Rural Trauma Team Development Course Positively Impacts its Desired Objectives.

BACKGROUND: The Rural Trauma Team Development Course (RTTDC) is designed to help rural hospitals better organize and manage trauma patients with limited resources. Although RTTDC is well-established, limited literature exists regarding improvement in the overall objectives for which the course was designed. The aim of this study was to analyze the goals of RTTDC, hypothesizing improvements in course objectives after course completion. METHODS: This was a prospective, observational study from 2015 through 2021. All hospitals completing the RTTDC led by our Level 1, academic trauma hospital were included. Our institutional database was queried for individual patient data. Cohorts were delineated before and after RTTDC was provided to the rural hospital. Basic demographics were obtained. Outcomes of interest included: Emergency Department (ED) dwell time, decision time to transfer, number of total images/computed tomography scans obtained, and mortality. Chi square and non-parametric median test were used. Significance was set at P < .05. RESULTS: Sixteen rural hospitals were included with a total of 472 patients transferred (240 before and 232 after). Patient demographics were similar before and after RTTDC. ED dwell time was significantly reduced by 64 min (P = .003) and decision to transfer time was cut by 62 min (P = .004) after RTTDC. Mean total radiographic images and CT scans were significantly reduced (P < .001 and P = .002, respectively) after RTTDC. Mortality was unaffected by RTTDC completion (P = .941). CONCLUSION: The RTTDC demonstrates decreased ED dwell time, decision time to transfer, and number of radiographic images obtained prior to transfer. More rural hospitals should be offered this course.

Kids gone wild - Alcohol use and patient characteristics in pediatric trauma during the coronavirus disease 2019 pandemic.

Importance: Reported coronavirus disease 2019 (COVID-19) pandemic effects on pediatric trauma have been variable. Objective: We investigated the characteristics of pediatric trauma including alcohol use during the pandemic at our urban trauma center. Methods: The trauma database of our adult level 1 trauma center was queried for all pediatric (age ≤ 18 years) patients presenting between March 1, 2020, and October 30, 2020. Data from 2017 to 2019 served as a control. Variables analyzed included demographics, mechanisms, injury severity, hospitalization characteristics, and positive blood alcohol. Results: Pandemic pediatric trauma volumes increased by 67.5% (330/year vs. 197/year). Pandemic patients were younger (median age 13 vs. 14 years, P = 0.011), but similar in gender, ethnicity, severity, hospital length of stay, mortality, and rates of penetrating injury. Falls doubled (79/year vs. 34/year) and shifted away from high falls >6 meters (0% vs. 7.9%) to moderate falls 1-6 meters (58.2% vs. 51.5%) (P = 0.028). Transportation injury rates were similar however mechanisms shifted from motor vehicle crashes (-13.5%) towards recreational vehicles including motorcycles (+2.1%), all-terrain vehicles (+8.6%), and bicycles (+3.8%) (P = 0.018). Pediatric-positive blood alcohol was significantly higher (11.2% vs. 5.1%, P < 0.001), especially for ages 14-18 years (21.7% vs. 9.5%, P < 0.001). Interpretation: Pediatric trauma volumes during the COVID-19 pandemic increased. Pandemic patients had more recreational vehicle injuries and higher rates of positive blood alcohol. This suggests an increased need for alcohol assessment and targeted interventions in the pediatric population during pandemics or periods of school closures.

Resuscitation and Preparation of the Emergency General Surgery Patient.

Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.

Visual Misrepresentations: The Lack of Skin Tone and Sex Equity in General Surgical Textbooks.

OBJECTIVE: Lack of racial and ethnic diversity in educational material contributes to health disparities. This study sought to determine if images of skin color and sex in general surgery textbooks were reflective of the U.S. DESIGN: All human figures with discernable sex characteristics and/or skin tone were evaluated independently by 4 coders. Each image was categorized as male or female. Skin tone in each image was categorized using the Massey- Martin skin color scale. This data was compared to 2020 U.S. Census Data. SETTING: U.S. Medical School. PARTICIPANTS: Not applicable. RESULTS: A total of 1179 images were evaluated for skin tone alone; 293 images for sex alone. 650 images depicted characteristics of both sex and skin tone. Interrater reliability was 0.78 for skin tone and 0.91 for sex. While the U.S. population is 59.3% white, 29.5% non-black persons of color and 13.6% black, in surgical textbooks, 90.7% of images were white, 6.5% were non-black persons of color, and 2.8% were black. Distribution of skin tone for all textbooks were significantly different. (p < 0.001) compared to the U.S. POPULATION: The U.S. population is 49.5% male and 50.5% female. When images of sex specific genitalia and breasts are excluded, surgical textbook images are 62.9% male and 37.1% female. Only 1 textbook had a distribution of sex that was similar to the U.S. CONCLUSIONS: Despite increasing diversity in the U.S. population there is a lack of skin tone and sex diversity in traditional surgical textbooks.

Increase in Alcohol Use Among the Geriatric Trauma Population During the COVID-19 Pandemic.

The COVID-19 pandemic has had profound effects on the everyday behaviors of all patients. At the same time, the United States population is aging, and an increasing portion of traumatically injured patients are geriatric. Our study aims to examine the effects of the COVID-19 pandemic on the geriatric trauma population. We performed a retrospective review of the trauma database from our single institution level I trauma center examining pandemics impact on geriatric trauma demographics, mechanism of injury, injury severity, hospitalization characteristics, and alcohol use. Data during the pandemic was compared to the prior 3 years and controlled for seasonality. Statistical analysis demonstrated an increase in duration of mechanical ventilation and alcohol use during the pandemic while other factors remained stable. This shows the need for targeted alcohol assessment in the geriatric trauma population during periods of social isolation and additional research into the effects of the COVID-19 on trauma patients.

Emergent initial presentation of congenital malrotation with midgut volvulus in 68-year-old.

Congenital malrotation is a pathology nearly exclusive to the infant population. In the rare instance when it is diagnosed in an adult, it is typically associated with a longstanding history of gastrointestinal symptoms. Unfortunately, this unique presentation in an unexpected population has the potential to be confounding, leading to delayed or mismanaged care. Here, we describe an intriguing case of congenital malrotation complicated by midgut volvulus in a 68-year-old woman. Even more curious, the patient did not have a medical history plagued by abdominal complaints. Careful, comprehensive evaluation yielded appropriate surgical management via Ladd's procedure and right hemicolectomy in this complex patient.

"Peas in a Pod": Clustering minorly injured trauma patients together during their hospitalization results in decreased hospital costs and fewer inpatient complications.

BACKGROUND: Trauma patient care is complex. Clustering these patients within the hospital seems intuitive. This study's purpose was to explore the benefits of trauma patient clustering, hypothesizing these patients will have decreased costs and better outcomes. METHODS: This was an analysis of all adult (18-99 years) trauma patients admitted from 1/2017-1/2019 without an intensive care unit stay. Patients were grouped into those admitted to the trauma unit (TU) versus non-trauma units (NTU). Outcomes evaluated between groups were baseline demographics, direct costs, complication rates (using our TQIP registry), and discharge location. T-test, median test, and chi squared test were used. Linear regression was performed. Significance was set at p < 0.05. RESULTS: 1481 patients (684 TU and 797 NTU) were analyzed. TU patients were younger. Injury Severity Score, mortality, and hospital length of stay were similar between groups. Direct hospital costs were decreased for TU patients ($4941(±$4740) versus $5639(±$4897), p = 0.006). Fewer TU patients experienced inpatient complications (7.8% versus 13.5%, p < 0.001). More TU patients were discharged to home (78.9% versus 73.8%, p = 0.02). Linear regression analysis demonstrated admission to NTUs predicted a direct cost increase of $766.35 (p < 0.001). CONCLUSIONS: Clustering minorly injured trauma patients on a dedicated unit resulted in reduced costs, decreased complications, and higher likelihood for discharge to home.

Sternal fixation for isolated traumatic sternal fractures improves pain and upper extremity range of motion.

INTRODUCTION: Sternal fractures are debilitating due to intractable pain, constant fracture movement and limited range of motion (ROM) of the upper extremities (UE). Traditional treatment comprises mainly of pain control, delaying return to daily activities. Recently, sternal fixation has gained popularity. There is, however, a lack of literature demonstrating efficacy. We report our experience of traumatically fractured sternal fixation. METHODS: Following IRB approval, a retrospective chart review was completed for all patients undergoing sternal fixation by a single trauma surgeon at our Level I trauma center. Basic demographics were obtained. Primary outcomes included average cumulative pain scores, total cumulative narcotic amounts and total number of pain medication agents utilized prior to and after sternal fixation. Secondary outcome included physical therapy UE ROM before and after surgery. Paired t tests were used for comparison; significance set at p < 0.05. RESULTS: Thirteen patients underwent sternal fixation from 8/2016 to 2/2018. Average age was 54.4 ± 20.8 years; 54% were female. All patients experienced blunt trauma; average injury severity score was 15.8 ± 10.9 and abbreviated chest injury score was 2.5 ± 0.51. Average intensive care unit/hospital length of stay was 2.3/10.2 days. Average pain scores significantly improved by a score of 3.5 postoperatively (preoperative = 7.08 ± 2.3, postoperative = 3.54 ± 2.5; p = 0.001). Total pain medications required by sternal fixation patients significantly decreased by 1 medication postoperatively (preoperative = 4.2 medications, postoperative = 3.2 medications; p = 0.002). Average narcotic requirements significantly decreased by 7.59 morphine milligram milliequivalents (MME) after sternal fixation (preoperative amount = 71.78 MME, postoperative amount = 64.19 MME; p = 0.041). Every patient had limited UE ROM preoperatively; however, all but one patient resumed full UE ROM postoperatively (p < 0.001). There were no postoperative complications. CONCLUSIONS: Sternal fixation is a safe and effective procedure resulting in improved pain, decreased narcotic requirements, and faster recovery.

Rib fracture displacement worsens over time.

PURPOSE: Rib fractures (RF) occur in 10% of trauma patients; associated with significant morbidity and mortality. Despite advancing technology of surgical stabilization of rib fractures (SSRF), treatment and indications remain controversial. Lack of displacement is often cited as a reason for non-operative management. The purpose was to examine RF patterns hypothesizing RF become more displaced over time. METHODS: Retrospective review of all RF patients from 2016-2017 at our institution. Patients with initial chest CT (CT1) followed by repeat CT (CT2) within 84 days were included. Basic demographics were obtained. Primary outcomes included RF displacement in millimeters (mm) between CT1 and CT2 in three planes (AP = anterior/posterior, O = overlap/gap, and SI = superior/inferior). Displacement was calculated by subtracting CT1 fracture displacement from CT2 displacement for each rib. Given anatomic and clinical characteristics, ribs were grouped (1-2, 3-6, 7-10, 11-12), averaged, and analyzed for displacement. Secondary outcome included number of missed RF on CT1. Non-parametric sign test and paired t test were used for analysis. Significance was set at p < 0.002. RESULTS: 78 of 477 patients with RF on CT1 had CT2 during the study period: primarily male (76%) and age 55.8 ± 20.1 with blunt mechanism of injury (99%). Median Injury Severity Score was 21 (IQR, 13-27) with Chest Abbreviated Injury Score of 3 (IQR, 3-4). Median time between CT1 and CT2 was 6 days (IQR, 3-12). Missed RF rate for CT1 was 10.1% (p = 0.11). Average fracture displacement was significantly increased for all rib groupings except 11-12 in all planes (p < 0.002). CONCLUSION: RF become more displaced over time. Pain regimens and SSRF considerations should be adjusted accordingly.

Spontaneous Diaphragmatic Rupture in Hypermobile Type Ehlers-Danlos Syndrome.

Ehlers-Danlos Syndrome refers to a spectrum of connective tissue disorders that have a variety of clinical manifestations. In this case, we present a spontaneous diaphragmatic rupture in a patient with type III Ehlers-Danlos Syndrome. The patient presented with worsening shortness of breath after failure of medical therapy for a presumed pneumonia. A CT scan was obtained which showed diaphragmatic rupture with splenic herniation which was repaired in the operating room via thoracotomy. It is important to include diaphragmatic rupture in the differential diagnosis for patients with connective tissue disease and acute onset tachypnea and pain, as this complication has the potential for significant morbidity without prompt surgical intervention.

Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates.

BACKGROUND: No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients. METHODS: A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients. RESULTS: Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41). CONCLUSIONS: The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.

Risks go beyond the violence: Association between intimate partner violence, mental illness, and substance abuse among females admitted to a rural Level I trauma center.

BACKGROUND: Intimate partner violence (IPV) is a significant cause of intentional injury among women but remains underrecognized, and its relationship to other risk factors for all-cause injury remains poorly defined. This study aimed to assess IPV and its association with alcohol abuse, illicit substance use, selected mental illnesses, and other risk factors for injury. METHODS: This is a cross-sectional study of prospectively collected data among adult females admitted to a rural, Level I trauma center. Well-validated instruments assessed IPV, substance abuse, and mental illness. Bivariate relationships were assessed with χ, odds ratios, and t test analyses. RESULTS: Eighty-one women were enrolled; 51% reported lifetime IPV, and 31% reported past-year IPV. Both groups were significantly more likely to have a mental illness than those without a history of IPV. Those reporting lifetime IPV exposure were significantly more likely to report illicit substance use, and past-year IPV was associated with alcohol abuse (28% vs. 7.1%, p = 0.01). Participants reporting past-year IPV were significantly more likely to have a partner possessing a firearm (40% vs. 12.5%, p = 0.005). CONCLUSION: The experience of lifetime and past-year IPV among women at a Level I, rural trauma center was high, and it was significantly associated with mental illness, substance abuse, and high-risk scenarios for intentional injury including firearm ownership by a significant other. These findings inform the potential value of IPV screening and intervention and suggest that IPV, mental illness, and substance abuse should be considered associated entities in prevention and recidivism reduction efforts in the female trauma population. LEVEL OF EVIDENCE: Prognostic study, level II; therapeutic study, level III.

Milestones: The Road to Faculty Development.

PURPOSE: Milestones for the assessment of residents in graduate medical education mark a change in our evaluation paradigms. The Accreditation Council for Graduate Medical Education has created milestones and defined them as significant points in development of a resident based on the 6 competencies. We propose that a similar approach be taken for resident assessment of teaching faculty. We believe this will establish parity and objectivity for faculty evaluation, provide improved data about attending surgeons' teaching, and standardize faculty evaluations by residents. METHODS: A small group of advanced surgery educators determined appropriate educational characteristics, resulting in creation of 11 milestones (Fig. 2) that were reviewed by faculty and residents. The residents have historically answered 16 questions, developed by our surgical education committee (Fig. 3), on a 5-point Likert score (never to very often). Three weeks after completing this Likert-type evaluation, the residents were asked to again evaluate attending faculty using the Faculty Milestones evaluation. The residents then completed a survey of 7 questions (scale of 1-9-disagree to strongly agree, neutral = 5), assessing the new milestones and compared with the previous Likert evaluation system. RESULTS: Of 32 surgery residents, 13 completed the Likert evaluations (3760 data points) and 13 completed the milestones evaluations (1800 data points). The number completing both or neither is not known, as the responses are anonymous when used for faculty feedback. The Faculty Milestones attending physicians' scores have far fewer top of range scores (21% vs 42%) and have a wider spread of data giving better indication of areas for improvement in teaching skills. The residents completed 17 surveys (116 responses) to evaluate the new milestones system. Surveys indicated that milestones were easier to use (average rating 6.13 ± 0.42 Standard Error (SE)), effective (6.82 ± 0.39) and efficient (6.11 ± 0.53), and more objective (6.69 ± 0.39/6.75 ± 0.38) than the Likert evaluations are. Average response was 6.47 ± 0.46 for overall satisfaction with the Faculty Milestones evaluation. More surveys were completed than evaluations, as all residents had an opportunity to review both evaluation systems. CONCLUSIONS: Faculty Milestones are more objective in evaluating surgical faculty and mirror the new paradigm in resident evaluations. Residents found this was an easier, more effective, efficient, and objective evaluation of our faculty. Although our Faculty Milestones are designed for surgical educators, they are likely to be applicable with appropriate modifications to other medical educators as well.

Permissive Hypotension: Potentially Harmful in the Elderly? A National Trauma Data Bank Analysis.

Permissive hypotension is a component of damage control resuscitation that aims to provide a directed, controlled resuscitation, while countering the "lethal triad." This principle has not been specifically studied in elderly (ELD) trauma patients (≥55 years). Given the ELD population's lack of physiologic reserve and risk of inadequate perfusion with "normal" blood pressures, we hypothesized that utilized a permissive hypotension strategy in ELD trauma patients would result in worse outcomes compared with younger patients (18-54 years). A retrospective review of National Trauma Data Bank reports from 2009 and 2010, identifying critically ill patients undergoing a "damage control laparotomy," was performed to determine the effect of age and systolic blood pressure on outcome. Logistic regression analysis, including evaluation of an interaction between age and admission blood pressure, was performed on mortality using admission demographics, physiology, injury severity, mechanism of injury, and in-hospital complications. Although there was a higher likelihood of death with greater age, lower admission systolic blood pressure, lower Glasgow Coma Score, increased injury severity score, and acute renal failure, a synergistic effect of age and blood pressure on mortality was not identified. Permissive hypotension appears to be a possible management strategy in ELD trauma patients.

An Unusual Presentation of a Posterior Mediastinal Schwannoma Associated with Traumatic Hemothorax.

Schwannomas of the thoracic cavity are typically an asymptomatic, benign neurogenic neoplasm of the posterior mediastinum. In this case, we present a traumatic hemothorax as the initial presentation for a previously undiscovered mediastinal mass. The patient presented with shortness of breath and right-sided chest pain after being struck in the chest with a soccer ball. An operative exploration was pursued due to persistent hemothorax with hemodynamic instability despite resuscitation and adequate thoracostomy tube placement. The intraoperative etiology of bleeding was discovered to be traumatic fracture of a large hypervascular posterior mediastinal schwannoma. Surgical resection is the treatment of choice for these tumors. Specific serological markers do not exist for this tumor, and radiographic findings can be variable, so tissue diagnosis is of importance in differentiating benign from malignant schwannomas, as well as other posterior mediastinal tumors. However, most patients have excellent survival following complete resection.

Perioperative management of obese patients.

Obesity prevalence has quadrupled since the 1980s in the United States. It is estimated that 30% of the population is obese or has a body mass index of greater than or equal to 30 as defined by the World Health Organization. Surgeons are likely to engage in the care of obese patients and need to be adept in every aspect of the patients' care in order to have a successful hospital course. There is significant controversy in perioperative management of obese patients. This article discusses perioperative management of obese patients to provide guidelines, education, and discussion of current issues.

Lung protective ventilation (ARDSNet) versus airway pressure release ventilation: ventilatory management in a combined model of acute lung and brain injury.

BACKGROUND: Concomitant lung/brain traumatic injury results in significant morbidity and mortality. Lung protective ventilation (Acute Respiratory Distress Syndrome Network [ARDSNet]) has become the standard for managing adult respiratory distress syndrome; however, the resulting permissive hypercapnea may compound traumatic brain injury. Airway pressure release ventilation (APRV) offers an alternative strategy for the management of this patient population. APRV was hypothesized to retard the progression of acute lung/brain injury to a degree greater than ARDSNet in a swine model. METHODS: Yorkshire swine were randomized to ARDSNet, APRV, or sham. Ventilatory settings and pulmonary parameters, vitals, blood gases, quantitative histopathology, and cerebral microdialysis were compared between groups using χ2, Fisher's exact, Student's t test, Wilcoxon rank-sum, and mixed-effects repeated-measures modeling. RESULTS: Twenty-two swine (17 male, 5 female), weighing a mean (SD) of 25 (6.0) kg, were randomized to APRV (n = 9), ARDSNet (n = 12), or sham (n = 1). PaO2/FIO2 ratio dropped significantly, while intracranial pressure increased significantly for all three groups immediately following lung and brain injury. Over time, peak inspiratory pressure, mean airway pressure, and PaO2/FIO2 ratio significantly increased, while total respiratory rate significantly decreased within the APRV group compared with the ARDSNet group. Histopathology did not show significant differences between groups in overall brain or lung tissue injury; however, cerebral microdialysis trends suggested increased ischemia within the APRV group compared with ARDSNet over time. CONCLUSION: Previous studies have not evaluated the effects of APRV in this population. While our macroscopic parameters and histopathology did not observe a significant difference between groups, microdialysis data suggest a trend toward increased cerebral ischemia associated with APRV over time. Additional and future studies should focus on extending the time interval for observation to further delineate differences between groups.

When birds can't fly: an analysis of interfacility ground transport using advanced life support when helicopter emergency medical service is unavailable.

BACKGROUND: Helicopter emergency medical service (HEMS) transport of trauma patients is costly and of unproven benefit. Recent retrospective studies fail to control for crew expertise and therefore compare highly trained advance life support with less-trained basic life support crews. The purpose of our study was to compare HEMS with ground, interfacility transport while controlling for crew training. We hypothesized that patients transported by HEMS would experience shorter interhospital transport time and reduced mortality. METHODS: Our National Trauma Registry of the American College of Surgeons database was retrospectively queried to identify consecutive interfacility, hospital transfers (January 1, 2008, to November 1, 2012) to our Level I trauma center. Transfers were stratified by transportation vehicle (i.e., HEMS vs. ground transport). Cohorts were compared across standard demographic and clinical variables using univariate analysis. Multivariate logistic regression was performed to determine the association of these variables with mortality. RESULTS: The HEMS (n = 2,190) and ground (n = 223) cohorts were well matched overall, with no significant differences for demographics, injury severity, physiology, hospital length of stay, or complications. Median (interquartile range) time to definitive care was significantly lower for HEMS (150 [114] minutes vs. 255 [157] minutes, p < 0.001), without change in mortality (9.0% vs. 8.1%, p = 0.71). Multivariate logistic regression did not identify an association between transport mode and mortality. CONCLUSION: Despite faster interfacility transport times, HEMS offered no mortality benefit compared with ground when crew expertise was controlled for, contradicting recent large, retrospective National Trauma Data Bank studies. Our study may represent the best approximation of a prospective study by focusing on patients deemed worthy of HEMS by referring providers. Although HEMS may seem intuitively beneficial for time-dependent injuries, larger studies with a similar methodology are warranted to justify the cost and risk of HEMS and identify subsets of patients who may benefit. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Pharmacokinetic analysis of piperacillin administered with tazobactam in critically ill, morbidly obese surgical patients.

STUDY OBJECTIVE: To evaluate the steady-state pharmacokinetic and pharmacodynamic parameters of piperacillin in morbidly obese, surgical intensive care patients. DESIGN: Open-label single-center prospective study. SETTING: Level I trauma center and university-affiliated teaching institution. PATIENTS: Nine morbidly obese (body mass index [BMI] 40.0 kg/m² or higher) hospitalized patients admitted to the trauma and surgical intensive care service who were treated with piperacillin-tazobactam between December 15, 2010, and April 18, 2012. INTERVENTION: Patients received intravenous piperacillin-tazobactam 4.5 g every 6 hours, administered as a 30-minute infusion. MEASUREMENTS AND MAIN RESULTS: Patients' blood samples were collected after the administration of the fourth, fifth, or sixth dose (i.e., at steady state). Serum piperacillin concentrations were determined by using a validated high-performance liquid chromatography assay; these concentrations were used to estimate pharmacokinetic parameters, and 5000-patient Monte Carlo simulations were performed. The probability of target attainment for 50% or higher of the dosing interval during which free (unbound) drug concentrations exceeded the minimum inhibitory concentration (%fT > MIC) of likely pathogens was calculated for piperacillin at various MICs. Patient demographic and clinical characteristics included a mean ± SD total body weight of 164 ± 50 kg, BMI of 57 ± 15.3 kg/m², and age 57 ± 11 years, and a median Acute Physiology and Chronic Health Evaluation II score of 22 (interquartile range 21-26). Compared with values previously reported in other populations, the volume of distribution was increased in the study patients, and total system clearance was decreased. The net result was a mean ± SD half-life of 3.7 ± 1.2 hours compared with ~1 hour reported in other populations. This contributed to an extended %fT > MIC for likely pathogens. Results from all nine patients showed %fT > MIC of 100% at the susceptibility breakpoint MIC of 16 mg/L and 85% or higher at an MIC of 32 mg/L. CONCLUSION: The pharmacokinetics of piperacillin is altered in morbidly obese, surgical intensive care patients. The use of standard-dosage piperacillin-tazobactam 4.5 g intravenously every 6 hours was shown to be an appropriate dosage for this study population.