Trauma patients have reduced ex vivo flow-dependent platelet hemostatic capacity in a microfluidic model of vessel injury.

Trauma is the leading cause of death in individuals up to 45 years of age. Alterations in platelet function are a critical component of trauma-induced coagulopathy (TIC), yet these changes and the potential resulting dysfunction is incompletely understood. The lack of clinical assays available to explore platelet function in this patient population has hindered detailed understanding of the role of platelets in TIC. The objective of this study was to assess trauma patient ex vivo flow-dependent platelet hemostatic capacity in a microfluidic model. We hypothesized that trauma patients would have flow-regime dependent alterations in platelet function. Blood was collected from trauma patients with level I activations (N = 34) within 60 min of hospital arrival, as well as healthy volunteer controls (N = 10). Samples were perfused through a microfluidic model of injury at venous and arterial shear rates, and a subset of experiments were performed after incubation with fluorescent anti-CD41 to quantify platelets. Complete blood counts were performed as well as plasma-based assays to quantify coagulation times, fibrinogen, and von Willebrand factor (VWF). Exploratory correlation analyses were employed to identify relationships with microfluidic hemostatic parameters. Trauma patients had increased microfluidic bleeding times compared to healthy controls. While trauma patient samples were able to deposit a substantial amount of clot in the model injury site, the platelet contribution to microfluidic hemostasis was attenuated. Trauma patients had largely normal hematology and plasma-based coagulation times, yet had elevated D-Dimer and VWF. Venous microfluidic bleeding time negatively correlated with VWF, D-Dimer, and mean platelet volume (MPV), while arterial microfluidic bleeding time positively correlated with oxygenation. Arterial clot growth rate negatively correlated with red cell count, and positively with mean corpuscular volume (MCV). We observed changes in clot composition in trauma patient samples reflected by significantly diminished platelet contribution, which resulted in reduced hemostatic function in a microfluidic model of vessel injury. We observed a reduction in platelet clot contribution under both venous and arterial flow ex vivo in trauma patient samples. While our population was heterogenous and had relatively mild injury severity, microfluidic hemostatic parameters correlated with different patient-specific data depending on the flow setting, indicating potentially differential mechanistic pathways contributing to platelet hemostatic capacity in the context of TIC. These data were generated with the goal of identifying key features of platelet dysfunction in bleeding trauma patients under conditions of flow and to determine if these features correlate with clinically available metrics, thus providing preliminary surrogate markers of physiological platelet dysfunction to be further studied across larger cohorts. Future studies will continue to explore those relationships and further define mechanisms of TIC and their relationship with patient outcomes.

Prolonged hourly neurological examinations are associated with increased delirium and no discernible benefit in mild/moderate geriatric traumatic brain injury.

BACKGROUND: Serial neurological examinations (NEs) are routinely recommended in the intensive care unit (ICU) within the first 24 hours following a traumatic brain injury (TBI). There are currently no widely accepted guidelines for the frequency of NEs. Disruptions to the sleep-wake cycles increase the delirium rate. We aimed to evaluate whether there is a correlation between prolonged hourly (Q1)-NE and development of delirium and to determine if this practice reduces the likelihood of missing the detection of a process requiring emergent intervention. METHODS: A retrospective analysis of patients with mild/moderate TBI, admitted to the ICU with serial NEs, was performed. Cohorts were stratified by the duration of exposure to Q1-NE, into prolonged (≥24 hours) and nonprolonged (<24 hours). Our primary outcomes of interest were delirium, evaluated using the Confusion Assessment Method; radiological progression from baseline images; neurological deterioration (focal neurological deficit, abnormal pupillary examination, or Glasgow Coma Scale score decrease >2); and neurosurgical procedures. RESULTS: A total of 522 patients were included. No significant differences were found in demographics. Patients in the prolonged Q1-NE group (26.1%) had higher Injury Severity Score with similar head Abbreviated Injury Score, significantly higher delirium rate (59% vs. 35%, p < 0.001), and a longer hospital/ICU length of stay when compared with the nonprolonged Q1-NE group. No neurosurgical interventions were found to be performed emergently as a result of findings on NEs. Multivariate analysis demonstrated that prolonged Q1-NE was the only independent risk factor associated with a 2.5-fold increase in delirium rate. The number needed to harm for prolonged Q1-NE was 4. CONCLUSION: Geriatric patients with mild/moderate TBI exposed to Q1-NE for periods longer than 24 hours had nearly a threefold increase in ICU delirium rate. One of five patients exposed to prolonged Q1-NE is harmed by the development of delirium. No patients were found to directly benefit as a result of more frequent NEs. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Does Negative Pressure Wound Therapy Impact the Outcome for Patients With Necrotizing Soft Tissue Infection Infected With Anaerobic Bacteria?

Background: A notable improvement in the treatment of necrotizing soft tissue infections (NSTIs) is the development of negative pressure wound therapy (NPWT). Clinicians are still debating whether NPWT is as successful as conventional wet-to-dry dressings at removing bacteria. Recent research has revealed potential oxygen deprivation effects of NPWT in underlying wound tissues, although clinical trials regarding the effects of reduced oxygen on anaerobic bacterial soft tissue infections remain noticeably lacking. Hypothesis: We hypothesized that NPWT-treated patients with NSTIs who were solely infected by anaerobic bacteria would have worse outcomes than those who were infected with other bacterial species. Patients and Methods: Our study included a retrospective examination of the 2008-2022 period of our Acute and Critical Care Surgery database. Patients who had been identified as having necrotizing fasciitis, Fournier gangrene, or gas gangrene and who had their conditions verified by positive wound cultures acquired during the initial debridement and subsequently received NPWT made up the study cohort. Comorbidities, surgical techniques, and clinical results were all covered by the data. Based on their wound infections, patients were divided into two groups: those with exclusively anaerobic NSTIs and those with different bacterial groups (such as polymicrobial and aerobic). Multiple regression, χ2 analysis, and analysis of variance (ANOVA) were among the analytical methods used. Results: One hundred twelve patients with NSTI who had received NPWT comprised the study cohort. Sixteen of these patients (14.3%) had NSTIs that were exclusively anaerobic, whereas the remaining 96 (85.7%) had NSTIs that were mixed aerobic, facultative, or polymicrobial. Between the two groups, there was no difference in the initial wound size. Patients with anaerobic NSTI who underwent NPWT showed a statistically significant increase in the number of debridements (3 [interquartile range {IQR},1-9] vs. 2 [IQR, 1-4]; p = 0.012) and an increased 100-day re-admission rate (37.5% vs. 12.5%; p = 0.012) when compared with patients with non-anaerobic NSTI. The 100-day re-admission rate increased three-fold in NPWT-treated anaerobic NSTIs, according to a logistic regression analysis (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.06-12.44; p = 0.04). Conclusions: In contrast to patients with other bacterial strains, our data show that patients with NSTI treated with NPWT who only have anaerobic bacterial infections have a larger number of debridements and are much more likely to require re-admission within 100 days. We call for additional prospective studies to be conducted to identify additional risk factors and consider alternate treatment options for individuals with exclusively anaerobic NSTIs in light of these findings.

Negative Pressure Wound Therapy With and Without Instillation in Necrotizing Soft Tissue Infections.

Background: Necrotizing soft tissue infections (NSTIs) are rare but deadly infections that require early and often extensive surgical debridement. After debridement, patients frequently have substantial morbidity because of large, open wounds. Hypothesis: Negative pressure wound therapy with instillation (NPWTi) results in higher wound closure rates compared with traditional negative pressure wound therapy (NPWT) or wet to dry dressings (moist wound care dressing). Patients and Methods: A prospectively maintained Acute and Critical Care Surgery database spanning 2008-2018 was queried for patients with a diagnosis of necrotizing fasciitis, Fournier gangrene, or gas gangrene. Data were collected on patient comorbidities, operative management, and clinical outcomes. Patients were stratified by use of moist wound care dressing, traditional NPWT, or NPWTi. Data were analyzed using analysis of variance (ANOVA), χ2, and logistic regression. Results: During the 10-year study period, patients were treated for NSTI; 173 were managed with moist wound care dressing, 150 with NPWT, and 48 with NPWTi. Patients were similar in terms of demographics, body mass index (BMI), diabetes mellitus, and smoking rates. Overall, complication rates were not substantially different, but mortality was higher in the moist wound care dressing group (16.2% vs. 10.7% NPWT vs. 2.1% NPWTi; p = 0.02). In the moist wound care dressing group, 81.5% of patients had an open wound at discharge compared with 52.7% of the NPWT group and only 14.6% of the NPWTi group (p < 0.001). On multivariable regression, NPWTi was associated with closure rates five times higher than the NPWT group (odds ratio [OR], 5.28; 95% confidence interval [CI], 2.40-11.61; p < 0.001) after controlling for smoking status, intravenous drug use, number of operations, and involvement of the most common region of the body. Conclusions: Negative pressure wound therapy with instillation is associated with higher rates of wound closure without increasing complication rates in patients with NSTI compared with traditional NPWT or moist wound care dressing. Although prospective studies are needed, this indicates the potential to improve patient quality of life through reduced pain and outpatient home health needs.

Ludwig's Angina: Higher Incidence and Worse Outcomes Associated With the Onset of the Coronavirus Disease 2019 Pandemic.

Background: Ludwig's angina (LA) is a diffuse cellulitis of the submandibular space and adjacent tissues. During the coronavirus disease 2019 (COVID-19) pandemic, odontogenic treatments were often delayed because of the implementation of safety measures to avoid the spread of the virus. We hypothesized that delayed odontogenic treatments associated with the onset of the COVID-19 pandemic would be associated with an increase in the incidence of LA and worse outcomes related to these infections. Patients and Methods: Patients from June 2018 to June 2022 with computed tomography images suggestive of LA and confirmed by ear, nose, throat (ENT) consult were included. We abstracted demographics, outcomes, clinical management, and microbiology. Patients were stratified into pre-COVID and COVID-onset. Our primary outcome, incidence of LA, was defined as: (new LA cases) ÷ (ED evaluations of oral or dental infections × 1.5 years). Results: In the pre-COVID group, we identified 32 of 1,301 patients with LA for an incidence of 0.02 per year. The COVID-onset group consisted of 41 of 641 patients, with an incidence of 0.04 per year. In the COVID-onset group, progression to necrotizing fasciitis was more likely (0% vs. 15%; p < 0.024), and they returned to the operating room for repeated debridement (3% vs. 22%; p < 0.020). Likewise, hospital length of stay, intensive care unit (ICU) length of stay, and ventilator days were higher (4.3 ± 3.5 vs. 9.5 ± 11.3; 1.1 ± 1.2 vs. 9.5 ± 7.1; 0.3 ± 1 vs. 3.6 ± 7.1; p < 0.001). Conclusions: Although the prognosis for dental infections diagnosed early is generally favorable, we observed a notable increase in the incidence of LA after the onset of the COVID-19 pandemic. Moreover, complications stemming from these infections became more severe in the COVID-onset era. Specifically, the likelihood of necrotizing fasciitis showed a substantial increase, accompanied by an increased risk of respiratory failure and mediastinitis.

Open Mandible and Maxillary Fractures Associated with Higher Risk of Infection in Victims of Assault.

Background: Victims of assault (VOA) often present with fractures of the mandible and maxilla. They represent a complex challenge because of possible compromise of the airway, and infection-related complications because of potential involvement of the oral cavity. We hypothesized that open mandible and maxillary fractures in VOA are associated with a higher rate of infection compared with non-VOA patients with open facial fractures. Patients and Methods: Patients admitted to our level 1 trauma center from 2005 to 2020 with a diagnosis of open mandible and maxillary fractures were included. Demographics, mechanisms of injury, fracture location, cultures, infectious complications, antibiotic treatments, and clinical outcomes were abstracted. Patients were stratified by their mechanism of injury into VOA or non-VOA and were compared using χ2 and Student t-test using SPSS (IBM Corp, Armonk, NY). Results: We identified 316 patients with open mandible and maxillary fractures. There were 198 patients categorized as being VOA, and 118 as non-VOA. Nineteen of 316 patients were diagnosed with infection related to the fracture (3.8% abscesses, 1.9% cellulitis, and 1.9% osteomyelitis). Although the Injury Severity Score (ISS) was higher in non-VOA patients (5.8 ± 2.6 vs. 4.9 ± 1.8; p < 0.013), most of the infections were in the VOA cohort (17/19; 89.5%; p < 0.013). Conclusions: Open fractures of the mandible and maxilla in VOA are associated with a greater risk of infection compared with non-victims of assault. The relation between VOA and poor SDH has been studied recently; clinicians should be aware of this association and implement special considerations and appropriate follow-up visits to decrease the rate of infection in this currently expanding population.