A clinical practice guideline using percentage of predicted forced vital capacity improves resource allocation for rib fracture patients.

BACKGROUND: Predicting rib fracture patients that will require higher-level care is a challenge during patient triage. Percentage of predicted forced vital capacity (FVC%) incorporates patient-specific factors to customize the measurements to each patient. A single institution transitioned from a clinical practice guideline (CPG) using absolute forced vital capacity (FVC) to one using FVC% to improve triage of rib fracture patients. This study compares the outcomes of patients before and after the CPG change. METHODS: A review of rib fracture patients was performed over a 3-year retrospective period (RETRO) and 1-year prospective period (PRO). RETRO patients were triaged by absolute FVC. Percentage of predicted FVC was used to triage PRO patients. Demographics, mechanism, Injury Severity Score, chest Abbreviated Injury Scale score, number of rib fractures, tube thoracostomy, intubation, admission to intensive care unit (ICU), transfer to ICU, hospital length of stay (LOS), ICU LOS, and mortality data were compared. A multivariable model was constructed to perform adjusted analysis for LOS. RESULTS: There were 588 patients eligible for the study, with 269 RETRO and 319 PRO patients. No significant differences in age, gender, or injury details were identified. Fewer tube thoracostomy were performed in PRO patients. Rates of intubation, admission to ICU, and mortality were similar. The PRO cohort had fewer ICU transfers and shorter LOS and ICU LOS. Multivariable logistic regression identified a 78% reduction in odds of ICU transfer among PRO patients. Adjusted analysis with multiple linear regression showed LOS was decreased 1.28 days by being a PRO patient in the study (B = -1.44; p < 0.001) with R2 = 0.198. CONCLUSION: Percentage of predicted FVC better stratified rib fracture patients leading to a decrease in transfers to the ICU, ICU LOS, and hospital LOS. By incorporating patient-specific factors into the triage decision, the new CPG optimized triage and decreased resource utilization over the study period. LEVEL OF EVIDENCE: Therapeutic/Care Management. Trauma, Rib, Triage, level IV.

Propofol Infusion Syndrome: Efficacy of a Prospective Screening Protocol.

Propofol infusion syndrome (PIS) is a potentially lethal complication of propofol marked by rhabdomyolysis, metabolic acidosis, and cardiac arrhythmias or collapse. The objective of this study was to determine the effectiveness of a prospective screening protocol to prevent PIS. All trauma patients admitted who received propofol as a continuous infusion were prospectively screened from November 1, 2013 to December 31, 2015. Variables studied included demographics, injury severity, laboratory values, infusion rates, and mortality. Serum creatine phosphokinase (CPK) and lactate were drawn daily. Propofol was stopped for a positive screen defined as an increase in CPK to greater than 5000 IU/L or lactate greater than 4 mmol/L. Positive and negative cohorts were compared. Two hundred and twenty-five patients met the inclusion criteria and 12 patients (5.3%) had propofol stopped because of elevated CPK. No differences were identified in demographics, transfusions, injury severity, hospital length of stay, or propofol dose. The positive screened group had longer intensive care unit length of stay (20 vs 13 days; P = 0.002) and increased vent days (14.5 vs 10 days; P = 0.008). Max serum osmolality (334 vs 305 mosm/kg; P = 0.049) and max serum CPK (6782 vs 1058 IU/L; P < 0.0001) were higher in the positive cohort. No cases of PIS occurred, and mortality (16.7 vs 15.5%; P = 0.999) was not different between the cohorts. The screening protocol was effective in eliminating PIS. Serial CPK evaluations provided an effective screening tool and serum lactate can be dropped from screening.

Impact of Beta-Blockers on Nonhead Injured Trauma Patients.

Catecholamine surge after traumatic injury may lead to dysautonomia with increased morbidity. Small retrospective studies have shown potential benefit of beta-blockers (BB) in trauma patients with and without traumatic brain injury (TBI). This study evaluates a large multiply injured cohort without TBI that received BB. Patients were identified from the trauma registry from January 1, 2003 to December 31, 2011. Patients who received >1 dose of BB were compared to controls. Patients with TBI, length of stay (LOS) < 2 days, and prehospital BB were excluded. Outcomes were mortality, intensive care unit (ICU) LOS, and LOS. Stepwise multivariable regression was used to identify variables significantly associated with mortality. During the study period, 19,151 eligible patients were admitted. The mean age was 39 years. Most were male (74%) and most sustained blunt mechanism (75%). A total of 1854 (11%) patients received BB. BB patients had longer LOS (16 vs 6 days), ICU LOS (7 vs 1 days), and higher mortality (2.8 vs 0.5%) (all P < 0.001). Multivariable regression demonstrated no benefit to BB after adjusting for potential confounding characteristics [odds ratio (OR) 0.952; confidence interval (CI) 0.620-1.461]. In conclusion, in this largest study to date, patients receiving BB were older, more severely injured, and had a higher mortality. Unlike TBI patients, multivariable regression showed no benefit from BB in this population.

Adherence to an established diagnostic threshold for ventilator-associated pneumonia contributes to low false-negative rates in trauma patients.

BACKGROUND: The diagnosis of ventilator-associated pneumonia (VAP) in our institution has followed an established diagnostic threshold (DT) of equal to or greater than 10 colony-forming units (CFU) per milliliter on bronchoalveolar lavage (BAL) based on our previous study (PS). Because mortality from VAP is related to treatment delay, some have advocated a lower DT. The purpose of the current study (CS) was to evaluate the impact of adherence to this DT for VAP on false-negative (FN) rates and mortality in trauma patients. METHODS: Consecutive patients over 9 years with VAP (defined as ≥10 CFU/mL in the BAL effluent) subsequent to the PS were identified. Data regarding each BAL performed and the colony counts of each organism identified were recorded. An FN BAL result was defined as any patient who had less than 10 CFU/mL and developed VAP with the same organism up to 7 days after the previous culture. The CS was then compared with the PS. RESULTS: Over 9 years, 1,679 patients underwent 3,202 BALs. Of these, 79% were male, 88% experienced blunt injury, mean age and Injury Severity Score (ISS) were 44 years and 31, respectively. Overall, there were 73 FN BAL results (2.3%) in the CS compared with 3% in the PS (p = 0.092). In those patients with 10 organisms, the FN rate was reduced (7.5% vs. 11%, p = 0.045), and mortality was unchanged (5.4% vs. 8.3%, p = 0.361) in the CS compared with the PS. The use of the threshold equal to or greater than 10 resulted in a cumulative reduction in antibiotic charges of $1.57 million. CONCLUSION: Continued adherence to the diagnostic threshold of equal to or greater than 10 for quantitative BAL in trauma patients has maintained a low incidence of FN BALs and reduced patient charges without impacting mortality. The purported benefit of a lower threshold is not supported. In addition, the potential sequelae of increased resistant organisms, antibiotic-related complications, and costs associated with prolonged unnecessary antibiotic exposure are minimized. LEVEL OF EVIDENCE: Prognostic study, level III.

Traumatic brain injury and ß-blockers: not all drugs are created equal.

BACKGROUND: Dysautonomia in traumatic brain injury patients may contribute to secondary injury. We hypothesize that propranolol is the best ß-blocker (BB) to block the excess catecholamines and improve mortality in this patient population. METHODS: Patients with traumatic brain injury admitted during a 48-month period who received BB were compared with those who did not after excluding patients who received preinjury BB, deaths within 48 hours, and head Abbreviated Injury Scale (AIS) score of less than 3 or greater than 5. In addition, propranolol was also compared with all other BBs. RESULTS: A total of 1,755 patients with traumatic brain injury were identified during the study period after exclusions. Patients who received BB (427) were older (49 years vs. 40 years; p < 0.0001), were more severely injured (Injury Severity Score [ISS], 30 vs. 24; p < 0.001), and had a more severe head injury (head AIS score, 4.2 vs. 4.0; p < 0.001). By univariate analysis, BB patients had a higher mortality (13% vs. 6%; p < 0.001); after adjusted analysis, no difference was identified (adjusted odds ratio, 0.850; 95% confidence interval, 0.536-1.348). Seventy-eight patients (18%) received propranolol during the study period. Propranolol patients were younger (30 years vs. 53 years; p < 0.001) but more severely injured (ISS, 33 vs. 29; p = 0.01; head AIS, 4.5 vs. 4.2; p < 0.001), with longer stay (44 days vs. 26 days, p < 0.001). Mortality was less in the propranolol group (3% vs. 15%, p = 0.002). Adjusted analysis confirmed the protective effect of propranolol (adjusted odds ratio, 0.199; 95% confidence interval, 0.043-0.920). CONCLUSION: Propranolol is the best BB to limit secondary injury and decrease mortality in patients with traumatic brain injury. LEVEL OF EVIDENCE: Therapeutic, study level III.

Propofol infusion syndrome: a lethal condition in critically injured patients eliminated by a simple screening protocol.

UNLABELLED: Propofol infusion syndrome (PIS) is defined by arrhythmia, rhabdomyolysis, lactic acidosis, and unrecognized leads to death. We sought to determine the incidence of PIS in trauma patients and evaluate the efficacy of a prospective screening protocol in this patient population. MATERIALS AND METHODS: In Phase I of the before-and-after study (1st January, 2005-31st December, 2005), trauma patients who received propofol were evaluated. Records were reviewed for demographics, injury severity, propofol time, dose, and rates, laboratory values, and adverse events. Patients were identified with PIS based on two of the following criteria: (1) cardiac arrhythmia/collapse, (2) metabolic acidosis, (3) rhabdomyolysis, and (4) acute kidney injury. Phase II (1st January, 2006-31st December, 2011) consisted of a prospective screening protocol (elevated lactate or creatine phosphokinase (CPK)) to identify patients at risk for PIS. RESULTS: 207 patients were identified in Phase I. 6 (2.9%) developed PIS with a 50% mortality. No differences were seen in age, gender, or mechanism. PIS patients were more injured (median ISS 44 vs 26, p=0.04; median head AIS 5 vs 4, p=0.003) and received more propofol (median 50,350 vs 9770 mg, p=0.001) with longer infusion times (413 vs 65 h, p=0.001). Sodium, creatinine, and CPK levels were higher in those that developed PIS (160 vs 145 mmol/L, p=0.001; 4.3 vs 1.1mg/dL, p=0.005; 59,871 vs 520 U/L; p=0.002). Pre-screening PIS incidence was 2.9% (6/207), but after screening (January 2006) the incidence dropped to 0.19% (2/1038, p<0.001). CONCLUSIONS: PIS is a morbid and lethal entity associated with sedation of critically injured patients. A simple screening procedure utilizing serum CPK (<5000 U/L) can essentially eliminate the development of PIS.

Methicillin-resistant Staphylococcus aureus in early ventilator-associated pneumonia: cause for concern?

BACKGROUND: Ventilator-associated pneumonia (VAP) accounts for almost 90% of infections in mechanically ventilated patients and more than one-quarter of all patients requiring intubation, with associated mortality rates as high as 70%. The rise in methicillin resistance within the community has led to a national increase in methicillin-resistant Staphylococcus aureus (MRSA) rates in early VAP and associated healthcare expenditure. METHODS: Trauma patients identified via an institutional VAP database were stratified by gender, age, severity of shock (24-h transfusions), and severity of injury. The primary outcome measure was evaluation of the incidence and trend of early MRSA VAP over a 6-y period. Secondary outcomes examined the adequacy of our current empiric antibiotic regimen as it pertained to outcome variables, including mortality. RESULTS: A total of 997 episodes of VAP were identified in 727 patients. Linear regression showed that the incidence of early Staphylococcus aureus (SA) VAP was stable over the 6-y period (slope=-0.911; p=0.490). Over the same 6 y, however, the percentage of MRSA in early SA VAP (slope=3.95; p=0.0154) and the incidence of early MRSA VAP increased. No difference in mortality was detected between early methicillin-susceptible SA and early MRSA VAP. After adjustment for age, ISS, and 24-h transfusion requirements, early MRSA was not an independent predictor of mortality (odds ratio [OR], 0.815; p=0.59). CONCLUSIONS: Although the incidence of early SA VAP with methicillin resistance increased significantly within the first 7 d of admission, this study showed no difference in mortality and resource utilization between early VAP from MRSA and other causative organisms, despite lack of empiric MRSA coverage.

Beta-adrenergic blockade and traumatic brain injury: protective?

BACKGROUND: Catecholamine surge after traumatic brain injury (TBI) is associated with infectious morbidity and potentially preventable mortality. Previous studies have supported the protective effect of beta-adrenergic blockade in patients with TBI. We hypothesize that suppression of the catecholamine surge in multiple-injured TBI patients with beta-adrenergic blockade decreases mortality. METHODS: The trauma registry at an urban Level I trauma center was queried for blunt TBI from June 1, 2003, to December 31, 2007. Patients who received more than one dose of beta-blockers (BB) were identified by a review of the hospital pharmacy order database. χ² and Student's t tests were used where appropriate. After adjusting for age, injury severity score, admission Glasgow Coma Score, and transfusions multivariable logistic regression was performed to analyze whether receiving BB was protective in patients sustaining TBI. RESULTS: A total of 2,601 patients were admitted with blunt TBI during the study period. Of these, 506 patients (20%) received BB. Despite higher age (51 years vs. 38 years, p < 0.0001) and more severe head injury (head Abbreviated Injury Scale score 4.14 vs. 3.81, p < 0.0001), there was no difference in mortality (15% vs. 16%). Multivariable logistic regression identified BB as protective in patients sustaining head injury (odds ratio, 0.347; confidence interval, 0.246-0.490), when compared with those who did not receive BB, reducing mortality by 65%. CONCLUSIONS: BB are associated with significantly reduced mortality in patients with TBI. This simple, inexpensive intervention may have a profound effect on mortality in this population of injured patients and requires further prospective study.

Efficacy of monotherapy in the treatment of Pseudomonas ventilator-associated pneumonia in patients with trauma.

BACKGROUND: Controversy persists regarding the optimal treatment regimen for Pseudomonas ventilator-associated pneumonia (VAP). Combination antibiotic therapy is used to broaden the spectrum of activity of empiric treatment and provide synergistic bacteriocidal activity. The relevance of such "synergy" is commonly supposed but poorly supported. The purpose of this study was to evaluate the efficacy of monotherapy in the treatment of Pseudomonas VAP as measured by microbiological resolution. METHODS: Patients admitted to the trauma intensive care unit during a 36-month period with gram-negative VAP diagnosed on initial bronchoalveolar lavage (BAL) (> or = 10(5) colony forming units [CFU]/mL) were evaluated. All patients received empiric antibiotic monotherapy based on the duration of intensive care unit stay. Patients with Pseudomonas VAP were identified and appropriate monotherapy was selected. Repeat BAL was performed on day 4 of appropriate antibiotic therapy to determine efficacy. Microbiological resolution was defined as < or = 10(3) CFU/mL. Combination therapy with an aminoglycoside was reserved for patients with either persistent positive or increasing colony counts on repeat BAL. Recurrence was defined as > or = 10(5) CFU/mL on subsequent BAL after 2 weeks of appropriate therapy. RESULTS: One hundred ninety-six patients were identified with late gram-negative VAP. There were 84 patients with Pseudomonas VAP. Monotherapy achieved microbiological resolution in 79 patients (94.1%) with zero recurrence. Thirty-six isolates were completely eradicated at repeat BAL. Five patients (5.9%) required combination therapy to achieve resolution. CONCLUSIONS: Monotherapy in the treatment of Pseudomonas VAP has an excellent success rate in patients with trauma. Empiric monotherapy therapy should be modified once susceptibility of the microorganism is documented (all isolates were sensitive to cefepime) and antibiotic choice should be based on local patterns of susceptibilities. The routine use of combination therapy for synergy is unnecessary. Combination therapy should be reserved for patients with persistent microbiological evidence of Pseudomonas VAP despite adequate therapy.

Reduction in inadequate empiric antibiotic therapy for ventilator-associated pneumonia: impact of a unit-specific treatment pathway.

Empiric antibiotic therapy is routinely initiated for patients with presumed ventilator-associated pneumonia (VAP). Reported mortality rates for inadequate empiric antibiotic therapy (IEAT) for VAP range from 45 to 91 per cent. The purpose of this study was to determine the effect of a unit-specific pathway for the empiric management of VAP on reducing IEAT episodes and improving outcomes in trauma patients. Patients admitted with VAP over 36-months were identified and stratified by gender, age, severity of shock, and injury severity. Outcomes included number of IEAT episodes, ventilator days, intensive care unit days, hospital days, and mortality. Three hundred and ninety-three patients with 668 VAP episodes were identified. There were 144 (22%) IEAT episodes: significantly reduced compared with our previous study (39%) (P < 0.001). Patients were classified by number of IEAT episodes: 0 (n = 271), 1 (n = 98) and > or = 2 (n = 24). Mortality was 12 per cent, 13 per cent, and 38 per cent (P < 0.001), respectively. Multivariable logistic regression identified multiple IEAT episodes as an independent predictor of mortality (odds ratio = 4.7; 95% confidence interval: 1.684-13.162). Multiple IEAT episodes were also associated with prolonged mechanical ventilation and intensive care unit stay (P < 0.001). Trauma patients with multiple IEAT episodes for VAP have increased morbidity and mortality. Adherence to a unit-specific pathway for the empiric management of VAP reduces multiple IEAT episodes. By limiting IEAT episodes, resource utilization and hospital mortality are significantly decreased.