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1.
J Trauma ; 68(6): 1279-87; discussion 1287-8, 2010 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-20539170

RESUMEN

BACKGROUND: Resource utilization in medicine is becoming a more and more urgent issue with ongoing national discussions on healthcare coverage. In the management of a trauma system, large amounts of resources and money are expended on individual patients in hope of a "great save." In addition, those of us caring for these patients are required to estimate outcomes daily to the family in an effort to choose the best course of care for an individual patient. Hence, we undertook a study to analyze the accuracy of outcomes predictions of various members of the healthcare team. METHODS: During a period of 38 months (July 2005 to August 2008), an observational study of patients admitted to a Level I Trauma Center Intensive Care Unit (ICU) was undertaken. Institutional Review Board permission was obtained before starting the study. Only patients older than 18 years were included. Patients who were moribund or expected discharge within 72 hours were excluded.Our traumatized ICU patients are cared for by a multidisciplinary team consisting of a trauma/ICU attending, all of whom have additional certification in surgical critical care and who rotate through the ICU on a weekly basis, a surgical ICU fellow, residents and medical students of several levels of training who rotate on a monthly basis, trauma advanced-level practitioners who rotate weekly, and bedside ICU nurses who work routine shifts. Respiratory therapists, nutritionists, ICU pharmacists, and other members of the rounding team were not included in the study because they do not provide global patient care. Regardless of admitting physician, the patients are managed by the team, and our practice of care is similar across the group, based on protocols and consensus.For each of the study patients, a survey tool was filled out by the ICU rounding team on hospital day 1 and hospital day 3. The tool was completed by members of the team providing global care to the patient and varied depending on the members of the group at each day's rounds. All current and admission data on injuries, study and laboratory results, and current patient status were available to all members of the team. Each member was expected to fill out the survey tool independently, and the results of the tool were not discussed during rounds.Concurrently, data were collected by the ICU fellow and research nurse. These data and the results of the survey tools were entered in a database for analysis after patient discharge. A retrospective analysis was undertaken to analyze the relative accuracy of the care, team members' assessment, and actual survival. Statistical analysis was done using by-chance accuracy comparisons. RESULTS: Two hundred twenty-three patients had 326 observations performed. Day 3 accuracy improved for most groups. In all groups, accuracy was found to be statistically significantly better than by-chance accuracy. Given that the majority of patients in the trauma population are survivors, sensitivity and positive predictive value of the observer's ability to predict death were also evaluated. CONCLUSIONS: Although significantly better than chance prediction, the ability of members of the ICU team to predict survival of trauma patients remains poor, particularly on initial evaluation. A period of clinical observation improves the accuracy. Unfortunately, experience of the observer does not seem to improve accuracy of survival prediction. This data indicate that care must be taken when describing likely outcomes to patient family members.


Asunto(s)
Recursos en Salud/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Análisis de Supervivencia , Centros Traumatológicos/estadística & datos numéricos , Heridas y Lesiones/mortalidad , Interpretación Estadística de Datos , Femenino , Indicadores de Salud , Mortalidad Hospitalaria , Humanos , Masculino , Grupo de Atención al Paciente/organización & administración , Valor Predictivo de las Pruebas , Pronóstico , Sensibilidad y Especificidad , Índices de Gravedad del Trauma
2.
Crit Care Med ; 37(12): 3124-57, 2009 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-19773646

RESUMEN

OBJECTIVE: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. DESIGN: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members. METHODS: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM. RESULTS: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion. CONCLUSIONS: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.


Asunto(s)
Cuidados Críticos , Enfermedad Crítica/terapia , Transfusión de Eritrocitos , Heridas y Lesiones/terapia , Adulto , Humanos
3.
J Trauma ; 67(2): 337-40, 2009 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-19667887

RESUMEN

BACKGROUND: The cost of care in elderly (ELD) trauma patients is high compared with younger patients, but the association between age and reimbursement relative to cost is less clear. The purpose of this study was to explore the relationship between total costs (TC) and reimbursement in young (YNG) and ELD trauma patients. METHODS: The National Trauma Registry of the American College of Surgeons was queried for patients admitted to a level I trauma center between January 2002 and December 2004. YNG patients (18-64 years) were compared with ELD patients (> or =65 years) for mechanism of injury, Injury Severity Score, and outcome variables. Data obtained from the hospital cost accounting system included TC, total payment, and net margin (P-L). Virtually, all patients were reimbursed based on the fixed diagnostic-related group payment. RESULTS: There were 641 ELD and 3,470 YNG patients included in the study. ELD patients were more commonly injured via a blunt mechanism than the YNG patients (97% vs. 83%; p < 0.001). The ELD were more severely injured (Injury Severity Score 14.9 +/- 10.8 vs. 13.3 +/- 10.9), developed more complications (54% vs. 34%), and died more frequently (17% vs. 4.7%; all p < 0.05). TC for the ELD were significantly higher than the YNG ($20,788.92 +/- $28,305.54 vs. $19,161.11 +/- $30,441.56; p = 0.02). Total payment ($20,049.75 +/- $29,754.52 vs. $16,766.14 +/- $31,169.15) and P-L (-$739.18 +/- $17,207.84 vs. -$2,294.98 +/- $22,309.51; both p < 0.05) were significantly better for the ELD cohort. However, a financial loss was realized for all patients with trauma. CONCLUSION: When compared with YNG trauma patients, reimbursement in the ELD appears favorable. However, compensation via diagnostic-related group payment fails to cover costs even in the ELD. Reimbursement for all patients with trauma is suboptimal and needs to be improved.


Asunto(s)
Costos de la Atención en Salud , Reembolso de Seguro de Salud , Heridas y Lesiones/economía , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Humanos , Persona de Mediana Edad , Sistema de Registros , Adulto Joven
4.
J Trauma ; 67(3): 441-3; discussion 443-4, 2009 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-19741383

RESUMEN

BACKGROUND: A tissue hemoglobin oxygen saturation (STO2) monitor was created to assess the perfusion status of a peripheral muscle bed using near infrared light to directly measure oxygen saturation in the microcirculation. Hypoperfusion has been noted when the STO2 is <75%. The use of this technology has not been tested in the prehospital setting. This pilot study was performed to assess the technology's ease of use in the field and to correlate STO2 readings with patient outcomes. METHODS: Hospital-based transport vehicles were equipped with STO2 monitors and personnel were asked to evaluate the functionality of the technology. Initial, average, and minimal STO2 values were collected and compared with data of the trauma registry. RESULTS: Forty five of 55 surveys were returned with 100% reporting ease of use and no reports of interference with monitors or avionics. Monitoring length averaged 16.9 minutes +/- 6.9 minutes. Forty-one patients had complete data sets and five deaths were reported for a mortality rate of 12%. STO2 endpoints revealed and increased risk of death for every 10% decrease in STO2. CONCLUSION: The STO2 monitor can easily be used in the prehospital environment. In addition, initial recordings were significantly different between survivors and nonsurvivors with every 10% decrease in STO2 increasing mortality threefold. This monitor seems to give the prehospital provider a noninvasive tool for assessment of hypoperfusion in the field and may allow for earlier resuscitative efforts to commence.


Asunto(s)
Músculo Esquelético/metabolismo , Oxígeno/metabolismo , Espectroscopía Infrarroja Corta/instrumentación , Transporte de Pacientes , Heridas y Lesiones/metabolismo , Adulto , Actitud del Personal de Salud , Volumen Sanguíneo/fisiología , Humanos , Proyectos Piloto , Pronóstico , Estudios Prospectivos , Reproducibilidad de los Resultados , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/mortalidad
5.
J Trauma ; 67(5): 915-23, 2009 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-19901648

RESUMEN

BACKGROUND: In 1999, a Level I Trauma Center committed significant resources for development, recruitment of trauma surgeons, and call pay for subspecialists. Although this approach has sparked a national ethical debate, little has been published investigating efficacy. This study examines the price of commitment and outcomes at a Level I Trauma Center. METHODS: Direct personnel costs including salary, call pay, and personnel expenses were analyzed against outcomes for two periods defined as PRE (1994-1999) and POST (2000-2005). Patient care costs and 1999 to 2000 transition data were excluded. Demographics, outcomes, and direct personnel costs were compared. Significant mortality reductions stratified by age and injury severity score (ISS) were used to calculate lives saved in relation to direct personnel costs. Student's t test and chi were used (significance *p < 0.05). RESULTS: In the PRE period, there were 7,587 admissions compared with 11,057 POST. There were no significant differences PRE versus POST for age (41.4 +/- 24.4 years vs. 41.3 +/- 24.9 years), gender (62.4% vs. 63.7% male), mechanism of injury (11.5% vs. 11.8% penetrating), and percent intensive care unit admissions (30.1 vs. 29.9). Significant differences were noted for ISS (10.5 +/- 9.7 vs. 11.6 +/- 10.1*), percent admissions with ISS >or=16 (18.5 vs. 27.3*), and revised trauma score (10.8 +/- 2.8 vs. 10.7 +/- 2.8*). Both the average length of stay (6.8 +/- 8.8 vs. 6.5 +/- 9.8*) and percent mortality for ISS >or=16 (23 vs. 17*) were reduced. When mortality was stratified by both age and ISS, significant reductions were noted and a total of 173 lives were saved as a result. However, direct personnel costs increased from $7.6 million to $22.7 million. When cost is allocated to lives saved; the cost of a saved life was more than $87,000. CONCLUSIONS: Resources for program development, including salary and call pay, significantly reduced mortality. Price of commitment: $3 million per year. The cost of a saved life: $87,000. The benefit: 173 surviving patients who would otherwise be dead.


Asunto(s)
Centros Traumatológicos/estadística & datos numéricos , Heridas y Lesiones/economía , Heridas y Lesiones/mortalidad , Adulto , Servicios Contratados/economía , Análisis Costo-Beneficio , Eficiencia Organizacional , Femenino , Costos de la Atención en Salud , Investigación sobre Servicios de Salud , Hospitales Universitarios/economía , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Masculino , Persona de Mediana Edad , North Carolina , Evaluación de Resultado en la Atención de Salud , Desarrollo de Programa , Estudios Retrospectivos , Salarios y Beneficios , Centros Traumatológicos/economía , Centros Traumatológicos/organización & administración , Traumatología/economía , Recursos Humanos , Adulto Joven
6.
Am J Crit Care ; 18(2): 144-8, 2009 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-19255104

RESUMEN

BACKGROUND: High-frequency oscillatory ventilation is an alternative ventilation mode that improves oxygenation in trauma patients in whom conventional ventilation strategies have been unsuccessful. OBJECTIVE: To evaluate the effect of high-frequency oscillatory ventilation on oxygenation, survival, and parameters predictive of survival in trauma patients. METHODS: A retrospective case series of 24 adult patients admitted to the trauma intensive care unit at a level I trauma center between November 2001 and July 2005 and treated with high-frequency oscillatory ventilation. Survivors and nonsurvivors were compared for mechanism and severity of injury, oxygenation parameters related to high-frequency oscillatory ventilation, and hospital course. RESULTS: Of the 8577 patients admitted during the study period, acute respiratory distress syndrome developed in 103 (1%). Of those 103 patients, 24 (23%) were treated with high-frequency oscillatory ventilation. Most of the patients treated with high-frequency oscillatory ventilation had sustained blunt trauma (79%). Oxygenation parameters improved significantly with high-frequency oscillatory ventilation in all patients, regardless of survival. Of the 24 patients treated with this ventilation mode, 15 (62%) survived. Survival did not correlate with improved oxygenation parameters but with the number of failed organ systems and injury severity. CONCLUSION: Although high-frequency oscillatory ventilation improves oxygenation, severity of traumatic injury and organ failure, not respiratory parameters, are predictors of survival. High-frequency oscillatory ventilation should be considered for pulmonary rescue of severely injured patients with acute respiratory distress syndrome.


Asunto(s)
Ventilación de Alta Frecuencia/estadística & datos numéricos , Centros Traumatológicos , Heridas y Lesiones/mortalidad , Heridas y Lesiones/terapia , Análisis de los Gases de la Sangre , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación , Estudios Retrospectivos , Análisis de Supervivencia
7.
Am Surg ; 74(6): 494-501; discussion 501-2, 2008 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-18556991

RESUMEN

Although acute care general surgery (ACS) coverage by trauma surgeons may help re-invigorate the field of trauma surgery, introducing additional responsibilities to an already overburdened system may negatively impact the trauma patient. Our purpose was to determine the impact on the trauma patient of a progressive integration of ACS coverage into a trauma service. Data from a university, Level I trauma registry was retrospectively reviewed to compare demographics, injury severity, complications, and outcomes over a 6-year period. During this study period, the trauma service treated only trauma patients for 32 months, then added ACS coverage 2 days per week for 32 months, and then expanded to 4 days per week coverage for 9 months. Trauma patients admitted during periods of ACS coverage were not different with respect to gender, mechanism of injury, Revised Trauma Score, or Glasgow Coma Score; however, they were slightly older and had slightly higher injury severity scores. As ACS coverage progressively increased, trauma patients had an increase in ventilator days (P < 0.0001), intensive care unit length of stay (P < 0.0001), and hospital length of stay (P < 0.0001). Occurrences of neurologic, pulmonary, gastrointestinal, and infectious complications were similar during all three time periods, whereas cardiac and renal complications progressively increased after ACS coverage was added. Mortality remained unchanged after ACS integration.


Asunto(s)
Especialidades Quirúrgicas/tendencias , Traumatología/tendencias , Heridas y Lesiones/cirugía , Distribución de Chi-Cuadrado , Servicio de Urgencia en Hospital , Humanos , Tiempo de Internación/estadística & datos numéricos , Complicaciones Posoperatorias , Índices de Gravedad del Trauma
8.
Arch Surg ; 142(1): 77-81, 2007 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-17224504

RESUMEN

HYPOTHESIS: Unlike the well-characterized urban trauma recidivist (RC), factors associated with the rural RC remain undefined. In an attempt to devise preventative strategies, we theorized that the rural RC profile would be similar to that of urban counterparts. DESIGN: Retrospective review. SETTING: Rural, university-affiliated, level I trauma center. PATIENTS: All trauma patients admitted between January 1, 1994, and December 30, 2002. INTERVENTIONS: Identification and characterization of rural trauma RCs. MAIN OUTCOME MEASURES: Trauma recidivism incidence, risk factors, and cost. RESULTS: Of 15 370 consecutive admissions, 528 (3.4%) were RCs. Demographic comparisons to a non-RC cohort demonstrated rural RCs to be significantly older (mean +/- SD age, 55.9 +/- 24.8 vs 39.7 +/- 24.1 years), disproportionately white (65.2% [344/528] vs 56.5% [8386/14 842]), and more likely female (49.1% [259/528] vs 37.3% [5537/14 842]) (P<.001 for all). Clinical comparisons revealed significant associations between recidivism and substance abuse. The percentage of positive blood ethanol screen results (58.7% [310/528] vs 39.9% [5923/14 842]) and the mean +/- SD blood ethanol content (132.1 +/- 139.9 mg/dL [28.7 +/- 30.4 mmol/L] vs 69.5 +/- 114.4 mg/dL [15.1 +/- 24.8 mmol/L]) were higher for RCs (P<.001 for both). In addition, cocaine use was significantly higher in the RC cohort (6.4% [34/528] vs 4.1% [607/14 842]; P=.02). The total cost for all RC admissions exceeded $7 million. CONCLUSIONS: The rural RC profile is strikingly different from urban counterparts. The common feature seems to be substance abuse. Correspondingly, prevention strategies for recidivism must be considerably different among rural and urban populations.


Asunto(s)
Población Rural/estadística & datos numéricos , Heridas y Lesiones/epidemiología , Adulto , Consumo de Bebidas Alcohólicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Trastornos Relacionados con Sustancias/epidemiología
9.
J Am Coll Surg ; 204(5): 1056-61; discussion 1062-4, 2007 May.
Artículo en Inglés | MEDLINE | ID: mdl-17481540

RESUMEN

BACKGROUND: The influence of increased body mass index (BMI) on morbidity and mortality in critically injured trauma patients has been studied, with conflicting results. The objective of this study was to investigate the relationship between stratified BMI and outcomes in blunt injured patients. STUDY DESIGN: Consecutive adult trauma patients from July 2001 to November 2005 with Injury Severity Score (ISS) > or = 16 and blunt mechanism were evaluated using the National Trauma Registry of the American College of Surgeons. Demographics, injury severity, hospital course, complications, and mortality were compared among standard BMI strata. Logistic regression was used to determine odds ratios (OR) with 95% confidence intervals and evaluate BMI as an independent risk factor for morbidity and mortality. Statistical significance was set at p < 0.05. RESULTS: The study group consisted of 1,543 patients. Controlling for age, gender, Injury Severity Score, and Revised Trauma Score, and using BMI 18.5 to 24.9 kg/m(2) as the reference category, morbid obesity (BMI> or =40 kg/m(2)) was associated with acute respiratory distress syndrome (OR 3.675, 95% CI, 1.237 to 10.916), acute respiratory failure (OR 2.793, 95% CI, 1.633 to 4.778), acute renal failure (OR 13.506, 2.388 to 76.385), multisystem organ failure (OR 2.639, 95% CI, 1.085 to 6.421), pneumonia (OR 2.487, 95% CI, 1.483 to 4.302), urinary tract infection (OR 2.332, 95% CI, 1.229 to 4.427), deep venous thrombosis (OR 4.112, 95% CI, 1.253 to 13.496), and decubitus ulcer (OR 2.841, 95% CI, 1.382 to 5.841). Morbid obesity was not associated with increased mortality (OR 0.810, 95% CI, 0.353 to 1.856). CONCLUSIONS: This is the largest study to date evaluating the relationship between BMI and outcomes in critically injured trauma patients. Increasing BMI increases morbidity while having no proved influence on mortality.


Asunto(s)
Índice de Masa Corporal , Enfermedad Crítica , Heridas no Penetrantes/complicaciones , Adulto , Distribución de Chi-Cuadrado , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Modelos Logísticos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Estadísticas no Paramétricas , Resultado del Tratamiento , Heridas no Penetrantes/mortalidad
10.
J Trauma ; 62(6): 1370-5; discussion 1375-6, 2007 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-17563651

RESUMEN

BACKGROUND: Recent data have demonstrated that intensive glycemic control during critical illness improves outcome. The purpose of our study was to evaluate the effect of a computerized hospital insulin protocol (CHIP) on glycemic control and outcome in critically ill trauma patients. METHODS: Two, 6-month cohorts were compared, one 6 months prior to chip implementation (pre-CHIP) and one from the 6-month period after implementation (post-CHIP), using finger stick blood glucose values and demographic, injury severity, and outcome variables for adult patients with intensive care unit length of stay (LOS) > or =72 hours. Infectious morbidity was based upon the National Trauma Registry of the American College of Surgeons definitions. Differences between cohorts were assessed using Student's t test and Fisher's exact test for continuous and categorical variables. RESULTS: The 129 pre- and 128 post-CHIP patients were well matched for demographics and injury severity. Significant reductions in mean finger stick blood glucose, rates of ventilator- associated pneumonia, central venous line infection, total infections, and all LOS categories were demonstrated in the post-CHIP cohort. However, mortality was significantly higher in the post-CHIP cohort. CONCLUSION: This preliminary study demonstrates significant morbidity and LOS reductions with the use of a CHIP, but significantly increased mortality. Further prospective studies are necessary to assess the effects of intensive glycemic control on outcome after injury, particularly in sub populations who might be adversely affected.


Asunto(s)
Quimioterapia Asistida por Computador , Hiperglucemia/tratamiento farmacológico , Hipoglucemiantes/administración & dosificación , Insulina/administración & dosificación , Heridas y Lesiones/epidemiología , Adulto , Enfermedad Crítica , Femenino , Humanos , Hiperglucemia/epidemiología , Hiperglucemia/etiología , Tiempo de Internación , Masculino , Persona de Mediana Edad , Heridas y Lesiones/complicaciones , Heridas y Lesiones/mortalidad
11.
Am Surg ; 83(8): 901-905, 2017 Aug 01.
Artículo en Inglés | MEDLINE | ID: mdl-28822399

RESUMEN

Timing of chest tube (CT) removal after transition from suction to water-seal (WS) varies when treating traumatic simple pneumothoraces (PTXs). Longer periods of WS may identify slow-occurring PTXs reducing CT replacement, whereas shorter periods may expedite patient disposition and have associated cost savings. Prior studies support the need for an interval of WS. We compare durations of WS, looking at rates of CT reinsertion. A 10-year retrospective review on trauma patients with a simple PTX requiring a CT was performed. WS duration of 1 to 8 hours (short - SG) versus 18 to 36 hours (long - LG) were compared. Univariate analysis and multivariate logistic regression were used. Of the 2000 patient charts reviewed, 209 met the criteria, with 43 in the SG and 166 in the LG. Patient demographics and mechanism of injury were similar. There was no difference in CT replacement [6.9% (SG) vs 4.8% (LG), P 0.59]. Logistic regression revealed an increase in CT replacement if the patient ever had positive pressure ventilation (OR 4.1, CI 1.1-17, P 0.04) and if returned to suction from WS (OR 6.3, CI 1.2-28, P 0.03). Short intervals of WS do not increase CT reinsertion while decreasing the total time and morbidity associated with CT.


Asunto(s)
Tubos Torácicos , Remoción de Dispositivos , Neumotórax/terapia , Adulto , Femenino , Humanos , Masculino , Estudios Retrospectivos , Succión , Factores de Tiempo , Agua
12.
J Trauma Acute Care Surg ; 83(6): 1041-1046, 2017 12.
Artículo en Inglés | MEDLINE | ID: mdl-28697025

RESUMEN

BACKGROUND: The use of resuscitative endovascular balloon occlusion as a maneuver for occlusion of the aorta is well described. This technique has life-saving potential in other cases of traumatic hemorrhage. Retrohepatic inferior vena cava (IVC) injuries have a high rate of mortality, in part, due to the difficulty in achieving total vascular isolation. The purpose of this study was to investigate the ability of resuscitative balloon occlusion of the IVC to control suprahepatic IVC hemorrhage in a swine model of trauma. METHODS: Thirteen swine were randomly assigned to control (seven animals) versus intervention (six animals). In both groups, an injury was created to the IVC. Hepatic inflow control was obtained via clamping of the hepatoduodenal ligament and infrahepatic IVC. In the intervention group, suprahepatic IVC control was obtained via a resuscitative balloon occlusion of the IVC placed through the femoral vein. In the control group, no suprahepatic IVC control was established. Vital signs, arterial blood gases, and lactate were monitored until death. Primary end points were blood loss and time to death. Lactate, pH, and vital signs were secondary end points. Groups were compared using the χ and the Student t test with significance at p < 0.05. RESULTS: Intervention group's time to death was significantly prolonged: 59.3 ± 1.6 versus 33.4 ± 12.0 minutes (p = 0.001); and total blood loss was significantly reduced: 333 ± 122 vs 1,701 ± 358 mL (p = 0.001). In the intervention group, five of the six swine (83.3%) were alive at 1 hour compared to zero of seven (0%) in the control group (p = 0.002). There was a trend toward worsening acidosis, hypothermia, elevated lactate, and hemodynamic instability in the control group. CONCLUSIONS: Resuscitative balloon occlusion of the IVC demonstrates superior hemorrhage control and prolonged time to death in a swine model of liver hemorrhage. This technique may be considered as an adjunct to total hepatic vascular isolation in severe liver hemorrhage and could provide additional time needed for definitive repair. LEVEL OF EVIDENCE: Therapeutic study, level II.


Asunto(s)
Oclusión con Balón/métodos , Procedimientos Endovasculares/métodos , Exsanguinación/terapia , Resucitación/métodos , Lesiones del Sistema Vascular/complicaciones , Vena Cava Inferior/lesiones , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/diagnóstico , Animales , Modelos Animales de Enfermedad , Exsanguinación/diagnóstico , Exsanguinación/etiología , Femenino , Masculino , Índice de Severidad de la Enfermedad , Porcinos , Lesiones del Sistema Vascular/diagnóstico , Lesiones del Sistema Vascular/terapia , Vena Cava Inferior/diagnóstico por imagen
13.
Curr Surg ; 63(3): 219-25, 2006.
Artículo en Inglés | MEDLINE | ID: mdl-16757377

RESUMEN

BACKGROUND: In an attempt to prevent or alter the course of acute renal failure, many surgeons continue to use low-dose dopamine. This article critically reviews the physiologic reasons why low-dose dopamine is not clinically efficacious. METHODS: A critical review of English language literature. RESULTS: The effect of dopamine on renal blood flow remains controversial. If dopamine does increase renal blood flow, the vascular anatomy of the kidney would limit its effectiveness. Rather than improving renal function, dopamine has been shown to impair renal oxygen kinetics, inhibit feedback systems that protect the kidney from ischemia, and may worsen tubular injury. Dopamine has not been proven useful in the prevention or alteration of the course of acute renal failure as a result of heart failure, cardiac surgery, abdominal aortic surgery, sepsis, and transplantation. Dopamine has been associated with multiple complications involving the cardiovascular, pulmonary, gastrointestinal, endocrine, and immune systems. CONCLUSIONS: Based on the anatomy and physiology of the kidney, low-dose dopamine would not be expected to improve renal failure and this has been demonstrated by the lack of efficacy in clinical trials.


Asunto(s)
Lesión Renal Aguda/prevención & control , Cardiotónicos/administración & dosificación , Dopamina/administración & dosificación , Riñón/irrigación sanguínea , Flujo Sanguíneo Regional/efectos de los fármacos , Procedimientos Quirúrgicos Cardíacos , Cardiotónicos/farmacocinética , Enfermedad Crítica , Dopamina/farmacocinética , Relación Dosis-Respuesta a Droga , Metabolismo Energético , Humanos , Riñón/metabolismo , Riñón/fisiología , Trasplante de Riñón , Oxígeno/metabolismo
14.
Surg Infect (Larchmt) ; 17(3): 363-8, 2016 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-26938612

RESUMEN

BACKGROUND: No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients. METHODS: A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients. RESULTS: Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41). CONCLUSIONS: The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.


Asunto(s)
Neumonía Asociada al Ventilador/diagnóstico , Heridas y Lesiones/complicaciones , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Neumonía Asociada al Ventilador/epidemiología , Neumonía Asociada al Ventilador/etiología , Sistema de Registros , Estudios Retrospectivos , Sensibilidad y Especificidad , Centros Traumatológicos , Estados Unidos , Adulto Joven
15.
Am Surg ; 70(9): 783-6, 2004 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-15481294

RESUMEN

Airway evaluation in trauma patients is performed immediately upon patient contact, with communication being a vital component to this exam. Language and communication barriers may lead to the unnecessary placement of an artificial airway with resultant patient risk and elevation of health care costs. The objective of our study was to evaluate potentially preventable intubations in Spanish-speaking patients. A 9-year retrospective review was performed using the National Trauma Registry for The American College of Surgeons (NTRACS) database. We evaluated patients intubated on arrival to the trauma center and remaining intubated for less than 48 hours. Deaths were excluded. Patients who typically speak English were compared with patients who typically speak Spanish. Mechanism of injury (MOI), hypotension during resuscitation (HDR), illicit substance use, alcohol use, mean Glasgow Coma Score (GCS), mean Injury Severity Score (ISS), payer source, and hospital cost were compared. Forty-nine per cent and 38 per cent of Spanish and English speaking individuals, respectively, were intubated for less than 48 hours (P = 0.072). MOI, HDR, ISS, illicit substance use, alcohol use, and payer source were similar. GCS was statistically higher in the Spanish-speaking group (14 vs 12; P = 0.004). Language and communication barriers lead to potentially preventable intubations in trauma patients.


Asunto(s)
Barreras de Comunicación , Hispánicos o Latinos , Intubación Intratraqueal/estadística & datos numéricos , Lenguaje , Atención al Paciente/métodos , Heridas y Lesiones/terapia , Adulto , Femenino , Humanos , Masculino , North Carolina , Estudios Retrospectivos
16.
Am Surg ; 69(6): 485-9; discussion 490, 2003 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-12852505

RESUMEN

Popliteal vascular trauma has historically been an urban phenomenon. We hypothesized that rural popliteal artery injury would result more often from blunt mechanisms of injury (MOI), have a longer time to operation, and result in a higher amputation rate. We retrospectively reviewed all cases of popliteal artery injury from December 1994 to May 2001 at our rural trauma center. Age, gender, Injury Severity Score (ISS), MOI, scene transport versus transfer from a referring hospital, time to operation, and operative times were studied. Significance was determined by Student's t test with a P value < or = 0.05. Thirty-two popliteal artery injuries were found. Blunt trauma accounted for 50 per cent of the injuries. Eighty-eight per cent of the patients were transferred from a referring hospital. Patients transported directly from the scene had a higher ISS. Longer operative times translated into an increased need for fasciotomy. The amputation rate was 19 per cent. This is the first attempt to delineate the specific nature of rural popliteal artery trauma. The amputation rate was not different between the two different MOI and was independent of the time to operation. Of those patients receiving an amputation 83 per cent were transferred from another hospital and despite a statistically lower ISS still required an amputation.


Asunto(s)
Arteria Poplítea/lesiones , Población Rural/estadística & datos numéricos , Centros Traumatológicos/estadística & datos numéricos , Enfermedades Vasculares/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Heridas no Penetrantes/cirugía , Adulto , Amputación Quirúrgica/estadística & datos numéricos , Fasciotomía , Femenino , Humanos , Recuperación del Miembro/estadística & datos numéricos , Masculino , Estudios Retrospectivos , Factores de Tiempo
17.
Am Surg ; 69(6): 491-7; discussion 497-8, 2003 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-12852506

RESUMEN

The predictive utility of the Injury Severity Score (ISS) and Glasgow Coma Score (GCS) in relation to rehabilitative potential and functional outcome in traumatic brain injury (TBI) is untested. The purpose of this study was to define the relationship of ISS and GCS to rehabilitative potential using the functional independence measure (FIM) score. Trauma and inpatient rehabilitation (IR) registries were queried for demographic, disposition, and injury scoring data. FIM scores at admission (A) and discharge (D) were assessed including IR FIM gain (G). Analysis of variance was used to examine the relationship of ISS and GCS to FIM with predictive utility investigated through bivariate analysis. Of 5488 patients admitted to a Level I trauma center (1999-2000) 1437 suffered TBI with 285 (20%) entering IR. Compared with low-ISS patients the high-ISS patients had significantly lower FIM-A and FIM-D, but FIM-G was static. GCS results were similar, excluding FIM-G which was significantly higher for GCS < or = 8 compared with GCS > 8. Bivariate analysis revealed no ISS correlation with FIM-G (r = 0.16) and a weak GCS correlation (FIM-G r = -0.15). As prospective predictive measures ISS and GCS correlate weakly with rehabilitative potential in TBI patients. Severely injured patients including those with severe TBI have a rehabilitative gain toward functional independence that is similar to that of when compared with those less severely injured.


Asunto(s)
Lesiones Encefálicas/rehabilitación , Personas con Discapacidad/rehabilitación , Escala de Coma de Glasgow , Puntaje de Gravedad del Traumatismo , Adolescente , Adulto , Anciano , Lesiones Encefálicas/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas
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