Probative Value of the D-Dimer Assay for Diagnosis of Deep Venous Thrombosis in the Coronavirus Disease 2019 Syndrome.

OBJECTIVES: To describe the predictive utility of the D-dimer assay among patients with the coronavirus disease 2019 syndrome for unprovoked lower extremity deep venous thrombosis. DESIGN: Prospective observational study with retrospective data analysis. SETTING: Academic medical center surgical ICU. PATIENTS: Seventy-two intubated patients with critical illness from coronavirus disease 2019. INTERVENTIONS: Therapeutic anticoagulation after imaging diagnosis of the first three deep venous thrombosis cases was confirmed; therapeutic anticoagulation as prophylaxis thereafter to all subsequent ICU admissions. MEASUREMENTS AND MAIN RESULTS: Seventy-two patients with severe coronavirus disease 2019 were screened for deep venous thrombosis after ICU admission with 102 duplex ultrasound examinations, with 12 cases (16.7%) of lower extremity deep venous thrombosis identified. There were no differences between groups with respect to age, renal function, or biomarkers except for D-dimer (median, 12,858 ng/mL [interquartile range, 3,176-30,770 ng/mL] for lower extremity deep venous thrombosis vs 2,087 ng/mL [interquartile range, 638-3,735 ng/mL] for no evidence of deep venous thrombosis; p < 0.0001). Clinical screening tools (Wells score and Dutch Primary Care Rule) had no utility. The C-statistic for D-dimer concentration was 0.874 ± 0.065. At the model-predicted cutoff value of 3,000 ng/mL, sensitivity was 100%, specificity was 51.1%, positive predictive value was 21.8%, and negative predictive value was 100%. CONCLUSIONS: Lower extremity deep venous thrombosis is prevalent in coronavirus disease 2019 disease and can be present on ICU admission. Screening has been recommended in the context of the pro-inflammatory, hypercoagulable background milieu. D-dimer concentrations are elevated in nearly all coronavirus disease 2019 patients, and the test appears reliable for screening for lower extremity deep venous thrombosis at or above a concentration of 3,000 ng/mL (more than 13-fold above the normal range). Full anticoagulation is indicated if the diagnosis is confirmed, and therapeutic anticoagulation should be considered for prophylaxis, as all coronavirus disease 2019 patients are at increased risk.

Successful Cholecystectomy After Endoscopic Ultrasound Gallbladder Drainage Compared With Percutaneous Cholecystostomy, Can it Be Done?

BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage (EGBD) with a lumen apposing metal stent is becoming a widely accepted alternative to percutaneous gallbladder drainage (PTGD) for patients who are not candidates for cholecystectomy (CCY). In some patients, medical comorbidites can improve, allowing them to undergo CCY. We compare feasibility and outcomes of interval CCY after EGBD versus PTGD. METHODS: We conducted a multicentered international cohort study of patients who underwent EGBD or PTGD and then underwent interval CCY. Baseline patient demographics, procedural details, and follow-up data were recorded and compared. RESULTS: In total, 34 patients were included. Thirteen patients underwent EGBD followed by CCY (mean age, 53.77±17.27, 46.15% male), and 21 patients underwent PTGD followed by CCY (mean age, 62.14±13.06, 61.9% male). There was no statistically significant difference in mean Charlson Comorbidity Index (P=0.12) or etiology of cholecystitis (P=0.85) between the 2 groups. All patients had a technically successful CCY. There was no difference between rates of open versus laparoscopic CCY (P=1). In addition, there was no difference in postsurgical adverse events (P=0.23). CONCLUSIONS: Surgical CCY after EGBD with lumen apposing metal stent is safe and feasible for the management of cholecystitis. If patient's underlying medical conditions improve, previous EUS-GLB drainage should not preclude patients from undergoing CCY as part of standard of care.

Transcutaneous Endoscopic Necrosectomy for Walled-off Pancreatic Necrosis in the Paracolic Gutter.

BACKGROUND: Walled-off pancreatic necrosis (WON) is a sequelae of acute pancreatitis that requires debridement, once infected. Recently, endoscopic necrosectomy has become the mainstay for management. However, peripancreatic collections that extend to the paracolic gutter or lesser sac, are more challenging to treat endoscopically. We report an endoscopic method for management of necrotic collections that extend into the paracolic gutter. METHODS: Consecutive patients, with symptomatic WON extending into the retroperitoneum, were included in a prospective registry. Each patient underwent transcutaneous endoscopic necrosectomy (TEN) through a fully covered self-expanding esophageal metal stent. After resolution of the collection, the external stent was removed, and the cutaneous fistula was allowed to close by secondary intention. Clinical success was defined as resolution of the WON, and successful removal of all percutaneous drains. Patient demographics, procedural/periprocedural adverse events, and follow-up data, were collected. RESULTS: Nine patients underwent direct TEN. Patients initially underwent CT-guided percutaneous drainage, with an average of 31 days between initial drainage and endoscopic necrosectomy. All patients had a technically successful placement of a fully covered esophageal metal stent through the cutaneous fistula. After a median of 3 endoscopic debridement sessions, 8 of 9 (89%) patients had successful removal of all percutaneous drains, and resolution of necrotic collections. One patient died of multisystem organ failure from severe acute pancreatitis. CONCLUSIONS: TEN for infected WON is a safe and efficacious technique for patients with endoscopically inaccessible collections.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Randomized, double-blind, placebo-controlled trial of effects of enteral iron supplementation on anemia and risk of infection during surgical critical illness.

BACKGROUND: Critical illness is characterized by hypoferremia, iron-deficient erythropoiesis (IDE), and anemia. The relative risks and benefits of iron supplementation in this setting are unknown. METHODS: Anemic, critically ill surgical patients with an expected intensive care unit length of stay (ULOS) >or= 5 days were randomized to either enteral iron supplementation (ferrous sulfate 325 mg three times daily) or placebo until hospital discharge. Outcomes included hematocrit, iron markers (i.e., serum concentrations of iron, ferritin, and erythrocyte zinc protoporphyrin [eZPP]), red blood cell (RBC) transfusion, transfusion rate (mL RBC/study day), nosocomial infection, antibiotic days, study length of stay (LOS), ULOS, and death. Iron-deficient erythropoiesis was defined as an elevated eZPP concentration. RESULTS: Two hundred patients were randomized; 97 received iron, and 103 received placebo. Socio-demographics, baseline acuity, hematocrit, and iron markers were similar in the two groups. No differences were observed between the iron and placebo groups with respect to either hematocrit or iron markers following up to 28 days. However, patients treated with iron were significantly less likely to receive an RBC transfusion (29.9% vs. 44.7%, respectively; p = 0.03) and had a significantly lower transfusion rate (22.0 mL/day vs. 29.9 mL/day; p = 0.03). Subgroup analysis revealed that these differences were observed in patients with baseline IDE only. Iron and placebo groups did not differ with respect to incidence of infection (46.8% vs. 48.9%; p = 0.98), antibiotic days (14 vs. 16; p = 0.45), LOS (14 vs. 16 days; p = 0.24), ULOS (12 vs. 14 days; p = 0.69), or mortality rate (9.4% vs. 9.9%; p = 0.62). CONCLUSIONS: Enteral iron supplementation of anemic, critically ill surgical patients does not increase the risk of infection and may benefit those with baseline IDE by decreasing the risk of RBC transfusion. A trial comparing enteral and parenteral iron supplementation in this setting is warranted (ClinicalTrials.gov number, NCT00450177).

Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients?

BACKGROUND: Ventilator-associated pneumonia (VAP) is a leading cause of mortality in critically ill patients. Although previous studies have shown that de-escalation therapy (DT) of antibiotics may decrease costs and the development of resistant pathogens, minimal data have shown its effect in surgical patients or in any patients with septic shock. We hypothesized that DT for VAP was not associated with an increased rate of recurrent pneumonia (RP) or mortality in a high acuity cohort of critically ill surgical patients. METHODS: All surgical intensive care unit (SICU) patients from January 2005 to May 2007 with VAP diagnosed by quantitative bronchoalveolar lavage with a positive threshold of 10,000 CFU/mL were identified. Data collected included age, gender, Acute Physiologic and Chronic Health Evaluation Score III (A3), type of bacterial or other pathogen, antibiotics used for initial and final therapy, mortality, RP, and appropriateness of initial therapy (AIT). Patients were designated as receiving AIT, DT, or escalation of antibiotic therapy based on microbiology for their VAP. RESULTS: One hundred thirty-eight of 1,596 SICU patients developed VAP during the study period (8.7%). For VAP patients, the mean Acute Physiologic and Chronic Health Evaluation III score was 82.7 points with a mean age of 63.8 years. The RP rate was 30% and did not differ between patients receiving DT (27.3%) and those who did not receive DT (35.1%). Overall mortality was 37% (55% predicted by A3 norms) and did not differ between those receiving DT (33.8%) or not (42.1%). The most common pathogens for primary VAP were methicillin-resistant Staphylococcus aureus (14%), Escherichia coli (11%), and Pseudomonas aeruginosa (9%) whereas P. aeruginosa was the most common pathogen in RP. The AIT for all VAP was 93%. De-escalation of therapy occurred in 55% of patients with AIT whereas 8% of VAP patients required escalation of antibiotic therapy. The most commonly used initial antibiotic choice was vancomycin/piperacillin-tazobactam (16%) and the final choice was piperacillin-tazobactam (20%). Logistic regression demonstrated no specific parameter correlated with development of RP. Higher A3 (Odds ratio, 1.03; 95% confidence interval, 1.01-1.05) was associated with mortality whereas lack of RP (odds ratio, 0.31; 95% confidence interval, 0.12-0.80), and AIT reduced mortality (odds ratio, 0.024; 95% confidence interval, 0.007-0.221). Age, gender, individual pathogen, individual antibiotic regimen, and the use of DT had no effect on mortality. CONCLUSION: De-escalation therapy did not lead to RP or increased mortality in critically ill surgical patients with VAP. De-escalation therapy was also shown to be safe in patients with septic shock. Because of its acknowledged benefits and lack of demonstrable risks, de-escalation therapy should be used whenever possible in critically ill patients with VAP.

Ileocecal valve lipoma with refractory hemorrhage.

BACKGROUND: Lipomas are the most common benign mesenchymal tumors of the gastrointestinal tract, with the colon being the most prevalent site. Intestinal lipomas are usually asymptomatic. Tumors >2 cm in diameter may occasionally cause nonspecific symptoms, including change in bowel habits, abdominal pain, or rectal bleeding, but with resection the prognosis is excellent. Herein, we describe the case of an elderly male who presented with painless hematochezia. METHODS: Both colonoscopy and computed tomography of the abdomen and pelvis confirmed the presence of a mass near the ileocecal valve. Because of continuing bleeding, the patient required laparoscopic-assisted right hemicolectomy to resect the mass. RESULTS: Both gross and microscopic pathology were consistent with lipoma at the ileocecal valve. CONCLUSION: Previous cases of ileocecal valve lipomas have been reported in the English literature, with the majority presenting as intussusception or volvulus. We present a rare case of an ulcerated ileocecal valve lipoma presenting as lower gastrointestinal bleeding that was treated successfully with laparoscopic resection.

The relationship between body mass index and postoperative mortality from critical illness.

BACKGROUND: Conflicting data exist regarding the effect of body mass index (BMI) on postoperative mortality from critical illness. Few studies have examined this issue in surgical patients specifically. We tested the hypothesis that BMI is associated with mortality from surgical critical illness. METHODS: Consecutive admissions to a university surgical intensive care unit (SICU) were analyzed from January 2005-August 2006. Admission BMI was analyzed as both a five-level categorical (underweight, <18.5 kg/m2; normal weight, 18.5-24.9 kg/m2; overweight, 25.0-29.9 kg/m2; obese, 30.0-39.9 kg/m2; morbidly obese, > or =40 kg/m2) and dichotomous (> or =40 kg/m2 vs. <40 kg/m2) variable among all patients as well as a subgroup of patients with a SICU length of stay (ULOS) > or =4 days. Multivariable logistic regression models were fit to determine the independent effect of BMI group on SICU mortality. RESULTS: The total sample size was 946, with 490 patients admitted to the SICU for > or =4 days (51.8%). Of the variables tested, age, acute physiology and chronic health evaluation III score, gender, diabetes mellitus, and need for insulin infusion varied significantly among the five BMI groups. After adjustment for these variables, BMI was not predictive of mortality when analyzed as either a five-level categorical or dichotomous variable, regardless of ULOS. CONCLUSION: BMI is not related to mortality of surgical critical illness. Several factors, including modern ICU care, may mitigate the risks of obesity in the SICU.

Treatment of severe sepsis secondary to mycobacterium avium-intracellulare with recombinant human activated protein C.

BACKGROUND: Mycobacterium avium-intracellulare (MAI) is a well-described pathogen in patients with acquired immune deficiency syndrome (AIDS). However, peritonitis and severe sepsis as a complication of disseminated MAI is rare. We report a case that represents the first successful use of recombinant human activated protein C (rhAPC) in the treatment of severe sepsis secondary to mycobacterial infection and only the second reported case of MAI peritonitis with no known predisposing factor other than AIDS. METHODS: Case report and review of the pertinent literature. RESULTS: A 36-year-old man with AIDS presented to the emergency department with acute-onset right-sided abdominal pain, fever, and chills. Abdominal computed tomography revealed multiple rim-enhancing fluid collections. Despite immediate surgical drainage and debridement and appropriate antimicrobial therapy targeting the non-tuberculous acid-fast bacilli found in intraperitoneal fluid, the patient developed severe sepsis and septic shock. Clinical improvement occurred after infusion of recombinant human activated protein C (rhAPC) and specific antimicrobial chemotherapy directed against MAI. CONCLUSIONS: Treatment with rhAPC decreases the mortality rate of bacterial sepsis of abdominal origin and may confer a similar benefit in the treatment of abdominal mycobacterial sepsis.

Decreasing magnitude of multiple organ dysfunction syndrome despite increasingly severe critical surgical illness: a 17-year longitudinal study.

BACKGROUND: Multiple organ dysfunction syndrome (MODS) remains prevalent and the leading cause of mortality in the surgical intensive care unit (ICU). Improvements in ICU care in the last 10 years (e.g., tight glycemic control, activated protein C, fewer transfusions causing fewer nosocomial infections) may have decreased the incidence, magnitude, and mortality of MODS, as hypothesized in this study. METHODS: Longitudinal 17-year prospective study of 11,314 ICU patients (academic/tertiary unit, Level I trauma center), 5,157 (45.5%) of whom developed any degree of MODS (Marshall score, cumulative). Data collected included Admission Acute Physiology and Chronic Health Evaluation (APACHE)-II and APACHE-III scores, MOD score (MODsc), hospital mortality, and the incidence and magnitude of MODS. The ratio of MODsc: APACHE III was calculated. Analyses (X +/- SEM, chi2, repeated-measures ANOVA, linear and polynomial regression, c-statistic) were performed for calendar-year intervals beginning in 1990 through 2006. RESULTS: Among MODS patients, the mean MODsc was 6.3 +/- 0.1 points, and the mortality rate was 22%. The APACHE III score increased significantly (p < 0.0001) over time, but the mortality rate was unchanged (r2 = 0.02). Adjusted for illness severity (MODsc:A3), the magnitude of MODS decreased significantly (p < 0.0001) during the time period. CONCLUSIONS: Despite significant increases in admission APACHE III score over 17 years, the adjusted magnitude of MODS (MODsc:A3) decreased. Given the strong association between MODS and mortality for critically ill surgical patients, it is likely that the unchanged risk-adjusted mortality observed over time is due to the reduced magnitude of MODS.

Insurance status, but not race, predicts perforation in adult patients with acute appendicitis.

BACKGROUND: Delay in treatment is a strong risk factor for perforation during acute appendicitis. In addition, lower socioeconomic status has been linked to impaired access to surgical care. We sought to examine the relationships among race, insurance status, and perforation in a recent, adult population with acute appendicitis. STUDY DESIGN: Data on adult patients with acute appendicitis were abstracted from the New York State Statewide Planning and Cooperative Systems Database for the years 2003 and 2004. A multiple logistic regression model, which adjusted for patient, community, and hospital factors, was used to examine the independent effects of both race and insurance status on likelihood of perforation. RESULTS: A total of 29,637 patients had acute appendicitis; 7,969 (26.9%) of these were perforated. Although Caucasian patients were more likely to perforate compared with minority patients, by univariate analysis, adjustment for age alone eliminated this disparity. In addition, by multivariable analysis, no difference existed in odds of perforation for Caucasian patients compared with African-American (odds ratio [OR]=1.03, 95% CI [0.93, 1.15], p=0.52), Hispanic (OR=0.99, 95% CI [0.90, 1.08], p=0.82), or Asian patients (OR=0.85, 95% CI [0.73, 1.00], p=0.05). But compared with privately insured patients, uninsured patients (OR 1.18, 95% CI [1.07 to 1.30], p=0.0005), Medicaid patients (OR=1.22, 95% CI [1.12 to 1.33], p < 0.0001), and Medicare patients (OR=1.14, 95% CI [1.03, 1.25], p=0.01) were significantly more likely to have perforation. CONCLUSIONS: Race does not appear to be an important variable in predicting perforation in adult patients with acute appendicitis, but the likelihood of perforation varies significantly according to insurance status. Future research is necessary to both understand and have an impact on this socioeconomic disparity.

Outcomes of acute respiratory distress syndrome (ARDS) in elderly patients.

BACKGROUND: Elderly patients have become an increasingly prevalent proportion of the intensive care unit population. Outcomes of patients with acute respiratory distress syndrome (ARDS) have been improving in recent years, but studies of ARDS rarely include substantial numbers of elderly patients. Historically, the mortality rate for ARDS has been 69% to 80% among elderly patients. We reviewed our experience with ARDS to determine whether outcomes were improving over time, and in particular whether outcomes were equally favorable among our elderly patients aged 65 years or older. METHODS: Patients who developed ARDS in a university surgical intensive care unit from 1993 to 2003 were identified and their data were collected prospectively. Data collected included age, gender, cause of ARDS, Acute Physiology and Chronic Health Evaluation (APACHE) III score (AIII), initial Pao2:FIO2, lung injury score (LIS), maximum positive end-expiratory pressure, multiple organ dysfunction pulmonary and nonpulmonary organ dysfunction scores (MODnp), vasopressor dependence, and development of ventilator-associated pneumonia. Outcomes of patients >65 years old with ARDS were compared with those of patients <65 years old. RESULTS: In the study period, 343 patients developed ARDS, 210 of whom were >65 years old. Overall, age was 65.2 +/- 0.2 years, with a mean APACHE III score of 83.4 +/- 2.0 points. Sixty-six percent were men. The initial Pao2:FIO2 for the entire group was 104.3 +/- 4.1, and was less in younger patients. Maximum positive end-expiratory pressure was 15.6 +/- 0.5 cm H2O, and mean LIS was 3.3 +/- 0.6 points; these values did not differ between cohorts. Elderly patients had a mortality of 51.9% when compared with 41.7% for younger patients (p = not significant). By logistic regression analysis, factors predicting mortality included APACHE III score (each point, odds ratio [OR], 1.022; 95% confidence interval [CI], 1.008-1.035; p < 0.01) and nonpulmonary multiple organ dysfunction score (each point, OR, 1.366; 95% CI, 1.223-1.526; p < 0.0001), but neither age (p = 0.37), LIS (p = 0.49), multiple organ dysfunction pulmonary (p = 0.90), nor year of treatment (p = 0.74) had any effect on mortality. CONCLUSIONS: The mortality rate for elderly patients with ARDS is lower in our experience when compared with historical series, even though illness severity may be higher, and comparable to that of other patients. Careful hemodynamic monitoring and resuscitation combined with other strategies to ameliorate nonpulmonary organ dysfunction achieved good outcomes in high-risk patients and could contribute in the future to further improved outcomes of elderly patients with ARDS.

Acute renal failure in critically ill surgical patients: persistent lethality despite new modes of renal replacement therapy.

OBJECTIVE: Despite improved resuscitation and sepsis care, acute renal failure (ARF) remains common in critically ill surgical patients. New methods of renal replacement therapy (RRT) are being used in surgical intensive care units (SICUs), including high-flux hemodialysis (HD) and continuous RRT (CRRT). RRT is being used increasingly early in the course of ARF, but data are scant to suggest that mortality is improved. Consequently, we determined whether outcomes were improved with CRRT in SICU patients, and hypothesized that CRRT lowers mortality for patients with ARF. METHODS: Patients who developed ARF (acute increase in serum creatinine concentration >or=2.4 mg/dL) in the SICU from 1993 to 2004 were identified. Data collected prospectively included year of admission, age, gender, Acute Physiology and Chronic Health Evaluation (APACHE) III score, cumulative multiple organ dysfunction score and its individual components, cumulative nonrenal organ dysfunction score, and need for RRT. Patients were stratified January 1994 to January 2001 (pre-CRRT) and February 2001 to December 2004 (post-CRRT). The primary endpoint was mortality. RESULTS: Among 8,505 SICU patients, 530 (6.2%) developed ARF. Three hundred and eleven patients were treated pre-CRRT and 219 thereafter. Female patients comprised 35% of ARF patients. The mean age was 69 years +/- 2 years, and the mean APACHE III score was 81 +/- 1 point for ARF patients. HD was performed in 15.6% of ARF patients before 2001 and 5.5% of ARF patients in 2001 and thereafter. CRRT was performed in 20.1% of ARF patients in 2001 and thereafter. Overall mortality for ARF patients was 45% (APACHE III normative predicted mortality: 55%) with no difference over time (pre-CRRT = 46.3%, post-CRRT = 45.2%, p = 0.86). Patients who required RRT had a mean APACHE III score of 91 +/- 1 point, with 61% mortality (predicted mortality: 67%), with no difference over time. Independent predictors of mortality overall and for ARF patients included age and the magnitude of renal, cardiovascular, hepatic, and neurologic dysfunction. In comparison with CRRT, HD was associated with a decreased risk of death. CONCLUSIONS: Despite more frequent RRT and the use of CRRT, the mortality of ARF in critically ill surgical patients remains high because of nonrenal organ dysfunction. Considering that ARF-related mortality was decreased by intermittent HD, and that intermittent RRT is less costly, patients who need RRT should be treated preferentially with HD.

Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: analysis of the New York State Administrative Database.

BACKGROUND: Previous studies addressing the relationship between anticoagulation and risk of traumatic intracranial hemorrhage (ICH) have provided conflicting results, and have examined infrequently elderly patients after falls. We used a statewide hospital discharge database to test the hypothesis that long-term anticoagulation (LTA) increases the likelihood of traumatic ICH and subsequent mortality in this patient population. METHODS: Patients aged 65 years or older and hospitalized as the result of a fall were extracted from the New York State Statewide Planning and Cooperative Systems Database for the year 2004. LTA, ICH, and additional injuries including skull fracture, vertebral fracture, rib fracture, lower extremity fracture, thoracic visceral injury, and abdominal visceral injury were defined using corresponding International Classification for Disease, Ninth Edition coding. Covariates included age, gender, and comorbidity. Additional outcomes included length of stay and mortality. Multivariable logistic regression was used to identify independent predictors of traumatic ICH and subsequent mortality. RESULTS: A total of 47,717 patients met the inclusion criteria. Falls were associated with a traumatic ICH in 2,517 patients (5.1%), and the mortality rate of patients with a fall-related, traumatic ICH was 15.5% (n = 394). A total of 1,511 (3.2%) patients hospitalized after a fall used LTA. Based on univariate analysis, ICH was the only injury that occurred more commonly in patients who used LTA, when compared with those who did not (8.0% vs. 5.3%, respectively, p < 0.0001). Furthermore, although overall mortality did not differ by use of LTA, mortality after ICH was significantly higher in patients who used LTA when compared with those who did not (21.9% vs. 15.2%, respectively, p = 0.04). Controlling for age, gender, and comorbidity, patients on LTA were 50% more likely to sustain a traumatic ICH after a fall (odds ratio = 1.50; 95% confidence interval, 1.23-1.81; p < 0.0001). Furthermore, among patients who sustained an ICH, mortality was 1.57-fold greater in patients on LTA (odds ratio = 1.57; 95% confidence interval, 1.02-2.45; p = 0.04). CONCLUSIONS: These data indicate that use of LTA is independently associated with traumatic ICH and subsequent mortality in elderly patients hospitalized after a fall.

Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients.

BACKGROUND: The relationship between preinjury warfarin use and outcomes after traumatic brain injury in elderly trauma patients remains controversial. We hypothesized that, among elderly warfarin users, the degree of anticoagulation, rather than warfarin therapy itself, would predict the severity of traumatic brain injury. METHODS: Retrospective study (2004-2006) of all elderly trauma patients (age >/=65 years) who were evaluated by the trauma service at a Level I trauma center and underwent computed tomography of the head for suspicion of an intracranial injury was performed. Three cohorts were grouped: (1) warfarin users with an admission International Normalized Ratio >/=2 (therapeutic group), (2) warfarin users with an admission International Normalized Ratio <2 (nontherapeutic group), and (3) warfarin nonusers. Main outcome variables were presenting with a Glasgow Coma Scale (GCS) score

Factors influencing DNR decision-making in a surgical ICU.

BACKGROUND: End-of-life decisions in the surgical ICU can be complicated by the unique characteristics of perioperative illness and the focus on life-extending interventions. We sought to determine whether illness severity correlated with the presence of DNR order in critically ill surgical patients. STUDY DESIGN: All surgical ICU patients who were given a DNR order from May 1, 1991 to May 31, 1998 were identified. Demographic data for all patients were collected prospectively. Patients who died without a DNR order were compared with patients with DNR orders. Variables in the analysis included date of DNR order, age, ICU, and hospital lengths of stay, APACHE II and III scores and maximum multiple organ dysfunction scores, past medical history, and mortality. ANOVA, multivariate ANOVA, and chi-square statistical tests were used to analyze the data, with p

Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline.

BACKGROUND: Prolonged courses of broad-spectrum antibiotics are often cited as the standard of care for prevention of infective complications of open fractures. The origins of these recommendations are obscure, however, and multi-drug-resistant systemic infections attributable to antibiotic overuse are common life-threatening problems in current intensive care unit practice. OBJECTIVE: To review systematically the effects of prophylactic antibiotic administration on the incidence of infections complicating open fractures. DATA SOURCES: Computerized bibliographic search of published research and citation review of relevant articles. STUDY SELECTION: All published clinical trials claiming to evaluate, or cited elsewhere as being authoritative regarding, the role of antibiotics in open fracture management were identified and then evaluated according to published guidelines for evidence-based medicine. Only small studies (<20 patients), practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis. DATA EXTRACTION: Information on demographics, study dates, fracture grade, antibiotic type, duration and route of administration, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted by the authors. The primary results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document. DATA SYNTHESIS: Current antibiotic management of open fractures is based on a small number of studies that generally are more than 30 years old and do not reflect current management priorities in trauma and critical care. With a few noteworthy exceptions, these primary studies suffer from a variety of methodologic problems, including co-mingling of prospective and retrospective data sets, absence of or inappropriate statistical analysis, lack of blinding, or failure of randomization. CONCLUSIONS: The data support the conclusion that a short course of first-generation cephalosporins, begun as soon as possible after injury, significantly lowers the risk of infection when used in combination with prompt, modern orthopedic fracture wound management. There is insufficient evidence to support other common management practices, such as prolonged courses or repeated short courses of antibiotics, the use of antibiotic coverage extending to gram-negative bacilli or clostridial species, or the use of local antibiotic therapies such as beads. Large, randomized, blinded trials are needed to prove or disprove the value of these traditional approaches. Such trials should be performed in patients with high-grade fractures who (1) are well-stratified according to the degree of local injury and (2) undergo standardized fracture and wound management. Trials also must be powered to study the effects of extended antibiotic coverage on nosocomial infections. Antibiotic regimens confirmed to improve local fracture outcomes in such studies could then be used rationally, balancing the risks of local fracture-related infections and of multi-drug-resistant systemic infections to achieve optimal global outcomes.

Efficacy and safety of drotrecogin alfa (activated) for the therapy of surgical patients with severe sepsis.

BACKGROUND: The efficacy of therapy with drotrecogin alfa (activated) (DrotAA) (recombinant human activated protein C) for surgical patients with severe sepsis has been questioned, and there is concern that patients who have undergone surgery recently may be at increased risk of bleeding complications from the drug. This review was performed to analyze recent data and clinical trends in the management of surgical patients with severe sepsis with respect to the efficacy and safety of therapy with DrotAA. METHODS: Review and synthesis of the pertinent English-language literature. RESULTS: Source control is the mainstay of therapy for surgical infections, including intraabdominal infections, whereas antibiotics, fluid resuscitation, and support of visceral organ function are necessary adjuncts. Therapy with DrotAA can be given to surgical patients, albeit with some delay (most protocols specify a 12-h wait after major surgery to mitigate the perceived increased risk of bleeding), but efficacy as well as safety have been questioned. In the pivotal PROWESS clinical trial, DrotAA therapy did not appear to be efficacious for surgical sepsis, but rigorous scrutiny of surgical indications and adequacy of source control by blinded reappraisal of the PROWESS database suggested that DrotAA therapy may be effective for surgical patients at high risk of death (Acute Physiology and Chronic Health Evaluation [APACHE] II score>or=25 points). Several comparable studies have now been aggregated in the INDEPTH database, which shows a significant reduction in mortality (OR 0.66; 95% CI 0.45-0.97) for therapy with DrotAA of surgical patients with severe sepsis and a high risk of death. The risk of bleeding is higher in surgical patients compared with DrotAA-treated non-surgical patients, but there is a substantial improvement in survival with DrotAA treatment. In contrast, surgical patients at a lower risk of death do not benefit from therapy with DrotAA but are placed at risk for bleeding. CONCLUSION: Accumulating experience indicates that surgical patients with severe sepsis and a high risk of death (APACHE II>or=25 points) have a significantly lower mortality rate if treated with DrotAA. The increased risk of bleeding associated with therapy is acceptable given the clear improvement in survival. Surgical patients with sepsis who are at lower risk of death do not appear to benefit from therapy with DrotAA, which should be withheld in most circumstances because of the increased risk of bleeding.

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank.

INTRODUCTION: While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims. PATIENTS AND METHODS: We conducted a retrospective analysis of the 2008-2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable "intent of injury." RESULTS: 3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18-59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults. CONCLUSIONS: Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.