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Introduction: Poor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU., Methods and Analysis: We will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or 'like family' member per eligible patient 5-7 days following their loved ones' admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients' length of stay in the ICU., Ethics and Dissemination: Institutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings., Trial Registration Number: NCT05780918., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Trauma patients are at high risk for venous thromboembolism (VTE) and bleeding. The purpose of this study was to characterize percentage of VTE chemoprophylaxis given to trauma patients with and without a VTE., Study Design: This retrospective case-control study evaluated trauma patients admitted to a Level I trauma center. Adult patients were included when hospitalized at least 2 days and had a head abbreviated injury score of 1 or less. Non-VTE patients were matched by decade of life and injury severity score (ISS). The primary outcome was percentage of VTE chemoprophylaxis received over the first 14 days of admission. Descriptive statistics, chi-squared test, Student's t-test, and Cox proportional hazard were used for analysis., Results: A total of 44 VTE patients were included with 125 matched non-VTE patients. Baseline demographics included age in years (50.7 ± 19.6 vs 49.6 ± 19.4), ISS (18.9 ± 11.3 vs 19 ± 11.6), and lower extremity fracture (54.5% vs 40%), for VTE and non-VTE groups, respectively. The primary outcome of VTE chemoprophylaxis doses given was significantly lower for VTE patients than non-VTE patients (49.3% vs 59.3%, p = 0.0069). Significant predictors of VTE were percentage of VTE chemoprophylaxis doses given (p < 0.0001) and weight (p = 0.0042) based on regression analysis. Notably, there was a 7% decrease in the hazard for VTE for every 1% increase in VTE chemoprophylaxis given., Conclusions: Patients who developed VTE were more likely to have delays and disruptions in VTE chemoprophylaxis, even after controlling for age, sex, ISS, lower extremity fractures, and number of operations., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Older patients compose approximately 30% of trauma patients treated in the USA but make up nearly 50% of deaths from trauma. To help standardize and elevate care of these patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program's best practice guidelines for geriatric trauma management was published in 2013 and that for palliative care was published in 2017. Here, we discuss how palliative care and geriatrics quality metrics can be tracked and used for performance improvement and leveraged as a strength for trauma verification., Methods: We discuss the viewpoint of the ACS Verification, Review, and Consultation and three case studies, with practical tips and takeaways, of how these measures have been implemented at different institutions., Results: We describe the use of (1) targeted educational initiatives, (2) development of a consultation tool based on institutional resources, and (3) application of a nurse-led frailty screen., Discussion: Specialized care and attention to these vulnerable populations is recommended, but the implementation of these programs can take many shapes. Level of evidence V., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

To determine whether the use of flumazenil reverses hypoactive delirium and increases delirium-free days in critically ill patients who were exposed to benzodiazepine therapy during the ICU admission., Design: This was a single-center, double-blinded, randomized placebo-controlled pilot study., Setting: Adult ICUs at a large academic medical center in the United States., Patients: Adult, critically ill patients with benzodiazepine exposure and hypoactive delirium based on the Confusion Assessment Method-ICU and Richmond Agitation Sedation Scale assessments were considered for enrollment., Interventions: Patients received a test dose of flumazenil starting at 0.1 mg intravenously and titrated up every 5 minutes by 0.1 mg increments up to a maximum total dose of 2 mg. Patients who demonstrated a Richmond Agitation Sedation Scale score increase of greater than 1 point were considered responders and randomized to flumazenil (0.05-0.3 mg/hr) or placebo infusion for up to 72 hours. Confusion Assessment Method-ICU scores were assessed twice daily for resolution of delirium., Measurements and Main Results: The trial was stopped early based on the observed size effect and power analysis. Twenty-two of the 25 patients responded to the flumazenil test dose (88%). The median number of delirium-free days alive without coma within 14 days of enrollment was similar between the two infusion groups (12.7 vs 9.2; p = 0.19). There was no difference in the probability of delirium resolution within the first 14 days with 90% versus 70% in the flumazenil and placebo groups, respectively ( p = 0.2). There was no statistical difference (odds ratio, 0.17; 95% CI, 0.022-1.23; p = 0.079) in delirium- and coma-free days at the end of the study drug infusion. There was no difference between groups in ICU length of stay (7.8 ± 4.8 vs 7 ± 8; p = 0.74). No serious adverse events occurred., Conclusions: This study found that flumazenil test dose and infusion present a potential option for hypoactive delirium associated with benzodiazepine exposure; however, the possible benefit is unknown. Larger studies are warranted to further evaluate these findings., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: Current evidence supports symptom-triggered therapy for alcohol withdrawal syndrome (AWS). Early, escalating therapy with benzodiazepines (BZD) appears to decrease ICU length of stay (LOS); however, the effect on hospital LOS remains unknown. The hypothesis of this study is that focused BZD treatment in the first 24 h will decrease hospital LOS. Design: Pre-post cohort study. Setting: Academic medical center. Patients: This study included patients with severe AWS. The pre-intervention cohort (PRE) was admitted between January and November 2015. The post-intervention cohort (POST) was admitted between April 2016 and March 2017. Severe AWS was defined as patients requiring diazepam doses of >30 mg. Focused treatment was defined as >50% of total diazepam usage within the first 24 h of recognition of AWS. Intervention: In the PRE group, patients received symptom-triggered, escalating doses of diazepam and phenobarbital based on their Richmond Agitation-Sedation Scale (RASS). In the POST group, patients received a revised, time-limited course of therapy: escalating doses of BZD and phenobarbital were given during a 24-h loading phase, and all therapy was discontinued after a 72-h tapering phase. The SHOT scale was used as an adjunct to RASS to assess non-agitation symptoms of AWS and guide additional diazepam doses. Measurements and main results: The primary outcome was hospital LOS; secondary outcomes included ICU LOS, BZD use, and ventilator-free days. Five hundred thirty-two patients were treated using the AWS protocol; 113 experienced severe AWS. The PRE ( n  = 75) and POST ( n  = 38) groups were evenly matched in age, sex, history of AWS, and severity of illness. There was a substantial difference in POST patients who received focused treatment (51.3% vs. 73.7%, p  = .03). The POST group had a significant decrease in hospital LOS (14.0 vs. 9.8 days, p  = .03) and ICU LOS (7.4 vs. 4.4 days, p  = .03). Conclusion: Early, focused management of severe AWS was associated with a decrease in ICU and hospital LOS.

Background: Opioids are the mainstay of pain management in critically ill trauma patients. However, the risks of opioid use mandate a different approach. Multimodal analgesia employs a combination of opioid and nonopioid agents using different mechanisms that have synergistic effects in treating pain. This study examines the effects of multimodal analgesia on the opioid requirements of critically ill trauma patients., Study Design: This was a pre-post cohort study of adult trauma ICU patients before and after implementation of a multimodal pain management order set. Patients were excluded if their hospital stay was less than 5 days, head Abbreviated Injury Scale score was greater than 1, or pre-injury medications included methadone or buprenorphine. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period on days 2 through 5 of admission and the last 24 hours before discharge using standardized ratios. The primary endpoint was cumulative OME doses over the second through fifth days of admission., Results: There were 65 patients in the pre-group and 62 in the post-group. Median cumulative OME dose was significantly lower in the post-group (125.6 mg, interquartile range [IQR] 45.0 to 415.0 mg) compared with the pre-group (481.5 mg, IQR 174.8 to 881.3 mg), p < 0.001. Patients who received 3 or more multimodal agents had a lower cumulative OME dose (116.3 mg, IQR 52.5 to 496.5 mg) compared with those who were on 1 to 2 multimodal agents (363 mg, IQR 115.5 to 743 mg) or 0 multimodal agents (479 mg, IQR 185 to 736.5 mg), p = 0.024. There were no differences between pre-group and post-group mean pain scores on hospital day 5 (4.48 ± 0.34 vs 3.50 ± 0.38, p = 0.058) or at hospital discharge (3.43 ± 0.34 vs 3.56 ± 0.32, p = 0.789)., Conclusions: Implementation of a multimodal pain management strategy significantly reduced opioid use in critically ill trauma patients without compromising patient comfort., (Copyright © 2019 American College of Surgeons. All rights reserved.)

Introduction: Confronted with the opioid epidemic, surgeons must play a larger role to reduce risk of opioid abuse while managing acute pain. Having a better understanding of the beliefs and practices of trauma and acute care surgeons regarding discharge pain management may offer potential targets for interventions beyond fixed legal mandates., Methods: An Institutional Review Board-approved electronic survey was sent to trauma and acute care surgeons who are members of the American Association for the Surgery of Trauma, and trauma and acute care surgeons and nurse practitioners at a Level 1 trauma center in February 2018. The survey included four case-based scenarios and questions about discharge prescription practices and beliefs., Results: Of 66 respondents, most (88.1%) were at academic institutions. Mean number of opioid tablets prescribed was 20-30 (range 5-90), with the fewest tablets prescribed for elective laparoscopic cholecystectomy and the most for rib fractures. Few prescribed both opioid and non-opioid medications (22.4% to 31.4 %). Most would not change the number/strength of medications (69.2%), dose (53.9%), or number of tablets of opioids (83.1%) prescribed if patients used opioids regularly prior to their operation. The most common factors that made providers more likely to prescribe opioids were high inpatient opioid use (32.4%), history of opioid use/abuse (24.5%), and if the patient lives far from the hospital (12.9%). Most providers in practice >5 years reported a decrease in opioids (71.9%) prescribed at discharge., Conclusion: Trauma and acute care surgeons and nurse practitioners reported decreasing the number/amount of opioids prescribed over time. Patients with high opioid use in the hospital, history of opioid use/abuse, or who live far from the provider may be prescribed more opioids at discharge., Level of Evidence: Level IV., Competing Interests: Competing interests: None declared.

Background: Data suggest that methamphetamine may increase the risk of nonocclusive mesenteric ischemia (NOMI). We describe patterns of presentation and outcomes of patients with methamphetamine use who present with NOMI to a single institution., Methods: This is an observational study of patients from January 2015 to September 2017 with methamphetamine use who presented with NOMI at an academic medical center in Northern California. We summarize patient comorbidities, clinical presentation, operative findings, pathologic findings, hospital course, and survival., Results: Ten patients with methamphetamine use and severe NOMI were identified. One patient was readmitted with a perforated duodenal ulcer, for a total of 11 encounters. Most presented with acute (n = 3) or acute-on-chronic (n = 4) abdominal pain. Distribution of ischemia ranged from perforated duodenal ulcer (n = 3), ischemia of the distal ileum (n = 1), ischemia of entire small bowel (n = 2), and patchy necrosis of entire small bowel and colon (n = 5). Six patients died, three within 1 week of admission and three between 3 months and 8 months., Conclusion: Methamphetamine use may be associated with significant microvascular compromise, increasing the risk of mesenteric ischemia. Providers in areas with high prevalence of methamphetamine use should have a high index of suspicion for intestinal ischemia in this patient population. Patients with methamphetamine use admitted for trauma or other pathology may be at particular risk of ischemia and septic shock, especially in the setting of dehydration. Use of vasoconstrictors in this patient population may also exacerbate intestinal ischemia., Level of Evidence: Therapeutic Case series study, level V.

Informed consent is an ethical concept that is codified in the law and is in daily practice at every health care institution. Three fundamental criteria are needed for clinical informed consent: the patient must be competent, adequately informed and not coerced. Physician-patient interaction is rooted in the ethical concept of beneficence, but over the 19th and 20th centuries, case law and societal changes brought respect for autonomy and with it--informed consent. This article briefly reviews the basics of informed consent, when is it required, how did informed consent evolve into what it is today and what can the surgeon do to truly achieve informed consent., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Recent studies have suggested the length of treatment of intra-abdominal infections (IAIs) can be shortened without detrimental effects on patient outcomes. However, data from high-risk patient populations are lacking. We hypothesized that patients at high risk for treatment failure will benefit from a longer course of antimicrobial therapy., Methods: Patients enrolled in the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated retrospectively to identify risk factors associated with treatment failure, which was defined as the composite outcome of recurrent IAI, surgical site infection, or death. Variables were considered risk factors if there was a positive statistical association with treatment failure. Patients were then stratified according to the presence and number of these risk factors. Univariable analyses were performed using the Kruskal-Wallis, χ 2 , and Fisher exact tests. Logistic regression controlling for risk factors and original randomization group, either a fixed four-day antimicrobial regimen (experimental) or a longer course based on clinical response (control), also was performed., Results: We identified corticosteroid use, Acute Physiology and Chronic Health Evaluation II score ≥5, hospital-acquired infection, or a colonic source of IAI as risk factors associated with treatment failure. Of the 517 patients enrolled, 263 (50.9%) had one or two risk factors and 16 (3.1%) had three or four risk factors. The rate of treatment failure rose as the number of risk factors increased. When controlling for randomization group, the presence and number of risk factors were independently associated with treatment failure, but the duration of antimicrobial therapy was not., Conclusions: We were able to identify patients at high risk for treatment failure in the STOP-IT trial. Such patients did not benefit from a longer course of antibiotic administration. Further study is needed to determine the optimum duration of antimicrobial therapy in high-risk patients.

Background: Acute appendicitis is the most common abdominal surgical emergency in the United States, with a lifetime risk of 7%-8%. The treatment paradigm for complicated appendicitis has evolved over the past decade, and many cases now are managed by broad-spectrum antibiotics. We determined the role of non-operative and operative management in adult patients with uncomplicated appendicitis., Methods: Several meta-analyses have attempted to clarify the debate. Arguably the most influential is the Appendicitis Acuta (APPAC) Trial., Results: According to the non-inferiority analysis and a pre-specified non-inferiority margin of -24%, the APPAC did not demonstrate non-inferiority of antibiotics vs. appendectomy. Significantly, however, the operations were nearly always open, whereas the majority of appendectomies in the United States are done laparoscopically; and laparoscopic and open appendectomies are not equivalent operations. Treatment with antibiotics is efficacious more than 70% of the time. However, a switch to an antimicrobial-only approach may result in a greater probability of antimicrobial-associated collateral damage, both to the host patient and to antibiotic susceptibility patterns. A surgery-only approach would result in a reduction in antibiotic exposure, a consideration in these days of focus on antimicrobial stewardship., Conclusion: Future studies should focus on isolating the characteristics of appendicitis most susceptible to antibiotics, using laparoscopic operations as controls and identifying long-term side effects such as antibiotic resistance or Clostridium difficile colitis.

Necrotizing soft tissue infections (NSTI) have been recognized for millennia and continue to impose considerable burden on both patient and society in terms of morbidity, death, and the allocation of resources. With improvements in the delivery of critical care, outcomes have improved, although disease-specific therapies are lacking. The basic principles of early diagnosis, of prompt and broad antimicrobial therapy, and of aggressive debridement have remained unchanged. Clearly novel and new therapeutics are needed to combat this persistently lethal disease. This review emphasizes the pillars of NSTI management and then summarizes the contemporary evidence supporting the incorporation of novel adjuncts to the pharmacologic and operative foundations of managing this disease.

Atrial fibrillation (AF) is the most common cardiac dysrhythmia. Its prevalence, risk factors, course, and complications are not well described in critically ill trauma patients. This was a retrospective, single-center, cohort study at an academic, level 1 trauma center. Trauma patients >18 years, identified from the trauma registry and admitted to the intensive care unit (ICU), were sequentially screened for AF. A matched cohort was created by selecting patients consecutively admitted before and after the patients who experienced AF. Of 2591 patients screened, 191 experienced AF, resulting in a prevalence of 7.4%. There was no difference in injury severity score (ISS) between those with and without AF, but patients with AF had higher observed mortality (15.5% vs 6.7%, P < .001). Patients with a history of AF (n = 75) differed from new-onset AF (n = 106) in their mean age, 78.9 ± 8.4 versus 69.2 ± 17.9 years; mean time to AF onset, 1.1 ± 2.3 versus 5.2 ± 10.2 days; median duration of AF, 29.8 (1-745.2) versus 5.9 (0-757) hours; and rate of AF resolution, 28% versus 82.1%, respectively. Despite a higher ISS, Sequential Organ Failure Assessment and length of stay, the new-onset AF group experienced a similar rate of mortality compared to the history of AF group (14.7% vs 16.0%). Patients with AF had a higher mortality when compared to those in sinus rhythm. The course of AF in the new-onset AF group occurred later was shorter and was more likely to convert; however, these patients had a longer ICU stay when compared to those who had a history of AF.

Background: A recent prospective, multicenter, randomized controlled trial found that 4 days of antibiotics after source control of complicated intra-abdominal infections resulted in similar outcomes when compared with longer duration. We hypothesized that the subset of patients presenting with sepsis have similar outcomes when treated with the shorter course of antibiotics., Study Design: Patients from the STOP-IT (Study to Optimize Peritoneal Infection Therapy) trial database meeting criteria for sepsis (ie, temperature <36°C or >38°C and a WBC count <4000 cells/mm(3) or >12,000 cells/mm(3)) were analyzed. Patients had been randomized to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 calendar days of therapy (n = 45), or to receive a fixed short-course of antibiotics for 4 ± 1 calendar days (n = 67). Outcomes included incidence of and time to surgical site infection, recurrent intra-abdominal infection, Clostridium difficile infection, and extra-abdominal infections, as well as hospital days and mortality., Results: One hundred and twelve of the 588 patients in the STOP-IT database met criteria for sepsis and were adherent to the protocol. With regard to short- vs long-course therapy, surgical site infection (11.9% vs 8.9%; p = 0.759), recurrent intra-abdominal infection (11.9% vs 13.3%; p = 1.00), extra-abdominal infection (11.9% vs 8.9%; p = 0.759), hospital days (7.4 ± 5.5 days vs 9.0 ± 7.5 days; p = 0.188), days to recurrent intra-abdominal infection (12.5 ± 6.6 days vs 18.0 ± 8.1 days; p = 0.185), days to extra-abdominal infection (12.6 ± 5.8 days vs 17.3 ± 3.9 days; p = 0.194), and mortality (1.5% vs 0%; p = 1.00) were similar. There were no cases of C difficile infection. Days to surgical site infection (6.9 ± 3.5 days vs 21.3 ± 6.1 days; p < 0.001) were fewer in the 4-day therapy group., Conclusions: There was no difference in outcomes between short and long-course antimicrobial therapy in patients with complicated intra-abdominal infection presenting with sepsis. Our findings suggest that the presence of systemic illness does not mandate a longer antimicrobial course if source control of complicated intra-abdominal infection is obtained., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: As North Atlantic Treaty Organization (NATO) countries begin troop withdrawal from Afghanistan, military medicine needs programs for combat surgeons to retain the required knowledge and surgical skills. Each military branch runs programs at various Level I academic trauma centers to deliver predeployment training and provide a robust trauma experience for deploying surgeons. Outside of these successful programs, there is no system-wide mechanism for nondeploying military surgeons to care for a high volume of critically ill trauma patients on a regular basis in an educational environment that promotes continued professional development. We hypothesize that fully integrated military-civilian relationship regional Level I trauma centers provide a surgical experience more closely mirroring that seen in a Role III hospital than local Level II and Level III trauma center or medical treatment facilities., Methods: We characterized the Level I trauma center practice using the number of trauma resuscitations, operative trauma/acute care surgery procedures, number of work shifts, operative density (defined as the ratio of operative procedures/days worked), and frequency of educational conferences. The same parameters were collected from two NATO Role III hospitals in Afghanistan during the peak of Operation Enduring Freedom. Data for two civilian Level II trauma centers, two civilian Level III trauma centers, and a Continental United States Military Treatment Facility without trauma designation were collected., Results: The number of trauma resuscitations, number of 24-hour shifts, operative density, and educational conferences are shown in the table for the Level I trauma center compared with the different institutions. Civilian center trauma resuscitations and operative density were highest at the Level I trauma center and were only slightly lower than what was seen in Afghanistan. Level II and III trauma centers had lower numbers for both. The Level I trauma center provided the most frequent educational opportunities., Conclusion: In a Level I academic trauma center integrated program, military and civilian surgeons have the same clinical and educational responsibilities: rounding and operating, managing critical care patients, covering trauma/acute care surgery call, and mentoring surgery residents in an integrated residency program. The Level I trauma center experience most closely mimics the combat surgeon experience seen at NATO Role III hospitals in Afghanistan compared with other civilian trauma centers. At high-volume Level I trauma centers, military surgeons will have a comprehensive trauma practice, including dedicated educational opportunities. We recommend integrated programs with Level I academic trauma centers as the primary mechanism for sustaining military combat surgical skills in the future.

Background: The successful treatment of intraabdominal infection requires a combination of anatomical source control and antibiotics. The appropriate duration of antimicrobial therapy remains unclear., Methods: We randomly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy (control group), or to receive a fixed course of antibiotics (experimental group) for 4±1 calendar days. The primary outcome was a composite of surgical-site infection, recurrent intraabdominal infection, or death within 30 days after the index source-control procedure, according to treatment group. Secondary outcomes included the duration of therapy and rates of subsequent infections., Results: Surgical-site infection, recurrent intraabdominal infection, or death occurred in 56 of 257 patients in the experimental group (21.8%), as compared with 58 of 260 patients in the control group (22.3%) (absolute difference, -0.5 percentage point; 95% confidence interval [CI], -7.0 to 8.0; P=0.92). The median duration of antibiotic therapy was 4.0 days (interquartile range, 4.0 to 5.0) in the experimental group, as compared with 8.0 days (interquartile range, 5.0 to 10.0) in the control group (absolute difference, -4.0 days; 95% CI, -4.7 to -3.3; P<0.001). No significant between-group differences were found in the individual rates of the components of the primary outcome or in other secondary outcomes., Conclusions: In patients with intraabdominal infections who had undergone an adequate source-control procedure, the outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics (approximately 8 days) that extended until after the resolution of physiological abnormalities. (Funded by the National Institutes of Health; STOP-IT ClinicalTrials.gov number, NCT00657566.).

Background: Approximately 18% to 25% of patients with alcohol use disorders admitted to the hospital develop alcohol withdrawal syndrome (AWS). Symptom-triggered dosing of benzodiazepines (BZDs) seems to lead to shorter courses of treatment, lower cumulative BZD dose, and more rapid control of symptoms in non-critically ill patients. This study compares the outcomes of critically ill patients with AWS when treated using a protocolized, symptom-triggered, dose escalation approach versus a nonprotocolized approach., Methods: This is a retrospective pre-post study of patients 18 years or older with AWS admitted to an intensive care unit (ICU). The preintervention cohort (PRE) was admitted between February 2008 and February 2010. The postintervention cohort (POST) was admitted between February 2012 and January 2013. The PRE patients were treated by physician preference and compared with POST patients who were given escalating doses of BZDs and/or phenobarbital according to an AWS protocol, titrating to light sedations (Richmond Agitation Sedation Scale score of 0 to -2)., Results: There were 135 episodes of AWS in 132 critically ill patients. POST patients (n = 75) were younger (50.7 [13.8] years vs. 55.7 [8.7] years, p = 0.03) than PRE patients (n = 60). Sequential Organ Failure Assessment (SOFA) scores were higher in the PRE group (6.1 [3.7] vs. 3.9 [2.9], p = 0.0004). There was a significant decrease in mean ICU length of stay from 9.6 (10.5) days to 5.2 (6.4) days (p = 0.0004) in the POST group. The POST group also had significantly fewer ventilator days (5.6 [13.9] days vs. 1.31 [5.6] days, p < 0.0001) as well as a significant decrease in BZD use (319 [1,084] mg vs. 93 [171] mg, p = 0.002). There were significant differences between the two cohorts with respect to the need for continuous sedation (p < 0.001), duration of sedation (p < 0.001), and intubation secondary to AWS (p < 0.001). In all of these outcomes, the POST cohort had a notably lower frequency of occurrence., Conclusion: A protocolized treatment approach of AWS in critically ill patients involving symptom-triggered, dose escalations of diazepam and phenobarbital may lead to a decreased ICU length of stay, decreased time spent on mechanical ventilation, and decreased BZD requirements., Level of Evidence: Epidemiologic study, level III; therapeutic study, level IV.

Background: Cervical spinal cord injury (CSCI) is often complicated by autonomic instability and life-threatening bradycardia. β-adrenergic receptors offer a potential target for modulating cardiac vagal activity and heart rate. Enteral albuterol may mitigate symptomatic bradycardia in CSCI patients. The purpose of this study was to examine the effect of enteral albuterol on the frequency of symptomatic bradycardia and the need for rescue therapy in CSCI patients., Methods: The charts of CSCI patients admitted to a Level I trauma center from February 2008 through March 2012 were reviewed for demographics, episodes of symptomatic bradycardia (defined as heart rate < 60 beats per minute and systolic blood pressure < 90 mm Hg), use of enteral albuterol, hospital days requiring chronotropic use, and total atropine administered. In the albuterol group, patients received scheduled enteral albuterol after experiencing symptomatic bradycardia, with chronotropic agents used as needed for rescue treatment. In the no-albuterol group, only chronotropic agents were used as needed for rescue treatment. The albuterol and no-albuterol groups were compared using independent-samples Kruskal-Wallis test for total number of bradycardic episodes, hospital days requiring chronotropic use, and total atropine administered., Results: Eighteen patients with CSCI-induced bradycardia were identified. Eight patients received treatment with enteral albuterol, and 10 patients did not. The median age did not differ significantly between the two groups. However, the median Injury Severity Score (ISS) was higher in the albuterol group (median ISS, 36.5; interquartile range, 35-66.5 vs. median ISS 26; interquartile range, 27-37.25 in no-albuterol group). Patients receiving albuterol experienced 1.8 symptomatic bradycardic episodes versus 4.3 episodes in those patients not receiving albuterol (p = 0.08). Hospital days on chronotropic agents were significantly less in the albuterol group (1.8 vs. 8.6, p = 0.01). One patient, in the no-albuterol group, required pacemaker placement., Conclusion: Enteral albuterol may reduce the frequency of symptomatic bradycardia in patients with CSCI, resulting in less rescue therapy using chronotropic agents., Level of Evidence: Therapeutic study, level IV.

This is a position article from members of the Western Trauma Association (WTA). Because there are no prospective randomized trials on the evaluation and management of peripheral vascular trauma, the algorithm is based on the expert opinion of the WTA members and published observational studies. It may not be applicable at all hospitals caring for injured patients. The algorithm contains letters that correspond to lettered text that is intentionally concise. This Part II algorithm focuses on operative techniques, while the Part I algorithm (J Trauma 2011;70: 1551-1556) emphasized evaluation, diagnosis, and need for operation versus a therapeutic procedure performed in an interventional suite.

Background: Clostridium difficile infection (CDI) is the primary cause of antibiotic-associated colitis and 15-25% of nosocomial antibiotic-associated diarrhea. Its clinical manifestations can range from mild diarrhea to toxic megacolon, bowel perforation, septic shock, and death. Over the past decade, more virulent strains have become increasingly common causes, and the incidence of CDI has risen, especially in elderly patients. These developments have led to an increase in recurrent CDI, which is more difficult to treat. This review focuses on recurrent CDI and its treatment., Methods: MEDLINE review using search terms Clostridium difficile, Clostridium difficile infection, recurrent Clostridium difficile infection., Results: A first recurrence may be treated with the same regimen as the first episode. Metronidazole 500 mg q 8 h for 10-14 days is the drug of choice for moderate infection, and vancomycin 125 mg q 6 h for 10-14 days is the drug of choice for severe CDI. Metronidazole should not be used for treatment of subsequent recurrences because of potential neurotoxicity and hepatic toxicity. Second recurrences should be treated with an oral vancomycin course and taper: 125 mg q 6  h × 10-14 days, 125 mg q 12 h × 7 days, 125 mg q 24 h × 7 days, 125 mg q 48-72  h × 2-8 weeks. Alternative agents are fecal bacteriotherapy, a "rifaximin chaser," nitazoxanide, probiotics, and intravenous immunoglobulin. Fidaxomicin has been approved recently. Monoclonal antibodies against C. difficile toxin remain investigational., Conclusion: Treatment of recurrent CDI remains challenging. Because of the lack of high-quality studies, recommendations for treatment are based on expert opinion. Metronidazole and vancomycin are the mainstays of treatment for both the initial infection and the first recurrence. For second recurrences, a vancomycin course plus taper is recommended. For subsequent recurrences, treatment options are many, with no one approach being entirely satisfactory. New drugs (fidaximicin) and treatments (monoclonal antibodies against the causative toxin) appear promising.

Purpose of Review: To review the current care of the patient with an injured spleen., Recent Findings: The initial care of the patient with splenic injury is dictated by their hemodynamic presentation and the institution's resources. Although most high-grade injuries require splenectomy, up to 38% are successfully managed nonoperatively. Angioembolization has increased splenic salvage with a minimum of complications. In the absence of injuries that mandate longer hospital stays, patients with low-grade injuries are successfully discharged in 1-2 days and high-grade injuries in 3-4 days. Delayed splenic hemorrhage remains a feared complication, but fortunately the 180-day readmission rate for splenectomy is low with the majority of those returning within 8 days of injury., Summary: Nonoperative management (NOM) is the standard of care for the hemodynamically stable patient with an isolated blunt splenic injury. Splenic salvage can be safely increased, even in higher grade injuries, with the use of angioembolization. Patients managed nonoperatively are successfully discharged as early as 1-2 days for low-grade injuries and as early as 3-4 days for higher grade. Safe management of the patient with blunt splenic injury requires careful selection for NOM, meticulous monitoring and follow-up.

Necrotizing soft tissue infection is a severe illness that is associated with significant morbidity and mortality. It is often caused by a wide spectrum of pathogens and is most frequently polymicrobial. Care for patients with necrotizing soft tissue infection requires a team approach with expertise from critical care, surgery, reconstructive surgery, and rehabilitation specialists. The early diagnosis of necrotizing soft tissue infection is challenging, but the keys to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. Early initiation of appropriate broad-spectrum antibiotic therapy must take into consideration the potential pathogens. Critical care management components such as the initial fluid resuscitation, end-organ support, pain management, nutrition support, and wound care are all important aspects of the care of patients with necrotizing soft tissue infection. Soft tissue reconstruction should take into account both functional and cosmetic outcome.

Background: Gastric function in trauma patients is poorly understood. In animals, shock causes gastric luminal alkalinization and bile reflux. In trauma patients, studies of stress gastritis prophylaxis demonstrated with continuous gastric pH monitoring that the stomach became alkaline even without antisecretory therapy. Therefore, we hypothesized that trauma patients have an alkaline gastric environment that may be because of bile reflux., Methods: A prospective observational study at an urban Level I trauma center was performed. All major torso trauma patients (severe head injuries excluded) who met the criteria for standardized shock resuscitation were eligible for inclusion. A 12.5 Fr silastic pH probe (Sandhill Scientific) was placed in the stomach and the gastric pH continuously monitored for 7 days. Patients received no stress gastritis prophylaxis. Gastric samples were obtained each day and assayed for total bile acids and pH., Results: Twelve patients were entered into the study. Mean age was 31 years +/- 4 years, 67% men, 75% blunt mechanism of injury, and mean Injury Severity Score 28 +/- 3. Three patients (25%) developed multiple organ failure and four acquired ventilator-associated pneumonia. During the first day of continuous pH monitoring, 9 of 12 patients had a gastric pH >4 for the majority of the day with 7 patients having essentially no acid production. During subsequent days, gastric pH began to drop and by the 4th day the majority of each day was spent at a pH <4. Additionally, gastric pH of patients with ventilator-associated pneumonia or multiple organ failure tended to be more alkaline. Bile acid was present in the gastric fluid of all patients in varying amounts. However, there was no significant correlation between gastric pH and bile acid concentration., Conclusions: Traumatic injury causes gastric luminal alkalinization that may be related, only in part, to bile acid reflux. Other alkalinizing factors remain to be elucidated.

The current shortage in intensive care unit (ICU) physician staffing coupled with Leapfrog initiatives has lead to novel ICU staffing paradigms including the use of nonsurgeon intensivists in surgical ICUs, increased development of telemedicine, and ICU regionalization.

Background: Acidosis, hypothermia, and coagulopathy were identified more than 20 years ago as a deadly triad for patients presenting with exsanguinating hemorrhage. This led to fundamental changes in initial management of severely injured patients. Despite major advances, hemorrhage remains a leading cause of early death in trauma patients. Recent studies report most severely injured patients to be coagulopathic at admission, before resuscitation interventions, and that traditional massive transfusion practice grossly underestimates needs. The hypothesis for this study is that our pre-intensive care unit (ICU) massive transfusion (MT) protocol does not adequately correct coagulopathy, and that early uncorrected coagulopathy is predictive of mortality., Methods: Data maintained in our Trauma Research Database were reviewed. Univariate logistic regression analysis was used to analyze the association of early ICU international normalized ratio (INR) and outcomes, including survival., Results: Ninety-seven of 200 patients admitted during 51 months (ending January 2003) and resuscitated using our standardized ICU shock resuscitation protocol received MT (> or =10 units packed red blood cells [PRBC]) during hospital day 1 (age, 39 +/- 2; ISS, 29 +/- 1; survival, 70%.) All patients required emergency operating room and/or interventional radiology procedures and arrived in the ICU 6.8 +/- 0.3 hours after admission. Coagulopathy, present at hospital admission (pre-ICU INR, 1.8 +/- 0.2), persisted at ICU admission (initial ICU INR, 1.6 +/- 0.1). Pre-ICU resuscitation, 9 +/- 1 L crystalloid fluid, 12 +/- 1 units PRBC, 5 +/- 0.4 units fresh frozen plasma (FFP), was consistent with our MT protocol by which FFP was not given until after 6 units PRBC. ICU resuscitation involved 11 +/- 1 L lactated Ringer's solution (LR) and 10 +/- 1 units PRBC. Mean pH was normal within 8 hours. Mean temperature increased from approximately 35 degrees C to >37 degrees C within 4 hours. In the ICU during resuscitation, patients received 10 +/- 1 units FFP for coagulopathy; the ratio of FFP:PRBC was 1:1. Mean INR decreased to 1.4 +/- 0.03 within 8 hours and remained nearly constant for the remaining 16 hours of ICU resuscitation, indicating moderate coagulopathy. Statistical analysis found severity of coagulopathy (INR) at ICU admission associated with survival outcome (p = 0.02; area under receiver operator curve [ROC] = 0.71.), Conclusion: These data indicate acidosis and hypothermia to be well managed. Coagulopathy was not corrected in the ICU despite adherence to pre-ICU MT and ICU protocols, likely because of inadequate pre-ICU intervention. More aggressive pre-ICU intervention to correct coagulopathy may be effective in decreasing PRBC requirement during ICU resuscitation, and, because of the association with increased mortality, could improve outcome. We have revised our pre-ICU MT protocol to emphasize early FFP in a FFP:PRBC ratio of 1:1. We think that treatment of coagulopathy can be improved with the development of standardized protocols, both empiric and data driven.

Background: We initiated a multidisciplinary clinical pathway targeting patients greater than 45 years of age with more than 4 rib fractures. The purpose of the current study was to evaluate the effect of this pathway on infectious morbidity and mortality., Methods: This was a prospective cohort study. Data evaluated included patient demographics, injury characteristics, pain management details, lengths of stay, morbidity, and mortality. Univariate and multivariate analyses were performed using a significance level of P < .05., Results: When adjusting for age, injury severity score, and number of rib fractures, the clinical pathway was associated with decreased intensive care unit length of stay by 2.4 days (95% confidence interval [CI] -4.3, -0.52 days, P = .01) hospital length of stay by 3.7 days (95% CI -7.1, -0.42 days, P = .02), pneumonias (odds ratio [OR] 0.12, 95% CI 0.04 to 0.34, P < .001), and mortality (OR 0.37, 95% CI 0.13 to 1.03, P = .06)., Conclusions: Implementation of a rib fracture multidisciplinary clinical pathway decreased mechanical ventilator-dependent days, lengths of stay, infectious morbidity, and mortality.

Background: The incidence of ventilator-associated pneumonia ranges from 10 to 25%, with mortality of 10 to 40%. It prolongs hospital stay and drives up hospital costs. Our Intensive Care Unit (ICU) ventilator-associated pneumonia (VAP) rates were hovering at the National Nosocomial Infection Surveillance (NNIS) 90th percentile (22.3-32.7 infections per 1,000 ventilator days from January 2002 through October 2002) necessitating a performance improvement initiative designed to decrease the incidence of VAP., Methods: A ventilator bundle that incorporates the Center for Disease Control (CDC) Guidelines for Prevention of Nosocomial Pneumonia was instituted in June of 2002. In October 2002, an intervention that audited compliance with the ventilator bundle and provided real-time feedback to ICU staff was started. VAP rates were followed using NNIS criteria. Costs were evaluated using hospital TSI data., Results: VAP did not decrease with institution of the ventilator bundle alone. However, VAP did significantly decrease when the compliance with the ventilator bundle was audited daily and weekly feedback was provided to the caregivers. From November 2002 through June 2003 VAP stayed between 0 and 12.8 per 1,000 ventilator days. The average cost of a VAP was 50,000 dollars., Conclusions: Prevention of VAP requires a concerted effort on the part of hospital administration, physicians, and ICU personnel. The program must be evidence-based, maintained, and accepted by ICU personnel. Continued education and feedback are crucial to maintaining a low VAP rate.