Low Molecular Weight Heparin Is Superior for Venous Thromboembolism Prophylaxis in High-Risk Geriatric Patients.

INTRODUCTION: Venous thromboembolism (VTE) is a source of preventable morbidity and mortality in critically ill trauma patients. Age is one independent risk factor. Geriatric patients embody a population at high thromboembolic and hemorrhagic risk. Currently, there is little guidance between low molecular weight heparin (LMWH) and unfractionated heparin (UFH) for anticoagulant prophylaxis in the geriatric trauma patient. METHODS: A retrospective review was conducted at an ACS verified, Level I Trauma center from 2014 to 2018. All patients 65 years or older, with high-risk injuries and admitted to the trauma service were included. Choice of agent was at provider discretion. Patients in renal failure, or those that received no chemoprophylaxis, were excluded. The primary outcomes were the diagnosis of deep vein thrombosis or pulmonary embolism and bleeding associated complications (gastrointestinal bleed, TBI expansion, hematoma development). RESULTS: This study evaluated 375 subjects, 245 (65%) received enoxaparin and 130 (35%) received heparin. DVT developed in 6.9% of UFH patients, compared to 3.3% with LMWH (P = .1). PE was present in 3.8% of UFH group, but only .4% in the LMWH group (P = .01). Combined rate of DVT/PE was significantly lower (P = .006) with LMWH (3.7%) compared to UFH (10.8%). 10 patients had documented bleeding events, and there was no significant association between bleeding and the use of LMWH or UFH. CONCLUSIONS: VTE events are more common in geriatric patients treated with UFH compared to LMWH. There was no associated increase in bleeding complications when LMWH was utilized. LMWH should be considered the chemoprophylatic agent of choice in high risk geriatric trauma patients.

Cost Effective Virtual Intensive Care Unit Expanding Capabilities in Critical Access Hospitals.

BACKGROUND: Tele-consults provide access to specialized care for a specific question and single point in time. eICU models utilize remote monitoring and ordering but have significant financial burden. We developed a virtual intensive care unit (VICU) for daily input of an intensivist working with local physicians. The purpose was to expand the acute care ability of the critical access hospital (CAH). The study evaluates the impact on the CAH and system. METHODS: The CAH developed an ICU team, led by a hospitalist, who staffed the intensive care unit (ICU). The CAH ICU team rounds daily via a secure video link to provide care in consultation with intensivists based at a university, tertiary care center (TC). A retrospective analysis was conducted 6 months before and after implementation (4/2018-3/2019). Fisher's exact test was used to compare pre- and post-intervention with significance at P < .04. RESULTS: After VICU implementation, there were 265 initial daily and 35 follow-up consults. Monthly transfers to a higher level of care decreased from 63 to 57 (P = .03). Transfers to TC increased from 49.6 to 62.0% (P = .001). Critical access hospital average monthly census and average monthly inpatient days increased (69 to 130 (P < .0001) and 158 to 319 (P < .0001), respectively). Critical access hospital physicians report increased comfort to admit ICU and non-ICU patients due to the program. The total startup cost was $5180. CAH hired 11 providers. There were no unanticipated deaths. DISCUSSION: VICU implementation resulted in new CAH jobs. The CAH experienced increased inpatient census and revenues (ICU and non-ICU) while decreasing patients transferred out of the system.

Traumatic complete urethral disruption: the West Virginia experience.

Type III complete urethral disruption is an uncommon injury that occurs primarily in male patients with pelvic trauma. Herein we present our results from management of this condition. Management should initially be conservative with a catheter placement in all cases. Full return of urinary function was noted in all patients managed endoscopically, and in 1 of 3 of patients managed with open urethroplasty. Erectile function was preserved in 2 of 3 of patients managed with endoscopic repair, and in none of the patients managed with open urethroplasty. The most common surgical urologic complication was traumatic urethral stricture.

Increases in endotracheal tube resistance are unpredictable relative to duration of intubation.

BACKGROUND: Accumulated secretions after intubation can affect the resistance of an endotracheal tube (ETT). Our objective was to measure extubated patient tubes and size-matched controls to evaluate differences in resistance. METHODS: New ETTs, with internal diameters of 7.0 through 8.5 mm, were tested as controls to establish the resistance of each size group as measured by pressure drop. Measurements were obtained using a mass flowmeter and pressure transducer. Pressure drop was measured at three flow rates. Seventy-one patient ETTs were evaluated after extubation by an identical method and compared with controls. RESULTS: In each control group, pressure drop was tightly clustered with low variation and no overlap between sizes. A total of 73 to 79% of the patient ETTs had a pressure drop of > 3 SDs of size-matched controls at all flow rates. Pressure drop in 48 to 56% (across three flow rates) of extubated tubes was equivalent to the next smaller size of controls. At 60 and 90 L/min, 10% and 15% of patient tubes, respectively, had the pressure drop of a control tube three sizes smaller. The pressure drop was unpredictable relative to the duration of intubation. CONCLUSIONS: Organized secretions can significantly increase resistance as measured by the pressure drop of ETTs. The degree of change was highly variable, occurs in all sizes, and was unrelated to the duration of intubation. The performance of an ETT may be comparable to new tubes one to four sizes smaller. This may impact the tolerance of ventilator weaning.