Adjunctive virtual reality pain relief after traumatic injury: a proof-of-concept within-person randomized trial.

ABSTRACT: In this study, we hypothesized that immersive virtual reality (VR) environments may reduce pain in patients with acute traumatic injuries, including traumatic brain injuries. We performed a randomized within-subject study in patients hospitalized with acute traumatic injuries, including traumatic brain injury with moderate pain (numeric pain score ≥3 of 10). We compared 3 conditions: (1) an immersive VR environment (VR Blu), (2) a content control with the identical environment delivered through nonimmersive tablet computer (Tablet Blu), and (3) a second control composed of donning VR headgear without content to control for placebo effects and sensory deprivation (VR Blank). We enrolled 60 patients, and 48 patients completed all 3 conditions. Objective and subjective data were analyzed using linear mixed-effects models. Controlling for demographics, baseline pain, and injury severity, we found differences by conditions in relieving pain (F 2,75.43 = 3.32, P = 0.042). VR Blu pain reduction was greater than Tablet Blu (-0.92 vs -0.16, P = 0.043), but VR Blu pain reduction was similar to VR Blank (-0.92 vs -1.24, P = 0.241). VR Blu was perceived as most effective by patients for pain reduction (F 2,66.84 = 16.28, P < 0.001), and changes in measures of parasympathetic activity including heart rate variability (F 2,55.511 = 7.87, P < 0.001) and pupillary maximum constriction velocity (F 2,61.41 = 3.50, 1-tailed P = 0.038) echoed these effects. There were no effects on opioid usage. These findings outlined a potential clinical benefit for mollifying pain related to traumatic injuries.

Pain Control and Anxiolysis After Subarachnoid Hemorrhage Using Immersive Virtual Reality: A Case Report.

Debilitating headache persists after acute aneurysmal subarachnoid hemorrhage (SAH). Despite high prevalence, little is known regarding optimal treatment strategies for SAH-related headache. Nonpharmacologic adjunctive therapies are emerging as tools to help treat pain and limit opioid exposure in the hospital. Virtual reality (VR) is an immersive audiovisual experience that has been shown to reduce pain perception in other patient populations. The role of VR in acute brain injury is unknown. Here we report a patient with SAH who suffered from persistent headache during her hospitalization despite escalation of analgesic pharmacotherapy. A trial of VR was used as an adjunct to medication over four days. The patient reported subjective improvement in pain and anxiety. VR may provide additional analgesia and anxiolysis over pharmacologic measures alone and warrants further study in patients with acute brain injury.

Evaluation Challenges for the Application of Extended Reality Devices in Medicine.

Augmented and virtual reality devices are being actively investigated and implemented for a wide range of medical uses. However, significant gaps in the evaluation of these medical devices and applications hinder their regulatory evaluation. Addressing these gaps is critical to demonstrating the devices' safety and effectiveness. We outline the key technical and clinical evaluation challenges discussed during the US Food and Drug Administration's public workshop, "Medical Extended Reality: Toward Best Evaluation Practices for Virtual and Augmented Reality in Medicine" and future directions for evaluation method development. Evaluation challenges were categorized into several key technical and clinical areas. Finally, we highlight current efforts in the standards communities and illustrate connections between the evaluation challenges and the intended uses of the medical extended reality (MXR) devices. Participants concluded that additional research is needed to assess the safety and effectiveness of MXR devices across the use cases.

Adjunctive virtual reality pain relief following traumatic injury: protocol for a randomised within-subjects clinical trial.

INTRODUCTION: The annual mortality and national expense of the opioid crisis continue to rise in the USA (130 deaths/day, $50 billion/year). Opioid use disorder usually starts with the prescription of opioids for a medical condition. Its risk is associated with greater pain intensity and coping strategies characterised by pain catastrophising. Non-pharmacological analgesics in the hospital setting are critical to abate the opioid epidemic. One promising intervention is virtual reality (VR) therapy. It has performed well as a distraction tool and pain modifier during medical procedures; however, little is known about VR in the acute pain setting following traumatic injury. Furthermore, no studies have investigated VR in the setting of traumatic brain injury (TBI). This study aims to establish the safety and effect of VR therapy in the inpatient setting for acute traumatic injuries, including TBI. METHODS AND ANALYSIS: In this randomised within-subjects clinical study, immersive VR therapy will be compared with two controls in patients with traumatic injury, including TBI. Affective measures including pain catastrophising, trait anxiety and depression will be captured prior to beginning sessions. Before and after each session, we will capture pain intensity and unpleasantness, additional affective measures and physiological measures associated with pain response, such as heart rate and variability, pupillometry and respiratory rate. The primary outcome is the change in pain intensity of the VR session compared with controls. ETHICS AND DISSEMINATION: Dissemination of this protocol will allow researchers and funding bodies to stay abreast in their fields through exposure to research not otherwise widely publicised. Study protocols are compliant with federal regulation and University of Maryland Baltimore's Human Research Protections and Institutional Review Board (protocol number HP-00090603). Study results will be published on completion of enrolment and analysis, and deidentified data can be shared by request to the corresponding author. TRIAL REGISTRATION NUMBER: NCT04356963; Pre-results.

The Impact of Corticosteroids on Secondary Infection and Mortality in Critically Ill COVID-19 Patients.

BACKGROUND: Corticosteroids are part of the treatment guidelines for COVID-19 and have been shown to improve mortality. However, the impact corticosteroids have on the development of secondary infection in COVID-19 is unknown. We sought to define the rate of secondary infection in critically ill patients with COVID-19 and determine the effect of corticosteroid use on mortality in critically ill patients with COVID-19. STUDY DESIGN AND METHODS: One hundred and thirty-five critically ill patients with COVID-19 admitted to the Intensive Care Unit (ICU) at the University of Maryland Medical Center were included in this single-center retrospective analysis. Demographics, symptoms, culture data, use of COVID-19 directed therapies, and outcomes were abstracted from the medical record. The primary outcomes were secondary infection and mortality. Proportional hazards models were used to determine the time to secondary infection and the time to death. RESULTS: The proportion of patients with secondary infection was 63%. The likelihood of developing secondary infection was not significantly impacted by the administration of corticosteroids (HR 1.45, CI 0.75-2.82, P = 0.28). This remained consistent in sub-analysis looking at bloodstream, respiratory, and urine infections. Secondary infection had no significant impact on the likelihood of 28-day mortality (HR 0.66, CI 0.33-1.35, P = 0.256). Corticosteroid administration significantly reduced the likelihood of 28-day mortality (HR 0.27, CI 0.10-0.72, P = 0.01). CONCLUSION: Corticosteroids are an important and lifesaving pharmacotherapeutic option in critically ill patients with COVID-19, which have no impact on the likelihood of developing secondary infections.

The use of venous Doppler to predict adverse kidney events in a general ICU cohort.

BACKGROUND: Changes in Doppler flow patterns of hepatic veins (HV), portal vein (PV) and intra-renal veins (RV) reflect right atrial pressure and venous congestion; the feasibility of obtaining these assessments and the clinical relevance of the findings is unknown in a general ICU population. This study compares the morphology of HV, PV and RV waveform abnormalities in prediction of major adverse kidney events at 30 days (MAKE30) in critically ill patients. STUDY DESIGN AND METHODS: We conducted a prospective observational study enrolling adult patients within 24 h of admission to the ICU. Patients underwent an ultrasound evaluation of the HV, PV and RV. We compared the rate of MAKE-30 events in patients with and without venous flow abnormalities in the hepatic, portal and intra-renal veins. The HV was considered abnormal if S to D wave reversal was present. The PV was considered abnormal if the portal pulsatility index (PPI) was greater than 30%. We also examined PPI as a continuous variable to assess whether small changes in portal vein flow was a clinically important marker of venous congestion. RESULTS: From January 2019 to June 2019, we enrolled 114 patients. HV abnormalities demonstrate an odds ratio of 4.0 (95% CI 1.4-11.2). PV as a dichotomous outcome is associated with an increased odds ratio of MAKE-30 but fails to reach statistical significance (OR 2.3 95% CI 0.87-5.96), but when examined as a continuous variable it demonstrates an odds ratio of 1.03 (95% CI 1.00-1.06). RV Doppler flow abnormalities are not associated with an increase in the rate of MAKE-30 INTERPRETATION: Obtaining hepatic, portal and renal venous Doppler assessments in critically ill ICU patients are feasible. Abnormalities in hepatic and portal venous Doppler are associated with an increase in MAKE-30. Further research is needed to determine if venous Doppler assessments can be useful measures in assessing right-sided venous congestion in critically ill patients.

Echo is a good, not perfect, measure of cardiac output in critically ill surgical patients.

BACKGROUND: Compared with a pulmonary artery catheter (PAC), transthoracic echocardiography (TTE) has been shown to have good agreement in cardiac output (CO) measurement in nonsurgical populations. Our hypothesis is that the feasibility and accuracy of CO measured by TTE (CO-TTE), relative to CO measured by PAC thermodilution (CO-PAC), is different in surgical intensive care unit patients (SP) and nonsurgical patients (NSP). METHODS: Surgical patients with PAC for hemodynamic monitoring and NSP undergoing right heart catheterization were prospectively enrolled. Cardiac output was measured by CO-PAC and CO-TTE. Pearson coefficients were used to assess correlation. Bland-Altman analysis was used to determine agreement. RESULTS: Over 18 months, 84 patients were enrolled (51 SP, 33 NSP). Cardiac output TTE could be measured in 65% (33/51) of SP versus 79% (26/33) of NSP; p = 0.17. Inability to measure the left ventricular outflow tract diameter was the primary reason for failure in both groups; 94% (17/18) in SP versus 86% (6/7) NSP; p = 0.47. Velocity time integral could be measured in all patients. In both groups, correlation between PAC and TTE measurement was strong; SP (r = 0.76; p < 0.0001), NSP (r = 0.86; p < 0.0001). Bland-Altman analysis demonstrated bias of -0.1 L/min, limits of agreement of -2.5 and +2.3 L/min, percentage error (PE) of 40% for SP, and bias of +0.4 L/min, limits of agreement of -1.8 and +2.5 L/min, and PE of 40% for NSP. CONCLUSION: There was strong correlation and moderate agreement between TTE and PAC in both SP and NSP. In both patient populations, inability to measure the left ventricular outflow tract diameter was a limiting factor. LEVEL OF EVIDENCE: Diagnostic tests or criteria, level III.

Ultrasound assessment of volume responsiveness in critically ill surgical patients: Two measurements are better than one.

BACKGROUND: The intended physiologic response to a fluid bolus is an increase in stroke volume (SV). Several ultrasound (US) measures have been shown to be predictive. The best measure(s) in critically ill surgical patients remains unclear. METHODS: This is a prospective observational study in critically ill surgical patients receiving a bolus of crystalloid, colloid or blood. A transthoracic echocardiogram was performed before (pre-transthoracic echocardiogram) and after. A positive volume response (+VR) was defined as a ≥15% increase in SV. Predictive measures were: left ventricular velocity time integral (VTI), respiratory SV variation (rSVV), passive leg raise SVV (plr SVV), positional internal jugular (IJ) vein change (0-90 degrees) and respiratory variation in the IJ sitting upright (90 degrees IJ). For each measure the area under the receiver operating curve (AUROC) was assessed and the best measure(s) determined. RESULTS: Between November 2013 and November 2015, 199 patients completed the study. After the pilot analyses, plr SVV was abandoned because it could not be reliably assessed. VTI, rv 90 degrees IJ, 0 degree to 90 degrees IJ, were all significantly associated with VR (p < 0.05), rSVV and rv inferior vena cava were not. For VTI AUROC was 0.71 (95% confidence interval [CI], 0.64-0.77). For rv 90 degrees, it was 0.65 (95% CI, 0.57-0.71), and 0.61 (95% CI, 0.54-0.69) for 0 degrees to 90 degrees IJ. When VTI and rv 90 degrees were considered together, the AUROC rose to 0.76 (95% CI, 0.69-0.82) for the population as a whole and 0.78 (95% CI, 0.69-0.85) in mechanically ventilated patients. The positive predictive value for combined assessment was 80% and the negative 70%. CONCLUSION: In a clinically relevant heterogeneous population, US is moderately predictive of VR. Inferior vena cava diameter change is not predictive. IJ change and VTI are the best measures, especially when used together. Future work should focus on combination metrics and the IJ. LEVEL OF EVIDENCE: Diagnostic test, level II.

Bridging the gap: Hybrid cardiac echo in the critically ill.

BACKGROUND: Point-of-care ultrasound often includes cardiac ultrasound. It is commonly used to evaluate cardiac function in critically ill patients but lacks the specific quantitative anatomic assessment afforded by standard transthoracic echocardiography (TTE). We developed the Focused Rapid Echocardiographic Examination (FREE), a hybrid between a cardiac ultrasound and TTE that places an emphasis on cardiac function rather than anatomy. We hypothesized that data obtained from FREE correlate well with TTE while providing actionable information for clinical decision making. METHODS: FREE examinations evaluating cardiac function (left ventricular ejection fraction), diastolic dysfunction (including early mitral Doppler flow [E] and early mitral tissue Doppler [E']), right ventricular function, cardiac output, preload (left ventricular internal dimension end diastole), stroke volume, stroke volume variation, inferior vena cava diameter, and inferior vena cava collapse were performed. Patients who underwent both a TTE and FREE on the same day were identified as the cohort, and quantitative measurements were compared. Correlation analyses were performed to assess levels of agreement. RESULTS: A total of 462 FREE examinations were performed, in which 69 patients had both a FREE and TTE. FREE ejection fraction was strongly correlated with TTE (r = 0.89, 95% confidence interval). Left ventricular outflow tract, left ventricular internal dimension end diastole, E, and lateral E' derived from FREE were also strongly correlated with TTE measurements (r = 0.83, r = 0.94, r = 0.77, and r = 0.88, respectively). In 82% of the patients, right ventricular function for FREE was the same as that reported for TTE; pericardial effusion was detected on both examinations in 94% of the cases. No significant valvular anatomy was missed with the FREE examination. CONCLUSION: Functionally rather than anatomically based hybrid ultrasound examinations, like the FREE, facilitate decision making for critically ill patients. The FREE's functional assessment correlates well with TTE measurements and may be of significant clinical value in critically ill patients, especially when used in remote operating environments where resources are limited. LEVEL OF EVIDENCE: Diagnostic test, level III.

Focused comprehensive, quantitative, functionally based echocardiographic evaluation in the critical care unit is feasible and impacts care.

OBJECTIVES: To determine whether comprehensive quantitative echocardiogram could be used as a resuscitation tool in critically ill surgical patients and to assess its effect on patient care. DESIGN: Prospective observational. SETTING: The Trauma and Surgical Intensive Care Units of the University of Maryland Medical Center. PATIENTS: Critically ill trauma and surgical patients. INTERVENTIONS: The Focused Rapid Echocardiographic Evaluation (FREE), an abbreviated version of a comprehensive transthoracic echocardiogram, which is under an approved protocol, was performed. MEASUREMENTS AND MAIN RESULTS: Over a 30-month period, 791 FREEs were performed on 659 patients. The mean patient age was 60 (±17) years. Ninety-one percent were intubated and 80% were postoperative. Ejection fraction was reported for 95%, and cardiac index was reported for 89% of FREE studies. Right heart function was assessed for 94%. Measures of volume status--internal left ventricular diameter, inferior vena cava diameter, diameter change, and stroke volume variation--were reported for 88%, 79%, 75%, and 89% of patients, respectively. The FREE was judged to be useful by the consulting primary care team for 95% of patients, and altered the plan of care for 57%. The most common change was administration of a fluid bolus (43%), followed by change from an original prestudy plan to one of monitoring (24%), diuresis (23%), addition/titration of an inotropic agent (19%), and/or addition/titration of a vasoconstrictor (8%). CONCLUSIONS: The FREE is feasible and alters care in the intensive care unit by providing clinical data not otherwise available at the bedside. Further studies are warranted to assess the impact of comprehensive echocardiogram-directed resuscitation on patient outcomes.

Acute respiratory distress syndrome and outcomes after near hanging.

PURPOSE: The purpose of this study is to assess the case rate of acute respiratory distress syndrome (ARDS) after near hanging and the secondary outcomes of traumatic and/or anoxic brain injury and death. Risk factors for the outcomes were assessed. METHOD: The method is a single-center, statewide retrospective cohort study of consecutive patients admitted between August 2002 and September 2011, with a primary diagnosis of nonjudicial "hanging injury." RESULTS: Of 56 patients, 73% were male. The median age was 31 (Interquartile range (IQR), 16-56). Upon arrival, 9% (5/56) did not have a pulse, and 23% (13/56) patients were intubated. The median Glasgow Coma Scale (GCS) was 13 (IQR, 3-15); 14% (8/56) had a GCS = 3. Acute respiratory distress syndrome developed in 9% (5/56) of patients. Traumatic anoxic brain injury resulted in 9% (5/56) of patients. The in-hospital case fatality was 5% (3/56). Lower median GCS (3 [IQR, 3-7] vs 14 [IQR, 3-15]; P = .0003) and intubation in field or in trauma resuscitation unit (100% [5/5] vs 16% [8/51]; P = .0003) were associated with ARDS development. Risk factors of death were GCS = 3 (100% [3/3] vs 9% [5/53]; P = .002), pulselessness upon arrival of emergency medical services (100% [3/3] vs 4% [2/53]; P < .001], and abnormal neurologic imaging (50% [1/2] vs zero; P = .04). CONCLUSIONS: The ARDS case rate after near hanging is similar to the general trauma population. Low GCS and intubation are associated with increased risk of ARDS development. The rate of traumatic and/or anoxic brain injury in this population is low.

Assessing trauma care provider judgement in the prediction of need for life-saving interventions.

INTRODUCTION: Human judgement on the need for life-saving interventions (LSI) in trauma is poorly studied, especially during initial casualty management. We prospectively examined early clinical judgement and compared clinical experts' predictions of LSI to their later occurrence. PATIENTS AND METHODS: Within 10-15 min of direct trauma admission, we surveyed the predictions of pre-hospital care providers (PHP, 92% paramedics), trauma centre nurses (RN), and attending or fellow trauma physicians (MD) on the need for LSI. The actual outcomes including fluid bolus, intubation, transfusion (<1h and 1-6h), and emergent surgical interventions were observed. Cohen's kappa statistic (K) and percentage agreement were used to measure agreement among provider responses. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated to compare clinical judgement to actual patient interventions. RESULTS: Among 325 eligible trauma patient admissions, 209 clinical judgement of LSIs were obtained from all three providers. Cohen's kappa statistic for agreement between pairs of provider groups demonstrated no "disagreement" (K<0) between groups, "fair" agreement for fluid bolus (K=0.12-0.19) and blood transfusion 0-6h (K=0.22-0.39), and "moderate" (K=0.45-0.49) agreement between PHP and RN regarding intubation and surgical interventions, but no "excellent" (K ≥ 0.81) agreement between any pair of provider groups for any intervention. The percentage agreement across the different clinician groups ranged from 50% to 83%. NPV was 90-99% across providers for all interventions except fluid bolus. CONCLUSIONS: Expert clinical judgement provides a benchmark for the prediction of major LSI use in unstable trauma patients. No excellent agreement exists across providers on LSI predictions. It is possible that quality improvement measures and computer modelling-based decision-support could reduce errors of LSI commission and omission found in resuscitation at major trauma centres and enhance decision-making in austere trauma settings by less well-trained providers than those surveyed.

Making the financial case for a surgeon-directed critical care ultrasound program.

BACKGROUND: We sought to demonstrate that a well-staffed, surgeon-directed, critical care ultrasound program (CCUP) is financially sustainable and provides administrative and educational support for point-of-care ultrasound. METHODS: The CCUP provides a clinical service and training as well as conducts research. Initial costs, annual costs (C), revenue (R), and savings (S) were prospectively recorded. Using data from the first 3 years, we calculated the projected C, R, and S at 5 years. We determined CCUP sustainability by C < R and C < R + S at 3 years and 5 years. RESULTS: During 36 months, the CCUP covered four surgical intensive care units (55 beds). Start-up costs included one basic and one cardiovascular device per 25 beds and a data storage system linking reports and images to the electronic medical record ($203,650). Billing increased threefold from Years 1 to 3, with a 21% increase between Years 2 to 3. Yearly costs included 0.5 full-time equivalent (FTE) sonographer and 0.2 FTE surgeon ($106,025); this was increased to 1 FTE and 0.25 FTE, respectively, for Years 4 and 5. The total 3-year cost was $521,725 and projected to be $863,325 by Year 5. The total 3-year revenue was $290,775 and projected to be $891,600 at 5 years. The total 3-year savings associated with the CCUP was $600,035 and is projected to be $1,194,220. With the use of the C < R, the CCUP meets operating expenses at Year 3 and covers overall cost at 5 years. If savings are included, then the CCUP is sustainable by its third year and is potentially profitable by Year 5. CONCLUSION: A surgeon-directed CCUP is financially sustainable, addresses administrative issues, and provides valuable training in point-of-care ultrasound.

Practical considerations for the dosing and adjustment of continuous renal replacement therapy in the intensive care unit.

Familiarity with the initiation, dosing, adjustment, and termination of continuous renal replacement therapy (CRRT) is a core skill for contemporary intensivists. Guidelines for how to administer CRRT in the intensive care unit are not well documented. The purpose of this review is to discuss the modalities, terminology, and components of CRRT, with an emphasis on the practical aspects of dosing, adjustments, and termination. Management of electrolyte and acid-base derangements commonly encountered with acute renal failure is emphasized. Knowledge regarding the practical aspects of managing CRRT in the intensive care unit is a prerequisite for achieving desired physiological end points.

Focused rapid echocardiographic evaluation versus vascular cather-based assessment of cardiac output and function in critically ill trauma patients.

BACKGROUND: Focused rapid echocardiographic evaluation (FREE) is a comprehensive transthoracic echocardiogram tailored for the intensive care unit. It assesses both the cardiac index (CI) and left ventricular ejection fraction (EF). FREE and vascular catheter-derived CI was compared, and the ability of CI to detect moderate to severe dysfunction (EF <40%) was determined. METHODS: FREE quality assurance database was reviewed to identify patients who had a hemodynamic catheter. RESULTS: Of 507 FREEs, 115 patients were identified, 25 pulmonary artery catheters (PACs) and 90 FloTrac Vigileo (FT/V) arterial catheters. There were 27 patients with an EF <40%. In 86%, the CI was determined by FREE, and it changed care in 59%. The CI correlation for FREE versus PAC was r = 0.88 and versus FT/V was r = 0.63 (p < 0.05). The PAC-FREE bias was -0.07 (95% confidence interval -0.89 to 0.74) and the FT/V-FREE bias was -0.13 (95% confidence interval -1.4 to 1.1). FREE-PAC categorized patients the same way 87% and FREE-FT/V 76%; in patients with EF <40%, this changed to 90% and 63%, respectively. Using a threshold value (CI ≤ 2.5), the PAC detected dysfunction in 62.5% and the F/VT in 6%, p < 0.05. CONCLUSIONS: There was excellent agreement between FREE and PAC but less with FT/V, especially in patients with and EF <40%. FREE can be used to validate catheter-derived data and provide important additional information. Further studies are needed to determine its impact on patient outcome. LEVEL OF EVIDENCE: III, diagnostic study.

Transfusion medicine in trauma patients: an update.

In 2008, we reviewed the practical interface between transfusion medicine and the surgery and critical care of severely injured patients. Reviewed topics ranged from epidemiology of trauma to patterns of resuscitation to the problems of transfusion reactions. In the interim, trauma specialists have adopted damage control resuscitation and become much more knowledgeable and thoughtful about the use of blood products. This new understanding and the resulting changes in clinical practice have raised new concerns. In this update, we focus on which patients need damage control resuscitation, current views on the optimal form of damage control resuscitation with blood products, the roles of newer blood products, and appropriate transfusion triggers in the postinjury setting. We will also review the role of new technology in patient assessment, therapy and monitoring.

Ultrasound-guided peripheral intravenous access in the intensive care unit.

PURPOSE: Central venous catheters continue to be a popular means of maintaining vascular access in surgical intensive care units despite well-described complications. With edema, obesity, and difficult to visualize veins potentially affecting the surgically ill, inability to obtain peripheral intravenous (PIV) access may hinder the clinician's ability to avoid the use of central lines. With ultrasound gaining increased popularity for obtaining vascular access, we evaluated its utility in ultrasonagraphically placing PIV catheters for the purposes of either avoiding central venous access or removing central venous catheters. MATERIALS AND METHODS: We performed a retrospective cohort review of our requests for ultrasound-guided PIV access in the intensive care unit between September 2007 and February 2008. RESULTS: Over a 6-month period, 77 requests for ultrasound-guided PIV access were made for 59 surgical, trauma, and cardiothoracic intensive care unit patients. Reasons for inability to obtain PIVs through standard means included edema (95%), obesity (42%), IV drug abuse history (8%), and emergency access (4%). Of the 148 PIV lines that were requested, 147 PIV catheters were successfully placed (99%). Of these, 105 PIV catheters were placed on the first attempt (71%). Complications of PIVs included IV infiltration (3.4%), inadvertent removal (2.7%), and phlebitis/cellulitis (0.7%). As a result of placing these PIV catheters, 40 central lines were discontinued and 34 central lines were avoided. The average number of line days at the time of central venous catheter removal was 11 ± 11 days. CONCLUSION(S): In intensive care unit patients who do not require central venous lines, ultrasound-guided PIV access can have a high placement success rate and can result in fewer central line days and/or less reliance on central venous catheters for access-only purposes.

Blood and coagulation support in trauma.

Injury is the leading cause of death in young people and a major cause of loss of years of productive life world wide. Acute surgical care can prevent injury from turning into disability or death but requires prompt access to safe blood products to support resuscitation and restorative surgical procedures. Speed in delivering blood products is critical in resuscitation. Achieving prompt blood product support requires advanced planning and an informed balancing of risks to insure the availability of red cells and coagulation products at the time and place where they are needed. Safety and diagnostic support are critical in the post-resuscitative period where transfusion complications can delay reconstructive surgery and prolong intensive care unit stays. This paper reviews the epidemiology of injury and modern patterns of trauma care against the background of developing knowledge about the coagulopathies of trauma and blood safety.

Transfusion medicine in trauma patients.

Injured patients stress the transfusion service with frequent demands for uncrossmatched red cells and plasma, occasional requirements for large amounts of blood products and the need for new and better blood products. Transfusion services stress trauma centers with demands for strict accountability for individual blood component units and adherence to indications in a clinical field where research has been difficult, and guidance opinion-based. New data suggest that the most severely injured patients arrive at the trauma center already coagulopathic and that these patients benefit from prompt, specific, corrective treatment. This research is clarifying trauma system requirements for new blood products and blood-product usage patterns, but the inability to obtain informed consent from severely injured patients remains an obstacle to further research.