Narcotic Consumption Analysis among Severely Injured and Advanced Aged Trauma Patients.

BACKGROUND: Multimodal pain management has been shown to be effective in treating pain in acutely injured trauma patients. Our community-based, level 1 trauma center previously published in 2022 the efficacy of implementing multimodal pain control (MMPC) protocol in our inpatient trauma population which decreased the use of opioids while maintaining similar pain control. The MMPC group had a trend toward higher age and was significantly less injured. We hypothesize MMPC will reduce opioid consumption in both the advanced aged and more severely injured trauma populations while still providing adequate pain control. METHODS: Defined by the year of admission, MMPC and physician managed pain control (PMPC) were compared in both advanced age groups and between the severely injured groups. The advanced age group included patients ≥55 years old. The severely injured group included ≥18 years old with ≥15 ISS. Primary outcomes were total opioid utilization per day, calculated in morphine milliequivalents (MME), and median daily pain scores. RESULTS: For the severely injured population, the MMPC group showed a 3-fold decrease in opioid use (30 MME/d vs 90.3 MME/d, P < .001) and lower pain scores (5/10 vs 6/10, P < .001) than the PMPC group. In the advance age group, there was no significant difference between MMPC and PMPC groups in opioid use (P = .974) or pain scores (P = .553). CONCLUSION: MMPC effectively reduces opioid consumption in a severely injured patient population while simultaneously improving pain control. Advanced age trauma patients can require complex pain management solutions and future research to determine their needs is recommended.

Interpersonal Violence and Social Determinants of Health.

Social determinants of health (SDOH) influence patient outcomes and risk assessment. This study focuses on interpersonal violence, trauma outcomes, and SDOH. We hypothesized patients with lower SDOH experience worse trauma outcomes and present from higher-risk communities. Demographics, SDOH, and outcomes for patients admitted to surgical trauma suffering interpersonal violence were collected and analyzed. Home addresses were plotted, identifying areas of need compared with Area Deprivation Index (ADI). Only 18.8% of patients had documented SDOH, yielding small sample size. Analysis revealed no statistically significant associations (P < .05) between SDOH and trauma outcomes, including ICU length of stay and stress concern (P = .0804). Heat mapping revealed several hot spots across our catchment area, correlating with higher-ranked ADIs and increased deprivation. This study demonstrated SDOH can bring value in determining patient risk, emphasizing resource dedication to documenting these factors. Home addresses in conjunction with ADIs can ascertain areas for resource allocation within communities.

Acquired Methemoglobinemia in the Surgical Intensive Care Unit.

Acquired methemoglobinemia is a potentially lethal medical condition caused by exposure to oxidizing xenobiotics, including antibiotics such as dapsone and inhaled anesthetics such as benzocaine. In this case report, we describe two presentations of acquired methemoglobinemia which presented to our surgical intensive care unit within one month. This highlights the potential connection between an emergent surgery or procedure and the development of methemoglobinemia in an environment where it is presumed that this condition would be extremely rare. High clinical suspicion for methemoglobinemia is warranted if the patient develops cyanosis or a decreased oxygen saturation unresponsive to supplemental oxygen when another etiology is not identifiable. If methemoglobinemia is suspected, a direct measurement of blood methemoglobin levels can be obtained to confirm the diagnosis. Prompt treatment with intravenous methylene blue is highly effective.

Multi-modal Pain Control Protocol Decreases Narcotic Consumption in an Inpatient Trauma Population.

INTRODUCTION: Opioid use after surgery or trauma has been implicated as a contributing factor to opioid dependence. The Acute Care Surgery (ACS) service at our community-based trauma center instituted an opioid-minimizing, multi-modal pain control (MMPC) protocol. The classes of pain medication included a non-opioid analgesic, a non-steroidal anti-inflammatory drug, a gabapentinoid, a skeletal muscle relaxant, and a topical anesthetic. We hypothesize that the MMPC will result in lower opioid consumption compared with the prior STP as evidenced by lower morphine milligram equivalents (MME) per day. METHODS: All adult patients (≥18 years) admitted to the ACS service from Jan 2014 to Dec 2015 and Jan 2018 to Dec 2019 were screened for inclusion. The standard pain control group (STP) and MMPC groups were defined by the year of admission. The primary outcome is opioid use per day, calculated in MME received. Secondary outcomes of the study include daily pain scores, incidence of opioid-related complications, death, ventilator days, intensive care unit length of stay, and hospital length of stay (HLOS) days. RESULTS: Multi-modal pain control protocol group was older and less injured than STP group. Daily opioid utilization was significantly less in the MMPC group (22.5 MMEs/d vs 60MMEs/d in the STP group, P < .0001). Additionally, daily pain scores were not different between groups. Secondary outcomes did not vary between the two groups. CONCLUSION: This study shows that implementation of a MMPC protocol resulted in lower opioid consumption in injured patients. Pain was equivalently controlled during the MMPC protocol period as demonstrated by similar pain scores.

Safety and Outcome of Intracranial Pressure Monitor Placement Performed by Trauma Critical Care Surgeons.

INTRODUCTION: The Brain Trauma Foundation advises intracranial pressure monitor placement (ICPM) following traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) score ≤8 and an abnormal head computed tomographic scan (CT) finding. Prior studies demonstrated that ICPMs could be placed by non-neurosurgeons. We hypothesized that ICPM placement by trauma critical care surgeons (TCCS) would increase appropriate utilization (AU), decrease time to placement (TTP), and have equivalent complications to those placed by neurosurgeons. METHODS: We retrospectively reviewed medical records of adult trauma patients admitted with a TBI in a historical control group (HCG) and practice change group (PCG). Demographics, Injury Severity Score (ISS), outcomes, ICPM placement by provider type, and time to placement were identified. Complications and appropriate utilization were recorded. RESULTS: 70 patients in the HCG and 84 patients in the PCG met criteria for inclusion. Demographics, arrival GCS, ICU GCS, ISS, and admission APACHE II scores were not statistically significant. AU was 7/70 for HCG vs 19/84 in the PCG (P = .04036). Median TTP was 6.5 hours for HCG vs 5.25 for PCG (P = .9308). Interquartile range showed the data clustered around an earlier placement time, 2.3-14.0 hours, in the PCG. Complications between the 2 groups were not statistically significant, 0/7 for HCG vs 5/19 for PCG (P = .2782). DISCUSSION: This study confirms that ICPMs can be safely placed by TCCS. Our results demonstrate that placement of ICPMs by TCCS improves AU and possibly improves TTP.

Rapid response teams: do they make a difference?

Hundreds of lives are now being saved in hospitals across the country with the use of rapid response teams. These teams are composed of clinicians who bring critical care expertise to the patient bedside. The purpose of these teams is to assess and stabilize the patient, assist with communication among the interdisciplinary care providers, educate and support the staff caring for the patient, and assist with transfer of the patient if necessary. Research has shown that, with successful implementation of a rapid response team, the percent of codes and mortality rates decrease. The purpose of this study was to evaluate the effectiveness of implementing a rapid response team at 1 medical center. The results from the study demonstrated a decrease in the percent of codes outside the critical care units. However, it did not show a decrease in overall mortality rates for the patients. Data review will continue as we strive to improve our overall mortality rates while maintaining a decrease in the amount of codes.