Intravenous metoprolol versus diltiazem for rate control in noncardiac, nonthoracic postoperative atrial fibrillation.

BACKGROUND: Little guidance exists on effective management of postoperative atrial fibrillation (POAF) following noncardiac, nonthoracic (NCNT) surgery. OBJECTIVES: The purpose of this study was to identify whether a difference exists between intravenous (IV) metoprolol and diltiazem when used to achieve hemodynamically stable rate control in POAF following NCNT surgery. METHODS: This retrospective cohort study examined critically ill adult surgical patients experiencing POAF with rapid ventricular response. Inclusion in the metoprolol or diltiazem treatment group was determined by the initial rate control agent chosen by the prescriber. The primary end point was hemodynamically stable rate control, defined by heart rate (HR) <110 beats/min and blood pressure >90 mm Hg, maintained for 6 hours. MAIN RESULTS: Patients on metoprolol (n = 66) and diltiazem (n = 55) were similar in age, comorbidities, surgical procedure distribution, acuity of illness, and home rate and rhythm control medications continued during hospitalization; 76% of diltiazem-treated patients achieved hemodynamically stable rate control, compared with only 53% of those receiving metoprolol (P = .005). Safety end points were similar between groups, including the portion requiring a new vasopressor or fluid bolus for hemodynamic support. CONCLUSIONS: In NCNT surgery, patients with POAF, IV diltiazem more effectively controlled HR and hemodynamics compared with metoprolol. Results warrant further research into optimal medical management of POAF in this population using these 2 agents.

Infrequent assessment of pain in elderly trauma patients.

There are inherent difficulties in assessing and managing pain in elderly trauma patients, especially those with chronic health conditions or diminished capacities for self-reporting pain. This retrospective study identifies and describes patterns of pain assessment for a trauma population of older adults (age ≥65 years). Gaps between patient assessments existed in all phases of hospitalization and did not meet hospital guidelines for frequency of assessment. In addition, assessment methods were not always appropriate for the patient population. We conclude that older patients were not assessed for pain frequently enough, and that more regular and routine pain assessments may improve patient outcomes.

The development and feasibility of a remote damage control resuscitation prehospital plasma transfusion protocol for warfarin reversal for patients with traumatic brain injury.

BACKGROUND: The rapid reversal of warfarin in the setting of traumatic brain injury (TBI) has been associated with improved outcomes. Until now, remote reversal of hypocoagulable states has not been possible in the prehospital environment. This manuscript describes the development and analysis of a prehospital plasma transfusion protocol to reverse warfarin at the earliest possible moment after TBI. STUDY DESIGN AND METHODS: A retrospective review of all TBI patients receiving plasma transfusion(s) in the prehospital environment for warfarin reversal between February 2009 and September 2010 was conducted. Thawed plasma was carried on every air ambulance flight centered at the main campus. RESULTS: A total of 2836 flights carried over 2500 units of thawed plasma throughout the study period. During this time, 16 patients received prehospital plasma resuscitation, five of who were on warfarin with a concurrent TBI. The median Injury Severity Score was 17 (8.5-27.5) with a median Glasgow Coma Score of 13 (8-15) and a mortality rate of 40%. A median of 2 (1.5-2.0) units of thawed plasma and 0 (0-0) units of RBCs were transfused en route. The pretransfusion point-of-care international normalized ratio improved from 3.1 (2.3-4.0) to 1.9 (1.3-3.6) upon trauma center admission (serum sample). One hundred percent of the transported, but unused, thawed plasma underwent subsequent transfusion prior to expiration. CONCLUSIONS: Remote prehospital plasma transfusions effectively reverse anticoagulation secondary to warfarin administration in TBI patients. It is feasible to transfuse thawed plasma in the prehospital setting via remote damage control techniques without increasing waste. Prospective studies are needed to determine if this practice can improve outcomes in this population.

Outcomes of damage control laparotomy with open abdomen management in the octogenarian population.

BACKGROUND: Controversy surrounds the role of abbreviated laparotomy and open abdomen (OA) in the octogenarian population in the acute care surgery model based on concern that the initial insult, combined with its sequelae, is beyond the physiologic reserve of these patients. As the population ages further, this dilemma will arise more frequently, requiring the analysis of futility or utility of OA in this demographic. METHODS: The institutional review board approval was obtained to analyze retrospectively patients aged 80 years or older with OA from 1997 to 2009. Univariate, multivariate, and Kaplan-Meier analyses were used to evaluate the effects that demographics, comorbidities, and clinical factors had on in-hospital mortality and overall survival. RESULTS: Sixty-seven patients (32 men and 35 women) were identified. Acute general surgery (including vascular procedures) was the most common indication for laparotomy (94%) with trauma a distant second (6%). Early definitive closure was obtained in 52% of patients with a 34% planned ventral hernia rate. Overall complication rate was 62% and overall in-hospital mortality was 37%. Multivariate analysis revealed congestive heart failure (odds ratio, 11.4; 95% confidence interval, 1.01-128.03) and acute renal failure (odds ratio, 11.8; 95% confidence interval, 2.00-69.12) correlated with in-hospital mortality. Of those surviving to hospital dismissal, 2-year survival was 66% with a 17-month median follow-up (range, 1-125 months). CONCLUSION: There is utility in octogenarians undergoing aggressive surgical management that requires OA. These patients have high mortality rates, but long-term survival can be better than their peers with other chronic diseases if they survive the surgical insult. Patient selection should be based on preexisting comorbidities such as congestive heart failure and the development of acute renal failure. Despite the adequate long-term survival, most patients will leave the hospital with a hernia.

Patterns in deer-related traffic injuries over a decade: the Mayo Clinic experience.

BACKGROUND: Our American College of Surgeons Level 1 Trauma Center serves a rural population. As a result, there is a unique set of accidents that are not present in an urban environment such as deer related motor vehicle crashes (dMVC). We characterized injury patterns between motorcycle/all-terrain vehicles (MCC) and automobile (MVC) crashes related to dMVC (deer motor vehicle crash) with the hypotheses that MCC will present with higher Injury Severity Score (ISS) and that it would be related to whether the driver struck the deer or swerved. METHODS: The records of 157 consecutive patients evaluated at our institution for injury related to dMVC from January 1st, 1997 to December 31st, 2006 were reviewed from our prospectively collected trauma database. Demographic, clinical, and crash specific parameters were abstracted. Injury severity was analyzed by the Abbreviated Injury Scale score for each body region as well as the overall Injury Severity Score (ISS). RESULTS: Motorcycle crashes presented with a higher median ISS than MVCs (14 vs 5, p < 0.001). Median Abbreviated Injury Score (AIS) of the spine for MCC riders was higher (3 vs 0, p < 0.001) if they swerved rather than collided. Seventy-seven percent of riders were not wearing a helmet which did not result in a statistically significant increase in median ISS (16 vs 10), head AIS (2 vs 0) or spine AIS (0 vs 0).Within the MVC group, there was no difference between swerving and hitting the deer in any AIS group. Forty-seven percent of drivers were not wearing seat belts which resulted in similar median ISS (6 vs 5) and AIS of all body regions. CONCLUSIONS: Motorcycle operators suffered higher ISS. There were no significant differences in median ISS if a driver involved in a deer-related motor vehicle crash swerved rather than collided, was helmeted, or restrained.