Image-Guided Resuscitation With Limited Transthoracic Echocardiogram in Pediatric Trauma Patients.

INTRODUCTION: Limited transthoracic echocardiogram (LTTE) has been shown to be a useful tool in guiding resuscitation in adult trauma patients. Our hypothesis is that image-guided resuscitation in pediatric trauma patients with LTTE is feasible. METHODS: A retrospective chart review was performed on highest level pediatric trauma alerts (age 18 years or younger) at our level I trauma center during a 6-month period. Patients were divided into 2 groups as follows: those who had LTTE performed (LTTE group) and those who did not have LTTE performed (non-LTTE group). RESULTS: A total of 31 charts were reviewed; 4 patients were excluded because they died on arrival to the emergency department. Fourteen patients had LTTE performed (LTTE group); 13 patients did not have LTTE performed (non-LTTE group). There was no difference in mechanism of injury, age, injury severity score, weight, or intensive care unit admission between the groups. The LTTE group received significantly less intravenous fluid than the non-LTTE group (1.2 vs 2.3 L, P = 0.0013).Within the LTTE group, 8 patients had "full" inferior vena cava (IVC) and 6 patients had "empty" IVC. There was no difference in injury severity score between these subgroups (P = 0.1018). Less fluid was given in the group labeled with full IVC [1.1 L (0.8-1.2)] than the group with empty IVC [2.4 L (1.7-2.6)], P = 0.0005. Four of the 6 patients with "empty" IVC had a confirmed source of bleeding. CONCLUSIONS: Limited transthoracic echocardiogram can limit the amount of unnecessary crystalloid resuscitation given to pediatric trauma patients who are not hypovolemic.

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: An Eastern Association for the Surgery of Trauma multicenter trial.

OBJECTIVES: The mortality of patients with Clostridium difficile-associated disease (CDAD) requiring surgery continues to be very high. Loop ileostomy (LI) was introduced as an alternative procedure to total colectomy (TC) for CDAD by a single-center study. To date, no reproducible results have been published. The objective of this study was to compare these two procedures in a multicentric approach to help the surgeon decide what procedure is best suited for the patient in need. METHODS: This was a retrospective multicenter study conducted under the sponsorship of the Eastern Association for the Surgery of Trauma. Demographics, medical history, clinical presentation, APACHE score, and outcomes were collected. We used the Research Electronic Data Capture tool to store the data. Mann-Whitney (continuous data) and Fisher exact (categorical data) were used to compare TC with LI. Logistic regression was performed to determine predictors of mortality. A propensity score analysis was done to control for potential confounders and determine adjusted mortality rates by procedure type. RESULTS: We collected data from 10 centers of patients who presented with CDAD requiring surgery between July 1, 2010 and July 30, 2014. Two patients died during the surgical procedure, leaving 98 individuals in the study. The overall mortality was 32%, and 75% had postoperative complications. Median age was 64.5 years; 59% were male. Concerning preoperative patient conditions, 54% were on pressors, 47% had renal failure, and 36% had respiratory failure. When comparing TC and LI, there was no statistical difference regarding these conditions. Univariate preprocedure predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. There was no statistical difference between the APACHE score of patients undergoing either procedure (TC, 22 vs LI, 16). Adjusted mortality (controlled for preprocedure confounders) was significantly lower in the LI group (17.2% vs 39.7%; p = 0.002). CONCLUSIONS: This is the first multicenter study comparing TC with LI for the treatment of CDAD. In this study, LI carried less mortality than TC. In patients without contraindications, LI should be considered for the surgical treatment of CDAD. LEVEL OF EVIDENCE: Therapeutic study, level III.

Low-Volume Resuscitation for Hemorrhagic Shock: Understanding the Mechanism of PEG-20k.

Hemorrhagic shock leads to cell and tissue swelling and no reflow from compressed capillaries. Cell impermeants, including polyethylene glycol-20,000 (PEG-20k), reverse ischemia-induced cell swelling, extend low-volume resuscitation (LVR) time after shock, and increase tolerance to the low-volume state. The purpose of this study was to explore the mechanisms of action of PEG-20k containing LVR solutions. We hypothesized that PEG-20k acts as both an oncotic agent and an impermeant in the microcirculation, which moves water out of the space and into the capillaries to affect peripheral capillary filling and enhanced perfusion during the low-volume state. Rats were hemorrhaged until arterial lactate reached 9-10 mM/liter. Then, saline-based LVR solutions containing various impermeant materials were administered (10% blood volume). The LVR times for these solutions were determined by measuring the amount of time required for plasma lactate to climb back to 9 to 10 mM after LVR administration (low-volume tolerance). Capillary blood flow was measured by colored microspheres, and blood volume was measured by fluorescein isothiocyanate-labeled albumin dilution. Gluconate (impermeant), albumin (colloid), and PEG-20k (hybrid) increased LVR time over saline by 4-, 3-, and 8-fold, respectively. The combination of impermeant + albumin produced a biologic effect that was similar to PEG-20k alone. Capillary blood flow and plasma volume were decreased after shock with saline LVR but increased with PEG-20k, relative to saline. These data are consistent with the hypothesis that PEG-20k may act by establishing multiple osmotic gradients in the microcirculation to drive cell-to-capillary water transfer during hypovolemic shock.

Piloting a pediatric trauma course in Western Jamaica: Lessons learned and future directions.

INTRODUCTION: Pediatric injuries are a leading cause of death in low- and middle-income countries (LMICs). Despite this, there are few formal pediatric-specific trauma educational initiatives available in LMICs. While new educational tools are being developed to address this, they have not been piloted in LMICs. In Jamaica, pediatric injuries are a leading cause of hospital admission but care is limited by a lack of training in triage and stabilization. Our objective was to implement and evaluate a pediatric trauma course in Jamaica to determine the impact this may have on further course development. MATERIALS AND METHODS: A pediatric trauma course was conducted at the Cornwall Regional Hospital in Montego Bay, Jamaica sponsored by the Children's Medical Services International, a nonprofit organization. Participants took part in six didactic modules, an infant airway intubation skills session, and three clinical simulation scenarios. Participants completed a postcourse survey at the conclusion of the course. RESULTS: Twenty-five participants including surgical, pediatric, and emergency medicine residents from regional- and district-level hospitals in Jamaica participated in the course. Participants viewed the course favorably. Strengths included good review of pediatric trauma physiology, short modules, hands-on practice, and applicable clinical scenarios. Using a Likert-type rating scale of 1 to 10, with 1 being minimal and 10 being very knowledgeable, precourse knowledge was ranked as 5.9, which increased to 9.2 after the course. Using a similar scale, the precourse comfort level to run a pediatric trauma was 4.9 and increased to 8.5 following the course. DISCUSSION: Implementation of this pilot pediatric trauma course was feasible and successful through collaboration with the hosting regional hospital. The lack of formal pediatric training can be overcome by a course such as this which includes both didactics and hands-on clinical patient simulations. LEVEL OF EVIDENCE: 4.

Low-volume resuscitation using polyethylene glycol-20k in a preclinical porcine model of hemorrhagic shock.

INTRODUCTION: Polyethylene glycol-20k (PEG-20k) is highly effective for low-volume resuscitation (LVR) by increasing tolerance to the low-volume state. In our rodent shock model, PEG-20k increased survival and expanded the "golden hour" 16-fold compared to saline. The molecular mechanism is largely attributed to normalizations in cell and tissue fluid shifts after low-flow ischemia resulting in efficient microvascular exchange. The objective of this study was to evaluate PEG-20k as an LVR solution for hemorrhagic shock in a preclinical model. METHODS: Anesthetized male Yorkshire pigs (30-40 kg) were hemorrhaged to a mean arterial pressure (MAP) of 35 to 40 mm Hg. Once lactate reached 7 mmol/L, either saline (n = 5) or 10% PEG-20k (n = 5) was rapidly infused at 10% calculated blood volume. The primary outcome was LVR time, defined by the time from LVR administration to the time when lactate again reached 7 mmol/L. Other outcomes measured included MAP, heart rate, cardiac output, mixed venous oxygen saturation, splanchnic blood flow, and hemoglobin. RESULTS: Relative to saline, PEG-20k given after controlled hemorrhage increased LVR time by 16-fold, a conservative estimate given that the lactate never rose after LVR in the PEG-20k group. Survival was 80% for PEG-20k LVR compared to 0% for the saline controls (p < 0.05). Polyethylene glycol-20k also significantly decreased heart rate after hemorrhage and increased cardiac output, MAP, splanchnic flow, and mixed venous oxygen saturation. Falling hemoglobin concentrations suggested sizable hemodilution from fluid shifts into the intravascular compartment. CONCLUSIONS: In a preclinical model of controlled hemorrhagic shock, PEG-20k-based LVR solution increased tolerance to the shock state 16-fold compared to saline. Polyethylene glycol-20k is a superior crystalloid for LVR that may increase safe transport times in the prehospital setting and find use in hospital emergency departments and operating rooms for patients awaiting volume replacement or normalization of cell, tissue, and compartment fluid volumes.

Donor gluconate rescues livers from uncontrolled donation after cardiac death.

BACKGROUND: Ischemia from organ preservation or donation causes cells and tissues to swell owing to loss of energy-dependent mechanisms of control of cell volume. These volume changes cause substantial preservation injury, because preventing these changes by adding cell impermeants to preservation solutions decreases preservation injury. The objective of this study was to assess if this effect could be realized early in uncontrolled donation after cardiac death (DCD) livers by systemically loading donors with gluconate immediately after death to prevent accelerated swelling injury during the warm ischemia period before liver retrieval. METHODS: Uncontrolled DCD rat livers were cold-stored in University of Wisconsin solution for 24 hours and reperfused on an isolated perfused liver (IPL) device for 2 hours or transplanted into a rat as an allograft for 7 days. Donors were pretreated with a solution of the impermeant gluconate or a saline control immediately after cardiac death. Livers were retrieved after 30 minutes. RESULTS: In vivo, gluconate infusion in donors immediately before or after cardiac death prevented DCD-induced increases in total tissue water, decreased vascular resistance, increased oxygen consumption and synthesis of adenosine triphosphate, increased bile production, decreased lactate dehydrogenase release, and decreased histology injury scores after reperfusion on the IPL relative to saline-treated DCD controls. In the transplant model, donor gluconate pretreatment significantly decreased both alanine aminotransferase the first day after transplantation and total bilirubin the seventh day after transplantation. CONCLUSION: Cell and tissue swelling plays a key role in preservation injury of uncontrolled DCD livers, which can be mitigated by early administration of gluconate solutions to the donor immediately after death.

New low-volume resuscitation solutions containing PEG-20k.

BACKGROUND: Hypovolemic shock reduces oxygen delivery and compromises energy-dependent cell volume control. Consequent cell swelling compromises microcirculatory flow, which reduces oxygen exchange further. The importance of this mechanism is highlighted by the effectiveness of cell impermeants in low-volume resuscitation (LVR) solutions in acute studies. The objectives of this study were to assess impermeants in survival models and to compare them with commonly used crystalloid solutions. METHODS: Adult rats were hemorrhaged to a pressure of 30 mm Hg to 35 mm Hg, held there until the plasma lactate reached 10 mM, and given an LVR solution (5-10% blood volume) with saline alone (control) and saline with various concentrations of polyethylene glycol-20k (PEG-20k), Hextend, or albumin. When lactate again reached 10 mM following LVR, full resuscitation was started with crystalloid and red blood cells. Rats were either euthanized (acute) or allowed to recover (survival). The LVR time, which is the time from the start of the LVR solution until the start of full resuscitation, was measured as was survival and diagnostic laboratory values. In some studies, the capillary oncotic reflection coefficient was determined for PEG-20k to determine its relative impermeant and oncotic effects. RESULTS: PEG-20k (10%) significantly increased LVR times relative to saline (eightfold), Hextend, and albumin. Lower amounts of PEG-20k (5%) were also effective but less so than 10% doses. PEG-20k maintained normal arterial pressure during the low-volume state. Survival of a 180-minute LVR time challenge was 0% in saline controls and 100% in rats given PEG-20k as the LVR solution. Surviving rats had normal laboratory values 24 hours later. PEG-20k had an oncotic reflection coefficient of 0.65, which indicates that the molecule is a hybrid cell impermeant with significant oncotic properties. CONCLUSION: PEG-20k-based LVR solutions are highly effective for inducing tolerance to the low-volume state and for improving survival.