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BACKGROUND Patients with traumatic brain (TBI) injury often require a high dosage of propofol, which can provide an excessive caloric intake. We evaluated our strategy of using liquid protein supplement boluses concurrently with high protein-containing enteral nutrition (EN) formulas and formula rate reduction to avoid caloric overfeeding and inadequate protein intake. METHODS Adult patients (aged >17 years) with TBI admitted to the trauma intensive care unit (TICU) who received concurrent propofol and EN were retrospectively reviewed. Caloric intakes from propofol and EN were obtained. Actual protein intake was compared with projected protein intakes from high protein content and standard protein content enteral formulas when given at an isocaloric intake. RESULTS Fifty-one patients were enrolled. Average caloric intake from propofol was 356 ± 243 kcal/d or 5 ± 3 kcal/kg/d (range

Vitamin D deficiency during critical illness has been associated with worsened outcomes. Because most critically ill patients with severe traumatic injuries are vitamin D deficient, we investigated the efficacy and safety of cholecalciferol therapy for these patients.Fifty-three patients (17 years of age) admitted to the trauma intensive care unit who had a serum 25-hydroxy vitamin D (25-OH vit D) concentration20 ng/mL were given 10,000 IU of cholecalciferol daily. Efficacy was defined as achievement of a 25-OH vit D of 30-79.9 ng/mL. Safety was evaluated by the presence of hypercalcemia (serum ionized calcium [iCa]1.32 mmol/L) or hypervitaminosis D (25-OH vit D79.9 nmol/L). Patients were monitored for 2 weeks during cholecalciferol therapy.Twenty-four patients (45%) achieved target 25-OH vit D. No patients experienced hypervitaminosis D. Hypercalcemia occurred in 40% (n = 21) of patients; 2 patients experienced an iCa1.49 nmol/L. 25-OH vit D was significantly greater for those who developed hypercalcemia (37.2 + 11.2 vs 28.4 + 5.6 ng/mL, respectively, P0.001) by the second week of cholecalciferol. Of 24 patients who achieved target 25-OH vit D, 14 (58%) experienced hypercalcemia in contrast to 24% of patients (7 out of 29) who did not achieve target 25-OH vit D (P = 0.024).Cholecalciferol normalized serum 25-OH vit D concentrations in less than half of patients yet was associated with a substantial proportion of patients with hypercalcemia without hypervitaminosis D.

The intent of this study was to ascertain the prevalence of augmented renal clearance (ARC) in patients with traumatic injuries who require nutrition therapy and identify factors associated with ARC. Adult patients admitted to the trauma intensive care unit from January 2015 to September 2016 who received enteral or parenteral nutrition therapy and had a 24 h urine collection within 4 to 14 days after injury were retrospectively evaluated. Patients with a serum creatinine concentration &gt, 1.5 mg/dL, required dialysis, or had an incomplete urine collection were excluded. ARC was defined as a measured creatinine clearance &gt, 149 mL/min/1.73 m2. Two hundred and three patients were evaluated. One hundred and two (50%) exhibited ARC. A greater proportion of patients with ARC were male (86% vs. 67%, p = 0.004), had traumatic brain injury (33% vs. 9%, p = 0.001), a higher injury severity score (30 ± 11 vs. 26 ± 12, p = 0.015), were younger (36 ± 15 vs. 54 ± 17 years, p = 0.001), had a lower serum creatinine concentration (0.7 ± 2 vs. 0.9 ± 0.2 mg/dL, p = 0.001) and were more catabolic (nitrogen balance of −10.8 ± 13.0 vs. −6.2 ± 9.2 g/d, p = 0.004). The multivariate analysis revealed African American race and protein intake were also associated with ARC. Half of critically ill patients with traumatic injuries experience ARC. Patients with multiple risk factors for ARC should be closely evaluated for dosing of renally-eliminated electrolytes, nutrients, and medications.

Two sliding scale regular human insulin (RHI) algorithms (SSI) were retrospectively evaluated to identify those who develop severe hyperglycemia (blood glucose (BG) > 180 mg/dL) and for glycemic management of continuously-fed, critically ill trauma patients with mild to moderate hyperglycemia (BG 126 to 179 mg/dL). Assignment of low or high SSI was based upon anticipated severity of difficulty in glycemic control. BG was obtained every 3 to 6 hours. Target BG range was 70 to 149 mg/dL. Patients who were unable to achieve a BG < 150 mg/dL with SSI and who required a continuous intravenous RHI infusion were identified. Twenty-five of 121 patients (21%) failed SSI necessitating more intensive insulin therapy. The low and high intensity SSI groups exhibited a baseline BG of 123 + 33 mg/dL and 164 + 20 mg/dL (P = 0.001). Average BG for each group was 129 ± 14 mg/dL and 145 ± 21 mg/dL (P = 0.001). Each group spent 20 ± 4 and 16 ± 5 hours/day within the target BG range (P = 0.001), respectively. Mild hypoglycemia (BG 40 - 60 mg/dL) occurred in 11% and 7% of patients from each group (P = N.S.). Severe hypoglycemia (BG < 40 mg/dL) occurred in zero and two (5%) patients, respectively (P = N.S). SSI served as a useful technique to identify those requiring more intensive insulin therapy and was safe and efficacious for continuously-fed, critically ill trauma patients with mild to moderate hyperglycemia.

Purpose: We report a case of a patient with gastrointestinal dysmotility and substantial drainage losses who required parenteral nutrition (PN) and developed a non–anion gap metabolic acidosis secondary to a shortage of concurrent potassium acetate and sodium acetate PN additives. We describe how severe PN-associated metabolic consequences were averted during this acetate shortage. Summary: The patient with inability to swallow and significant weight loss was admitted to the hospital and given PN after failure to tolerate either gastric or jejunal feeding due to dysmotility and severe abdominal distension and discomfort. PN was initiated and the nasogastric and jejunal tubes were left to low intermittent suction or gravity drainage (average losses of 800 mL and 1600 mL daily, respectively) to reduce abdominal distension. The patient had been stable on PN for approximately 2 months prior to when a shortage in potassium acetate and sodium acetate occurred. As a result, potassium and sodium requirements had to be met with chloride and phosphate salts. The patient developed a non–anion gap metabolic acidosis after 11 days of acetate-free PN. Progression to severe acidemia was avoided by administration of sodium bicarbonate daily for 3 days and replacement of 0.9% sodium chloride supplemental intravenous fluid with lactated ringers solution. Conclusion: This case report illustrates that PN component shortages require clinicians to closely monitor patients who require PN. In addition, clinicians may need to use creative therapeutic strategies to avoid potential serious patient harm during PN component shortages.

Objective: The aim of this study was to evaluate the feasibility of enteral nutrition (EN) for critically ill trauma patients with severe traumatic duodenal injuries who received placement of concurrent decompressing and feeding jejunostomies. Methods: Adult patients admitted to the trauma intensive care unit from January 2010 to December 2013, given concurrent afferent decompressing and efferent feeding jejunostomies for severe duodenal injury and provided EN or parenteral nutrition (PN), were retrospectively evaluated. Enteral feeding intolerance was defined as an increase in the decompressing jejunostomy drainage volume output, worsening abdominal distension, or cramping/pain unrelated to surgical incisions. Patients who failed initial EN were transitioned to PN. Results: Twenty-six patients were enrolled. Of the 24 patients given EN within the first 2 wk posthospitalization, 18 (75%) failed EN within 2 � 2 d of initiating EN. EN was discontinued when increases were seen in decompressing jejunostomy drainage volume output (n ¼ 11) and output with abdominal pain and/or distension (n ¼ 6), or abdominal pain/distension was seen without an increase in output (n ¼ 1). Jejunostomy drainage volume output increased from 474 � 425 mL/d to 1168 � 725 mL/d (P < 0.001) during EN intolerance. More patients with blunt intestinal injury than those with penetrating injuries (75% versus 15%, respectively; P ¼ 0.035) tolerated EN. Patients initially given PN (n ¼ 13) received more calories (P < 0.005) and protein (P < 0.001) than those given initial EN (n ¼ 13). Conclusion: The majority of patients with severe duodenal injuries and concurrent decompressing/ feeding tube jejunostomies failed initial EN therapy.

The presence of obesity may confound cholecalciferol dosing in vitamin D-deficient patients owing to potentially decreased bioavailability. The aim of this retrospective study was to evaluate cholecalciferol therapy in vitamin D-deficient, critically ill trauma patients with and without obesity.Adult patients with severe traumatic injuries who had a serum 25-hydroxyvitamin D (25-OH vit D)50nmol/L were prescribed 10 000 IU of liquid cholecalciferol daily. Efficacy was defined as achievement of a 25-OH vit D of 75 to 200nmol/L. Safety was evaluated by the presence of hypercalcemia (serum ionized calcium1.32 mmol/L). Fifty-three patients (18 obese, 35 non-obese) were identified for study.Despite similar baseline concentrations (36 ± 7 versus 37 ± 7 nmol/L; P = NS), 25-OH vit D response was attenuated for those with obesity after 1 and 2 wk of cholecalciferol therapy (51 ± 18 versus 66 ± 27nmol/L, P0.01; 68 ± 19 versus 92 ± 25nmol/L, P0.01, respectively). Patients with obesity also tended to experience less hypercalcemia (22% versus 49% of patients, respectively) post-cholecalciferol therapy.Obesity alters the response to cholecalciferol therapy in critically ill patients with severe traumatic injuries.

Glycemic control is an important component of the metabolic management of the critically ill patient. Nutrition support teams are frequently challenged by complicated patients who exhibit multiple concurrent etiologies for hyperglycemia. Nutrition support teams can serve in a pivotal role in the development and evaluation of safe and effective techniques for achieving glycemic control. This review describes the efforts of a nutrition support team in achieving safe and effective glycemic control at their institution. Identification of target blood glucose concentration range, development, initiation, monitoring of a continuous intravenous insulin infusion algorithm, nursing adherence to the algorithm, modification of the algorithm based on the presence of conditions that alter insulin metabolism and glucose homeostasis, and transition of the patient who receives continuous enteral nutrition from a continuous intravenous insulin infusion to intermittent subcutaneous insulin therapy are discussed.

BACKGROUND The purpose of this study was to evaluate the safety and efficacy of central venous administration of a hypotonic 0.225% sodium chloride (one-quarter normal saline [¼ NS]) infusion for critically ill patients with hypernatremia. METHODS Critically ill, adult patients with traumatic injuries and hypernatremia (serum sodium [Na] >150 mEq/L) who were given ¼ NS were retrospectively studied. Serum sodium, fluid balance, free water intake, sodium intake, and plasma free hemoglobin concentration (fHgb) were assessed. RESULTS Twenty patients (age, 50 ± 18 years; Injury Severity Score, 29 ± 12) were evaluated. The ¼ NS infusion was given at 1.5 ± 1.0 L/d for 4.6 ± 1.6 days. Serum sodium concentration decreased from 156 ± 4 to 143 ± 6 mEq/L (P < .001) over 3-7 days. Total sodium intake was decreased from 210 ± 153 to 156 ± 112 mEq/d (P < .05). Daily net fluid balance was not significantly increased. Plasma fHgb increased from 4.9 ± 5.4 mg/dL preinfusion to 8.9 ± 7.4 mg/dL after 2.6 ± 1.3 days of continuous intravenous (IV) ¼ NS in 10 patients (P = .055). An additional 10 patients had a plasma fHgb of 10.2 ± 9.0 mg/dL during the infusion. Hematocrit and hemoglobin decreased (26% ± 3% to 24% ± 2%, P < .001 and 9.1 ± 1.1 to 8.2 ± 0.8 g/dL, P < .001, respectively). CONCLUSIONS Although IV ¼ NS was effective for decreasing serum sodium concentration, evidence for minor hemolysis warrants further research to establish its safety before its routine use can be recommended.

BACKGROUND The management of arterial injury at the thoracic outlet has long hinged on the fundamental principles of extensile exposure and vascular anastomosis. Nonetheless, treatment options for such injuries have evolved to include both endovascular stent placement and temporary vascular shunts. The purpose of this study was to evaluate our recent experience with penetrating cervicothoracic arterial injuries in light of these developments in trauma care. METHODS Patients with penetrating injuries to the innominate, carotid, subclavian, or axillary arteries managed at a single civilian trauma center between 2000 and 2013 were categorized as the modern era (ME) cohort. The management strategies and outcomes pertaining to the ME group were compared to those of previously reported experience (PE) concerning injuries to the innominate, carotid, subclavian, or axillary arteries at the same institution from 1974 to 1988. RESULTS Over the two eras, there were 202 patients: 110 in the ME group and 92 in the PE group. Most of the injuries in both groups were managed with primary repair (45% vs. 46%; p = 0.89). A similar proportion of injuries in each group was managed with anticoagulation alone (14% vs. 10%; p = 0.40). In the ME group, two cases were managed with temporary shunt placement, and endovascular stent placement was performed in 12 patients. Outcomes were similar between the groups (bivariate comparison): mortality (ME, 15% vs. PE, 14%; p = 0.76), amputation following subclavian or axillary artery injury (ME, 5% vs. PE, 4%; p = 0.58), and posttreatment stroke following carotid injury (ME, 2% vs. PE, 6%; p = 0.57). CONCLUSIONS Experience with penetrating arterial cervicothoracic injuries at a high-volume urban trauma center remained remarkably similar with respect to both anatomic distribution of injury and treatment. Conventional operative exposure and repair remain the cornerstone of treatment for most civilian cervicothoracic arterial injuries. LEVEL OF EVIDENCE Therapeutic study, level V.

The use of continuous intravenous regular human insulin (RHI) infusion is often necessary to achieve glycemic control in critically ill patients. Because insulin is a high-risk medication owing to the potential for severe hypoglycemia, it is imperative that insulin infusion algorithms are designed to be safe, effective, and instructionally clear. The safety and efficacy of our intravenous RHI infusion algorithm protocol has been previously established (Nutrition 2008;24:536-45); however, the protocol violations by nursing personnel were not examined. The objective of this study was to assess nursing adherence to our RHI infusion algorithm.Continuous RHI infusion algorithm violations were retrospectively evaluated in adult patients admitted to a trauma intensive care unit who received concurrent continuous enteral and/or parenteral nutrition therapy and our algorithm for at least 3 d. Blood glucose (BG) monitoring was done every 1 to 2 h with the target BG at 70 to 149 mg/dL (3.9 to 8.3 mmol/L). Nursing adherence to the RHI infusion protocol was evaluated for each patient by comparing the adjustments in insulin infusion rates documented by the nursing personnel with the prescribed adjustments per our graduated continuous intravenous RHI infusion algorithm.A total of 4150 BG measurements necessitating the determination of the appropriate RHI dosage rate by nursing personnel in 40 patients occurred during the observational period. The target BG was achieved for a mean of 20 h/d and none of the patients had an episode of severe hypoglycemia (BG40 mg/dL or 2.2 mmol/L). The overall rate of algorithm violations was 12.1%. The algorithm violations accounted for a single episode of mild to moderate hypoglycemia (BG 40 to 60 mg/dL or 2.2 to 3.3 mmol/L) in 4 patients and 65 total episodes of hyperglycemia (BG ≥150 mg/dL or 8.3 mmol/L) in 18 patients.An adherence rate of nearly 90% is indicative of excellent nursing adherence compared with other published paper-based algorithms that examined protocol adherence. These data, combined with our previously published glycemic control data, indicate that this RHI infusion algorithm is an effective one for hyperglycemic trauma patients receiving continuous enteral and/or parenteral nutritional therapy.

The objective of this study was to determine if patients requiring levothyroxine therapy develop hypothyroidism during concurrent continuous enteral nutrition (EN).Adult patients with a history of hypothyroidism, given levothyroxine via the feeding tube at the same dose given prior to hospital admission and who were referred to the nutrition support service for EN were evaluated. Thyroid function tests (TFTs) were performed prior to administration of levothyroxine-continuous EN, then approximately weekly thereafter. Patients who received less than 14 days of concurrent EN-levothyroxine therapy were excluded from the analysis.Thirteen patients who received 20 ± 5 days of concurrent EN and levothyroxine were evaluated. Two patients developed subclinical hypothyroidism (thyrotropin [TSH]6 and10 mcIU/mL + normal fT(4)), and 6 developed overt hypothyroidism (TSH10 mcIU/mL + low fT(4)) within 2 to 3 weeks of concurrent EN-levothyroxine therapy. Five patients remained euthyrotic. Differences between those who developed subclinical or overt hypothyroidism versus those who remained euthyrotic could not be explained by age, weight, levothyroxine dose, type of EN formula, or amount of EN received.More than half of the patients receiving concurrent levothyroxine-continuous EN developed subclinical or overt hypothyroidism requiring therapeutic intervention. Routine weekly monitoring of TFTs for patients receiving concurrent levothyroxine-continuous EN is recommended.

Objective The intent of this study was to ascertain whether multiple trauma patients with traumatic brain injury (TBI) had lower serum concentrations of potassium and phosphorus and required more aggressive supplementation than multiple trauma patients without TBI. Methods Ventilator-dependent adult patients without renal impairment who were admitted to the trauma intensive care unit or neurosurgical intensive care unit and who received enteral nutrition were evaluated for the first 14 d after hospital admission. Patients were grouped according to the presence or absence of TBI. Target serum concentrations for potassium and phosphorus were 4 mEq/L and 4 mg/dL, respectively. Electrolyte repletion therapy was given according to the nutritional support service guidelines. Results Fifty trauma patients (25 with and without TBI) were studied. Daily serum potassium concentrations were consistently lower for those with TBI ( P ≤ 0.001), whereas the mean net potassium intake was greater (1.3 ± 0.5 versus 0.7 ± 0.3 mEq · kg −1 · d −1 , respectively, P ≤ 0.001). Serial serum phosphorus concentrations were similar between groups ( P = NS) except for a significantly lower serum phosphorus concentration for trauma patients with TBI on day 3 after hospital admission (2.5 ± 0.5 versus 2.9 ± 0.7 mg/dL, respectively, P ≤ 0.05). However, the mean net phosphorus intake was significantly greater for trauma patients with TBI (0.65 ± 0.25 versus 0.45 ± 0.17 mmol · kg −1 · d −1 , P ≤ 0.001). Conclusion Potassium and phosphorus requirements are greater for multiple trauma patients with TBI compared with those without TBI.

Patients with traumatic brain injury (TBI) have delayed gastric emptying and often require prokinetic drug therapy to improve enteral feeding tolerance. The authors hypothesized that metoclopramide was less efficacious for improving gastric feeding tolerance for trauma patients with TBI compared to trauma patients without TBI. A retrospective analysis was conducted of patients admitted to the trauma or neurosurgical intensive care unit who received gastric feeding from January 2006 to April 2008. Gastric feeding intolerance was defined by a gastric residual volume >200 mL or emesis with abdominal distension or discomfort. Patients with gastric feeding intolerance were given metoclopramide 10 mg intravenously every 6 hours, followed by a dose escalation to 20 mg, and then combination therapy with metoclopramide and erythromycin 250 mg intravenously every 6 hours if intolerance persisted. In total, 882 trauma patients (49% with TBI) were evaluated. TBI patients had a higher incidence of gastric feeding intolerance than those without TBI (18.6% vs 10.4%, P < or = .001). Efficacy rates for metoclopramide 10 mg, metoclopramide 20 mg, and metoclopramide-erythromycin were 55%, 62%, and 79%, respectively (P < or = .03). Metoclopramide failure occurred in 54% of patients with TBI compared to 35% of patients without TBI, respectively (P < or = .02), due to a greater prevalence of tachyphylaxis. Single-drug therapy with metoclopramide was less effective for TBI trauma patients compared to trauma patients without TBI. Combination therapy with erythromycin as first-line therapy for TBI trauma patients with gastric feeding intolerance is indicated if there are no contraindications or significant drug interactions.

Empiric antibiotic therapy is routinely initiated for patients with presumed ventilator-associated pneumonia (VAP). Reported mortality rates for inadequate empiric antibiotic therapy (IEAT) for VAP range from 45 to 91 per cent. The purpose of this study was to determine the effect of a unit-specific pathway for the empiric management of VAP on reducing IEAT episodes and improving outcomes in trauma patients. Patients admitted with VAP over 36-months were identified and stratified by gender, age, severity of shock, and injury severity. Outcomes included number of IEAT episodes, ventilator days, intensive care unit days, hospital days, and mortality. Three hundred and ninety-three patients with 668 VAP episodes were identified. There were 144 (22%) IEAT episodes: significantly reduced compared with our previous study (39%) ( P < 0.001). Patients were classified by number of IEAT episodes: 0 (n = 271), 1 (n = 98) and ≥ 2 (n = 24). Mortality was 12 per cent, 13 per cent, and 38 per cent ( P < 0.001), respectively. Multivariable logistic regression identified multiple IEAT episodes as an independent predictor of mortality (odds ratio = 4.7; 95% confidence interval: 1.684–13.162). Multiple IEAT episodes were also associated with prolonged mechanical ventilation and intensive care unit stay ( P < 0.001). Trauma patients with multiple IEAT episodes for VAP have increased morbidity and mortality. Adherence to a unit-specific pathway for the empiric management of VAP reduces multiple IEAT episodes. By limiting IEAT episodes, resource utilization and hospital mortality are significantly decreased.

The intent of this study was to evaluate the safety and efficacy of our protocol for providing continuous intravenous regular human insulin (RHI) infusion to hyperglycemic critically ill trauma patients receiving specialized nutritional support.Capillary blood glucose (BG) concentrations were determined every 1-2 h. Glucose control was defined as a BG concentration in the target range of 70-149 mg/dL (3.9-8.3 mmol/L). Data were recorded for 1 d before the RHI infusion and for a maximum of 8 d thereafter while receiving the RHI infusion.Forty adult critically ill trauma patients received 102 +/- 62 units of RHI daily for 10 +/- 6 d. BG control was achieved within 5 +/- 3 h. BG decreased from 194 +/- 55 mg/dL (10.8 +/- 3.1 mmol/L) to 134 +/- 19 mg/dL (7.4 +/- 1.1 mmol/L) after 1 d of RHI infusion (P0.001). Average daily BG ranged from 119 to 124 mg/dL and the target range was maintained for 19.6 +/- 4.7 h/d. None of the patients experienced severe hypoglycemia (40 mg/dL); 14 patients had asymptomatic hypoglycemia (60 mg/dL or3.3 mmol/L) for a total of 23 episodes out of 4140 measurements (0.56%). Estimated creatinine clearance for those with hypoglycemia was 69 +/- 32 mL/min compared with 117 +/- 58 mL/min for the others (P0.01).Our protocol was safe and effective for the management of hyperglycemia in critically ill trauma patients receiving specialized nutritional support but should be used with caution in patients with renal insufficiency.

Although still controversial, upper endoscopy is frequently performed before bariatric surgery. This study investigated the hypothesis that morbidly obese patients would prefer anesthesiologist-monitored sedation (AMS) compared to surgeon-monitored sedation (SMS) during preoperative endoscopy.All patients who underwent endoscopy before their bariatric surgery were given a post-procedure survey regarding their experience with the preoperative endoscopy. The survey inquired about issues during and after the procedure. We compared patients who had AMS with IV propofol versus SMS IV narcotics and benzodiazepines.There were 100 patients (SMS=49 and AMS=51). Few patients complained of pain in the abdomen or throat during the procedure (AMS vs. SMS=2 vs. 8% and 2 vs. 10%, respectively; p=NS). More patients complained about throat pain after the procedure (AMS vs. SMS=37 vs. 45%; p=NS). More patients in the SMS group remembered the scope being placed in the mouth versus AMS (33 vs. 10%; p0.02). More patients remembered gagging during the procedure in the SMS group versus the AMS group, but this did not reach statistical significance (24 vs. 10%; p=0.06). There was a trend that more patients in the AMS group felt they recovered in less than 1 h (53%) compared to the SMS group (37%; p=0.1).Patients who undergo upper endoscopy with either AMS or SMS seem to tolerate the procedure well. The preliminary benefits seen with AMS need to be further explored. AMS should be considered for patients undergoing preoperative upper endoscopy before bariatric surgery.

Nonoperative management of blunt splenic injury (BSI) has become the standard of care for hemodynamically stable patients. Successful nonoperative management raises two related questions: (1) what is the time course for splenic healing and (2) when may patients safely return to usual activities? There is little evidence to guide surgeon recommendations regarding return to full activities. Our hypothesis was that time to healing is related to severity of BSI.The trauma registry at a level I trauma center was queried for patients diagnosed with a BSI managed nonoperatively between 2002 and 2007. Follow-up abdominal computed tomography scans were reviewed with attention to progression to healing of BSI. Kaplan-Meier curves were compared for mild (American Association for the Surgery of Trauma grades I-II) and severe (grades III-V) BSI.Six hundred thirty-seven patients (63.9% mild spleen injury and 36.1% severe injury) with a BSI were eligible for analysis. Fifty-one patients had documented healing as inpatients. Ninety-seven patients discharged with BSI had outpatient computed tomography scans. Nine had worsening of BSI as outpatients and two (1 mild and 1 severe) required intervention (2 splenectomies). Thirty-three outpatients were followed to complete healing. Mild injuries had faster mean time to healing compared with severe (12.5 vs. 37.2 days, p0.001). Most healing occurred within 2 months but approximately 20% of each group had not healed after 3 months.Although mild BSIs heal faster than severe BSIs, nearly 10% of all the BSIs followed as outpatients worsened. Close observation of patients with BSI should continue until healing can be confirmed.

Study Objective. To assess the influence of withholding continuous enteral nutrition for 1 hour before and after warfarin administration compared with the coadministration of warfarin with continuous enteral nutrition on changes in international normalized ratios (INRs). Design. Retrospective, crossover case series. Setting. Intensive care units of a university-affiliated medical center. Patients. Six adults who required nutritional support for at least the first 10 consecutive days of warfarin therapy; during that 10-day period, they had a period of at least 3 consecutive days during which the enteral feeding was withheld for 1 hour before and after warfarin administration, and had a period of at least 3 consecutive days when feedings were not withheld during warfarin administration. Patients with advanced liver disease and those who received therapies, during the observation period, that significantly alter warfarin metabolism were omitted from the study. Measurements and Main Results. The change in INR during the 3-day observation period when feedings were withheld for 1 hour before and after warfarin administration was significantly different versus the change in INR during coadministration of warfarin with continuous feeding (mean ± SD 0.74 ± 0.66 vs -0.13 ± 0.81, p≤0.05). This difference in INR response occurred despite the administration of similar dosages of warfarin (5.6 ± 2.1 vs 5.7 ±2.1 mg/day, p>0.05). Also noted was a clinically irrelevant, but statistically significant, difference in vitamin K intake between treatment periods (77 ± 36 μg/day when feedings were withheld vs 102 ± 28 μg/day when feedings were not withheld, p≤0.05). Conclusion. Continuous enteral nutrition should be withheld for 1 hour before and after warfarin administration to prevent enteral nutrition-associated warfarin resistance.

The intent of this study was to ascertain to what extent serum total calcium concentration (tCa)7 mg/dL reflects hypocalcemia (defined by ionized calcium concentration [iCa] ofor = 1.12 mmol/L) in critically ill patients receiving specialized nutrition support.Adult patients (or = 18 years) admitted to the trauma, surgical, medical, burn, or neurosurgical intensive care units, trauma stepdown unit, or progressive care unit and referred to the nutrition support service were retrospectively identified for potential inclusion into the study. Serum chemistries, arterial blood gas measurements, nutrition markers, and serum iCa were simultaneously obtained from each patient approximately 1 day after initiation of specialized nutrition support. Patients with a serum creatinineor = 2 mg/dL, hyperphosphatemia (or = 6 mg/dL), severe hypomagnesemia (or = 1.12 mg/dL), history of metabolic bone disease, or parathyroid disease were excluded from the analysis.One hundred ninety-five patients (91% who had multiple trauma, with a mean Injury Severity Score 31 +/- 13) were enrolled into the study. Specialized nutrition support was initiated 2.8 +/- 1.8 days and calcium status was studied 4.2 +/- 3.1 days after hospital admission, respectively. The majority (28 of 33, or 85%) of patients with a tCa7 mg/dL were hypocalcemic compared with 33% (22 out of 66) of patients with a tCa of 7-7.4 mg/dL, and 11% (11 of 96) of those with a tCa of 7.5-7.9 mg/dL (p.001).Critically ill patients with a serum total calcium concentration of7 mg/dL have a high rate of hypocalcemia (iCaor = 1.12 mmol/L). Hypocalcemia, defined as a serum iCa ofor = 1.12 mmol/L, occurs in 85% of acutely ill patients with a serum tCa7 mg/dL.

The use of serial chest radiographs (CXRs) to evaluate patients with penetrating thoracic trauma is common practice. However, the time interval between these studies and the duration of observation remains uncertain. The purpose of this study was to evaluate whether a noncontrast chest CT is as reliable as a 6-hour CXR for detecting delayed pneumothorax (PTX) after penetrating thoracic trauma. Hemodynamically stable patients with isolated penetrating thoracic trauma were prospectively evaluated with a CXR and a noncontrast chest CT. If there was no PTX or hemothorax, or a finding that did not require immediate intervention, a 6-hour CXR was obtained. Findings were treated as clinically indicated and patients were discharged if all three studies were negative. One hundred eighteen patients were evaluated (89 stab wounds and 29 gunshot wounds). All initial CXRs were negative. CT identified six PTXs and one hemothorax. Two patients required operative intervention. There were no delayed findings on CXR provided the CT was negative. The mean time to CT and before disposition was 19 minutes and 8 hours, respectively, with a potential decrease in charges of $313.32 per patient. The use of serial CXRs provided no additional information that was not available on the initial chest CT, allowing for expedited discharge, decompressing overcrowded emergency areas, and reducing the number of patients leaving before completion of their work-up.

Our recent data indicate that 21% of critically ill, adult, multiple-trauma patients receiving specialized nutrition support experience hypocalcemia. However, evidence-based methods for the treatment of moderate to severe acute hypocalcemia (ionized calcium concentration [iCa]1 mmol/L) are lacking.The efficacy of an infusion of 4 g of calcium gluconate was evaluated in 20 critically ill, adult, multiple-trauma patients with moderate to severe hypocalcemia (iCa1 mmol/L). The calcium gluconate was infused at a rate of 1 g/h in a small volume admixture. A serum iCa determination was obtained on the following day.Calcium gluconate infusion significantly increased serum iCa from 0.90 +/- 0.08 mmol/L to 1.16 +/- 0.11 mmol/L (p.001) on the following day. This dosage regimen was successful for achieving a serum iCa1 mmol/L for 19 of 20 (95%) hypocalcemic patients and achieved a concentration1.12 mmol/L in 14 (70%) of the patients. Two patients developed mild hypercalcemia (iCa of 1.34 mmol/L and 1.38 mmol/L) postinfusion.A short-term infusion of 4 g of intravenous (IV) calcium gluconate for the treatment of moderate to severe hypocalcemia appears to be a promising regimen for critically ill, adult, multiple-trauma patients.

The purpose of this investigation was to evaluate the dose-dependent characteristics of intravenous calcium gluconate therapy for hypocalcemic critically ill patients.The dose-dependent characteristics of 2 g versus 4 g of intravenous calcium gluconate therapy were evaluated in 25 critically ill, adult multiple trauma patients with hypocalcemia. The calcium gluconate was infused at a rate of 1 g/h for both groups. Patients weighed within 90% to 120% of ideal body weight, had normal renal function, did not receive diuretic therapy, and did not have anasarca.Fifteen patients with mild hypocalcemia (serum ionized calcium concentration [iCa] 1-1.12 mmol/L) were given 2 g of calcium gluconate. Ten patients with moderate to severe hypocalcemia (iCa1 mmol/L) were given 4 g. Each dosage group had a significant (Por = 0.001) increase in iCa (from 1.07 +/- 0.05 to 1.17 +/- 0.05 mmol/L and from 0.92 +/- 0.08 to 1.16 +/- 0.11 mmol/L, respectively). Each dosage group retained about half of the dose in the exchangeable calcium space (P = NS between groups), but the higher dosage group retained significantly more elemental calcium overall (81 +/- 38 versus 201 +/- 50 mg, respectively, Por = 001). Serum ionized calcium concentrations achieved a plateau without a further decline in iCa by 10 h after completion of the infusion for each dosage.About half of the administered elemental calcium dose was retained for each dosage group, with the higher dose (4 g) resulting in significantly more elemental calcium retention in the exchangeable calcium space. An iCa determination performed aboutor =10 h after the completion of the calcium gluconate infusion should be sufficient time to ensure equilibration of iCa to assess the efficacy of the therapy. This mode of calcium therapy serves as an effective means for providing calcium to the acutely hypocalcemic, critically ill, multiple trauma patient.

The intent of this study was to evaluate the safety and efficacy of an intravenous (IV) potassium (K) dosing algorithm for hypokalemic critically ill trauma patients.Adult patients, admitted to the trauma intensive care unit from June 2010 to October 2012 and who received IV K therapy according to a standardized dosing algorithm, were retrospectively evaluated. Patients who received IV K during resuscitation or following initiation of nutrition therapy, IV fluids containing20 mEq/L of potassium, or medications known to alter K homeostasis or those with an arterial pH change0.1, diarrhea, hypomagnesemia, renal impairment, or morbid obesity were excluded.In total, 715 patients were reviewed to obtain 100 evaluable patients. Serum K for patients with mild depletion (serum K, 3.5-3.9 mEq/L, n = 74) remained unchanged at 0.0 ± 0.3 mEq/L ( P = ns) following 46 ± 8 mEq. Serum K increased by 0.4 ± 0.3 mEq/L ( P = .001) following 78 ± 18 mEq during moderate depletion (serum K, 3-3.4 mEq/L). None of the patients experienced hyperkalemia (serum K,5.2 mEq/L) postinfusion. The presence of traumatic brain injury (TBI) blunted the response to IV K for mild K depletion as only 26% had an increase in serum K compared with 55% of patients without TBI ( P = .025).The Nutrition Support Service-guided IV K dosing algorithm was safe for patients with mild and moderate hypokalemia and efficacious for those with moderate hypokalemia. Further study in patients with severe hypokalemia (serum K,3 mEq/L) is warranted.

The aim of this study was to evaluate the dose-response relationship between ergocalciferol therapy and serum 25-hydroxyvitamin D concentrations in enterally fed, critically ill patients with traumatic injuries.A retrospective cohort of critically ill patients with traumatic injuries and vitamin D deficiency (25-OH vitamin D50 nmol/L) were given either 50 000 IU of liquid ergocalciferol weekly, twice weekly, or three times weekly while in the intensive care unit (ICU). Serum 25-OH vitamin D and ionized calcium concentrations were monitored weekly. Ergocalciferol therapy was stopped when the serum 25-OH vitamin D was75 nmol/L, if the patient experienced hypercalcemia (ionized calcium1.34 mmol/L), when the patient was discharged from the ICU, or if enteral nutrition was discontinued.Sixty-five patients (16, 18, and 31 per dosage group) were examined. One (6%), two (11%), and eight (26%) patients achieved normal 25-OH vitamin D concentrations after 2 to 4 wk of ergocalciferol therapy for each dosage group, respectively (P0.001). Serum 25-OH vitamin D concentrations improved from 36 ± 6, 40 ± 7, and 37 ± 6 nmol/L to 50 ± 15, 54 ± 21, and 62 ± 17 nmol/L, respectively, after 2 wk of ergocalciferol therapy (P0.001) Two (13%), one (6%), and seven (23%) patients developed hypercalcemia for each dosage group, respectively (P = NS).Ergocalciferol therapy improved baseline serum 25-OH vitamin D concentrations but was inadequate for consistently achieving normal serum concentrations of 25-OH vitamin D during critical illness. The trend in increasing appearance of mild hypercalcemia for the highest dosage group is concerning.

Although supplemental enteral nutrition may have first been delivered by enema, the modern era of surgically placed feeding tubes began in the mid to late 1800s. Early procedures were generally disastrous, however, techniques rapidly improved. The basic techniques of surgical enteral access have not changed significantly in the last century, although endoscopic, radiologic and laparoscopic modifications have been described and adopted in the last 25 years. This article reviews some of the landmark surgical highlights in the United States and European literature regarding surgical enteral access.

Recent data indicate that critically ill, adult multiple trauma patients receiving specialized nutrition support commonly experience hypocalcemia (ionized serum calcium [iCa]or =1.12 mmol/L). However, validated methods for the treatment of acute hypocalcemia are lacking.The efficacy of a single dose of calcium gluconate using an empiric IV calcium gluconate graduated dosing regimen was evaluated in 37 patients. Patients with an iCa of 1-1.12 mmol/L (mild hypocalcemia) were provided 1-2 g of IV calcium gluconate. Patients with an iCa of1 mmol/L (moderate to severe hypocalcemia) were given 2-4 g. The calcium gluconate was infused at a rate of 1 g/h in a small-volume admixture. Serum iCa determination was repeated on the following day.One to 2 g of IV calcium gluconate was effective in normalizing iCa for 23 out of 29 patients (79%) with mild hypocalcemia and 2-4 g was effective for 3 of 8 patients (38%) with moderate to severe hypocalcemia. The individual response to calcium therapy (g/d) or when normalized to body weight (mg/kg/d) was highly variable.One to 2 g of IV calcium gluconate were effective for most patients with mild hypocalcemia; however, treatment of moderate to severe hypocalcemia with 2-4 g of IV calcium gluconate was often unsuccessful. Further study with frequent serial ionized serum calcium and phosphorus determinations and electrocardiographic monitoring appears to be indicated for patients with moderate to severe hypocalcemia.

BACKGROUND Computer-based simulated biologic neural network models have made significant strides in clinical medicine. METHODS To determine the predictive performance of a conventional regression model and an artificial neural network for estimating urea nitrogen appearance (UNA) during critical illness, 125 adult patients admitted to the trauma intensive care unit who required specialized nutrition support were studied. The first 100 consecutive patients were used to develop the 2 models. The first model used stepwise multivariate regression analysis. The second model entailed the use of a feeding-forward, back-propagation, supervised neural network. Bias and precision of both methods were evaluated in 25 separate patients. RESULTS Multivariate regression analysis revealed a significant highly correlative relationship (r(2) = .918, p < or = .01): Predicted UNA (g/d) = (0.29 x WT) + (1.20 x WBC) + (0.44 x SUN) with WT as current body weight in kg, WBC as white blood cell count in cells/mm(3), and SUN as serum urea nitrogen concentration (mg/dL). The regression method was biased toward overestimating measured UNA, whereas the neural network was unbiased. Precision (95% confidence interval) of the neural network was significantly better than the regression (3.3-7.2 g vs 7.3-11.6 g, respectively, p < .01). Regression analysis successfully predicted UNA within 3 g of measured UNA in 16% (4 of 25) of patients, whereas the neural network successfully predicted UNA in 44% (11 out of 25) of patients (p < .06). CONCLUSIONS These preliminary data indicate that use of an artificial neural network may be superior to conventional regression modeling techniques for estimating UNA in critically ill adult multiple-trauma patients receiving specialized nutrition support.

Objective: Increased medical staff workload has been associated with worse outcomes in several studies. Inappropriate staffing has also been implicated in the increased risk of mortality for medical patients admitted on weekends. A theoretical threshold patient load may exist, beyond which the resources are strained and patient outcomes suffer. The goal of the study was to see whether trauma patients admitted during 'high' patient-load periods, at night, or on weekends had worse outcomes. Methods: Trauma patients admitted to a high-volume Level I trauma center from 1994 to 2002 were analyzed. Patient load was defined as a combination of the number of patients admitted and the severity of their illness. On the basis of a multivariate regression model, a probability of fatal outcome was calculated for each patient as a marker for the severity of illness. For each patient, two new variables were calculated, the number of admissions (#ad) and the average probability of fatal outcome (PFO) for the 24-hour period in which the patient was admitted (excluding the patient him- or herself). The above variables, night/d, and week-end/d were placed in a multivariate regression model. Results: There were 30,686 patients. Age, mechanism of injury, Injury Severity Score, maximum head Abbreviated Injury Scale score, admission Glasgow Coma Scale score, systolic blood pressure, and intubation status were the independent predictors of mortality. This model had an outstanding predictive power, with an area under the receiver operating characteristic curve of 0.96. The mean #ad was 11 ± 4 and PFO was 0.08 ± 0.07. Values above the 90th percentile were considered 'high' for #ad > 17 or PFO > 0.18. There was no difference in mortality for patients admitted during high #ad (odds ratio [OR], 0.95; p = 0.7) or high PFO (OR, 0.99; p = 0.9) versus low. There was no difference in mortality if a patient was admitted on weekends versus weekdays (OR, 0.9; p = 0.2) or at night versus day (OR, 0.9; p = 0.2). There was no difference in hospital length of stay for high #ad, high PFO, nights, or weekends. Conclusion: At this Level I trauma center that is part of an established state-wide trauma system, patient outcomes were not compromised during high-patient-load periods, at night, or on weekends.

We investigated the accuracy of methods to estimate total urinary nitrogen (TUN) excretion from urinary urea nitrogen (UUN) excretion for patients who have multiple trauma and receive specialized nutritional support.Fifty-five critically ill, adult patients who had multiple trauma and were receiving specialized nutritional support were evaluated. A 24-h urine collection for urea nitrogen and total nitrogen was performed 4.4 +/- 2.6 d after admission to the trauma intensive care unit. Patients with significant renal impairment, liver dysfunction, or obesity (150% of ideal body weight) were excluded from study entry. Eight publications that examined the relation between TUN and UUN were evaluated for bias and precision in estimating TUN from UUN.TUN was 20.8 +/- 10.8 g/d with an average difference of 3.8 +/- 2.8 g/d between TUN and UUN. Linear regression analysis comparing TUN with UUN indicated a significant correlative relation (TUN = 1.1 x UUN + 2; r = 0.958, P0.001). The difference between TUN and UUN varied based on UUN: for UUN lower than 10 g/d, TUN minus UUN was 1.5 +/- 1.0 g/d; for UUN 10 to 20 g/d, TUN minus UUN was 4.1 +/- 3.2 g/d; and for UUN higher than 20 g/d, TUN minus UUN was 5.3 +/- 1.9 g/d (P0.001). Six methods were biased toward underpredicting TUN, one method was unbiased, and one was biased toward overpredicting TUN. A practical method for estimating TUN from UUN was developed: TUN = UUN + 2 for those with UUN lower than 10 g/d and TUN = 1.1 x UUN + 2 for those with UUN of at least 10 g/d.Our method, the modified Velasco method, UUN/0.84, and UUN/0.85 provided reasonable estimates of TUN from UUN in critically ill, adult patients who had multiple trauma and were receiving specialized nutritional support; however, our method requires further validation.

The purpose of this study was to determine the accuracy of 22 published methods to estimate serum ionized calcium (iCa) and "corrected" total serum calcium (totCa) concentrations in critically ill, multiple trauma patients. Seven of these formulas estimated iCa and 15 were directed toward predicting a "corrected" totCa.Adult patients admitted to the trauma intensive care unit who received specialized nutrition support were consecutively recruited for study. Patients who received blood products, i.v. calcium, or therapeutic doses of heparin within 24 hours before the laboratory measurements or had a history of cancer, bone disease, parathyroid disease, hyperphosphatemia (or = 6 mg/dL), hyperbilirubinemia (3.5 mg/dL), or renal failure requiring dialysis were excluded. The 22 published methods were analyzed for sensitivity, specificity, percentage false negatives, and percentage false positives for predicting hypocalcemia or hypercalcemia.One hundred patients were studied 4.9 +/- 3.3 days postinjury and were receiving enteral nutrition (n = 81), parenteral nutrition (n = 18), or both (n = 1) at the time of study. Twenty-one patients were hypocalcemic (iCaor = 1.12 mmol/L) and 6 were hypercalcemic (iCaor = 1.32 mmol/L). The mean sensitivity of the 22 methods for assessing hypocalcemia was 25% +/- 32% and the specificity was 90% +/- 18%. Although the average percentage of false positives for assessing hypocalcemia was 10% +/- 18%, the mean percentage of false negatives was inordinately high at 75% +/- 32%. The most common method for determination of "corrected" totCa concentration ["corrected" calcium = totCa + (0.8 x (4-serum albumin concentration))] had a sensitivity of only 5%. The McLean-Hastings nomogram method, the most common method for estimating serum iCa concentration, had a sensitivity of 67% but unfortunately also had a significant false-positive rate of 27%. Serum totCa correlated modestly with iCa (r2 = .334, p.001). Those patients with a serum albuminor = 2 g/dL (n = 43) had a significantly higher prevalence of hypocalcemia than those with a higher serum albumin concentration (37% incidence of hypocalcemia vs 10%, respectively, p.002).Aberrations in calcium homeostasis are frequent (27%) in postresuscitative critically ill multiple trauma patients. Methods for predicting hypocalcemia lack sensitivity and are often associated with an unacceptable rate of false negatives. Predictive methods for estimating ionized or corrected serum concentrations should not be used. Direct measurement of serum iCa concentration is indicated for assessing calcium status for this population.

OBJECTIVE To report a case of hyponatremia in a patient receiving systemic unfractionated heparin (UFH) therapy and parenteral nutrition. CASE SUMMARY A 70-year-old African American woman was started on parenteral nutrition for postoperative ileus following an elective surgical procedure. Three days later, she was diagnosed with a pulmonary embolism and intravenous UFH therapy was initiated. During the 7-day course of UFH therapy, the patient's serum sodium concentration steadily declined and urine sodium concentration progressively increased. Physical examination revealed no signs or symptoms of hypo- or hypervolemia. The patient's serum potassium concentration increased modestly, although significant hyperkalemia was not observed. After discontinuation of UFH, serum concentrations of both sodium and potassium returned to baseline levels. DISCUSSION Although heparin-induced hyperkalemia is well documented, cases associated with substantial hyponatremia have been reported less frequently. An objective causality assessment revealed that the adverse drug reaction was probable in this case. Hyponatremia and hyperkalemia result from the antagonism of aldosterone by UFH within the zona glomerulosa of the adrenal glands. CONCLUSION The use of UFH may result in significant hyponatremia as well as hyperkalemia. Reversal of these electrolyte disturbances occurs after discontinuation of heparin.

The protective effect of gender on posttraumatic mortality or acute complications (acute respiratory distress syndrome [ARDS], pneumonia, and sepsis) is unclear. To assess potential effects, we performed a retrospective case-controlled study, matching patients for injury factors including overall severity (Injury Severity Sscore), the presence of shock (systolic blood pressure [SBP]90 mm Hg) at admission, and the presence of closed head injury (CHI).All female patients admitted over a 61/2-year period were reviewed and divided into four groups: group 1, SBP90, no CHI; group 2, SBP90, no CHI; group 3, SBP90, with CHI; and group 4, SBP90, with CHI. Each cohort was matched one to one with an equivalent male counterpart. Cohorts were compared for mortality or the development of ARDS, pneumonia, and systemic sepsis using standard definitions.Overall, 1,229 female patients were identified for study. The average Injury Severity Score was 16.3 and overall mortality was 2.7%. Analysis of the groups described previously demonstrated no statistically significant difference in the development of ARDS, pneumonia, systemic sepsis, or overall mortality between male and female patients including patients presenting with shock, CHI, or both.We conclude that female gender offers no protection from the development of ARDS, pneumonia, sepsis, or decreased mortality after blunt trauma.

Despite antiulcer prophylaxis 19 severely injured patients at our institution developed stress ulceration (SU) between 1989 and 1999 requiring surgery for perforation (n = 4) or bleeding (n = 15). A herald bleed (HB) 10.7 ± 1.2 days after admission, 7.2 ± 1.2 days before definitive operative therapy, and requiring 7.1 ± 0.9 units of blood occurred in 93 per cent of patients operated on for bleeding. Bleeding preceded perforation in one patient. Central nervous system damage was part of the injury pattern in 68 per cent of the patients including spinal cord (42%), severe head injury (16%), or both (10%). Forty-two per cent had acalculous cholecystitis found at surgery. Eight patients had vagotomy and antrectomy (VA), and 11 patients had vagotomy and pyloroplasty (VP). VA required more time than VP (255 ± 41 vs 158 ± 13 minutes; P = 0.02). One patient (12.5%) rebled after VA versus two (18%) after VP; one patient in each group required reoperation. There was no difference in mortality, length of stay, or intensive care unit stay. A herald bleed preceded recurrent hemorrhage of SU by one week. Spinal cord or head injury increase the risk of SU. More than 40 per cent of patients with SU had acalculous cholecystitis found at operation. VA provides no benefit on rebleeding or reoperation over VP, so anatomical considerations and not rebleed rates should determine the surgical procedure.

“While small lacerations of the liver substance may be, and no doubt are, recovered from without operative interference: if the laceration be extensive and vessels of any magnitude are torn, hemorrhage will, owing to the structural arrangement of the liver, go on continuously.” J.H. Pringle, 1908 1 Operative therapy has been the standard of care for liver injuries from the beginning of the century until the beginning of the 1990s. This has been based on the dual rationale of hemostasis and bile drainage. In 1991 we reported a prospective comparative trial of methods of liver drainage in 482 consecutive patients with liver injuries undergoing operative management. 2 In that trial it was shown that lack of bile drainage did not adversely affect outcome. A “paradigm shift” is said to occur when the rules governing a process are fundamentally changed, and such is the case with the treatment of liver injuries. Since the early 1980s, sporadic reports of adult patients with blunt hepatic trauma treated nonoperatively have appeared in the literature. 3–18 Two large series of nonoperative management, one of 495 patients collected from a literature review 19 and the other of 404 patients from the collective experience of 13 level 1 trauma centers, 20 were reported in 1995 and 1996, respectively. However, there were drawbacks to these larger studies. First, the numbers of patients from the individual series or centers were small (16–72 patients). Second, the criteria for nonoperative management were not uniform, so the percentage of patients with blunt hepatic injury who were treated nonoperatively varied from 17% to 60%. Finally, nearly all reports either described only the nonoperatively managed patients, or compared them with operatively managed patients in the same period. Those characteristics make it difficult to compare the results of operative versus nonoperative therapy because the groups are not comparable relative to the degree of hepatic injury. Similarly, we cannot draw valid conclusions about the total impact that this new method of management has had on the overall outcome of blunt hepatic trauma. In an attempt to address some of the questions about nonoperative management, we previously conducted a prospective pilot study in which all hemodynamically stable patients with blunt hepatic trauma, regardless of grade of injury or amount of hemoperitoneum, were managed nonoperatively. 17 The outcomes of nonoperatively managed patients were compared with a matched cohort of patients who had been operatively managed from the previous study. 2 Encouraged by the results, nonoperative management has been applied to all hemodynamically stable patients with blunt hepatic injury at our institution since that time. The current study consists of 661 consecutive patients with blunt hepatic trauma during the recent 5-year period during which all hemodynamically stable patients were managed nonoperatively. Results of management in the most recent cohort are compared with the two previous studies to assess the impact of this fundamental change in therapy. This study was performed to address two specific issues: first, the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and second, the impact of this approach on the outcome of all blunt hepatic injuries.

Questions regarding the effects of the route of nutrition began to surface shortly after the introduction of total parenteral nutrition (TPN). Although TPN has become a life-saving therapy for patients who cannot tolerate enteral nutrition, it is not the panacea it was hoped to be. It appears that the enteral route of nutrition decreases rates of infectious complications compared with parenteral feeding. Reasons for this phenomenon are not clear, but it seems that enteral nutrition supports the gut barrier and gut-associated lymphoid tissue, which may have effects on infections at distant sites such as the lung. These effects do not appear to be due solely to prevention to malnutrition, as the infectious complications develop early after injury or illness. However, the lack of understanding of the mechanisms does not negate the fact that in many clinical studies the enteral route of nutrition is superior to the parenteral route in terms of reducing infectious complications in critically ill or injured patients.

Delayed gastric emptying is a common postoperative complication in critically ill patients that impedes successful administration of early enteral feeding. Transgastric jejunal feeding tubes (TJTs) simultaneously decompress the stomach while permitting postpyloric feedings. Earlier designs were associated with inadequate gastric decompression and reflux of feedings into the stomach; however, a new tube (Medical Innovations Corporation, Milpetas, CA) appears to be an improvement, thus warranting an evaluation of its safety and efficacy. TJTs were placed in 29 patients who were followed for complications associated with the tube. Seventeen problems occurred: three were due to user errors, six were due to mechanical dysfunction, and four tubes were dislodged. Ten patients had a nasogastric tube in addition to their TJT; however, only four of the nasogastric tubes were thought to be needed because of inadequate gastric drainage. The TJT adequately decompressed the stomach in most patients, allowing small-bowe...

OBJECTIVE: This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA: Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS: Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS: One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS: Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.

Objective The aim of this study was to evaluate the safety and efficacy of a new intravenous (IV) regular human insulin infusion (RHI) algorithm for glycemic control in critically ill patients with renal failure. Methods Adult trauma patients with renal failure who received a new RHI algorithm were compared with those who received the discontinued RHI algorithm (historical control). Target blood glucose (BG) concentration was 70 to 149 mg/dL (3.9–8.3 mmol/L). Patients were evaluated for 7 d while receiving the RHI infusion and continuous enteral or parenteral nutrition. Results Mean BG was higher for the new RHI algorithm group (n = 25) compared with control (n = 21): 145 ± 10 mg/dL or 8.1 ± 0.6 mmol/L versus 133 ± 14 mg/dL or 7.4 ± 0.8 mmol/L ( P = 0.001). The new RHI algorithm resulted in less time within the target BG range (11.9 ± 2.5 h/d versus 16.1 ± 3.3 h/d; P = 0.001); however, BGs were within 70 to 179 mg/dL (or 3.9–10 mmol/L) for 16.3 ± 2.6 h/d. The proportion of patients who experienced an episode of moderate hypoglycemia (BG 40–60 mg/dL or 2.2–3.3 mmol/L) or severe hypoglycemia (BG P = 0.001) and eliminated (0% versus 29%, P = 0.006), respectively. Conclusions The new RHI algorithm improved patient safety by decreasing the prevalence of moderate hypoglycemia and eliminating severe hypoglycemia. The duration of glycemic control within the target BG range was decreased, but acceptable within a higher target BG ceiling.

The efficacy of prophylactic vena caval filters (VCF) in reducing morbidity and mortality from pulmonary embolism (PE) in high-risk trauma patients has been shown, but minimal follow-up data is currently available. VCFs were prophylactically placed in 110 patients between August 1991 and June 1995. There was an early VCF complication rate of 7%. Twenty-two patients died; the remaining 88 patients formed the basis for the follow-up study. Forty-five patients were located and interviewed by phone, and 30 of these patients (34%) returned for evaluation. The mean follow-up time was 18 months (range, 4-42 months). There was no incidence of caval thrombosis on follow-up. Eleven patients had physical findings, and duplex evidence consistent with postphlebitic syndrome. An additional three patients had evidence of old deep venous thrombosis (DVT) by duplex, but no significant symptomatology. VCF are effective in preventing PE related deaths and have few major complications. The long-term morbidity associated with posttraumatic venous thrombosis is significant. This morbidity is related not to PE or VCF, but to the underlying DVT. Improved strategies against DVT are necessary.

Objective : Recently, transesophageal echocardiography (TEE) has been proposed as the standard for the diagnosis of traumatic disruption of the aorta (TDA), replacing aortography. The purpose of this study was to evaluate the accuracy and practicality of TEE in the diagnosis of TDA. Design : Prospective clinical trial. Materials and Methods : Patients with blunt trauma admitted with a suspected diagnosis of TDA were evaluated with TEE and aortography. Measurements and Main Results : Thirty-four patients were evaluated with TEE and aortography. TEE was unsuccessful in five patients (15%). Of the remaining 29 patients, TEE results were true-positive in four and true-negative in 20. TEE results were false-positive in two patients, and three injuries were missed (two were proximal to the left subclavian artery, and one was a localized aortic disruption). Sensitivity and specificity of TEE were 57% and 91%, respectively, compared with aortography, for which sensitivity was 89% and specificity was 100%. Conclusion : Although the use of TEE in the diagnosis of TDA has several advantages, it is not more accurate than aortography. TEE should not replace aortography as the standard for the diagnosis of TDA.

Older patients require more protein than younger patients to achieve anabolism, but age-associated renal dysfunction may limit the amount of protein that can be safely provided. This study examined whether older, critically ill trauma patients with obesity can safely achieve nitrogen equilibrium and have positive clinical outcomes similar to younger obese patients during hypocaloric, high-protein nutrition therapy.Adult patients with traumatic injury and obesity (body mass index [BMI]30 kg/m(2)), admitted to the Presley Trauma Center from January 2009 to April 2011, were evaluated. Patients were targeted to receive hypocaloric, high-protein nutrition therapy (25 kcal/kg ideal body weight [IBW]/d and2 g/kg IBW/d of protein) for10 days. Patients were stratified as older (≥60 years) or younger (18-59 years).Seventy-four patients (33 older, 41 younger) were studied. Older and younger patients were similar in BMI and injury severity. When given isonitrogenous regimens (2.3 ± 0.2 g/kg IBW/d), nitrogen balance was similar between older and younger patients (-3.2 ± 5.7 g/d vs -4.9 ± 9.0 g/d; P = .363). Older patients experienced a greater mean serum urea nitrogen concentration than younger patients (30 ± 14 mg/dL vs 20 ± 9 mg/dL; P = .001) during nutrition therapy. Clinical outcomes were not different between groups.Older critically ill trauma patients exhibited an equivalent net protein response as younger patients during hypocaloric, high-protein nutrition therapy. Older patients are at greater risk for developing azotemia. Close monitoring is warranted.

BACKGROUND: Studies regarding protein requirements for patients with critical illness are inconclusive owing to small sample size and population heterogeneity. The primary objectives of this study were to determine the amount of protein required to achieve nitrogen equilibrium or a positive nitrogen balance (NB, -4 g/d or better) and ascertain whether patients with traumatic brain injury (TBI) exhibit greater protein catabolism than those without TBI. METHODS: Adult patients admitted to the trauma center, given specialized nutrition support, and had an NB determination within 5 days to 14 days after injury were evaluated. Patients with obesity, incomplete urine collection, kidney disease, corticosteroid or pentobarbital therapy, or an oral diet were excluded. RESULTS: A total of 300 NB determinations from 249 patients were evaluated. Increasing the protein dosage generally resulted in improved NB; however, the data were highly variable. Of the patients who received a protein intake of 2 g/kg per day or greater, 54% achieved nitrogen equilibrium or positive NB (-4 g/d or better) in contrast to 38% and 29% of patients who received 1.5 g/kg per day to 1.99 g/kg per day and 1 g/kg per day to 1.49 g/kg per day, respectively (p < 0.001). There was no significant difference in NB between patients with and without TBI at similar protein intakes. CONCLUSION: A higher protein intake was generally associated with an improved NB; yet, many patients remained having a negative NB. A protein dosage of 2 g/kg per day or greater was more successful in achieving nitrogen equilibrium than were lower-dosage intakes. Patients with TBI do not exhibit significantly greater protein catabolism than do patients without TBI. LEVEL OF EVIDENCE: Prognostic study, level III.

The intent of this study was to evaluate the efficacy and safety of transitioning from a continuous intravenous (IV) regular human insulin (RHI) or intermittent IV RHI therapy to subcutaneous neutral protamine Hagedorn (NPH) insulin with intermittent corrective IV RHI for critically ill patients receiving continuous enteral nutrition (EN).Data were obtained from critically ill trauma patients receiving continuous EN during transitional NPH insulin therapy. Target blood glucose concentration (BG) range was 70-149 mg/dL. BG was determined every 1-4 hours.Thirty-two patients were transitioned from a continuous IV RHI infusion (CIT) to NPH with intermittent corrective IV RHI therapy. Thirty-four patients had NPH added to their preexisting supplemental intermittent IV RHI therapy (SIT). BG concentrations were maintained in the target range for 18 ± 3 and 15 ± 4 h/d for the CIT and SIT groups, respectively (P.05). Thirty-eight percent of patients experienced a BG60 mg/dL, and 9% had a BG40 mg/dL. Hypoglycemia was more prevalent for those who were older (P.01) or exhibited greater daily BG variability (P.01) or worse HgbA1C (p0.05).Transitional NPH therapy with intermittent corrective IV RHI was effective for achieving BG concentrations within 70-149 mg/dL for the majority of the day. NPH therapy should be implemented with caution for those who are older, have erratic daily BG control, or have poor preadmission glycemic control.

Many ventilated trauma patients thought to have nosocomial pneumonia have pulmonary contusion or systemic inflammatory response syndrome with tracheobronchial colonization. Fiberoptic bronchoscopy with quantitative culture techniques of protected specimen brush (PSB; threshold 10(3) cfu/mL) or bronchoalveolar lavage (BAL; threshold 10(5) cfu/mL) can potentially eliminate the false positive cultures of the upper airway seen with routine sputum aspirates (RS). However, bronchoscopy is expensive, and routine use may not be cost effective. This prospective study evaluated the patient charges associated with bronchoscopy and quantitative cultures compared with RS for the diagnosis of nosocomial pneumonia. Specimens were obtained by RS, PSB, and BAL from the lower airway in 107 trauma patients (136 sets of triplicate cultures). All patients had clinical evidence suggestive of pneumonia (fever, leukocytosis, purulent sputum, abnormal roentgenographic findings). Typical oral flora were considered contaminants; no gram-negative specimens were excluded. Mean age was 40 years and mean ISS was 29. Seventy-eight percent had blunt injuries, 22% penetrating, and 42% had chest injuries. The incidence of nosocomial pneumonia according to each method was: RS-73%; PSB-34%; BAL-25%. Considering all charges involved (bronchoscopy, equipment, microbiologic analysis, and antibiotics), and based on a 14-day course of ceftazidime and vancomycin, the charges for PSB were 58% of RS, and charges for BAL were 43% of RS. We conclude that the charges associated with bronchoscopy are high, but can be offset by antibiotic savings. Side effects of unnecessary antibiotic therapy would be avoided. Further study is needed to determine the efficacy of PSB or BAL in trauma patients.

The enteral route is the preferred method of nutrition support in patients with functional gastrointestinal tracts. Many techniques for obtaining enteral access are available, and the decision regarding which one to use depends on several issues, including anticipated duration of support, aspiration risk, and local expertise. Using laparotomy, laparoscopy, fluoroscopy, or endoscopy, tubes can be placed into the stomach, the duodenum, and the jejunum. Nasogastric and nasoenteric tubes are useful for short-term supplementation; however, patients needing support for more than 6 weeks may be better served with a more permanent tube. In this review, specific methods for obtaining enteral access are discussed along with their advantages and disadvantages.