Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

Circulatory death determination in uncontrolled organ donors: a panel viewpoint.

One barrier for implementing programs of uncontrolled organ donation after the circulatory determination of death is the lack of consensus on the precise moment of death. Our panel was convened to study this question after we performed a similar analysis on the moment of death in controlled organ donation after the circulatory determination of death. We concluded that death could be determined by showing the permanent or irreversible cessation of circulation and respiration. Circulatory irreversibility may be presumed when optimal cardiopulmonary resuscitation efforts have failed to restore circulation and at least a 7-minute period has elapsed thereafter during which autoresuscitation to restored circulation could occur. We advise against the use of postmortem organ support technologies that reestablish circulation of warm oxygenated blood because of their risk of retroactively invalidating the required conditions on which death was declared.

Long-term outcome in elderly patients after operation for traumatic intracranial hemorrhage.

OBJECTIVE: This study examined outcomes in elderly TBI patients who underwent a cranial operation. METHODS: We identified TBI patients > or = 65 who underwent a cranial operation from January 1, 2004 to December 31, 2008. Data collected included: age, admission GCS, mechanism of injury, ISS, Head AIS, type of operation, hemorrhage acuity, time to operation, pre-hospital warfarin or clopidogrel, and in-hospital death. Survivors were contacted by phone to determine an Extended Glasgow Outcome Score (GOSE). A favorable outcome was defined as having a GOSE of > or = 5 at follow-up, an unfavorable outcome was defined as: in-hospital death, death within one year of injury, and a GOSE < 5 at follow-up. Chi-square and student's t-test were used. RESULTS: One hundred sixty-four elderly TBI patients underwent cranial surgery. Mean age was 79.2 +/- 7.6 years. Most patients: had a ground level fall (86.0%), suffered a subdural hematoma (95.1%), and underwent craniotomy (89.0%). Twenty-eight percent died in the hospital and another 20.1% died within one year. Fifty-six patients were eligible for a GOSE interview of these: 17 were lost to follow-up, seven refused the GOSE interview, 22 had a GOSE > or = 5, and ten had a GOSE < 5. Mean follow-up was 42.6 +/- 14.9 months. Of all the factors analyzed, only older age was associated with an unfavorable outcome. CONCLUSIONS: While age was associated with outcome, we were unable to demonstrate any other early factors that were associated with long-term functional outcome in elderly patients that underwent a cranial operation for TBI.

Emergency repair of a radiation-induced aortoesophageal fistula with endograft: report of a case.

This report presents the case of the emergency repair of a radiation-induced aortoesophageal fistula (AEF) with an endograft. The patient presented with multiple episodes of upper gastrointestinal bleeding. The fistula was discovered and treated in the operating room. The placement of a temporary aortic endograft was successful. The patient unfortunately exsanguinated while awaiting definitive aortic and esophageal repair. The potential occurrence of AEF should be considered in any patient presenting with massive hematemesis without a clear source of the bleeding. Although the patient succumbed to the fistula, this case illustrates the cryptic nature of an AEF and the difficult issues that are inherent in its treatment.

Massive postpartum hemorrhage: recombinant factor VIIa use is safe but not effective.

OBJECTIVE: Postpartum hemorrhage is a leading cause of maternal mortality. Massive transfusion in obstetric patients is rare. Recombinant Factor VIIa (rFVIIa) use in trauma patients with massive transfusion is efficacious. Our goal was to evaluate the safety and efficacy of rFVIIa use in obstetric patients with massive postpartum hemorrhage (MPH). METHODS: Patients records with MPH from 2003 to 2006 were reviewed. Data collected were demographics, APACHE II scores, International Normalized Ratio (INR), fibrinogen level, blood product administration, rates of pulmonary embolism (PE), deep vein thrombosis (DVT), myocardial infarction (MI), hysterectomy, and mortality. Continuous variables within groups were analyzed with paired t-test, and independent t-test between groups. Categorical variables were compared via chi2 or Fishers Exact test and significance was denoted by a p < or = 0.05. RESULTS: Twenty-seven patients with MPH were investigated, eight received rFVIIa (study group) and 19 did not (control group). All patients received a massive transfusion, six units of packed red blood cells (pRBCs), via a massive transfusion protocol. The study group's mean APACHE II score 25.8 +/- 8.5, predicted mortality of 56.2 percent, was higher than control, p = 0.009. An increase in transfused units of cryoprecipitate, p < 0.001, pRBCs, p = 0.004, decrease in INR, p < 0.001, and length of stay in the high risk obstetrical unit, p = 0.019, existed in the study group. Hysterectomy was required in 85.7 percent of the study group. No patients developed a DVT, PE, or MI and all survived. CONCLUSIONS: Recombinant Factor VIIa use in MPH is safe, improves coagulopathy, was not effective in decreasing blood product transfusion requirements, and may contribute to an improved predicted mortality.

The circulatory-respiratory determination of death in organ donation.

OBJECTIVE: Death statutes permit physicians to declare death on the basis of irreversible cessation of circulatory-respiratory or brain functions. The growing practice of organ donation after circulatory determination of death now requires physicians to exercise greater specificity in circulatory-respiratory death determination. We studied circulatory-respiratory death determination to clarify its concept, practice, and application to innovative circulatory determination of death protocols. RESULTS: It is ethically and legally appropriate to procure organs when permanent cessation (will not return) of circulation and respiration has occurred but before irreversible cessation (cannot return) has occurred because permanent cessation: 1) is an established medical practice standard for determining death; 2) is the meaning of "irreversible" in the Uniform Determination of Death Act; and 3) does not violate the "Dead Donor Rule." CONCLUSIONS: The use of unmodified extracorporeal membrane oxygenation in the circulatory determination of death donor after death is declared should be abandoned because, by restoring brain circulation, it retroactively negates the previous death determination. Modifications of extracorporeal membrane oxygenation that avoid this problem by excluding brain circulation are contrived, invasive, and, if used, should require consent of surrogates. Heart donation in circulatory determination of death is acceptable if proper standards are followed to declare donor death after establishing the permanent cessation of circulation. Pending additional data on "auto-resuscitation," we recommend that all circulatory determination of death programs should utilize the prevailing standard of 2 to 5 mins of demonstrated mechanical asystole before declaring death.

Challenging issues in surgical critical care, trauma, and acute care surgery: a report from the Critical Care Committee of the American Association for the Surgery of Trauma.

Critical care workforce analyses estimate a 35% shortage of intensivists by 2020 as a result of the aging population and the growing demand for greater utilization of intensivists. Surgical critical care in the U.S. is particularly challenged by a significant shortfall of surgical intensivists, with only 2586 surgeons currently certified in surgical critical care by the American Board of Surgery, and even fewer surgeons (1204) recertified in surgical critical care as of 2009. Surgical critical care fellows (160 in 2009) represent only 7.6% of all critical care trainees (2109 in 2009), with the largest number of critical care fellowship positions in internal medicine (1472, 69.8%). Traditional trauma fellowships have now transitioned into Surgical Critical Care or Acute Care Surgery (trauma, surgical critical care, emergency surgery) fellowships. Since adult critical care services are a large, expensive part of U.S. healthcare and workforce shortages continue to impact our healthcare system, recommendations for regionalization of critical care services in the U.S. is considered. The Critical Care Committee of the AAST has compiled national data regarding these important issues that face us in surgical critical care, trauma and acute care surgery, and discuss potential solutions for these issues.

Preinjury warfarin worsens outcome in elderly patients who fall from standing.

INTRODUCTION: Fall from standing (FFS) has become one of the most common mechanisms of injury for admission to the trauma center in the elderly population. Many of these patients present anticoagulated with warfarin. This two-center study was designed to examine the effects of preinjury warfarin use on outcome in the elderly. METHODS: A retrospective review of prospectively collected registry data at two Level I trauma centers was conducted from 2003 to 2006. The study population included patients age > or = 65 admitted to the trauma center after an FFS. These centers are relatively close geographically and have similar patient demographics. Data collected included: age, Injury Severity Score, Abbreviated Injury Score (AIS) for head, mortality, admission Glasgow Coma Score, and admission international normalized ratio (INR). Patients were divided into two groups based on the preinjury condition of warfarin use. Statistical differences were determined by unpaired t test for continuous variables and chi and odds ratios (ORs) for dichotomous variables. RESULTS: Of the 27,812 patients admitted to these two trauma centers over this time period, 2,791 (10.0%) were of age > or = 65 and admitted after an FFS. INR was 2.8 +/- 1.1 in warfarin group (+warf). The number of patients with AIS head 4 and 5 was similar between groups (-warf 22.1%, +warf 25.9%). Overall, preinjury warfarin use had a negative effect on the in-hospital mortality rate, +warf 8.6% and -warf 5.7% (OR 1.54, 1.09-2.19, p = 0.015). There was no difference in mortality between groups in patients with an AIS head < 4. The negative impact of preinjury warfarin use on mortality was most pronounced in patients with an AIS head 4 and 5 who presented awake (Glasgow Coma Score 14 and 15), +warf 13.5% and -warf 6.4% (OR 2.30, 95% confidence interval 1.12-4.70, p = 0.019). CONCLUSION: Preinjury warfarin use has an adverse effect on outcome (mortality) in elderly FFS patients. Importantly, this effect is most prominent in patients admitted awake with significant findings on computed tomography scan. This argues for rapid emergency department triage to computed tomography scan and rapid INR correction in this population.

A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center.

BACKGROUND: Adult trauma centers are major providers of medical management for pediatric trauma patients in the United States. Medication administration in this patient population is complex and fraught with potential error. METHODS: We designed a multidisciplinary team consisting of a pediatric hospitalist, pediatric care coordinator, pediatric nurse, pharmacist, and the trauma service to manage pediatric trauma patients from admission until discharge. The team mandated collective decision making for medication dosing and administration, weight documentation, and implemented a medication error reporting system. Our goal was to derive and implement a multidisciplinary practice and education-based model of pediatric trauma patient care to identify and decrease adverse medication events. RESULTS: Two hundred fifty-nine pediatric trauma patients were studied from January 1, 2003 to December 31, 2004, 125 pre-team implementation (control group) and 134 post-team implementation (study group). There were no significant differences in age, sex, mechanism of injury, injury severity score, or hospital length of stay between groups. There were significant reductions in number of medication prescribing errors (25 vs 15 errors; P = 0.05) and number of medication administration errors (19 vs 9 errors; P = 0.05) in the study group. Weight documentation improved significantly in the study group (90% vs 81%; P = 0.048). CONCLUSIONS: Instituting a multidisciplinary approach to pediatric trauma patient care is practical and can significantly decrease adverse medication events.

Are there still selected applications for resuscitative thoracotomy in the emergency department after blunt trauma?

Resuscitative thoracotomy has an integral role for open cardiac massage and can be preformed after penetrating trauma with cardiovascular collapse. Its role in blunt trauma is questionable. We performed a retrospective chart review of patients who underwent an emergency department (ED) resuscitative thoracotomy. The goal was to define the role of resuscitative thoracotomy in blunt trauma at our institution. Forty-two patients underwent a resuscitative thoracotomy, 26 penetrating trauma (61.9%) and 16 blunt trauma (38.1%). Of these (n=16), there were 13 thoracic injuries (81.2%), eight cardiac injuries (50.0%), seven isolated abdominal injuries (43.7%) and 13 multiple (two or more locations) injuries (81.2%). Therapeutic interventions included pericardiotomy in 14 (87.5%), cardiac repair in three (18.7%), and pulmonary laceration repair in two (12.5%). All study patients had signs of life in the field; 13 maintained signs of life in transit (81.3%) and 12 upon admission to ED (75%). Average time from field to ED was 10.72 +/- 5.74 minutes. There were two survivors after blunt trauma (12.5%) and one after penetrating trauma (3.8%). Signs of life in the field and a cardiac repair were independent predictors of survival after blunt trauma (p=0.001 and p=0.004 respectively). We conclude that in select trauma patients after blunt injury with cardiovascular collapse, resuscitative thoracotomy still has a vital role.

A protocol for the rapid normalization of INR in trauma patients with intracranial hemorrhage on prescribed warfarin therapy.

Trauma patients on prescribed warfarin therapy sustaining intracranial hemorrhage can be difficult to manage. Rapid normalization of coagulopathy is imperative to operative intervention and may affect outcomes. To identify and expedite warfarin reversal, we designed a protocol to administer a prothrombin complex concentrate. A Proplex T protocol was instituted in May 2004. It dictated that trauma patients with an International Normalized Ratio (INR) greater than 1.5, history of prescribed warfarin therapy, and intracranial hemorrhage on CT scan receive a prothrombin complex concentrate for reversal of their coagulopathy. Neither the protocol nor the factor concentrate was validated for use in this subset of trauma patients; therefore, adherence to the protocol and use of the factor concentrate was not mandatory. Patients not administered the prothrombin complex concentrate received vitamin K and fresh-frozen plasma. The protocol resulted in an increased number of patients receiving Proplex T (54.3% vs 35.4%, P = 0.047). Protocol patients had improved times to normalization of INR (331.3 vs 737.8 minutes, P = 0.048), number of patients with reversal of coagulopathy (73.2% vs 50.9%, P = 0.026), and time to operative intervention (222.6 vs 351.3 minutes, P = 0.045) compared with control subjects. There were no differences in intensive care unit (ICU) days, hospital days, or mortality. The Proplex T protocol increased the number of patients who received prothrombin complex concentrate, provided rapid normalization of INR, and improved time to operative intervention.

Improving care of the sepsis patient.

BACKGROUND: In 2004, Christiana Care Health System (Christiana Care), a 1,100-bed tertiary care facility, used the Surviving Sepsis Campaign guidelines as the foundation for an independent initiative to reduce the mortality rate by at least 25%. METHODS: In 2004, an interdisciplinary sepsis team developed a process for rapidly recognizing at-risk patients; evaluating a patient's clinical status; and providing appropriate, timely therapy in three major areas of sepsis care; recognition of the sepsis patient, resuscitation priorities, and intensive care management. The Sepsis Alert program, which did not require additional staffing, was developed and implemented in 10 months. The Sepsis Alert packet included a care management guideline, a treatment algorithm, an emergency department treatment order set, and multiple adjuncts to streamline patient identification and management. RESULTS: Introduction of sepsis resuscitation and critical care management standards led to a 49.4% decrease in mortality rates (p < .0001), a 34.0% decrease in average length of hospital stay (p < .0002), and a 188.2% increase in the proportion of patients discharged to home (p < .0001) when the historic control group is compared with the postimplementation group from January 2005 through December 2007. DISCUSSION: An integrated leadership team, using existing resources, transformed frontline clinical practice by providers from multiple disciplines to reduce mortality in the population of patients with sepsis.

Special issues in plastic and reconstructive surgery.

Intensivists frequently collaborate with plastic and reconstructive surgeons in treating patients with major wounds, following significant reconstructive procedures, and following free-tissue transfers. Pressure ulcers are a significant source of morbidity and mortality in the intensive care unit; prevention, early recognition, and multidisciplinary treatment are critical components for successful management. Necrotizing fasciitis is an aggressive, soft-tissue infection that requires rapid diagnosis, early surgical intervention frequent operative debridements, and soft-tissue reconstruction Catastrophic abdominal injuries and infections can be treated with an open abdominal approach and require the expertise of a plastic surgeon to reconstruct the abdominal wall. The success of free-tissue transfers and complex reconstructive procedures requires a thorough understanding of the factors that improve flap survival.

Improved removal rates for retrievable inferior vena cava filters with the use of a 'filter registry'.

The American Association for the Surgery of Trauma challenged the trauma community to improve a 22 per cent average removal rate for retrievable inferior vena cava filters (r-IVCFs). Since 2006, we maintained a "filter registry" documenting all IVCFs placed in trauma patients. Our goal was to improve removal rates for r-IVCF. Patients receiving an IVCF before implementation of filter registry, 2003-2005, comprised the control group. Patients receiving an IVCF after implementation of filter registry, 2006-2009, comprised the study group. Data obtained included age, gender, Injury Severity Score (ISS), length of stay (LOS), mortality, filter inserted, placement indication, removal rates, and reasons why removal did not occur. Fisher exact test and chi square were used for nominal variables. Stepwise logistic regression analysis was used to define predictors of removing and not removing an IVCF. Three hundred seven patients received an IVCF, 142 preregistry and 165 postregistry. No significant difference existed between groups in age, gender, ISS, placement indication, or mortality. A significant difference existed between groups in LOS and presence of deep vein thrombosis (DVT) and pulmonary embolism. A total of 98.2 per cent of postregistry patients received a Günther Tulip filter and all retrievals were performed by Interventional Radiology. Retrieval rates improved, 15.5 to 31.5 per cent post registry (P < 0.001). No differences existed in lost to follow-up (LTF) between groups. Univariate analysis identified age, IVC clot, DVT, and LTF as predictors for not removing a filter. Stepwise logistic regression revealed the filter registry independently predicts the removal of an r-IVCF. A filter registry is effective in improving rates of removal for r-IVCFs.

Phlegmonous gastritis and group A streptococcal toxic shock syndrome in a patient following functional endoscopic sinus surgery.

BACKGROUND: Phlegmonous gastritis is a rare and often fatal condition that can affect healthy individuals in 50% of cases. The condition has been described in accounts dating back to the pre-antibiotic era, during which time mortality was nearly 100%. Over the past century, case reports average about one per year. The etiology remains unclear, although Streptococcus species is isolated frequently. The optimum treatment has not been delineated clearly but likely involves a combination of antibiotics with or without surgical resection. METHODS: A case report was presented and the pertinent literature was reviewed. CASE REPORT: A 45-year-old man with a history of recent paranasal sinus surgery presented with acute abdominal pain and criteria consistent with toxic shock syndrome. Computed tomography scan showed diffuse thickening of the gastric wall and free intraperitoneal fluid. Exploratory laparotomy revealed a thickened stomach wall with outer fibrinous exudate and murky peritoneal fluid, which grew Streptococcus pyogenes. Intraoperative esophagogastroduodenoscopy revealed thickened gastric folds with a "cobblestone" appearance and no evidence of perforation. He was treated with antibiotics intravenously and sustained a difficult intensive care unit course complicated by ventilator-dependent respiratory failure, renal failure, and coagulopathy, but survived without major disability. CONCLUSIONS: This is an unusual case presentation of a rare but potentially lethal condition, whose optimal treatment is unclear. Phlegmonous gastritis should be considered when isolated gastric wall thickening is encountered in the clinical setting of toxic shock syndrome.

Intravenous esomeprazole pharmacodynamics in critically ill patients.

OBJECTIVE: A widely held belief contends that food-induced proton pump activation is important for optimal proton pump inhibitor-induced inhibition of gastric acid secretion. This study was undertaken to assess intragastric acid control with intravenous (IV) esomeprazole in critically ill patients. RESEARCH DESIGN AND METHODS: This open-label, single-arm, exploratory trial was conducted at five university or regional hospital intensive care units in the US. Adult patients admitted to an intensive care unit who required mechanical ventilation and had at least one additional risk factor for stress-induced ulcer received twice-daily IV esomeprazole 40 mg for 48 hours and could continue for another 24 hours if no prepyloric enteral feedings were planned. CLINICAL TRIAL REGISTRATION: D9612L00107; ClinicalTrials.gov Identifier NCT00428701. MAIN OUTCOME MEASURES: The primary efficacy variable was the linear-interpolated percentage of time intragastric pH was > or =4 during 24-48 hours. Secondary efficacy variables included the interpolated percentage of time intragastric pH was > or =4 during 0-24, 0-48, and 48-72 hours, the percentage of gastric aspirates collected with pH > or =4 during 0-24, 24-48, 0-48, and 48-72 hours, and time to stable pH > or =4. Safety was assessed based on adverse events (AEs), physical examinations, vital signs, laboratory tests, and electrocardiograms. RESULTS: Forty-five patients were enrolled (one was excluded because of previous partial gastrectomy). Interpolated mean percentage time pH > or =4 was 88.8%, 80.7%, and 83.5% for 24-48, 0-24, and 0-48 hours, respectively. For 0-72 hours, > or =78% of gastric aspirates had pH > or =4. Median time to stable pH was 1 hour (95% confidence interval: 0.67, 2.00). Treatment was well tolerated, with no evidence of gastrointestinal bleeding. A total of 75 AEs occurred in 34 patients, none considered treatment related. CONCLUSIONS: In this noncontrolled exploratory study, twice-daily IV esomeprazole 40 mg rapidly decreased intragastric acidity and effectively maintained pH >/=4 during 0-72 hours in fasting, critically ill, mechanically ventilated patients at high risk for stress ulcers.

Human polymerized hemoglobin for the treatment of hemorrhagic shock when blood is unavailable: the USA multicenter trial.

BACKGROUND: Human polymerized hemoglobin (PolyHeme, Northfield Laboratories) is a universally compatible oxygen carrier developed to treat life-threatening anemia. This multicenter phase III trial was the first US study to assess survival of patients resuscitated with a hemoglobin-based oxygen carrier starting at the scene of injury. STUDY DESIGN: Injured patients with a systolic blood pressure

A prospective randomized trial of nebulized morphine compared with patient-controlled analgesia morphine in the management of acute thoracic pain.

BACKGROUND: Successfully managing pain for the trauma patient decreases morbidity, improves patient satisfaction, and is an essential component of critical care. Using patient-controlled analgesia (PCA) morphine to control pain may be complicated by concerns of respiratory depression, hemodynamic instability, addiction, urinary retention, and drug-induced ileus. Morphine is rapidly absorbed by mucosal surfaces in the respiratory tract, achieving systemic concentrations equal to 20% of equivalent intravenous doses. The purpose of this study was to evaluate the safety, efficacy, and utility of nebulized morphine in patients with posttraumatic thoracic pain. METHODS: This double-blinded, prospective study randomized patients with severe posttraumatic thoracic pain into two groups. The experimental group (NMS) received nebulized morphine every 4 hours and normal saline by PCA. The control group (PCA) received nebulized saline every 4 hours and morphine by PCA. Dose adjustments were made based on patient response to treatments using a 10-point visual analog scale (VAS) for pain. Pulmonary function, pain relief (VAS), level of sedation (0-3), total drug administration, and systematic side effects were recorded. RESULTS: Forty-four patients were randomized (22 per group). Seven hundred seventy observations were made. The mean 4-hour dose of morphine was 11.96 +/- 3.4 mg for NMS and 6.22 +/- 4.7 mg for PCA (p < 0.001). Patients with NMS had lower heart rates compared with PCA (79 +/- 11 bpm versus 92 +/- 12 bpm; p < 0.001) and were less sedated (0.33 +/- 0.7 versus 0.56 +/- 0.9; p = 0.03). The mean pain level (VAS) was 3.38 +/- 1.8 for NMS and 3.84 +/- 2.7 for PCA (p = 0.2). There was no difference between pain levels before and after dosing. There were no differences between groups with respect to arterial blood pressure, respiratory rate, vital capacity, mean forced expiratory volume in 1 second, spirometric volumes, or Sao2. CONCLUSION: Nebulized morphine can be safely and effectively used to control posttraumatic thoracic pain. Pain can be successfully managed while vital capacity, mean forced expiratory volume in one second, and spirometric volumes are maintained. Compared with PCA morphine, nebulized morphine provides equivalent pain relief with less sedative effects.