72-Hour Clinical Pulmonary Infection Score May Have Prognostic Value Among Trauma Patients With Ventilator Associated Pneumonia

Background: Ventilator-associated pneumonia (VAP) is a common, serious nosocomial infection; reduction of morbidity and mortality is achieved by prompt diagnosis and early initiation of appropriate empiric antimicrobial therapy. While Clinical Pulmonary Infection Score (CPIS) on the day of VAPdiagnosis has not been proven a consistently effective device, we postulate the CPIS 72 hours after VAPdiagnosis may serve as a clinical prognostic indicator. The purpose of this study is to assess the potential value of CPIS in trauma patients with VAP. Methods:We performed a retrospective chart review of 50 intubated trauma patients with VAPadmitted to the intensive care unit (ICU) of an urban level-I trauma center from January-December 2013. Patients were consecutively identied via trauma registry, and data were abstracted on demographics; injury severity score (ISS); vital signs; laboratory values; microbiological cultures; ventilator settings; antibiotic therapy; time of VAP diagnosis; outcomes; and survival to discharge. We calculated modied CPIS at initial diagnosis and 72-hours post-diagnosis. Incomplete records were excluded from analysis. Results: Forty-nine patients, 25 females and 24 males, with mean age of 66.1±5.2 years were analyzed. Overall mortality was 18.4% (n=9); mean ISS was 18.3±1.2; mean length of stay (LOS) was 20.7±3 days; mean ICU-LOS was 16.7±3.1 days; mean ventilator days was 15±3.2; mean day-1 CPIS was 5.8±0.5; and mean day-3 CPIS was 4.9±0.6. Multidrug resistant organisms (MDROs) were identied in 26 patients and associated with higher 72-hour CPIS (5.8±0.9 vs 3.7±0.7, p=0.025). 72-hour CPIS <6 was signicantly associated with shorter LOS (16.8±3.1 vs 27.3±5.2 d), shorter ICU-LOS (12.4±2.9 vs 24.1±5.6 d), shorter duration of mechanical ventilation (10.8±3 vs 22.1±5.9 d), and earlier VAPdiagnoses (hospital day 4.4±0.6 vs 7.1±1.4, p<0.001). Conclusions:Initial CPIS calculations after VAPdiagnosis have no clinical value. While not associated with survival to discharge, CPIS calculated 72 hours after VAPdiagnosis may be used as a prognostic indicator for MDROs and improved short-term outcomes for trauma patients.

Anticoagulation Is Associated With Increased Morbidity And Mortality In Concussive Injury Among Elderly Trauma Patients

To study the association between concussive injury in elderly patients on anticoagulation and development of non-bleeding complication. A retrospective data analysis was performed comparing elderly trauma patients with concussion on antiplatelet therapy, anticoagulation or both. Data obtained included age, ISS, likelihood of development mental status alteration, change in CTscan, hospital length of stay, and survival. 1000 patients patients age > 65 years [elderly] with concussion were enrolled, 622 women and 378 men, all on either antiplatelet therapy, anticoagulation or dual therapy. Patients had an average age of 80 years with average ISS of 1.4. Between the 3 groups (antiplatelet, anticoagulation and dual therapy), notable differences were found in alteration of mental status requiring the obtaining of a repeat CTscan (44% vs. 63% vs. 85%, p < .0001), changes noted in CT scan at 24 hours (8% vs. 19% vs. 56%, p< .0001), hospital length of stay (days) (4.5 vs. 5.1 vs. 6.0, p < .0001), and survival (100% vs. 94% vs. 85%, p < .0001). We also noted a signicant difference between patients on aspirin or clopidogrel with regard to hospital length of stay (days) (4.2 vs. 5.4, p < .0001). Elderly patients on antiplatelet therapy with concussive injury were less prone to develop morbidity such mental status changes, changes in CT at 24 hours and prolonged hospital length of stay when compared to patients on anticoagulation or dual therapy. With 100% survival and hospital length of stay ranging between 4.2 to 5.4 days, raises questions with regard to resource allocation in concussed patients on only antiplatelet therapy. In patients on anticoagulation with or without antiplatelet therapy, changes in CT scan were unrelated to bleeding but more commonly found to be due to worsening of chronic conditions -- edema and prior infarction - possibly related to withholding of anticoagulation or antiplatelet therapy. Concussive injury in patients on anticoagulation is associated with a higher morbidity and mortality than patients with similar injury only on antiplatelet therapy. The change in mental status even with antiplatelet therapy would suggest observing these patients for at least 24 hours.

Objective Clinical Pain Assessment By Independent Service Identifies Significant Gaps In Pain Assessment And Control.

Pain is highly subjective. Standardized measurements are necessary to ensure adequate analgesia. Our objective was to examine whether an independent objective clinical assessment differs from existing provider documented assessment of pain levels. We performed a retrospective analysis of randomly selected patients admitted to the trauma service at our Urban level I Trauma Ctr. (448 bed), over the course of 2 months. During this time period an independent team headed by the trauma medical director (AC) performed pain assessments on these patients using an objective numeric scale, (with 0 being no pain and 10 being the worst possible pain) within 1 hour of scheduled assessment by the primary care givers be they ED, Nursing or Physician. Medical records were reviewed for type of injury, objective pain level as documented on nursing, physician, and emergency department (ED) notes, objective pain level as documented by the independent team, and analgesic treatment. A total of 101 patients were included. Types of injury included fall (n= 38), fall with fracture (n=21), motor vehicle collision (n=19), fracture (n=12), assault (n=8), and miscellaneous (n=3). The mean overall pain level as documented by the independent team was 4.35 ± 0.76; 36 patients reported no pain, 7 patients reported mild pain (level 1-3), 17 patients reported moderate pain (level 4-6), 30 patients reported severe pain (level 7- 9), and 11 patients reported experiencing the worst possible pain (level 10). Pain assessment documentation was missing in 36.6 % of emergency department notes (n=37), 31.1 % of nursing notes (n=32) and 64.4% of physician notes (n=65). Mean pain level varied by ED (5.37 0.85), nursing (1.98 ± 0.67) and physician (2.94 ± 0.96) notes. Analgesic treatment was composed of morphine (n=23), Oxycodone/acetaminophen (n=10), Ibuprofen (n=10), acetaminophen (n=9), acetaminophen/codeine (n=2), ketorolac (n=3), or any combination thereof (n=41). Three patients did not receive analgesic medication. The assessment of pain level was absent in over 30 % of all clinical documentation, with physicians being the worst offenders. Despite receiving pain medication 57.4% of patients reported experiencing moderate to excruciating pain on an objective assessment. Further prospective research is necessary to examine the utility of these ndings on a large scale basis. The utilization of independent objective clinical assessment is valuable to ensure appropriate pain management in trauma patients.

Initial Prealbumin Level And Ability To Normalize Prealbumin Are Highly Predictive Of Increased Mortality And Morbidity In Elderly Trauma Patients

Prealbumin is a well characterized indicator of nutritional status more recently found to be an inverse inammatory marker. At our urban level 1 trauma center, we sought to study the relationship between malnutrition and outcomes in elderly trauma patients. Using prealbumin as a surrogate marker for nutritional status, we hypothesized that patients with reduced prealbumin on initial evaluation have worse outcomes, and in patients where initial prealbumin that was reduced, ability to correct is associated with improved outcomes. We performed a retrospective cohort study involving 200 consecutive patients over the age of 65 admitted to our trauma service. Based on initial prealbumin, patients were divided into 3 groups - below 5 mg/dL, 5-10 mg/dLand greater than 10 mg/dL. Prealbumin was then re-assessed 4 days after admission and patients were again divided into 2 groups based on ability to normalize prealbumin. Data obtained included age, gender, revised trauma score (RTS), injury severity score (ISS), days on a ventilator, ICU length of stay (ICU-LOS), hospital length of stay (HLOS), survival, initial prealbumin, and ability to correct prealbumin within 4 days after admission. Of the 200 patients enrolled, patients were divided into 3 groups using initial prealbumin - 71 patients below 5 mg/dL, 101 patients 5-10 mg/dL, and 28 patients greater than 10 mg/dL. There were 180 patients who were hospitalized for over a 4 day period. Normalization of prealbumin was achieved in 128 patients while 52 patients did not. Mean age was 79.2 years. RTS was found to be decreased in patients with initial prealbumin below 5 mg/dLin comparison to the other groups (11.3 vs. 11.8 vs. 11.8, p = 0.0002), with greater ISS (25.1 vs. 18.8 vs. 19.7, p < 0.0001), ICU LOS (days) (11.3 vs. 3.9 vs. 3.0, p < 0.0001), ventilator days (7.9 vs. 0.8 vs. 0.1, p < 0.0001), HLOS (days) (17.4 vs 7.8 vs. 7.1, p < 0.0001) and decreased survival (66% vs. 95% vs. 100%, p < 0.0001). Patients with prealbumin corrected within 4 days had lower ISS (19.9 vs. 29.2, p < 0.0001), as well as reduction in ventilator days (0.9 vs. 10.1, p < 0.0001), ICU LOS (days) (4.2 vs. 13.8, p < 0.0001), HLOS (days) (8.3 vs. 21.3, p < 0.0001) and improved survival (94% vs. 63%, p < 0.0001). Prealbumin is able to provide short term information regarding current nutritional status and response to therapy. Recent evidence suggest prealbumin may be a prognostic indicator for risk of malnutrition and inammation in critically ill trauma patients. In management of critically ill trauma patients, prealbumin can provide a valuable clinical indication of response to therapeutic intervention and potentially guide management strategy.

Risk Assessment For Vte: All Are Not Equal

Venous Thromboembolism [VTE] risk assessment has become common in most hospitals. However, the comparison of effectiveness between quantitative and qualitative risk assessments is sparse in the literature. We performed a comparative analysis between a quantitative and qualitative assessment in 146 consecutive adult trauma patients. Of the 146 patients enrolled, 64 of whom had no contraindications to VTE prophylaxis, 99 were men and 47 were women. Mean population age was 52.3 years and mean injury severity score [ISS] was 20.0 (+ 9.9). ISS did not correlate with VTE risk. Elderly patients were found to be at higher risk for development of VTE. The non-quantitative risk assessment assigned 38 low risk, 80 moderate risk and 28 high risk patients. Each grouping was re-evaluated to provide a mean quantitative risk for each category of the non-quantitative assessment: 1.5 points for low risk, 3 points for moderate risk, and 3.96 for high risk. Based on recommended guidelines of the quantitative risk score, adequacy of VTE prophylaxis was assessed for each non-quantitative category: 72.2% for low risk, 64.7% for moderate risk and 58.3% for high risk. After re-evaluating all patients using the quantitative risk score, adequacy of VTE prophylaxis was assessed again: 100% for low risk, 83% for moderate risk, 74% for high risk, and 29% for very high risk. We found that the qualitative assessment tended to underscore the risk and therefore resulted in an under-treatment of the highest risk patients. Our data shows that quantitative assessment is superior to qualitative risk assessment.