Adrenocorticotropic hormone and cortisol response to corticotropin releasing hormone in the critically ill-a novel assessment of the hypothalamic-pituitary-adrenal axis.

BACKGROUND: The pathophysiology of adrenal insufficiency, common in surgical intensive care units, has not been fully elucidated. METHODS: Patients at risk (age > 55 years, in the surgical intensive care unit >1 week, baseline cortisol < 20 µg/dL) were enrolled. After measuring cortisol and adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH) was administered. ACTH and cortisol were measured over 120 minutes. Short and long cosyntropin stimulation tests determined adrenal function. Area under the curve (AUC) and mixed linear models were used to compare cortisol and ACTH responses. Patients were grouped according to survival and response to stimulation testing. Chi-square and t tests were performed, and P values < .05 were considered statistically significant. RESULTS: Six of 25 patients responded poorly to cosyntropin, and 5 died compared with 3 after a normal response (P < .01). ACTH (AUC) and ACTH peak were increased in nonsurvivors after CRH administration. Cortisol peak and AUC were not different. CONCLUSIONS: ACTH responsiveness was increased in nonsurvivors and may predict mortality.

Nonventilatory interventions in the acute respiratory distress syndrome.

Acute respiratory distress syndrome was first described in 1967. Acute respiratory distress syndrome and acute lung injury are diseases the busy intensivist treats almost daily. The etiologies of acute respiratory distress syndrome are many. A significant distinction is based on whether the insult to the lung was direct, such as in pneumonia, or indirect, such as trauma or sepsis. Strategies for managing patients with acute respiratory distress syndrome/acute lung injury can be subdivided into 2 large groups, those based in manipulation of mechanical ventilation and those based in nonventilatory modalities. This review focuses on the nonventlilatory strategies and includes fluid restriction, exogenous surfactant, inhaled nitric oxide, manipulation of production, or administration of eicosanoids, neuromuscular blocking agents, prone position ventilation, glucocorticoids, extracorporeal membrane oxygenation, and administration of beta-agonists. Most of these therapies either have not been studied in large trials or have failed to show a benefit in terms of long-term patient mortality. Many of these therapies have shown promise in terms of improved oxygenation and may therefore be beneficial as rescue therapy for severely hypoxic patients. Recommendations regarding the use of each of these strategies are made, and an algorithm for implementing these strategies is suggested.

Outcomes of cocaine-induced gastric perforations repaired with an omental patch.

Crack cocaine has been associated with acute gastric perforation. The appropriate surgical treatment and long-term outcomes remain unclear. A retrospective chart review of all gastroduodenal perforations associated with crack cocaine use was performed. Data abstracted included details of short- and long-term outcomes. Kaplan-Meier methods were used to evaluate surgical outcomes. Over the 14-year period ending December 2005, 16 cases of crack-induced gastric perforations were identified. Most (75%) were treated with an omental patch. The other patients underwent a formal antiulcer operation, including one vagotomy and pyloroplasty (V&P), one vagotomy and antrectomy, one subtotal gastrectomy, and one ulcer excision and V&P. All patients after antiulcer procedures were followed for a median of 63 months (range 27-120) with no recurrences. Follow-up data were available in 75% of the omental patch patients. Recurrence of disease was observed in 56% of these omental patch patients at a median of 20 months (range 11-39). Those without recurrence were followed for a median of 67 months (range 12-96). The recurrence rate was borderline lower in the antiulcer group (P = 0.072). Omental patch closure results in a recurrence rate over 50% compared with no recurrence for formal antiulcer procedures.

Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients.

BACKGROUND: This study compared an intermittent feeding regimen (one-sixth of daily needs infused every 4 hours) with a continuous (drip) feeding regimen for critically ill trauma patients. There were two outcome variables: time to reach goal volume and the days on 100% of caloric needs via an enteral route in the first 10 days of the intensive care unit stay. Adverse events were also tallied. METHODS: A prospective randomized trial was conducted in the trauma intensive care unit in a university Level I trauma center. A total of 164 trauma patients, 18 years of age and older were admitted to the trauma intensive care unit with a noninjured gastrointestinal tract and required more than 48 hours of mechanical ventilation. Patients were randomized to receive enteral nutrition via an intermittent feeding regimen versus a continuous feeding regimen. A single nutritionist calculated caloric and protein goals. A strict protocol was followed where hourly enteral intake, interruptions and their causes, diarrhea, and pneumonia were recorded, as well as standard guidelines for intolerance. RESULTS: A total of 164 patients were randomized and 139 reached their calculated nutritional goal within 7 days. There were no statistical differences in complications of tube feeding. The patients intermittently fed reached the goal faster and by day 7 had a higher probability of being at goal than did the patients fed continuously (chi = 6.01, p = 0.01). Intermittent patients maintained 100% of goal for 4 of 10 days per patient (95% CI = 3.5-4.4) as compared with the drip arm goal for only 3 of 10 days per patient (95% CI = 2.7-3.6). CONCLUSIONS: Patients from both the intermittent and continuous feeding regimens reached the goal during the study period of 7 days but the intermittent regimen patients reached goal enteral calories earlier. The intermittent gastric regimen is logistically simple and has equivalent outcomes to a standard drip-feeding regimen.

Bioavailability of oral fluconazole in critically ill abdominal trauma patients with and without abdominal wall closure: a randomized crossover clinical trial.

BACKGROUND: Patients with non-apposed fascial edges, known as laparostomy patients, have traditionally been given intravenous medications, because enteral absorption of medications was thought to be unpredictable. We hypothesized that critically ill patients with "open abdomens" would have bioavailability similar to that of matched patients with closed fascial edges. METHODS: Fluconazole, a commonly prescribed anti-fungal with good bioavailability was used as a marker of absorption. Postoperative abdominal trauma patients were enrolled in a case-control (laparostomy versus closed abdomen) crossover design study to receive either an oral or parenteral fluconazole (400 mg loading dose followed by 200 mg QD) for one week. After a washout period, the alternate route of administration was used for the second week. Blood levels were collected at the end of each week of therapy. Rectal swab stool specimens were cultured for fungi on days 0, 7, and 15. RESULTS: Sixteen patients were studied. The mean injury severity score was 23 (range 9-41). The bioavailability of enteral fluconazole was 51% +/- 30% in the open abdomen and 63% +/- 19% (p = 0.347) in the closed abdomen patients. There was great variation in the bioavailability between the individual patients, with a range of 30%-100% in both groups. Three patients developed rectal colonization with Candida krusei. CONCLUSION: The bioavailability of enterally dosed fluconazole was highly variable in both the open and closed abdomen patients. Intravenous administration of pharmaceuticals may provide more reliable serum levels in the first 2 weeks after trauma-related laparotomy.

Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study.

BACKGROUND: Tracheostomy is a commonly performed procedure in ventilator dependent patients. Many critical care practitioners believe that performing a tracheostomy early in the postinjury period decreases the length of ventilator dependence as well as having other benefits such as better patient tolerance and lower respiratory dead space. We conducted a randomized, prospective, single institution study comparing the length ventilator dependence in critically ill multiple trauma patients who were randomized to two different strategies for performance of a tracheostomy. We hypothesized that earlier tracheostomy would reduce the number of days of mechanical ventilation, frequency of pneumonia and length of intensive care unit (ICU) stay. METHODS: Patients were eligible if they were older than 15 years and either a Glasgow Coma Score (GCS) >4 with a negative brain computed tomography (CT) (no anatomic head injury), or a GCS >9 with a positive head CT (known anatomic head injury). Patients who required tracheostomy for facial/neck injuries were excluded. Patients were randomized to an intention to treat strategy of tracheostomy placement before day 8 or after day 28. RESULTS: The study was halted after the first interim analysis. There were 60 enrolled patients, who had comparable demographics between groups. There was no significant difference between groups in any outcome variable including length of ventilator support, pneumonia rate, or death. CONCLUSION: A strategy of tracheostomy before day 8 postinjury in this group of trauma patients did not reduce the number of days of mechanical ventilation, frequency of pneumonia or ICU length of stay as compared with the group with a tracheostomy strategy involving the procedure at 28 days postinjury or more.

Inter- and intrarater reliability in computed axial tomographic grading of splenic injury: why so many grading scales?

OBJECTIVE: After splenic trauma, critical decisions regarding operative intervention are often made with the aid of computed axial tomographic (CT) scan findings. No CT scan-based grading scale has been demonstrated to predict accurately which patients require operative or radiologic intervention for their splenic injuries. We hypothesized that use of the most common grading scale, the American Association for the Surgery of Trauma scale, would be associated with low intra- and interreliability scores. We assessed the ability of experienced trauma radiologists to differentiate grade III from grade IV splenic injuries. METHODS: The films of patients who had undergone abdominal CT scanning before splenectomy for grade III or IV injuries were serially evaluated by four trauma radiology faculty weekly for 3 weeks. We assessed intra- and interrater reliability for grading and for presence of contrast blush. RESULTS: Intrarater reproducibility yielded a weighted kappa score of 0.15 to 0.77. Interrater reliability weighted kappa scores ranged from 0 to 0.84, with a mean value of 0.23. CONCLUSION: CT imaging is not reliable for identifying grades III and IV splenic injury, as experienced radiologists often underestimate the magnitude of injury. Interrater reliability is poor. Factors other than the CT grade of splenic injury should determine whether patients require operative or angiographic therapy.

Unexpected findings in trauma patients dying in the intensive care unit: results of 153 consecutive autopsies.

BACKGROUND: The true incidence of missed injuries in trauma-related deaths is unknown, because in only about 60% of injury-related deaths nationwide is an autopsy performed. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. We attempted to evaluate the incidence and nature of missed injuries and complications in trauma- and burn-related deaths in our ICU given an autopsy rate of close to 100%. STUDY DESIGN: The medical records of all trauma- and burn-related deaths in the ICU over a 2-year period were reviewed retrospectively. Missed diagnoses were classified as class 1: major diagnosis that if recognized and treated appropriately might have changed outcomes; class II: major diagnosis that if recognized and treated appropriately would not have changed outcomes; and class III: minor diagnosis. RESULTS: Complete antemortem records were available for 158 patients, of which 153 (97%) underwent autopsy. Mean age was 50 years, and 72% were males. Mean ICU stay was 10 15 days. Four (3%) patients had class I missed diagnoses: bowel infarction, meningitis, retroperitoneal abscess, and bleeding gastric ulcer. Twenty-five (16%) patients had class II diagnoses, and 12 (8%) patients had class III diagnoses. Overall, 81% of 153 patients had either class III diagnoses or no missed injuries or complications. Pneumonia was the most common missed diagnosis. CONCLUSIONS: With an autopsy rate of 97%, 3% of deaths bad missed major diagnoses that might have affected outcomes if recognized antemortem. Autopsy findings can still provide valuable feedback in Improving the quality of care of critically ill trauma patients.