A prospective comparative study of the functional results associated with the use of Björk flap tracheostomy versus standard tracheostomy.

BACKGROUND: Placement of a tracheostomy for patients requiring prolonged mechanical ventilation (PMV) improves patients' comfort, decreases dead space ventilation, allows superior airway hygiene, and reduces the incidence of ventilator-associated pneumonia. Controversy still exists regarding the role of standard tracheostomy (ST) as opposed to the less frequently done Björk flap tracheostomy (BFT). This study compares the functional outcomes of these two techniques. STUDY DESIGN: Seventy-nine patients receiving tracheostomy in a 12-month period: 38 BFT vs. 41 ST. Data included demographics, indications for PMV, ventilator days before tracheostomy, time to and a number of patients who passed the fiberoptic endoscopic evaluation of swallowing (FEES), time to and a number of patients decannulated. RESULTS: Indications in both groups were PMV from trauma (18/38 vs 15/41), pneumonia (13/38 vs 13/41), and ARDS (7/38 vs 11/4), respectively (p > 0.05). Patients in both groups did not differ with regard to age, sex, GCS, duration of PMV before tracheostomy, the time to and a number of patients who passed the 1st FEES. However, the number of days and the number of FEES required before the next successful FEES in the 20 BFT and 21 ST patients who failed the 1st was 9 (4) vs. 16 (5), and 2 (1) vs. 4 (1), respectively (p < 0.05). Additionally, the number of intraoperative complications in aggregate were 0/38 in the BFT as opposed to 6/41 in the ST group (p < 0.05). CONCLUSION: We conclude that BFT may be associated with an overall shorter time to restoration of normal swallowing when compared to ST.

Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification.

INTRODUCTION: Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification. METHODS: Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016. RESULTS: A total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock. CONCLUSIONS: Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Correlation of brain flow variables and metabolic crisis: a prospective study in patients with severe traumatic brain injury.

INTRODUCTION: Current treatment guidelines for patients with severe TBI (sTBI) are aimed at preventing secondary brain injury targeting specific endpoints of intracranial physiology to avoid the development of metabolic crisis. We sought to identify factors contributing to development of metabolic crisis in the setting of a Multi-modality Monitoring and Goal-Directed Therapy (MM&GDTP) approach to patients with severe TBI. METHODS: Prospective monitoring of sTBI patients was performed, with retrospective data analysis. MM&GDTP was targeted to intracranial pressure (ICP) ≤ 20 mmHg, cerebral perfusion pressure (CPP) ≥ 60 mmHg, brain tissue oxygen pressure (PbtO2) ≥ 20 mmHg, and cerebral oxygen extraction measured by bi-frontal Near infrared Spectroscopy (NIRS) > 55%. Brain flow abnormality was defined by one of the following combinations: CPP < 60 mmHg with NIRS < 55% (Type 1), CPP < 60 mmHg with PbtO2 < 20 mmHg (Type 2), or PbtO2 < 20 mmHg with NIRS < 55% (Type 3). Cerebral micro-dialysate was analyzed hourly for glucose, lactate, pyruvate, glutamate, glycerol, and lactate/pyruvate ratio (LPR). Statistical analysis was performed with student t-test, chi-square and Pearson's tests as applicable. RESULTS: A total of 109,474 consecutive minutes of recorded multimodality monitoring was available for analysis. There was a significant difference in the number of minutes of brain flow abnormalities between survivors and non-survivors: 0.8% (875) versus 7.49% (8,199), respectively (p < 0.05). The duration of Type 1-3 flow abnormality per patient was higher in non-survivors (5.7 ± 2.5 h) compared to survivors (0.7 ± 0.6 h) as well as the duration of metabolic crisis, namely, 5.2 ± 2.2 versus 0.6 ± 1.0 h per patient. The occurrence of severe metabolic crisis was associated with a Type 2 flow abnormality (CPP < 60 mmHg and PbtO2 < 20 mmHg), r = 0.97, p < 0.001, but not with Type 1 and 3. CONCLUSIONS: Metabolic crisis can occur despite a MM&GDTP approach aimed at optimizing cerebral blood flow. Severe metabolic crisis is associated to failure to maintain CPP and PbtO2 above 60 and 20 mmHg, respectively. The occurrence of severe metabolic crisis portends a poor prognosis in patients with sTBI.

Incidence and effects of deep vein thrombosis on the outcome of patients with coronavirus disease 2019 infection.

BACKGROUND: Deep vein thrombosis (DVT) has been reported to occur at different rates in patients with coronavirus disease 2019 (COVID-19). Limited data exist regarding comparisons with non-COVID-19 patients with similar characteristics. Our objective was to compare the rates of DVT in patients with and without COVID-19 and to determine the effect of DVT on the outcomes. METHODS: We performed a retrospective, observational cohort study at a single-institution, level 1 trauma center comparing patients with and without COVID-19. The 573 non-COVID-19 patients (age, 61 ± 17 years; 44.9% male) had been treated from March 20, 2019 to June 30, 2019, and the 213 COVID-19 patients (age, 61 ± 16 years; 61.0% male) had been treated during the same interval in 2020. Standard prophylactic anticoagulation therapy consisted of 5000 U of heparin three times daily for the medical patients without COVID-19 who were not in the intensive care unit (ICU). The ICU, surgical, and trauma patients without COVID-19 had received 40 mg of enoxaparin daily (not adjusted to weight). The patients with COVID-19 had also received enoxaparin 40 mg daily (also not adjusted to weight), regardless of whether treated in the ICU. The two primary outcomes were the rate of deep vein thrombosis (DVT) in the COVID-19 group vs that in the historic control and the effect of DVT on mortality. The subgroup analyses included patients with adult respiratory distress syndrome (ARDS), pulmonary embolism (PE), and intensive care unit patients (ICU). RESULTS: The rate of DVT and PE for the non-COVID-19 patients was 12.4% (71 of 573) and 3.3% (19 of 573) compared with 33.8% (72 of 213) and 7.0% (15 of 213) for the COVID-19 patients, respectively. Unprovoked PE had developed in 10 of 15 COVID-19 patients (66.7%) compared with 8 of 497 non-COVID-19 patients (1.6%). The 60 COVID-19 patients with ARDS had had an incidence of DVT of 46.7% (n = 28). In contrast, the incidence of DVT for the 153 non-COVID-19 patients with ARDS was 28.8% (n = 44; P = .01). The COVID-19 patients requiring the ICU had had an increased rate of DVT (39 of 90; 43.3%) compared with the non-COVID-19 patients (33 of 123; 33.3%; P = .01). The risk factors for mortality included age, DVT, multiple organ failure syndrome, and prolonged ventilatory support with the following odd ratios: 1.030 (95% confidence interval [CI], 1.002-1.058), 2.847 (95% CI, 1.356-5.5979), 4.438 (95% CI, 1.973-9.985), and 5.321 (95% CI, 1.973-14.082), respectively. CONCLUSIONS: The incidence of DVT for COVID-19 patients receiving standard-dose prophylactic anticoagulation that was not weight adjusted was high, especially for ICU patients. DVT is one of the factors contributing to increased mortality. These results suggest a reevaluation is necessary of the present standard-dose thromboprophylaxis for patients with COVID-19.

Predictive Factors for Surgical Site Infections in Patients Undergoing Surgery for Breast Carcinoma.

INTRODUCTION: Operative interventions for breast cancer are generally classified as clean surgeries. Surgical site infections (SSIs), while rare, do occur. This study sought to identify risk factors for SSI, using the National Surgical Quality Improvement Program (NSQIP). METHODS: NSQIP's participant use data files (PUF) between 2012 and 2015 were examined. Female patients with invasive breast cancer who underwent surgery were identified through CPT and ICD9 codes. Non-SSI and SSI groups were compared and the statistical differences were addressed through propensity score weighting. Multivariate logistic regression testing was used to identify predictors of SSI. RESULTS: This study examined 30 544 lumpectomies and 23 494 mastectomies. SSI rate was 1126/54 038 patients (2.1%). In the weighted dataset, mastectomy, diabetes, smoking, COPD, ASA class-severe, BMI >35 kg/m2, and length of stay (LOS) >1 day were associated with an increased odds ratio (OR) of SSI. The OR for SSI was highest after mastectomy with reconstruction (OR 2.626, P < .001; 95% CI 2.073-3.325). Postoperative variables associated with an increased OR of SSIs included systemic infection, unplanned reoperation wound dehiscence, and renal failure. CONCLUSION: Mastectomy, diabetes, smoking, COPD, ASA class-severe, BMI >35 kg/m2, length of stay (LOS) >1 day are associated with an increased OR for SSIs following breast surgery.

Factors associated with severity of accidental hypothermia: A cohort retrospective multi-institutional study.

BACKGROUND: Frequently it is difficult to determine illness severity in hypothermic patients. Our goal was to determine if there are factors associated with illness severity of hypothermic emergency department (ED) patients. METHODS: Multi-hospital retrospective cohort. Consecutive patients in 24 EDs (1-1-2012 to 4-30-2015). Hypothermic patients (≤35 °C) were identified using ICD codes. We used hospital admission as marker of illness severity. Student's t-test was used for differences between mean age and temperature for admitted and discharged patients. We calculated the percent of patients admitted by factor, the difference from overall admission rate and 95% confidence interval (CI) of difference. RESULTS: There were 2094 visits with hypothermia ICD code. Of these, 132 patients had initial rectal temperatures ≤35 °C. Females comprised 42%; the mean age was 55 ± 23 years, and overall admission rate was 62%. The percent of patients with alcohol, trauma and found indoors were 39%, 27% and 27%, respectively. For admitted and discharged patients the mean ages were 60 and 48 years, respectively (p = 0.01), and initial mean temperature 32.3 °C vs. 33 °C, respectively (p = 0.07). Found indoors was associated with an 86% admission rate, a 22% increase (95% CI, 3%-34%) compared to overall admission rate. There was no statistically significant difference in admission rates from overall admission rate based on gender, alcohol or trauma. CONCLUSIONS: For hypothermic ED patients increased severity of illness was associated with older age and found indoors but not associated with initial temperature, gender, alcohol or trauma. These findings may assist physicians in treatment and disposition decisions.

Pancreatic trauma: Management and literature review. / Traumatismos de páncreas: manejo y revisión de la literatura.

Pancreatic injury is an uncommon event often difficult to diagnose at an early stage. After abdominal trauma, the surgeon must always be aware of the possibility of pancreatic trauma due to the complications associated with missed pancreatic injuries. Due to its retroperitoneal position, asociated organs and vascular injuries are almost always present, which along with frequent extra abdominal injuries explain the high morbidity and mortality. The aim of this study is to present a concise description of the incidence of these injuries, lesional mechanisms, recommended diagnostic methods, therapeutic indications including nonoperative management, endoscopy and surgery, and an analysis of pancreas-specific complications and mortality rates in these patients based on a 60-year review of the literature, encompassing 6,364 patients. Due to pancreatic retroperitoneal position, asociated organs and vascular injuries are almost always present, which along with frequent extraaabdominal injuries explain the high morbidity and mortality of these patients.

Pericardiocentesis followed by thoracotomy and repair of penetrating cardiac injury caused by nail gun injury to the heart.

INTRODUCTION: Work site injuries involving high projectile tools such as nail guns can lead to catastrophic injuries. Generally, penetrating cardiac injuries are associated with a high mortality rate. PRESENTATION OF CASE: A construction worker was brought to the emergency room having sustained a nail gun injury to the chest. The patient was hypotensive, tachycardic with prominent jugular venous distention, and had a profound lactic acidosis. Bedside ultrasound confirmed the presence of pericardial fluid. Pericardiocentesis was performed twice using a central venous catheter inserted into the pericardial space, resulting in improvement in the patient's hemodynamics. Thereafter he underwent left anterolateral thoracotomy and repair of a right atrial laceration. He recovered uneventfully. DISCUSSION: Penetrating cardiac injuries caused by nail guns, although rare, have been previously described. However, pericardiocentesis, while retaining a role in the management of medical causes of cardiac tamponade, has been reported only sporadically in the setting of trauma. We report a rare case of penetrating nail gun injury to the heart where pericardiocentesis was used as a temporizing measure to stabilize the patient in preparation for definitive but timely operative intervention. CONCLUSION: We propose awareness that percardiocentesis can serve as a temporary life saving measure in the setting of trauma, particularly as a bridge to definitive therapy. To our knowledge, this represents the first reported case of catheter pericardiocentesis used to stabilize a patient until definitive repair of a penetrating cardiac injury caused by a nail gun.

Treatment of complex perineal trauma. A review of the literature. / Tratamiento del trauma perineal complejo. Revisión de la literatura.

Perineal injuries are uncommon, but not rare. They may present a wide variety of injury patterns which demand an accurate diagnostic assessment and treatment. Perineal injuries may occur as isolated injuries to the soft tissues or may be associated with pelvic organ, abdominal or even lower extremity injury. Hence the importance to know in depth not only the anatomy of the perineum and its organs, but also the implications of the patient's hemodynamic stability on the decision making process when treating these injuries using established trauma guidelines. The purpose of this review is to describe the current epidemiology and clinical presentation of perineal injuries in order to provide specific guidelines for the diagnosis and treatment of both stable and unstable patients.

The impact of early flow and brain oxygen crisis on the outcome of patients with severe traumatic brain injury.

BACKGROUND: Multimodality monitoring and goal-directed therapy may not prevent blood flow and brain oxygen (Flow/BrOx) crisis. We sought to determine the impact of these events on outcome in patients with severe traumatic brain injury (sTBI). METHODS: Twenty-four patients with sTBI were treated to maintain intracranial pressure (ICP) less than or equal to 20 mm Hg, cerebral perfusion pressure (CPP) greater than or equal to 60 mm Hg, brain oxygen greater than or equal to 20 mm Hg, and near infrared spectroscopy greater than or equal to 60%. Flow/BrOx crisis events were recorded. The 14-day predicted mortality was compared with actual mortality. RESULTS: Nonsurvivors had a significantly higher number of crisis events nonresponsive to treatment (P < .05). Mortality was 87.5% in patients with greater than or equal to 20 events versus 6.3% in patients with less than 20 events. The predicted mortality was 58%, whereas actual mortality was 33.3% (8/24), yielding a 42% reduction in mortality. CONCLUSIONS: A multimodality monitoring and goal-directed therapy may decrease mortality in sTBI. However, Flow/BrOx crisis events still occur and predict a poor outcome.

The effect of body mass index on the outcome of critically ill surgical patients.

BACKGROUND: The incidence of obesity is rising, and an increasing number of obese patients are admitted to surgical intensive care units (SICUs). However, it is not clear whether obesity is an independent risk factor for increased morbidity and mortality in SICU patients. We examined the effect of obesity on morbidity and mortality in patients admitted to the SICU in this study. METHOD: We reviewed prospectively acquired SICU data in normal and obese patients with an SICU length of stay >24 hours. Comparability of the groups was assessed using a χ(2) test or Fisher exact test, as appropriate, for categorical variables and analysis of variance (ANOVA) or the Kruskal-Wallis test, as appropriate, for continuous variables. RESULTS: Of the 1792 consecutive patients evaluated, 711 had a normal body mass index (BMI), and 993 were either preobese or obese. There was no statistically significant difference across the 5 BMI groups with respect to any of the 3 comorbidity indices (Acute Physiology and Chronic Health Evaluation III [APACHE III], Simplified Acute Physiology Score, or Multiple Organ Dysfunction Score). There was no statistically significant difference in the intensive care unit (ICU) length of stay and hospital length of stay or time-to-ICU mortality (log-rank test P = .054) among the 5 BMI groups. A Cox regression analysis and backward elimination algorithm selected APACHE III to be the most important explanatory variable for survival time. CONCLUSION: Obesity does not affect the mortality of patients admitted to the SICU. We conclude that obesity cannot be used as an independent predictive mortality outcome variable in patients admitted to the SICU.

Subcutaneous heparin does not increase postoperative complications in neurosurgical patients: An institutional experience.

INTRODUCTION: Prophylaxis for venous thromboembolic disease continues to pose a challenging management problem in postoperative neurosurgical patients, particularly those in the intensive care unit (ICU). This study evaluates neurosurgical patients admitted to the surgical ICU (SICU) at a tertiary hospital and compared those who had received subcutaneous unfractionated heparin (SQUFH) to those who did not. This study was conducted to better evaluate if the administration of SQUFH to neurosurgical patients is safe and whether the administration of SQUFH is an independent risk factor for bleeding in this patient population. METHODS: Retrospective analysis was performed on prospectively collected data on all postoperative neurosurgical patients admitted over the course of 11 years to the SICU at Long Island Jewish Medical Center. This study included neurosurgical patients who received SQUFH and those who did not. Data acquired included demographic information, hemodynamic monitoring, pharmacologic interventions, laboratory results, and survival outcomes as well as occurrences of heparin-induced thrombocytopenia and pulmonary embolism. Subcutaneous unfractionated heparin for venous thromboembolic prophylaxis were dosed according to previously established literature based hospital protocols. Data were analyzed by χ(2), Fisher exact test, Mann-Whitney U test, or the product limit method, where appropriate. RESULTS: Five hundred twenty-two neurosurgical patients were included in the study. Two hundred thirteen patients (40.8%) with mean age of 58 years received SQUFH (133 patients received SQUFH within 24 hours of surgery and 80 patients received SQUFH 24 hours postoperatively). Once SQUFH was initiated, it was continued until discharge from the hospital. Three hundred nine patients (59.2%) with mean age 57.8 years received no anticoagulation. In the SQUFH patient population, 72 patients (33.8%) had a diagnosis of subarachnoid hemorrhage compared with 125 patients (40.5%) from the group who had not received anticoagulation. There was no significant difference in ICU length of stay between the groups, 5.8 ± 5.4 (no deep vein thrombosis prophylaxis), and those receiving SQUFH, 6.7 ± 6.1 (over 24 hours) and 5.9 ± 4.8 (over 24 hours). No postoperative hemorrhages were observed (confirmed by computed tomography of the brain) in any of the neurosurgical patients with subarachnoid hemorrhage, intracerebral hemorrhage, or subdural or epidural hemorrhage. No instances of heparin-induced thrombocytopenia (HIT) or pulmonary embolism (PE) were observed. CONCLUSIONS: Administration of SQUFH dosed according to the risk for thromboembolism does not appear to contribute to postoperative hemorrhage in neurosurgical patients. This study supports the concept that the administration of SQUFH is safe in postoperative neurosurgical population.

Human ghrelin ameliorates organ injury and improves survival after radiation injury combined with severe sepsis.

In the terrorist radiation exposure scenario, radiation victims are likely to suffer from additional injuries such as sepsis. Our previous studies have shown that ghrelin is protective in sepsis. However, it remains unknown whether ghrelin ameliorates sepsis-induced organ injury and mortality after radiation exposure. The purpose of this study is to determine whether human ghrelin attenuates organ injury and improves survival in a rat model of radiation combined injury (RCI) and, if so, the potential mechanism responsible for the benefit. To study this, adult male rats were exposed to 5-Gy whole body irradiation followed by cecal ligation and puncture (CLP, a model of sepsis) 48 h thereafter. Human ghrelin (30 nmol/rat) or vehicle (saline) was infused intravenously via an osmotic minipump immediately after radiation exposure. Blood and tissue samples were collected at 20 h after RCI (68 h after irradiation or 20 h after CLP) for various measurements. To determine the longterm effect of human ghrelin after RCI, the gangrenous cecum was removed at 5 h after CLP and 10-d survival was recorded. In addition, vagotomy or sham vagotomy was performed in sham and RCI animals immediately prior to ghrelin administration, and various measurements were performed at 20 h after RCI. Our results showed that serum levels of ghrelin and its gene expression in the stomach were decreased markedly at 20 h after RCI. Administration of human ghrelin attenuated tissue injury markedly, reduced proinflammatory cytokine levels, decreased tissue myeloperoxidase activity, and improved survival after RCI. Furthermore, elevated plasma levels of norepinephrine (NE) after RCI were reduced significantly by ghrelin. However, vagotomy prevented ghrelin's beneficial effects after RCI. In conclusion, human ghrelin is beneficial in a rat model of RCI. The protective effect of human ghrelin appears to be attributed to re-balancing the dysregulated sympathetic/parasympathetic nervous systems.