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3.
J Trauma Acute Care Surg ; 88(2): 249-257, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31804414

RESUMO

BACKGROUND: The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest. METHODS: Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared. RESULTS: One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02). CONCLUSION: In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest. LEVEL OF EVIDENCE: Therapeutic, level II.


Assuntos
Fixação de Fratura/métodos , Fraturas Múltiplas/cirurgia , Hemotórax/epidemiologia , Dor Pós-Operatória/diagnóstico , Fraturas das Costelas/cirurgia , Adolescente , Adulto , Idoso , Feminino , Fraturas Múltiplas/complicações , Fraturas Múltiplas/diagnóstico , Hemotórax/etiologia , Hemotórax/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/terapia , Estudos Prospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/diagnóstico , Índices de Gravidade do Trauma , Resultado do Tratamento , Adulto Jovem
4.
J Trauma Acute Care Surg ; 88(2): 279-285, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31738314

RESUMO

BACKGROUND: Trauma-induced coagulopathy is a major driver of mortality following severe injury. Viscoelastic goal-directed resuscitation can reduce mortality after injury. The TEG 5000 system is widely used for viscoelastic testing. However, the TEG 6s system incorporates newer technology, with encouraging results in cardiovascular interventions. The purpose of this study was to validate the TEG 6s system for use in trauma patients. METHODS: Multicenter noninvasive observational study for method comparison conducted at 12 US Levels I and II trauma centers. Agreement between the TEG 6s and TEG 5000 systems was examined using citrated kaolin reaction time (CK.R), citrated functional fibrinogen maximum amplitude (CFF.MA), citrated kaolin percent clot lysis at 30 minutes (CK.LY30), citrated RapidTEG maximum amplitude (CRT.MA), and citrated kaolin maximum amplitude (CK.MA) parameters in adults meeting full or limited trauma team criteria. Blood was drawn ≤1 hour after admission. Assays were repeated in duplicate. Reliability (TEG 5000 vs. TEG 6s analyzers) and repeatability (interdevice comparison) was quantified. Linear regression was used to define the relationship between TEG 6s and TEG 5000 devices. RESULTS: A total of 475 patients were enrolled. The cohort was predominantly male (68.6%) with a median age of 49 years. Regression line slope estimates (ß) and linear correlation estimates (p) were as follows: CK.R (ß = 1.05, ρ = 0.9), CFF.MA (ß = 0.99, ρ = 0.95), CK.LY30 (ß = 1.01, ρ = 0.91), CRT.MA (TEG 6s) versus CK.MA (TEG 5000) (ß = 1.06, ρ = 0.86) as well as versus CRT.MA (TEG 5000) (ß = 0.93, ρ = 0.93), indicating strong reliability between the devices. Overall, within-device repeatability was better for TEG 6s versus TEG 5000, particularly for CFF.MA and CK.LY30. CONCLUSION: The TEG 6s device appears to be highly reliable for use in trauma patients, with close correlation to the TEG 5000 device and equivalent/improved within-device reliability. Given the potential advantages of using the TEG 6s device at the site of care, confirmation of agreement between the devices represents an important advance in diagnostic testing. LEVEL OF EVIDENCE: Diagnostic test, level II.


Assuntos
Transtornos da Coagulação Sanguínea/diagnóstico , Sistemas Automatizados de Assistência Junto ao Leito , Tromboelastografia/instrumentação , Ferimentos e Lesões/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ferimentos e Lesões/sangue , Adulto Jovem
5.
Trauma Surg Acute Care Open ; 4(1): e000351, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31799416

RESUMO

Introduction: Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. Methods: We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. Results: 825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. Conclusion: We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. Level of evidence: Level II.

6.
Cureus ; 11(8): e5506, 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31511821

RESUMO

The objective of this study was to describe the atypical presentation of combined intrapleural and extrapleural hematomas in patients on anticoagulant therapy and explain the best workup and treatment for this pathology. This case report details the presentation, initial treatment, initial workup, and subsequent final treatment and workup of an elderly female patient that arrived at our trauma facility after suffering a blunt force trauma. The patient received anticoagulation therapy for her comorbidities prior to this incident. The outcome of interest was to better understand the best diagnostic and treatment modalities for treating combined intrapleural and extrapleural hematomas.

7.
J Trauma Acute Care Surg ; 87(1): 61-67, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31259869

RESUMO

BACKGROUND: Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS: Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS: Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001). CONCLUSION: There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE: Therapeutic, level IV.

8.
Trauma Surg Acute Care Open ; 4(1): e000319, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31245623

RESUMO

More than three million patients every year develop emergency general surgical (EGS) conditions and this number is rising. EGS diseases range from straightforward to potentially life-threatening, and if severe or complex may require extensive resources. Given the looming surgeon shortage and concerns about access to care, regionalization of EGS care, in a manner similar to trauma care, has been proposed. We present a unique pro-con debate highlighting the salient arguments for and against regionalization of EGS care in the USA.

9.
J Trauma Acute Care Surg ; 87(6): 1277-1281, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31107433

RESUMO

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is increasingly used for severe rib fractures/flail chest. There are no reports discussing mechanisms of failure of implanted hardware, its clinical presentation, or consequences. The purpose of this study was to evaluate the incidence, presenting signs, and clinical sequela of hardware failure after SSRF. METHODS: A multicenter, retrospective study was performed by a group of surgeons with a large SSRF case volume. All cases with known hardware failure from January 1, 2010, to December 31, 2017, were included. The surgeon's experience at the time of hardware implantation, specific implant used, number of failures the surgeon had experienced with the same system, and time from implantation to hardware failure were recorded. Additionally, patient demographics, including age, comorbid conditions, and number and location of rib fractures were recorded. Symptomatology associated with hardware failure and need for explant and/or reimplantation of hardware was also recorded. Nonparametric statistical tests were used to compare cohorts. RESULTS: Of 1,224 patients who underwent SSRF, 38 patients with 233 rib fractures and 279 fracture segments experienced hardware failure and were enrolled in the study. Twelve patients presented more than 3 months following injury. Median age was 54 years old and 34% were active smokers. One hundred forty-four plates were implanted with a median of four plates per patient. Median number of SSRF cases by each surgeon was 100 (range, 1-280). Fractures and hardware failure were most frequent in the anterolateral/lateral region. Hardware failure was mostly due to screw migration and plate fracture. Hardware failure was asymptomatic in 40% and presented as pain in 42% of cases. Fifty-five percent of the cases required explantation of hardware, and only 10% required SSRF again. There was no difference between the acute and chronic fracture cohorts. CONCLUSION: Hardware failure after SSRF is rare and often asymptomatic. When present, it rarely requires redo SSRF. LEVEL OF EVIDENCE: Therapeutic, level V.

10.
J Trauma Acute Care Surg ; 87(1): 61-67, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31033883

RESUMO

BACKGROUND: Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS: Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS: Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001). CONCLUSION: There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Traumatismos Cranianos Penetrantes/complicações , Infecção dos Ferimentos/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Antibioticoprofilaxia/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Resultado do Tratamento , Infecção dos Ferimentos/prevenção & controle , Adulto Jovem
11.
Am J Surg ; 218(2): 266-270, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30509454

RESUMO

BACKGROUND: Following blunt abdominal trauma, bowel injuries are often missed on admission computed tomography (CT) scan. METHODS: Multicenter retrospective analysis of 176 adults with moderate-critical blunt abdominal trauma and admission CT scan who underwent operative exploration. Patients with a bowel injury missed on CT (n = 36, 20%) were compared to all other patients (n = 140, 80%). RESULTS: The missed injury group had greater incidence free fluid without solid organ injury on CT scan (44% vs. 25%, p = 0.038) and visceral adhesions (28% vs. 6%, p = 0.001). Independent predictors of missed bowel injury included prior abdominal inflammation (OR 3.74, 95% CI 1.37-10.18), CT evidence of free fluid in the absence of solid organ injury (OR 2.31, 95% CI 1.03-5.19) and intraoperative identification of visceral adhesions (OR 4.46, 95% CI 1.52-13.13). CONCLUSIONS: Patients with visceral adhesive disease and indirect evidence of bowel injury on CT scan were more likely to have occult bowel injury.


Assuntos
Traumatismos Abdominais/complicações , Intestinos/diagnóstico por imagem , Intestinos/lesões , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/complicações , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
12.
J Trauma Acute Care Surg ; 86(4): 737-743, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30531333

RESUMO

BACKGROUND: Despite an aging population and increasing number of geriatric trauma patients annually, gaps in our understanding of best practices for geriatric trauma patients persist. We know that trauma center care improves outcomes for injured patients generally, and palliative care processes can improve outcomes for disease-specific conditions, and our goal was to determine effectiveness of these interventions on outcomes for geriatric trauma patients. METHODS: A priori questions were created regarding outcomes for patients 65 years or older with respect to care at trauma centers versus nontrauma centers and use of routine palliative care processes. A query of MEDLINE, PubMed, Cochrane Library, and EMBASE was performed. Letters to the editor, case reports, book chapters, and review articles were excluded. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to perform a systematic review and create recommendations. RESULTS: We reviewed seven articles relevant to trauma center care and nine articles reporting results on palliative care processes as they related to geriatric trauma patients. Given data quality and limitations, we conditionally recommend trauma center care for the severely injured geriatric trauma patients but are unable to make a recommendation on the question of routine palliative care processes for geriatric trauma patients. CONCLUSIONS: As our older adult population increases, injured geriatric patients will continue to pose challenges for care, such as comorbidities or frailty. We found that trauma center care was associated with improved outcomes for geriatric trauma patients in most studies and that utilization of early palliative care consultations was generally associated with improved secondary outcomes, such as length of stay; however, inconsistency and imprecision prevented us from making a clear recommendation for this question. As caregivers, we should ensure adequate support for trauma systems and palliative care processes in our institutions and communities and continue to support robust research to study these and other aspects of geriatric trauma. LEVEL OF EVIDENCE: Systematic review/guideline, level III.

13.
World J Surg ; 43(2): 457-465, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30225563

RESUMO

BACKGROUND: Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma. METHODS: We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2-5) blunt abdominal trauma, comparing patients with prior laparotomy (n = 31) to patients with no prior laparotomy (n = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury. RESULTS: There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p = 0.010) and mesenteric injury (61 vs. 31%, p = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6-16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74-0.88). CONCLUSIONS: Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.


Assuntos
Traumatismos Abdominais/complicações , Intestinos/lesões , Laparotomia/efeitos adversos , Mesentério/lesões , Aderências Teciduais/complicações , Ferimentos não Penetrantes/complicações , Traumatismos Abdominais/cirurgia , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Intestinos/cirurgia , Masculino , Mesentério/cirurgia , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resistência ao Cisalhamento , Ferimentos não Penetrantes/cirurgia
14.
J Surg Case Rep ; 2018(9): rjy241, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30214713

RESUMO

Cecal volvulus is the rotation of a mobile cecum resulting in a large bowel obstruction. We present the case of a 55-year-old female who underwent a roux-en-y gastric bypass in 2003 and presented to the emergency department with worsening abdominal pain, distention and obstipation. Roentgenogram demonstrated a 14 cm colon suggestive of sigmoid volvulus, but CT scan showed rectal contrast abruptly ending in the distal transverse colon, mesenteric swirling and a distended cecum, consistent with cecal, rather than sigmoid, volvulus. Upon surgical exploration the majority of the small bowel, cecum and ascending colon had herniated through the transverse mesocolon defect created during her prior gastric bypass. The bowel was reduced through the mesenteric defect, and an ileocecectomy was performed. This is, to our knowledge, the first reported case of cecal volvulus caused by an internal hernia through a mesocolon defect created during a prior roux-en-y gastric bypass operation.

16.
J Trauma Acute Care Surg ; 84(5): 736-744, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29283970

RESUMO

BACKGROUND: Spine immobilization in trauma has remained an integral part of most emergency medical services protocols despite a lack of evidence for efficacy and concern for associated complications, especially in penetrating trauma patients. We reviewed the published evidence on the topic of prehospital spine immobilization or spinal motion restriction in adult patients with penetrating trauma to structure a practice management guideline. METHODS: We conducted a Cochrane style systematic review and meta-analysis and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology to construct recommendations. Qualitative and quantitative analyses were used to evaluate the literature on the critical outcomes of mortality, neurologic deficit, and potentially reversible neurologic deficit. RESULTS: A total of 24 studies met inclusion criteria, with qualitative review conducted for all studies. We used five studies for the quantitative review (meta-analysis). No study showed benefit to spine immobilization with regard to mortality and neurologic injury, even for patients with direct neck injury. Increased mortality was associated with spine immobilization, with risk ratio [RR], 2.4 (confidence interval [CI], 1.07-5.41). The rate of neurologic injury or potentially reversible injury was very low, ranging from 0.002 to 0.076 and 0.00034 to 0.055, with no statistically significant difference for neurologic deficit or potentially reversible deficit, RR, 4.16 (CI, 0.56-30.89), and RR, 1.19 (CI, 0.83-1.70), although the point estimates favored no immobilization. CONCLUSION: Spine immobilization in penetrating trauma is associated with increased mortality and has not been shown to have a beneficial effect on mitigating neurologic deficits, even potentially reversible neurologic deficits. We recommend that spine immobilization not be used routinely for adult patients with penetrating trauma. LEVEL OF EVIDENCE: Systematic review with meta-analysis study, level III.


Assuntos
Serviços Médicos de Emergência/normas , Imobilização/normas , Guias de Prática Clínica como Assunto , Sociedades Médicas , Traumatismos da Coluna Vertebral/terapia , Traumatologia , Ferimentos Penetrantes/terapia , Humanos , Estados Unidos
17.
J Vasc Interv Radiol ; 28(9): 1248-1254, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28642012

RESUMO

PURPOSE: To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients. MATERIALS AND METHODS: In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval. RESULTS: The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission. CONCLUSIONS: This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.


Assuntos
Cateteres Venosos Centrais , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Filtros de Veia Cava , Ferimentos e Lesões/complicações , Adulto , Cateteres Venosos Centrais/efeitos adversos , Estado Terminal , Remoção de Dispositivo , Segurança de Equipamentos , Feminino , Fluoroscopia , Humanos , Unidades de Terapia Intensiva , Masculino , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento , Estados Unidos , Filtros de Veia Cava/efeitos adversos
18.
Phys Ther ; 96(5): 696-703, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26893511

RESUMO

BACKGROUND AND PURPOSE: Pompe disease is an inherited disorder notable for severe, progressive ventilatory compromise. Although ventilatory failure has been attributed to myofiber dysfunction secondary to diaphragmatic glycogen accumulation, neural involvement of the phrenic motor system is also a prominent feature. Direct diaphragm pacing supplements respiratory function in other disorders of the phrenic motor system. Accordingly, it is hypothesized that augmented neuromuscular activity via diaphragm pacing would promote weaning from mechanical ventilation in patients with Pompe disease who are unresponsive to conventional, muscle-directed treatments. CASE DESCRIPTION: Three patients with Pompe disease developed diaphragm paresis that resulted in chronic mechanical ventilation dependence. After preoperative inspiratory muscle strengthening exercises failed to improve function, fine-wire pacing electrodes were laparoscopically implanted into the diaphragm. Diaphragm conditioning was initiated the first postoperative week and consisted of gradual increases in stimulation parameters, lengthening of stimulation sessions, and ventilator weaning. Ventilation and intramuscular electromyographic activity were recorded periodically during conditioning to quantify diaphragm neuromuscular function. OUTCOMES: During paced breathing without mechanical ventilation, tidal volumes increased, and 2 patients were weaned from daytime ventilator dependence within the first 3 months of pacing, which has been sustained over the long-term. A third patient reduced reliance on daytime ventilation, but weaning was delayed by malacia of the large airways. In all patients, pacing appeared to facilitate spontaneous phrenic motor unit activity during independent breathing without ventilator or pacer support. DISCUSSION: The findings are consistent with the view that diaphragm pacing has potential rehabilitative value to reduce reliance on mechanical ventilation in people with Pompe disease, but further study is needed. Diaphragm pacing represents a paradigm shift in the management of respiratory insufficiency for Pompe disease that warrants further controlled examination.


Assuntos
Diafragma/fisiopatologia , Terapia por Estimulação Elétrica , Doença de Depósito de Glicogênio Tipo II/fisiopatologia , Doença de Depósito de Glicogênio Tipo II/reabilitação , Respiração , Insuficiência Respiratória/reabilitação , Pré-Escolar , Eletrodos Implantados , Eletromiografia , Doença de Depósito de Glicogênio Tipo II/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva , Ventilação Pulmonar , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Desmame do Respirador
19.
Surg Infect (Larchmt) ; 16(4): 421-7, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26207402

RESUMO

BACKGROUND: The epidemiology of Clostridium difficile-associated infection (CDI) has changed, and it is evident that susceptibility is related not only to exposures and bacterial potency, but host factors as well. Several small studies have suggested that CDI after trauma is associated with a different patient phenotype. The purpose of this study was to examine and describe the epidemiologic factors associated with C. difficile in blunt trauma patients without traumatic brain injury using the Trauma-Related Database as a part of the "Inflammation and Host Response to Injury" (Glue Grant) and the University of Florida Integrated Data Repository. METHODS: Previously recorded baseline characteristics, clinical data, and outcomes were compared between groups (67 C. difficile and 384 uncomplicated, 813 intermediate, and 761 complicated non-C. difficile patients) as defined by the Glue Grant on admission and at days seven and 14. RESULTS: The majority of CDI patients experienced complicated or intermediate clinical courses. The mean ages of all cohorts were less than 65 y and CDI patients were significantly older than uncomplicated patients without CDI. The CDI patients had increased days in the hospital and on the ventilator, as well as significantly higher new injury severity scores (NISS), and a greater percentage of patients with NISS >34 points compared with non-CDI patients. They also had greater Marshall and Denver multiple organ dysfunction scores than non-CDI uncomplicated patients, and greater creatinine, alkaline phosphatase, neutrophil count, lactic acid, and PiO2:FiO2 compared with all non-CDI cohorts on admission. In addition, the CDI patients had higher glucose concentrations and base deficit from uncomplicated patients and greater leukocytosis than complicated patients on admission. Several of these changes persisted to days seven and 14. CONCLUSION: Analysis of severe blunt trauma patients with C. difficile, as compared with non-CDI patients, reveals evidence of increased inflammation, immunosuppression, worse acute kidney injury, higher NISS, greater days in the hospital and on the ventilator, higher organ injury scores, and prolonged clinical courses. This supports reports of an increased prevalence of CDI in a younger population not believed previously to be at risk. This unique population may have specific genomic or inflammation-related risk factors that may play more important roles in disease susceptibility. Prospective analysis may allow early identification of at-risk patients, creation of novel therapeutics, and improved understanding of how and why C. difficile colonization transforms into infection after severe blunt trauma.


Assuntos
Infecções por Clostridium/complicações , Infecções por Clostridium/epidemiologia , Clostridium difficile , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas/complicações , Lesões Encefálicas/epidemiologia , Feminino , Humanos , Inflamação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Adulto Jovem
20.
Surg Infect (Larchmt) ; 16(4): 455-60, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26069992

RESUMO

BACKGROUND: Fulminant Clostridium difficile colitis (fCDC) is a highly lethal disease with mortality rates ranging between 12% and 80%. Although often these patients require a total abdominal colectomy (TAC) with ileostomy, there is no established management protocol for post-operative antibiotics. In this study we aim to make some recommendations for post-operative antibiotic usage, while describing the practice across different institutions. METHODS: Multi-institutional retrospective case series including fCDC patients who underwent a TAC between January 1, 2007, and June 30, 2012. We first analyzed the complete cohort and consecutively performed a survivor analysis, comparing different antibiotic regimens. Additionally we stratified by time interval (antibiotics for ≤7 d, or ≥8 d). Primary outcome was in-hospital mortality. Additional secondary outcomes included hospital length of stay (HLOS), ICU LOS, number of ventilator-free days, and occurrence of intra-abdominal complications (proctitis, abscess, sepsis, etc.). RESULTS: A total of 100 fCDC patients that underwent a TAC were included across five institutions. Four different antibiotic regimens were compared; A (metronidazole IV+vancomycin PO), B (metronidazole IV), C (metronidazole IV+vanco PO and PR), and D (metronidazole IV+vancomycin PR). The combination of IV metronidazole with or without PO vancomycin showed superior outcomes in terms of a shorter ICU length of stay and more ventilator-free days. However, when comparing metronidazole alone vs. metronidazole and any combination of vancomycin, no significant differences were found. Neither the addition of vancomycin enema, nor the time interval changed outcomes. CONCLUSION: Patients, after a TAC for fCDC, may be placed on either IV metronidazole or PO vancomycin depending upon local antibiograms, and proctitis may be treated with the addition of a vancomycin enema (PR). There was no data to support routine treatment of more than 7 d.


Assuntos
Antibacterianos/uso terapêutico , Clostridium difficile , Colectomia/efeitos adversos , Enterocolite Pseudomembranosa , Ileostomia/efeitos adversos , Complicações Pós-Operatórias , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/administração & dosagem , Enterocolite Pseudomembranosa/tratamento farmacológico , Enterocolite Pseudomembranosa/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos
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