Massive transfusions and severe hypocalcemia: An opportunity for monitoring and supplementation guidelines.

BACKGROUND: Massive transfusion protocols (MTPs) are associated with severe hypocalcemia, contributing to coagulopathy and mortality in severely injured patients. Severity of hypocalcemia following massive transfusion activation and appropriate treatment strategies remain undefined. STUDY DESIGN AND METHODS: This was a retrospective study of all MTP activations in adult trauma patients at a Level 1 trauma center between August 2016 and September 2017. Units of blood products transfused, ionized calcium levels, and amount of calcium supplementation administered were recorded. Primary outcomes were ionized calcium levels and the incidence of severe ionized hypocalcemia (iCa ≤1.0 mmol/L) in relation to the volume of blood products transfused. RESULTS: Seventy-one patients had an MTP activated during the study period. The median amount of packed red blood cells (PRBCs) transfused was 10 units (range 1-52). A total of 42 (59.1%) patients had periods of severe hypocalcemia. Patients receiving 13 or more units of PRBC had a greater prevalence of hypocalcemia with 83.3% having at least one measured ionized calcium ≤1.0 mmoL/L (p = .001). The number of ionized calcium levels checked and the amount of supplemental calcium given in patients who experienced hypocalcemia varied considerably. DISCUSSION: Severe hypocalcemia commonly occurs during MTP activations and correlates with the number of packed red blood cells transfused. Monitoring of ionized calcium and amount of calcium supplementation administered is widely variable. Standardized protocols for recognition and management of severe hypocalcemia during massive transfusions may improve outcomes.

Aggressive treatment of acute kidney injury and hyperkalemia improves survival in a combat relevant trauma model in swine.

INTRODUCTION: Our swine model of pulmonary contusion (PC) and hemorrhagic shock (HS) was initially complicated by renal failure, hyperkalemia, and premature death. To study the effects of novel therapies on organ failure, improved survival was necessary requiring the design of an aggressive treatment regimen. METHODS: Anesthetized swine sustained either PC or PC with grade V liver injury to induce HS (PC + HS). After injury, animals were resuscitated followed by either standard care (SC) with maintenance intravenous fluids (IVF) and treatment at potassium level of 6.0 mmol/L (n = 7; 3 PC, 4 PC + HS) or aggressive care (AC) with increased initial IVF, early and frequent potassium monitoring, and treatment at potassium level of 5.0 mmol/L (n = 15, 8 PC, 7 PC + HS). Hyperkalemia was treated with calcium, insulin, and glucose in both groups. RESULTS: Survival to 48 h was achieved in 13/15 (87%) in the AC group and 2/7 (29%) in the SC group (p = 0.014). Compared to SC, AC improved median survival (48 vs. 18 h, p = 0.008) and lowered potassium (5.0 vs. 7.5 mmol/L), creatinine (2.4 vs. 4.0 mg/dL), BUN (27.5 vs. 39.0 mg/dL), and lactate (0.97 vs. 3.57 mmol/L) at the last observed time-point prior to death. For PC + HS animals, survival to 48 h was achieved in 6/7 in the AC group and 0/4 in the SC group with an improved median survival in the AC group (48 vs. 18 h, p = 0.011) DISCUSSION: Aggressive and early hyperkalemia treatment prolongs survival while reducing kidney injury and potassium levels in a combat relevant injury model in swine.

Conscious sedation versus rapid sequence intubation for the reduction of native traumatic hip dislocation.

BACKGROUND: Traumatic hip dislocations (THD) are a medical emergency. There is debate whether the painful reduction of a dislocated hip should be first attempted using primary conscious sedation (PCS) or primary general anesthesia (PGA) METHODS: All cases of native THD from 2006 to 2015 in the trauma registry of a level 1 trauma center were reviewed. The primary outcome was successful reduction of the THD. RESULTS: 67 patients had a native, meaning not a hip prosthesis, THD. 34 (50.7%) patients had successful PCS, 12 (17.9%) failed PCS and underwent reduction following PGA. 21 (31.3%) underwent PGA. Patients in the PGA group were more severely injured. Time to reduction greater than 6 h was associated with PCS failure (Odds ratio (95% confidence interval) 19.75 (2.06,189.10) p = 0.01). CONCLUSION: Clinicians treating patients with a THD can utilize either PCS or PGA with many patients safely reduced under PCS. However, patients whose hip have been dislocated for more than 6 h are at risk for failure with PCS, and are good candidates for PGA.

Institutional review of the implementation and use of a Clostridium difficile infection bundle and probiotics in adult trauma patients.

BACKGROUND: Clostridium difficile infection (CDI) is a common cause of healthcare associated infections contributing to morbidity and mortality. Our objective was to evaluate the impact of the implementation of a CDI bundle along with probiotic utilization. METHODS: A retrospective review of trauma admissions from 2008 to 2014 was performed. The CDI bundle was implemented in stages from 2009 through 2014 with probiotics initiated in 2010. The bundle included changes in cleaning practices, education, screening, and contact precautions. RESULTS: 4632 (49%) patients received antibiotics with 21% receiving probiotics. Probiotic use was associated with increased age, male sex, more severely injured, and antibiotic use. CDI incidence decreased from 11.2 to 4.8 per 1000 admissions, p = .03. Among patients who received antibiotics CDI incidence decreased from 2.2% to 0.7%, p = .01. CONCLUSIONS: We report the largest series of a CDI bundle implementation including probiotics. During the period of adoption of these interventions, the incidence of CDI decreased significantly.