J Trauma
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Emergency surgery patients are older, often critically ill, and at high risk of morbidity and mortality. We studied factors associated with issuance of a do-not-resuscitate (DNR) order and impact on morbidity and mortality in emergency surgery patients. ⋯ Female sex and, to a lesser extent, age were associated with issuance of DNR in series of patients who received emergency surgery. The association of DNR with female sex is an unexpected finding and may indicate clinician bias and necessitate the performance of further analysis.
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Comparative Study
National nosocomial infection surveillance system: from benchmark to bedside in trauma patients.
Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in the injured patient. Identification of those with VAP is important both in immediate clinical decision making as well as for the epidemiologic evaluation of the disease and benchmarking of rates across institutions with variable practice patterns. Despite this, controversy exists over the optimal method of VAP diagnosis. Many centers currently use invasive culture methods such as bronchoalveolar lavage (BAL) for diagnosis. Another diagnostic method, and the most common epidemiologic tool used to track VAP, is the definition employed by the National Nosocomial Infections Surveillance (NNIS) system. This relies on a combination of clinical and culture data. Our goal was to evaluate the accuracy of the NNIS definition as compared with BAL diagnosis in trauma patients. ⋯ Compared with strict bacteriologic criteria for VAP, the NNIS definition has good overall agreement and seems to have utility as an epidemiologic benchmarking tool in trauma patients. However, the NNIS definition has less utility as a bedside decision-making tool in this population, leading to under-treatment in a significant number of patients.
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Initial management of solid organ injuries in hemodynamically stable patients is nonoperative. Therefore, early identification of those injuries likely to require surgical intervention is key. We sought to identify factors predictive of the need for nephrectomy after trauma. ⋯ Overall, injury severity, severity of renal injury grade, hemodynamic instability, and transfusion requirements are predictive of nephrectomy after both blunt and penetrating trauma. Nephrectomy is more likely after penetrating injury.
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Comparative Study
HSPTX protects against hemorrhagic shock resuscitation-induced tissue injury: an attractive alternative to Ringer's lactate.
Conventional fluid resuscitation with Ringer's lactated (RL) activates neutrophils and causes end-organ damage. We have previously shown that HSPTX, a combination of small volume hypertonic saline (HS) and pentoxifylline (PTX), a phosphodiesterase-inhibitor, downregulates in vitro neutrophil activation and proinflammatory mediator synthesis. Herein, we hypothesized that HSPTX decreases end-organ injury when compared with RL in an animal model of hemorrhagic shock. ⋯ HSPTX, a small volume resuscitation strategy with marked immunomodulatory potential led to a marked decrease in end-organ damage. HSPTX is an attractive alternative to RL in hemorrhagic shock resuscitation.
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Rapid induction of profound hypothermic arrest (suspended animation) can provide valuable time for the repair of complex injuries and improve survival. The optimal rate for re-warming from a state of profound hypothermia is unknown. This experiment was designed to test the impact of different warming rates on outcome in a swine model of lethal hemorrhage from complex vascular injuries. ⋯ Rapid induction of hypothermic arrest maintains viability of brain during repair of lethal vascular injuries. Long-term survival is influenced by the rate of reversal of hypothermia.