Evaluating the Utility of High Sensitivity Troponin in Blunt Cardiac Injury.

INTRODUCTION: Screening for blunt cardiac injury (BCI) includes obtaining a serum troponin level and an electrocardiogram for patients diagnosed with a sternal fracture. Our institution has transitioned to the use of a high sensitivity troponin I (hsTnI). The aim of this study was to determine whether hsTnI is comparable to troponin I (TnI) in identifying clinically significant BCI. MATERIALS AND METHODS: Trauma patients presenting to a level I trauma center over a 24-mo period with the diagnosis of sternal fracture were screened for BCI. Any initial TnI more than 0.04 ng/mL or hsTnI more than 18 ng/L was considered positive for potential BCI. Clinically significant BCI was defined as a new-bundle branch block, ST wave change, echocardiogram change, or need for cardiac catheterization. RESULTS: Two hundred sixty five patients with a sternal fracture were identified, 161 underwent screening with TnI and 104 with hsTnI. For TnI, the sensitivity and specificity for detection of clinically significant BCI was 0.80 and 0.79, respectively. For hsTnI, the sensitivity and specificity for detection of clinically significant BCI was 0.71 and 0.69, respectively. A multivariate analysis demonstrated the odds ratio for significant BCI with a positive TnI was 14.4 (95% confidence interval, 3.9-55.8, P < 0.0001) versus an odds ratio of 5.48 (95% confidence interval 1.9-15.7, P = 0.002) in the hsTnI group. CONCLUSIONS: The sensitivity of hsTnI is comparable to TnI for detection of significant BCI. Additional investigation is needed to determine the necessity and interval for repeat testing and the need for additional diagnostic testing.

Laparoscopic Appendectomy and Cholecystectomy Timing Predicts Hand-Offs but Not Miscounts.

INTRODUCTION: Intraoperative hand-offs are poorly coordinated and associated with risk of surgical miscount. We evaluated hand-off patterns for nursing staff during two common operations hypothesizing that hand-off patterns would be associated with increased surgical miscounts and vary during operations performed standard versus nonstandard operating hours. METHODS: We retrospectively analyzed laparoscopic cholecystectomy (N = 3888) and appendectomy (N = 1768) from 2012 to 2021 at a single institution using electronic medical records. We evaluated intraoperative hand-off patterns and the presence of miscounts for operations performed during standard versus nonstandard hours. Standard operating hours were defined as M-F 7:30 am to 5:00 pm. RESULTS: Across 5656 operations, 10 cases had surgical miscounts and were significantly longer than those without (156.5 versus 101 min P = 0.0178). More than half (51.3%) of cases had no identified hand-offs, and 42.9% of cases occurred during nonstandard hours. Cases during standard versus nonstandard hours were more likely to have hand-offs (56.0% versus 38.9%), P < 0.0001 and had shorter interval between hand-offs (64 versus 75 min), P < 0.0001. The period between patient entry to the room and intubation, which includes initial counts, had a disproportionately high percentage of hand-offs (P < 0.0001). CONCLUSIONS: Variability in hand-off occurrence and frequency in operations performed during standard and nonstandard hours suggest that hand-offs are influenced by staffing patterns. Few surgical miscounts occurred but were associated with longer cases. Hand-offs disproportionately occurred between patient entry and intubation, with a potential for disruption of initial instrument counts. Future work optimizing hand-off coordination is an opportunity to mitigate risk to patients.

The Association of Norepinephrine Utilization With Mortality Risk in Trauma Patients.

INTRODUCTION: While the pillars of trauma resuscitation are surgical hemostasis and blood product administration, norepinephrine (NE) can be used as an adjunct. The goal of this study was to evaluate the relationship between the maximum dose of NE, timing of NE administration, and mortality in trauma patients. METHODS: Patients admitted between January 2013 and January 2021 treated with NE were reviewed. Univariate and multivariate logistic regression were used to assess whether maximum NE dose was independently associated with mortality. Optimal dosage rates for NE were determined via Youden Index. Subgroup analyses comparing those who received NE within versus after the first 24 h of admission were conducted. RESULTS: Three hundred fifty-first trauma patients were included, with 217 (62%) surviving. Patients who died received an average maximum dose of 16.7 mcg/min compared to 9.1 mcg/min in survivors (P = 0.0003). Mortality rate increased with dosage (P < 0.0001), with doses greater than 20 mcg/min having 79% mortality. Those who received NE within the first 24 h had an inflection point in mortality at 16 mcg/min (Youden = 0.45) (OR 1.06; 95% CI 1.03-1.10). For patients who received NE after the first 24 h, an inflection point in mortality was at 10 mcg/min (Youden = 0.34) (OR 1.09; 95% CI 1.04-1.14). CONCLUSIONS: Higher maximum doses of NE were associated with increased mortality. Patients initiated on NE more than 24 h into their admission displayed an inflection point at a lower dose than those initiated later. This suggests that trauma patients initiated on NE after 24 h from injury may have a dire prognosis.

Ketamine Stability over Six Months of Exposure to Moderate and High Temperature Environments.

Background: All medications should be stored within temperature ranges defined by manufacturers, but logistical and operational challenges of prehospital and military settings complicate adherence to these recommendations. Lorazepam and succinylcholine experience clinically relevant heat-related degradation, whereas midazolam does not. Because ketamine's stability when stored outside manufacturer recommendations is unknown, we evaluated the heat-related degradation of ketamine exposed to several temperature ranges. Methods: One hundred twenty vials of ketamine (50 mg/mL labeled concentration) from the same manufacturer lot were equally distributed and stored for six months in five environments: an active EMS unit in southwest Ohio (May-October 2019); heat chamber at constant 120 °F (C1); heat chamber fluctuating over 24 hours from 86 °F-120 °F (C2); heat chamber fluctuating over 24 hours from 40 °F-120 °F (C3); heat chamber kept at constant 70 °F (manufacturer recommended room temperature, C4). Four ketamine vials were removed every 30 days from each environment and sent to an FDA-accredited commercial lab for high performance liquid chromatography testing. Data loggers and thermistors allowed temperature recording every minute for all environments. Cumulative heat exposure was quantified by mean kinetic temperature (MKT), which accounts for additional heat-stress over time caused by temperature fluctuations and is a superior measure than simple ambient temperature. MKT was calculated for each environment at the time of ketamine removal. Descriptive statistics were used to describe the concentration changes at each time point. Results: The MKT ranged from 73.6 °F-80.7 °F in the active EMS unit and stayed constant for each chamber (C1 MKT: 120 °F, C2 MKT: 107.3 °F, C3 MKT: 96.5 °F, C4 MKT: 70 °F). No significant absolute ketamine degradation, or trends in degradation, occurred in any environment at any time point. The lowest median concentration occurred in the EMS-stored samples removed after 6 months [48.2 mg/mL (47.75, 48.35)], or 96.4% relative strength to labeled concentration. Conclusion: Ketamine samples exhibited limited degradation after 6 months of exposure to real world and simulated extreme high temperature environments exceeding manufacturer recommendations. Future studies are necessary to evaluate ketamine stability beyond 6 months.

Routine platelet transfusion in patients with traumatic intracranial hemorrhage taking antiplatelet medication: Is it warranted?

BACKGROUND: After a traumatic intracranial hemorrhage (tICH), patients often receive a platelet transfusion to reverse the effects of antiplatelet medication and to reduce neurologic complications. As platelet transfusions have their own risks, this study evaluated their effects on tICH progression, need for operations and mortality. METHODS: In this retrospective study, we identified patients admitted to a level 1 trauma centre with a tICH from 2011 to 2015 who were taking acetylsalicylic acid (ASA) or clopidogrel, or both. We categorized patients into 2 groups: platelet transfusion recipients and nonrecipients. We collected data on demographic characteristics, changes in brain computed tomography findings, neurosurgical interventions, in-hospital death and intensive care unit (ICU) length of stay (LOS). We used multivariable logistic regression to compare outcomes between the 2 groups. RESULTS: We identified 224 patients with tICH, 156 (69.6%) in the platelet transfusion group and 68 (30.4%) in the no transfusion group. There were no between-group differences in progression of bleeds or rates of neurosurgical interventions. In the transfusion recipients, there was a trend toward increased ICU LOS (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 0.74-3.40) and in-hospital death (adjusted OR 3.23, 95% CI 0.48-21.74). CONCLUSION: There were no differences in outcomes between patients who received platelet transfusions and those who did not; however, the results suggest a worse clinical course, as indicated by greater ICU LOS and mortality, in the transfusion recipients. Routine platelet transfusion may not be warranted in patients taking ASA or clopidogrel who experience a tICH, as it may increase ICU LOS and mortality risk.

Influence of Cystic Fibrosis-Related Diabetes on Mental Health in Adults: A Single-Center Study.

PURPOSE: People with cystic fibrosis (CF) are predisposed to chronic conditions, such as CF-related diabetes (CFRD). Recent attention has been focused on the addition of screening for anxiety and depression in the CF population. Independently, CFRD and mental health conditions are associated with worse clinical outcomes; however, research assessing the impact of both conditions together is limited. We aimed to characterize the association between CFRD and selected diagnoses of anxiety or depressive disorders on clinical outcomes in adults with CF. METHODS: A single-center, retrospective, cross-sectional study in adult patients with CF was performed. Group comparisons included selected diagnoses of depression, anxiety, and CFRD using two-sample t-tests or rank-sum tests for continuous variables, and Chi-square or Fisher's exact tests for categorical variables. RESULTS: A total of 209 adults were enrolled (mean age of 31.4 ± 11.4 years). Those with a selected diagnoses of depression had a significantly higher proportion of CFRD than those without depression (48% vs. 28%, respectively, p = 0.005), and CFRD was associated with increased odds of depression [OR (CI) = 2.33 (1.28, 4.26), p = 0.006]. We did not see a higher proportion of adults with CFRD and selected diagnoses of anxiety than those without anxiety (41% vs. 31% respectively, p = 0.12), nor an increased odds of anxiety in those with CFRD [OR (CI) = 1.58 (0.88, 2.84), p = 0.12]. CONCLUSION: We show a significant association between CFRD and selected diagnoses of depression in a cohort of adult patients.

Correction to: Influence of Cystic Fibrosis­Related Diabetes on Mental Health in Adults: A Single­Center Study.

The original version of this article unfortunately contained a mistake in one of the co-author name Prof. Don Hayes Jr. During production process, "Jr." was missed to add after the author name. The author name is corrected with this correction. The original article has been corrected.

Non-invasive carbon dioxide monitoring in patients with cystic fibrosis during general anesthesia: end-tidal versus transcutaneous techniques.

INTRODUCTION: The gold standard for measuring the partial pressure of carbon dioxide remains arterial blood gas (ABG) analysis. For patients with cystic fibrosis undergoing general anesthesia or polysomnography studies, continuous non-invasive carbon dioxide monitoring may be required. The current study compares end-tidal (ETCO2), transcutaneous (TCCO2), and capillary blood gas carbon dioxide (Cap-CO2) monitoring with the partial pressure of carbon dioxide (PaCO2) from an ABG in patients with cystic fibrosis. METHODS: Intraoperatively, a single CO2 value was simultaneously obtained using ABG (PaCO2), capillary (Cap-CO2), TCCO2, and ETCO2 techniques. Tests for correlation (Pearson's coefficient) and agreement (Bland-Altman analysis) were performed. Data were further stratified into two subgroups based on body mass index (BMI) and percent predicted forced expiratory volume in 1 s (FEV1%). Additionally, the absolute difference in the TCCO2, ETCO2, and Cap-CO2 values versus PaCO2 was calculated. The mean ± SD differences were compared using a paired t test while the number of times the values were ≤ 3 mmHg and ≤ 5 mmHg from the PaCO2 were compared using a Fishers' exact test. RESULTS: The study cohort included 47 patients (22 males, 47%) with a mean age of 13.4 ± 7.8 years, median (IQR) BMI of 18.7 kg/m2 (16.7, 21.4), and mean FEV1% of 87.3 ± 18.3%. Bias (SD) was 4.8 (5.7) mmHg with Cap-CO2 monitoring, 7.3 (9.7) mmHg with TCCO2 monitoring, and 9.7 (7.7) mmHg with ETCO2 monitoring. Although there was no difference between the degree of bias in the population as a whole, when divided based on FEV1% and BMI, there was greater bias with ETCO2 in patients with a lower FEV1% and a higher BMI. The Cap-CO2 vs. PaCO2 difference was 5.2 ± 5.3 mmHg (SD), with 16 (48%) ≤ 3 mmHg and 20 (61%) ≤ 5 mmHg from the ABG value. The TCCO2-PaCO2 difference was 9.1 ± 7.2 mmHg (SD), with 11 (27%) ≤ 3 mmHg and 15 (37%) ≤ 5 mmHg from the ABG value. The ETCO2-PaCO2 mean difference was 11.2 ± 7.9 mmHg (SD), with 5 (12%) ≤ 3 mmHg and 11 (26%) ≤ 5 mmHg from the ABG value. CONCLUSIONS: While Cap-CO2 most accurately reflects PaCO2 as measured on ABG, of the non-invasive continuous monitors, TCCO2 was a more accurate and reliable measure of PaCO2 than ETCO2, especially in patients with worsening pulmonary function (FEV1% ≤ 81%) and/or a higher BMI (≥ 18.7 kg/m2).

Impact of a Make-A-Wish experience on healthcare utilization.

OBJECTIVES: To evaluate the impact of receiving a wish from the Make-A-WishR Foundation on (1) patient healthcare utilization and (2) savings benefit measures. STUDY DESIGN: Make-A-WishR arranges experiences, or "wishes," to children with progressive, life-threatening, or life-limiting illness. A retrospective, case-control analysis was performed comparing patients who received or did not receive a wish and associated impact on healthcare utilization and costs across 2 years. Healthcare utilization was defined as visits to primary, urgent, emergent care, and planned/unplanned inpatient hospitalizations. We defined wish savings benefit as a decline in the cost of care from years 1 to 2, which exceeded the average cost of a wish in 2016, $10,130. RESULTS: From 2011 to 2016, 496 Nationwide Children's Hospital patients received a wish. We matched these patients to 496 controls based on age, gender, disease category, and disease complexity. Patients who received a wish were 2.5 and 1.9 times more likely to have fewer unplanned hospital admissions and emergency department visits, respectively. These decreases were associated with a higher likelihood (2.3-fold and 2.2-fold greater odds) of the wish achieving a savings benefit compared to hospital charges. CONCLUSIONS: Participation in the Make-A-WishR program may provide children quality of life relief while reducing hospital visits and healthcare expenditures.

Albumin priming improves the efficiency of the Minntech HPH Jr. hemoconcentrator.

The desired use of the HPH Jr. is optimal due to the low priming volume; however, the lower rate of volume removal necessitates utilization of a larger hemofilter. Larger hemofilters carry a higher prime volume, which is impactful in the pediatric setting. Pediatric cardiac surgery patients under 18 kilograms requiring cardiopulmonary bypass were randomly assigned to one of two study groups. Group 1 (coated) contained an HPH Jr. hemofilter that was primed with the addition of 25% albumin and heparin. Group 2 (non-coated) contained an HPH Jr. hemofilter that was primed with only Normosol-R®. After cardioplegia delivery, zero balance ultrafiltration (ZBUF) was initiated and maintained for thirty consecutive minutes. The flow through the hemofilter was standardized at 70 ml/min and the vacuum applied to the effluent line was set at -150 mmHg. Effluent fluid removal was measured at the termination of thirty minutes and compared between the groups. Group comparisons between the coated vs non-coated hemofilter groups were assessed using two-sample t-tests or the Mann-Whitney U test, when appropriate. Forty-two patients were included in the analysis. There were 22 patients who had the non-coated hemofilter and 20 patients with a coated hemofilter. The differences between the two groups are illustrated in Table 1. There was a statistically significant higher ultrafiltration volume with the coated hemofilter group (p=0.008) (Figure 1). These results illustrate the improved efficiency of the HPH Jr. with the addition of 25% albumin and heparin during the priming process.

Similarities Between Large Animal-Related and Motor Vehicle Crash-Related Injuries.

OBJECTIVE: Many Americans sustain large animal-related injuries (LARIs) from blunt trauma. We compare the injuries and management of LARI in our region of the United States with those of motor vehicle crashes (MVCs). METHODS: A 15-year retrospective study of trauma patients with LARI matched to MVC controls by Injury Severity Score (ISS), age, and sex was conducted. Values were statistically compared, and differences were considered statistically significant at P < .05. RESULTS: There were 156 LARI cases, of which 87% were related to horses, 8% to bulls, and the remainder to deer, mules, bison, cows, and rams. In the LARI group, the age was 42±18 years (mean±SD), ISS was 7±4, and 61% were females. The MVC group had a significantly longer length of hospital stay (5±5 vs 4±3 days) and blood alcohol concentration (35±84 vs 3±20 g/L). There were no significant differences in injury patterns between LARI and MVC; however, additional radiological studies (RS) were performed on MVC (9±6 vs 7±5). LARI patients were more often transferred from rural locations (39% vs 25%) and traveled further to our trauma center (40±32 vs 24±29 km) than did MVC patients. CONCLUSIONS: LARI has a similar pattern of injury to MVC, but fewer RS. LARI typically occurred further away, requiring transfer from rural areas to our institution. We recommend a similar approach for the evaluation of LARI and MVC.

Mother-daughter coping and disordered eating.

This study explores whether the coping style of teenage girls with and without an eating disorder is similar to that of their mothers' (biological and adoptive), and whether teens with disordered eating utilize more maladaptive coping compared with those without. Eating disorder was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria, and the Coping Inventory for Stressful Situations was administered to distinguish the coping style of the participants. Our findings suggest that daughters coped very similarly to their mothers in either group. Contrary to previous studies, our sample of teenage girls with eating disorders as well as their mothers utilized less frequently the avoidance-distraction coping compared with the girls without eating disorders and their mothers. These findings reinforce the importance for family involvement and for simultaneous focus on intrapersonal and interpersonal maintenance factors during eating disorder treatment.

Impact of Rank, Provider Specialty, and Unit Sustainment Training Frequency on Military Critical Care Air Transport Team Readiness.

BACKGROUND: The Critical Care Air Transport (CCAT) Advanced Course utilizes fully immersive high-fidelity simulations to assess personnel readiness for deployment. This study aims to determine whether simple well-defined demographic identifiers can be used to predict CCAT students' performance at CCAT Advanced. MATERIALS AND METHODS: CCAT Advanced student survey data and course status (pass/fail) between March 2006 and April 2020 were analyzed. The data included students' Air Force Specialty Code (AFSC), military status (active duty and reserve/guard), CCAT deployment experience (yes/no), prior CCAT Advanced training (yes/no), medical specialty, rank, and unit sustainment training frequency (never, frequency less often than monthly, and frequency at least monthly). Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCAT Advanced course for each provider type. RESULTS: A total of 2,576 student surveys were analyzed: 694 (27%) physicians (MDs), 1,051 (40%) registered nurses (RNs), and 842 (33%) respiratory therapists (RTs). The overall passing rates were 92.2%, 90.3%, and 85.4% for the MDs, RNs, and RTs, respectively. The students were composed of 579 (22.5%) reserve/guard personnel, 636 (24.7%) with CCAT deployment experience, and 616 (23.9%) with prior CCAT Advanced training. Regression analysis identified groups with lower odds of passing; these included (1) RNs who promoted from Captain to Major (post-hoc analysis, P = .03), (2) RTs with rank Senior Airman, as compared to Master Sergeants (post-hoc analysis, P = .04), and (3) MDs with a nontraditional AFSC (P = .0004). Predictors of passing included MDs and RNs with CCAT deployment experience, odds ratio 2.97 (P = .02) and 2.65 (P = .002), respectively; and RTs who engaged in unit CCAT sustainment at least monthly (P = .02). The identifiers prior CCAT Advanced training or reserve/guard military status did not confer a passing advantage. CONCLUSION: Our main result is that simple readily available metrics available to unit commanders can identify those members at risk for poor performance at CCAT Advanced readiness training; these include RNs with rank Major or above, RTs with rank Senior Airman, and RTs who engage in unit sustainment training less often than monthly. Finally, MD specialties which are nontraditional for CCAT have significantly lower CCAT Advanced passing rates, reserve/guard students did not outperform active duty students, there was no difference in the performance between different RN specialties, and for MD and RN students' previous deployment experience was a strong predictor of passing.

Remnant Blood Quantification: Informing the Definition of Minimal Risk in Clinical Research.

Guidelines from the Office for Human Research Protections regarding categories of research that institutional review boards (IRBs) may review through expedited procedures limit the volume of blood that can be obtained from research participants for minimal risk research purposes. As defined by the Common Rule, minimal risk research is research in which the probability and magnitude of harm or discomfort anticipated are not greater than the probability and magnitude of harm or discomfort encountered from routine clinical tests. For this study, we considered the volume of remnant blood following routine clinical tests in light of the current definition of minimal risk in research. Conducted at a single institution, this was a prospective cross-sectional study that evaluated blood draws from 122 patients. The median daily remnant blood volume was 11.6 (interquartile range [IQR]: 12.3, 15.2) ml for all patients and 12.9 (IQR: 13.1, 16.9) ml for patients admitted to the intensive care unit. Our findings regarding daily remnant blood volume suggest that the currently allowable blood-volume limits to qualify for expedited review or to qualify as not more than minimal risk research involving blood draws from nonhealthy adults are less than what patients experience in routine medical testing. These findings support permitting an increase in the allowable blood-volume limits to meet the regulatory definition of minimal risk research for obtaining expedited IRB review of studies in which blood samples will be collected.

Descriptive Analysis of Intratheater Critical Care Air Transport Team Patient Movements During Troop Drawdown: Afghanistan (2017-2019).

BACKGROUND: The majority of critical care air transport (CCAT) flights are regulated, meaning that a theater-validating flight surgeon has confirmed that the patient is medically cleared for flight and that evacuation is appropriate. If the conditions on the ground do not allow for this process, the flight is unregulated. Published data are limited regarding CCAT unregulated missions to include the period of troop drawdown at the end of the Afghanistan conflict. The objective of our study was to characterize the unregulated missions within Afghanistan during troop drawdown and compare them to regulated missions during the same timeframe. STUDY DESIGN: We performed a retrospective review of all CCAT medical records of patients transported via CCAT within Afghanistan between January 2017 and December 2019. We abstracted data from the records, including mission characteristics, patient demographics, injury descriptors, preflight military treatment facility procedures, CCAT procedures, in-flight CCAT treatments, in-flight events, and equipment issues. Following descriptive and comparative analysis, a Cochran-Armitage test was performed to evaluate the statistical significance of the trend in categorical data over time. Multivariable regression was used to assess the association between vasopressors and preflight massive transfusions, preflight surgical procedures, injury patterns, and age. RESULTS: We reviewed 147 records of patients transported via CCAT: 68 patients were transported in a regulated fashion and 79 on an unregulated flight. The number of patients evacuated increased year-over-year (n = 22 in 2017, n = 57 in 2018, and n = 68 in 2019, P < .001), and the percentage of missions that were unregulated grew geometrically (14%, n = 3 in 2017; 37%, n = 21 in 2018; and 81%, n = 55 in 2019, P < .001). During the time studied, CCAT teams were being used more to decompress forward surgical teams (FST) and, therefore, they were transporting patients just hours following initial damage control surgery in an unregulated fashion. In 2 instances, CCAT decompressed an FST following a mass casualty, during which aeromedical evacuation (AE) crews assisted with patient care. For the regulated missions, the treatments that were statistically more common were intravenous fluids, propofol, norepinephrine, any vasopressors, and bicarbonate. During unregulated missions, the statistically more common treatments were ketamine, fentanyl, and 3% saline. Additional analysis of the mechanically ventilated patient subgroup revealed that vasopressors were used twice as often on regulated (38%) vs. unregulated (13%) flights. Multivariable regression analysis demonstrated that traumatic brain injury (TBI) was the only significant predictor of in-flight vasopressor use (odds ratio = 3.53, confidence interval [1.22, 10.22], P = .02). CONCLUSION: During the troop drawdown in Afghanistan, the number of unregulated missions increased geometrically because the medical footprint was decreasing. During unregulated missions, CCAT providers used ketamine more frequently, consistent with Tactical Combat Casualty Care guidelines. In addition, TBI was the only predictor of vasopressor use and may reflect an attempt to adhere to unmonitored TBI clinical guidelines. Interoperability between CCAT and AE teams is critical to meet mass casualty needs in unregulated mission environments and highlights a need for joint training. It remains imperative to evaluate changes in mission requirements to inform en route combat casualty care training.

Maximizing Oxygen Delivery in Portable Ventilators.

BACKGROUND: Military transport of critically ill/injured patients requires judicious use of resources. Maintaining oxygen (O2) supplies for mechanically ventilated is crucial. O2 cylinders are difficult to transport due to the size and weight and add the risk of fire in an aircraft. The proposed solution is the use of a portable oxygen concentrator (POC) to supply O2 for mechanical ventilation. As long as power is available, a POC can provide an endless supply of O2. Anecdotal evidence suggests that as little as 3 L/min of O2 could manage as many as 2/3 of the mechanically ventilated military aeromedical transport patients. MATERIALS AND METHODS: We evaluated two each of the AutoMedx SAVe II, Hamilton T1, Zoll 731, and Ventec VOCSN portable ventilators over a range of settings paired with 1 and 2 Caire SAROS POCs at ground level and simulated altitudes of 8,000 feet, 16,000 feet, and 22,000 feet. The Ventec VOCSN has the capability of utilizing an internal O2 concentrator that uses pulsed dose technology, which was also evaluated. Each ventilator was attached to a Michigan Instruments Training Test Lung. Output from the POC was bled into each ventilator via the mechanism provided with each device. A Fleisch pneumotach was used to measure delivered tidal volume (VT), and a fast-response O2 analyzer was used to measure FiO2 within the simulated lung. Ventilator parameters and FiO2 were continuously measured and recorded at each altitude. One-way analysis of variance was used to determine statistically significant differences (P < .05) in FiO2 between ventilators and among the same ventilator model at each testing condition. RESULTS: Delivered FiO2 varied widely between ventilator models and between devices of the same model with some testing conditions. Differences in FiO2 between ventilators at a majority (98.5%) of testing conditions were statistically significant (P < .05) but not all were clinically important. The Zoll 731 delivered the highest and most consistent FiO2 over all ventilator/POC settings at all altitudes. Differences in FiO2 at a given ventilator/POC setting from ground level to 22,000 feet were not clinically important (<5%) with this device. The VOCSN utilizing the integrated internal O2 concentrator delivered the lowest FiO2 across all ventilator/POC settings and altitudes. Due to the inability of the SAVe II to operate at the minute ventilation and positive end expiratory pressure (PEEP) settings required by the testing protocol, the device was only tested at one ventilator setting. The Hamilton T1 failed to operate appropriately at the highest VT/PEEP setting at 16,000 feet and all but one ventilator setting at 22,000 feet. The delivered FiO2 was not included in the analysis for those ventilator settings. The highest delivered FiO2 was 0.85 ± 0.05 at the 250 mL VT setting using 2 POCs (P < .0001) at ground level with the Zoll 731. CONCLUSIONS: Oxygen delivery utilizing POCs is dependent upon multiple factors including ventilator operating characteristics, ventilator settings, altitude, and the use of pulsed dose or continuous flow O2. Careful patient selection would be paramount to provide safe mechanical ventilation using this method of O2 delivery.

Low Volume Blood Product Transfusion Patterns And Ratios After Injury.

BACKGROUND: The benefit of a balanced resuscitation in low volume transfusions remains unclear This study is aimed at characterizing blood product ratios in this cohort. METHODS: A retrospective analysis (2017-2019) of the ACS TQIP was performed to identify adult trauma patients who received ≥1 unit of packed red blood cells (pRBCs) 4 and 24 h after admission. Blood products received were used to calculate plasma and platelet ratios. RESULTS: Plasma and platelet ratios were closer to the target 1:1 ratio for ≤4 units pRBCs. Plasma and platelet ratios increased for those receiving ≤10 units pRBCs, demonstrating increasingly unbalanced resuscitation. Transfusion ratios were unbalanced for those receiving ≥5 units pRBC. CONCLUSION: Transfusion ratios were closer to the desired transfusion ratio for low volume blood product resuscitation. In those receiving ≥5 units pRBC, plasma and platelet ratios were not balanced. The optimal transfusion ratio in low volume trauma resuscitation is unknown.

Oxygenation and Respiratory System Compliance Associated With Pulmonary Contusion.

BACKGROUND: Blunt pulmonary contusions are associated with severe chest injuries and are independently associated with worse outcomes. Previous preclinical studies suggest that contusion progression precipitates poor pulmonary function; however, there are few current clinical data to corroborate this hypothesis. We examined pulmonary dynamics and oxygenation in subjects with pulmonary contusions to evaluate for impaired respiratory function. METHODS: A chest injury database was reviewed for pulmonary contusions over 5 years at an urban trauma center. This database was expanded to capture mechanical ventilation parameters for the first 7 days on all patients with pulmonary contusion and who were intubated. Daily [Formula: see text]:[Formula: see text], oxygenation indexes (OI), and dynamic compliances were calculated. Pulmonary contusions were stratified by severity. The Fisher exact and chi square tests were performed on categorical variables, and Mann-Whitney U-tests were performed on continuous variables. Significance was assessed at a level of 0.05. RESULTS A TOTAL OF: 1,176 patients presented with pulmonary contusions, of whom, 301 subjects (25.6%) required intubation and had available invasive mechanical ventilation data. Of these, 144 (47.8%) had mild-moderate pulmonary contusion and 157 (52.2%) had severe pulmonary contusion. Overall injury severity score was high, with a median injury severity score of 29 (interquartile range, 22-38). The median duration of mechanical ventilation for mild-moderate pulmonary contusion was 7 d versus 10 d for severe pulmonary contusion (P = .048). All the subjects displayed moderate hypoxemia, which worsened until day 4-5 after intubation. Severe pulmonary contusion was associated with significantly worse early hypoxia on day 1 and day 2 versus mild-moderate pulmonary contusion. Severe pulmonary contusion also had a higher oxygenation index than mild-moderate pulmonary contusion. This trend persisted after adjustment for other factors, including transfusion and fluid administration. CONCLUSIONS: Pulmonary contusions played an important role in the course of subjects who were acutely injured and required mechanical ventilation. Contusions were associated with hypoxemia not fully characterized by [Formula: see text]: [Formula: see text], and severe contusions had durable elevations in the oxygenation index despite confounders.

Tracheostomy decreases continuous analgesia and sedation requirements.

BACKGROUND: The goals of sedation in the critically ill surgical patient are to minimize pain, anxiety, and agitation without hindering cardiopulmonary function. One potential benefit of tracheostomy during endotracheal intubation is the reduction of sedation and analgesia; however, there are little data to support this supposition. We hypothesized that patients undergoing tracheostomy would have a rapid reduction in sedation and analgesia following tracheostomy. METHODS: A retrospective review of tracheostomies performed at a single Level I trauma center from January 2013 to June 2018 was completed. An evaluation of Glasgow Coma Scale, Richmond Agitation-Sedation Scale, and Confusion Assessment Method for the intensive care unit 72 hours pretracheostomy to 72 hours posttracheostomy was performed. The total daily dose of sedation, anxiolytic, and analgesic medications administered were recorded. Mixed-effects models were used to evaluate longitudinal drug does over time (hours). RESULTS: Four hundred sixty-eight patients included for analysis with a mean age of 58.8 ± 18.3 years. There was a significant decrease in propofol and fentanyl utilization from 24 hours pretracheostomy to 24 hours posttracheostomy in both dose and number of patients receiving these continuous intravenous medications. Similarly, total morphine milligram equivalents (MME) use and continuous midazolam significantly decreased from 24 hours pretracheostomy to 24 hours posttracheostomy. By contrast, intermittent enteral quetiapine and methadone administration increased after tracheostomy. Importantly, Richmond Agitation-Sedation Scale, Glasgow Coma Scale, and Confusion Assessment Method scoring were also significantly improved as early as 24 hours posttracheostomy. Total MME use was significantly elevated in patients younger than 65 years and in male patients pretracheostomy compared with female patients. Patients admitted to the medical intensive care unit had significantly higher MME use compared with those in the surgical intensive care unit pretracheostomy. CONCLUSION: Tracheostomy allows for a rapid and significant reduction in intravenous sedation and analgesia medication utilization. Posttracheostomy sedation can transition to intermittent enteral medications, potentially contributing to the observed improvements in postoperative mental status and agitation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Relevance of Deployment Experience and Clinical Practice Characteristics on Military Critical Care Air Transport Team Readiness: A Study of Simulation Construct Validity.

INTRODUCTION: The Critical Care Air Transport Team (CCATT) Advanced course utilizes fully immersive high-fidelity simulations to train CCATT personnel and assess their readiness for deployment. This study aims to (1) determine whether these simulations correctly discriminate between students with previous deployment experience ("experienced") and no deployment experience ("novices") and (2) examine the effects of students' clinical practice environment on their performance during training simulations. MATERIALS AND METHODS: Critical Care Air Transport Team Advanced student survey data and course status (pass/no pass) between March 2006 and April 2020 were analyzed. The data included students' specialty, previous exposure to the CCATT Advanced course, previous CCATT deployment experience, years in clinical practice (<5, 5-15, and >15 years), and daily practice of critical care (yes/no), as well as a description of the students' hospital to include the total number of hospital (<100, 100-200, 201-400, and >400) and intensive care unit (0, 1-10, 11-20, and >20) beds. Following descriptive analysis and comparative tests, multivariable regression was used to identify the predictors of passing the CCATT Advanced course. RESULTS: A total of 2,723 surveys were analyzed: 841 (31%) were physicians (MDs), 1,035 (38%) were registered nurses, and 847 (31%) were respiratory therapists (RTs); 641 (24%) of the students were repeating the course for sustainment training and 664 (24%) had previous deployment experience. Grouped by student specialty, the MDs', registered nurses', and RTs' pass rates were 92.7%, 90.6%, and 85.6%, respectively. Multivariable regression results demonstrated that deployment experience was a robust predictor of passing. In addition, the >15 years in practice group had a 47% decrease in the odds of passing as compared to the 5 to 15 years in practice group. Finally, using MDs as the reference, the RTs had a 61% decrease in their odds of passing. The daily practice of critical care provided a borderline but nonsignificant passing advantage, whereas previous CCATT course exposure had no effect. CONCLUSION: Our primary result was that the CCATT Advanced simulations that are used to evaluate whether the students are mission ready successfully differentiated "novice" from "experienced" students; this is consistent with valid simulation constructs. Finally, novice CCATT students do not sustain their readiness skills during the period between mandated refresher training.