Does Ileus Represent the Forgotten End Organ Failure in Critical Illness?

PURPOSE OF REVIEW: This review evaluates the current literature on ileus, impaired gastrointestinal transit (IGT), and acute gastrointestinal injury (AGI) and its impact on multiple organ dysfunction syndrome. RECENT FINDINGS: Ileus is often under recognized in critically ill patients and is associated with significant morbidity and is potentially a marker of disease severity as seen in other organs like kidneys (ATN).

Ethical Implications of Nutrition Therapy at the End of Life.

PURPOSE OF REVIEW: Provide an evidence-based resource to inform ethically sound recommendations regarding end of life nutrition therapy. RECENT FINDINGS: • Some patients with a reasonable performance status can temporarily benefit from medically administered nutrition and hydration(MANH) at the end of life. • MANH is contraindicated in advanced dementia. • MANH eventually becomes nonbeneficial or harmful in terms of survival, function, and comfort for all patients at end of life. • Shared decision-making is a practice based on relational autonomy, and the ethical gold standard in end of life decisions. A treatment should be offered if there is expectation of benefit, but clinicians are not obligated to offer non-beneficial treatments. A decision to proceed or not should be based on the patient's values and preferences, a discussion of all potential outcomes, prognosis for given outcomes taking into consideration disease trajectory and functional status, and physician guidance provided in the form of a recommendation.

Futility Assessment of Recombinant Factor VII Activated for the Treatment of Hemorrhagic Shock Requiring Massive Transfusion.

OBJECTIVE: Recombinant human factor VII activated (rFVIIa) is an adjuvant therapy in patients receiving massive transfusion for hemorrhagic shock. We compared patient characteristics and outcomes to determine futility criteria for the administration of rFVIIa in patients receiving massive transfusion for hemorrhagic shock. METHODS: This was a retrospective cohort analysis of patients who received both massive transfusion and rFVIIa. Consecutive trauma patients were allocated to 1 of 2 cohorts: survivors and nonsurvivors. RESULTS: Seventy-two subjects comprised the study: 27 were survivors and 45 were nonsurvivors. A univariate analysis revealed that nonsurvivors were older and had a more profound coagulopathy as measured by prothrombin time. A stepwise logistic regression revealed an increased odds of death in those patients who were older (odds ratio [OR], 1.048; 95% CI, 1.008 -1.091), had a higher admission prothrombin time (OR, 1.561; 95% CI, 1.152-2.116), and received more fresh frozen plasma (OR, 1.098; 95% CI 1.023-1.179). In addition we saw a protective effect with increased platelet administration (OR, 0.645; 95% CI, 0.446-0.932). CONCLUSION: The use of rFVIIa for massive transfusion in middle-aged patients with moderate coagulopathy experiencing hemorrhagic shock may be considered futile. However, if rFVIIa is to be used as part of a massive transfusion protocol, adequate administration of platelets should be ensured.

Lower Extremity Sandblast Injury: A Rarely Seen Injury Mechanism in the Civilian Population.

Blast injuries are both complex and rare in the civilian population. This combination can often lead to missed opportunities for early, effective intervention. This is a case report of a 31-year-old male who suffered a lower extremity blast injury while using an industrial sandblaster. This blast injury presented as a closed degloving, or Morel-Lavallee lesion, which can easily be mistreated and lead to infection and further disability. Following assessment, identification, and confirmation of the Morel-Lavallee lesion via radiographic imaging, this patient underwent debridement surgery, wound vac therapy, and antibiotic treatment before being discharged home with no major physiologic or neurologic deficits. The purpose of this report is to highlight the importance of assessing for closed degloving injuries when presented with blast injury traumas in the civilian trauma setting, and outlines the process utilized for assessment and treatment.

Sunken Skin Flap Syndrome: Neurological Dysfunction After Decompressive Craniectomy.

Sunken Skin Flap Syndrome (or Syndrome of the Trephined) following a head trauma is rare, but most often results from complications after decompressive craniectomy. This syndrome is most often characterized by neurological dysfunction that improves with cranioplasty. Early diagnosis and treatment are critically important to long term neurological improvement. This is a case report of a 49-year-old male who fell down a flight of stairs and was found unresponsive. Initial imaging revealed extensive head trauma. Neurosurgery performed an emergency decompressive craniectomy, but his post-operative course was complicated by the development of sunken flap syndrome one month after his initial surgery, diagnosed by an acute neurological decline and emergent CT imaging. A review of the literature indicates that this is a rarely documented finding, and this case report discusses the critical components of diagnosis and treatment of this unusual and potentially lethal condition.

A National Survey Assessing the Variability in the Management of Traumatic Cardiac Arrest.

BACKGROUND: Resuscitation of traumatic cardiac arrest (TCA) is variable, with approaches that overlap Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) algorithms. There is no standard algorithm for TCA, with some withholding ACLS protocols given abysmal outcomes. This study aims to assess surgeon practices and attitudes toward resuscitation practices in TCA. MATERIALS AND METHODS: A 16-question web-based survey was distributed to the membership of a national trauma association. Respondent demographics and management of TCA were analyzed. Chi-squared tests determined statistical significance. Open-ended responses were coded and analyzed inductively. RESULTS: Two hundred and three surveys were completed. 73.4% of respondents reported utilizing ACLS, while 26.6% reported they never utilized ACLS. A statistically significant difference in the performance of ACLS was found based on number of years in practice (P = .025) and the state of practice (P = .006). There was no significant difference in self-reported survival rates or legal, ethical, or interpersonal conflicts. Qualitative data highlighted themes of interpersonal conflict and futility. DISCUSSION: This study shows that one-quarter of respondents never utilize ACLS in TCA. Of those that utilize ACLS, there was variability in the technique, indication, and duration of resuscitation. Despite significant variability in technique, there appears to be similar survival rates and incidence of conflict. The association between years in practice and ACLS use suggests this may represent an emerging change in practice. The low response rate limits generalizability; however, there is significant variability in practice, highlighting a need for evidence-based guidelines.

Carbohydrate provision in the era of tight glucose control.

Glycemic control in the critically ill patient has remained a controversial issue over the last decade. Several large trials, with widely varying results, have generated significant interest in defining the optimal target for blood-glucose control necessary for improving care while minimizing morbidity. Nutritional support has evolved into an additional area of critical care where appropriate practices have been associated with improved patient outcomes. Carbohydrate provision can impact blood-glucose levels, and the relationship between nutrition and glucose levels has become more complex in the era of improved glycemic control. This review discusses the controversy surrounding intensive-insulin therapy in the intensive care unit and explores the relationship with nutritional support, both in the enteral and parenteral form. Achieving realistic goals in both carbohydrate provision and glycemic control may improve patient outcome, and are not mutually exclusive practices.

Appropriate protein and specific amino acid delivery can improve patient outcome: fact or fantasy?

Protein utilization and requirements in critical illness are much researched and debated topics. The enhanced turnover and catabolism of protein in the setting of critical illness is well described and multifactorial in nature. The need to preserve lean body mass and enhance nitrogen retention in this state to improve immunologic function and reduce morbidity is well described. Debates as to the optimum amount of protein to provide in such states still exist, and a significant amount of research has contributed to our understanding of not only how much protein to supply to these patients, but how best to do so. Small peptide formulations, intact protein formulations, branched chain amino acids, and specialty formulas all exist, and their benefits, drawbacks, and potential uses have been investigated. Specific amino acid therapy has become part of the concept of immunonutrition, or the modification and enhancement of the immune response with specific nutrients. In this article, we describe the changes in outcomes demonstrated through the provision of protein, both as a macronutrient and as specific amino acids.

Missed injuries in the era of the trauma scan.

BACKGROUND: A rapid computed tomography technique or "trauma scan" (TS) provides high-resolution studies of the head, cervical spine, chest, abdomen, and pelvis. We sought to determine whether TS has decreased missed injuries. A previous study of TS found a 3% missed rate. METHODS: After institutional review board approval, trauma patients from January 2001 through December 2008 were reviewed for delayed diagnosis (DD) of injury to the head, cervical spine, chest, abdomen, or pelvis. Missed extremity injuries were excluded. Injury Severity Score, length of stay, type of injury, outcomes, and days to detection were captured. RESULTS: Of 26,264 patients reviewed, 90 patients had DD, with an incidence of 0.34%. DD most commonly presented on day 2. Injuries included 16 bowel/mesentery, 12 spine, 11 pelvic, 8 spleen, 6 diaphragm, 5 clavicle, 4 scapula, 4 cervical spine, 4 intracranial, 4 sternum, 3 maxillofacial, 3 liver, 2 heart/aorta, 2 vascular, 2 urethra/bladder, 2 pneumothorax, and 2 pancreas/common bile duct. DD resulted in 1 death, 6 prolonged intensive care unit stays, 19 operative interventions, and 38 additional interventions. CONCLUSIONS: TS is an effective way of evaluating trauma patients for intracranial, cervical spine, chest, abdomen, and pelvic injuries that have the potential to impact morbidity and mortality. The incidence of injuries missed in these crucial areas has been reduced at our institution by the use of this radiographic modality. The most common missed injury remains bowel, and so a high index of suspicion and the tertiary survey must remain a mainstay of therapy.

"The Gluten-Free Diet and Its Relationship with Metabolic Syndrome: Dietary Friend or Foe?"

PURPOSE OF REVIEW: Celiac disease (CD) is a prevalent digestive illness as well as a budding area of research in the field of gastroenterology. While investigations are underway to find new and improved pharmacological therapies for CD, the gluten-free diet (GFD) remains the only option to effectively manage the condition. RECENT FINDINGS: While the GFD is recommended for patients diagnosed with CD and other gluten-related conditions, studies show the number of individuals on the GFD surpasses the projected number of patients with these medical indications (1). The implications of widespread adoption of this dietary approach are still being determined, with many patients believing this diet will improve overall health and cardiovascular risk. This review analyzes the relationship between a GFD and metabolic syndrome in both non-celiac and celiac patients, concluding that although the diet may slightly improve overall cardiac risk factors, weight, and/or insulin resistance, its use in the absence of a gluten-related disorder is controversial.

Hemorrhagic Anuria With Acute Kidney Injury After a Single Dose of Acetazolamide: A Case Study of a Rare Side Effect.

Acetazolamide (ACZ) is a relatively commonly used medication in critical illness, glaucoma and altitude sickness. ACZ is sometimes used in the intensive care unit to assist with the treatment of metabolic alkalosis in ventilated patients. This is a case report of a patient who received two doses of ACZ, one week apart, for metabolic alkalosis and subsequently developed renal colic and dysuria that progressed to hemorrhagic anuria and acute kidney injury. This is an incredibly rare side effect of ACZ therapy, and has been reported in a few case reports in the literature, but usually is associated with a longer duration of therapy. This case resolved entirely within 24 hours with aggressive fluid therapy. Clinicians using ACZ therapy for any reason should be aware of this rare but significant side effect.

Two Cases of Isolated Ureteral Injury Secondary to Blunt Force Trauma.

Ureteral injuries although rare can cause serious issues. The mechanism of injury is most commonly penetrating but in some rare cases blunt forces can contribute. It is important to diagnose ureteral injuries as soon as possible because they can have significant morbidity and mortality. Here we present two cases of isolated ureteral injury secondary to blunt force trauma. Both patients had the ureteral injury diagnosed by computed tomography (CT) scan and confirmed by a ureterogram with extravasation of contrast. Both patients also had peripelvic cyst, which could have been a contributing risk factor for injury. In both cases, the ureteral injury was repaired using a stent and both patients had no complications. We present these cases along with presentation, diagnostic work-up, and treatment.

Delayed Small Bowel Perforation in a Pre-Existing Ventral Hernia After Blunt Trauma.

A hollow viscus injury is an uncommon but potentially dangerous intra-abdominal injury that can result from blunt abdominal trauma. It can be misdiagnosed in patient, particularly when the patient has other concerning findings. Also, diagnosis can be increasingly difficult in a patient with a pre-existing ventral hernia and chronic abdominal pain. In this case we present a 66-year-old women, with a history of a large ventral hernia and chronic abdominal pain, who presented to the emergency department after a motor vehicle crash (MVC). Patient denied abdominal tenderness at the time of presentation and the initial computed tomography (CT) did not demonstrate any abnormal findings within the abdomen. Patient later began experiencing increased abdominal pain and presented with a small bowel perforation within the hernia that required a bowel resection and hernia repair.  A review of the literature reveals that not only are hollow viscus injuries rare but there appears to be few documented cases of viscus injuries occurring within a existing ventral hernia.

Examining Effects of Age on Outcomes after Nontraditional Motorized Vehicle Accidents.

This study examined patient outcomes from accidents involving nontraditional motorized vehicles. A total of 558 patients aged >17 years were observed retrospectively. The study groups were divided by age. The Adult Trauma Group (ATG) (N=452) consisted of patients aged 18-64 years and the Elderly Trauma Group (ETG) (N=106) consisted of patients aged ≥65 years. All-terrain vehicle (ATV) accidents were the most common (N=437, 78%) among both study groups and also the primary cause of death, with 17 deaths (4%). The most common discharge disposition was home or self-care (routine discharge) with 427 patients (77%). The mortality rate of the total population was 4.1% (23 total deaths). There was a statistically significant difference in length of hospital stay (p=0.03) and length of Intensive Care Unit (ICU) stay (p=0.03) between the two groups and patients ≥65 years were statistically more likely to be discharged to a care facility vs. home. Nontraditional motorized vehicles continue to grow in popularity in all ages and the effect of age on patient outcomes after injury is an important area to evaluate.

Impact of Injuries on Hospital Resource Utilization Among Trauma Patients Admitted due to Accidents Caused by Farm Animals.

This study examined the impact of injuries on the hospital resource utilization rate among trauma patients admitted to the Johnson City Medical Center (TN, USA), a rural Level I trauma center, due to accidents caused by farm animals. A total of 52 patients aged >3 years were studied, with the average age being 44 years. Patients above 65 years of age made up almost a quarter of the study population (23%); 63% of the patient population were male. All patients survived their injuries. Twenty-six percent of the patients required orthopedic intervention, with the majority of those patients being male (nine males, five females).

Pneumatosis Intestinalis in Patients Receiving Tube Feeds.

Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values < 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio >30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr >30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.

Nonsteroidal anti-inflammatory drugs' impact on nonunion and infection rates in long-bone fractures.

BACKGROUND: There is a dearth of clinical data regarding the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on long-bone fracture (LBF) healing in the acute trauma setting. The orthopedic community believes that the use of NSAIDs in the postoperative period will result in poor healing and increased infectious complications. We hypothesized that, first, NSAID use would not increase nonunion/malunion and infection rates after LBF. Second, we hypothesized that tobacco use would cause higher rates of these complications. METHODS: A retrospective study of all patients with femur, tibia, and/or humerus fractures between October 2009 and September 2011 at a Level 1 academic trauma center was performed . In addition to nonunion/malunion and infection rates, patient records were reviewed for demographic data, mechanism of fracture, type of fracture, tobacco use, Injury Severity Score (ISS), comorbidities, and medications given. RESULTS: During the 24-month period, 1,901 patients experienced LBF; 231 (12.1%) received NSAIDs; and 351 (18.4%) were smokers. The overall complication rate including nonunion/malunion and infection was 3.2% (60 patients). Logistic regression analysis with adjusted odds ratios were calculated on the risk of complications given NSAID use and/or smoking, and we found that a patient is significantly more likely to have a complication if he or she received an NSAID (odds ratio, 2.17; 95% confidence interval, 1.15-4.10; p < 0.016) in the inpatient postoperative setting. Likewise, smokers are significantly more likely to have complications (odds ratio, 3.19; 95% confidence interval, 1.84-5.53; p < 0.001). CONCLUSION: LBF patients who received NSAIDs in the postoperative period were twice as likely and smokers more than three times likely to suffer complications such as nonunion/malunion or infection. We recommend avoiding NSAID in traumatic LBF. LEVEL OF EVIDENCE: Epidemiologic & therapeutic study; level II.

Perioperative nutrition: what is the current landscape?

Poor nutrition status has long been linked to increases in postoperative complications and adverse outcomes for the patient undergoing elective surgery. While optimal planning for nutrition therapy should be comprehensive spanning throughout the perioperative period, recent advances have focused on the concept of "prehabilitation" to best prepare the patient prior to the insult of surgery. Adding immune/metabolic modulating formulas the week of surgery with carbohydrate drinks to optimize glycogen deposition immediately prior to surgery, enhances patient recovery and return to baseline function. Such nutrition strategies should now be combined with a host of other practices (such as smoking cessation, weight loss, glucose control, and specialized exercise program) as part of a structured protocol to maximize patients' chances for a full and rapid recovery from their elective surgical procedure.

Factors that impact patient outcome: nutrition assessment.

Defining malnutrition and nutrition risk has been a topic of many papers and discussions throughout the modern literature. Multiple definitions have been proposed, ranging from simple body weight measurements to a more all-encompassing concept looking at disease-specific inflammatory states. Biochemical markers, elements of a history examination, physical examination findings, calculations, and technical tests have all been proposed to help further characterize and delineate those who might be at risk for malnutrition, translating to an increased risk of adverse outcomes after major surgery. The purpose of this paper is to summarize some of the most utilized and most reliable ways to determine nutrition status within the scope of the North American Surgical Nutrition Summit (2012) and discuss how to incorporate these methods into the way that patients are screened preoperatively for elective surgery.