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Antibiotic prophylaxis is routinely used in the surgical management of proximal femur fractures. The role of bacterial colonization of the skin and urine in the development of deep surgical site infections (SSI) is yet to be elucidated. This study aimed to evaluate the role of previous skin and urine colonization in the development of deep SSI after a proximal femoral fracture surgery. We conducted a prospective observational study in 326 patients > 64 years old, who were scheduled to surgery. Cultures from skin samples of the surgical site and from urine were performed prior to the procedure, and cefazoline was administered as prophylaxis. Skin microbiota was isolated in 233 (71.5%) cases; 8 (2.5%) samples were positive for other bacteria, and 85 (26%) were negative. Of 236 urine samples, 168 were negative or contaminated (71.2%), and 68 (28.8%) were positive, being 58/236 for Enterobacterales (24.6%). Acute deep SSI were diagnosed in nine out of 326 patients (2.7%), and two (22%) were infected by Gram-negative bacilli. Of the 9 cases, normal skin microbiota was isolated in 7 (78%), and the remaining two were negative. Seven cases had negative or contaminated urine cultures, and the one with E. coli did not correlate with SSI bacteria. In our elderly hip fracture population, most patients harbored normal skin microbiota, and Enterobacterales urine cultures were positive in one-quarter of cases. There was no relationship between skin colonization, urine culture, and deep SSI. We therefore do not believe that our patients would benefit from modifying the current antibiotic prophylaxis.

Malnutrition is commonly associated with elderly patients with femoral fractures. Approximately 50% of hospitalized patients with a femoral fracture are malnourished or at risk of malnourishment. This situation may have a negative impact on outcomes and results for these patients. Malnourishment has been associated with an increased risk of complications, mortality, poor recovery, and delayed length of stay.A retrospective observational study was conducted at our institution to evaluate the prevalence of malnutrition or risk of malnourishment in 766 hospitalized patients from January 2016 to December 2019. Furthermore, we identified factors that are associated with malnutrition. We also compared length of stay and mortality according to the degree of malnutrition.The mean age for patients included was 84.6 years and 75% of patients were female. The Mini Nutritional Assessment test results showed 7.9% of patients were malnourished and 31.5% at risk of malnourishment.Our study results indicate a high prevalence of malnutrition and risk of malnourishment in hospitalized elderly patients with a femoral fracture.

Objective Ischemic postconditioning (PC) using three intentional pauses at the start of cardiopulmonary resuscitation (CPR) improves outcomes after cardiac arrest in pigs when epinephrine (epi) is used before defibrillation. We hypothesized PC, performed during basic life support (BLS) in the absence of epinephrine, would reduce reperfusion injury and enhance 24h functional recovery. Design Prospective animal investigation. Setting Animal laboratory Subjects Female farm pigs ( n =46, 39±1kg). Interventions Protocol A: After 12min of ventricular fibrillation (VF), 28 pigs were randomized to four groups: (A) Standard CPR (SCPR), (B) active compression-decompression CPR with an impedance threshold device (ACD-ITD), (C) SCPR+PC (SCPR+PC) and (D) ACD-ITD CPR+PC. Protocol B: After 15min of VF, 18 pigs were randomized to ACD-ITD CPR or ACD-ITD+PC. The BLS duration was 2.75min in Protocol A and 5min in Protocol B. Following BLS, up to three shocks were delivered. Without return of spontaneous circulation (ROSC), CPR was resumed and epi (0.5mg) and defibrillation delivered. The primary end point was survival without major adverse events. Hemodynamic parameters and left ventricular ejection fraction (LVEF) were also measured. Data are presented as mean±SEM. Measurements and Main Results Protocol A: ACD-ITD+PC (group D) improved coronary perfusion pressure after 3min of BLS versus the three other groups (28±6, 35±7, 23±5 and 47±7 for groups A, B, C, D respectively, p =0.05). There were no significant differences in 24h survival between groups. Protocol B LVEF 4h post ROSC was significantly higher with ACD-ITD+PC vs ACD-ITD alone (52.5±3% vs. 37.5±6.6%, p =0.045). Survival rates were significantly higher with ACD-ITD+PC vs. ACD-ITD alone ( p =0.027). Conclusions BLS using ACD-ITD+PC reduced post resuscitation cardiac dysfunction and improved functional recovery after prolonged untreated VF in pigs. Protocol number 12-11.

Background Intraoperative hypotension secondary to acute blood loss and fluid shifts increases morbidity and mortality. Intrathoracic pressure regulation (IPR) is a new therapy that enhances circulation by increasing venous return with a negative intrathoracic pressure created noninvasively, either actively (vacuum source or patient inspiration) or passively (chest recoil during cardiopulmonary resuscitation). Objective In this Phase II pilot study, we tested the hypothesis that active IPR therapy would improve the haemodynamic status of patients who developed clinically significant hypotension during abdominal surgery. Design A phase II, single cohort, interventional pilot study. Setting University of Minnesota Fairview Hospital. Patients Twenty-two patients [American Society of Anesthesiologists (ASA) physical status I to III] were enrolled prospectively of whom 15 experienced intraoperative hypotension. Intervention If intraoperative hypotension occurred more than 10 min after induction, the IPR device was applied immediately for a minimum of 10 min. Main outcome measure The hypotensive SBP immediately before the start of IPR treatment was compared with the SBP obtained at the end of IPR therapy. The paired Student's t-test was used to determine statistical significance (P Results Fifteen of the 22 patients enrolled experienced 18 hypotensive episodes, which were treated with at least 10 min of IPR therapy. Fourteen episodes responded to IPR alone and four episodes (four patients) required additional fluid and vasopressor therapy to treat the hypotension. The group mean ± SD SBPs at the onset of the IPR treatment and at the end of IPR treatment were 90.7 ± 9.7 and 98.4 ± 17.4 mmHg (P = 0.02), respectively. The maximum SBP reached during the treatment was 105.6 ± 19.6 mmHg. Pulse pressure increased from 36.8 ± 8.5 mmHg immediately before IPR treatment to 41.5 ± 11.1 mmHg (P = 0.02) at the end of IPR treatment. Mean arterial pressure (MAP) increased from 66.3 ± 9.4 mmHg immediately before IPR treatment to 71.5 ± 14.4 mmHg (P = 0.03) at the end of IPR treatment. No adverse events were identified with use of the IPR device. Conclusion IPR may be useful in treating intraoperative hypotension without additional fluid or vasopressor therapy. No significant adverse events were observed. On the basis of this phase II pilot study, a larger study is justified.

To improve the likelihood for survival with favorable neurologic function after cardiac arrest, we assessed a new advanced life support approach using active compression-decompression cardiopulmonary resuscitation plus an intrathoracic pressure regulator.Prospective animal investigation.Animal laboratory.Female farm pigs (n = 25) (39 ± 3 kg).Protocol A: After 12 minutes of untreated ventricular fibrillation, 18 pigs were randomized to group A-3 minutes of basic life support with standard cardiopulmonary resuscitation, defibrillation, and if needed 2 minutes of advanced life support with standard cardiopulmonary resuscitation; group B-3 minutes of basic life support with standard cardiopulmonary resuscitation, defibrillation, and if needed 2 minutes of advanced life support with active compression-decompression plus intrathoracic pressure regulator; and group C-3 minutes of basic life support with active compression-decompression cardiopulmonary resuscitation plus an impedance threshold device, defibrillation, and if needed 2 minutes of advanced life support with active compression-decompression plus intrathoracic pressure regulator. Advanced life support always included IV epinephrine (0.05 μg/kg). The primary endpoint was the 24-hour Cerebral Performance Category score. Protocol B: Myocardial and cerebral blood flow were measured in seven pigs before ventricular fibrillation and then following 6 minutes of untreated ventricular fibrillation during sequential 5 minutes treatments with active compression-decompression plus impedance threshold device, active compression-decompression plus intrathoracic pressure regulator, and active compression-decompression plus intrathoracic pressure regulator plus epinephrine.Protocol A: One of six pigs survived for 24 hours in group A versus six of six in groups B and C (p = 0.002) and Cerebral Performance Category scores were 4.7 ± 0.8, 1.7 ± 0.8, and 1.0 ± 0, respectively (p = 0.001). Protocol B: Brain blood flow was significantly higher with active compression-decompression plus intrathoracic pressure regulator compared with active compression-decompression plus impedance threshold device (0.39 ± 0.23 vs 0.27 ± 0.14 mL/min/g; p = 0.03), whereas differences in myocardial perfusion were not statistically significant (0.65 ± 0.81 vs 0.42 ± 0.36 mL/min/g; p = 0.23). Brain and myocardial blood flow with active compression-decompression plus intrathoracic pressure regulator plus epinephrine were significantly increased versus active compression-decompression plus impedance threshold device (0.40 ± 0.22 and 0.84 ± 0.60 mL/min/g; p = 0.02 for both).Advanced life support with active compression-decompression plus intrathoracic pressure regulator significantly improved cerebral perfusion and 24-hour survival with favorable neurologic function. These findings support further evaluation of this new advanced life support methodology in humans.

Introduction: Ischemic postconditioning (PC) using 3 intentional short pauses at the start of cardiopulmonary resuscitation (CPR) improves outcomes after cardiac arrest in pigs when epinephrine (epi) is used before defibrillation. Hypothesis: Basic life support (BLS) with PC will protect against reperfusion injury and enhance 24 hour functional recovery in the absence of epi. Methods: Female pigs (n=46; wt ~ 40 kg) were anesthetized (isoflurane). PC was delivered using 3 cycles alternating between automated CPR for 20 sec and no CPR for 20 sec at the start of each protocol. Protocol A: After 12 minutes of ventricular fibrillation (VF), 28 pigs were randomized in 4 groups: A/ Standard CPR (SCPR), B/ active compression-decompression with an impedance threshold device (ACD-ITD), C/ SCPR+PC (SCPR+PC) and D/ ACD-ITD+PC. Protocol B: After 15 min of VF, 18 pigs were randomized to ACD-ITD CPR or ACD-ITD + PC. The BLS duration was 2.75 min in Protocol A and 5 min in Protocol B. Following BLS up to 3 shocks were delivered. Without return of spontaneous circulation (ROSC) CPR was resumed and epi (0.5 mg) and defibrillation delivered. The primary end point was the incidence of major adverse outcomes at 24 h (defined as death or coma, refractory seizures and cardio-respiratory distress leading to euthanasia). Hemodynamic parameters and left ventricular ejection fraction (LVEF) were also measured. Data are presented as mean ± standard error of mean. Results: Protocol A: ACD-ITD CPR + PC (group D) provided the highest coronary perfusion pressure after 3 min of BLS compared with the 3 other groups (28 ± 6, 35 ± 7, 23 ± 5 and 47 ± 7 for groups A, B, C, D respectively, p= 0.05 by ANOVA). ROSC with BLS was achieved in 0, 3, 0, and 3 pigs in groups A, B, C and D, respectively (p=0.22) with no significant differences in 24-hour survival between groups. Protocol B: Four hours post ROSC, LVEF was significantly higher with ACD-ITD+IPC vs ACD-ITD alone (52.5 ± 3% vs. 37.5 ± 6.6%, p = 0.045). There was a significantly lower incidence of major adverse outcomes 24 hr after ROSC with ACD-ITD+PC compared with ACD-ITD alone (Log-rank comparison, p=0.027). Conclusion: BLS using ACD-ITD + PC mitigates post resuscitation cardiac dysfunction and facilitates neurological recovery after prolonged untreated VF in pigs.

Background The objective of this investigation was to evaluate changes in intrathoracic pressure (Ppl), airway pressure (Paw) and vital organ perfusion pressures during standard and intrathoracic pressure regulation (IPR)-assisted cardiopulmonary resuscitation (CPR). Methods Multiple CPR interventions were assessed, including newer ones based upon IPR, a therapy that enhances negative intrathoracic pressure after each positive pressure breath. Eight anesthetized pigs underwent 4 min of untreated ventricular fibrillation followed by 2 min each of sequential interventions: (1) conventional standard CPR (STD), (2) automated active compression decompression (ACD) CPR, (3) ACD+ an impedance threshold device (ITD) CPR or (4) ACD+ an intrathoracic pressure regulator (ITPR) CPR, the latter two representing IPR-based CPR therapies. Intrapleural (Ppl), airway (Paw), right atrial, intracranial, and aortic pressures, along with carotid blood flow and end tidal CO2, were measured and compared during each CPR intervention. Results The lowest mean and decompression phase Ppl were observed with IPR-based therapies [Ppl mean (mean ± SE): STD (0.8 ± 1.1 mmHg); ACD (−1.6 ± 1.6); ACD-ITD (−3.7 ± 1.5, p

Time to awakening after out-of-hospital cardiac arrest (OHCA) and post-resuscitation therapeutic hypothermia (TH) varies widely. We examined the time interval from when comatose OHCA patients were rewarmed to 37°C to when they showed definitive signs of neurological recovery and tried to identify potential predictors of awakening.With IRB approval, a retrospective case study was performed in OHCA patients who were comatose upon presentation to a community hospital during 2006-2010. They were treated with TH (target of 33°C) for 24h, rewarmed, and discharged alive. Comatose patients were generally treated medically after TH for at least 48h before any decision to withdraw supportive care was made. Pre-hospital TH was not used. Data are expressed as medians and interquartile range.The 89 patients treated with TH in this analysis were divided into three groups based upon the time between rewarming to 37°C and regaining consciousness. The 69 patients that regained consciousness in ≤48h after rewarming were termed "early-awakeners". Ten patients regained consciousness 48-72h after rewarming and were termed "intermediate-awakeners". Ten patients remained comatose and apneic72h after rewarming but eventually regained consciousness; they were termed "late-awakeners". The ages for the early, intermediate and late awakeners were 56 [49,65], 62 [48,74], and 58 [55,65] years, respectively. Nearly 67% were male. Following rewarming, the time required to regain consciousness for the early, intermediate and late awakeners was 9 [2,18] (range 0-47), 60.5 [56,64.5] (range 49-71), and 126 [104,151]h (range 73-259), respectively. Within 90 days of hospital admission, favorable neurological function based on a Cerebral Performance Category (CPC) score of 1 or 2 was reported in 67/69 early, 10/10 intermediate, and 8/10 late awakeners.Following OHCA and TH, arbitrary withdrawal of life support48h after rewarming may prematurely terminate life in many patients with the potential for full neurological recovery. Additional clinical markers that correlate with late awakening are needed to better determine when withdrawal of support is appropriate in OHCA patients who remain comatose48h after rewarming.