Computer versus paper system for recognition and management of sepsis in surgical intensive care.

BACKGROUND: A system to provide surveillance, diagnosis, and protocolized management of surgical intensive care unit (SICU) sepsis was undertaken as a performance improvement project. A system for sepsis management was implemented for SICU patients using paper followed by a computerized system. The hypothesis was that the computerized system would be associated with improved process and outcomes. METHODS: A system was designed to provide early recognition and guide patient-specific management of sepsis including (1) modified early warning signs-sepsis recognition score (MEWS-SRS; summative point score of ranges of vital signs, mental status, white blood cell count; after every 4 hours) by bedside nurse; (2) suspected site assessment (vascular access, lung, abdomen, urinary tract, soft tissue, other) at bedside by physician or extender; (3) sepsis management protocol (replicable, point-of-care decisions) at bedside by nurse, physician, and extender. The system was implemented first using paper and then a computerized system. Sepsis severity was defined using standard criteria. RESULTS: In January to May 2012, a paper system was used to manage 77 consecutive sepsis encounters (3.9 ± 0.5 cases per week) in 65 patients (77% male; age, 53 ± 2 years). In June to December 2012, a computerized system was used to manage 132 consecutive sepsis encounters (4.4 ± 0.4 cases per week) in 119 patients (63% male; age, 58 ± 2 years). MEWS-SRS elicited 683 site assessments, and 201 had sepsis diagnosis and protocol management. The predominant site of infection was abdomen (paper, 58%; computer, 53%). Recognition of early sepsis tended to occur more using the computerized system (paper, 23%; computer, 35%). Hospital mortality rate for surgical ICU sepsis (paper, 20%; computer, 14%) was less with the computerized system. CONCLUSION: A computerized sepsis management system improves care process and outcome. Early sepsis is recognized and managed with greater frequency compared with severe sepsis or septic shock. The system has a beneficial effect as a clinical standard of care for SICU patients. LEVEL OF EVIDENCE: Therapeutic study, level III.

A better understanding of why murine models of trauma do not recapitulate the human syndrome.

OBJECTIVE: Genomic analyses from blood leukocytes have concluded that mouse injury poorly reflects human trauma at the leukocyte transcriptome. Concerns have focused on the modest severity of murine injury models, differences in murine compared with human age, dissimilar circulating leukocyte populations between species, and whether similar signaling pathways are involved. We sought to examine whether the transcriptomic response to severe trauma in mice could be explained by these extrinsic factors, by utilizing an increasing severity of murine trauma and shock in young and aged mice over time, and by examining the response in isolated neutrophil populations. DESIGN: Preclinical controlled in vivo laboratory study and retrospective cohort study. SETTING: Laboratory of Inflammation Biology and Surgical Science and multi-institution level 1 trauma centers. SUBJECTS: Six- to 10-week-old and 20- to 24-month-old C57BL/6 (B6) mice and two cohorts of 167 and 244 severely traumatized (Injury Severity Score > 15) adult (> 18 yr) patients. INTERVENTIONS: Mice underwent one of two severity polytrauma models of injury. Total blood leukocyte and neutrophil samples were collected. MEASUREMENTS AND MAIN RESULTS: Fold expression changes in leukocyte and neutrophil genome-wide expression analyses between healthy and injured mice (p < 0.001) were compared with human total and enriched blood leukocyte expression analyses of severe trauma patients at 0.5, 1, 4, 7, 14, and 28 days after injury (Glue Grant trauma-related database). We found that increasing the severity of the murine trauma model only modestly improved the correlation in the transcriptomic response with humans, whereas the age of the mice did not. In addition, the genome-wide response to blood neutrophils (rather than total WBC) was also not well correlated between humans and mice. However, the expression of many individual gene families was much more strongly correlated after injury in mice and humans. CONCLUSIONS: Although overall transcriptomic association remained weak even after adjusting for the severity of injury, age of the animals, timing, and individual leukocyte populations, there were individual signaling pathways and ontogenies that were strongly correlated between mice and humans. These genes are involved in early inflammation and innate/adaptive immunity.

Persistent inflammation, immunosuppression, and catabolism syndrome after severe blunt trauma.

BACKGROUND: We recently proffered that a new syndrome persistent inflammation, immunosuppression, and catabolism syndrome (PICS) has replaced late multiple-organ failure as a predominant phenotype of chronic critical illness. Our goal was to validate this by determining whether severely injured trauma patients with complicated outcomes have evidence of PICS at the genomic level. METHODS: We performed a secondary analysis of the Inflammation and Host Response to Injury database of adults with severe blunt trauma. Patients were classified into complicated, intermediate, and uncomplicated clinical trajectories. Existing genomic microarray data were compared between cohorts using Ingenuity Pathways Analysis. Epidemiologic data and outcomes were also analyzed between cohorts on admission, Day 7, and Day 14. RESULTS: Complicated patients were older, were sicker, and required increased ventilator days compared with the intermediate/uncomplicated patients. They also had persistent leukocytosis as well as low lymphocyte and albumin levels compared with uncomplicated patients. Total white blood cell leukocyte analysis in complicated patients showed that overall genome-wide expression patterns and those patterns on Days 7 and 14 were more aberrant from control subjects than were patterns from uncomplicated patients. Complicated patients also had significant down-regulation of adaptive immunity and up-regulation of inflammatory genes on Days 7 and 14 (vs. magnitude in fold change compared with control and in magnitude compared with uncomplicated patients). On Day 7, complicated patients had significant changes in functional pathways involved in the suppression of myeloid cell differentiation, increased inflammation, decreased chemotaxis, and defective innate immunity compared with uncomplicated patients and controls. Subset analysis of monocyte, neutrophil, and T-cells supported these findings. CONCLUSION: Genomic analysis of patients with complicated clinical outcomes exhibit persistent genomic expression changes consistent with defects in the adaptive immune response and increased inflammation. Clinical data showed persistent inflammation, immunosuppression, and protein depletion. Overall, the data support the hypothesis that patients with complicated clinical outcomes are exhibiting PICS. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Acute kidney injury is surprisingly common and a powerful predictor of mortality in surgical sepsis.

BACKGROUND: Acute kidney injury (AKI) is a common and often catastrophic complication in hospitalized patients; however, the impact of AKI in surgical sepsis remains unknown. We used Risk, Injury, Failure, Loss, End stage (RIFLE) consensus criteria to define the incidence of AKI in surgical sepsis and characterize the impact of AKI on patient morbidity and mortality. METHODS: Our prospective, institutional review board-approved sepsis research database was retrospectively queried for the incidence of AKI by RIFLE criteria, excluding those with chronic kidney disease. Patients were grouped into sepsis, severe sepsis, and septic shock by refined consensus criteria. Data including demographics, baseline biomarkers of organ dysfunction, and outcomes were compared by Student's t test and χ test. Multivariable regression analysis was performed for the effect of AKI on mortality adjusting for age, sex, African-American race, elective surgery, Acute Physiology and Chronic Health Evaluation II score, septic shock versus severe sepsis, and sepsis source. RESULTS: During the 36-month study period ending on December 2010, 246 patients treated for surgical sepsis were evaluated. AKI occurred in 67% of all patients, and 59%, 60%, and 88% of patients had sepsis, surgical sepsis, and septic shock, respectively. AKI was associated with Hispanic ethnicity, several baseline biomarkers of organ dysfunction, and a greater severity of illness. Patients with AKI had fewer ventilator-free and intensive care unit-free days and a decreased likelihood of discharge to home. Morbidity and mortality increased with severity of AKI, and AKI of any severity was found to be a strong predictor of hospital mortality (odds ratio, 10.59; 95% confidence interval, 1.28-87.35; p = 0.03) in surgical sepsis. CONCLUSION: AKI frequently complicates surgical sepsis, and serves as a powerful predictor of hospital mortality in severe sepsis and septic shock. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Is there value in plasma cytokine measurements in patients with severe trauma and sepsis?

For the past thirty years, since IL-1ß and TNFα were first cloned, there have been efforts to measure plasma cytokine concentrations in patients with severe sepsis and trauma, and to use these measurements to predict clinical outcome and response to therapies. The numbers of cytokines and chemokines that have been measured in the plasma have literally exploded with the development of multiplex immune approaches. Dozens of relatively small cohort studies have shown plasma cytokine concentrations correlating with outcome in sepsis and trauma. Despite what appears to be a consensus that plasma cytokine concentrations should be useful in the clinical setting, only two cytokines, IL-6 and procalcitonin, have approached routine clinical use. IL-6 has been used as a research tool for entry into sepsis-intervention trials, while procalcitonin is being used clinically at a large number of institutions to distinguish sepsis from other inflammatory processes. For most cytokines, the relative lack of sensitivity and specificity of individual or multiplex cytokine measurements has hindered their utility to predict clinical trajectory in individual patients. The problem rests with a general misunderstanding of cytokine biology, failing to appreciate the general paracrine nature of these mediators, the presence of binding proteins, chaperones and inhibitors in the plasma, and the rapid clearance of these proteins by binding to cell receptors and clearance predominantly by the kidney. The future of using plasma cytokine measurements as an indicator of sepsis/trauma severity or predicting outcome is generally behind us, although there is optimism that procalcitonin measurements may ultimately prove to have utility in the diagnosis of severe sepsis.

Persistent inflammation and immunosuppression: a common syndrome and new horizon for surgical intensive care.

Surgical intensive care unit (ICU) stay of longer than 10 days is often described by the experienced intensivist as a "complicated clinical course" and is frequently attributed to persistent immune dysfunction. "Systemic inflammatory response syndrome" (SIRS) followed by "compensatory anti-inflammatory response syndrome" (CARS) is a conceptual framework to explain the immunologic trajectory that ICU patients with severe sepsis, trauma, or emergency surgery for abdominal infection often traverse, but the causes, mechanisms, and reasons for persistent immune dysfunction remain unexplained. Often involving multiple-organ failure (MOF) and death, improvements in surgical intensive care have altered its incidence, phenotype, and frequency and have increased the number of patients who survive initial sepsis or surgical events and progress to a persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Often observed, but rarely reversible, these patients may survive to transfer to a long-term care facility only to return to the ICU, but rarely to self-sufficiency. We propose that PICS is the dominant pathophysiology and phenotype that has replaced late MOF and prolongs surgical ICU stay, usually with poor outcome. This review details the evolving epidemiology of MOF, the clinical presentation of PICS, and our understanding of how persistent inflammation and immunosuppression define the pathobiology of prolonged intensive care. Therapy for PICS will involve innovative interventions for immune system rebalance and nutritional support to regain physical function and well-being.

The epidemiology of sepsis in general surgery patients.

BACKGROUND: Sepsis is increasing in hospitalized patients. Our purpose is to describe its current epidemiology in a general surgery (GS) intensive care unit (ICU) where patients are routinely screened and aggressively treated for sepsis by an established protocol. METHODS: Our prospective, Institutional Review Board-approved sepsis research database was queried for demographics, biomarkers reflecting organ dysfunction, and mortality. Patients were grouped as sepsis, severe sepsis, or septic shock using refined consensus criteria. Data are compared by analysis of variance, Student's t test, and χ test (p<0.05 significant). RESULTS: During 24 months ending September 2009, 231 patients (aged 59 years ± 3 years; 43% men) were treated for sepsis. The abdomen was the source of infection in 69% of patients. Several baseline biomarkers of organ dysfunction (BOD) correlated with sepsis severity including lactate, creatinine, international normalized ratio, platelet count, and d-dimer. Direct correlation with mortality was noted with particular baseline BODs including beta natriuretic peptide, international normalized ratio, platelet count, aspartate transaminase, alanine aminotransferase, and total bilirubin. Most patients present with severe sepsis (56%) or septic shock (26%) each with increasing multiple BODs. Septic shock has prohibitive mortality rate (36%), and those who survive septic shock have prolonged ICU stays. CONCLUSION: In general surgery ICU patients, sepsis is predominantly caused by intra-abdominal infection. Multiple BODs are present in severe sepsis and septic shock but are notably advanced in septic shock. Despite aggressive sepsis screening and treatment, septic shock remains a morbid condition.

Computer protocol facilitates evidence-based care of sepsis in the surgical intensive care unit.

BACKGROUND: Care of sepsis has been the focus of intense research and guideline development for more than two decades. With ongoing success of computer protocol (CP) technology and with publication of Surviving Sepsis Campaign (SSC) guidelines, we undertook protocol development for management of sepsis of surgical intensive care unit patients in mid-2006. METHODS: A sepsis protocol was developed and implemented in The Methodist Hospital (TMH) (Houston, TX) surgical intensive care unit (27 beds) together with a sepsis research database. We compare paper-protocol (PP) (2008) and CP (2009) performance and results of the SSC guideline performance improvement initiative (2005-2008). TMH surgical intensive care unit sepsis protocol was developed to implement best evidence and to standardize decision making among surgical intensivists, nurse practitioners, and resident physicians. RESULTS: The 2008 and 2009 sepsis protocol cohorts had very similar number of patients, age, % male gender, Acute Physiology and Chronic Health Evaluation scoring system II, and Sequential Organ Failure Assessment scores. The 2008 PP patients had greater baseline lactate concentration consistent with greater mortality rate. Antibiotic agents were administered to 2009 CP cohort patients sooner than 2008 PP cohort patients. Both cohorts received similar volume of intravenous fluid boluses. Comparing 6-hour resuscitation bundle compliance, the 2009 CP cohort was substantially greater than SSC eighth quarter and 2008 PP cohorts (79% vs. 31% vs. 29%), and mortality rate was much less when using the CP (14% vs. 31% vs. 24%). CONCLUSIONS: Our comprehensive sepsis protocol has enabled rapid and consistent implementation of evidence-based care, and, implemented as a bedside CP, contributed to decreased mortality rate for management of surgical sepsis.

Identification of cardiac dysfunction in sepsis with B-type natriuretic peptide.

BACKGROUND: B-type natriuretic peptide (BNP) is secreted in response to myocardial stretch and has been used clinically to assess volume overload and predict death in congestive heart failure. More recently, BNP elevation has been demonstrated with septic shock and is predictive of death. How BNP levels relate to cardiac function in sepsis remains to be established. STUDY DESIGN: Retrospective review of prospectively gathered sepsis database from a surgical ICU in a tertiary academic hospital. Initial BNP levels, patient demographics, baseline central venous pressure levels, and in-hospital mortality were obtained. Transthoracic echocardiography was performed during initial resuscitation per protocol. RESULTS: During 24 months ending in September 2009, two hundred and thirty-one patients (59 ± 3 years of age, 43% male) were treated for sepsis. Baseline BNP increased with initial sepsis severity (ie, sepsis vs severe sepsis vs septic shock, by ANOVA; p < 0.05) and was higher in those who died vs those who lived (by Fisher's exact test; p < 0.05). Of these patients, 153 (66%) had early echocardiography. Low ejection fraction (<50%) was associated with higher BNP (by Fisher's exact test; p < 0.05) and patients with low ejection fraction had a higher mortality (39% vs 20%; odds ratio = 3.03). We found no correlation between baseline central venous pressure (12.7 ± 6.10 mmHg) and BNP (526.5 ± 82.10 pg/mL) (by Spearman's ρ, R(s) = .001) for the entire sepsis population. CONCLUSIONS: In surgical sepsis patients, BNP increases with sepsis severity and is associated with early systolic dysfunction, which in turn is associated with death. Monitoring BNP in early sepsis to identify occult systolic dysfunction might prompt earlier use of inotropic agents.

Computerized clinical decision support improves mortality in intra abdominal surgical sepsis.

BACKGROUND: The management of surgical sepsis is challenging because of the complexity of interventions. The authors therefore created a computerized clinical decision support program to facilitate this process, with the goal of improving abdominal sepsis mortality. METHODS: The authors evaluated a prospective database for all patients requiring surgery for abdominal sepsis. Patient demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained. Observed mortality was compared with predicted mortality using Fisher's exact test. RESULTS: Eighty-seven patients met the inclusion criteria. The average age was 59 ± 17.0 years, and 39% were men. The most common source of infection was the colon (45%). The average Acute Physiology and Chronic Health Evaluation II score was 27.6 ± 9.72. The overall actual mortality rate for the cohort was 24% compared with a predicted Acute Physiology and Chronic Health Evaluation II mortality of 62.5% (P < .0001). CONCLUSION: The use of computerized clinical decision support results in significantly improved survival in patients with intra-abdominal surgical sepsis.

Performance of a computerized protocol for trauma shock resuscitation.

BACKGROUND: A computerized protocol was developed and used to standardize bedside clinician decision making for resuscitation of shock due to severe trauma during the first day in the intensive care unit (ICU) at a metropolitan Level I trauma center. We report overall performance of a computerized protocol for resuscitation of shock due to severe trauma, incorporating two options for resuscitation monitoring and intervention intensity, according to: (1) duration of use and (2) acceptance of computerized protocol-generated instructions. METHODS: A computerized protocol operated by clinicians, using a personal computer (PC) at the bedside, was used to guide clinical decision making for resuscitation of patients meeting specific injury and shock criteria. The protocol generated instructions that could be accepted or declined. Clinician acceptance of the protocol instructions was stored by the PC software in a database for each patient. A rule-based, data-driven protocol was developed using literature evidence, expert opinion, and ongoing protocol performance analysis. Logic-flow diagrams were used to facilitate communication among multidisciplinary protocol development team members. The protocol was computerized using standard programming methods and implemented using cart-mounted PCs with a touch screen and keyboard interfaces. Protocol progression began with patient demographic data and criteria entry, confirmation of hemodynamic monitor instrumentation, request for specific hemodynamic performance data, and instructions for specific interventions (or no intervention). Use and performance of the computerized protocol was recorded in a protocol execution database. The protocol was continuously maintained with new literature evidence and database performance analysis findings. Initially implemented in 2000, the computerized protocol was refined in 2004 with two options for resuscitation intensity: pulmonary artery catheter- and central venous pressure-directed resuscitation. RESULTS: Over 2 years ending at August 2006, a total of 193 trauma patients (mean Injury Severity Score was 27, survival rate 89%) were resuscitated using the computerized protocol. Protocol duration was 4400 hours or 22.7 +/- 0.4 hours per patient. The computerized protocol generated 3724 instructions (19 +/- 1 per patient) that required a bedside clinician response. In all, 94% of these instructions were accepted by the bedside clinician users. CONCLUSIONS: A computerized protocol to guide decision making for trauma shock resuscitation in a Level 1 trauma center surgical ICU was developed and used as standard of care. During 2 years ending at August 2006, 94% of computer-generated instructions for specific interventions or measurements of hemodynamic performance were accepted by bedside clinicians, indicating appropriate, useful design and reliance on the computerized protocol system.

Central venous pressure versus pulmonary artery catheter-directed shock resuscitation.

Previously, we developed a protocol for shock resuscitation of severe trauma patients to reverse shock and regain hemodynamic stability during the first 24 intensive care unit (ICU) hours. Key hemodynamic measurements of cardiac output and preload were obtained using a pulmonary artery catheter (PAC). As an alternative, we developed a protocol that used central venous pressure (CVP) to guide decision making for interventions to regain hemodynamic stability [mean arterial pressure (MAP) >or= 65 mmHg and heart rate (HR) or= 6 mEq/L or systolic blood pressure < 90 mmHg, 3) transfusion of >or= 1 unit packed red blood cells (PRBC), or >or= age 65 years with two of three criteria. Patients with brain injury were excluded. Data were recorded prospectively. In 24 months ending July 31, 2006, of 193 patients, 114 (59%) were assigned CVP- directed resuscitation, and 79 (41%) were assigned PAC-directed resuscitation. A subgroup of 11 (10%) initially assigned CVP was reassigned PAC-directed resuscitation (7 +/- 2 h after start) due to hemodynamic instability. Crystalloid fluid and PRBC resuscitation volumes for PAC (8 +/- 1 L lactated Ringer's [LR], 5 +/- 0.4 units PRBC) were > CVP (5 +/- 0.4 L LR, 3 +/- 0.3 units PRBC) and similar to CVP - PAC protocol subgroup patients (9 +/- 2 L LR, 5 +/- 1 units PRBC). Intensive care unit (ICU) stay and survival rate for PAC (18 +/- 2 days, 75%) were similar to CVP - PAC (17 +/- 4 days, 73%) and worse than CVP protocol subgroup patients (9 +/- 1 days, 98%). Traumatic shock resuscitation is feasible using CVP as a primary hemodynamic monitor as part of a protocol that includes explicit definition of hemodynamic instability and where PAC monitoring is readily available. Computerized decision support provides a technique to implement complex protocol care processes and analyze patient response.

Early cytokine production risk stratifies trauma patients for multiple organ failure.

BACKGROUND: Shock is a prime inciting event for postinjury multiple organ failure (MOF), believed to induce a state of injurious systemic inflammation. In animal models of hemorrhagic shock, early (< 24 hours) changes in cytokine production are an index of the systemic inflammatory response syndrome. However, their predictive value in trauma patients remains to be fully elucidated. STUDY DESIGN: In a prospective observational pilot study of > 1 year at an urban Level I trauma center, serial (every 4 hours) serum cytokine levels were determined during a 24-hour period using multiplex suspension immunoassay in patients with major torso trauma (excluding severe brain injury) who met criteria for standardized shock resuscitation. Temporal cytokine expression was assessed during shock resuscitation in severe trauma patients to predict risk for MOF. MOF was assessed with the Denver score. RESULTS: Of 48 study patients (mean age 39 +/- 3 years, 67% men, 88% blunt mechanism, mean Injury Severity Score 25 +/- 2), MOF developed in 11 (23%). MOF patients had a considerably higher mortality (64% versus 3%) and fewer ICU-free days (3.5 +/- 2 versus 17.8 +/- 1.3 days) compared with non-MOF patients. Traditional predictors of MOF, including age (45 +/- 7 versus 38 +/- 3 years; p=0.21), Injury Severity Score (26 +/- 3 versus 25 +/- 2; p=0.67), admission hemoglobin (11.4 +/- 0.9 versus 12.1 +/- 0.5 g/dL; p=0.22), international normalized ratio (1.6 +/- 0.2 versus 1.4 +/- 0.06; p=0.17), and base deficit (9.0 +/- 2 versus 7.1 +/- 0.8; p=0.19), were not significantly different between MOF and non-MOF patients. Statistical analysis identified six candidate predictors of MOF: inducible protein 10, macrophage inflammatory protein-1beta, interleukin-10, interleukin-6, interleukin-1Ra, and eotaxin. CONCLUSIONS: These data provide insight into cytokine expression during traumatic shock that can enable earlier identification of patients at risk for development of MOF.

Validation of a screening tool for the early identification of sepsis.

BACKGROUND: Sepsis is the leading cause of mortality in noncoronary intensive care units. Recent evidence based guidelines outline strategies for the management of sepsis and studies have shown that early implementation of these guidelines improves survival. We developed an extensive logic-based sepsis management protocol; however, we found that early recognition of sepsis was a major obstacle to protocol implementation. To improve this, we developed a three-step sepsis screening tool with escalating levels of decision making. We hypothesized that aggressive screening for sepsis would improve early recognition of sepsis and decrease sepsis-related mortality by insuring early appropriate interventions. METHODS: Patients admitted to the surgical intensive care unit were screened twice daily by our nursing staff. The initial screen assesses the systemic inflammatory response syndrome parameters (heart rate, temperature, white blood cell count, and respiratory rate) and assigns a numeric score (0-4) for each. Patients with a score of > or = 4 screened positive proceed to the second step of the tool in which a midlevel provider attempts to identify the source of infection. If the patients screens positive for both systemic inflammatory response syndrome and an infection, the intensivist was notified to determine whether to implement our sepsis protocol. RESULTS: Over 5 months, 4,991 screens were completed on 920 patients. The prevalence of sepsis was 12.2%. The screening tool yielded a sensitivity of 96.5%, specificity of 96.7%, a positive predictive value of 80.2%, and a negative predictive value of 99.5%. In addition, sepsis-related mortality decreased from 35.1% to 23.3%. CONCLUSIONS: The three step sepsis screening tool is a valid tool for the early identification of sepsis. Implementation of this tool and our logic-based sepsis protocol has decreased sepsis-related mortality in our SICU by one third.

Is there a role for aggressive use of fresh frozen plasma in massive transfusion of civilian trauma patients?

BACKGROUND: Damage control resuscitation (DCR) with early plasma in combat casualties requiring massive transfusion (MT) decreases early deaths from bleeding. METHODS: To ascertain the potential role of early plasma DCR in civilian MT, we queried a prospective traumatic shock database of 383 civilians. RESULTS: Ninety-three (24%) of the traumatic shock civilians received a MT, of which 26 (28%) died early, predominantly from bleeding within 6 hours. Comparatively, this early MT death cohort arrived in more severe shock and were coagulopathic (mean INR 2.4). In the critical period of MT (ie, the first 3 hours), these patients received 20 U of packed red blood cells (PRBCs) but only 4 U of fresh frozen plasma (FFP). They remained severely acidotic and their coagulopathy worsened as they exsanquinated. CONCLUSION: Civilians who arrived in traumatic shock, required a MT, and died early had worsening coagulopathy, which was not treated. DCR with FFP may have a role in civilian trauma.

Computerized clinical decision support for traumatic shock resuscitation.

PURPOSE OF REVIEW: To review what we learned through implementation of computerized decision support for ICU resuscitation of major torso trauma patients who arrive in shock. RECENT FINDINGS: Overall, these patients respond well to preload-directed goal-orientated ICU resuscitation; however, the subset of patients destined to develop abdominal compartment syndrome do not respond well. In fact, this strategy precipitates the full-blown syndrome that is a new iatrogenic variant of multiple organ failure. The clinical trajectory of abdominal compartment syndrome starts early after emergency department admission and its course is fairly well defined by the time patients reach the ICU. It occurs in patients who arrive with severe bleeding that is not readily controlled. These patients require a very different emergency department management strategy. Hemorrhage control is paramount. Alternative massive transfusion protocols should be used with an emphasis on hemostasis and avoidance of excessive isotonic crystalloids. Finally, near-infrared spectroscopy that measures tissue hemoglobin saturation in skeletal muscle (StO2) is good at identifying high-risk patients. A falling StO2 in the setting of ongoing resuscitation is a harbinger of death from early exsanguination and multiple organ failure. SUMMARY: Fundamental changes are needed in the care of trauma patients who arrive in shock and require a massive transfusion.

Massive transfusion in trauma patients: tissue hemoglobin oxygen saturation predicts poor outcome.

BACKGROUND: Severely bleeding trauma patients requiring massive transfusion (MT) often experience poor outcomes. Our purpose was to determine the potential role of near infrared spectrometry derived tissue hemoglobin oxygen saturation (StO2) monitoring in early prediction of MT, and in the identification of those MT patients who will have poor outcomes. METHODS: Data from a prospective multi-institution StO2 monitoring study were analyzed to determine the current epidemiology of MT (defined as transfusion volume >/=10 units packed red blood cells in 24 hours of hospitalization). Multivariate logistic regression was used to develop prediction models. RESULTS: Seven US level I trauma centers (TC) enrolled 383 patients. 114 (30%) required MT. MT progressed rapidly (40% exceeded MT threshold 2 hours after TC arrival, 80% after 6 hours). One third of MT patients died. Two thirds of deaths were due to early exsanguination and two thirds of early exsanguination patients died within 6 hours. One third of the early MT survivors developed multiple organ dysfunction syndrome. MT could be predicted with standard, readily available clinical data within 30 minutes and 60 minutes of TC arrival (area under the receiver operating characteristic curve = 0.78 and 0.80). In patients who required MT, StO2 was the only consistent predictor of poor outcome (multiple organ dysfunction syndrome or death). CONCLUSION: MT progresses rapidly to significant morbidity and mortality despite level I TC care. Patients who require MT can be predicted early, and persistent low StO2 identifies those MT patients destined to have poor outcome. The ultimate goal is to identify these high risk patients as early as possible to test new strategies to improve outcome. Further validation studies are needed to analyze appropriate allocation and study appropriate use of damage control interventions.

Computerized clinical decision support: a technology to implement and validate evidence based guidelines.

UNLABELLED: Faced with a documented crisis of patients not receiving appropriate care, there is a need to implement and refine evidence-based guidelines (EBGs) to ensure that patients receive the best care available. Although valuable in content, among their deficiencies, EBGs do not provide explicit methods to bring proven therapies to the bedside. Computerized information technology, now an integral part of the US healthcare system at all levels, presents clinicians with information from laboratory, imaging, physiologic monitoring systems, and many other sources. It is imperative that we clinicians use this information technology to improve medical care and efficacy of its delivery. If we do not do this, nonclinicians will use this technology to tell us how to practice medicine. Computerized clinical decision support (CCDS) offers a powerful method to use this information and implement a broad range of EBGs. CCDS is a technology that can be used to develop, implement, and refine computerized protocols for specific processes of care derived from EBGs, including complex care provided in intensive care units. We describe this technology as a desirable option for the trauma community to use information technology and maintain the trauma surgeon/intensivist's essential role in specifying and implementing best care for patients. We describe a process of logical protocol development based on standardized clinical decision making to enable EBGs. The resulting logical process is readily computerized, and, when properly implemented, provides a stable platform for systematic review and study of the process and interventions. CONCLUSION: : CCDS to implement and refine EBG derived computerized protocols offers a method to decrease variability, test interventions, and validate improved quality of care.

A report on associations among gastric pH, bleeding, duodenogastric reflux, and outcomes after trauma.

BACKGROUND: The pathogenesis of multiple organ failure (MOF) in trauma patients may involve the gastrointestinal tract, but its exact origins remain elusive. In a prospective study, the gastric fluid of major torso trauma patients was examined for evidence of duodenogastric reflux and potential gastric injury, and was compared with patient outcomes regarding MOF. METHODS: Patient samples were collected daily for 4 days by nasogastric tube and analyzed for pH, hemoglobin, and bile acid. Blood was collected for analysis of C-reactive protein (CRP). Outcomes were recorded for the presence or absence of MOF. RESULTS: The results showed that most patients exhibited alkaline gastric contents (pH >/=4.9) and elevated levels of hemoglobin immediately after the trauma. Although non-MOF patients demonstrated a decline of both mean gastric pH and bleeding by day 4, MOF patients maintained significant elevations in pH during this time period. Mean total bile acid levels were increased in all patients, signifying the presence of duodenogastric reflux. However, there were no clear differences in mean bile acid concentrations between MOF and non-MOF patients over time, although MOF patients tended to exhibit higher levels. All patients showed a progressive rise in serum CRP during the first 24 hours after trauma, which was maintained for 4 days. The initial rise in serum CRP in MOF patients was delayed compared with that in non-MOF patients. CONCLUSIONS: We conclude that duodenogastric reflux occurs in trauma patients in the first few days after trauma and may contribute to elevated gastric pH and bleeding. Further study is needed to verify whether monitoring the gastric juice of trauma patients during the first several days of hospitalization, for alkaline pH and excessive blood in the gastric lumen, could lead to better assessments of patient status.