Outcomes in Ventilated Burn Patients With Acute Respiratory Distress Syndrome: An Evaluation of Early High-PEEP Strategy Using Berlin Criteria.

Acute respiratory distress syndrome (ARDS) remains a formidable sequela, complication, and mortality risk in patients with large burns with or without inhalation injury. Alveolar recruitment using higher Positive end expiratory pressures (PEEP) after the onset of ARDS has been tried with varying success. Studies have identified benefits for several rescue maneuvers in ARDS patients with refractory hypoxemia. A prophylactic strategy utilizing an early recruitment maneuver, however, has not, to our knowledge, been explored in ventilated burn patients. This study was designed to evaluate the natural progression and clinical outcomes of ARDS severity (mild, moderate, and severe) using Berlin criteria in ventilated burn patients treated with an early high-PEEP ventilator strategy. A single-center retrospective review of burn patients who were mechanically ventilated for greater than 48 hours utilizing an early high-PEEP >10 mmHg (10.36) ventilator strategy was performed at the Level 1 trauma and regional burn center in Wright State University. ARDS severity was defined according to the Berlin criteria and then compared to published results of ARDS severity, clinical outcomes, and mortality. Demographic data, as well as respiratory and clinical outcomes, were evaluated. Eighty-three patients met inclusion criteria and were evaluated. Utilizing the Berlin definition as a benchmark, 42.1% of patients met ARDS criteria on admission, and most patients (85.5%) developed ARDS within the first seven days: 28 (34%) mild, 32 (38.6%) moderate, and 11 (13.3%) severe ARDS. The mean percent total body surface area was 24.6 + 22.1, with 68.7% of patients diagnosed with inhalation injury. The highest incidence of ARDS was 57.8% on day 2 of admission. Most cases remained in the mild to moderate ARDS category with severe ARDS (2.4%) being less common by hospital day 7. Overall, 30-day in-hospital and inhalation injury mortality rates were 9.6% and 15.8%, respectively. No correlation was observed between plateau pressures (22.8), mean arterial pressures (84.4), or vasopressor requirements; and oxygen requirements down trended quickly over the first 24 to 48 hours. In our study, implementing prophylactic, immediate high-PEEP in mechanically ventilated burn patients was associated with trends toward decreased severity and rapid resolution of ARDS in the first week following burn injury. This correlated with low 30-day in-hospital mortality in this population. This short and less severe course suggests that early high-PEEP support may be a viable protective strategy in the treatment of ventilated burn patients with ARDS.

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE: Prognostic, level III.

VR Simulation Leads to Enhanced Procedural Confidence for Surgical Trainees.

OBJECTIVE: Active learning techniques result in greater knowledge acquisition compared to passive methods. For medical students with limited hands-on operative experiences, virtual reality platforms represent active learning and may enhance procedural training. We hypothesize that virtual reality simulators like Toolkit for Illustration of Procedures in Surgery (TIPS) are a more effective modality in teaching laparoscopic surgical techniques to medical students when compared to passive learning tools like videos. DESIGN: In this crossover study, participants were randomly assigned to perform either a TIPS laparoscopic appendectomy followed by video of a laparoscopic cholecystectomy, or video of a laparoscopic appendectomy followed by TIPS laparoscopic cholecystectomy. A knowledge assessment followed each intervention. A postsurvey was used to gather feedback and subjective impressions of the learning experience. SETTING: University of Central Florida College of Medicine. PARTICIPANTS: Second, third, and fourth-year medical students (n = 37). RESULTS: Validation of the content assessments revealed strong internal consistency (Cronbach's α = 0.73). A 2-tailed Fisher's exact test revealed that the video had greater ease of use (p = 0.032), but TIPS had greater utility as a learning tool (p < 0.001) and instilled greater confidence in the ability to reproduce procedural steps (p < 0.001). A 2-tailed t test of the average content quiz scores revealed no significant difference in percentage correct between groups on the laparoscopic appendectomy quiz (p = 0.772), but a difference favoring video learning on the laparoscopic cholecystectomy quiz (p = 0.042) CONCLUSIONS: Video and TIPS both enhanced different aspects of student learning; however, the active TIPS platform produced greater confidence in the ability to reproduce the steps of the procedure and had greater utility as a learning strategy. Videos are simple to use and can serve a complementary role in curriculum design.

Barriers to healthcare services and supports for signing deaf older adults.

OBJECTIVE: Although developmental stages and identity have been studied as part of aging, one category of both identity and biological difference that has received little attention in the medical and public health literature is that of older adults who were born deaf and/or who identify as part of the signing Deaf community. RESEARCH METHOD: Researchers conducted a systematic search of the literature for barriers to care access related to both aging and deafness. RESULTS: Lack of cultural competence among providers, coupled with inconsistent access to interpreters in medical settings, puts deaf individuals at risk for treatment without adequate consent, or insufficient care due to communication barriers or misperceptions of expression or culture. CONCLUSIONS/IMPLICATIONS: Individuals may face unusual challenges, indicating a serious public health crisis on the horizon as the demographic of deaf older adults continues to grow. This paper will discuss what is known about the intersection of aging, Deaf culture, and health care access, and suggest policy and practice recommendations for the future. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Delirium and Antipsychotic Medications at Hospital Intake: Screening to Decrease Likelihood of Aggression in Inpatient Settings Among Unknown Patients With Dementia.

For individuals with dementia, disorientation and both external and internal stimuli may trigger behaviors that are difficult to manage or dangerous to health-care providers. Identification of correlational risk factors to aggressive behavior in patients who are unknown to the hospital can allow providers to adapt patient care quickly. Records for patients aged 60+ who spent at least 24 hours at the hospital other than in the psychiatric unit were used (N = 14 080). The first 4000 records and every 10th person who met criteria (N = 5008) were searched for documentation of dementia (n = 505). Logistic regressions and χ2 tests were used to examine relationships between variables. Recognition of delirium (P = .014, Exp(B) = 2.53), coupled with an existing prescription for antipsychotic medication at intake (P < .001, Exp(B) < 4.37), may be a reliable means of screening for risk and intervening at the earliest possible contact, improving quality of care and safety in acute care for individuals with dementia.