OPTICC: A multicentre trial of Occult Pneumothoraces subjected to mechanical ventilation: The final report.

INTRODUCTION: Patients with occult pneumothorax (OPTX) requiring positive-pressure ventilation (PPV) face uncertain risks of tension pneumothorax or chest drainage complications. METHODS: Adults with traumatic OPTXs requiring PPV were randomized to drainage/observation, with the primary outcome of composite "respiratory distress" (RD)). RESULTS: Seventy-five (75) patients were randomized to observation, 67 to drainage. RD occurred in 38% observed and 25% drained (p = 0.14; Power = 0.38), with no mortality differences. One-quarter of observed patients failed, reaching 40% when ventilated >5 days. Twenty-three percent randomized to drainage had complications or ineffectual drains. CONCLUSION: RD was not significantly different with observation. Thus, OPTXs may be cautiously observed in stable patients undergoing short-term PPV when prompt "rescue drainage" is immediately available. As 40% of patients undergoing prolonged (≥5 days) ventilation (PPPV) require drainage, we suggest consideration of chest drainage performed with expert guidance to reduce risk of chest tube complications. LEVEL OF EVIDENCE: Therapeutic study, level II.

Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers.

BACKGROUND: Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers. METHODS: This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity. RESULTS: Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury. CONCLUSION: Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system. LEVEL OF EVIDENCE: Therapeutic/care management, level V; Prognostic and epidemiological, level IV.

Vasopressor use following traumatic injury - A single center retrospective study.

OBJECTIVES: Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers. METHODS: We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management. RESULTS: Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7-38.5). CONCLUSIONS: In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards.

The use of higher platelet: RBC transfusion ratio in the acute phase of trauma resuscitation: a systematic review.

OBJECTIVE: With the recognition of early coagulopathy, trauma resuscitation has shifted toward liberal platelet transfusions. The overall benefit of this strategy remains controversial. Our objective was to compare the effects of a liberal use of platelet (higher platelet:RBC ratios) with a conservative approach (lower ratios) in trauma resuscitation. DATA SOURCES: We systematically searched Medline, Embase, Web of Science, Biosis, Cochrane Central, and Scopus. STUDY SELECTION: Two independent reviewers selected randomized controlled trials and observational studies comparing two or more platelet:RBC ratios in trauma resuscitation. We excluded studies investigating the use of whole blood or hemostatic products. DATA EXTRACTION: Two independent reviewers extracted data and assessed the risk of bias. Primary outcomes were early (in ICU or within 30 d) and late (in hospital or after 30 d) mortality. Secondary outcomes were multiple organ failure, lung injury, and sepsis. DATA SYNTHESIS: From 6,123 citations, no randomized controlled trials were identified. We included seven observational studies (4,230 patients) addressing confounders through multivariable regression or propensity scores. Heterogeneity of studies precluded meta-analysis. Among the five studies including exclusively patients requiring massive transfusions, four observed a lower mortality with higher ratios. Two studies considering nonmassively bleeding patients observed no benefit of using higher ratios. Two studies evaluated the implementation of a massive transfusion protocol; only one study observed a decrease in mortality with higher ratios. Of the two studies at low risk of survival bias, one study observed a survival benefit. Three studies assessed secondary outcomes. One study observed an increase in multiple organ failure with higher ratios, whereas no study demonstrated an increased risk in lung injury or sepsis. CONCLUSIONS: There is insufficient evidence to strongly support the use of a precise platelet:RBC ratio for trauma resuscitation, especially in nonmassively bleeding patients. Randomized controlled trials evaluating both the safety and efficacy of liberal platelet transfusions are warranted.

Interest and applicability of acute care surgery among surgeons in Quebec: a provincial survey.

BACKGROUND: Acute care surgery (ACS) comprises trauma and emergency surgery. The purpose of this new specialty is to involve trauma and nontrauma surgeons in the care of acutely ill patients with a surgical pathology. In Quebec, few acute care surgery services (ACSS) exist, and the concept is still poorly understood by most general surgeons. This survey was meant to determine the opinions and interest of Quebec general surgeons in this new model. METHODS: We created a bilingual electronic survey using a Web interface and sent it by email to all surgeons registered with the Association québécoise de chirurgie. A reminder was sent 2 weeks later to boost response rates. RESULTS: The response rate was 36.9%. Most respondents had academic practices, and 16% worked in level 1 trauma centres. Most respondents had a high operative case load, and 66% performed at least 10 urgent general surgical cases per month. Although most (88%) thought that ACS was an interesting field, only 45% were interested in participating in an ACSS. Respondents who deemed this concept least applicable to their practices were more likely to be working in nonacademic centres. CONCLUSION: Despite a strong interest in emergency general surgery, few surgeons were interested in participating in an ACSS. This finding may be explained by lack of comprehension of this new model and by comfort with traditional practice. We aim to change this paradigm by demonstrating the feasibility and benefits of the new ACSS at our centre in a follow-up study.

CONTEXTE: Les soins intensifs chirurgicaux comprennent la chirurgie traumatologique et la chirurgie d'urgence. Cette nouvelle spécialité a pour but de faire participer les chirurgiens traumatologues et non traumatologues aux soins des patients gravement malades qui nécessitent une chirurgie. Au Québec, il existe peu de services de soins intensifs chirurgicaux et ce concept est encore méconnu de la plupart des chirurgiens généraux. Ce sondage visait à sonder l'opinion et l'intérêt des chirurgiens généraux du Québec au sujet de ce nouveau modèle. of General Surgery, Centre Hospitalier Affilié Universitaire de Québec, Québec, Que. MÉTHODES: Nous avons créé un questionnaire électronique bilingue au moyen d'une interface Web et l'avons envoyé par courriel à tous les chirurgiens inscrits auprès de l'Association québécoise de chirurgie. Un rappel a été envoyé 2 semaines plus tard pour améliorer le taux de réponse au questionnaire. RÉSULTANTS: Le taux de réponse a été de 36,8 %. La plupart des répondants occupaient des postes universitaires et 16 % travaillaient dans des centres de traumatologie de niveau 1. La plupart des répondants ont dit opérer beaucoup et 66 % ont dit pratiquer au moins 10 chirurgies générales urgentes chaque mois. Même si la majorité des répondants (88 %) se sont dits d'avis que les soins intensifs chirurgicaux étaient un domaine intéressant, seulement 45 % ont exprimé le souhait de participer à un service de ce type. Les répondants pour qui ce concept a semblé le moins applicable à leur pratique étaient plus susceptibles d'exercer dans des centres non universitaires. CONCLUSIONS: Malgré un intérêt marqué à l'endroit des soins intensifs chirurgicaux, peu de chirurgiens ont semblé souhaiter participer à un service de ce type. Ce fait peut s'expliquer par la méconnaissance de ce nouveau modèle et par la force de l'habitude associée à la pratique traditionnelle. Nous visons à modifier ce paradigme en démontrant la faisabilité et les avantages d'un nouveau modèle de service de soins intensifs chirurgicaux dans notre centre lors d'une étude de suivi.

Role of persistent processus vaginalis in hydroceles found in a tropical population.

BACKGROUND: Lymphatic obstruction by Wuchereria bancrofti is thought to be the mechanism for development of tropical hydrocele in men and for elephantiasis, mostly in women. Hydrocele prevalence is used to determine the effectiveness of para site eradication programs. METHODS: We maintained a prospective log of operations performed at 1 Canadian Field Hospital during its relief mission to Léogâne, Haiti. Information regarding duration of symptoms, type of previous surgery (if any), surgical approach, associated inguinal hernia and volume and appearance of hydrocele fluid in patients with tropical hydroceles were recorded. RESULTS: From January to March 2010, 4922 patients were seen, none of whom had elephantiasis. Of the 64 patients who collectively underwent 69 inguino-scrotal procedures, 5 patients had inguinal hernia repair several years after hydrocele excision via the scrotum, 19 patients with bilateral hydroceles underwent a scrotum-only approach, and 45 patients had an inguinal approach (33 unilateral and 12 bilateral) to repair 57 hydroceles. A patent processus vaginalis was present in 50 of 57 (88%) hydroceles where the groin was explored. CONCLUSION: Hydroceles remain common in Léogâne despite successful eradication of filariasis with mass drug administration using diethylcarbamazine-fortified cooking salt. Persistent patent processus vaginalis is a more likely cause than persistent filariasis. There is probably little difference between hydrocele in developed countries and tropical hydrocele other than neglect. Hydrocele prevalence is not a measure of the effectiveness of parasite eradication programs.

Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces.

BACKGROUND: Patients with an occult pneumothoraces (OPTXs) may be at risk of tension pneumothoraces (TPTXs) without drainage or pleural drainage complications if treated. METHODS: Adults with traumatic OPTXs and requiring positive-pressure ventilation (PPV) were randomized to pleural drainage or observation (one side only enrolled if bilateral). All subsequent care and method of pleural drainage was per attending physician discretion. The primary outcome was a composite of respiratory distress (RD) (need for urgent pleural drainage, acute/sustained increases in O2 requirements, ventilator dysynchrony, and/or charted respiratory events). RESULTS: Ninety severely injured patients (mean [SD], Injury Severity Score [ISS], 33 [11]) were studied at four centers: Calgary (55), Toronto (27), Quebec (6), and Sherbrooke (3). Forty were randomized to tube thoracostomy, and 50 were randomized to observation. The risk of RD was similar between the observation and tube thoracostomy groups (relative risk, 0.71; 95% confidence interval, 0.40-1.27). There was no difference in mortality or intensive care unit (ICU), ventilator, or hospital days between groups. In those observed, 20% required subsequent pleural drainage (40% PTX progression, 60% pleural fluid, and 20% other). One observed patient (2%) undergoing PPV at enrollment had a TPTX, which was treated with urgent tube thoracostomy without sequelae. Drainage complications occurred in 15% of those randomized to drainage, while suboptimal tube thoracostomy position occurred in an additional 15%. There were three times (24% vs. 8%) more failures and more RDs (p = 0.01) among those observed with OPTXs requiring sustained PPV versus just for an operation, which increases threefold after a week in the ICU (p = 0.07). CONCLUSION: Our results suggest that OPTXs may be safely observed in hemodynamically stable patients undergoing PPV just for an operation, although one third of those requiring a week or more of ICU care received drainage, and TPTXs still occur. Complications of pleural drainage remain unacceptably high, and future work should attempt to delineate specific factors among those observed that warrant prophylactic drainage. LEVEL OF EVIDENCE: Therapeutic study, level III.

1 Canadian Field Hospital in Haiti: surgical experience in earthquake relief.

The Canadian Forces' (CF) deployable hospital, 1 Canadian Field Hospital, was deployed to Haiti after an earthquake that caused massive devastation. Two surgical teams performed 167 operations over a 39-day period starting 17 days after the index event. Most operations were unrelated to the earthquake. Replacing or supplementing the destroyed local surgical capacity for a brief period after a disaster can be a valuable contribution to relief efforts. For future humanitarian operations/disaster response missions, the CF will study the feasibility of accelerating the deployment of surgical capabilities.

Admission base deficit and lactate levels in Canadian patients with blunt trauma: are they useful markers of mortality?

BACKGROUND: Elevated base deficit (BD) and lactate levels at admission in patients with injury have been shown to be associated with increased mortality. This relationship is undefined in the Canadian experience. The goal of this study was to define the association between arterial blood gas (ABG) values at admission and mortality for Canadians with severe blunt injury. METHODS: A retrospective review of 3,000 consecutive adult major trauma admissions (Injury Severity Score, ≥ 12) to a Canadian academic tertiary care referral center was performed. ABG values at the time of arrival were analyzed with respect to associated mortality and length of stay. RESULTS: A total of 2,269 patients (76%) had complete data available for analysis. After exclusion of patients who sustained a penetrating injury or were admitted for minor falls (ground levels or low height), 445 had an ABG drawn within 2 hours of arrival. Patients who died displayed a higher median lactate (3.6 vs. 2.2, p < 0.0001), a worse median BD (-10 vs. -5, p < 0.0001), and a lower pH (7.23 vs. 7.31, p < 0.0001) at arrival compared with those of survivors. A statistically significant association was also observed between lactate and BD values at arrival and both mortality and length of stay (p < 0.0001). CONCLUSION: Despite population differences, ABGs at admission in Canadian patients with blunt trauma accurately reflect mortality in a similar manner to the previously published literature. Survival curves with lactate and BD values at arrival should be available to all clinicians within their individual trauma centers for both acute care and quality assurance. LEVEL OF EVIDENCE: Prognostic study, level III.

Causes of death in Canadian Forces members deployed to Afghanistan and implications on tactical combat casualty care provision.

BACKGROUND: As part of its contribution to the Global War on Terror and North Atlantic Treaty Organization's International Security Assistance Force, the Canadian Forces deployed to Kandahar, Afghanistan, in 2006. We have studied the causes of deaths sustained by the Canadian Forces during the first 28 months of this mission. The purpose of this study was to identify potential areas for improving battlefield trauma care. METHODS: We analyzed autopsy reports of Canadian soldiers killed in Afghanistan between January 2006 and April 2008. Demographic characteristics, injury data, location of death within the chain of evacuation, and cause of death were determined. We also determined whether the death was potentially preventable using both explicit review and implicit review by a panel of trauma surgeons. RESULTS: During the study period, 73 Canadian Forces members died in Afghanistan. Their mean age was 29 (+/-7) years and 98% were male. The predominant mechanism of injury was explosive blast, resulting in 81% of overall deaths during the study period. Gunshot wounds and nonblast-related motor vehicle collisions were the second and third leading mechanisms of injury causing death. The mean Injury Severity Score was 57 (+/-24) for the 63 study patients analyzed. The most common cause of death was hemorrhage (38%), followed by neurologic injury (33%) and blast injuries (16%). Three deaths were deemed potentially preventable on explicit review, but implicit review only categorized two deaths as being potentially preventable. CONCLUSIONS: The majority of combat-related deaths occurred in the field (92%). Very few deaths were potentially preventable with current Tactical Combat Casualty interventions. Our panel review identified several interventions that are not currently part of Tactical Combat Casualty that may prevent future battlefield deaths.

Interdisciplinary approach to the management of an 18-month-old burn victim in Afghanistan.

An 18-month-old boy with partial and full thickness burns to his upper face and scalp was treated by an interdisciplinary team at the Role 3 Multinational Medical Unit in Kandahar. A novel approach to his burn management is presented, highlighting some of the issues and constraints that military surgeons are faced with while on operational deployment in a theater of conflict.

Ileocolic perforation secondary to sodium polystyrene sulfonate in sorbitol use: a case report.

Hyperkalemia is a common condition encountered in medical and surgical patients. It can lead to various complications including cardiac arrhythmias. Sodium polystyrene sulfonate (SPS) in sorbitol is an ion-exchange resin that can be used to treat hyperkalemia. It can be used in enema or in oral form. The present article describes the case of an intensive care unit patient who experienced severe, diffuse, intestinal perforation induced by the use of SPS-sorbitol, requiring multiple laparotomies, followed by a brief review of the relevant literature and recommendations regarding the use of SPS-sorbitol.

The OPTICC trial: a multi-institutional study of occult pneumothoraces in critical care.

BACKGROUND: The management of pneumothoraces detected on CT but not on supine chest radiographs remains controversial, especially in those undergoing positive pressure ventilation (PPV) who are at risk for complications with both observation and treatment. Previous limited study yielded confusion regarding the need for routine drainage of these occult pneumothoraces (OPTXs). We conducted a pilot study at 2 trauma centers to address the feasibility and safety of randomizing traumatized patients undergoing PPV to drainage or observation. METHODS: Stable mechanically ventilated (or en route to surgery) adults with OPTXs were identified at 2 centers (Calgary and Quebec). Patients were randomized to observation (unless drainage became clinically indicated) or to chest drainage. Episodes of respiratory distress (need for thoracostomy tube, acute/sustained increase in oxygen requirements, difficulty in achieving adequate ventilation and self-reported distress) and subsequent imaging abnormalities were recorded until discharge. RESULTS: From August 2006 to April 2008, 24 trauma patients were enrolled (17 Calgary and 7 Quebec), with 2 later exclusions (final CT found no OPTX). Thirteen patients (59%) were randomized to observation, 9 to drainage (41%). Four observed (31%) later had chest tubes placed nonurgently for worsening OPTXs/effusions; none with increased morbidity. Overall rates of respiratory distress (drainage: 33%, observation: 41%) and mortality (drainage: 22%, observation: 15%) were similar across groups, as were median intensive care unit (drainage: 3, observation: 4) and in-hospital days (drainage: 10, observation: 16). CONCLUSIONS: With no important differences in morbidity, the OPTICC pilot lays the foundation for a future definitive trial comparing drainage or observation in posttraumatic OPTXs requiring PPV.

Clinical predictors of occult pneumothoraces in severely injured blunt polytrauma patients: A prospective observational study.

INTRODUCTION: The supine antero-posterior (AP) chest radiograph (CXR) is an insensitive test for detecting post-traumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) that were not diagnosed on CXR. The purpose of this study was to prospectively determine the incidence, and validate previously identified clinical predictors, of OPTXs after blunt trauma. METHODS: All severe blunt injured patients (injury severity score (ISS)>or=12) presenting to a level 1 trauma centre over a 17-month period were prospectively evaluated. Thoracoabdominal CT scans and corresponding CXRs were reviewed at the time of admission. Patients with OPTXs were compared to those with overt PTXs regarding incidence and previously identified predictive risk factors (subcutaneous emphysema, rib fractures, female sex and pulmonary contusion). RESULTS: CT imaging was performed concurrent to CXR in 405 blunt trauma patients (ISS>or=12) during the study period. PTXs were identified in 107 (26%) of the 405 patients. Eighty-one (76%) of these were occult when CXRs were interpreted by the trauma team. Concurrent chest trauma predictive of OPTXs was limited to subcutaneous emphysema (p=0.003). Rib fractures, pulmonary contusions and female sex were not predictive. CONCLUSIONS: OPTXs were missed in up to 76% of all seriously injured patients when CXRs were interpreted by the trauma team. This is higher than previously reported in retrospective studies and is likely based on the difficult conditions in which the trauma team functions. Subcutaneous emphysema remains a strong clinical predictor for concurrent OPTXs.

Outcomes of Acinetobacter baumannii infection in critically ill surgical patients.

BACKGROUND: Multi-drug resistant (MDR) organisms in intensive care units (ICUs) are a growing concern. The emergence of several infections with MDR Acinetobacter baumannii prompted a review of cases and evaluation of the efficacy of intervention. OBJECTIVE: To determine the rate of clinical cure, the incidence of drug resistance, and the mortality rate associated with A. baumannii infection. METHOD: Retrospective review of A. baumannii infections in three surgical ICUs between January, 2004 and November, 2005. Infection was identified in 291 patients, 20 of whom were excluded because of incomplete documentation. Of the remaining 271 patients, 71% were male, and the mean age was 47 +/- 18 years (range 13-90 years). RESULTS: Patients had a mean length of stay in the ICU of 14 days (range 0-136 days) before infection. The initial positive cultures were from bronchoalveolar lavage fluid (BAL) in 72.3%, blood in 16.2%, a catheter tip in 6.3%, urine in 1.8%, wound in 2.2%, and abscess in 1.1%. In 46.9% of patients, the first culture was polymicrobial. The Acinetobacter isolates were resistant or intermediate-resistant to imipenem-cilastatin in 81.2% of cases; 19.9% were resistant to all drugs except colistin, and two were resistant to all tested drugs. Colistin was used in 75.6% of patients (intravenous 61.5%, nebulized 38.5%). The mean duration of treatment was 13 +/- 8.9 days (range 0-56 days), and clinical cure was achieved in 73.8% of patients. Recurrent infection after initial cure was found in 19.2% of patients. There was no significant difference in clinical cure rates between patients treated with colistin and those treated with other culture-directed drugs (75.1% vs. 69.7%), or between patients treated with intravenous vs. nebulized colistin (72.4% vs. 79.5%). The mortality rate was 26.2% for the entire group and was significantly higher in the subgroup of transplant patients (n = 31) (64.5% vs. 21.4%; p < 0.001). CONCLUSION: The majority of A. baumannii isolates were MDR, and a significant proportion were sensitive only to colistin. Treatment of A. baumannii infection with colistin is effective by both intravenous and nebulized routes of administration. However, infection with A. baumannii in critically ill surgical patients is associated with a high mortality rate, particularly in transplant patients.

Outcomes of Acinetobacter baumannii infection in critically ill burned patients.

The objective of this study was to determine the incidence of drug resistance among isolates of Acinetobacter baumannii from our Burn Intensive Care Unit (BICU), the rate of clinical cure, and the mortality rate. We undertook a retrospective review of all cases of infection from the BICU between January 2004 and November 2005. The group consisted of 24 men (80%) and 6 women with a mean age of 43 years (range, 17-76 years, +/-14.5 years). Mean TBSA burned was 43% (range, 9-75%, +/-19%). Mean BICU length of stay was 49 days (range, 5-118 days, +/-30 days). Patients developed their first infection after a mean of 16 days (5-73 days, +/-14 days). The initial site of infection was bronchoalveolar lavage in 21 (70%), blood in 6 (20%), central venous catheter tip in 2 (7%), and urine in 1 (3%). The isolates displayed resistance to imipenem in 87% of cases. No organism displayed resistance to colistin (polymixin E). Patients were treated with colistin in 20 cases (67%), with amikacin in 8 cases (27%), and with imipenem in 2 cases (7%). A total of 10 patients (33%) died, 1 from gastrointestinal bleeding and 9 from active infection, giving an infection related mortality of 30%. In 21 cases (70%), a cure was achieved with a mean duration of treatment of 16 days (range, 4-30 days, +/-7 days). The majority of A. baumannii isolates were multidrug resistant; however, no isolate displayed resistance to colistin. Cure rate was 70% and infection-related mortality reached 30%. More investigation is warranted to improve prevention and to assess new therapeutic agents.

Survival after prolonged length of stay in a trauma intensive care unit.

BACKGROUND: Intensive care unit (ICU) patients comprise a small proportion of patients in the hospital but consume a disproportionate amount of hospital resources. In our cost-conscious environment, it becomes necessary to address the overall performance of our ICUs. This study was designed to analyze survival among trauma ICU (TICU) patients with a length of stay (LOS) >1 month. METHODS: We retrospectively reviewed the prospectively collected Trauma Registry Database between January 1, 1995, and January 1, 2005, in an adult TICU from a Level I trauma center. Data on demographics, mechanism of injury, Injury Severity Score (ISS), LOS, and in-hospital survival was collected. Descriptive statistics were calculated and student's t test and comparison of proportions were performed where appropriate. Logistic regression was performed to analyze independent predictors of mortality with significance when p < 0.05. RESULTS: The initial cohort consisted of 3,556 patients with a mean LOS of 9.8 days (range, 0-274 days). Sixty-nine percent were men, mean age was 44.3 years (range, 0-104 years), and mean ISS was 18 (range, 0-75). The mechanism of injury was blunt trauma in 75%, burns in 15%, and penetrating trauma in 10%. Overall survival was 87%. A total of 339 patients had a LOS >1 month. There was no difference in survival between patients with a LOS <1 month and those with a LOS >1 month (87.1% versus 86.7%). Patients >50 years old (n = 1,251) had a longer LOS (12.5 versus 8.4 days; p < 0.001) and increased mortality (22.1% versus 8.0%; p < 0.001). Age remained an independent predictor of mortality when controlling for ISS. CONCLUSION: In our TICU population, extended LOS did not preclude a significant chance of survival. Patients >50 years old had longer LOS and increased mortality. This suggests that the utilization of resources in patients with a prolonged LOS is reasonable and justified.