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Introduction: Historically, a zone II hematoma mandated exploration after penetrating trauma, but this has been challenged given potentially higher nephrectomy rates and the advent of therapeutic endovascular and endoscopic interventions. We hypothesized penetrating mechanism was not a predictor for delayed intervention in the modern era. Methods: This single-center, retrospective study included renal trauma patients from 3/2019 to 6/2022. Our institutional practice is selective exploration of zone II hematomas for active bleeding and expanding hematoma only, regardless of mechanism. Descriptive statistics and multivariable logistic regression (MLR) were performed. Results: One-hundred and forty-four patients were identified, with median age 32 years (IQR:23,49), 66% blunt mechanism, and injury severity score 17(IQR:11,26). Forty-three (30%) required operative intervention, and of the 20 that had a zone II exploration, 3 (15%) underwent renorrhaphy and 17 (85%) underwent nephrectomy. Penetrating patients more frequently underwent immediate operative intervention (67%vs10%, P <.0001), required nephrectomy (27%vs5%, P =.0003), and were less likely to undergo pre-intervention CT (51%vs96%, P <.0001) compared to blunt patients. Delayed renal interventions were higher in penetrating (33%vs13%, P =.004) with no difference in mortality or length of stay compared to blunt mechanism. Ureteral stent placement and renal embolization were the most common delayed interventions. On MLR, the only independent predictor for delayed intervention was need for initial operative intervention (OR 3.803;95%CI:1.612-8.975, P =.0023). Four (3%) required delayed nephrectomy, of which only one underwent initial operative intervention without zone 2 exploration. Conclusions: The most common delayed interventions after renal trauma were renal embolization and ureteral stent. Penetrating mechanism was not a predictor of delayed renal intervention in a trauma center that manages zone II retroperitoneal hematomas similarly regardless of mechanism. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the efficacy and safety of intragastric administration of small volumes of sodium enema solution containing phosphorus as phosphorus replacement therapy in critically ill patients with traumatic injuries who required continuous enteral nutrition. Adult patients (>17 years of age) who had a serum phosphorus concentration <3 mg/dL (0.97 mmol/L) were evaluated. Patients with a serum creatinine concentration >1.4 mg/dL (124 µmol/L) were excluded. Patients were given 20 mL of saline enema solution intragastrically, containing 34 mmol of phosphorus and mixed in 240 mL water. A total of 55% and 73% of patients who received one (n = 22) or two doses (n = 11) had an improvement in the serum phosphorus concentration, respectively. The serum phosphorus concentration increased from 2.5 [2.1, 2.8] mg/dL (0.81 [0.69, 0.90] mmol/L) to 2.9 [2.2, 3.0] mg/dL (0.94 [0.71, 0.97 mmol/L) for those who received two doses (p = 0.222). Excluding two patients with a marked decline in serum phosphorus by 1.3 mg/dL (0.32 mmol/L) resulted in an increase in the serum phosphorus concentration from 2.3 [2.0, 2.8] mg/dL (0.74 [0.65, 0.90] mmol/L) to 2.9 [2.5, 3.2] mg/dL (0.94 [0.81, 1.03] mmol/L; n = 9; p = 0.012). No significant adverse effects were noted. Our data indicated that intragastric phosphate administration using a small volume of saline enema solution improved the serum phosphorus concentrations in most patients. [ABSTRACT FROM AUTHOR]

Background: Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation. Methods: Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE. Results: A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation. Conclusion: Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis. [ABSTRACT FROM AUTHOR]

Disclaimer: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time., Purpose: The intent of this study was to evaluate the predictive performance of two common methods for estimating kidney function in critically ill trauma patients with presumed normal kidney function., Methods: A retrospective analysis of 2 common methods for estimating kidney function, the Cockcroft-Gault (CG) and Chronic Kidney Disease Epidemiology Collaboration (2021 CKD-EPI) equations, was undertaken for adult trauma patients. Patients with a 24-hour urine collection for determination of measured creatinine clearance (mCrCl) within 4 to 14 days after admission were included in the study. Patients with a serum creatinine concentration of >1.5 mg/dL or who required dialysis were excluded., Results: The 200 patients included in the study had a median (IQR) mCrCl of 184 (141-233) mL/min; both the CG and CKD-EPI equations were biased towards underpredicting mCrCl, with median (IQR) values of 135 (100-177) mL/min and 135 (113-155) mL/min, respectively (P < 0.001). One hundred twenty-two patients had augmented renal clearance (ARC), defined as an mCrCl of >129 mL/min/1.73m2, and those patients had a median (IQR) mCrCl of 216 (188-265) mL/min; both the CG and CKD-EPI equations were biased towards underpredicting mCrCl in patients with ARC: the median (IQR) estimates were 160 (126-197) mL/min and 147 (129-164) mL/min, respectively (P < 0.001). For those without ARC (n = 78), the median (IQR) mCrCl was 125 (98-153) mL/min; both the CG and CKD-EPI equations underpredicted mCrCl, with median estimates of 98 (76-116) mL/min and 112 (92-132) mL/min, respectively (P < 0.001). The CKD-EPI equation outperformed the CG method for all markers of precision in patients without ARC (P < 0.003)., Conclusion: Common predictive equations for assessing kidney function in critically ill patients with traumatic injuries underpredicted mCrCl, especially in those with ARC., (© American Society of Health-System Pharmacists 2025. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: It is unclear why differences in patient location change organisms causing ventilator-associated pneumonia (VAP). We investigated VAP organisms in three geographically separate trauma intensive care units (TICUs). Patients and Methods: A retrospective review of organisms causing VAP (bronchoalveolar lavage [BAL] performed ≤7 d after admission and growing ≥10 5 cfu/mL) in three geographically separate TICUs was conducted. Patients were treated by similar multidisciplinary teams and protocolized pathways. The primary outcome was the incidence of multi-drug resistant (MDR) VAP. Secondary outcomes were the incidence of inappropriate empiric antimicrobial therapy (IEAT) and the determination of risk factors for MDR VAP. Chi-squared, Kruskal-Wallis, and multi-variable logistic regression analyses were used accordingly. Results: In total, 271 patients were included: 142 in TICU-1, 63 in TICU-2, and 66 in TICU-3. The incidence of MDR VAP was similar across TICUs at 33.8%, 47.6%, and 39.4%, respectively (p = 0.17). Gram-negative MDRs were more prevalent in TICU-1 (70.8%) versus TICU-2 (60.0%) or TICU-3 (26.9%) (p = 0.001). Gram-positive MDRs were identified more in TICU-3 (73.1%) versus TICU-2 (43.3%) or TICU-1 (35.4%). IEAT did not differ by unit overall but was significantly greater for MDR gram-positive organisms in TICU-3 (70.4%) versus TICU-2 (44.8%) or TICU-1 (37.5%) (p = 0.02) and highest for MDR gram-negative organisms in TICU-1 (64.6%) versus TICU-2 (62.1%) or TICU-3 (55.8%) (p = 0.02). Multi-variable regression analyses revealed antibiotic days before BAL and kidney replacement therapy (KRT) as significant predictors of MDR VAP. Conclusions: Different TICU locations did not influence the overall incidence of MDR VAP, but differences in MDR organisms were observed. IEAT rates for both gram-positive and gram-negative organisms in different units may necessitate changes in empiric therapy. Antibiotic days prior to the BAL and KRT significantly increased the odds of early MDR VAP.

Background: The purpose of this study was to determine whether successful outpatient management of diabetes, as assessed by hemoglobin A1c (Hgb A1c), influences inpatient glycemic control., Methods: Adult patients, aged >17 years, admitted to the trauma intensive care unit, who received continuous nutrition therapy, and exhibited a blood glucose concentration (BG) > 149 mg/dl or 8.3 mmol/L were retrospectively evaluated. Controlled diabetes mellitus (DM-C) was defined as a history of DM and a Hgb A1c < 7%. Uncontrolled DM (DM-U) was defined as an Hgb A1c ≥ 7%. Those without a history of DM and an Hgb A1c < 6.5% were classified as without DM (no DM). Patients were managed via intravenous regular human insulin (RHI) infusion or subcutaneous neutral protamine Hagedorn insulin with intravenous sliding scale RHI (SSI) or SSI alone. Target BG range was 70-149 mg/dl (3.9-8.3 mmol/L). Glycemic control was evaluated for the first 7 days of nutrition therapy., Results: Twenty-two patients with DM-C, 24 with DM-U, and 32 with no DM were evaluated. Despite no difference in carbohydrate intake, those with DM-U received 70 ± 54 units daily vs 15 ± 16 and 14 ± 18 units daily for the DM-C and no DM groups, respectively (P = 0.001). Target BG range was achieved for 11 ± 5 h/day vs 14 ± 7 and 16 ± 6 h/day, respectively (P = 0.01)., Conclusion: Early identification of DM-U would assist in recognizing patients with difficulty achieving glycemic control., (© 2024 American Society for Parenteral and Enteral Nutrition.)

The use of prophylactic measures, including perioperative antibiotics, for the prevention of surgical site infections is a standard of care across surgical specialties. Unfortunately, the routine guidelines used for routine procedures do not always account for many of the factors encountered with urgent/emergent operations and critically ill or high-risk patients. This clinical consensus document created by the American Association for the Surgery of Trauma Critical Care Committee is one of a three-part series and reviews surgical and procedural antibiotic prophylaxis in the surgical intensive care unit. The purpose of this clinical consensus document is to provide practical recommendations, based on expert opinion, to assist intensive care providers with decision-making for surgical prophylaxis. We specifically evaluate the current state of periprocedural antibiotic management of external ventricular drains, orthopedic operations (closed and open fractures, silver dressings, local, antimicrobial adjuncts, spine surgery, subfascial drains), abdominal operations (bowel injury and open abdomen), and bedside procedures (thoracostomy tube, gastrostomy tube, tracheostomy)., 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.)