Critical care ultrasound in geriatric trauma resuscitation leads to decreased fluid administration and ventilator days.

BACKGROUND: Geriatric trauma populations respond differently than younger trauma populations. Critical care ultrasound (CCUS) can guide resuscitation, and it has been shown to decrease intravenous fluid (IVF), lower time until operation, and lower mortality in trauma. Critical care ultrasound-guided resuscitation has not yet been studied in geriatric trauma. We hypothesized that incorporation of CCUS would decrease amount of IVF administered, decrease time to initiation of vasopressors, and decrease end organ dysfunction. METHODS: A PRE-CCUS geriatric trauma group between January 2015 and October 2016 was resuscitated per standard practice. A POST-CCUS group between January 2017 and December 2018 was resuscitated based on CCUS performed by trained intensivist upon admission to the intensive care unit and 6 hours after initial ultrasound. The PRE-CCUS and POST-CCUS groups underwent propensity score matching, yielding 60 enrollees in each arm. Retrospective review was conducted for demographics, clinical outcomes, and primary endpoints, including amount of IVF in the first 48 hours, duration to initiation of vasopressor use, and end organ dysfunction. Wilcoxon two-sample, χ2 tests, and κ statistics were performed to check associations between groups. RESULTS: There was no statistical difference between PRE-CCUS and POST-CCUS demographics and Injury Severity Scores. Intravenous fluid within 48 hours decreased from median [interquartile range] of 4941 mL [4019 mL] in the PRE-CCUS to 2633 mL [3671 mL] in the POST-CCUS (p = 0.0003). There was no significant difference between the two groups in time to initiation of vasopressors, vasopressor duration, lactate clearance, intensive care unit length of stay, or hospital length of stay. There was a significant decrease in ventilator days, with 26.7% PRE-CCUS with ventilation longer than 2 days, and only 6.7% POST-CCUS requiring ventilation longer than 2 days (p = 0.0033). CONCLUSION: Critical care ultrasound can be a useful addition to geriatric resuscitation. The POST-CCUS received less IV fluid and had decreased ventilator days. While mortality, lactate clearance, complications, and hospital stay were not statistically different, there was a perception that CCUS was a useful adjunct for assessing volume status and cardiac function. LEVEL OF EVIDENCE: Therapeutic, level II.

Efficacy of Oscillation and Lung Expansion in Reducing Postoperative Pulmonary Complication.

BACKGROUND: Postoperative pulmonary complications (PPCs) cause high morbidity and mortality. Targeted treatment for patients at risk for PPCs can improve outcomes. This multicenter prospective trial examined the impact of oscillation and lung expansion (OLE) therapy, using continuous high-frequency oscillation and continuous positive expiratory pressure on PPCs in high-risk patients. METHODS: In stage I, CPT and ICD codes were queried for patients (n = 210) undergoing thoracic, upper abdominal, or aortic open procedures at 3 institutions from December 2014 to April 2016. Patients were selected randomly. Age, comorbidities, American Society of Anesthesiologists physical status classification scores, and PPC rates were determined. In stage II, 209 subjects were enrolled prospectively from October 2016 to July 2017 using the same criteria. Stage II subjects received OLE treatment and standard respiratory care. The PPCs rate (prolonged ventilation, high-level respiratory support, pneumonia, ICU readmission) were compared. We also compared ICU length of stay (LOS), hospital LOS, and mortality using t-tests and analysis of covariance. Data are mean ± SD. RESULTS: There were 419 subjects. Stage II patients were older (61.1 ± 13.7 years vs 57.4 ± 15.5 years; p < 0.05) and had higher American Society of Anesthesiologists scores. Treatment with OLE decreased PPCs from 22.9% (stage I) to 15.8% (stage II) (p < 0.01 adjusted for age, American Society of Anesthesiologists score, and operation time). Similarly, OLE treatment reduced ventilator time (23.7 ± 107.5 hours to 8.5 ± 27.5 hours; p < 0.05) and hospital LOS (8.4 ± 7.9 days to 6.8 ± 5.0 days; p < 0.05). No differences in ICU LOS, pneumonia, or mortality were observed. CONCLUSIONS: Aggressive treatment with OLE reduces PPCs and resource use in high-risk surgical patients.

A Repeated Measures Pilot Comparison of Trajectories of Fluctuating Endogenous Hormones in Young Women with Traumatic Brain Injury, Healthy Controls.

OBJECTIVE: To compare baseline and 72-hour hormone levels in women with traumatic brain injury (TBI) and controls. SETTING: Hospital emergency department. PARTICIPANTS: 21 women ages 18-35 with TBI and 21 controls. DESIGN: Repeated measures. MAIN MEASURES: Serum samples at baseline and 72 hours; immunoassays for estradiol (E2), progesterone (PRO), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and cortisol (CORT); and health history. RESULTS: Women with TBI had lower E2 (p = 0.042) and higher CORT (p = 0.028) levels over time. Lower Glasgow Coma Scale (GSC) and OCs were associated with lower FSH (GCS p = 0.021; OCs p = 0.016) and higher CORT (GCS p = 0.001; OCs p = 0.008). CONCLUSION: Acute TBI may suppress E2 and increase CORT in young women. OCs appeared to independently affect CORT and FSH responses. Future work is needed with a larger sample to characterize TBI effects on women's endogenous hormone response to injury and OC use's effects on post-TBI stress response and gonadal function, as well as secondary injury.

Impact of Multiprofessional Rounds on Critical Care Outcomes in the Surgical Trauma Intensive Care Unit.

Multiprofessional rounds (MPR) represent a mechanism for the coordination of care in critically ill patients. Herein, we examined the impact of MPR on ventilator days (Vent-day), ICU length of stay (LOS), hospital LOS (HLOS), and mortality. A team developed guidelines for MPR, which began in February 2016. Patients admitted between November 2015 and March 2017 with Acute Physiology and Chronic Health Evaluation (APACHE) IV and injury severity scores were included. Outcome data consisted of Vent-day, Vent-day observed/expected ratio (O/E), ICU LOS, ICU LOS O/E, HLOS, HLOS-O/E, and mortality. Linear regression models are constructed to assess statistical significance. A total of 3372 patients were included. Among surgical patients (n = 343 pre-MPR, n = 1675 post-MPR), MPR was associated with decreases in Vent-day O/E (0.74 pre, 0.59 post, P = 0.03), ICU LOS O/E (0.67 pre, 0.61 post, P = 0.01), and HLOS-O/E (1.47 pre, 1.22 post, P = 0.0005). No mortality difference was observed. For trauma patients (n = 221 pre, n = 1133 post), MPR resulted in a reduction in Vent-days (2.2 days pre, 1.6 days post, P = 0.05). However, no differences were observed for Vent-day O/E, ICU LOS O/E, HLOS-O/E, and mortality. Implementation of MPR was associated with improved outcomes for surgical trauma ICU patients. Sustainability of MPR remains a challenge and requires education and engagement.

Probabilistic Matching of Deidentified Data From a Trauma Registry and a Traumatic Brain Injury Model System Center: A Follow-up Validation Study.

In a previous study, individuals from a single Traumatic Brain Injury Model Systems and trauma center were matched using a novel probabilistic matching algorithm. The Traumatic Brain Injury Model Systems is a multicenter prospective cohort study containing more than 14,000 participants with traumatic brain injury, following them from inpatient rehabilitation to the community over the remainder of their lifetime. The National Trauma Databank is the largest aggregation of trauma data in the United States, including more than 6 million records. Linking these two databases offers a broad range of opportunities to explore research questions not otherwise possible. Our objective was to refine and validate the previous protocol at another independent center. An algorithm generation and validation data set were created, and potential matches were blocked by age, sex, and year of injury; total probabilistic weight was calculated based on of 12 common data fields. Validity metrics were calculated using a minimum probabilistic weight of 3. The positive predictive value was 98.2% and 97.4% and sensitivity was 74.1% and 76.3%, in the algorithm generation and validation set, respectively. These metrics were similar to the previous study. Future work will apply the refined probabilistic matching algorithm to the Traumatic Brain Injury Model Systems and the National Trauma Databank to generate a merged data set for clinical traumatic brain injury research use.

Phase-aware echocardiogram stabilization using keyframes.

This paper presents an echocardiogram stabilization method designed to compensate for unwanted auxilliary motion. Echocardiograms contain both deformable cardiac motion and approximately rigid motion due to a number of factors. The goal of this work is to stabilize the video, while preserving the informative deformable cardiac motion. Our approach incorporates synchronized side information, extracted from electrocardiography (ECG), which provides a proxy for cardiac phase. To avoid the computational expense of pairwise alignment, we propose an efficient strategy for keyframe selection, formulated as a submodular optimization problem. We evaluate our approach quantitatively on synthetic data and demonstrate its benefit as a preprocessing step for two common echocardiogram applications: denoising and left ventricle segmentation. In both cases, preprocessing with our method improved the performance compared to no preprocessing or other alignment approaches.

Does history of substance use disorder predict acute traumatic brain injury rehabilitation outcomes?

BACKGROUND/OBJECTIVE: The study explored whether premorbid substance use disorder (SUD) predicts acute traumatic brain injury (TBI) outcomes. METHODS: 143 participants with moderate (34.2%) and severe (65.8%) TBI were enrolled at two Level 1 trauma center inpatient brain injury rehabilitation units. Acute outcomes were measured with the Disability Rating Scale (DRS), the FIMTM; self and informant ratings of the Patient Competency Rating Scale (PCRS); self and family rating of the Frontal Systems Behavioral Scale (FrSBe), and the Neurobehavioral Rating Scale-Revised (NRS-R). RESULTS: Hierarchical linear modeling revealed that SUD history significantly predicted trajectories of PCRS clinician ratings, PCRS self-family and PCRS self-clinician discrepancy scores, and more negative FrSBE family ratings. These findings indicate comparatively greater post-injury executive functions (EF) impairments, particularly self-awareness (SA) of injury-related deficits, for those with SUD history. No significant SUD*time interaction effect was found for FIM or NRS-R scores. CONCLUSIONS: SUD history and TBI are associated with impaired SA and EF but their co-occurrence is not a consistent predictor of acute post-injury functional outcomes. Pre-morbid patient characteristics and rater expectations and biases may moderate associations between SA and recovery after TBI.

Echocardiogram enhancement using supervised manifold denoising.

This paper presents data-driven methods for echocardiogram enhancement. Existing denoising algorithms typically rely on a single noise model, and do not generalize to the composite noise sources typically found in real-world echocardiograms. Our methods leverage the low-dimensional intrinsic structure of echocardiogram videos. We assume that echocardiogram images are noisy samples from an underlying manifold parametrized by cardiac motion and denoise images via back-projection onto a learned (non-linear) manifold. Our methods incorporate synchronized side information (e.g., electrocardiography), which is often collected alongside the visual data. We evaluate the proposed methods on a synthetic data set and real-world echocardiograms. Quantitative results show improved performance of our methods over recent image despeckling methods and video denoising methods, and a visual analysis of real-world data shows noticeable image enhancement, even in the challenging case of noise due to dropout artifacts.

MitoQ modulates oxidative stress and decreases inflammation following hemorrhage.

BACKGROUND: Oxidative stress associated with hemorrhagic shock and reperfusion (HSR) results in the production of superoxide radicals and other reactive oxygen species, leading to cell damage and multiple-organ dysfunction. We sought to determine if MitoQ, a mitochondria-targeted antioxidant, reduces morbidity in a rat model of HSR by limiting oxidative stress. METHODS: HSR was achieved in male rats by arterial blood withdrawal to a mean arterial pressure of 25 ± 2 mm Hg for 1 hour before resuscitation. MitoQ (5 mg/kg), TPP (triphenylphosphonium, 5 mg/kg) or saline (0.9% vol./vol.) was administered intravenously 30 minutes before resuscitation, followed by an intraperitoneal administration (MitoQ, 20 mg/kg) immediately after resuscitation (n = 5 per group). Morbidity was assessed based on cumulative markers of animal distress (0-10 scale). Rats were sacrificed 2 hours after procedure completion, and liver tissue was collected and processed for histology or assayed for lipid peroxidation (thiobarbituric acid reactive substance [TBARS]) or endogenous antioxidant (catalase, glutathione peroxidase [GPx], and superoxide dismutase) activity. RESULTS: HSR significantly increased morbidity as well as TBARS and catalase activities versus sham. Conversely, no difference in GPx or superoxide dismutase activity was measured between sham, HSR, and TPP, MitoQ administration reduced morbidity versus HSR (5.8 ± 0.3 vs. 7.6 ± 0.3; p < 0.05), while TPP administration significantly reduced hepatic necrosis versus both HSR and HSR-MitoQ (1.2 ± 0.1 vs. 2.0 ± 0.2 vs. 1.9 ± 0.2; p < 0.05, n = 5). Analysis of oxidative stress demonstrated increased TBARS and GPx in HSR-MitoQ versus sham (12.0 ± 1.1 µM vs. 6.2 ± 0.5 µM and 37.9 ± 3.0 µmol/min/mL vs. 22.9 ± 2.7 µmol/min/mL, TBARS and GPx, respectively, n = 5; p < 0.05). Conversely, catalase activity in HSR-MitoQ was reduced versus HSR (1.96 ± 1.17 mol/min/mL vs. 2.58 ± 1.81 mol/min/mL; n = 5; p < 0.05). Finally, MitoQ treatment decreased tumor necrosis factor α (0.66 ± 0.07 pg/mL vs. 0.92 ± 0.08 pg/mL) and interleukin 6 (7.3 ± 0.8 pg/mL vs. 11 ± 0.9 pg/mL) versus HSR as did TPP alone (0.58 ± 0.05 pg/mL vs. 0.92 ± 0.08 pg/mL; 6.7 ± 0.6 pg/mL vs. 11 ± 0.9 pg/mL; n = 5; p < 0.05). CONCLUSION: Our data demonstrate that MitoQ treatment following hemorrhage significantly limits morbidity and decreases hepatic tumor necrosis factor α and interleukin 6. In addition, MitoQ differentially modulates oxidative stress and hepatic antioxidant activity.

Delays in transfer of elderly less-injured trauma patients can have deadly consequences.

Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals' length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.

Comparison of procedural complications between resident physicians and advanced clinical providers.

BACKGROUND: In the era of resident work hour restrictions, many trauma centers across the country have incorporated advanced clinical providers (ACPs) as integral partners in the care of critically ill patients. In addition to providing daily care, ACPs have also begun performing invasive procedures. Few studies have addressed ACPs procedural complications. The purpose of this study was to compare the complication rates from surgical procedures performed by resident physicians (RPs) and ACPs in the critical care setting. METHODS: We conducted a retrospective review of all procedures performed from January to December of 2011 in our trauma and surgical intensive care units. Under attending supervision, ACPs performed procedures for surgical critical care patients and RPs for trauma patients. Procedures consisted of arterial lines, central venous lines, bronchoalveolar lavage, thoracostomy tubes, percutaneous endoscopic gastrostomy, and tracheostomies. Data included demographics, Acute Physiology and Chronic Health Evaluation III scores, complications, and outcomes and were divided into RP versus ACP groups. Complications were assessed by postprocedure radiography, operative notes, and postprocedure notes. Dichotomous data were compared using χ and continuous variables by Student's t tests. RESULTS: There were a total of 1,404 patients; the mean ± SE Acute Physiology and Chronic Health Evaluation III score for patients in the RP group was 40.8 ± 0.9 compared with ACP group at 47.7 ± 0.7 (p < 0.05). Our RPs performed 1,020 procedures, and 21 complications were noted (complication rate, 2%). The ACPs completed 555 procedures; 11 complications were incurred (complication rate, 2%). There were no difference in the mean ± SE intensive care unit (RP, 3.9 ± 0.2 days vs. ACP, 3.7± 0.1 days) and hospital (RP, 12.2 ± 0.4 days vs. ACP, 13.3 ± 0.3 days) length of stay. Mortality rates were also comparable between the two groups (RP, 11% vs. ACP, 9.7%). CONCLUSION: In critically ill patients, ACPs can competently perform invasive procedures safely. Our ACPs' responsibilities can be expanded to include invasive procedures in the critical care setting with appropriate supervision. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Resveratrol attenuates hypoxic injury in a primary hepatocyte model of hemorrhagic shock and resuscitation.

BACKGROUND: Oxidative stress following hemorrhagic shock and resuscitation (HSR) is regulated, in part, by inflammatory and apoptotic mediators such as necrosis factor κB (NF-κB) and p53. Sirtuin 1 (Sirt-1) is a metabolic intermediary that regulates stress responses by suppressing NF-κB and p53 activity. Resveratrol is a naturally occurring polyphenolic antioxidant and Sirt-1 agonist. The aim of this study was to determine whether resveratrol protects hepatocytes following HSR or hypoxia. METHODS: In vivo, HSR was achieved in male rats by arterial blood withdrawal to 30 ± 2 mm Hg for 1 hour before resuscitation with or without resveratrol (Res, 30 mg/kg). Hepatic tissue was stained and scored for necrosis, interleukin 6, and Sirt-1 expression. In vitro, primary rat hepatocytes were subjected to 8 hours of hypoxia without or with Res (100 µM). Cells were analyzed immediately or after 6 hours of normoxia, for survival and markers of injury (lactate dehydrogenase assay, lipid peroxidation, and mitochondrial integrity). Cell lysates were collected for cytochrome c analysis and immunoprecipitated using antibodies against NF-κB (p65) or p53. RESULTS: In vivo, animals subject to HSR exhibited increased expression of markers of hepatocyte damage compared with those sham operated, concomitant with lower Sirt-1 expression. In vitro, hypoxia followed by normoxia resulted in increased cell death, an effect that was blunted by Res. Analysis of cell and mitochondrial function demonstrated that Res inhibited the detrimental effects of hypoxia in isolated hepatocytes. CONCLUSION: Resveratrol prevents cell death in HSR and exerts a protective effect on the mitochondria in a hepatocyte model of hypoxic injury-reoxygenation possibly via Sirt-1 modulation of p53 and NF-κB activity.

Endovascular graft repair for blunt traumatic disruption of the thoracic aorta: experience at a nonuniversity hospital.

Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.

Mopeds: the legal loophole for repeat driving while intoxicated offenders.

BACKGROUND: Mopeds have less stringent licensing laws than automobiles. Moped operators in motorized vehicle collisions (MVCs) exhibit significantly higher rates of driving while intoxicated (DWI) and higher blood alcohol levels than automobile or motorcycle operators. This study evaluates the public safety issue of DWI recidivism among moped operators. METHODS: Moped operators evaluated after MVCs were identified from 2007 to 2009. Demographics, hospital data, and Department of Motor Vehicles records were reviewed. RESULTS: Sixty-five moped operators were evaluated. Thirty-two (49%) had a positive blood alcohol level, 29 (45%) had a previous DWI, and 21 (72%) of those were repeat offenders. Twenty-five (38%) had a revoked license at the time of injury. Of these, 19 (76%) incurred multiple revocations. Twenty-two (34%) showed prior charges of driving with a revoked license (DWRL), with 15 (68%) incurring multiple DWRL charges. CONCLUSIONS: Moped operators are often intoxicated at the time of injury and represent a public safety hazard. The majority are recidivists with multiple alcohol-related traffic charges. Current laws allow repeat offenders the sustained opportunity to operate motorized vehicles. Re-evaluation of current moped laws is needed to keep habitual offenders off the road.

Tracking colliding cells in vivo microscopy.

Leukocyte motion represents an important component in the innate immune response to infection. Intravital microscopy is a powerful tool as it enables in vivo imaging of leukocyte motion. Under inflammatory conditions, leukocytes may exhibit various motion behaviors, such as flowing, rolling, and adhering. With many leukocytes moving at a wide range of speeds, collisions occur. These collisions result in abrupt changes in the motion and appearance of leukocytes. Manual analysis is tedious, error prone,time consuming, and could introduce technician-related bias. Automatic tracking is also challenging due to the noise inherent in in vivo images and abrupt changes in motion and appearance due to collision. This paper presents a method to automatically track multiple cells undergoing collisions by modeling the appearance and motion for each collision state and testing collision hypotheses of possible transitions between states. The tracking results are demonstrated using in vivo intravital microscopy image sequences.We demonstrate that 1)71% of colliding cells are correctly tracked; (2) the improvement of the proposed method is enhanced when the duration of collision increases; and (3) given good detection results, the proposed method can correctly track 88% of colliding cells. The method minimizes the tracking failures under collisions and, therefore, allows more robust analysis in the study of leukocyte behaviors responding to inflammatory conditions.

An initiative by midlevel providers to conduct tertiary surveys at a level I trauma center.

INTRODUCTION: Increased patient volume and residents' work hour restrictions have escalated the workload at trauma centers. Because tertiary surveys (TSs) are integral to care, midlevel providers (MLPs) can help streamline this time-consuming process. In this study, we implemented a care plan in which MLPs conduct all TSs, initiate appropriate consultations, and offload residents' work hours. METHODS: From January 2007 to December 2008, we conducted a prospective evaluation of an initiative in which MLPs performed all TSs within 48 hours of admission. A TS consisted of a complete history and physical examination, follow-up of radiologic interpretations, and appropriate consultations. Data included patient demographics, incidence of additional diagnoses noted during TSs and reduction in residents' work hours. Data are presented as mean +/- standard error. RESULTS: During the 2-year period, there were 5,143 patients admitted to the trauma service. The mean age was 36 years +/- 4.8 years, and mean Injury Severity Score (ISS) was 14.2 +/- 4.2. Overall mortality was 5%. Blunt mechanisms accounted for 85%, and penetrating mechanisms resulted in 14% of injuries. MLPs conducted TSs in 56% of patients during the first year and 76% in the second year. In 80 patients (mean age of 44 years +/- 7.1 years, mean Injury Severity Score 21.7 +/- 2.8; p < 0.05 vs. entire cohort), TSs revealed additional injuries, for an incidence of 1.5%. The majority of these diagnoses were of "minor" fractures, half requiring consultations, and 9% necessitating operative intervention. Residents' workload was reduced by 1,802 hours. CONCLUSIONS: Implementation of a MLP initiative to conduct TSs in trauma patients can achieve a consistent and comprehensive workup while offsetting residents' workload and helping to ensure compliance with the 80-hour resident work policy.

Removal of erythropoietin from anaemia trauma practice guideline does not increase red blood cell transfusions and decreases hospital utilization costs.

INTRODUCTION: We previously demonstrated that utilization of erythropoietin (r-EPO) did not significantly reduce blood utilization in trauma patients. We undertook this study to analyze blood utilization 1 year after r-EPO removal from our trauma service anaemia practice management guideline. METHODS: Electronic records of patients admitted to the trauma service were retrospectively reviewed for units of packed red blood cells (pRBCs) transfused and for units of r-EPO administered 12 months before the initiation of an anaemia practice guideline (PRE), 12 months during the use of an anaemia guideline (GUIDE), and 12 months following removal of r-EPO from the guideline (POST). Hospital acquisition cost was also reviewed for the respective time periods. Nominal data were analyzed using chi-squared or Fisher's exact tests, and interval data were compared using ANOVA followed by Tukey's test where appropriate. Results were considered significant for P<0.05. RESULTS: Over the 3-year study period, 4881 patients were admitted to the trauma service and included in this study. The hospital length of stay, intensive care unit length of stay, and units of pRBC transfused were similar among all three groups. Group I (PRE) received a total of 228 doses of r-EPO at a cost of $102,600. Group II (GUIDE) received a total of 410 doses at a cost of $184,500. Group III (POST) received 28 doses of r-EPO at a cost of $12,600. CONCLUSION: Removal of erythropoietin from our trauma service anaemia practice management guideline did not result in increased blood utilization. However, it yielded a hospital acquisition cost savings of $171,900.

Optimal management strategy for incidental findings in trauma patients: an initiative for midlevel providers.

BACKGROUND: Increasing patient volume and residents' work hour restrictions have increased the workload at trauma centers. Further, comprehensive tertiary surveys after initial stabilization and appropriate follow-up plans for incidental findings are time consuming. Midlevel providers (MLP) can help streamline this process. We initiated a care plan in which MLPs conducted all tertiary surveys and coordinated follow-ups for incidental findings. METHODS: From November 2005 through May 2006, we implemented a MLP-driven initiative aimed at performing tertiary surveys within 48 hours of admission on all trauma patients admitted to our Level-1 trauma center. Tertiary surveys consisted of a complete history and physical, radiographic evaluations and appropriate consultations. Incidental findings were recorded and communicated to the trauma attending. A follow-up plan was devised, and the course of action was documented. Patients or family members were informed, and their acknowledgments were filed. Data are presented as mean +/- SE. RESULTS: There were 1,027 patients admitted during the study period. Blunt mechanisms accounted for 81% of the injuries (primarily motor vehicle crashes and falls). Seventy-six patients had 87 incidental findings (7.4%); 53 were men. The mean age was 51.8 years +/- 2.1 years and mean injury severity score was 18.5 +/- 1.4. Incidental findings of clinical significance included 18 pulmonary nodules or neoplasms, 9 adrenal masses (>4 mm), 7 patients with lymphadenopathy, 5 benign cystic lesions, and 3 renal masses. Other neoplastic lesions included bladder (2), thyroid (2), ovary (1), breast (1), and rectum (1). CONCLUSIONS: With prevalent medicolegal pressure and restricted residents' work hours, a MLP-initiative to streamline the tertiary survey effectively addresses incidental findings. This MLP-driven care plan can help reduce residents' workload, provides appropriate follow-up, and minimizes legal risks inherent to incidental findings on the trauma service.

The role of transesophageal echocardiography in optimizing resuscitation in acutely injured patients.

BACKGROUND: The goal of resuscitation is to correct the mismatch between oxygen delivery and that of cellular demands. The pulmonary artery catheter (PAC) is frequently used to gauge the adequacy of resuscitation and guide therapy based on ventricular filling pressures. Transesophageal echocardiography (TEE) has emerged as a potential tool in assessing adequacy of acute hemodynamic resuscitation. The purpose of this study was to evaluate the role of TEE in assessing preload during ongoing volume resuscitation in trauma patients. METHODS: A retrospective review was conducted of acutely injured patients undergoing TEE during resuscitation from hemorrhagic shock from January 2002 to 2004 at a Level I trauma center. The indication for TEE was persistent hemodynamic instability in the absence of ongoing surgical hemorrhage. Variables included hemodynamic and PAC parameters, pre-TEE resuscitation volume, and vasopressor requirements. The impact of TEE findings on therapeutic decisions was evaluated. RESULTS: Twenty-five patients underwent TEE, 18 (72%) had an indwelling PAC with a mean pulmonary artery occlusion pressure of 19.3 mm Hg (range, 12-29 mm Hg) and mean cardiac index of 2.9 L/min/m2 (range, 1.6-4.6 L/min/m2). Twelve patients (48%) were receiving inotropes and/or vasopressors for hypotension at the time of TEE. Resuscitation volume within 6 hours before TEE included a mean of 6.5 L of crystalloid and 12.2 units of blood products (packed red blood cells, fresh frozen plasma, and platelets). TEE revealed left ventricular hypovolemia in 13 patients (52%) and altered therapy in 16 patients (64%), including additional volume (n = 13), addition of an inotrope (n = 4), and addition of a vasodilator (n = 1) in one patient with ventricular overdistention. Comparison of the abnormal and normal TEE groups revealed that only cardiac index was significantly different (2.6 L/min/m2 in the abnormal group vs. 3.9 L/min/m2 in the normal group; p = 0.005). Significant mitral valve regurgitation leading to valve replacement was identified in one patient. No clinically relevant pericardial effusion was identified. CONCLUSION: TEE altered resuscitation management in almost two thirds of patients. Many patients with "acceptable" pulmonary artery occlusion pressure parameters may in fact have inadequate left ventricular filling. In addition, TEE offers the advantage of direct assessment of cardiac valve competency, myocardial wall contractility, and pericardial fluid.

Functional link between ETB receptors and eNOS maintain tissue oxygenation in the normal liver.

OBJECTIVE: Endothelins and their receptors play a crucial role in regulating liver microcirculation in pathophysiological conditions. The authors investigated the functional significance of the coupling of ET(B) receptors and eNOS in maintaining regional perfusion and tissue oxygenation in the normal liver. METHODS: The effect of endothelin-1 or the ET(B) agonist IRL1620 on oxygen consumption was determined in isolated perfused liver and isolated hepatocytes. Oxygen delivery to the liver tissue was determined in vivo. Following eNOS or iNOS blockade, either ET-1 or IRL1620 was infused via the portal vein. Hepatic tissue oxygenation, redox state, and microcirculation were investigated by intravital microscopy. Injury was estimated by serum LDH. RESULTS: Although IRL1620 and endothelin-1 increased oxygen consumption in isolated hepatocytes, in intact liver, endothelin decreased oxygen consumption while IRL1620 produced no change. In vivo, ET(B) stimulation modestly altered hepatic tissue P(O(2)), redox potential, and microcirculation. eNOS inhibition and ET(B) activation dramatically reduced microcirculatory blood flow, oxygen supply, and increased LDH release. Inhibition of iNOS resulted in small but not significant changes in these parameters. Concomitant ET(A)/ET(B) receptor activation increased microcirculatory failure and decreased tissue oxygen even without NOS inhibition. In contrast, hepatocellular injury was significantly increased following eNOS inhibition. CONCLUSIONS: Coupling between ET(B) receptor stimulation and eNOS activation decreases sinusoidal constriction and plays a functionally important role in maintaining microcirculation and tissue oxygenation in the normal liver.