Consequences of anemia in geriatric hip fractures: how low is too low?

Background: The transfusion threshold for low hemoglobin (Hgb) in geriatric patients with hip fractures is widely debated. In certain populations, low Hgb is associated with poor outcomes. Our objective was to evaluate the relationship between lowest Hgb and outcome to identify the Hgb threshold where poor outcomes were more prevalent. Methods: This retrospective cohort study included consecutive patients with hip fractures, aged ≥60 years, evaluated at two level 1 trauma centers from 2018 to 2021. Patients who did not undergo operative fixation or had a length of stay <1 day were excluded. The primary endpoint was adverse outcome defined as the composite of myocardial infarction, stroke, new-onset arrhythmia or death. We compared lowest Hgb and possible confounders between patients with and without adverse outcomes. Classification and regression tree (CART) analysis was performed to identify the threshold for Hgb where adverse outcomes were more prevalent. Multivariate analysis was performed. Results: We evaluated 935 patients. Mean age was 80±10 years; admission Hgb was 12.5±1.7 g/dL. Diabetes was present in 20%, and 20% had coronary artery disease. Adverse outcomes were noted in 57 patients (6.1%). CART identified ≤7.1 g/dL as the Hgb threshold where adverse outcomes were more prevalent (15% vs. 4.1%, p<0.001). Additionally, a greater number of adverse outcomes were noted in the subgroup of patients having both a hemoglobin ≤7.1 g/dL and advanced age (age >79 years (22%)). After controlling for age, American Society of Anesthesiologist Physical Status Classification (ASA), antiplatelet medication, admission Hgb, time to operation and blood transfusions, lowest Hgb ≤7.1 g/dL remained a risk factor for adverse outcomes. Conclusions: In geriatric patients with isolated hip fractures, Hgb ≤7.1 g/dL is associated with a significantly higher rate of adverse outcomes. This risk was most pronounced in patients older than 79 years; particular care should be taken in this demographic. Level of evidence/study type: Level III/prognostic and epidemiological.

Reversal of pre-injury factor-Xa inhibitors with prothrombin complex concentrates in patients following traumatic brain injury.

INTRODUCTION: There is substantial debate on the best method to reverse factor Xa-inhibitors in patients following traumatic brain injury (TBI). Prothrombin complex concentrates (PCC) have been used for this indication but their role has been questioned. This study reported failure rates with PCC in patients following TBI and as a secondary objective, compared 4-factor (4 F-PCC) and activated PCC (APCC). MATERIAL AND METHODS: Consecutive patients with TBI on factor Xa-inhibitors admitted to one of two trauma centers were retrospectively identified. Patients with penetrating TBI, delays in PCC administration (>6 h), receipt of tranexamic acid, factor VIIa or no follow up CT-scan were excluded. The primary outcome was treatment failure defined as hematoma expansion > 20% from baseline for SDH, EDH or IPH, a new hematoma not present on the initial CT scan or any expansion of a SAH or IVH. Hematoma expansion was further categorized as symptomatic or asymptomatic, designated by a change in the motor GCS score, neurologic exam or change ≥ 3 in NIH Stroke Scale. Multi-variate analysis was performed. RESULTS: There were 43 patients with a mean age of 77 ± 13 years with primarily mild TBI (95%) after a ground level fall (79%). The mean dose was 41 ± 12 units/kg. Sixty percent received 4 F-PCC and 40% APCC. The incidence of treatment failure was 28% (12/43). Of the 12 patients with hematoma expansion, only 3 were symptomatic (9.3%). Hematoma expansion with 4 F-PCC and APCC were similar (27% vs. 29%,p = .859). Only sex was associated with hematoma expansion on multivariate analysis [OR (95% CI) = 6.7 (1.1 - 40.9)]. CONCLUSION: PCC was an effective option for factor Xa inhibitor reversal following TBI. The relationship between radiographic expansion and clinical expansion was poor.

The safety of continuous fascia iliaca block in patients with hip fracture taking pre-injury anticoagulant and/or antiplatelet medications.

BACKGROUND: Fascia iliaca compartment block (FICB) is an effective method to treat pain in adult trauma patients with hip fracture. Of importance is the high prevalence of preinjury anticoagulants and antiplatelet medications in this population. To date, we have not identified any literature that has specifically evaluated the safety of FICB with continuous catheter infusion in patients on antiplatelet and/or anticoagulant therapy. The purpose of this study is to quantify the complication rate associated with FICB in patients who are actively taking prescribed anticoagulant and/or antiplatelet medications prior to injury and identify factors that may predispose patients to an adverse event. METHODS: This retrospective study included consecutive adult trauma patients (age ≥18) with hip fracture who underwent placement of FICB within 24 h of admission and had been taking anticoagulant and/or antiplatelet medications pre-injury. Patients were excluded if their catheter was placed more than 24 h post-hospital admission. Patients were evaluated for demographics, injury severity, laboratory values, medication history, receipt of coagulation-related reversal medications, and complications related to FICB placement. Complications included bleeding at the insertion site requiring catheter removal and 30-day catheter site infection. The incidence of complications was reported and risk factors for complications were identified using univariate and multivariate statistics. RESULTS: There were 124 patients included. The mean age was 81 ± 10 years, and the most common mechanism was ground level fall (94%). Most patients were taking single antiplatelet therapy (65%), followed by anticoagulant alone (21%), combined antiplatelet and anticoagulant therapy (7.3%) and dual antiplatelet therapy (7.3%). The most common antiplatelet was aspirin (88%) and the most common anticoagulant was warfarin (60%). Of the patients taking warfarin, the average INR on admission was 2.3 ± 0.8. Only 1 bleeding complication (0.8%) was noted in a patient prescribed clopidogrel pre-injury which occurred 5 days post-catheter placement. This same patient was noted to have superficial surgical site bleeding most likely secondary to the use of enoxaparin for post-operative deep venous thrombosis prophylaxis. There were 4 orthopedic superficial surgical site infections (3.2%), all remote from the catheter site. The pre-injury medication prescribed in these patients was aspirin 81 mg, aspirin 325 mg, rivaroxaban and dabigatran, respectively. No factors were associated with a complication thus multivariate analysis was not performed. CONCLUSION: The incidence of complications associated with fascia iliaca compartment block (FICB) in adult trauma patients prescribed pre-injury anticoagulants or antiplatelet medications is low. In this retrospective review, we did not identify any complications that were directly associated with the FICB procedure. Fascia iliaca block with continuous infusion catheter placement can be safely performed on patients who are on therapeutic anticoagulant and/or antiplatelet agents.

N -acetylcysteine is associated with reduction of postconcussive symptoms in elderly patients: A pilot study.

INTRODUCTION: N -acetylcysteine (NAC) may be neuroprotective by minimizing postconcussion symptoms after mild traumatic brain injury (TBI), but limited data exist. This study evaluated the effects of NAC on postconcussion symptoms in elderly patients diagnosed with mild TBI. METHODS: This prospective, quasirandomized, controlled trial enrolled patients 60 years or older who suffered mild TBI. Patients were excluded if cognitive function could not be assessed within 3-hours postinjury. Patients were allocated to receive NAC plus standard care, or standard care alone, based on the trauma center where they presented. The primary study outcome was the severity of concussive symptoms measured using the Rivermeade Postconcussion Symptoms Questionnaire (RPQ). Symptoms were evaluated on days 0, 7, and 30. The RPQ scores were compared both within and between treatment groups. RESULTS: There were 65 patients analyzed (NAC, n = 34; control, n = 31) with an average age of 76 ± 10 years. Baseline demographics and clinical variables were similar. No group differences in head Abbreviated Injury Scale score or Glasgow Coma Scale score were observed. Baseline RPQ scores (6 [0-20] vs. 11 [4-20], p = 0.300) were indistinguishable. The RPQ scores on day 7 (2 [0-8] vs. 10 [3-18], p = 0.004) and 30 (0 [0-4] vs. 4 [0-13], p = 0.021) were significantly lower in the NAC group. Within-group differences were significantly lower in the NAC ( p < 0.001) but not control group ( p = 0.319). CONCLUSION: N -acetylcysteine was associated with significant improvements in concussion symptoms in elderly patients with mild TBI. These results justify further research into using NAC to treat TBI. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Identification of Risk Factors for Acute Kidney Injury from Intravenous Ketorolac in Geriatric Trauma Patients.

BACKGROUND: Ketorolac is an effective analgesic but the potential for acute kidney injury (AKI) is concerning, particularly in geriatric "G-60 trauma" patients. The objectives of this study are to report the incidence of AKI in patients who receive ketorolac, identify risk factors for AKI, and develop a risk factor-guided algorithm for safe utilization. METHODS: This retrospective cohort study included trauma patients age 60 years and older who received intravenous ketorolac. The primary endpoint was the incidence of AKI. RESULTS: Among 316 patients evaluated, the incidence of AKI was 2.5%. Patients with AKI received more nephrotoxins, had more comorbidities, and higher use of loop diuretics or vasopressors. Loop diuretic therapy and number of comorbidities were independent predictors of AKI. CONCLUSIONS: Risk for AKI with ketorolac was low, being more prevalent with comorbidities or receipt of loop diuretics.

72nd Southwestern Surgical Congress Claude H. Organ, Jr. memorial lecture: Rise ofacutecareroboticsurgery forcommonemergencygeneralsurgeryconditions.

Dr. Claude Organ rose above poverty, racism, and untold insurmountable odds to become a masterful surgeon and revered leader in numerous academic and professional circles. But it's his impact on surgical education and his philosophy to "teach, give back, and keep advancing" that inspired this lecture. Acute care robotic surgery (ACRS) utilizes the strengths of robotic assisted laparoscopic surgery (RALS) for a high-volume population of emergency general surgery (EGS) patients. The future benefits of ACRS may include improvements in resident training, patient safety, and outcomes. General surgery residencies that have a robust ACRS program are likely to be more competitive than those without.

The Role of Desmopressin on Hematoma Expansion in Patients with Mild Traumatic Brain Injury Prescribed Pre-injury Antiplatelet Medications.

BACKGROUND/OBJECTIVE: Desmopressin (DDAVP) has been suggested for antiplatelet medication reversal in patients with traumatic brain injury (TBI) but there are limited data describing its effect on clinical outcomes. The purpose of this study was to evaluate the effect of DDAVP on hematoma expansion and thrombosis in patients with TBI who were prescribed pre-injury antiplatelet medications. METHODS: Consecutive adult patients who were admitted to our level I trauma center and prescribed pre-injury antiplatelet medications between July, 2012, and May, 2018, were retrospectively identified. Patients were excluded if their hospital length of stay was < 24 h, if DDAVP was administered by any route other than intravenous, if they received a DDAVP dose < 0.3 mcg/kg or there was no evidence of brain hemorrhage on computed tomography (CT) scan. Patients were stratified based on the use of DDAVP, and the incidence of hematoma expansion was compared between groups. Thrombotic events were reviewed as a secondary outcome. Multivariate analysis was utilized to control for confounding variables. RESULTS: Of 202 patients included in analysis, 158 (78%) received DDAVP. The mean age was 76 ± 12 years; the most common injury mechanism was falls (76%); 69% had acute subdural hematoma, and 49% had multi-compartmental hemorrhage. Initial Glasgow coma score was between 13 and 15 for 91% of patients. Aspirin was the most common antiplatelet regimen prescribed (N = 151, 75%), followed by dual antiplatelet regimens (N = 26, 13%) and adenosine diphosphate (ADP)-receptor inhibitors (N = 25, 12%). The incidence of hematoma expansion was 14% and 30% for patients who did and did not receive DDAVP, respectively (p = 0.015). After controlling for age, injury severity score, multi-compartmental hemorrhage, and receipt of pre-injury high-dose aspirin (> 81 mg), ADP-receptor inhibitors, oral anticoagulants, prothrombin complex concentrates or platelets in a multivariate analysis, the association between DDAVP and hematoma expansion remained significant (adjusted OR 0.259 [95% CI 0.103-0.646], p = 0.004). Thrombotic events were similar between the two groups (DDAVP, 2.5%, no DDAVP, 4.5%; p = 0.613). CONCLUSIONS: DDAVP was associated with a lower incidence of hematoma expansion in patients with mild TBI who were prescribed pre-injury antiplatelet medications. These results justify a randomized controlled trial to further evaluate the role of DDAVP for this indication.

Utilization of Augmented Renal Clearance in Trauma Intensive Care Scoring System to Improve Vancomycin Dosing in Trauma Patients at Risk for Augmented Renal Clearance.

Background: The Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) scoring system is a validated system to predict augmented renal clearance in trauma patients. This study examined the ability of the ARCTIC score to identify patients at risk for subtherapeutic vancomycin trough concentrations relative to estimated creatinine clearance (eCrCl) alone. Methods: Trauma patients admitted to the intensive care unit from September 2012 to December 2017 who received vancomycin and had a vancomycin trough concentration recorded were included. Patients were excluded if their serum creatinine concentration was >1.3 mg/dL, if they had received vancomycin doses <30 mg/kg per day, an improperly timed trough concentration measurement, or renal replacement therapy. The primary endpoint was an initial subtherapeutic vancomycin trough concentration (<10 mg/L). Classification and regression tree (CART) analysis was used to identify thresholds for the ARCTIC score and other continuous data where subtherapeutic troughs were more common. A step-wise logistic regression analysis was performed to control for confounders for subtherapeutic troughs whereby inclusion of ARCTIC was modeled sequentially after eCrCl. Results: A total of 119 patients with a mean age of 42 ± 17 years and eCrCl 142 ± 39 mL/min met the inclusion criteria. The mean daily vancomycin dose was 44 ± 9 mg/kg, and the incidence of subtherapeutic trough concentration was 46%. The CART analysis identified two variables creating three groups where subtherapeutic trough concentrations differed: eCrCl >105 mL/min and ARCTIC score ≥7, eCrCl >105 mL/min and ARCTIC score <7, and eCrCl ≤105 mL/min. The base logistic regression model identified eCrCl >105 mL/min and pelvic fracture as risk factors for subtherapeutic trough values. The final model included the addition of ARCTIC score ≥7, which improved the model significantly (p = 0.009). Predictors of subtherapeutic trough concentrations were (odds ratio [95% confidence interval]): eCrCl >105 mL/min (6.5 [1.66-25.07]), ARCTIC score ≥7 (3.26 [1.31-8.09]), and pelvic fracture (4.36 [1.27-14.93]). Conclusion: The ARCTIC score is useful when applied in conjunction with eCrCl. Patients with a eCrCl >105 mL/min and an ARCTIC score ≥7 may require a more aggressive dosing strategy.

Invasive fungal wound infection in an otherwise healthy trauma patient (Mucor Trauma).

BACKGROUND: Mucor fungi are found ubiquitously in the environment and rarely cause infections in humans. Mucormycosis is typically seen in immunocompromised patients, but has been increasingly documented in previously healthy trauma patients. Mortality due to these infections can be high due to delayed diagnosis from a subtle clinical presentation and spread of infection by angioinvasion. Early recognition and prompt treatment is critical for survival. We describe a case of invasive mucormycosis in a previously healthy trauma patient treated at a Level 1 trauma center. CASE REPORT: A 22-year-old male presented to the hospital after being involved in a motor vehicle accident. He sustained multiple traumatic injuries and developed multi-system organ failure within 48 hours of admission. He developed invasive, soft tissue mucormycosis (Rhizopus sp) at the laparotomy site, requiring multiple surgical debridements and prompt antifungal therapy. The fungus was also cultured from respiratory secretions and likely associated with his abdominal infection. We suspect the patient was predisposed to an invasive fungal infection in the setting of multi-system organ failure and multiple blood transfusions. The patient ultimately did well and continued to improve on follow up in the outpatient setting. CONCLUSIONS: Mucormycosis is a rare infection that has been increasingly documented in trauma patients. Early recognition together with prompt debridement and antifungal therapy is key to successful management. Understanding risk factors for post-traumatic mucormycosis should raise our index of suspicion and prompt early diagnosis and initiation of treatment. Aggressive debridement is a critical component of appropriate management due to the angioinvasive spread of the mucor fungi. This means frequent debridement beyond the demarcation of gangrenous tissue. The management of our patient demonstrates the importance of early recognition of the clinical presentation, prompt initiation of antifungal therapy, and aggressive debridement of the wound.

Lacosamide versus phenytoin for the prevention of early post traumatic seizures.

PURPOSE: To compare the efficacy and safety of lacosamide versus phenytoin for seizure prophylaxis following TBI. MATERIALS AND METHODS: All TBI patients who received prophylaxis with either phenytoin or lacosamide were retrospectively identified. The incidence of seizures within the first 7 days of injury were compared along with adverse effects requiring drug discontinuation. A planned sub-group analysis was performed for patients with severe TBI (GCS < 9). RESULTS: There were 481 patients (phenytoin, n = 116; lacosamide, n = 365). Demographics were similar but age (50 ±â€¯21 vs 58 ±â€¯22 years, P < .001) and initial GCS (11.3 ±â€¯4.3 vs 12.5 ±â€¯3.8, P = .010) were lower in the phenytoin group. The need for mechanical ventilation was higher (53% vs 38%, P = .004). Seizures occurred in 0.9% of the phenytoin group and 1.4% of the lacosamide group (P = 1.00). ADEs were significantly higher with phenytoin (5.2% vs 0.5%, P = .003). This difference remained significant upon multivariate analysis [OR(95% CI) = 9.4(1.8-48.9)]. Subgroup analysis for patients with severe TBI revealed no difference in seizures (phenytoin, 0% vs lacosamide, 1.5%; P = 1.00) but more ADEs with phenytoin (12.5% vs 0%, P = .010). CONCLUSION: There was no difference between lacosamide and phenytoin in the prevention of early post traumatic seizures in patients following TBI. Lacosamide may have a more tolerable side effect profile.

Utilization of Geriatric Consultation and Team-Based Care.

Geriatric surgical patients experience higher mortality and morbidity rates than their younger counterparts. Three models of geriatric surgical care are described, with a focus on people, plans, and evaluation. These models include geriatric consultation services, geriatric wards, and geriatric multidisciplinary teams. The optimal care plan should be definitive, aggressive, sustainable, safe, and effective, with consideration for patient treatment preferences and wishes.

Bilateral Pneumothoraces in a Trauma Patient After Dobhoff Tube Insertion.

BACKGROUND Dobhoff tube insertion is a common procedure used in the clinical setting to deliver enteral nutrition. Although it is often viewed as an innocuous bedside procedure, there are risks for numerous complications such as tracheobronchial insertion, which could lead to deleterious consequences. We present to our knowledge the first reported case of bilateral pneumothoraces caused by the insertion of a Dobhoff tube. In addition, we also discuss common pitfalls for confirming the positioning of Dobhoff tubes, as well as risk factors that can predispose a patient to improper tube placement. CASE REPORT We present the case of a 74-year-old male patient with multiple orthopedic injuries following an auto-pedestrian collision. Five attempts were made to place a Dobhoff tube to maintain enteral nutrition. Follow-up abdominal x-ray revealed displacement of the Dobhoff tube in the left pleural space. After removal of the tube, a follow-up chest x-ray revealed iatrogenic bilateral pneumothoraces. Acute hypoxemic respiratory failure ensued; therefore, bilateral chest tubes were placed. Over the next three weeks, the patient's respiratory status improved and both chest tubes were removed. The patient was eventually discharged to a skilled nursing facility. CONCLUSIONS Improper placement of Dobhoff tubes can lead to rare complications such as bilateral pneumothoraces. This unique case report of bilateral pneumothoraces after Dobhoff tube placement emphasizes the necessity of using proper diagnostic techniques for verifying proper tube placement, as well as understanding the risk factors that predispose a patient to a malpositioned tube.

Geriatric (G60) trauma patients with severe rib fractures: Is muscle sparing minimally invasive thoracotomy rib fixation safe and does it improve post-operative pulmonary function?

BACKGROUND: Patient outcomes after muscle sparing minimally invasive thoracotomy rib fixation (MSMIT-ORF) in geriatric G60 trauma patients remain poorly studied. This study determined the effect of MSMIT-ORF on pulmonary function (PFT). Non-operatively managed (NOM) patients were also described. METHODS: Medical records of G60 patients with severe rib fractures with PFTs measured before and after MSMIT-ORF were examined. Patient outcomes (MSMIT-ORF vs NOM) were adjusted in a multivariate logistic regression model. RESULTS: 64 patients underwent MSMIT-ORF, 135 were NOM patients. MSMIT-ORF treated patients showed improvements in PFTs on postoperative day 5, p = 0.001. After adjustment analysis, MSMIT-ORF was associated with increased hospital length of stay (OR 44.9; 95% CI, 9.8-205, p < 0.001), but a more favorable discharge disposition. There was no difference in the rates of pneumonia (p = 0.996) or death (p = 0.140). CONCLUSIONS: MSMIT-ORF is safe and improves pulmonary function in G60 trauma patients diagnosed with severe rib fractures. Future randomized control studies are needed for confirmation.

Stress Ulcer Prophylaxis in Neurocritical Care.

Stress ulcer prophylaxis (SUP) with acid-suppressive drug therapy is widely utilized in critically ill patients following neurologic injury for the prevention of clinically important stress-related gastrointestinal bleeding (CIB). Data supporting SUP, however, largely originates from studies conducted during an era where practices were vastly different than what is considered routine by today's standard. This is particularly true in neurocritical care patients. In fact, the routine provision of SUP has been challenged due to an increasing prevalence of adverse drug events with acid-suppressive therapy and the perception that CIB rates are sparse. This narrative review will discuss current controversies with SUP as they apply to neurocritical care patients. Specifically, the pathophysiology, prevalence, and risk factors for CIB along with the comparative efficacy, safety, and cost-effectiveness of acid-suppressive therapy will be described.

A multicenter evaluation of the optimal timing of surgical stabilization of rib fractures.

BACKGROUND: The optimal timing of surgical stabilization of rib fractures (SSRF) remains debated. We hypothesized that (1) demographic, radiologic, and clinical variables are associated with time to surgery and (2) shorter time to SSRF improves acute outcomes. METHODS: Prospectively collected SSRF databases from four trauma centers were merged and analyzed (2006-2016). The independent variable was days from hospital admission to SSRF (early [<1 day], mid [1-2 days], and late [3-10 days]). Outcomes included length of operation, number of ribs repaired, prolonged (>24 hours) mechanical ventilation, pneumonia, tracheostomy, length of stay, and mortality. Multivariable logistic regression was used to control for significant differences in covariates between groups. RESULTS: Five hundred fifty-one patients were analyzed. The median time to SSRF was 1 day (range, 0-10); 207 (37.6%) patients were in the early group, 168 (30.5%) in the midgroup, and 186 (31.9%) in the late group. There was a significant shift toward earlier SSRF over the study period. Time to SSRF was significantly associated with study center (p < 0.01), year of surgery (p < 0.01), age (p = 0.02), mechanism of injury (p = 0.04), and body mass index (p = 0.02). Injury severity was not associated with time to surgery. Despite repairing the same median number of ribs (4; range, 1-13), median length of surgery was 68 minutes longer for the late as compared to the early group (p < 0.01). After controlling for the aforementioned significant covariates, each additional hospital day before SSRF was independently associated with a 31% increased likelihood of pneumonia (p < 0.01), a 27% increased likelihood of prolonged mechanical ventilation (p < 0.01), and a 26% increased likelihood of tracheostomy (p < 0.01). CONCLUSION: Surgical stabilization of rib fractures within 1 day of admission is associated with certain demographic and physiologic variables. After controlling for confounding factors, early SSRF was accomplished using less operative time, and was associated with favorable outcomes. When indicated and feasible, SSRF should occur as early as possible. LEVEL OF EVIDENCE: Therapy, level III.

Identifying augmented renal clearance in trauma patients: Validation of the Augmented Renal Clearance in Trauma Intensive Care scoring system.

BACKGROUND: Augmented renal clearance (ARC) is common in trauma patients and associated with subtherapeutic antimicrobial concentrations. This study reported the incidence of ARC, identified ARC risk factors, and described a model to predict ARC (i.e., ARCTIC) that is specific to trauma patients. METHODS: Consecutive trauma patients who were admitted to the intensive care unit between March 2015 and January 2016 and had a measured creatinine clearance (CrCl) were considered for inclusion. Patients were excluded if their serum creatinine (SCr) was greater than 1.3 mg/dL. ARC was defined as a measured CrCl of 130 mL/min or greater. Demographic and trauma-specific variables were then compared, and multivariate analysis was performed. Using these results, a weighted scoring system was constructed and evaluated using receiver operating characteristic curve analysis. ARCTIC score cutoffs were chosen based on sensitivity, specificity, positive predictive value, and negative predictive value. The derived scoring system was then compared to a previously published scoring system for accuracy. RESULTS: There were 133 patients with a mean age of 48 ± 19 years and SCr of 0.8 ± 0.2 mg/dL. The mean measured CrCl was 168 ± 65 mL/min, and the incidence of ARC was 67%. Multivariate analysis revealed the following risk factors for ARC (age, <56: odds ratios [OR], 58.3; 95% confidence interval [CI], 5.2-658.9; age, 56 to 75: OR, 13.5; 95% CI, 1.2-151.7), SCr less than 0.7 mg/dL (OR, 12.5; 95% CI, 3-52.6), and male sex (OR, 6.9; 95% CI, 1.9-24.9). Using these results, the ARCTIC scoring system was: 4 points if younger than 56 years, 3 points if aged 56 years to 75 years, 3 points if SCr less than 0.7 mg/dL, and 2 points if male sex. Receiver operating characteristic curve analysis revealed an area (95% CI) of 0.813 (0.735-0.892) (p < 0.001). An ARCTIC score of 6 or higher had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.843, 0.682, 0.843, and 0.682, respectively. CONCLUSION: The incidence of ARC in trauma patients is high. The ARCTIC score represents a practical, pragmatic system that can be easily applied at the bedside. An ARCTIC score of 6 or higher represents an appropriate cutoff to screen for ARC where antimicrobial adjustments should be considered. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

The importance of empiric antibiotic dosing in critically ill trauma patients: Are we under-dosing based on augmented renal clearance and inaccurate renal clearance estimates?

BACKGROUND: An accurate assessment of creatinine clearance (CrCl) is essential when dosing medications in critically ill trauma patients. Trauma patients are known to experience augmented renal clearance (i.e., CrCl ≥130 mL/min), and the use of CrCl estimations may be inaccurate leading to under-/over-dosing of medications. As such, our Level I trauma center began using measured CrCl from timed urine collections to better assess CrCl. This study sought to determine the prevalence of augmented renal clearance and the accuracy of calculated CrCl in critically ill trauma patients. METHODS: This observational study evaluated consecutive ICU trauma patients with a timed 12-hour urine collection for CrCl. Data abstracted were patient demographics, trauma-related factors, and CrCl. Augmented renal clearance was defined as measured CrCl ≥130 mL/min. Bias and accuracy were determined by comparing measured and estimated CrCl using the Cockcroft-Gault and other formulas. Bias was defined as measured minus calculated CrCl, and accuracy was calculated CrCl that was within 30% of measured. RESULTS: There were 65 patients with a mean age of 48 years, serum creatinine (SCr) of 0.8 ± 0.3 mg/dL, and injury severity score of 22 ± 14. The incidence of augmented renal clearance was 69% and was more common when age was <67 years and SCr <0.8 mg/dL. Calculated CrCl was significantly lower than measured (131 ± 45 mL/min vs. 169 ± 70 mL/min, p < 0.001) and only moderately correlated (r = 0.610, p < 0.001). Bias was 38 ± 56 mL/min, which was independent of age quartile (p = 0.731). Calculated CrCl was inaccurate in 33% of patients and trauma-related factors were not predictive. CONCLUSION: The prevalence of augmented renal clearance in critically ill trauma patients is high. Formulas used to estimate CrCl in this population are inaccurate and could lead to under-dosing of medications. Measured CrCl should be used in this setting to identify augmented renal clearance and allow for more accurate estimates of renal function. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Early recognition of delirium in trauma patients.

OBJECTIVE: Evaluate change in practice and beliefs regarding delirium among nurses, pharmacists, respiratory therapists and physicians in a trauma intensive care unit. METHODOLOGY/DESIGN/SETTING: Descriptive pre and post-design at a Level One Trauma Center. Education on causes of delirium, risk factors, strategies to prevent delirium and routine screening. OUTCOME MEASURES: Change in practice and beliefs regarding delirium. RESULTS: McNemars test measured the differences between pre- and post-questionnaires comparing the proportion of staff changed their responses in one direction to those who went in the opposite direction. Changes in "Delirium is largely preventable", were statistically significant (p=0.035). Haldol was the medication of choice for treating delirium, with an increase in use (p=0.062) post-intervention. The majority of participants believed a high percentage of patients experience delirium in a trauma intensive care. The two most frequent medical complications associated with delirium pre-questionnaire was over sedation 8 (22%) and falls 9 (24%) and in post-questionnaire, over sedation 12 (26%) and falls 13 (28%). CONCLUSIONS: An educational intervention emphasising the importance of screening for delirium, risk factors for delirium and approaches to decrease the incidence of delirium can improve identifying and correctly treating delirium in a critical care setting. An educational program had concrete results in respondents' knowledge about delirium.