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Introduction: The relationship between outcomes following severe trauma and American College of Surgeons (ACS) trauma centre designation has been studied. Little is known, however, about the association between ACS level and outcomes associated with ventilator-associated pneumonia (VAP)., Methods: The National Trauma Databank (NTDB, Version 5.0) was queried to identify adult (age 18)trauma patients who (1) developed VAP and (2) were admitted to either an ACS level I or level II centre.Transfer and burn patients were excluded. Univariate analysis defined differences between patient cohorts. Logistic regression analysis was utilised to identify independent risk factors for mortality., Results: A total of 3465 patients were identified where 65.6% were admitted to a level I facility and 34.4%to a level II centre. Patients admitted to a level I centre were more likely to have an age > 55 (71.5% vs.66.8%, p = 0.004) and to be hypotensive (SBP < 90) on admission (16.2% vs. 13.6%, p = 0.042). They were also more likely to have a longer duration of mechanical ventilation (18.5 days vs. 16.5 days, p = 0.001),longer hospital LOS (34.2 days vs. 29.6 days, p < 0.001) and a higher rate of early (±7 days) tracheostomy(33.1% vs. 29.1%, p = 0.017). Level I admission was, however, associated with lower mortality rates (10.8%vs. 14.7%, p = 0.001) and a higher likelihood of achieving discharge to home (20.2% vs. 16.1%, p < 0.001).Logistic regression analysis identified admission to a level II facility as an independent risk factor for mortality (OR 1.34, 95% CI 1.08–1.66; p = 0.008) in patients developing post-traumatic VAP., Conclusion: For adults who develop VAP after trauma, admission to a level I facility is associated with improved survival. Further prospective study is needed., (2009 Elsevier Ltd. All rights reserved.)

Introduction: The purpose of this study was to assess the role of decompressive craniectomy (DC) inpatients with post-traumatic intractable intracranial hypertension (ICH) in the absence of an evacuable intracerebral haemorrhage., Methods: Retrospective study at LAC+USC Medical Centre including patients who underwent DC for post-traumatic malignant brain swelling or ICH without space occupying haemorrhage, during the period 01/2004 to 12/2008. The analysis included the effect of DC on intracranial pressure (ICP) and timing of DC on functional outcomes and survival., Results: Of 106 patients who underwent DC, 43 patients met inclusion criteria. Of those, 34 were operated within the first 24 h from admission. DC decreased the ICP significantly from 37.8 ± 12.1 mmHg to 12.7 ± 8.2 mmHg in survivors and from 52.8 ± 13.0 to 32.0 ± 17.3 mmHg in non-survivors. Overall 25.6%died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). No tendency towards either increased or decreased incidence in favourable outcome was found relative to the time from admission to DC.Six of the 18 patients (33.3%) with favourable outcome were operated on within the first 6 h., Conclusions: DC lowers ICP and raises CPP to high normal levels in survivors compared to non-survivors.The timing of DC showed no clear trend, for either good neurological outcome or death. Overall, the survival rate of 74.4% is promising and 41.9% had favourable neurological outcome., (2010 Elsevier Ltd. All rights reserved.)

Background: Several authors have examined the relationship between outcomes following severe trauma and American College of Surgeons (ACS) trauma centre designation. Little is known, however, about the association between ACS level and outcomes following complications of trauma., Methods: The National Trauma Databank (NTDB, v. 5.0) was queried to identify adult (age > or =18) trauma patients developing post-traumatic ARDS, who were admitted to either ACS level 1 or level 2 trauma centres from 2000 to 2004. Patients transferred between institutions and injuries following burns were excluded. Univariate analysis was used to assess differences between those patients admitted to ACS level 1 and level 2 facilities. Adjusted mortality was derived using logistic regression analysis., Results: A total of 902 adult trauma patients with ARDS after 48 h of mechanical ventilation were identified from the NTDB. Five hundred and thirty six patients were admitted to a level 1 ACS verified centre and 366 to a level 2 facility. Univariate analysis revealed no statistical differences in clinical and demographic characteristics between the two groups. On univariate comparison, patients admitted to level 1 facilities had longer mean hospital and ICU length of stay and higher hospital related charges than level 2 counterparts. Patients admitted to a level 1 centre were, however, significantly more likely to achieve discharge to home. Using multivariate logistic regression, ACS level designation was shown to have no statistical effect on mortality. Hypotension on admission and age greater than 55 were the only independent predictors of mortality., Conclusion: ACS trauma centre designation level is not an independent predictor of mortality following post-traumatic ARDS.

Objective: The association between hospital volume and outcomes following mechanical ventilation has been previously examined in diverse patient populations. The American College of Surgeons (ACS) Committee on Trauma has outlined criteria for trauma centre level designations with specific requirements for both specialty capabilities and hospital volume. Our objective is to determine the relationship between ACS centre designation and outcomes for trauma patients undergoing mechanical ventilation., Methods: We conducted a retrospective cohort study using the National Trauma Databank (NTDB), identifying 13,933 adult (age>or=18) trauma patients receiving mechanical ventilation for greater than 48 h from 2000 to 2004 who were admitted to either an ACS Level I or Level II trauma centre. The primary endpoints examined were mortality, pneumonia and Acute Respiratory Distress Syndrome (ARDS). Univariate analysis defined differences between those patients admitted to ACS Level I and Level II facilities. Logistic regression analysis was used to identify if ACS level designation was an independent risk factor for the goal outcomes., Results: Patients admitted to a Level I facility and mechanically ventilated for greater than 48 h were more commonly greater than age 55 (71.3% vs. 67.9%, p<0.01), hypotensive (SBP<90) (16.1% vs. 12.8%, p<0.01), and likely to have sustained injury due to penetrating mechanism (11.1% vs. 5.1%, p<0.01). On univariate analysis, mortality and the incidence of pneumonia did not differ between the two groups. Level I admission was, however, less commonly associated with the development of ARDS (5.8% vs. 7.7%, p<0.01) and patients admitted to Level I facilities were significantly more likely to be discharged to home than Level II counterparts (29.7% vs. 22.9%, p<0.01). Logistic regression revealed that, while ACS Level designation was not a predictive factor for mortality or the development of pneumonia, admission to an ACS Level II facility was an independent predictor for the development of ARDS [p<0.01, odds ratio, 95% CI: 1.35 (1.18-1.59)]., Conclusion: For trauma patients requiring mechanical ventilation for >48 h, ACS trauma centre designation had no effect on overall mortality or the incidence of pneumonia. Compared to Level I counterparts, however, patients admitted to an ACS Level II facility were significantly more likely to develop ARDS following trauma. This finding needs further investigation in a large, prospective analysis.

Aim: To establish whether total parenteral nutrition (TPN) for ventilated trauma victims is associated with late-onset acute respiratory distress syndrome (ARDS) independent of ventilation and transfusion parameters., Method: Intensive care unit data over 6 years from a level I centre regarding all trauma victims > or = 16 years old who underwent mechanical ventilation within the first 48 h of admission were examined. Patients were prospectively followed for late ARDS. Variables were examined for significant changes over time and independent associations with late ARDS were determined., Results: Of 2346 eligible patients among whom 404 (17.2%) were exposed to TPN, 192 (8.2%) met criteria for late ARDS. The incidence of late ARDS among those exposed to TPN was 28.7% (116/404) compared with 3.9% (76/1942) among those not so exposed. Adjustments for potential confounding associated risk factors were made., Conclusions: TPN administration is independently associated with late ARDS, and its use among critically ill trauma victims should be carefully scrutinised.