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Introduction: Estimated blood loss (EBL) is an important part of the perioperative process. This project aims to determine the accuracy of perioperative team members to estimate blood volume on drapes and the operating room floor., Methods: Aliquots of unused human blood were used to create surgical scenarios, and standardized pictures and videos were taken. Physicians, residents, nurses, medical students, and surgical technicians were surveyed and asked to estimate the blood volume for each series. Accuracy and consistency of responses was analyzed., Results: One hundred and forty five responses were recorded: 57 attending physicians, 36 residents, 27 registered nurses, 17 medical students, and seven circulating surgical techs. Median percent error (PE) for all cases was 211.11%, demonstrating a global overestimation of blood volume. PE for the 150 mL images was statistically significantly lower than that of the 50 and 100 mL images. Circulating Surgical Technicians were the most accurate group, with a median PE of 125%, followed closely by Medical Students (PE = 158.33%). The most accurate specialty was Orthopedics (PE = 168.06%). The least accurate groups were Attending Physicians (PE = 286.11%) and General surgery (GSGY) (PE = 327.78%). The most accurate orthopedic surgery and GSGY subspecialties were Hand (PE = 237.64%) and Vascular (PE = 108.33%), respectively. Statistical analyses showed no significant differences by clinical role, surgical specialty, or subspecialty., Conclusion: This study demonstrates a global overestimation of blood volume when using the visual method, with improved accuracy at higher volumes. Our findings highlight the limitations of visual estimation methods for EBL., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: Variations in the anatomy of the anterior rib cage and costal margin have been observed. We sought to evaluate the location of interchondral joints and evaluate their effect on mobility of the rib cage., Methods: Cadaveric dissections were performed to evaluate the anatomy of the anterior ribs and the composition of the costal margin. Experienced chest wall surgeons and anatomists evaluated this anatomy through a standardized dissection and assessment. The presence of interchondral joints, and morphology and mobility of ribs were quantified. In addition, the movement and interactions of the ribs with upward pressure on the costal margin at the tip of the 10th rib were assessed., Results: Twenty-eight cadavers were evaluated bilaterally. In all patients, the first rib attached to the manubrium, the second rib attached to the sternal/manubrial junction, and ribs 3 to 6 attached directly to the sternum. Interchondral joints were present between ribs 4/5 in 0%, 5/6 in 35%, 6/7 in 96%, and 7/8 in 96%. The eighth/ninth ribs had free tips in 58% and 92%, respectively, and 10th rib was floating in 46%. Upward pressure on the costal margin resulted in compression of the ribs up to, on average, the 5.7 ± 0.6 rib with no compression above this level. This level corresponded to the rib interspace just above the most superior interchondral joint in 98% of evaluation. The transmission of these upward forces demonstrated an articulation of the ribs at the costal cartilage-sternal junction in the lower ribs., Conclusion: Bridging interchondral joints are common between ribs 5 to 8 and participate in distributing forces from the costal margin across the chest wall. Upward forces at the costal margin are transmitted across the lower rib cage and result in increased mobility of the lower half of the ribs. The eighth/ninth ribs often have mobile tips, and the 10th is often a floating rib., Level of Evidence: Diagnostic Test; Level II., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers., Methods: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded., Results: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF., Conclusion: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach., Level of Evidence: Therapeutic/Care Management; Level V., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions., Methods: A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis., Results: Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001)., Conclusion: Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Purpose: Research on rib fracture management has exponentially increased. Predicting fracture patterns based on the mechanism of injury (MOI) and other possible correlations may improve resource allocation and injury prevention strategies. The Chest Injury International Database (CIID) is the largest prospective repository of the operative and nonoperative management of patients with severe chest wall trauma. The purpose of this study was to determine whether the MOI is associated with the resulting rib fracture patterns. We hypothesized that specific MOIs would be associated with distinct rib fracture patterns., Methods: The CIID was queried to analyze fracture patterns based on the MOI. Patients were stratified by MOI: falls, motor vehicle collisions (MVCs), motorcycle collisions (MCCs), automobile-pedestrian collisions, and bicycle collisions. Fracture locations, associated injuries, and patient-specific variables were recorded. Heat maps were created to display the fracture incidence by rib location., Results: The study cohort consisted of 1,121 patients with a median RibScore of 2 (range, 0-3) and 9,353 fractures. The average age was 57±20 years, and 64% of patients were male. By MOI, the number of patients and fractures were as follows: falls (474 patients, 3,360 fractures), MVCs (353 patients, 3,268 fractures), MCCs (165 patients, 1,505 fractures), automobile-pedestrian collisions (70 patients, 713 fractures), and bicycle collisions (59 patients, 507 fractures). The most commonly injured rib was the sixth rib, and the most common fracture location was lateral. Statistically significant differences in the location and patterns of fractures were identified comparing each MOI, except for MCCs versus bicycle collisions., Conclusions: Different mechanisms of injury result in distinct rib fracture patterns. These different patterns should be considered in the workup and management of patients with thoracic injuries. Given these significant differences, future studies should account for both fracture location and the MOI to better define what populations benefit from surgical versus nonoperative management., Competing Interests: Conflicts of interest Evert A. Eriksson is an educational speaker for DePuy Synthes. Andrew R. Doben received royalties for an unrelated product from Zimmer Biomet and is an educational consultant for KLS Martin. The authors have no other conflicts of interest to declare., (© 2024 The Korean Society of Traumatology.)

Study Objective: Four-factor prothrombin complex concentrate (4F-PCC) is standard of care for emergent vitamin K antagonist (VKA) reversal but optimal dosing is uncertain. This meta-analysis estimated the proportion of patients treated with fixed dose (FD) 4F-PCC who achieved adequate reversal and compared safety and efficacy of FD versus weight-based dose (WB) strategies., Methods: This review was conducted according to PRISMA guidelines. Medline and Scopus were searched and included studies evaluating FD regimens and comparing FD and WB for emergent VKA reversal. Data was pooled using random effects. Subgroup analyses examined heterogeneity. Risk of bias was assessed with Newcastle-Ottawa Scale and RoB2 score., Results: Twenty-three studies (n = 2055) were included with twelve (n = 1143) comparing FD versus WB. The proportion of patients achieving goal INR with FD varied depending on the INR target, being significantly higher for INR <2 (90.9%, 95% Confidence Interval (CI) 87.2, 94.06) compared to INR <1.6 (70.97%, 95%CI 65.33, 76.31). Compared to WB, FD was less likely to achieve a goal INR <1.6 (Risk Difference (RD) -13%, 95% CI -21, -4) but achieved similar reversal for a goal INR <2.0, (RD -1%, 95%CI -7, 4). There was no difference in hospital mortality (RD 4%, 95%CI -2, 9) or thrombosis (RD 0.0%, 95%CI -3, 3)., Conclusion: FD VKA reversal was associated with significantly lower attainment of goal INR compared to WB with lower INR targets. This did not translate to differences in hospital mortality, but these results should be interpreted cautiously in light of the observational nature of the included studies., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: State guidelines for re-triage, or emergency inter-facility transfer, have never been characterized across the United States., Methods: All 50 states' Department of Health and/or Trauma System websites were reviewed for publicly available re-triage guidelines within their rules and regulations. Communication was made via phone or email to state agencies or trauma advisory committees to obtain or confirm the absence of guidelines where public data was unavailable. Guideline criteria were abstracted and grouped into domains of Center for Disease Control Field Triage Criteria: pattern/anatomy of injury, vital signs, special populations, and mechanisms of injury. Re-triage criteria were summarized across states using median and interquartile ranges for continuous data and frequencies for categorical data. Demographic data of states with and without re-triage guidelines were compared using the Wilcoxon rank sum test., Results: Re-triage guidelines were identified for 22 of 50 states (44%). Common anatomy of injury criteria included head trauma (91% of states with guidelines), spinal cord injury (82%), chest injury (77%), and pelvic injury (73%). Common vital signs criteria included Glasgow Coma Score (91% of states) ranging from 8 to 14, systolic blood pressure (36%) ranging from 90 to 100 mm Hg, and respiratory rate (23%) with all using 10 respirations/minute. Common special populations criteria included mechanical ventilation (73% of states), age (68%) ranging from <2 or >60 years, cardiac disease (59%), and pregnancy (55%). No significant demographic differences were found between states with versus without re-triage guidelines., Conclusion: A minority of US states have re-triage guidelines. Characterizing existing criteria can inform future guideline development., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The presence of six or more rib fractures or a displaced rib fracture due to cardiopulmonary resuscitation (CPR) has been associated with longer hospital and intensive care unit (ICU) length of stay (LOS). Evidence on the effect of surgical stabilization of rib fractures (SSRF) following CPR is limited. This study aimed to evaluate outcomes after SSRF versus nonoperative management in patients with multiple rib fractures after CPR., Methods: An international, retrospective study was performed in patients who underwent SSRF or nonoperative management for multiple rib fractures following CPR between January 1, 2012, and July 31, 2020. Patients who underwent SSRF were matched to nonoperative controls by cardiac arrest location and cause, rib fracture pattern, and age. The primary outcome was ICU LOS., Results: Thirty-nine operatively treated patient were matched to 66 nonoperatively managed controls with comparable CPR-related characteristics. Patients who underwent SSRF more often had displaced rib fractures (n = 28 [72%] vs. n = 31 [47%]; p = 0.015) and a higher median number of displaced ribs (2 [P 25 -P 75 , 0-3] vs. 0 [P 25 -P 75 , 0-3]; p = 0.014). Surgical stabilization of rib fractures was performed at a median of 5 days (P 25 -P 75 , 3-8 days) after CPR. In the nonoperative group, a rib fixation specialist was consulted in 14 patients (21%). The ICU LOS was longer in the SSRF group (13 days [P 25 -P 75 , 9-23 days] vs. 9 days [P 25 -P 75 , 5-15 days]; p = 0.004). Mechanical ventilator-free days, hospital LOS, thoracic complications, and mortality were similar., Conclusion: Despite matching, those who underwent SSRF over nonoperative management for multiple rib fractures following CPR had more severe consequential chest wall injury and a longer ICU LOS. A benefit of SSRF on in-hospital outcomes could not be demonstrated. A low consultation rate for rib fixation in the nonoperative group indicates that the consideration to perform SSRF in this population might be associated with other nonradiographic or injury-related variables., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In 2019, we sought to develop a chest wall injury and reconstruction clinic (CWIRC) to treat patients with chest wall pain and rib fractures. This initiative was fueled by the recognition of an unmet need and evolving research demonstrating improved patient care and experience. We will describe the evolution of this clinic program from an acute care surgery/general surgery (ACS/GS) clinic to a CWIRC., Methods: We identified outpatient encounters generated from a general surgery clinic staffed by a physician and nurse practitioner team. A retrospective cohort review was performed to identify all outpatient encounters and surgeries associated with these encounters from January 1, 2017, to November 30, 2021. Outpatient and operative work relative value unit (wRVU) production as well as payer mix was compared as the primary outcome., Results: Over this time period, the number of clinic interactions decreased (2017-284 vs. 2021-229). Clinic productivity increased however from 181 wRVUs in 2017 to 295 wRVUs in 2021. The CWIRC patient visits increased from 4% to 70%. In addition, telehealth visits increased from 0% to 23% of encounters. The operative wRVU productivity attributable to outpatient clinic visits increased (2017-253 vs. 2021-591). Combined, the CWIRC resulted in an overall growth of 104% in total wRVUs. The payer mixes for patients with rib diagnosis have a higher number of Blue Cross Blue Shield, Medicare, and Managed Care compared with ACS/GS. The most common diagnosis was rib fracture initial evaluation (37%), rib fracture subsequent encounter (25%), rib pain (24%), and flail chest initial evaluation (4%)., Conclusion: The initiation of a CWIRC increased wRVU production despite a decrease in clinical encounters. These clinics may produce more wRVUs per encounter than ACS/GS clinics. An underserved population has been identified of chest wall pathology patients presenting for initial evaluation as outpatients. Further investigation into this concept is warranted to serve this population., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue., Observations: Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery., Lessons: Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Purpose: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients., Methods: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern., Results: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034)., Conclusion: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery., (© 2022. The Author(s).)

Background: Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR., Methods: A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able., Results: Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home., Conclusion: Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed., Level of Evidence: Therapeutic, Level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jtd-21-1198). JD Forrester reports unrestricted research funding from Varian. ZM Bauman is the educational consultant for Zimmer-Biomet and KLS-Martin. AR Doben is the educational consultant for Zimmer-Biomet. E Eriksson is the speaker for Synthes.

Background: Rib fractures are common after motor vehicle collisions. The hormonal changes associated with pregnancy decrease the stiffness and increase the laxity of cartilage and tendons. The effect of these changes on injury mechanics is not completely understood., Objectives: To compare the incidences of chest wall injury following blunt thoracic trauma between pregnant and nonpregnant women., Methods: The authors conducted a retrospective review of female patients seen at a level I trauma center from 2009 to 2017 after a motor vehicle collision. Patient characteristics were compared to determine if pregnancy affected the incidence of chest wall injury. Statistics were calculated with SPSS version 24 and are presented as mean (SD) or median (interquartile range)., Results: In total, 1618 patients were identified. The incidence of rib/sternal fracture was significantly lower in pregnant patients (7.9% vs 15.2%, P = .047), but the incidence of intrathoracic injury was similar between the groups. Pregnant and nonpregnant patients with rib/sternal fractures had similar Injury Severity Score results (21 [13-27] vs 17 [11-22], P = .36), but pregnant patients without fractures had significantly lower scores (1 [0-5] vs 4 [1-9], P < .001)., Conclusions: Pregnant patients have a lower rate of rib fracture after a motor vehicle collision than nonpregnant patients. The difference in injury mechanics may be due to hormonal changes that increase elasticity and resistance to bony injury of the ribs. In pregnant trauma patients, intrathoracic injury without rib fracture should raise concerns about injury severity. A multicenter evaluation of these findings is needed., (©2021 American Association of Critical-Care Nurses.)

Background: Rib fractures account for more than one-third of blunt thoracic injuries and are associated with serious complications. Use of nonopioid adjunctive agents such as methocarbamol for pain control has increased considerably., Objective: This study aimed to assess the impact of methocarbamol addition to the pain control regimen on daily opioid requirements for young adults with rib fractures., Methods: This observational, retrospective study included patients aged 18 to 39 years with 3 or more rib fractures who were admitted to a level 1 trauma center between July 2014 and July 2018. Patients were dichotomized based on admission before and after methocarbamol addition to the institutional rib fracture protocol. The primary outcome was to determine the impact of methocarbamol on daily opioid requirements. Secondary outcomes included hospital length of stay (LOS) and diagnosis of pneumonia., Results: A total of 50 patients were included, with 22 and 28 patients in the preprotocol and postprotocol groups, respectively. All patients in the latter group received methocarbamol, whereas no patient in the preprotocol group received methocarbamol. Cumulative opioid exposure was significantly less for patients admitted after methocarbamol addition to the protocol (219 vs 337 mg oral morphine equivalents; P = 0.01), and hospital LOS was also decreased (4 vs 3 days; P = 0.03). No significant differences in the incidence of pneumonia or adverse effects were observed., Conclusion and Relevance: This is the first study to evaluate the impact of methocarbamol on reducing opioid requirements. Given the risks associated with opioids, use of methocarbamol as an analgesia-optimizing, opioid-sparing multimodal agent may be reasonable.

Purpose: To summarize selected meta-analyses and trials related to critical care pharmacotherapy published in 2019., Materials and Methods: The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 36 journals monthly for impactful articles and reviewed 113 articles during 2019 according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria., Results: Articles with a 1A grade, including three clinical practice guidelines, six meta-analyses, and five original research trials are reviewed here from those included in the monthly CCPLU. Clinical practice guidelines on the use of polymyxins and antiarrhythmic drugs in cardiac arrest as well as meta-analyses on antipsychotic use in delirium, stress ulcer prophylaxis (SUP), and vasoactive medications in septic shock and cardiac arrest were summarized. Original research trials evaluated delirium, sedation, neuromuscular blockade, SUP, anticoagulation reversal, and hemostasis., Conclusion: This clinical review and expert opinion provides summary and perspectives of clinical practice impact on influential critical care pharmacotherapy publications in 2019., Competing Interests: Declaration of Competing Interest Authors have no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI., Methods: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI., Results: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034)., Conclusion: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI., Level of Evidence: Therapeutic, level IV., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Percutaneous endoscopic gastrostomy (PEG) tubes and ventriculoperitoneal shunts (VPS) are commonly placed in neurologically impaired patients. There is concern about safety of VPS coexisting with PEG tubes due to the potential for an increased risk of infection. In this study, we assess the risk of VPS infection and the amount of time between both procedures., Patients and Methods: Retrospective chart review of patients from our institution who had VPS and PEG tubes placed during the same hospitalization between 2014 and 2018. Our primary focus was assessing risk of VPS infection and timing of procedures in this patient population. Additionally, we assessed other factors which may contribute to VPS infection including SIRS criteria at time of VPS placement, comorbidities and other procedures performed. None of the SIRS factors were associated with VPS infection., Results: 45 patients met inclusion criteria. Our VPS infection rate was found to be 7% (n = 3). These patients had 4, 16, and 36 days between procedures. 89% of our patients had PEG tube placed prior to VPS with 2 of these patients developing a VPS infection. At the time of VPS placement 42% of patients had SIRS. None of the SIRS factors were associated with VPS infection., Conclusion: Our VPS infection rate remained low even when they were performed during the same hospitalization as a PEG tube placement. SIRS is not associated with the development of VPS infections and is not an absolute contraindication to placing a VPS., (© 2020 Published by Elsevier Ltd.)

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.

Background: The reported risk of delayed intracranial hemorrhage (ICH) in a trauma patient on warfarin is estimated to be between 0.6% and 6%. The risk of delayed ICH in trauma patients taking novel oral anticoagulants (NOACs) is not well-defined., Objective: We hypothesized that there was a significant number of delayed presentations of ICH in patients on NOACs., Methods: A retrospective review of our trauma registry was performed on geriatric patients (age older than 64 years) who were initially evaluated at our level I trauma center, had fall from standing height or less, and were anticoagulated (warfarin or NOACs), from April 2017 to March 2018., Results: Seventy-seven patients met inclusion criteria. The mean age was 80 ± 7.7 years and 46% of patients were male. The admission head computed tomography scan was positive in 20.8% of patients. Positive scans were more common in patients on warfarin vs. NOACs (30% vs. 14%; p = 0.074) and had a significantly higher Injury Severity Score (median [interquartile range]: 9 [3-15] vs. 5 [1-9]; p = 0.030) and Abbreviated Injury Scale-Head score (median [interquartile range]: 1 [0-3] vs. 1 [0-2]; p = 0.035). The agreement between loss of consciousness (LOC) and ICH was 72% (κ = -0.064; p = 0.263). Fifty-one percent of patients had a repeat head CT. New ICH was diagnosed in 9.6% of patients. All of these patients were on NOACs., Conclusions: A fall from standing or less in anticoagulated geriatric patients is a significant mechanism of injury resulting in ICH. The absence of LOC does not eliminate the possibility of ICH. There is a significant risk of delayed ICH for patients on NOACs and repeat evaluations should be performed. A prospective multicenter evaluation of this finding is warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Oral factor Xa (fXa) inhibitor-related bleeding is a concerning drug safety problem. There is considerable controversy surrounding available reversal strategies. The recently approved reversal agent andexanet alfa has limited data, an unclear safety profile, and imparts a substantial financial burden. This has led to the off-label use of four-factor prothrombin complex concentrates (4F-PCC) for this indication. This study aimed to assess the safety and efficacy of 4F-PCC for the management of major bleeding related to oral fXa inhibitors. This observational, retrospective study included adult patients admitted from 2014 to 2018 who received 4F-PCC (Kcentra ® ) for fXa inhibitor-related major bleeding. Efficacy was assessed using criteria described by Sarode et al. Secondary outcomes included the incidence of thromboembolism, mortality, and a cost analysis comparing 4F-PCC to andexanet alfa for reversal of oral fXa inhibitors. Thirty-one patients received 4F-PCC for major bleeding associated with apixaban (55%) or rivaroxaban (45%). Intracranial hemorrhage (58%) and pericardial effusion (16%) accounted for the majority of bleeding events. Most patients received a single weight-based 4F-PCC dose of 25 units/kg (38.7%) or 50 units/kg (51.6%). Effective hemostasis was achieved in 80.6% of patients. Five patients (16%) died due to acute bleeding and no thromboembolic events were observed. Administration of 4F-PCC was effective for most patients requiring emergent reversal of anticoagulation with apixaban or rivaroxaban and was associated with a low risk of thromboembolic events. Considerable cost differences limit the use of andexanet alfa and may warrant further study of 4F-PCC for fXa inhibitor reversal.

Background: Thoracic disk herniations (TDHs) represent only 0.15% to 1.8% of surgically managed disk herniations but have posed a particular challenge to spine surgeons. Numerous surgical approaches have been cited in the literature with varying degrees of success, technical complexity, and complication profiles., Objective: To report a case of a combined lateral retropleural and dorsal transdural approach for complex thoracic discectomy., Methods: In this report, we describe a combined lateral/retropleural and posterior transdural approach for a patient with a giant calcified TDH that was not amenable to safe removal using a single approach., Results: In complex situations such as this, a dual corridor approach allows for improved visualization and maximal resection opportunity and opens up yet another option to address recalcitrant TDH., Conclusion: The staged dual corridor approach is safe and represents a further surgical option for extremely difficult TDH., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Background: Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality., Methods: Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed., Results: One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care., Conclusion: Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research., Level of Evidence: Epidemiologic, level II.

The use of Airway Pressure Release Ventilation (APRV) in patients with traumatic brain injury (TBI) remains controversial. Some believe that elevated mean airway pressures transmitted to the thorax may cause clinically significant increases in Central Venous Pressure (CVP) and intracranial pressure (ICP) from venous congestion. We perform a retrospective review from 2009 to 2015 of traumatically injured patients who were transitioned from traditional ventilator modes to APRV and also had an ICP monitor in place. Fifteen patients undergoing 19 transitions to APRV were identified. Prior to transitioning to APRV the average static and dynamic compliance was 22.9 +/- 5.6 and 16.5 +/- 4.12 mL/cm H2O. There was no statistical difference in ICP, MAP, and CPP prior to and after transition to APRV. There was a statistically significant increase in CVP, PaO2, and P:F ratio. Individually, only 4 patients had ICP values >20 in the first hour after transitioning to APRV and the rate of ICP elevations was similar between the two modes of ventilation. These data show that APRV is a viable mode of ventilation in patients with TBI who have low lung compliance. The increased CVP of this mode of ventilation did not affect ICP or hemodynamic parameters., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Dosing regimens of quetiapine to treat delirium in critically ill patients are titrated to effect, and may utilize doses higher than previously reported. This study aimed to assess the safety of quetiapine for this indication., Materials and Methods: A retrospective medical chart review was conducted, identifying 154 critically ill adults that were initiated on quetiapine to treat delirium and monitored for QTc prolongation., Results: The median average daily dose was 150 mg (79-234) and median max dose was 225 mg (100-350). The overall range was 25-800 mg daily. The time to peak dose was 3 days (1-8). Patients with QTc prolongation were significantly older (age 54 ± 11 vs 45 ± 17 years (p = 0.002)) and with higher baseline QTc (454 ± 33 vs 442 ± 30 (p = 0.045)). Regression analysis revealed only dose as a significant factor (OR = 1.006 (1.003-1.009) (p < 0.001))., Conclusion: The dose of quetiapine has very little correlation with QTc and change from baseline. A small number of side effects were observed. Overall, titrating quickly to large doses of quetiapine is safe for treating delirium., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Stress gastropathy is a rare complication of the intensive care unit stay with high morbidity and mortality. There are data that support the concept that patients tolerating enteral nutrition have sufficient gut blood flow to obviate the need for prophylaxis; however, no robust studies exist. This study assesses the incidence of clinically significant gastrointestinal bleeding in surgical trauma intensive care unit (STICU) patients at risk of stress gastropathy secondary to mechanical ventilation receiving enteral nutrition without pharmacologic prophylaxis., Design: A retrospective cohort study of records from 2008 to 2013., Setting: Adult patients in a single-center STICU were included., Patients: Patients were included if they received full enteral nutrition while on mechanical ventilation. Exclusion criteria were coagulopathy, glucocorticoid use, prior-to-admission acid-suppressive therapy use, direct trauma or surgery to the stomach, failure to tolerate goal enteral nutrition, orders to allow natural death, and deviation from the intervention., Intervention: Pharmacologic stress ulcer prophylaxis was discontinued once enteral nutrition was providing full caloric requirements for patients requiring mechanical ventilation., Measurements and Main Results: A total of 200 patients were included. The median age was 42 years, 83.0% were male, and 96.0% were trauma patients. The incidence of clinically significant gastrointestinal bleeding was 0.50%, with a subset analysis of traumatic brain injury patients yielding an incidence of 0.68%. Rates of ventilator-associated pneumonia and Clostridium difficile infection were low at 1.0 case/1000 ventilator days and 0.2 events/1000 patient days, respectively. Hospital all-cause mortality was 2.0%. Cost savings of US$121/patient stay were realized., Conclusion: Stress gastropathy is rare in this population. Surgical and trauma patients at risk for stress gastropathy did not benefit from continued pharmacologic prophylaxis once they tolerated enteral nutrition. Pharmacologic prophylaxis may safely be discontinued in this patient population. Further investigation is warranted to determine whether continued prophylaxis after attaining enteral feeding goals is detrimental.

Background: Subclavian and axillary artery injuries are uncommon. In addition to many open vascular repairs, endovascular techniques are used for definitive repair or vascular control of these anatomically challenging injuries. The aim of this study was to determine the relative roles of endovascular and open techniques in the management of subclavian and axillary artery injuries comparing hospital outcomes, and long-term limb viability., Methods: A multicenter, retrospective review of patients with subclavian or axillary artery injuries from January 1, 2004, to December 31, 2014, was completed at 11 participating Western Trauma Association institutions. Statistical analysis included χ, t-tests, and Cochran-Armitage trend tests. A p value less than 0.05 was significant., Results: Two hundred twenty-three patients were included; mean age was 36 years, 84% were men. An increase in computed tomography angiography and decrease in conventional angiography was observed over time (p = 0.018). There were 120 subclavian and 119 axillary artery injuries. Procedure type was associated with injury grade (p < 0.001). Open operations were performed in 135 (61%) patients, including 93% of greater than 50% circumference lacerations and 83% of vessel transections. Endovascular repairs were performed in 38 (17%) patients; most frequently for pseudoaneurysms. Fourteen (6%) patients underwent a hybrid procedure. Use of endovascular versus open procedures did not increase over the duration of the study (p = 0.248). In-hospital mortality rate was 10%. Graft or stent thrombosis occurred in 7% and graft or stent infection occurred in 3% of patients. Mean follow-up was 1.6 ± 2.4 years (n = 150). Limb salvage was achieved in 216 (97%) patients., Conclusion: The management of subclavian and axillary artery injuries still requires a wide variety of open exposures and procedures, especially for the control of active hemorrhage from more than 50% vessel lacerations and transections. Endovascular repairs were used most often for pseudoaneurysms. Low early complication rates and limb salvage rates of 97% were observed after open and endovascular repairs., Level of Evidence: Prognostic/epidemiologic, level IV.

Background: A subset of patients explored for abdominal injury have persistent hepatic bleeding on postoperative computed tomography (CT) and/or angiography, either not identified or not manageable at initial laparotomy. To identify patients at risk for ongoing hemorrhage and guide triage to angiography, we investigated the relationship of early postoperative CT scan with outcomes in operative hepatic trauma., Methods: This is a retrospective review of 528 patients with hepatic injury taken to laparotomy without imaging within 6 hours of arrival to six trauma centers from 2007 to 2013, coordinated through the Western Trauma Association multicenter trials group., Results: A total of 528 patients were identified, with a mean age of 31 years, 82% male, and 37% blunt injury; mean (SD) Injury Severity Score (ISS) was 27 (16) and base deficit was -9 (6); in-hospital mortality was 26%. Seventy-three patients died during initial exploration. Of 455 early survivors, 123 (27%) had a postoperative contrast CT scan within 24 hours of laparotomy. CT patients had more common blunt injury, higher ISS, and lower base deficit than those who did not undergo CT. CT identified hepatic contrast extravasation or pseudoaneurysm in 10 patients (8%). Hepatic bleeding on CT was 83% sensitive and 75% specific (likelihood ratio, 3.3) for later positive angiography; negative CT finding was 96% sensitive and 83% specific (likelihood ratio, 5.7) for later negative or not performed angiography. Despite occurring in a more severely injured cohort, performance of early postoperative CT was associated with reduced mortality (odds ratio, 0.16) in multivariate analysis. Blunt mechanism was also a multivariate predictor of mortality (odds ratio, 3.0)., Conclusion: Early postoperative CT scan after laparotomy for hepatic trauma identifies clinically relevant ongoing bleeding and is sufficiently sensitive and specific to guide triage to angiography. Contrast CT should be considered in the management algorithm for hepatic trauma, particularly in the setting of blunt injury. Further study should identify optimal patient selection criteria and CT scan timing in this population., Level of Evidence: Care management/therapeutic study, level IV; epidemiologic/prognostic study, level III.

Introduction: Little is known about the incidence and etiology of fat embolism in pediatric patients. We sought to determine the incidence, time course, and associated factors of pulmonary fat embolism (PFE), cerebral fat embolism (CFE), and kidney fat embolism (KFE) in trauma and nontrauma pediatric patients at the time of autopsy., Methods: Retrospectively, a convenience sample of consecutive pediatric patients (age, ≤10 years) who had undergone autopsy between 2008 and 2012 were evaluated for fat embolism. Patients who had no documented cause of death or who were hospital births and died during the same hospitalization were excluded. Formalin-fixed paraffin sections were reviewed by a forensic pathologist for evidence of fat embolism and nuclear elements. Autopsy reports were used to determine cause of death, injuries, resuscitative efforts taken, sex, height, weight, and age., Results: Sixty-seven decedents were evaluated. The median age was 2.0 years (interquartile range, 0.75-4), median body mass index (BMI) was 18.0 kg/m(2) (interquartile range, 15.7-19.0 kg/m(2)), and 55% of the patients were male. Pulmonary fat embolism, CFE, and KFE were present in 30%, 15%, and 3% of all patients, respectively. The incidence of PFE was not significantly different by cause of death (trauma 33%, drowning 36%, burn 14%, medical 28%). Patients with PFE but not CFE had significantly higher age, height, weight, and BMI. Half of the PFE and 57% of the CFE occurred in patients who lived less than 1 hour after beginning of resuscitation. Seventy-one percent of patients with CFE did not have a patent foramen ovale. Multivariate regression revealed an increased odds ratio of PFE based on BMI (1.244 [95% confidence interval, 1.043-1.484], P = .015). None of the samples evaluated demonstrated nuclear elements., Conclusions: Pulmonary fat embolism, CFE, and KFE are common in pediatric trauma and medical deaths. Body mass index is independently associated with the development of PFE. Absence of nuclear elements suggests that fat embolism did not originate from intramedullary fat., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Traumatically injured patients have multiple causes for acute respiratory decompensation. We reviewed the use of computed tomography pulmonary angiography (CTPA) in critically injured patients to evaluate the results and impact on patient care., Methods: The charts of trauma patients (age >16 years) admitted to our intensive care unit for greater than 48 hours, who underwent CTPA for acute respiratory decompensation, were reviewed to determine the results of these studies and the effect on patient care., Results: We identified 188 patients who underwent CTPA for acute physiologic changes. Pertinent clinical finding were identified in 95% of studies and included atelectasis/collapse (56%), pleural effusion (18%), pneumonia (15%), and pulmonary embolus (18%). These results prompted interventions designed to improve patient outcome. The most frequent interventions were modifications of ventilator therapy (52%), antibiotic therapy (28%), mini-bronchoalveolar lavage (15%), or bronchoscopy (15%). Diagnostic agreement between chest x-ray and CTPA was poor to moderate (κ = 0.013-0.512)., Conclusions: Computed tomography pulmonary angiography is valuable in the evaluation of cardiopulmonary deterioration in critically ill traumatically injured patients. Computed tomography pulmonary angiography offers the ability to identify causes of acute physiologic changes not detected using standard chest x-ray. The results of these studies provide insight into the underlying pathophysiology and offer an opportunity to direct subsequent patient care., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Blunt abdominal aortic injury (BAAI) is a rare injury. The objective of the current study was to examine the presentation and management of BAAI at a multi-institutional level., Methods: The Western Trauma Association Multi-Center Trials conducted a study of BAAI from 1996 to 2011. Data collected included demographics, injury mechanism, associated injuries, interventions, and complications., Results: Of 392,315 blunt trauma patients, 113 (0.03%) presented with BAAI at 12 major trauma centers (67% male; median age, 38 years; range, 6-88; median Injury Severity Score [ISS], 34; range, 16-75). The leading cause of injury was motor vehicle collisions (60%). Hypotension was documented in 47% of the cases. The most commonly associated injuries were spine fractures (44%) and pneumothorax/hemothorax (42%). Solid organ, small bowel, and large bowel injuries occurred in 38%, 35%, and 28% respectively. BAAI presented as free aortic rupture (32%), pseudoaneurysm (16%), and injuries without aortic external contour abnormality on computed tomography such as large intimal flaps (34%) or intimal tears (18%). Open and endovascular repairs were undertaken as first-choice therapy in 43% and 15% of cases, respectively. Choice of management varied by type of BAAI: 89% of intimal tears were managed nonoperatively, and 96% of aortic ruptures were treated with open repair. Overall mortality was 39%, the majority (68%) occurring in the first 24 hours because of hemorrhage or cardiac arrest. The highest mortality was associated with Zone II aortic ruptures (92%). Follow-up was documented in 38% of live discharges., Conclusion: This is the largest BAAI series reported to date. BAAI presents as a spectrum of injury ranging from minimal aortic injury to aortic rupture. Nonoperative management is successful in uncomplicated cases without external aortic contour abnormality on computed tomography. Highest mortality occurred in free aortic ruptures, suggesting that alternative measures of early noncompressible torso hemorrhage control are warranted., Level of Evidence: Epidemiologic study, level III; therapeutic study, level IV.

Background: In 2012, the National Healthcare Safety Network presented a new surveillance definition for ventilator-associated events (VAEs) to objectively define worsening pulmonary status in ventilated patients. VAE subcategories, ventilator-associated condition (VAC), infection-related VAC, and probable ventilator-associated pneumonia (PrVAP), were vetted predominantly in medical intensive care units. Our goal was to evaluate how well VAE criteria characterize pulmonary complications in surgical intensive care unit (SICU) patients., Methods: Since September 2012, all intubated SICU patients were screened prospectively for VAE and monitored for sustained respiratory dysfunction that did not meet VAE criteria. We diagnosed ventilator-associated pneumonia (VAP) using a clinical definition: Clinical Pulmonary Infection Score (CPIS) greater than 6 and catheter-directed bronchoalveolar lavage cultures with 10 or more colony-forming units per milliliter of pathogenic organisms., Results: We admitted 704 intubated patients. A total of 437 were intubated for two or more days (mean [SD], age 46 [18] years; 65% male; median ventilator days, 4 [range, 2-9]; median Sequential Organ Failure Assessment [SOFA] score, 8 [range, 5-10]). Using VAE criteria, we identified 37 patients with VAC, 31 with infection-related VAC, and 22 with PrVAP. While the remaining 400 patients did not meet VAE criteria, we identified 111 patients (28%) with respiratory deterioration and diagnosed 99 additional pneumonias. Of the 111 patients, 85 (77%) never had a period of stable/decreasing oxygenation, requiring elevated vent settings upon initiation of ventilation preventing them from meeting VAE criteria. Of the 99 pneumonia patients, 10% had sustained respiratory deterioration treated with elevations in mean airway pressure; they did not meet VAE criteria as the positive end-expiratory pressure or FIO2 was not elevated. Twenty-seven percent never had a period of stable/decreasing oxygenation. Fifty-eight percent had less than 2 days of respiratory deterioration. Agreement between PrVAP and clinical VAP was 77.3% (κ = 0.243, p < 0.001)., Conclusion: The applicability of the new National Healthcare Safety Network categories of VAE to critically ill surgery patients is limited. Agreement between PrVAP and clinical VAP in SICU patients is poor. Most surgical patients are not well categorized by this new definition; a better method of surveillance should be created for this patient population., Level of Evidence: Diagnostic study, level III.

Objectives: To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda., Data Sources: Review of the published medical literature, governmental documents, and opinions of experts from the Society of Critical Care Medicine ICU Telemedicine Committee., Data Synthesis: Formal ICU telemedicine programs now support 11% of nonfederal hospital critically ill adult patients. There is increasingly robust evidence of association with lower ICU (0.79; 95% CI, 0.65-0.96) and hospital mortality (0.83; 95% CI, 0.73-0.94) and shorter ICU (-0.62 d; 95% CI, -1.21 to -0.04 d) and hospital (-1.26 d; 95% CI, -2.49 to -0.03 d) length of stay. Physicians in training report experiences with telemedicine intensivists that are positive and increased patient safety. Early studies suggest that implementation of ICU telemedicine programs has been associated with lower numbers of malpractice claims and costs. The requirements for Medicare reimbursement and states with legislation addressing providing professional services by telemedicine are detailed., Conclusions: The inclusion of an ICU telemedicine program as a major part of their critical care delivery paradigm has been implemented for 11% of critically ill U.S. adults as a solution for the problem of access to adult critical care services. Implementation of an ICU telemedicine program is one practical way to increase access and reduce mortality as well as length of stay. ICU telemedicine research including comparative effectiveness studies is urgently needed.

Background: We evaluated the role of serial catheter-directed bronchoalveolar lavage (CDBAL) in the diagnosis and management of pneumonia in ventilated surgical intensive care unit patients., Methods: Intubated surgical intensive care unit patients were prospectively evaluated with serial CDBALs from September 1, 2012, to May 31, 2013. Initial CDBALs were performed if patients developed the following signs of pneumonia: white blood cell count greater than 11 or less than 4, temperature greater than 38.5°C or less than 36°C, qualitative purulent sputum, worsening oxygenation, or new infiltrate on plain chest x-ray. Subsequent CDBALs were performed every 4 days. Pneumonia was diagnosed using a Clinical Pulmonary Infection Score of greater than 6 and CDBAL cultures with greater than or equal to 10 colony-forming units of pathogenic organisms. Patients were also evaluated for sustained (≥48 hours) respiratory deterioration (increased FIO2 or positive end-expiratory pressure) corresponding to the National Healthcare Safety Network definition of ventilator-associated event (VAE)., Results: A total of 159 patients were intubated for 5 days or longer, of whom 80 patients were diagnosed with clinical pneumonia. Of these patients, 67 had serial CDBALs performed, and 81 ventilator-associated pneumonias (VAPs) were diagnosed in these patients. Of the patients with VAP, 16 also met the National Healthcare Safety Network criteria for VAE. Patients with VAP that had sustained respiratory deterioration demonstrated resolution of their compromise 60 hours (interquartile range [IQR], 41-107 hours) after starting antibiotics. Of the patients with pneumonia, 66 (81%) had resolution of the pathogenic bacteria in subsequent CDBAL cultures or were extubated within 4 days (IQR, 4-5 days) after starting antibiotics. The duration of antibiotic therapy in this group was 8 days (IQR, 7-9 days). The remaining 15 patients had multiple positive serial CDBAL cultures that isolated the same organism despite antibiotic treatment. The duration of antibiotic therapy was 14 days (IQR, 10-19 days) in these patients. The culture results were used to adjust antibiotic regimens a median of one time (IQR, 1-2 times) in 13 (87%) and two or more times in 6 (40%) of these patients., Conclusion: Serial CDBALs help guide antibiotic treatment duration in patients with pneumonia and VAE. Patients with sustained hypoxia or persistent bacterial growth may require prolonged therapy., Level of Evidence: Diagnostic test, level III. Therapeutic study, level IV.

Purpose: The goal of this study was to determine the impact of surgical rib fixation (SRF) in a treatment protocol for severe blunt chest trauma., Materials and Methods: Patients with flail chest admitted between September 2009 and June 2010 to our level I trauma center who failed traditional management and underwent SRF were matched with an historical group. Outcome variables evaluated include age, injury severity score, intensive care unit length of stay (LOS), hospital LOS, ventilator days, total number of rib fractures, and total number of segmental rib fractures., Results: The 2 groups were similar in age, injury severity score, intensive care unit LOS, hospital LOS, total number of rib fractures, and total segmental rib fractures. The operative group demonstrated a significant reduction in total ventilator days as compared with the nonsurgical group (4.5 [0-30] vs 16.0 [4-40]; P = .040). Patients with SRF were permanently liberated from the ventilator within a median of 1.5 days (0-8 days)., Conclusions: Surgical rib fixation resulted in a significant decrease in ventilator days and may represent a novel approach to decreasing morbidity in flail chest patients when used as a rescue therapy in patients with declining pulmonary status. Larger studies are required to further identify these benefits., (© 2013.)

Necrotizing fasciitis and toxic shock syndrome are life-threatening conditions that can be seen after any surgical procedure. With only 4 previous published case reports in the obstetrics and gynecology literature of these two conditions occurring secondary to Clostridium septicum, we describe a case of necrotizing fasciitis and toxic shock syndrome occurring after a term cesarean delivery caused by this microorganism, requiring aggressive medical and surgical intervention.

Purpose: This study aimed to identify predictive factors resulting in glucose values greater than 200 mg/dL in patients with trauma transitioned from an insulin infusion to a basal-bolus subcutaneous insulin regimen., Materials and Methods: Thirty-nine patients with trauma on goal enteral nutrition in the intensive care unit receiving an insulin infusion for at least 48 hours and transitioned to a basal-bolus regimen were retrospectively identified., Results: Ten patients had hyperglycemic events after transition. Hyperglycemia was significantly associated with increased age (42 [17] years vs 56 [13] years, P=.02), admission glucose (128 [39] mg/dL vs 214 [91] mg/dL, P=.015), and insulin drip rate 48 hours before transition (87 [38] units/d vs 127 [49] units/d, P=.012). There was no difference between groups with respect to injury severity, demographics, or physiologic parameters. Multiple regression analysis revealed that increased age (odds ratio [OR], 1.215 [1.000-1.477]; P=.05), increased admission blood glucose (OR, 1.053 [1.006-1.101]; P=.025), and higher insulin infusion rates 48 hours before transition (OR, 1.061 [1.009-1.116]; P=.020) predisposed patients to severe hyperglycemic episodes., Conclusions: Older patients with trauma and patients with higher blood glucose on admission are more likely to experience severe hyperglycemia when transitioned to basal-bolus glucose control. Higher insulin infusion rates at 48 hours before transition are also associated with severe hyperglycemia., (© 2013.)

Background: Ventilator-associated pneumonia is a problem in trauma and emergency general surgery patients. Our hospital-acquired infection prevention committee approved the use of early nonbronchoscopic bronchoalveolar lavage (screening-BAL) in the surgical intensive care unit (SICU) to identify ventilated patients with bronchiolar bacteria before 48 hours. We reviewed the results of this quality improvement initiative., Methods: All ventilated patients in the SICU (March 2011 to June 2012) underwent a screening-BAL 36 hours to 48 hours after intubation; quantitative culture results (>5 × 10(4) colony-forming unit per milliliter) were used to identify positive specimens. Clinical pneumonia was defined as clinical pulmonary infection score greater than 6 with a subsequent positive diagnostic-BAL result. Sequential organ failure assessment scores were averaged for the first 48 hours in the SICU. Continuous and dichotomous data were compared, and a multivariate regression analysis was performed on the screening-BAL and pneumonia results., Results: Screening-BALs were performed in 150 patients (99 trauma and 51 emergency general surgery patients), 72 of these specimens had positive findings. Fifty-three clinical pneumonias were diagnosed, and 45 (positive predictive value, 0.85) identified the same organism as the screening-BAL. Clinical pneumonia developed in eight patients with a negative screening-BAL (negative predictive value, 0.85). Antibiotic therapy at the time of the screening-BAL was associated with a negative screen (odds ratio, 0.44; p = 0.026). Pneumonia developed on median postintubation Day 4 (2-15 days) in patients with a positive screening-BAL results as compared with day 7.5 in the patients with a negative screening-BAL results (3.5-15 days; p = 0.007). Field intubation is an independent risk factor (odds ratio, 3.5; p = 0.004)., Conclusion: Positive screening-BAL results in trauma and emergency general surgery patients are associated with the development of ventilator-associated pneumonia by the same organism and may play a role in identifying patients at risk for pneumonia. Further studies must be conducted to evaluate the role of screening-BAL in this patient population., Level of Evidence: Diagnostic/prognostic study, level III.

Background: Brain tissue oxygen monitoring (pBtO2) has been advocated in the treatment of patients with severe traumatic brain injuries (TBI); however, controversy exists regarding the improvements that pBtO2 monitoring provides. The objective of our study was to evaluate our experience and effect on mortality with goal directed pBtO2 monitoring for severe TBI compared to traditional ICP/CPP monitoring., Methods: All patients admitted with severe TBI (GCS < 8) to our Level 1 trauma center from June 2007 through June 2009 were retrospectively analyzed. All patients had ICP monitoring and pBtO2 monitors were placed based on the current practices of the attending neurosurgeon producing two temporally matched cohorts of patients with and without pBtO2 monitors. Exclusion criteria were age <18 years and survival <24 h. Goal-directed therapy was utilized in all patients to maintain ICP <20 mmHg and CPP >60 mmHg. Patients with pBtO2 monitors were managed to maintain a level >20 mmHg., Results: 74 patients were treated for severe TBI over the 2-year study period with 37 patients in each group. Both groups were similar in age, sex, and admission Glascow Coma Score(GCS).The pBtO2-monitored group did, however, have significantly lower injury severity score [26 (25-30) vs. 30 (26-36), p = 0.03] and AIS Chest [0 (0-0) vs. 2 (0-3), p = 0.02]. There was no survival difference found (64.9 vs. 54.1 %, p = 0.34). No difference with respect to discharge GCS or discharge Functional Independence Measure score was identified., Conclusions: Compared with ICP/CPP-directed therapy alone, the addition of pBtO2 monitoring did not provide a survival or functional status improvement at discharge. The true clinical benefit of pBtO2 monitoring will require further study.

Purpose: The purposes of the study were to determine the incidence of adrenal insufficiency (AI) using several published techniques, compare the response rates using a low-dose (LD) corticotropin (ACTH) stimulation test vs a standard dose (SD), and identify the technique that is most closely related to vasopressor use., Materials and Methods: Consecutive adult patients who were undergoing open heart surgery for CAD or valvular disease were prospectively enrolled. Exclusion criteria included history of steroid use, operative steroid, or etomidate administration. Postoperatively, each patient underwent ACTH stimulation with 1 μg (LD) and 249 μg (SD), 60 minutes apart. Agreement among the tests was evaluated, and vasopressor use was compared between groups., Results: There were 40 patients evaluated. The incidence of AI based on operative change, postoperative values, and LD-ACTH and SD-ACTH tests was 53%, 38%, 60%, and 38%, respectively. Agreement between the LD- and SD-ACTH tests was 73% (κ = 0.476, P = .001). There was a significant difference in the need for (93% vs 52%, P = .013) and duration (18.9 [0-180.6] vs 0.6 [0-73.2] hours, P = .003) of vasopressor therapy in patients with and without AI but only using the SD-ACTH definition., Conclusion: The incidence of AI will vary greatly based on technique used for diagnosis. The SD-ACTH stimulation test should be used to determine AI in open heart patients postoperatively because of the close association with vasopressor usage., (Copyright © 2012 Elsevier Inc. All rights reserved.)