Venous thromboembolism during combat operations: a 10-y review.

BACKGROUND: This article examines the incidence of venous thromboembolism (VTE) in combat wounded, identifies risk factors for pulmonary embolism (PE), and compares the rate of PE in combat with previously reported civilian data. METHODS: A retrospective review was performed of all U.S. military combat casualties in Operation Enduring Freedom and Operation Iraqi Freedom with a VTE recorded in the Department of Defense Trauma Registry from September 2001 to July 2011. The Military Amputation Database of all U.S. military amputations during the same 10-y period was also reviewed. Demographic data, injury characteristics, and outcomes were evaluated. RESULTS: Among 26,634 subjects, 587 (2.2%) had a VTE. This number included 270 subjects (1.0%) with deep venous thrombosis (DVT), 223 (0.8%) with PE, and 94 (0.4%) with both DVT and PE. Lower extremity amputation was independently associated with PE (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.07-2.69). A total of 1003 subjects suffered a lower extremity amputation, with 174 (17%) having a VTE. Of these, 75 subjects (7.5%) were having DVT, 70 (7.0%) were having PE, and 29 (2.9%) were found to have both a DVT and a PE. Risk factors found to be independently associated with VTE in amputees were multiple amputations (OR, 2; 95% CI, 1.35-3.42) and above the knee amputation (OR, 2.11; 95% CI, 1.3-3.32). CONCLUSIONS: Combat wounded are at a high risk for thromboembolic complications with the highest risk associated with multiple or above the knee amputations.

Invasive Apophysomyces variabilis infection in a burn patient.

Apophysomyces variabilis is an emerging fungal pathogen that can cause significant infections in immunocompetent patients. We report a case of A. variabilis invasive wound infection in a 21-year-old male after a self-inflicted burn injury.

Pythium aphanidermatum infection following combat trauma.

Pythium aphanidermatum is a fungus-like plant pathogen which has never been reported as a cause of human infection. We report a case of P. aphanidermatum invasive wound infection in a 21-year-old male injured during combat operations in Afghanistan.

Mechanism of injury affects acute coagulopathy of trauma in combat casualties.

BACKGROUND: Recent evidence suggests trauma involving total body tissue damage increases the acute coagulopathy of trauma (ACOT) by various mechanisms, especially in massive transfusion (MT). Our hypothesis was that MT patients injured by explosion will have a higher international normalization ratio (INR) at admission than MT patients injured by gunshot wound (GSW). METHODS: A retrospective review was performed on US military injured in Operation Iraqi Freedom/Operation Enduring Freedom from March 2003 to September 2008, who received MT (≥ 10 red blood cells in 24 hours) and had an INR on admission. Two cohorts were created based on mechanism. Admission vital signs, labs, transfusion, and mortality data were compared. RESULTS: Seven hundred fifty-one MT patients were identified. Four hundred fifty patients had admission INR and were injured by either GSW or explosion. Patients demonstrated similar injury severity scale and Glasgow Coma Scale. Patients injured by explosion presented with higher INR, greater base deficit, and more tachycardic than patients injured by GSW. Transfusion of blood products was similar between both groups. CONCLUSIONS: The primary finding of this study is that patients injured by explosion presented with a higher INR than those injured by GSW, even with similar injury severity scale. In addition, patients injured by explosion presented more tachycardic and with a greater base deficit. These findings support the theory that ACOT is affected by the amount of tissue injured. Further research is needed into the pathophysiology of ACOT because this may impact care of patients with total body tissue damage/hypoxia and improve the treatment of their coagulopathy while minimizing the attendant complications.

Impact of improved combat casualty care on combat wounded undergoing exploratory laparotomy and massive transfusion.

BACKGROUND: Studies have shown decreased mortality after improvements in combat casualty care, including increased fresh frozen plasma (FFP):red blood cell (RBC) ratios. The objective was to evaluate the evolution and impact of improved combat casualty care at different time periods of combat operations. METHODS: A retrospective review was performed at one combat support hospital in Iraq of patients requiring both massive transfusion (≥ 10 units RBC in 24 hours) and exploratory laparotomy. Patients were divided into two cohorts based on year wounded: C1 between December 2003 and June 2004, and C2 between September 2007 and May 2008. Admission data, amount of blood products and fluid transfused, and 48 hour mortality were compared. Statistical significance was set at p < 0.05. RESULTS: There was decreased mortality in C2 (47% vs. 20%). Patients arrived warmer with higher hemoglobin. They were transfused more RBC and FFP in the emergency department (5 units ± 3 units vs. 2 units ± 2 units; 3 units ± 2 units vs. 0 units ± 1 units, respectively) and received less crystalloid in operating room (3.3 L ± 2.2 L vs. 8.5 L ± 4.9 L). The FFP:RBC ratio was also closer to 1:1 in C2 (0.775 ± 0.32 vs. 0.511 ± 0.21). CONCLUSIONS: The combination of improved prehospital care, trauma systems approach, performance improvement projects, and improved transfusion or resuscitation practices have led to a 50% decrease in mortality for this critically injured population. We are now transfusing blood products in a ratio more consistent with 1 FFP to 1 RBC. Simultaneously, crystalloid use has decreased by 61%, all of which is consistent with hemostatic resuscitation principles.

High-frequency percussive ventilation and low tidal volume ventilation in burns: a randomized controlled trial.

OBJECTIVES: In select burn intensive care units, high-frequency percussive ventilation is preferentially used to provide mechanical ventilation in support of patients with acute lung injury, acute respiratory distress syndrome, and inhalation injury. However, we found an absence of prospective studies comparing high-frequency percussive ventilation with contemporary low-tidal volume ventilation strategies. The purpose of this study was to prospectively compare the two ventilator modalities in a burn intensive care unit setting. DESIGN: Single-center, prospective, randomized, controlled clinical trial, comparing high-frequency percussive ventilation with low-tidal volume ventilation in patients admitted to our burn intensive care unit with respiratory failure. SETTING: A 16-bed burn intensive care unit at a tertiary military teaching hospital. PATIENTS: Adult patients ≥ 18 yrs of age requiring prolonged (> 24 hrs) mechanical ventilation were admitted to the burn intensive care unit. The study was conducted over a 3-yr period between April 2006 and May 2009. This trial was registered with ClinicalTrials.gov as NCT00351741. INTERVENTIONS: Subjects were randomly assigned to receive mechanical ventilation through a high-frequency percussive ventilation-based strategy (n = 31) or a low-tidal volume ventilation-based strategy (n = 31). MEASUREMENTS AND MAIN RESULTS: At baseline, both the high-frequency percussive ventilation group and the low-tidal volume ventilation group had similar demographics to include median age (interquartile range) (28 yrs [23-45] vs. 33 yrs [24-46], p = nonsignificant), percentage of total body surface area burn (34 [20-52] vs. 34 [23-50], p = nonsignificant), and clinical diagnosis of inhalation injury (39% vs. 35%, p = nonsignificant). The primary outcome was ventilator-free days in the first 28 days after randomization. Intent-to-treat analysis revealed no significant difference between the high-frequency percussive ventilation and the low-tidal volume ventilation groups in mean (± sd) ventilator-free days (12 ± 9 vs. 11 ± 9, p = nonsignificant). No significant difference was detected between groups for any of the secondary outcome measures to include mortality except the need for "rescue" mode application (p = .02). Nine (29%) in the low-tidal volume ventilation arm did not meet predetermined oxygenation or ventilation goals and required transition to a rescue mode. By contrast, two in the high-frequency percussive ventilation arm (6%) required rescue. CONCLUSIONS: A high-frequency percussive ventilation-based strategy resulted in similar clinical outcomes when compared with a low-tidal volume ventilation-based strategy in burn patients with respiratory failure. However, the low-tidal volume ventilation strategy failed to achieve ventilation and oxygenation goals in a higher percentage necessitating rescue ventilation.

Outcomes with the use of recombinant human erythropoietin in critically ill burn patients.

Recent data demonstrate a possible mortality benefit in traumatically injured patients when given subcutaneous recombinant human erythropoietin (rhEPO). The purpose of this report is to examine the effect of rhEPO on mortality and transfusion in burn patients. We conducted a review of burn patients (greater than 30% total body surface area, intensive care unit [ICU] days greater than 15) treated with 40,000 u rhEPO over an 18-month period (January 2007 to July 2008). Matched historical controls were identified and a contemporaneous cohort of subjects not administered rhEPO was used for comparison (NrhEPO). Mortality, transfusions, ICU and hospital length of stay were assessed. A total of 105 patients were treated (25 rhEPO, 53 historical control group, 27 NrhEPO). Hospital transfusions (mean 13,704 +/- mL vs. 13,308 +/- mL; P = 0.42) and mortality (29.6 vs. 32.0%; P = 0.64) were similar. NrhEPO required more blood transfusions (13,308 +/- mL vs. 6827 +/- mL; P = 0.004). No difference in mortality for the rhEPO and NrhEPO (32.0 vs. 22.2%; P = 0.43) was found. Thromboembolic complications were similar in all three groups. No effect was seen for rhEPO treatment on mortality or blood transfusion requirements in the severely burned.

Association of shock, coagulopathy, and initial vital signs with massive transfusion in combat casualties.

BACKGROUND: Timely initiation of a massive transfusion (MT) protocol is associated with improved survival and reduced transfusion for patients requiring MT; however, a priori identification of this population is difficult. The objective of this study was to compare the results of an MT prediction model and actual MT incidence in combat casualties. METHODS: We performed a retrospective review of the Joint Theater Trauma Registry transfusion database for all US service personnel injured in combat during overseas contingency operations who received at least 1 unit of blood. Systolic blood pressure at the time of admission, heart rate, hemoglobin, international normalized ratio, and base deficit were used in a previously developed prediction model for MT. RESULTS: Casualties (n = 1124) were identified who had received at least 1 unit of blood and had all data points. Of these patients, 420 patients (37%) received an MT. Subjects presenting with any two of four possible variables (heart rate >110, systolic blood pressure <110 mm Hg, base deficit < or = -6, and hemoglobin <11) had a 54% incidence of MT with a model sensitivity of 69%. Patients predicted but not observed to receive an MT had earlier time of death and an increased incidence of head injuries compared with those predicted and observed to receive an MT. Patients not predicted but observed to receive an MT had increased chest, abdominal, and extremity injuries than those neither predicted nor observed to receive an MT. CONCLUSION: The decision to implement an MT seems to rely heavily on clinical evaluation of severity of abdominal and extremity injury rather than physiologic derangement. Using a model based on the physiologic parameters--a more objective measure--may decrease mortality in combat casualties.

Impact of policy change on US Army combat transfusion practices.

BACKGROUND: Clinical practice guidelines (CPGs) are used to keep providers up-to-date with the most recent literature and to guide in decision making. Adherence is typically improved although many have a muted impact. In March 2006, the US Army issued a damage control resuscitation CPG, encouraging 1:1 plasma:red blood cell (RBC) transfusions and limiting crystalloid use. The objective of this study was to determine whether the CPG was associated with a change in the transfusion practices in combat-wounded patients. METHODS: All US service members injured in Operation Iraqi Freedom/Operation Enduring Freedom who received massive transfusions (MTs; > or = 10 RBC in 24 hours) were queried from the US Army Institute of Surgical Research transfusion database. Whole blood, when used, was counted as 1 unit of RBC, fresh frozen plasma (FFP), and platelet. Subjects were divided into pre- and post-CPG cohorts. Primary outcomes were ratios of FFP:RBC and crystalloid use. RESULTS: A total of 777 MT patients were identified. The cohorts were similar in age (25 years +/- 6 years vs. 25 years +/- 6 years; p = ns) and injury severity scale score (24 +/- 12 vs. 25 +/- 12; p = ns). The post-CPG cohort was warmer (96.5 degrees F +/- 7.8 degrees F vs. 98.2 degrees F +/- 1.9 degrees F; p < 0.05) and was transfused more RBC, platelets, and plasma but received less crystalloid (17 units +/- 12 units vs. 19 units +/- 11 units, 1 unit +/- 2 units vs. 2 units +/- 3 units, 8 units +/- 8 units vs. 14 units +/- 11 units, 14 L +/- 14 L vs. 9 L +/- 13 L, respectively; p < 0.05). The post-CPG cohort also received a higher ratio transfusion (0.5 +/- 0.31 vs. 0.8 +/- 0.31; p < 0.05) representing a change in practice. Overall mortality was not different between the two groups (24 vs. 19%; p = 0.115). CONCLUSIONS: MT patients are now receiving a higher FFP:RBC ratio and less crystalloid after implementation of the CPG. Additionally, patients are now presenting normothermic and have higher hemoglobin levels. All of these changes are consistent with the principles of damage control resuscitation. Changes in practice were associated with implementation of the CPG, maturity of the battlefield, and increased availability of products.

Lower interbreath interval complexity is associated with extubation failure in mechanically ventilated patients during spontaneous breathing trials.

OBJECTIVE: To determine whether lower complexity of interbreath interval as measured with nonlinear analysis techniques will identify patients who fail to separate from mechanical ventilation after 30-minute spontaneous breathing trials (SBTs). METHODS: Respiratory waveforms from SBT of patients in surgical or burn intensive care units were recorded for later analysis. The decision to extubate was made by attending physician. Extubated patients were observed for 48 hours; during this time, reintubation or noninvasive positive pressure ventilation was considered as a failure. Analysis of waveform data by software was performed post hoc. Sample entropy (SampEn) and other nonlinear measures were 48 hours of extubation. RESULTS: Thirty-two patients (24 burn, 8 trauma/surgical admissions; mean age, 40.2 +/- 16.9 years; 26 men and 6 women) who were intubated >24 hours were extubated after SBT. Twenty-four patients were successfully separated from mechanical ventilation and eight failed. Age, gender, and mechanism of injury did not influence outcome. SampEn calculated for the two groups presented in this study was different with the cohort that failed extubation having a lower mean value (1.35 +/- 0.39 vs. 1.87 +/- 0.27; p < 0.001). Other nonlinear metrics were moved in concert with SampEn. The stationarity in the respiratory signal was not different between groups. CONCLUSION: In intubated patients, the interbreath interval in those who were successfully separated from mechanical ventilation was more irregular than those who failed, as measured by nonlinear techniques. When available at bedside, these metrics may be useful markers of pulmonary health and assist in clinical decision making.

Fenoldopam use in a burn intensive care unit: a retrospective study.

BACKGROUND: Fenoldopam mesylate is a highly selective dopamine-1 receptor agonist approved for the treatment of hypertensive emergencies that may have a role at low doses in preserving renal function in those at high risk for or with acute kidney injury (AKI). There is no data on low-dose fenoldopam in the burn population. The purpose of our study was to describe our use of low-dose fenoldopam (0.03-0.09 mug/kg/min) infusion in critically ill burn patients with AKI. METHODS: We performed a retrospective analysis of consecutive patients admitted to our burn intensive care unit (BICU) with severe burns from November 2005 through September 2008 who received low-dose fenoldopam. Data obtained included systolic blood pressure, serum creatinine, vasoactive medication use, urine output, and intravenous fluid. Patients on concomitant continuous renal replacement therapy were excluded. Modified inotrope score and vasopressor dependency index were calculated. One-way analysis of variance with repeated measures, Wilcoxson signed rank, and chi-square tests were used. Differences were deemed significant at p < 0.05. RESULTS: Seventy-seven patients were treated with low-dose fenoldopam out of 758 BICU admissions (10%). Twenty (26%) were AKI network (AKIN) stage 1, 14 (18%) were AKIN stage 2, 42 (55%) were AKIN stage 3, and 1 (1%) was AKIN stage 0. Serum creatinine improved over the first 24 hours and continued to improve through 48 hours (p < 0.05). There was an increase in systolic blood pressure in the first 24 hours that was sustained through 48 hours after initiation of fenoldopam (p < 0.05). Urine output increased after initiation of fenoldopam without an increase in intravenous fluid requirement (p < 0.05; p = NS). Modified inotrope score and vasopressor dependency index both decreased over 48 hours (p < 0.0001; p = 0.0012). CONCLUSIONS: These findings suggest that renal function was preserved and that urine output improved without a decrease in systolic blood pressure, increase in vasoactive medication use, or an increase in resuscitation requirement in patients treated with low-dose fenoldopam. A randomized controlled trial is required to establish the efficacy of low-dose fenoldopam in critically ill burn patients with AKI.

Continuous venovenous hemofiltration in severely burned patients with acute kidney injury: a cohort study.

INTRODUCTION: Acute kidney injury (AKI) is a common and devastating complication in critically ill burn patients with mortality reported to be between 80 and 100%. We aimed to determine the effect on mortality of early application of continuous venovenous hemofiltration (CVVH) in severely burned patients with AKI admitted to our burn intensive care unit (BICU). METHODS: We performed a retrospective cohort study comparing a population of patients managed with early and aggressive CVVH compared with historical controls managed conservatively before the availability of CVVH. Patients with total body surface area (TBSA) burns of more than 40% and AKI were treated with early CVVH and their outcomes compared with a group of historical controls. RESULTS: Overall, the 28-day mortality was significantly lower in the CVVH arm (n = 29) compared with controls (n = 28) (38% vs. 71%, P = 0.011) as was the in-hospital mortality (62% vs. 86%, P = 0.04). In a subgroup of patients in shock, a dramatic reduction in the pressor requirement was seen after 24 and 48 hours of treatment. Compared with controls (n = 19), significantly fewer patients in the CVVH group (n = 21) required vasopressors at 24 hours (100% vs 43%, P < 0.0001) and at 48 hours (94% vs 24%, P < 0.0001). In those with acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), there was a significant increase from baseline in the partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio at 24 hours in the CVVH group (n = 16, 174 +/- 78 to 327 +/- 122, P = 0.003) but not the control group (n = 20, 186 +/- 64 to 207 +/- 131, P = 0.98). CONCLUSIONS: The application of CVVH in adult patients with severe burns and AKI was associated with a decrease in 28-day and hospital mortality when compared with a historical control group, which largely did not receive any form of renal replacement. Clinical improvements were realized in the subgroups of patients with shock and ALI/ARDS. A randomized controlled trial comparing early CVVH to standard care in this high-risk population is planned.

Impact of extremity amputation on combat wounded undergoing exploratory laparotomy.

BACKGROUND: Combat casualties with traumatic amputations (TA) and requiring laparotomy present unique clinical challenges. The purpose of this study was to determine the association of TA on blood/blood product usage, emergency department (ED) and operating room (OR) times, and mortality in those undergoing exploratory laparotomy after combat injury. METHODS: A retrospective study was performed at one combat support hospital in Iraq of patients requiring exploratory laparotomy for abdominal injury. These patients were divided into two cohorts based on the presence or absence of TA. Initial vital signs, international normalization ratio, pH, blood product usage, time in ED and OR, and mortality were compared between groups. RESULTS: We reviewed 171 consecutive laparotomies performed between September 2007 and May 2008. Twenty one were identified with TA. Presenting systolic pressure, hemoglobin, platelets, international normalization ratio, and arterial pH did not differ between groups. The TA group presented more tachycardic, received more blood/blood products in ED and OR, and were more likely to meet requirements of massive transfusion. There was no difference in mortality between groups. Time in ED was shorter and time in OR was longer for the TA cohort. CONCLUSION: TA with penetrating abdominal injuries are associated with increased transfusions of blood products beginning at patient arrival. Massive transfusion protocols should be activated as soon as this injury is identified. The severity of this injury pattern was only manifested by an increased heart rate at admission. TA with abdominal injury spent less time in ED and a longer time in OR; however, there was no increase in mortality.

Advances in surgical care: management of severe burn injury.

BACKGROUND: Management of combat casualties with severe burns and associated traumatic injuries requires a coordinated interaction of surgical, critical care, and evacuation assets. These patients present enormous challenges to the entire medical system as a result of the severity of injury combined with the great distance required for transport to definitive care. OBJECTIVE: The objective of this study was to review and highlight some of the advances in burn critical care experienced during recent combat operations. This review focuses on initial resuscitation, respiratory support, care of the burn wound, and long range evacuation. DATA SOURCE: The authors conducted a search of the MEDLINE database and manual review of published articles and abstracts from national and international meetings in addition to Institute of Surgical Research Burn Center registry. CONCLUSIONS: Fluid resuscitation during the first 24 to 48 hrs after injury remains a significant challenge for all who manage burn casualties. Guidelines have been developed in an effort to standardize fluid resuscitation during this time. These guidelines along with the standardization of burn wound care and continued provider education have resulted in decreased morbidity and mortality in severely burned patients returning from war zones. This system of care for severely burned patients facilitates the transfer of the burn casualty between healthcare providers and facilities and is now being integrated into the catchment area for the Institute of Surgical Research Burn Center.

Long range transport of war-related burn casualties.

BACKGROUND: US military burn casualties are evacuated to the US Army Institute of Surgical Research Burn Center in San Antonio, TX. Patients are transported by US Army Institute of Surgical Research Burn Flight Teams, Air Force Critical Care Air Transport Teams, or routine aeromedical evacuation. This study characterizes the military burn casualties transported by each team and reports associated outcomes. METHODS: We performed a retrospective review of burn center registry data, identifying all US burn casualties admitted to the Army's burn center between March 2003 and February 2007. Data included total body surface area (TBSA) burn, ventilatory status, inhalational injury, associated injuries, injury severity, disposition, morbidity, and mortality. RESULTS: During 4 years of military operations in Iraq and Afghanistan, 540 casualties were admitted to our burn center for treatment of injuries resulting from war-related operations. Mean burn size was 16.7% total body surface area (range, <1%-95%) with a mean Injury Severity Score of 12.2 +/- 13.7. One hundred eight-one (33.5%) casualties required ventilatory support in flight; inhalation injury was confirmed in 69 (12.7%) patients. Two hundred six (38.1%) were transported by the Burn Flight Team and 174 (32.2%) were transported by Critical Care Air Transport Team, with a mean transit time of 4 days after injury. One hundred sixty (29.6%) patients were routine aeromedical evacuees. There were no in-flight deaths reported; 30 (5.6%) patients died of their wounds at our burn center. CONCLUSIONS: Burn casualties represent a group of patients with severe traumatic injuries. Our current system of selectively using specialty medical transport teams for the long-range transport of burn casualties is safe and effective.

Global evacuation of burn patients does not increase the incidence of venous thromboembolic complications.

BACKGROUND: Case-control studies have suggested that air travel may be a risk factor for the development of Venous Thromboembolism (VTE). Burned patients from the current war in Iraq and Afghanistan, are transported across three continents to our Burn Center with total ground and air transport time being approximately 24 hours spread over 3 days to 4 days. We hypothesized global evacuation results in increased VTE rates. METHODS: Retrospective review of 1,107 consecutive patients admitted to our burn center from January 2003 to December 2005. RESULTS: In the time period evaluated, no detectible differences were found in incidence of VTE between air-evacuated soldiers and those admitted to our facility from South Texas (1.31% vs. 0.83%, p = ns). The air-evacuated soldiers were younger (26 +/- 7 vs. 41 +/- 19, p < 0.0001) but had a higher incidence of inhalation injury (14.4% vs. 8.0%, p < 0.0001) and higher Injury Severity Score (10.9 +/- 13.0 vs. 6.5 +/- 9.2, p < 0.0001). No difference in average percent total body surface area involvement was found (15.8 +/- 19.4 vs. 15.5 +/- 18.4, p = ns). Overall, 11 of 1,107 (0.99%) burned patients developed VTE. CONCLUSION: Prolonged global evacuation is not associated with increased risk of VTE.

Continuous renal replacement therapy improves survival in severely burned military casualties with acute kidney injury.

BACKGROUND: Acute kidney injury in severely burned patients is associated with high mortality. We wondered whether early use of continuous renal replacement therapy (CRRT) changes outcomes in severely burned military casualties with predetermined criteria for acute kidney injury. METHODS: Between November 2005 and June 2007, casualties admitted to our burn intensive care unit after sustaining burns in Iraq and Afghanistan, who subsequently developed acute kidney injury or circulatory shock or both, underwent CRRT. Baseline demographic, laboratory, and hemodynamic parameters were recorded. Both 28-day mortality and in- hospital mortality were evaluated and compared with a consecutive group of burn casualties with greater than 40% total body surface area (TBSA) burns, acute kidney injury, or nephrology consultation in the 2 years before the existence of our CRRT program. RESULTS: One hundred forty-seven severely burned military casualties were admitted to our intensive care unit before CRRT program initiation, and 102 were admitted after CRRT program initiation. Before the CRRT program, 16 patients were identified as having >40% TBSA burns with kidney injury with or without nephrology consultation (control group); 18 were treated with CRRT since (CRRT group). Groups were similar for %TBSA, %full-thickness TBSA, incidence of inhalation injury, blood urea nitrogen, creatinine, and Injury Severity Score. Of the CRRT patients, seven soldiers were treated for isolated acute kidney injury, whereas 11 were treated for a combination of acute kidney injury and shock. The dose of therapy was 50.2 +/- 13 mL/kg/h with a treatment course of 5.2 +/- 3 days. Of the 11 patients in the CRRT group treated for shock, eight were off vasopressors by 24 hours and the remaining three within 48 hours. None of the patients in the control group were placed on renal replacement therapy with nephrology consultation in eight patients. Both 28-day mortality (22% vs. 75%, p = 0.002) and in-hospital mortality (56% vs. 88%, p = 0.04) were lower in the CRRT group compared with that in the control group. CONCLUSION: Aggressive application of CRRT in severely burned casualties with kidney injury significantly improves survival.

Effects of recombinant activated factor VII in traumatic nonsurgical intracranial hemorrhage.

OBJECTIVE: To determine whether treatment with recombinant activated factor VII (rFVIIa) will prevent progression of bleeding in nonsurgical hemorrhagic traumatic brain injury (TBI). METHODS: Chart review from the trauma registry of a level 1 trauma center between January 1, 2002 and December 31, 2004 identified 2 patients who received rFVIIa for progressive hemorrhagic TBI. These patients were given a single dose of rFVIIa (120 mcg/kg) after a repeat head computed tomography (CT) scan showed worsening of intracranial bleeding. Pre-rFVIIa and post-rFVIIa coagulation parameters and postintervention CT scans were performed. A matched convenience sample was drawn from the institution's trauma registry reflecting similar injury patterns. RESULTS: The 2 patients who received rFVIIa were ages 61 and 79 years; the patients in the matched convenience sample were 57 and 63 years. Both sets of patients comprised 1 man and 1 woman who had suffered blunt trauma, including hemorrhagic TBI, and were matched according to age, gender, and injury severity score (ISS). During their hospital course, repeat CT scans documented worsening of intracranial hemorrhage in both cohorts. In the rFVIIa patients, follow-up CT showed overall improvement of head injury compared with the convenience sample. The rFVIIa patients also saw an appreciable decrease in both prothrombin time (PT) and international normalized ratio (INR). CONCLUSIONS: In hemorrhagic TBI, rFVIIa has the potential to limit or even halt the progression of bleeding that would otherwise place growing pressure on the brain. A prospective, randomized multicenter trial is planned to elucidate this hypothesis.

Short-Term Outcomes and Complications of Damage Control and Definitive Laparotomy in Deployed Combat Environments: 2002 to 2011.

INTRODUCTION: Damage control laparotomy (DCL) in an austere environment is an evolving surgical modality. METHODS: A retrospective evaluation of all patients surviving 24 hours who underwent a laparotomy from 2002 to 2011 in Iraq and Afghanistan was performed. DCL was defined as a patient undergoing laparotomy at two distinct North American Treaty Organization (NATO) Role 2 or 3 medical treatment facilities (MTFs); a NATO Roles 2 and 3 MTFs, and/or having the International Classification of Diseases, 9th Revision, Clinical Modification procedure code 54.12, for reopening of recent laparotomy site. Definitive laparotomy (DL) was defined as patients undergoing one operative procedure at one NATO Role 2 or 3 MTF. Demographic data including injury severity scores, hematological transfusion, mortality, intraperitoneal or retroperitoneal operative interventions, and complications were compared. RESULTS: DCL composed of 26.5% (n = 331) of all 1,248 laparotomies performed between March 2002 and September 2011. Total intra-abdominal, acute respiratory distress syndrome, and thromboembolic complications for DCL versus DL were 8.5% and 5.6% (p = 0.07), 2.1% and 0.8% (p = 0.06), and 1.5% and 0.7% (p = 0.17), respectively. Theater discharge mortality from DCL and DL were 1.5% (n = 5), and 1.4% (n = 13) (p = 0.90), respectively. CONCLUSIONS: In conclusion, excluding deaths with the first 24 hours, DCL and DL had comparable mortality and complication rates at NATO Roles 2 and 3 MTFs.

Elevations in growth hormone and glucagon-like peptide-2 levels on admission are associated with increased mortality in trauma patients.

BACKGROUND: Burn and trauma patients present a clinical challenge due to metabolic derangements and hypermetabolism that result in a prolonged catabolic state with impaired healing and secondary complications, including ventilator dependence. Previous work has shown that circulating levels of growth hormone (GH) are predictive of mortality in critically ill adults, but few studies have examined the prognostic potential of GH levels in adult trauma patients. METHODS: To investigate the utility of GH and other endocrine responses in the prediction of outcomes, we conducted a prospective, observational study of adult burn and trauma patients. We evaluated the serum concentration of GH, insulin-like growth factor 1 (IGF-1), IGF binding protein 3 (IGFBP-3), and glucagon-like peptide-2 (GLP-2) weekly for up to 6 weeks in 36 adult burn and trauma patients admitted between 2010 and 2013. RESULTS: Non-survivors had significantly higher levels of GH and GLP-2 on admission than survivors. DISCUSSION: This study demonstrates that GH has potential as a predictor of mortality in critically ill trauma and burn patients. Future studies will focus on not only the role of GH, but also GLP-2, which was shown to correlate with mortality in this study with a goal of offering early, targeted therapeutic interventions aimed at decreasing mortality in the critically injured. CONCLUSIONS: GH and GLP-2 may have clinical utility for outcome prediction in adult trauma patients.