Loss of protein, immunoglobulins, and electrolytes in exudates from negative pressure wound therapy.

BACKGROUND: A relatively new technology in wound care, negative pressure wound therapy (NPWT), has become widely used for the management of open abdomens and soft tissue wounds and provides a means to collect wound exudate to quantify protein loss. METHODS: A prospective observational study was conducted in surgical, trauma, or burn patients (8 patients with open abdomens and 9 patients with acute soft tissue wounds on NPWT). NPWT exudate was collected and assayed to characterize loss of protein, electrolyte, and immunoglobulins over multiple days of NPWT. RESULTS: Total protein was present in open abdomen NPWT exudate, 2.9 ± 0.9 g/dL. In the soft tissue wound exudate, a similar mean concentration was found, 2.59 ± 0.6 g/dL (P = .34). Exudate concentrations of albumin, urea nitrogen, immunoglobulins, and electrolytes between wound types were also not significantly different. There were significant (P = .03) differences in the median volume of exudate, 1031 mL/d for open abdomens in contrast to 245 mL/d soft tissue wounds. Therefore, 24-hour losses of proteins and electrolytes were greater in patients with open abdomens than soft tissue wounds. Mean total protein loss was 25 ± 17 g/d for open abdomens and 8 ± 5 g/d for soft tissue wounds. CONCLUSION: There are significant losses of proteins in wound exudate. As there is no significant difference in the concentration of total protein between wound type, the rate of loss may be calculated as 2.9 g/dL times the volume of wound exudate. The rate of protein loss from wounds is similar to the presently assumed insensible loss rate of 12-25 g/d.

Primary blast injury: update on diagnosis and treatment.

BACKGROUND: : Injuries from combat and terrorist explosions are increasing worldwide. As such, physicians can expect to treat more patients with complex and unique patterns of injury produced not only by fragments and blunt trauma, but also by high-pressure air expanding from the detonation center. DISCUSSION: : Tissue damage from the blast wave or primary blast injury can be an important cause of occult trauma to the ocular, aural, pulmonary, cardiovascular, musculoskeletal, and neurologic systems. Awareness of the extensive corporal effects of the blast wave is an essential prerequisite to diagnosis. SUMMARY: : This article focuses on the incidence, risk factors, diagnosis, management, and screening for primary blast injury.

Community meetings for emergency research community consultation.

OBJECTIVE: To survey attendees at community meetings for an emergency research protocol and determine whether these meetings aid participants' understanding and decision to support the proposed emergency research. DESIGN: Postmeeting questionnaire. SETTING: Three community meetings for the PolyHeme study in San Antonio area. SUBJECTS: One hundred fifty community meeting attendees. INTERVENTIONS: PolyHeme research team representatives made a study presentation concerning exception to informed consent regulations. In addition, institutional review board (IRB) members attended these meetings and made a separate presentation about the IRB approval of research and the exception to informed consent in emergency research. The IRB members requested attendees to voluntarily complete an additional Community Consultation Survey assessing demographics, community meeting satisfaction, and impact of the community meeting on their attitudes toward emergency research studies. MEASUREMENTS AND MAIN RESULTS: Feedback to the PolyHeme investigators with their validation questions indicated that 35% of the respondents objected to research without prior consent, but 82% gave approval for the study in the local community; 137 attendees completed the additional Community Consultation Survey. The average score on the adequacy of information provided about the PolyHeme study was 0.58 on a 5-point Likert scale (-2 to +2). Adequacy of IRB background information on human subjects research received an average score of 0.56, and the overall clarity of the information on community consultation was 0.91. Although 80% of respondents felt there was a potential benefit from PolyHeme, <67% would either want to participate or enroll their family members with or without prior consent. CONCLUSIONS: The majority of community meeting attendees understand basic concepts and regulations of emergency research without prior consent. Despite an 82% concurrence with the study in their community, approximately 30% of persons would not willingly choose to participate in emergency research or provide consent for their family members despite knowledge about the process.

A regional medical operations center improves disaster response and inter-hospital trauma transfers.

BACKGROUND: Delays in both inter-hospital trauma transfers and disaster response are common. We hypothesized patient flow could be improved by formal adoption of systems that improve cooperation and communication. METHODS: The regional trauma database of the Southwest Texas Regional Advisory Council for Trauma and the Regional Medical Operations Center (RMOC) database were queried to test the hypothesis. RESULTS: A total of 9507 trauma patients were transferred. Medcom resulted in decreased transfer process times. The RMOC was activated during Hurricanes Katrina and Rita. During two 24-hour periods, the RMOC coordinated the inter-hospital transfer of 781 patients and the movement of thousands of evacuees and special needs patients. CONCLUSIONS: Medcom, an organized system combining a communications center with formal trauma center cooperation, improves patient flow and reduces trauma transfer times. The RMOC, based on the same principles of cooperation and communication, allows for rapid transfer of hospitalized and special needs patients during disaster/mass casualty situations.

Effects of recombinant activated factor VII in traumatic nonsurgical intracranial hemorrhage.

OBJECTIVE: To determine whether treatment with recombinant activated factor VII (rFVIIa) will prevent progression of bleeding in nonsurgical hemorrhagic traumatic brain injury (TBI). METHODS: Chart review from the trauma registry of a level 1 trauma center between January 1, 2002 and December 31, 2004 identified 2 patients who received rFVIIa for progressive hemorrhagic TBI. These patients were given a single dose of rFVIIa (120 mcg/kg) after a repeat head computed tomography (CT) scan showed worsening of intracranial bleeding. Pre-rFVIIa and post-rFVIIa coagulation parameters and postintervention CT scans were performed. A matched convenience sample was drawn from the institution's trauma registry reflecting similar injury patterns. RESULTS: The 2 patients who received rFVIIa were ages 61 and 79 years; the patients in the matched convenience sample were 57 and 63 years. Both sets of patients comprised 1 man and 1 woman who had suffered blunt trauma, including hemorrhagic TBI, and were matched according to age, gender, and injury severity score (ISS). During their hospital course, repeat CT scans documented worsening of intracranial hemorrhage in both cohorts. In the rFVIIa patients, follow-up CT showed overall improvement of head injury compared with the convenience sample. The rFVIIa patients also saw an appreciable decrease in both prothrombin time (PT) and international normalized ratio (INR). CONCLUSIONS: In hemorrhagic TBI, rFVIIa has the potential to limit or even halt the progression of bleeding that would otherwise place growing pressure on the brain. A prospective, randomized multicenter trial is planned to elucidate this hypothesis.

The clinical and laboratory response to recombinant factor VIIA in trauma and surgical patients with acquired coagulopathy.

OBJECTIVE: In bleeding patients who are coagulopathic, the clinical response to administration of recombinant factor VIIa (rFVIIa) relates to the changes in prothrombin time (PT). DESIGN: Retrospective review of all surgical and trauma patients who were coagulopathic and received factor VIIa at the authors' institution over the past 27 months. SETTING: Academic tertiary referral facility and level I trauma center. PARTICIPANTS: Eighteen patients met inclusion criteria, 10 trauma and 8 surgical. Mean age 50 years (range, 17-84). RESULTS: Overall mortality was 39%. All but 1 patient (17/18) had resolution of coagulopathic bleeding with rFVIIa, and all clinical responders (n = 17) (defined as clinical cessation of bleeding within 24 hours determined by either attending surgeon or chief resident progress note) had a decrease in PT to normal range. In contrast, the single clinical nonresponder had an insignificant PT decrease (19 to 18 seconds). Prothrombin time decreased from 20 +/- 4 seconds to 12 +/- 2 seconds, p < 0.05 (n = 17). International Normalized Ratio (INR) decreased from 1.59 to 0.86, p < 0.05 (n = 17). Fibrinogen before administration was 299.73 (range, 105-564) (n = 15). pH before administration was 7.25 (+/-0.18) (n = 10). Patient temperature was 98.64 (+/-2.06). Effect in partial thromboplastin time (PTT) was inconsistent (50 +/- 49 seconds to 34 +/- 6 seconds, p > 0.05). Transfusion requirements for red blood cells (14 to 3 units) and plasma (12 to 3 units) were significantly reduced after rFVIIa. There were no significant differences in percentage PT decrease between dose > or =100 mcg/kg vs <100 mcg/kg, surgical vs trauma patients, survivors vs nonsurvivors, and those with pretreatment platelet count > or =100 K vs <100 K. CONCLUSIONS: The administration of rFVIIa caused a decrease in the PT in nearly all patients. There were an insufficient number of patients to support the use of PT as a clinical predictor of response; however, the data are suggestive of such utility. If the PT does not correct, then it is likely that there is a deficiency of other factors of the coagulation cascade.

Informed consent and ethical issues in military medical research.

Informed consent in military research shares many of the same fundamental principles and regulations that govern civilian biomedical research. In fact, much of modern research ethics is grounded in events that occurred in the context of war or government-sponsored research. Despite these similarities and common origins, research in the military has additional requirements designed to preserve service members' informed consent rights. The special nature of the superior-subordinate relationship in the military necessitates careful protections to avoid perceptions of coercion or undue influence on a military subject. Additionally, current legal and regulatory requirements for advanced informed consent significantly restrict the flexibility of the military to conduct research using waiver of consent. This has implications on the ability of the nation to develop effective medical treatments for the global war on terrorism. Nevertheless, work is under way to realign defense research policy with the norms of civilian biomedical practice. Future directions include the adoption of waivers for military emergency research, and the cautious introduction of human subject studies on the battlefield. This paper discusses historical background, regulatory differences, and concerns and challenges of some of these regulatory differences for research personnel that apply to informed consent and waiver of said informed consent for emergency research conducted by the U.S. military.