A Systematic Review and Meta-Analysis of Ligation Versus Repair of Inferior Vena Cava Injuries.

OBJECTIVE: Inferior vena cava (IVC) injuries have a high mortality rate that may be related to the location of injury and type of repair. Previous studies have been either single center series or database studies lacking granular detail. These have reported conflicting results. We aimed to perform a systematic review and meta-analysis of published literature evaluating ligation versus repair. METHODS: Studies published in English on MEDLINE or EMBASE from 1946 through October 2018 were examined to evaluate mortality among patients treated with ligation versus repair of IVC injuries. Studies were included if they provided mortality associated with ligation versus repair and reported IVC injury by level. Risk of bias was assessed regarding incomplete and selective outcome reporting with Newcastle-Ottawa score of 7 or higher to evaluate study quality. We used a random-effects model with restricted maximum likelihood estimation method in R using the Metafor package to evaluate outcomes. RESULTS: Our systematic review identified 26 studies, of which 14 studies, including 855 patients, met our inclusion criteria for meta-analysis. IVC ligation was associated with higher mortality than IVC repair (OR: 3.12, P < 0.01, I2 = 49%). Ligation of infrarenal IVC injuries was not statistically associated with mortality (OR: 3.13, P = 0.09). Suprarenal injury location compared to infrarenal (OR 3.11, P < 0.01, I2 = 28%) and blunt mechanism compared to penetrating (OR: 1.91, P = 0.02, I2 = 0%) were also associated with higher mortality. CONCLUSIONS: In this meta-analysis, ligation of IVC injuries was associated with increased mortality compared to repair, but not specifically for infrarenal IVC injuries. Suprarenal IVC injury, and blunt mechanism was associated with increased mortality compared to infrarenal IVC injury and penetrating mechanism, respectively. Data are limited regarding acute renal injury and venous thromboembolic events after IVC ligation and may warrant multicenter studies. Standardized reporting of IVC injury data has not been well established and is needed in order to enable comparison of outcomes across institutions. In particular, reporting of injury location, severity, and repair type should be standardized. A contemporary prospective, multicenter study is needed in order to definitively compare surgical technique.

Early hypermetabolism is uncommon in trauma intensive care unit patients.

BACKGROUND: Classic experiments demonstrating hypermetabolism after major trauma were performed in a different era of critical care. We aim to describe the modern posttraumatic metabolic response in the trauma intensive care unit (TICU). METHODS: This prospective observational study enrolled TICU mechanically ventilated adults (aged ≥18) from 3/2018-2/2019. Multiple, daily resting energy expenditure (REE) measurements were recorded. Basal energy expenditure (BEE) was calculated by the Harris-Benedict equation. Hypometabolism was defined as average daily REE < 0.85*BEE and hypermetabolism defined as average daily REE > 1.15*BEE. Demographics, interventions, and clinical outcomes were abstracted. Descriptive statistics and multivariable logistical regression models evaluating demographics with the outcome variable of hypermetabolism for the first 3 days ("sustained hypermetabolism") were performed, along with group-based trajectory modeling (GBTM). RESULTS: Fifty-five patients were analyzed: median age was 38 (28-56) years; 38 (69%) were male; body mass index (kg/m2 ) was 28 (26-32); and Injury Severity Score was 27 (19-34), with (38 [71%] blunt, 8 [15%] penetrating, 7 [13%] burn) injury mechanism. Overall, 19 (35%) had hypermetabolism on day 1 ("immediate hypermetabolism"), and 11 (21%) had sustained hypermetabolism for the first 3 days. Logistic regression analysis identified penetrating mechanism (adjusted odds ratio [AOR], 16.4; 95% CI, 1.9-199.6; p = .015), burn mechanism (AOR, 11.1; 95% CI, 1.3-116.8; p =.029), and maximum temperature (AOR, 4.2; 95% CI, 1.3-20.3; p= .041) as independent predictors of sustained hypermetabolism. GBTM identified 4 nutrition phenotypes, with 2 hyperconsumptive phenotypes associated with increased risk of malnutrition at discharge. CONCLUSION: Only a minority of injured patients is hypermetabolic in the first week after injury. Elevated temperature, penetrating mechanism, and burn mechanism are independently associated with sustained hypermetabolism. Hyperconsumptive phenotype patients are more likely to develop malnutrition during hospitalization.

Rapid Diagnosis of Altered Mental Status in Home Parenteral Nutrition Patient.

This report describes the application of a routine lab test to confirm a diagnosis of hypernatremia suspected to be secondary to an error in parenteral nutrition compounding. The novel aspect of this case is the use of the "urine electrolytes" laboratory test to verify that the electrolyte concentration of the mixture is consistent with what was printed on the bag label.

Vitamin C and thiamine are associated with lower mortality in sepsis.

BACKGROUND: The efficacy of vitamin C (VitC) and thiamine (THMN) in patients admitted to the intensive care unit (ICU) with sepsis is unclear. The purpose of this study was to evaluate the effect of VitC and THMN on mortality and lactate clearance in ICU patients. We hypothesized that survival and lactate clearance would be improved when treated with thiamine and/or VitC. METHODS: The Philips eICU database version 2.0 was queried for patients admitted to the ICU in 2014 to 2015 for 48 hours or longer and patients with sepsis and an elevated lactate of 2.0 mmol/L or greater. Subjects were categorized according to the receipt of VitC, THMN, both, or neither. The primary outcome was in-hospital mortality. Secondary outcome was lactate clearance defined as lactate less than 2.0 mmol/L achieved after maximum lactate. Univariable comparisons included age, sex, race, Acute Physiology Score III, Acute Physiology and Chronic Health Evaluation (APACHE) IVa score, Sequential Organ Failure Assessment, surgical ICU admission status, intubation status, hospital region, liver disease, vasopressors, steroids, VitC and THMN orders. Kaplan-Meier curves, logistic regression, propensity score matching, and competing risks modeling were constructed. RESULTS: Of 146,687 patients from 186 hospitals, 7.7% (n = 11,330) were included. Overall mortality was 25.9% (n = 2,930). Evidence in favor of an association between VitC and/or THMN administration, and survival was found on log rank test (all p < 0.001). After controlling for confounding factors, VitC (adjusted odds ratio [AOR], 0.69 [0.50-0.95]) and THMN (AOR, 0.71 [0.55-0.93]) were independently associated with survival and THMN was associated with lactate clearance (AOR, 1.50 [1.22-1.96]). On competing risk model VitC (AOR, 0.675 [0.463-0.983]), THMN (AOR, 0.744 [0.569-0.974]), and VitC+THMN (AOR, 0.335 [0.13-0.865]) were associated with survival but not lactate clearance. For subgroup analysis of patients on vasopressors, VitC+THMN were associated with lactate clearance (AOR, 1.85 [1.05-3.24]) and survival (AOR, 0.223 [0.0678-0.735]). CONCLUSION: VitC+THMN is associated with increased survival in septic ICU patients. Randomized, multicenter trials are needed to better understand their effects on outcomes. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.

The lung rescue unit-Does a dedicated intensive care unit for venovenous extracorporeal membrane oxygenation improve survival to discharge?

BACKGROUND: The use of venovenous extra corporeal membrane oxygenation (VV ECMO) for acute respiratory failure (ARF)/acute respiratory (ARDS) has increased since 2009. Specialized units for patients requiring VV ECMO are not standard and patients are often cohorted with other critically ill patients. The purpose of this study was to report the outcome of adult patients admitted in 2015 to the lung rescue unit, which, to our knowledge, is the first intensive care unit in the United States that has been specifically created to provide care for patients requiring VV ECMO. METHODS: Data were collected on all patients admitted to the lung rescue unit on VV ECMO between January 1, 2015, and December 31, 2015. Demographics, medical history, pre-ECMO data, indication for VV ECMO as well as duration of ECMO and survival to decannulation and discharge were recorded. Means (± standard deviation) and medians (interquartile range [IQR]) were reported when appropriate. RESULTS: Forty-nine patients were enrolled. Median age was 48 years (IQR, 32-57). Median PaO2/FIO2 ratio before cannulation was 66 (IQR, 53-86). Median ventilator days before cannulation was 2 (IQR, 1-4). Median time on VV ECMO for all patients was 311 hours (IQR, 203-461). Thirty-eight (78%) patients were successfully decannulated with 35 (71%) patients surviving to hospital discharge. CONCLUSION: The use of VV ECMO for ARF/ARDS is increasing. We have demonstrated that a dedicated multidisciplinary intensive care unit for the purpose of providing standardized care with specialized trained providers can improve survival to discharge for patients that require VV ECMO for ARF/ARDS. LEVEL OF EVIDENCE: Therapeutic, level V.

Surgical Care Required for Populations Affected by Climate-related Natural Disasters: A Global Estimation.

BACKGROUND: Climate extremes will increase the frequency and severity of natural disasters worldwide.  Climate-related natural disasters were anticipated to affect 375 million people in 2015, more than 50% greater than the yearly average in the previous decade. To inform surgical assistance preparedness, we estimated the number of surgical procedures needed.   METHODS: The numbers of people affected by climate-related disasters from 2004 to 2014 were obtained from the Centre for Research of the Epidemiology of Disasters database. Using 5,000 procedures per 100,000 persons as the minimum, baseline estimates were calculated. A linear regression of the number of surgical procedures performed annually and the estimated number of surgical procedures required for climate-related natural disasters was performed. RESULTS: Approximately 140 million people were affected by climate-related natural disasters annually requiring 7.0 million surgical procedures. The greatest need for surgical care was in the People's Republic of China, India, and the Philippines. Linear regression demonstrated a poor relationship between national surgical capacity and estimated need for surgical care resulting from natural disaster, but countries with the least surgical capacity will have the greatest need for surgical care for persons affected by climate-related natural disasters. CONCLUSION: As climate extremes increase the frequency and severity of natural disasters, millions will need surgical care beyond baseline needs. Countries with insufficient surgical capacity will have the most need for surgical care for persons affected by climate-related natural disasters. Estimates of surgical are particularly important for countries least equipped to meet surgical care demands given critical human and physical resource deficiencies.