Cervical spine MRI in patients with negative CT: A prospective, multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).

BACKGROUND: Although cervical spine CT (CSCT) accurately detects bony injuries, it may not identify all soft tissue injuries. Although some clinicians rely exclusively on a negative CT to remove spine precautions in unevaluable patients or patients with cervicalgia, others use MRI for that purpose. The objective of this study was to determine the rates of abnormal MRI after a negative CSCT. METHODS: Blunt trauma patients who either were unevaluable or had persistent midline cervicalgia and underwent an MRI of the C-spine after a negative CSCT were enrolled prospectively in eight Level I and II New England trauma centers. Demographics, injury patterns, CT and MRI results, and any changes in cervical spine management as a result of MRI imaging were recorded. RESULTS: A total of 767 patients had MRI because of cervicalgia (43.0%), inability to evaluate (44.1%), or both (9.4%). MRI was abnormal in 23.6% of all patients, including ligamentous injury (16.6%), soft tissue swelling (4.3%), vertebral disc injury (1.4%), and dural hematomas (1.3%). Rates of abnormal neurological signs or symptoms were not different among patients with normal versus abnormal MRI. (15.2 vs. 18.8%, p = 0.25). The c-collar was removed in 88.1% of patients with normal MRI and 13.3% of patients with an abnormal MRI. No patient required halo placement, but 11 patients underwent cervical spine surgery after the MRI results. Six of the eleven had neurological signs or symptoms. CONCLUSIONS: In a select population of patients, MRI identified additional injuries in 23.6% of patients despite a normal CSCT. It is uncertain if this is a true limitation of CT technology or represents subtle injuries missed in the interpretation of the scan. The clinical significance of these abnormal MRI findings cannot be determined from this study group. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Postoperative delirium is associated with increased intensive care unit and hospital length of stays after liver transplantation.

BACKGROUND: Delirium is increasingly recognized as a common and important postoperative complication that significantly hinders surgical recovery. However, there is a paucity of data examining the incidence and impact of delirium after liver transplantation. METHODS: Retrospective case series in a tertiary care center examining all (n = 144) adult patients who underwent liver transplantation during a 6-y period. RESULTS: Delirium occurred in 25% of the patients with an average duration of 4.56 d. Patients who developed delirium were older (P = 0.007), had higher preoperative model for end-stage liver disease score (P = 0.019) and longer pretransplant hospital length of stay (LOS; P = 0.003). Patients with delirium were also more likely to have alcohol ingestion as an etiology of the liver failure (P = 0.033). Delirious patients had a trend toward increased ventilator days (P = 0.235) and significantly longer postoperative hospital (P = 0.001) and intensive care unit LOS (P = 0.001). Delirium was also associated with an increased frequency of hospital acquired infections including urinary tract infections (P = 0.005) and pneumonias (P = 0.001). CONCLUSIONS: Delirium is a common occurrence among liver transplant patients associated with increased complications and LOSs. Further prospective studies are needed to determine the specific risk factors in this complex population and to determine if delirium has an impact on long-term outcomes.

In situ pediatric trauma simulation: assessing the impact and feasibility of an interdisciplinary pediatric in situ trauma care quality improvement simulation program.

OBJECTIVE: This study aimed to evaluate the feasibility and measure the impact of an in situ interdisciplinary pediatric trauma quality improvement simulation program. METHODS: Twenty-two monthly simulations were conducted in a tertiary care pediatric emergency department with the aim of improving the quality of pediatric trauma (February 2010 to November 2012). Each session included 20 minutes of simulated patient care, followed by 30 minutes of debriefing that focused on teamwork, communication, and the identification of gaps in care. A single rater scored the performance of the team in real time using a validated assessment instrument for 6 subcomponents of care (teamwork, airway, intubation, breathing, circulation, and disability). Participants completed a survey and written feedback forms. RESULTS: A trend analysis of the 22 simulations found statistically significant positive trends for overall performance, teamwork, and intubation subcomponents; the strength of the upward trend was the strongest for the teamwork (τ = 0.512), followed by overall performance (τ = 0.488) and intubation (τ = 0.433). Two hundred fifty-one of 398 participants completed the participant feedback form (response rate, 63%), reporting that debriefing was the most valuable aspect of the simulation. CONCLUSIONS: An in situ interdisciplinary pediatric trauma simulation quality improvement program resulted in improved validated trauma simulation assessment scores for overall performance, teamwork, and intubation. Participants reported high levels of satisfaction with the program, and debriefing was reported as the most valuable component of the program.

Using the Rothman index to predict early unplanned surgical intensive care unit readmissions.

BACKGROUND: The Rothman index (RI) is a numerical score calculated hourly from 26 data points in the electronic medical record by a commercial software package. Although it is purported to serve as an indicator of change in a patient's condition, it has not been extensively evaluated in the literature. Our objective was to determine whether the RI can be used to predict early surgical intensive care unit (SICU) readmissions. METHODS: This is a single-institution, retrospective 12-month period review of all patients transferred from the SICU to the surgical floor. Patients readmitted to the SICU within 48 hours were compared with patients who did not require readmission during this time (control). Demographics and continuous RI scores were collected at admission, 24 hours before SICU transfer, and for the first 48 hours on the surgical floor or until readmission to the SICU. RESULTS: A total of 1,152 SICU patients were transferred to the surgical floor; 27 patients were readmitted within 48 hours of transfer. Demographics were similar in both groups. The SICU length of stay was longer in the readmission group (mean [SD], 4.7 [8.1] vs. 16.5 [15.2]; p < 0.001). The RI immediately before SICU transfer was higher in the control group (70.4 [20.3] vs. 49.1 [20.9], p < 0.001) and was uniformly improved from the RI at the initial SICU admission. In comparison, readmitted patients had more variable RI trends from admission to SICU transfer (mean Δ, 6.51; range, -54.10 to 48.6), and 40.74% of readmitted patients actually had a decreased RI score on transfer. No patient with a RI score greater than 82.90 required readmission within 48 hours. CONCLUSION: An increased RI score or a score greater than 82.90 correlates with appropriateness for SICU transfer to the surgical floor. A decreased RI score is strongly associated with SICU readmission within 48 hours and should be explored as a potential quality metric. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Continuous glucose monitoring in the surgical intensive care unit: concordance with capillary glucose.

BACKGROUND: The role of intensive glycemic control (IGC) in the surgical intensive care unit (SICU) remains controversial. Continuous glucose monitoring systems (CGMSs) may mitigate the major risk of IGC, namely hypoglycemia, and improve clinical outcomes. METHODS: All patients admitted to the SICU requiring insulin infusion were eligible. CGMS (Medtronic Guardian REAL-Time CGM, Northridge, CA) was placed in the subcutaneous tissue of the abdomen or thigh and calibrated every 8 hours, based on capillary (fingerstick) blood glucose (CBG) readings. Monitors were changed every 72 hours until 144 hours of observation was complete or insulin infusion stopped. CGM data were compared with CBG at least every 2 hours. Other data collected included demographics, diagnoses, fluid balance, doses of vasopressors and/or steroids, and any intravenous or enteral glucose source. CGMS and CBG readings were compared (mean and median absolute difference, correlation coefficients, Bland-Altman plots, and Clarke error grids). RESULTS: Twenty-four patients were enrolled (11 men; mean [SD] age, 59 [14.1] years; mean [SD] body mass index 37.9 [10.1] kg/m; mean [SD] fluid resuscitation in the first 24 hours, 6.1 [3.5] L; 17 requiring vasopressor therapy). Correlation coefficient between CGMS and CBG was 0.61 (p < 0.001). The mean (SD) absolute difference was 22.0 [21.9] mg/dL and the median absolute difference was 16.0 mg/dL (interquartile rage, 7-31 mg/dL). The Bland-Altman plot did not identify any trends in accuracy. Clarke error grid analysis demonstrated that 98.92% of data points were in Zone A (71.30%), indicating agreement with CBG ± 20%, or Zone B (27.62%) (divergent but discrepancy would likely not lead to patient harm). Just 0.81% of data points were in Zone C (potentially dangerous overcorrection likely), and only 0.27% were in Zones D or E (potentially dangerous failure to detect hypoglycemia/hyperglycemia). CONCLUSION: CGMS seems reasonably accurate in the SICU, despite widespread use of pressors and large-volume resuscitation. Further investigation into the accuracy and precision of these devices to assist clinicians in achieving IGC is warranted. LEVEL OF EVIDENCE: Diagnostic study, level III.