Applying the antecedent, behaviour, and consequence taxonomy to unintentional firearm injury as determined by a collaborative firearm injury database.

BACKGROUND: Unintentional firearm injury (UFI) remains a significant problem in the USA with respect to preventable injury and death. The antecedent, behaviour and consequence (ABC) taxonomy has been used by law enforcement agencies to evaluate unintentional firearm discharge. Using an adapted ABC taxonomy, we sought to categorise civilian UFI in our community to identify modifiable behaviours. METHODS: Using a collaborative firearm injury database (containing both a university-based level 1 trauma registry and a metropolitan law enforcement database), all UFIs from August 2008 through December 2021 were identified. Perceived threat (antecedent), behaviour and injured party (consequence) were identified for each incident. RESULTS: During the study period, 937 incidents of UFI were identified with 64.2% of incidents occurring during routine firearm tasks. 30.4% of UFI occurred during neglectful firearm behaviour such as inappropriate storage. Most injuries occurred under situations of low perceived threat. UFI involving children was most often due to inappropriate storage of weapons, while cleaning a firearm was the most common behaviour in adults. Overall, 16.5% of UFI involved injury to persons other than the one handling the weapon and approximately 1.3% of UFI resulted in mortality. CONCLUSIONS: The majority of UFI occurred during routine and expected firearm tasks such as firearm cleaning. Prevention programmes should not overlook these modifiable behaviours in an effort to reduce UFIs, complications and deaths.

Predictors of oliguria in post-traumatic acute kidney injury.

BACKGROUND: Acute kidney injury is classified by urine output into non-oliguric and oliguric variants. Non-oliguric acute kidney injury has lower morbidity and mortality and accounts for up to 64% of acute kidney injury in hospitalized patients. However, the incidence of non-oliguric acute kidney injury in the trauma population and whether the 2 variants of acute kidney injury share the same risk factors is unknown. We hypothesized that oliguria would be present in the majority of acute kidney injury in severely injured trauma patients and that unique risk factors would predispose patients to the development of oliguria. METHODS: Patients admitted to the trauma intensive care unit and diagnosed with an acute kidney injury between 2016 to 2021 were identified. Cases were categorized based on urine output into oliguric (<400 mL per day) and non-oliguric (>400 mL per day) disease. Risk factors, management, and outcomes were compared. Logistic regression was used to identify risk factors associated with oliguria. RESULTS: A total of 227 patients met inclusion criteria. Non-oliguric acute kidney injury accounted for 74% of all cases and was associated with greater survival (78% vs 35.6%, P < .001). Using logistic regression, female sex, vasopressor use, and a greater net fluid balance at 48 hours were all predictive of oliguria (while controlling for age, race, shock index, massive transfusion, operative intervention, cardiac arrest, and nephrotoxic medication exposure). CONCLUSION: Non-oliguria accounts for the majority of post-traumatic acute kidney injury and is associated with improved survival. Specific risk factors for the development of oliguric acute kidney injury include female sex, vasopressor use, and a higher net fluid balance at 48 hours.

A Decade of Analysis of Unplanned Extubation Etiology in Trauma Patients Including the Impact of the COVID Pandemic.

BACKGROUND: Unplanned extubations (UEs) in injured patients are potentially fatal, but etiology and patient characteristics are not well described. We have been prospectively characterizing the etiology of UEs after we identified a high rate of UEs and implemented an educational program to address it. This period of monitoring included the years of the COVID-19 pandemic that produced high rates of workforce turnover in many hospitals, dramatically affecting nursing and respiratory therapy services. We hypothesized that frequency of UEs would depend on the etiology and that the workforce changes produced by the COVID-19 pandemic would increase UEs. METHODS: This study was a prospective tracking and retrospective review of trauma registry and performance improvement data from 2012-2021. RESULTS: UE subjects were younger, were more frequently male, were diagnosed more frequently with pneumonia (38% vs 27%), and had longer hospital (19 d vs 15 d) and ICU length of stay (LOS) (12 d vs 10 d) (all P < .05). Most UEs were due to patient factors (self-extubation) that decreased after education, while UEs from other etiologies (mechanical, provider) were stable. Subjects with UEs from mechanical or provider etiologies had longer ICU LOS, higher mortality, and were less likely to be discharged home. The COVID-19 pandemic was associated with more total patient admissions and more days of ventilator use, but the rate of UEs was not changed. CONCLUSIONS: UEs were decreased by education with ongoing tracking, and UEs from patient factors were associated with better outcome than other etiologies. Workforce changes produced by the COVID-19 pandemic did not change the rate of UEs.

The limitations of hospital and law enforcement databases in characterizing the epidemiology of firearm injury.

BACKGROUND: Current data on the epidemiology of firearm injury in the United States are incomplete. Common sources include hospital, law enforcement, consumer, and public health databases, but each database has limitations that exclude injury subgroups. By integrating hospital (inpatient and outpatient) and law enforcement databases, we hypothesized that a more accurate depiction of the totality of firearm injury in our region could be achieved. METHODS: We constructed a collaborative firearm injury database consisting of all patients admitted as inpatients to the regional level 1 trauma hospital (inpatient registry), patients treated and released from the emergency department (ED), and subjects encountering local law enforcement as a result of firearm injury in Jefferson County, Kentucky. Injuries recorded from January 1, 2016, to December 31, 2020, were analyzed. Outcomes, demographics, and injury detection rates from individual databases were compared with those of the combined collaborative database and compared using χ2 testing across databases. RESULTS: The inpatient registry (n = 1,441) and ED database (n = 1,109) were combined, resulting in 2,550 incidents in the hospital database. The law enforcement database consisted of 2,665 patient incidents, with 2,008 incidents in common with the hospital database and 657 unique incidents. The merged collaborative database consisted of 3,207 incidents. In comparison with the collaborative database, the inpatient, total hospital (inpatient and ED), and law enforcement databases failed to include 55%, 20%, and 17% of all injuries, respectively. The hospital captured nearly 94% of survivors but less than 40% of nonsurvivors. Law enforcement captured 93% of nonsurvivors but missed 20% of survivors. Mortality (11-26%) and injury incidence were markedly different across the databases. DISCUSSION: The utilization of trauma registry or law enforcement databases alone do not accurately reflect the epidemiology of firearm injury and may misrepresent areas in need of greater injury prevention efforts. LEVEL OF EVIDENCE: Epidemiological, level IV.

A Review of "Prehospital Hypotension as a Valid Indicator of Trauma Team Activation" (2000).

Prehospital hypotension has been utilized for decades as a surrogate marker of injury severity. Several studies have discussed the correlation between injury and hypotension both in the field as well as in the emergency department. Increases have been noted in injury severity score and mortality. Resource utilization is higher in this patient population. This study revisits our original work from 2000 and reviews the current literature regarding hypotension and injury severity. We also examine the role of prehospital hypotension as an indicator of trauma team activation and resource allocation. This review serves as a part of a Literary Festschrift in honor of Dr J David Richardson's role as the Editor-in-Chief of The American Surgeon.

Recidivism rates following firearm injury as determined by a collaborative hospital and law enforcement database.

BACKGROUND: Recidivism is a key outcome measure for injury prevention programs. Firearm injury recidivism rates are difficult to determine because of poor longitudinal follow-up and incomplete, disparate databases. Reported recidivism rates from trauma registries are 2% to 3%. We created a collaborative database merging law enforcement, emergency department, and inpatient trauma registry data to more accurately determine rates of recidivism in patients presenting to our trauma center following firearm injury. METHODS: A collaborative database for Jefferson County, Kentucky, was constructed to include violent firearm injuries encountered by the trauma center or law enforcement from 2008 to 2019. Iterative deterministic data linkage was used to create the database and eliminate redundancies. From patients with at least one hospital encounter, raw recidivism rates were calculated by dividing the number of patients injured at least twice by the total number of patients. Cox proportional hazard models were used to evaluate risk factors for recidivism. The cumulative incidence of recidivism over time was estimated using a Kaplan-Meier survival model. RESULTS: There were 2, 363 assault-type firearm injuries with at least 1 hospital encounter, approximately 9% of which did not survive their initial encounter. The collaborative database demonstrated raw recidivism rates for assault-type firearm injuries of 9.5% compared with 2.5% from the trauma registry alone. Risk factors were young age, male sex, and African American race. The predicted incidence of recidivism was 3.6%, 5.6%, 11.4%, and 15.8% at 1, 2, 5, and 10 years, respectively. CONCLUSION: Both hospital and law enforcement data are critical for determining reinjury rates in patients treated at trauma centers. Recidivism rates following violent firearm injury are four times higher using a collaborative database compared with the inpatient trauma registry alone. Predicted incidence of recidivism at 10 years was at least 16% for all patients, with high-risk subgroups experiencing rates as high as 26%. LEVEL OF EVIDENCE: Epidemiological, level III.

Operative Management of Thoracic Gunshot Wounds: More Aggressive Treatment Has Been Required over Time.

Our department has a database of thoracic gunshot wounds (GSWs), which has cataloged these injury patterns over the past five decades. Prevailing wisdom on the management of these injuries suggested operative treatment beyond tube thoracostomy is not commonly required. It was our clinical impression that the operative treatment required beyond chest tube placement has greatly increased over the past several decades, whereas the operative management of cardiac GSWs seemed to be increasingly infrequent events. To test these observations, we analyzed the treatment of GSWs to the chest and heart in four distinct time periods, categorized as "historical" (1973-1975 and 1988-1990) and "modern" (2005-2007 and 2015-2017). There was a significant increase in emergent thoracotomy, delayed thoracic operations, overall operative interventions, and pulmonary resections from the historical period to the modern era. There was a decline in cardiac injuries treated, whereas the number of injuries remained constant. Mortality was unchanged between the early and later periods. Operative treatment beyond tube thoracostomy was much more prevalent for noncardiac thoracic GSWs in the past two decades than in the prior decades, whereas the number of cardiac wounds treated decreased by half.

Self-Inflicted Stab Wounds: A Single-Center Experience from 2010 to 2016.

Despite low mortality rates, self-inflicted stab wounds (SISWs) can result in significant morbidity and often reflect underlying substance abuse and mental health disorders. This study aimed to characterize demographics, comorbidities, and outcomes seen in self-inflicted stabbings and compare these metrics to those seen in assault stabbings. A Level I trauma center registry was queried for patients with stab injuries between January 2010 and December 2015. Classification was based on whether injuries were SISWs or the result of assault stab wounds (ASWs). Demographic, injury, and outcome measures were recorded. Differences between genders, ethnicities, individuals with and without psychiatric comorbidities, and SISW and ASW patients were assessed. Within the SIWS cohort, no differences were found when comparing age, gender, or race, including need for operative intervention. However, patients with psychiatric histories were less likely to have a positive toxicology test on arrival than those without psychiatric histories (22% vs. 0%, P = 0.04). When compared with 460 ASW patients, SISW were older (41 vs. 35, P < 0.001), more likely to be white (92% vs. 64%, P < 0.001), more likely to have a psychiatric history (15% vs. 4%, P < 0.001), require operative intervention (65% vs. 50%, P = 0.008), and be discharged to a psychiatric facility (47% vs. 0.2%, P < 0.001). SISW patients have higher rates of psychiatric illness and an increased likelihood to require operative intervention as compared with ASW patients. This population demonstrates an acute need for both inpatient and outpatient psychiatric care with early involvement of multidisciplinary teams for treatment and discharge planning.

Patterns of geographic variability in mortality and eligible deaths between organ procurement organizations.

Eligible deaths are currently used as the denominator of the donor conversion ratio to mitigate the effect of varying mortality patterns in the populations served by different organ procurement organizations (OPOs). Eligible death is an OPO-reported metric rather than a product of formal epidemiological analysis, however, and may be confounded with OPO performance. Using Scientific Registry of Transplant Recipients and Centers for Disease Control and Prevention data, patterns of mortality and eligible deaths within each OPO were analyzed with the use of formal geostatistical analysis to determine whether eligible deaths truly reflect the geographic patterns they are intended to mitigate. There was a 2.1-fold difference in mortality between the OPOs with the highest and lowest rates, with significant positive spatial autocorrelation evident in mortality rates (Moran I = .110; P < .001), meaning geographically proximate OPOs tended to have similar mortality rates. The eligible death ratio demonstrated greater variability, with a 4.5-fold difference between the OPOs with the highest and lowest rates. Contrary to the pattern of mortality rates, the geographic distribution of eligible deaths among OPOs was random (Moran I = -.002; P = .410). This finding suggests geographic patterns do not play a significant role in eligible deaths, thus questioning its continuing use in OPO performance comparisons.

Gunshot Injuries to the Extremity: Is Immediate General Surgery Presence Needed?

Gunshot wounds (GSW) are becoming increasingly prevalent in urban settings. GSW to the trunk mandate full trauma activation and immediate surgeon response because of the high likelihood of operative intervention. Extremity GSW proximal to the knee/elbow also require full trauma activation based on American College of Surgeons Committee on trauma standards. However, whether isolated extremity GSW require frequent operative intervention is unclear. We evaluated GSW at our Level I trauma center from January 2012 to December 2016. Demographic data and injury patterns were abstracted from the trauma registry and charts. The number of GSW increased yearly but the age, gender, Injury Severity Score and injury pattern did not change (P = ns, not shown). There were 504 GSW that included an extremity and 194 (38%) involved multiple body regions. There were 310 GSW (62%) isolated to an extremity and 176 were proximal to the elbow/knee. If proximal GSW had an Emergency Department systolic blood pressure <90 mm Hg, 53 per cent underwent vascular repair, 12 per cent had soft tissue repair, and 29 per cent required no operation. If proximal GSW had an Emergency Department blood pressure >90 mm Hg, 57 per cent underwent orthopedic repair, 22 per cent required no surgery, and only 13 per cent required vascular repair (P < 0.01). In the absence of other criteria for full trauma activation such as shock, the need for the immediate presence of a general surgeon to perform emergency surgery for a GSW isolated to the extremity is low.

Correlating Geographic Location with Incidence of Motor Vehicle-Induced Pedestrian Injury.

To date, no studies have examined the relationship between geographic and socioeconomic factors and the frequency of pedestrians sustaining traumatic injuries from a motor vehicle. The objective of this study was to analyze the impact of location on the frequency of pedestrian injury by motor vehicle. The University of Louisville Trauma Registry was queried for patients who had been struck by a motor vehicle from 2010 to 2015. Demographic and injury information as well as outcome measures were evaluated to identify those impacting risk of pedestrian versus motor vehicle accidents. Number of incidents was correlated with lower median household income. There was also a moderate correlation between the number of incidents and population density. Multivariable analysis demonstrated a significant association between increased median household income and distance from downtown Louisville and decreased risk of death following pedestrian versus motor vehicle accident. Incidence of pedestrian injury by motor vehicles is influenced by regional socioeconomic status. Efforts to decrease the frequency of these events should include further investigation into the mechanisms underpinning this relationship.

Randomized Controlled Trial Evaluating the Efficacy of Peritoneal Resuscitation in the Management of Trauma Patients Undergoing Damage Control Surgery.

BACKGROUND: Peritoneal resuscitation (PR) represents a unique modality of treatment for severely injured trauma patients requiring damage control surgery. These data represent the outcomes of a single institution randomized controlled trial into the efficacy of PR as a management option in these patients. STUDY DESIGN: From 2011 to 2015, one hundred and three patients were enrolled in a prospective randomized controlled trial evaluating the use of PR in the treatment of patients undergoing damage control surgery compared with conventional resuscitation (CR) alone. Patient demographics, clinical variables, and outcomes were collected. Univariate and multivariate analysis was performed with a priori significance at p ≤ 0.05. RESULTS: After initial screening, 52 patients were randomized to the PR group and 51 to the CR group. Age, sex, initial pH, and mechanism of injury were used for randomization. Method of abdominal closure was standardized across groups. Time to definitive abdominal closure was reduced in the PR group compared with the CR group (4.1 ± 2.2 days vs 5.9 ± 3.5 days; p ≤ 0.002). Volume of resuscitation and blood products transfused in the initial 24 hours was not different between the groups. Primary fascial closure rate was higher in the PR group (83% vs 66%; p ≤ 0.05). Intra-abdominal complications were lower in the PR compared with the CR group (8% vs 18%), with abscess formation rate (3% vs 14%; p < 0.05) being significant. Patients in the PR group had a lower 30-day mortality rate, despite similar Injury Severity Scores (13% vs 28%; p = 0.06). CONCLUSIONS: Peritoneal resuscitation enhances management of damage control surgery patients by reducing time to definitive abdominal closure, intra-abdominal infections, and mortality rates.

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

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

Intubated Trauma Patients Do Not Require Full Trauma Team Activation when Effectively Triaged.

BACKGROUND: Full trauma team activation in evaluating injured patients is based on triage criteria and associated with significant costs and resources that should be focused on patients who truly need them. Overtriage leads to inefficient care, particularly when resources are finite, and it diverts care from other vital areas. Although shock and gunshot wounds to the abdomen are accepted indicators for full trauma activation, intubation as the sole criterion is controversial. We evaluated our experience to assess if intubation alone merited the highest level of trauma activation. STUDY DESIGN: All trauma patients from 2012 to 2013 were assessed for level of activation, injury characteristics, presence of intubation, and outcomes. RESULTS: Of 5,881 patients, 646 (11%) were level 1 (full) and 2,823 (48%) were level 2 (partial) activations. Level 1 patients were younger (40 ± 17 vs 45 ± 20 years), had more penetrating injuries (42% vs 9%), and had higher mortality (26% vs 8%)(p < 0.001). Intubated level 2 patients (n = 513), compared with intubated level 1 patients (n = 320), had higher systolic blood pressure (133 ± 44 vs 90 ± 58 mmHg), lower Injury Severity Score (21 ± 13 vs 25 ± 16), more falls (25% vs 3%), fewer penetrating injuries (11% vs 23%), and lower mortality (31% vs 48%)(p < 0.01). Fewer intubated level patients went directly to the operating room from the emergency department (ED)(16% vs 33%), and most who did had a craniotomy (63% vs 13%). Only 3% of intubated level 2 patients underwent laparotomy compared with 20% of intubated level 1 patients (p < 0.001). The ED lengths of stay before obtaining a head CT (47 ± 26 vs 48 ± 31 minutes) and craniotomy (109 ± 61 vs 102 ± 46 minutes) were similar. Deaths in intubated level 2 patients were primarily from fatal brain injuries. CONCLUSIONS: When appropriately triaged, selected intubated trauma patients do not require full trauma activation to receive timely, efficient care.

Organ donation as an outcome of traumatic cardiopulmonary arrest: A cost evaluation.

BACKGROUND: Survival after traumatic cardiopulmonary arrest (TCPA) is rare and requires significant resource expenditure. Organ donation as an outcome of TCPA resuscitation has not yet been included in a cost analysis. The aims of this study were to identify variables associated with survival and organ donation after TCPA, and to estimate the cost of achieving these outcomes. We hypothesized that the inclusion of organ donation as a potential outcome would make TCPA resuscitation more cost-effective. METHODS: Adult patients who required resuscitation for TCPA at a level I trauma center were retrospectively reviewed over 36 months. Data were obtained from medical records, hospital accounting records, and the local organ procurement agency. Outcomes included survival to discharge, neurologic function, and organ donor eligibility. An individual-level state-transition cost-effectiveness model was used to evaluate the cost of TCPA resuscitation with and without organ donation included as an outcome. Incremental cost-effectiveness ratio was calculated to determine additional cost per life saved when organ donation is included. RESULTS: Over the study period, 8,932 subjects were evaluated. Traumatic cardiopulmonary arrest occurred in 237 patients (3%). The mortality rate was 97%. Variables associated with survival included emergency department disposition to the operating room (p < 0.01) and reactive pupils (p < 0.001). Of seven survivors, four were discharged neurologically intact. Of the patients with TCPA, 5% were eligible for organ donation with a procurement rate of 2%. Organ donor eligibility was associated with arrest after arrival to the emergency department (p < 0.01) and transfusion of fresh frozen plasma (p = 0.01). The cost of TCPA resuscitation per survivor was $1.8 million; cost per survivor or life saved by donation was $538,000. The incremental cost-effectiveness ratio was $76,816 per additional life saved including donation as an outcome. CONCLUSION: The decision to pursue resuscitation should continue to be based on the presence of signs of life, especially pupil reactivity and duration of arrest. If the primary objective is survival, organ procurement will be maximized without conflict of interest. Early fresh frozen plasma transfusion may increase successful organ donation. The financial burden of TCPA resuscitation can be mitigated by expanding end points to include organ donation. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III; cost analysis, level V.

Machine perfusion: not just for marginal kidney donors.

Interest in machine perfusion (MP) for donated kidneys has markedly increased in the past decade as a means to improve graft function, although the donor populations in which it should be applied have not yet been resolved. All adults undergoing de-novo isolated kidney transplantation from standard-criteria donors in the UNOS database 2005 to 2011 were reviewed with the primary endpoint of delayed graft function (DGF), defined as dialysis within seven days of transplantation, in those who received kidneys that underwent MP versus cold storage (CS) alone. Three methods were used to control for differences between groups. Multivariable logistic regression was performed, adjusting for donor and recipient characteristics significantly associated with DGF. Rates were also compared in a cohort of propensity-matched MP vs CS recipients. Finally, a paired-kidney study was performed, where one kidney underwent MP and the contralateral underwent CS. There were 36,323 patients, with unadjusted DGF rates of 18.6 per cent (n = 1830/9882) and 22.4 per cent (n = 5931/26,441; P < 0.001) in the MP vs CS groups, respectively. After multivariable analysis, the odds ratio for DGF in the MP group was 0.59 (P < 0.001) versus CS. In the propensity-matched cohort, there were 8929 patients each in the MP and CS groups. DGF occurred in 16.8 per cent of the MP group vs 25.3 per cent with CS (P < 0.001, OR 0.59). In the paired-kidney study, rates of DGF were 16.7 per cent vs 24.3 per cent (P < 0.001) in the 1665 recipients each in the MP versus CS groups (OR 0.6). In conclusion, machine perfusion is beneficial in reducing DGF even when standard donors are utilized, and thus should not be limited to marginal kidneys.

Does chest tube location matter? An analysis of chest tube position and the need for secondary interventions.

BACKGROUND: Tube thoracostomy is a common procedure used in the management of thoracic trauma. Traditional teaching suggests that chest tubes should be directed in specific locations to improve function. Common examples include anterior and superior placement for pneumothorax, inferior and posterior placement for hemothorax, and avoidance of the pulmonary fissure. The purpose of this study was to examine the effect of specific chest tube position on subsequent chest tube function. METHODS: A retrospective review of all patients undergoing tube thoracostomy for trauma from January 1, 2010, to September 30, 2012, was performed. Only patients undergoing computed tomography scans following chest tube insertion were included so that positioning could be accurately determined. Rib space insertion level and positioning of the tube relative to the lung parenchyma were recorded. The duration of chest tube drainage and the need for secondary interventions were determined and compared for tubes in different rib spaces and locations. For purposes of comparison, tubes placed above the sixth rib space were considered "high," and those at or below it were considered "low." RESULTS: A total of 291 patients met criteria for inclusion. Forty-eight patients (16.5%) required secondary intervention. Neither high chest tube placement nor chest tube location relative to lung parenchyma was associated with an increased need for secondary interventions. On multivariate analysis, only chest Abbreviated Injury Scale (AIS) scores, mechanism, and volume of hemothorax were found to be significant risk factors for the need for secondary interventions. CONCLUSION: Chest tube location does not influence the need for secondary interventions as long as the tube resides in the pleural space. The severity of chest injury is the most important factor influencing outcome in patients undergoing tube thoracostomy for trauma. Tube thoracostomy technique should focus on safe insertion within the pleural space and not on achieving a specific tube location. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Addition of direct peritoneal lavage to human cadaver organ donor resuscitation improves organ procurement.

BACKGROUND: Brain dead organ donors have altered central hemodynamic performance, impaired hormone physiology, exaggerated systemic inflammatory response, end-organ microcirculatory dysfunction, and tissue hypoxia. A new treatment, direct peritoneal resuscitation (DPR), stabilizes vital organ blood flow after conventionally resuscitated shock to improve these derangements. STUDY DESIGN: A prospective case-control study of adjunctive DPR compared 26 experimental patients (brain dead organ donors) to 52 controls (protocolized conventionally resuscitated donors). Actual organ procurement rates were compared with the Scientific Registry of Transplant Recipient predicted organ yield per patient. Achievement of donor management goals and effective hepatic blood flow were recorded. RESULTS: Fourteen of 26 (53.8%) patients treated with DPR achieved all donor management goals compared with 17 of 52 (32.7%) patients treated with conventionally resuscitated (odds ratio = 2.4; 95% CI, 0.92-6.3; p = 0.06). Patients treated with DPR were more than 2 times as likely to achieve final pO2 >100 on 40% FiO2 compared with controls (odds ratio = 2.8; 95% CI, 1-7.69; p = 0.03). Also, DPR-treated patients required less IV crystalloid during the first 12 hours of management (DPR: 3,167 ± 1,893 mL vs 4,154 ± 2,100 mL; p = 0.046) and required less vasopressor agents at 12 hours post resuscitation (odds ratio = 7.7; 95% CI, 0.82-42; p = 0.02). Direct peritoneal resuscitation patients had enhanced effective hepatic blood flow and significantly higher organs transplanted per donor rates compared with controls (3.7 ± 1.7 vs 3.1 ± 1.3; p = 0.024). CONCLUSIONS: Direct peritoneal resuscitation reduced IV fluid requirement and IV pressor use as well as increased hepatic blood flow and organs transplanted per donor. Direct peritoneal resuscitation studies show it to be a safe, effective method to augment organ donor resuscitation and additional large-scale trials should be conducted to validate these findings.

Volume-Based Feeding in the Critically Ill Patient.

INTRODUCTION: Critically ill patients placed on enteral nutrition (EN) are usually underfed. A volume-based feeding (VBF) protocol designed to adjust the infusion rate to make up for interruptions in delivery should provide a greater volume of EN than the more common fixed hourly rate-based feeding (RBF) method. METHODS: This single-center, randomized (3:1; VBF/RBF) prospective study evaluated critically ill patients on mechanical ventilation expected to receive EN for ≥ 3 days. Once goal rate was achieved, the randomized feeding strategy was implemented. In the VBF group, physicians used a total goal volume of feeds to determine an hourly rate. For the RBF group, physicians determined a constant hourly rate of infusion to meet goal feeds. RESULTS: Sixty-three patients were enrolled in the study with a mean age of 52.6 years (60% male). Six patients were excluded after randomization because of early extubation. The VBF group (n = 37) received 92.9% of goal caloric requirements with a mean caloric deficit of -776.0 kcal compared with the RBF group (n = 20), which received 80.9% of goal calories (P = .01) and a caloric deficit of -1933.8 kcal (P = .01). Uninterrupted EN was delivered for 51.7% of all EN days in VFB patients compared with 54.5% in RBF patients. On days when feeding was interrupted, VFB patients overall received a mean 77.6% of goal calories (while RBF patients received 61.5% of goal calories, P = .001). No vomiting, regurgitation, or feeding intolerance occurred due to VBF. CONCLUSIONS: A VBF strategy is safe and improves delivery to better meet caloric requirements than the standard more commonly used rate-based strategy.

Targeted Physician Education Positively Affects Delivery of Nutrition Therapy and Patient Outcomes: Results of a Prospective Clinical Trial.

BACKGROUND: Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize that targeted physician education should help reduce caloric deficits and improve patient outcomes. MATERIALS AND METHODS: We performed a prospective trial of patients (n = 121) assigned to 1 of 2 trauma groups. The experimental group (EG) received targeted education consisting of strategies to increase delivery of early enteral nutrition. Strategies included early enteral access, avoidance of nil per os (NPO) and clear liquid diets (CLD), volume-based feeding, early resumption of feeds postprocedure, and charting caloric deficits. The control group (CG) did not receive targeted education but was allowed to practice in a standard ad hoc fashion. Both groups were provided with dietitian recommendations on a multidisciplinary nutrition team per standard practice. RESULTS: The EG received a higher percentage of measured goal calories (30.1 ± 18.5%, 22.1 ± 23.7%, P = .024) compared with the CG. Mean caloric deficit was not significantly different between groups (-6796 ± 4164 kcal vs -8817 ± 7087 kcal, P = .305). CLD days per patient (0.1 ± 0.5 vs 0.6 ± 0.9), length of stay in the intensive care unit (3.5 ± 5.5 vs 5.2 ± 6.8 days), and duration of mechanical ventilation (1.6 ± 3.7 vs 2.8 ± 5.0 days) were all reduced in the EG compared with the CG (P < .05). EG patients had fewer nosocomial infections (10.6% vs 23.6%) and less organ failure (10.6% vs 18.2%) than did the CG, but these differences did not reach statistical significance. CONCLUSION: Implementation of specific educational strategies succeeded in greater delivery of nutrition therapy, which favorably affected patient care and outcomes.