health diagnostic methodology as well as community health problem prioritization applying the principles of an evidence-based approach. The method also improves students' awareness of their health and makes them better ambassadors of promoting a healthy lifestyle.

High-risk HPV testing improves accuracy in detection of CIN2+ lesions in ASC-H postmenopausal women? An academic hospital experiences.

Reflex human papilloma virus (HPV) testing with "atypical squamous cells, cannot exclude high-grade squamous lesion (ASC-H)" cytologic diagnosis is not recommended by American Society for Colposcopy and Cervical Pathology guidelines. Studies have shown human papillomavirus (HPV)-negative ASC-H patients of increased age are low risk for cervical intraepithelial neoplasia 2 or worse (CIN2+) lesions on colposcopic follow-up. We retrospectively assessed the efficacy of reflex HPV testing in postmenopausal women with ASC-H in the Los Angeles County hospitals and clinics in a 5-year period. Of a total 85 clinically postmenopausal women with ASC-H, 31 (36.5%) women were found to have CIN2+ lesions on follow-up biopsy and five of them were HPV-negative. Of the women with CIN2+ lesions and positive HPV, 13 (41.9%) were high-risk HPV (hrHPV) 16/18/45 positive and 13 (41.9%) were hrHPV-other subtype positive. Women with positive HPV had an over 3-fold increased risk of developing CIN2+ lesions (P = 0.008). Relative risk of hrHPV16/18/45 was 1.79-fold higher than that of hrHPV-other subtype. The positive predictive value and negative predictive value of hrHPV were 49.1% and 84.4%, respectively. CIN2+ detection rate in Hispanic women with positive hrHPV was higher than in non-Hispanic women (53.8% versus 35.7%). Overall, postmenopausal women with ASC-H cytology result and negative hrHPV were less likely to develop CIN2+ lesions, whereas about half of ASC-H postmenopausal women develop CIN2+ lesions if hrHPV positive, especially if hrHPV 16/18/45 positive. Therefore, triaging ASC-H postmenopausal women with cotesting or, ideally, hrHPV genotyping should be considered as optimal clinical practice to avoid overtreatment.

Impact of the duration of platelet storage in critically ill trauma patients.

BACKGROUND: There is increasing evidence that the duration of red blood cell (RBC) storage negatively impacts outcomes. Data regarding prolonged storage of other blood components, however, are lacking. The aim of this study was to evaluate how the duration of platelet storage affects trauma patient outcomes. METHODS: Trauma patients admitted to a Level I trauma center requiring platelet transfusion (2006-2009) were retrospectively identified. Apheresis platelets (aPLT) containing ≥3 × 10(11) platelets/unit were used exclusively. Patients were analyzed in three groups: those who received only aPLT stored for ≤3 days, 4 days, and 5 days. The outcomes included mortality and complications (sepsis, acute respiratory distress syndrome, renal, and liver failure). RESULTS: Three hundred eighty-one patients were available for analysis (128 received aPLT ≤3 days old; 109 = 4 days old; and 144 = 5 days old). There were no significant demographic differences between groups. Patients receiving aPLT aged = 4 days had significantly higher Injury Severity Score (p = 0.022) and were more likely to have a head Abbreviated Injury Scale ≥3 (p = 0.014). There were no differences in volumes transfused or age of RBC, plasma, cryoprecipitate, or factor VIIa. After adjusting for confounders, exposure to older aPLT did not impact mortality; however, with increasing age, complications were significantly higher. The rate of sepsis, in particular, was significantly increased (5.5% for aPLT ≤3 days vs. 9.2% for aPLT = 4 days vs. 16.7% for aPLT = 5 days, adjusted p = 0.033). For acute respiratory distress syndrome and renal and liver failure, similar trends were observed. CONCLUSIONS: In critically ill trauma patients, there was a stepwise increase in complications, in particular sepsis, with exposure to progressively older platelets. Further evaluation of the underlying mechanism and methods for minimizing exposure to older platelets is warranted.

Verification and Implementation of HIV Antibody Differentiation Testing to Improve Turnaround Time for the HIV Diagnostic Algorithm.

BACKGROUND: Relying on reference laboratories for HIV confirmation testing may lead to delays in treatment and can cause stress for patients who have positive HIV screening results. OBJECTIVE: To internalize HIV-1/HIV-2 antibody differentiation testing within the hospital laboratory. METHODS: We analytically verified an HIV antibody differentiation immunoassay and subsequently compared result turnaround times (TATs) for HIV antibody differentiation and HIV-1 qualitative RNA in the months before and after the test internalization. RESULTS: HIV antibody differentiation was successfully verified. TATs for HIV antibody differentiation and HIV-1 RNA significantly improved, from medians of 40.4 hours and 156.5 hours to medians of 17.7 hours and 56.5 hours, respectively, after the internalization. The 90th-percentile turnaround times declined by 72% and 44%, respectively. CONCLUSIONS: It is feasible for a hospital laboratory to verify HIV antibody-differentiation testing. Its implementation may considerably improve result TATs for the HIV diagnostic algorithm.

Diagnostic reproducibility of cervical intraepithelial neoplasia 3 and atrophy in menopausal women on hematoxylin and eosin, Ki-67, and p16 stained slides.

OBJECTIVE: To establish diagnostic accuracy and reproducibility of a diagnosis of cervical intraepithelial neoplasia 3 (CIN 3) in menopausal women on routinely stained hematoxylin and eosin (H&E) slides and compare it to slides processed for p16 and Ki-67. MATERIALS AND METHODS: Confirmed cases of CIN 3 and benign atrophic changes were reviewed independently by 4 pathologists. The samples were studied on separate occasions using H&E staining, p16, and Ki-67. Differences in sensitivity and specificity between reviewers or methods were tested for significance using the McNemar test, whereas differences in positive and negative predictive values were tested for significance using a marginal probability generalized linear model for agreement. RESULTS: Sensitivity was high for H&E (93.3%-100%) and Ki-67 (93.3%-100%) and lower for p16 (70.0%-90.0%). Intraobserver variability was also lower for p16 (76.7% vs 90.0%, although this difference was not statistically significant, p = .219). p16 agreement, however, for CIN 3 is significantly lower than that for atrophy (76.7% vs 97.4%, p = .018). CONCLUSIONS: Routine histopathologic diagnosis of CIN 3 in menopausal women is highly accurate and reproducible. Both H&E and Ki-67 are useful immunohistochemical stains in helping differentiate atrophy from high-grade cervical intraepithelial lesions in postmenopausal cervical biopsies. There may be more disagreement among readers using p16.

Group A emergency-release plasma in trauma patients requiring massive transfusion.

BACKGROUND: Both groups A and AB plasma have been approved for emergency-release transfusion in acutely bleeding trauma patients before blood grouping being performed. The safety profile associated with this practice has not been well characterized, particularly in patients requiring massive transfusion. METHODS: This secondary analysis of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios trial examined whether exposure to group A emergency-release plasma (ERP) was noninferior to group AB ERP. We also examined patients whose blood groups were compatible with group A ERP versus patients whose blood groups were incompatible with group A ERP. Outcomes included 30-day mortality and complication rates including systemic inflammatory response syndrome, infection, renal injury, pulmonary dysfunction, and thromboembolism. RESULTS: Of the 680 patients predicted to receive a massive transfusion, 584 (85.9%) received at least 1 U of ERP. Of the 584 patients analyzed, 462 (79.1%) received group AB and 122 (20.9%) received group A ERP. Using a hazard ratio (HR) of 1.35 as the noninferiority margin, transfusion with group A versus group AB ERP was not associated with increased thromboembolic rates (HR, 0.52; 95% confidence interval [CI], 0.31-0.90). Mortality (HR, 1.15; 95% CI, 0.91-1.45) and nonfatal complication rates (HR, 1.24; 95% CI, 0.87-1.77) were inconclusive. In the subgroup analysis, transfusion with incompatible ERP (group B or AB patients receiving group A ERP) was not associated with increased nonfatal complications (HR, 1.02; 95% CI, 0.80-1.30). There were no reported hemolytic transfusion reactions. CONCLUSION: The use of ERP is common in patients requiring massive transfusion and facilitates the rapid balanced resuscitation of patients who have sustained blood loss. Group A ERP is an acceptable option for patients requiring massive transfusion, especially if group AB ERP is not readily available. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV; Prognostic, level III.

Impact of plasma transfusion in massively transfused trauma patients.

OBJECTIVE: The objective of this study was to determine the optimal use of fresh-frozen plasma (FFP) in trauma. Our hypothesis was that a higher FFP: packed red blood cells (PRBC) ratio is associated with improved survival. METHODS: This is a 6-year retrospective trauma registry and blood bank database study in a level I trauma center. All massively transfused patients (> or =10 PRBC during 24 hours) were analyzed. Patients with severe head trauma (head Abbreviated Injury Severity score > or =3) were excluded from the analysis. Patients were classified into four groups according to the FFP:PRBC ratio received: low ratio (< or =1:8), medium ratio (>1:8 and < or =1:3), high ratio (>1:3 and < or =1:2), and highest ratio (>1:2). RESULTS: Of 25,599 trauma patients, 4,241 (16.6%) received blood transfusion. Massive transfusion occurred in 484 (11.4%) of the transfused. After exclusion of 101 patients with severe head injury 383 patients were available for analysis. The mortality rate decreased significantly with increased FFP transfusion. However, there does not seem to be a survival advantage after a 1:3 FFP:PRBC ratio has been reached. Using the highest ratio group as a reference, the relative risk of death was 0.97 (p = 0.97) for the high ratio group, 1.90 (p < 0.01) for the medium ratio group, and 3.46 (p < 0.01) for the low ratio group. There was an increasing trend toward more FFP use during time with the mean units per patient increasing 83% from 6.3 +/- 4.6 in 2000 to 11.5 +/- 9.7 in 2005. CONCLUSION: Higher FFP:PRBC ratio is an independent predictor of survival in massively transfused patients. Aggressive early use of FFP may improve outcome in massively transfused trauma patients.

Methamphetamines in trauma: effect on injury patterns and outcome.

BACKGROUND: The association of methamphetamine exposure and outcomes after trauma is not known. METHODS: This study included trauma patients who underwent alcohol and illicit drug screening. Patients who had a screen positive for Methamphetamine only [METH (+)] were compared with patients with a completely negative screen for illicit drugs or alcohol [TOX (-)]. Patients with polysubstance or alcohol abuse were excluded. Logistic regression was used to determine whether METH (+) status was independently associated with injury patterns or outcomes. Associations were further evaluated by patient matching with respect to age, gender, mechanism, injured body area abbreviated injury scores, and injury severity. RESULTS: There were 5,372 patients eligible where 526 (9.8%) were METH (+). On multivariate analysis, the METH (+) group had a significantly higher adjusted rate of intensive care unit (ICU) admission but there was no difference in mortality or complications or ICU stay. On matching, there was no difference in mortality (11.1% vs. 10.9%, p = 0.87), complication rate (5.6% vs. 4.2%, p = 0.40), and lengths of ICU and hospital stay but the METH (+) group had a higher rate of laparotomy. CONCLUSION: Patients exposed to Methamphetamines do not have increased mortality or complications or lengths of ICU and hospital stay. However, they are more likely to require admission to the ICU.

Essentials of emergency transfusion-The complement to stop the bleed.

Over the past decade, the shift toward damage control surgery for bleeding trauma patients has come with an increased emphasis on optimal resuscitation. Two lifesaving priorities predominate: to quickly stop the bleed and effectively resuscitate the hemorrhagic shock. Blood is separated into components for efficient storage and distribution; however, bleeding patients require all components in a balanced ratio. A variety of blood products are available to surgeons, and these products have evolved over time. This review article describes the current standards for resuscitation of bleeding patients, including characteristics of all available products. The relevant details of blood donation and collection, blood banking, blood components, and future therapies are discussed, with the goal of guiding surgeons in their emergency transfusion practice.

Blood transfusions in trauma: six-year analysis of the transfusion practices at a Level I trauma center.

The objective of this study was to analyze the transfusion practices in trauma patients in one institution. A retrospective analysis of the Trauma Registry linked with the Blood Bank Database of a Level 1 trauma center was conducted. Over 6 years, 17 per cent of the 25,599 trauma patients received blood transfusions. The overall mortality in transfused patients was 20 per cent and remained the same during the study period. There was no change in the proportion of patients receiving transfusions throughout the years, however there was a significant 23.5 per cent reduction in the mean number of packed red blood cells (PRBC) units transfused (P < 0.001 for trend). This reduction in PRBC used remained true and even more evident in the group of more severely injured patients (Injury Severity Score > or = 16), with a 27.9 per cent decrease in mean units of PRBC (P < 0.001 for trend). The highest reduction in PRBC transfusion was seen in blunt trauma patients (34.6%, P < 0.001). During the study period there was a concurrent increase in mean units of fresh frozen plasma used (60.7%, P < 0.001) and no change in the use of platelets and cryoprecipitate. In conclusion, transfusions of PRBC were significantly reduced over time in trauma patients without any evident negative impact on mortality.

The impact of uncross-matched blood transfusion on the need for massive transfusion and mortality: analysis of 5,166 uncross-matched units.

BACKGROUND: The objective of this study was to analyze the outcomes associated with uncross-matched blood transfusion during trauma resuscitation. Our hypothesis was that uncross-matched blood transfusion is a predictor of the need for massive transfusion and mortality. METHODS: All injured patients receiving packed red blood cell (PRBC) transfusion during a 6-year period ending December 2005 were identified from the blood bank database at a level I trauma center. Uncross-matched red blood cell (URBC) and cross-matched red blood cells, plasma and platelet utilization, and injury demographics were abstracted for each patient. RESULTS: Of 25,599 trauma patients, 4,241 (16.6%) patients received 29,375 units of PRBC and 1,236 (29.1%) of the transfused patients received 5,166 units of URBC during their resuscitation. Patients requiring URBC had a higher mortality (39.6% vs. 11.9%, p < 0.001) and were more likely to require massive (> or = 10 PRBC during 12 hours) transfusion (29.3% vs. 1.8%, p < 0.001). There was a stepwise increase in mortality with increasing URBC transfusion. After adjusting for age, gender, mechanism, hypotension at admission, emergency department intubation, initial hemoglobin, Glasgow Coma Scale, Abbreviated Injury Scale, Injury Severity Score, and amount of blood products received; URBC remained an independent predictor of mortality (adjusted odds ratio 2.15; 95% confidence interval 1.58-2.94; p < 0.001) and massive transfusion (adjusted odds ratio, 11.87; 95% confidence interval, 8.43-16.7; p < 0.001). Patients receiving URBC also utilized more blood components (11.9 +/- 12.7 vs. 4.9 +/- 5.8 units of PRBC, p < 0.001; 5.1 +/- 8.9 vs. 2.0 +/- 4.8 units of plasma, p < 0.001; and 1.1 +/- 2.5 vs. 0.4 +/- 1.6 units of platelets, p < 0.001). CONCLUSION: The requirement for uncross-matched blood during the acute resuscitation of trauma patients is an independent predictor of mortality and the need for massive transfusion. A URBC request during resuscitation should be considered by the blood bank as a potential trigger to prepare for massive transfusion.