Emergent initial presentation of congenital malrotation with midgut volvulus in 68-year-old.

Congenital malrotation is a pathology nearly exclusive to the infant population. In the rare instance when it is diagnosed in an adult, it is typically associated with a longstanding history of gastrointestinal symptoms. Unfortunately, this unique presentation in an unexpected population has the potential to be confounding, leading to delayed or mismanaged care. Here, we describe an intriguing case of congenital malrotation complicated by midgut volvulus in a 68-year-old woman. Even more curious, the patient did not have a medical history plagued by abdominal complaints. Careful, comprehensive evaluation yielded appropriate surgical management via Ladd's procedure and right hemicolectomy in this complex patient.

Visual Misrepresentations: The Lack of Skin Tone and Sex Equity in General Surgical Textbooks.

OBJECTIVE: Lack of racial and ethnic diversity in educational material contributes to health disparities. This study sought to determine if images of skin color and sex in general surgery textbooks were reflective of the U.S. DESIGN: All human figures with discernable sex characteristics and/or skin tone were evaluated independently by 4 coders. Each image was categorized as male or female. Skin tone in each image was categorized using the Massey- Martin skin color scale. This data was compared to 2020 U.S. Census Data. SETTING: U.S. Medical School. PARTICIPANTS: Not applicable. RESULTS: A total of 1179 images were evaluated for skin tone alone; 293 images for sex alone. 650 images depicted characteristics of both sex and skin tone. Interrater reliability was 0.78 for skin tone and 0.91 for sex. While the U.S. population is 59.3% white, 29.5% non-black persons of color and 13.6% black, in surgical textbooks, 90.7% of images were white, 6.5% were non-black persons of color, and 2.8% were black. Distribution of skin tone for all textbooks were significantly different. (p < 0.001) compared to the U.S. POPULATION: The U.S. population is 49.5% male and 50.5% female. When images of sex specific genitalia and breasts are excluded, surgical textbook images are 62.9% male and 37.1% female. Only 1 textbook had a distribution of sex that was similar to the U.S. CONCLUSIONS: Despite increasing diversity in the U.S. population there is a lack of skin tone and sex diversity in traditional surgical textbooks.

Kids gone wild - Alcohol use and patient characteristics in pediatric trauma during the coronavirus disease 2019 pandemic.

Importance: Reported coronavirus disease 2019 (COVID-19) pandemic effects on pediatric trauma have been variable. Objective: We investigated the characteristics of pediatric trauma including alcohol use during the pandemic at our urban trauma center. Methods: The trauma database of our adult level 1 trauma center was queried for all pediatric (age ≤ 18 years) patients presenting between March 1, 2020, and October 30, 2020. Data from 2017 to 2019 served as a control. Variables analyzed included demographics, mechanisms, injury severity, hospitalization characteristics, and positive blood alcohol. Results: Pandemic pediatric trauma volumes increased by 67.5% (330/year vs. 197/year). Pandemic patients were younger (median age 13 vs. 14 years, P = 0.011), but similar in gender, ethnicity, severity, hospital length of stay, mortality, and rates of penetrating injury. Falls doubled (79/year vs. 34/year) and shifted away from high falls >6 meters (0% vs. 7.9%) to moderate falls 1-6 meters (58.2% vs. 51.5%) (P = 0.028). Transportation injury rates were similar however mechanisms shifted from motor vehicle crashes (-13.5%) towards recreational vehicles including motorcycles (+2.1%), all-terrain vehicles (+8.6%), and bicycles (+3.8%) (P = 0.018). Pediatric-positive blood alcohol was significantly higher (11.2% vs. 5.1%, P < 0.001), especially for ages 14-18 years (21.7% vs. 9.5%, P < 0.001). Interpretation: Pediatric trauma volumes during the COVID-19 pandemic increased. Pandemic patients had more recreational vehicle injuries and higher rates of positive blood alcohol. This suggests an increased need for alcohol assessment and targeted interventions in the pediatric population during pandemics or periods of school closures.

Increase in Alcohol Use Among the Geriatric Trauma Population During the COVID-19 Pandemic.

The COVID-19 pandemic has had profound effects on the everyday behaviors of all patients. At the same time, the United States population is aging, and an increasing portion of traumatically injured patients are geriatric. Our study aims to examine the effects of the COVID-19 pandemic on the geriatric trauma population. We performed a retrospective review of the trauma database from our single institution level I trauma center examining pandemics impact on geriatric trauma demographics, mechanism of injury, injury severity, hospitalization characteristics, and alcohol use. Data during the pandemic was compared to the prior 3 years and controlled for seasonality. Statistical analysis demonstrated an increase in duration of mechanical ventilation and alcohol use during the pandemic while other factors remained stable. This shows the need for targeted alcohol assessment in the geriatric trauma population during periods of social isolation and additional research into the effects of the COVID-19 on trauma patients.

Hypothermia in trauma patients: predicting the big chill.

Physicians commonly ignore hypothermia, an often-underappreciated event associated with mortality in trauma patients, in general due to its prevalence and belief that it is secondary to the injury itself (secondary hypothermia). Over the past several decades, hypothermia in trauma has been studied concerning its effects on mortality; however, very little has been done to identify the major risk factors associated with it. The study by Lapostolle and colleagues has attempted to incorporate environmental risk factors and prehospital care along with more traditional variables for the prediction of hypothermia at admission.

Sternal fixation for isolated traumatic sternal fractures improves pain and upper extremity range of motion.

INTRODUCTION: Sternal fractures are debilitating due to intractable pain, constant fracture movement and limited range of motion (ROM) of the upper extremities (UE). Traditional treatment comprises mainly of pain control, delaying return to daily activities. Recently, sternal fixation has gained popularity. There is, however, a lack of literature demonstrating efficacy. We report our experience of traumatically fractured sternal fixation. METHODS: Following IRB approval, a retrospective chart review was completed for all patients undergoing sternal fixation by a single trauma surgeon at our Level I trauma center. Basic demographics were obtained. Primary outcomes included average cumulative pain scores, total cumulative narcotic amounts and total number of pain medication agents utilized prior to and after sternal fixation. Secondary outcome included physical therapy UE ROM before and after surgery. Paired t tests were used for comparison; significance set at p < 0.05. RESULTS: Thirteen patients underwent sternal fixation from 8/2016 to 2/2018. Average age was 54.4 ± 20.8 years; 54% were female. All patients experienced blunt trauma; average injury severity score was 15.8 ± 10.9 and abbreviated chest injury score was 2.5 ± 0.51. Average intensive care unit/hospital length of stay was 2.3/10.2 days. Average pain scores significantly improved by a score of 3.5 postoperatively (preoperative = 7.08 ± 2.3, postoperative = 3.54 ± 2.5; p = 0.001). Total pain medications required by sternal fixation patients significantly decreased by 1 medication postoperatively (preoperative = 4.2 medications, postoperative = 3.2 medications; p = 0.002). Average narcotic requirements significantly decreased by 7.59 morphine milligram milliequivalents (MME) after sternal fixation (preoperative amount = 71.78 MME, postoperative amount = 64.19 MME; p = 0.041). Every patient had limited UE ROM preoperatively; however, all but one patient resumed full UE ROM postoperatively (p < 0.001). There were no postoperative complications. CONCLUSIONS: Sternal fixation is a safe and effective procedure resulting in improved pain, decreased narcotic requirements, and faster recovery.

Damage control in trauma and abdominal sepsis.

Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.

Impact of hypothermia in the rural, pediatric trauma patient.

OBJECTIVE: Hypothermia is an independent predictor of mortality in adult trauma studies. However, the impact of hypothermia on the pediatric trauma population has not been described. The purpose of this study is to evaluate hypothermia as a cofactor to mortality, complications, and among survivors, hospital length of stay parameters in the pediatric trauma population. DESIGN: Retrospective review of a prospectively collected database (National Trauma Registry of the American College of Surgeons) over a 5-yr period (July 2002 to June 2007). SETTING: A rural, level I trauma center. PATIENTS: One thousand six hundred twenty-nine pediatric patients admitted with a traumatic injury. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariate regression models were used to evaluate the association of hypothermia with mortality, infectious complications, organ dysfunction, and among survivors, hospital length of stay parameters. Of 1,629 pediatric trauma patients admitted, 182 (11.1%) patients were hypothermic (temperature below 36 degrees C) on admission. Hypothermia had an adjusted odds ratio (AOR) of 2.41 (95% confidence interval [CI], 1.12-5.22, p = .025) for mortality. After controlling for covariates, hypothermia had associations with developing pneumonia (AOR, 0.185, 95% CI, 0.040-0.853; p = .031) and a bleeding diathesis (AOR, 3.14, 95% CI, 1.04-9.44; p = .042). The median days in the hospital, intensive care unit (ICU), and ventilator were longer in the hypothermic cohort; however, after controlling for covariates, hypothermia was not associated with differences in hospital days, ICU days, or ventilator days. CONCLUSIONS: Hypothermia is a common problem at admission among pediatric trauma patients. Hypothermia is associated with an increase in the odds of death and the development of a bleeding diathesis, while having decreased odds for developing pneumonia. While the length of stay indicators were longer in the hypothermic cohort among survivors, no significant association was noted with hypothermia for hospital, ICU, or ventilator days after controlling for confounders.

Running out of gas but not trauma patients: the effect of the price of gas on trauma admissions.

As fuel costs steadily rise and motor vehicle collisions continue to be a leading cause of morbidity and mortality, we examined the relationship between the price of gasoline and the rate of trauma admissions related to gasoline consumption (GRT). The National Trauma Registry of the American College of Surgeons data of a rural Level I trauma center were queried over 27 consecutive months to identify the rate of trauma admissions/month related to gas utilization compared with the number of nongasoline related trauma admissions, based on season and day of the week. The average price/gallon of regular gas in our region was obtained from the NorthCarolinaGasPrices. com database. A log linear model with a Poisson distribution was created. No significant association exists between the average price/gallon of gasoline and the GRT rate across the months, seasons, and weekday and weekend periods. As the price of gas continues to rise, the rate of rural GRT does not decrease. Over a longer period of time and with skyrocketing prices, this relationship may not hold true. These findings may also be explained by the rural area where limited alternative transportation opportunities exist and a trauma patient population participating in high risk behavior regardless of cost.

"Damage control" in the elderly: futile endeavor or fruitful enterprise?

BACKGROUND: Damage control laparotomy (DCL) provides effective management in carefully selected, exsanguinating trauma patients. However, the effectiveness of this approach has not been examined in the elderly. The purpose of this study was to characterize elderly DCL patients. METHODS: The National Trauma Registry of the American College of Surgeons was queried for patients admitted to our Level I trauma center between January 2003 and June 2008. Patients who underwent a DCL were included in the study. Elderly (55 years or older) and young (16-54 years) patients were compared for demographics, injury severity, intraoperative transfusion volume, complications, and mortality. RESULTS: During the study period, 62 patients met inclusion criteria. Elderly and young cohorts were similar in gender (male, 78.6% vs. 75.0%, p = 0.78), Injury Severity Score (25.1 ± 2.1 vs. 23.8 ± 1.7, p = 0.49), packed red blood cell transfusion volume (3036 mL ± 2760 mL vs. 2654 mL ± 2194 mL, p = 0.51), and number of complications (3.21 ± 0.48 vs. 3.33 ± 0.38, p = 0.96). Mortality was greater in the elderly cohort (42.9% vs. 12.5%, p = 0.02). The mean time to death for the elderly was 9.8 days ± 10.2 days and 26 days ± 21.5 days in the young (p = 0.485). CONCLUSIONS: Despite the severity of injury, the outcome of elderly DCL patients is better than what might be predicted. They succumb to their injuries more frequently and earlier in the hospital course compared with the young, but the majority of these patients survive. DCL in the elderly is not a futile endeavor.

Trauma intensive care unit survival: how good is an educated guess?

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.

The elderly trauma patient: an investment for the future?

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.

Impact of acute care general surgery coverage by trauma surgeons on the trauma patient.

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.

Spontaneous Diaphragmatic Rupture in Hypermobile Type Ehlers-Danlos Syndrome.

Ehlers-Danlos Syndrome refers to a spectrum of connective tissue disorders that have a variety of clinical manifestations. In this case, we present a spontaneous diaphragmatic rupture in a patient with type III Ehlers-Danlos Syndrome. The patient presented with worsening shortness of breath after failure of medical therapy for a presumed pneumonia. A CT scan was obtained which showed diaphragmatic rupture with splenic herniation which was repaired in the operating room via thoracotomy. It is important to include diaphragmatic rupture in the differential diagnosis for patients with connective tissue disease and acute onset tachypnea and pain, as this complication has the potential for significant morbidity without prompt surgical intervention.

Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates.

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.

An Unusual Presentation of a Posterior Mediastinal Schwannoma Associated with Traumatic Hemothorax.

Schwannomas of the thoracic cavity are typically an asymptomatic, benign neurogenic neoplasm of the posterior mediastinum. In this case, we present a traumatic hemothorax as the initial presentation for a previously undiscovered mediastinal mass. The patient presented with shortness of breath and right-sided chest pain after being struck in the chest with a soccer ball. An operative exploration was pursued due to persistent hemothorax with hemodynamic instability despite resuscitation and adequate thoracostomy tube placement. The intraoperative etiology of bleeding was discovered to be traumatic fracture of a large hypervascular posterior mediastinal schwannoma. Surgical resection is the treatment of choice for these tumors. Specific serological markers do not exist for this tumor, and radiographic findings can be variable, so tissue diagnosis is of importance in differentiating benign from malignant schwannomas, as well as other posterior mediastinal tumors. However, most patients have excellent survival following complete resection.

Permissive Hypotension: Potentially Harmful in the Elderly? A National Trauma Data Bank Analysis.

Permissive hypotension is a component of damage control resuscitation that aims to provide a directed, controlled resuscitation, while countering the "lethal triad." This principle has not been specifically studied in elderly (ELD) trauma patients (≥55 years). Given the ELD population's lack of physiologic reserve and risk of inadequate perfusion with "normal" blood pressures, we hypothesized that utilized a permissive hypotension strategy in ELD trauma patients would result in worse outcomes compared with younger patients (18-54 years). A retrospective review of National Trauma Data Bank reports from 2009 and 2010, identifying critically ill patients undergoing a "damage control laparotomy," was performed to determine the effect of age and systolic blood pressure on outcome. Logistic regression analysis, including evaluation of an interaction between age and admission blood pressure, was performed on mortality using admission demographics, physiology, injury severity, mechanism of injury, and in-hospital complications. Although there was a higher likelihood of death with greater age, lower admission systolic blood pressure, lower Glasgow Coma Score, increased injury severity score, and acute renal failure, a synergistic effect of age and blood pressure on mortality was not identified. Permissive hypotension appears to be a possible management strategy in ELD trauma patients.

Perioperative management of obese patients.

Obesity prevalence has quadrupled since the 1980s in the United States. It is estimated that 30% of the population is obese or has a body mass index of greater than or equal to 30 as defined by the World Health Organization. Surgeons are likely to engage in the care of obese patients and need to be adept in every aspect of the patients' care in order to have a successful hospital course. There is significant controversy in perioperative management of obese patients. This article discusses perioperative management of obese patients to provide guidelines, education, and discussion of current issues.

Lung protective ventilation (ARDSNet) versus airway pressure release ventilation: ventilatory management in a combined model of acute lung and brain injury.

BACKGROUND: Concomitant lung/brain traumatic injury results in significant morbidity and mortality. Lung protective ventilation (Acute Respiratory Distress Syndrome Network [ARDSNet]) has become the standard for managing adult respiratory distress syndrome; however, the resulting permissive hypercapnea may compound traumatic brain injury. Airway pressure release ventilation (APRV) offers an alternative strategy for the management of this patient population. APRV was hypothesized to retard the progression of acute lung/brain injury to a degree greater than ARDSNet in a swine model. METHODS: Yorkshire swine were randomized to ARDSNet, APRV, or sham. Ventilatory settings and pulmonary parameters, vitals, blood gases, quantitative histopathology, and cerebral microdialysis were compared between groups using χ2, Fisher's exact, Student's t test, Wilcoxon rank-sum, and mixed-effects repeated-measures modeling. RESULTS: Twenty-two swine (17 male, 5 female), weighing a mean (SD) of 25 (6.0) kg, were randomized to APRV (n = 9), ARDSNet (n = 12), or sham (n = 1). PaO2/FIO2 ratio dropped significantly, while intracranial pressure increased significantly for all three groups immediately following lung and brain injury. Over time, peak inspiratory pressure, mean airway pressure, and PaO2/FIO2 ratio significantly increased, while total respiratory rate significantly decreased within the APRV group compared with the ARDSNet group. Histopathology did not show significant differences between groups in overall brain or lung tissue injury; however, cerebral microdialysis trends suggested increased ischemia within the APRV group compared with ARDSNet over time. CONCLUSION: Previous studies have not evaluated the effects of APRV in this population. While our macroscopic parameters and histopathology did not observe a significant difference between groups, microdialysis data suggest a trend toward increased cerebral ischemia associated with APRV over time. Additional and future studies should focus on extending the time interval for observation to further delineate differences between groups.