Low-dose Prothrombin Complex Concentrate for Warfarin-Associated Intracranial Hemorrhage with INR Less Than 2.0.

BACKGROUND: Prothrombin complex concentrates (PCCs) have become the first-line therapy for warfarin reversal in the setting of central nervous system (CNS) hemorrhage. Randomized, controlled studies comparing agents for warfarin reversal excluded patients with international normalized ratio (INR) <2, yet INR values of 1.6-1.9 are also associated with poor outcomes. METHODS: We retrospectively reviewed our use of a low-dose (15 units/kg) strategy of 4-factor PCC (4F-PCC) on warfarin reversal (INR 1.6-1.9) in the setting of both traumatic and spontaneous intracranial bleeding. RESULTS: A total of 21/134 (15.7%) patients with either spontaneous or traumatic intracranial hemorrhage presented with an INR value of 1.6-1.9. Nine patients (43%) presented with traumatic bleeding and 12 (57%) with spontaneous bleeding. The median (IQR) presenting INR was 1.8 (1.7, 1.9) which decreased to 1.3 (1.2, 1.3) following the administration of low-dose 4F-PCC (median dose = 1062 units; 15.2 units/kg). A total of 19/20 (95%) patients achieved a goal INR value of ≤1.5 on the first check following dosing and 17/20 (85%) achieved an INR value ≤1.3. One patient did not have follow-up INR testing due to withdrawal of life support. No patient experienced hematoma expansion within 48 h of 4F-PCC, and there were no thromboembolic events within 72 h of administration. CONCLUSIONS: The administration of low dose (15 units/kg) of 4F-PCC for urgent warfarin reversal in the setting of CNS hemorrhage was effective in correcting the INR in patients presenting with INR values of 1.6-1.9. Further assessment of low-dose PCC for urgent reversal of modest INR elevation is warranted.

Pneumonia prevention in intubated patients given sucralfate versus proton-pump inhibitors and/or histamine II receptor blockers.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common cause of infectious morbidity and mortality in the intensive care unit (ICU). The type of stress-ulcer prophylaxis (SUP) given to ventilated patients may, in part, be responsible. We observed an increase in VAP as ventilator bundle compliance increased and a decrease in VAP when bundle compliance decreased. We reasoned that SUP which raises gastric pH such as proton-pump inhibitors (PPIs) and histamine II (H2) receptor antagonists as opposed to SUP which does not raise pH such as sucralfate (S) may be responsible and also may alter the causative bacteria. MATERIALS AND METHODS: This is a single-center retrospective cohort analysis of all intubated, adult surgical patients admitted to the surgical ICU between January and June during the 3-y period 2012-2014. Demographics, APACHE II, Injury Severity Score, VAP occurrence, culprit bacteria, ventilator days, and ICU days were recorded based on the type of SUP given. RESULTS: There were 45 instances of VAP in the 504 study patients, 33 in the PPI/H2 group, and 12 in the S group (P < 0.01). VAP per 1000 ventilator days were 10.2 for PPI/H2 and 3.7 for S (P < 0.01). Culprit bacteria were mostly Pseudomonas, gram-negative bacilli, and methicillin-resistant Staphylococcus aureus in PPI/H2 patients (n = 29) compared with oropharyngeal flora in S patients (n = 6; P < 0.001). CONCLUSIONS: There was a substantial difference in VAP occurrence and in the culprit bacteria between S and PPI/H2 treated patients due perhaps to gastric alkalization.

Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis.

OBJECTIVE: To examine the clinical and neurological outcome of patients who sustained a severe non-penetrating traumatic brain injury (TBI) and underwent unilateral decompressive craniectomy (DC) for refractory intracranial hypertension. DESIGN: Single center, retrospective, observational. SETTING: Level I Trauma Center in Portland, Maine. PATIENTS: 31 patients aged 16-72 of either sex who sustained a severe, non-penetrating TBI and underwent a unilateral DC for evacuation of parenchymal or extra-axial hematoma or for failure of medical therapy to control intracranial pressure (ICP). INTERVENTIONS: Review of the electronic medical record of patients undergoing DC for severe TBI and assessment of extended Glasgow Outcome Score (e-GOS) at 6-months following DC. MEASUREMENTS AND MAIN RESULTS: The mean age was 39.3y ± 14.5. The initial GCS was 5.8 ± 3.2, and the ISS was 29.7 ± 6.3. Twenty-two patients underwent DC within the first 24 h, two within the next 24 h and seven between the 3rd and 7th day post injury. The pre-DC ICP was 30.7 ± 10.3 and the ICP was 12.1 ± 6.2 post-DC. Cranioplasty was performed in all surviving patients 1-4 months post-DC. Of the 29 survivors following DC, the e-GOS was 8 in seven patients, and 7 in ten patients. The e-GOS was 5-6 in 6 others. Of the 6 survivors with poor outcomes (e-GOS = 2-4), five were the initial patients in the series. CONCLUSIONS: In patients with intractable cerebral hypertension following TBI, unilateral DC in concert with practice guideline directed brain resuscitation is associated with good functional outcome and acceptable-mortality.

Time lapse and comorbidities influence patient knowledge and pursuit of medical care after traumatic splenectomy.

BACKGROUND: There is insufficient knowledge of infectious risk in patients after splenectomy; minimal data exists specifically for trauma patients. This study evaluated patient knowledge and practices regarding infection risk after traumatic splenectomy. Our hypothesis was that patients with poor knowledge regarding their asplenic state would be less likely to pursue medical care in the event of an illness than those with good knowledge. METHODS: Non-randomized, cohort study of all posttraumatic splenectomy patients < or =11 years after injury in 2 rural trauma centers. Patients received a validated questionnaire; weighted responses determined knowledge about infection risks and appropriate follow-up actions. RESULTS: Fifty-four percent of patients responded to the questionnaire. Overall, 47% of responders were identified as having adequate knowledge regarding infectious risk, and only 28% would pursue appropriate medical care. Of patients with adequate knowledge, 42% were more likely to pursue appropriate care versus 15% of patients with inadequate knowledge (p = 0.06). Patients with adequate knowledge were more likely to receive an annual influenza vaccine (p = 0.03) and contact their provider with fewer symptoms (p = 0.03). Logistic regression revealed significant interactions between knowledge and presence of comorbidities (p = 0.04). Focusing on patients with poor knowledge and absence of comorbidities, none would engage in appropriate action in the event of illness (p < 0.01). A longer time since injury, >3 years, was associated with a diminished likelihood of appropriate action (p = 0.03). The relationship between knowledge and action was not accounted for by other potential confounders. CONCLUSIONS: Trauma patients retain minimal knowledge about infection risk after splenectomy and are not likely to pursue appropriate medical care. Time since injury negatively influences patient actions. Healthcare providers must be more proactive to develop new strategies in educating these patients, particularly those without comorbidities and those greater than 3 years postsplenectomy.

Stability of cervical spine fractures after gunshot wounds to the head and neck.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To determine the frequency of stable and unstable cervical spine fractures after gunshot wounds to the head or neck; to identify potential risk factor(s) for an unstable versus stable cervical spine fracture. SUMMARY OF BACKGROUND DATA: Cervical spine fractures after gunshot wounds to the head and neck are common. Because of the nature of their injuries, patients often present with concomitant airway obstruction and large blood vessel injury that can necessitate emergent procedures. In some cases, acute treatment of these problems can be hindered by the presence of a cervical collar or strict adherence to spinal precautions (i.e., patient laying supine). In such situations, information regarding the probability of a stable versus unstable cervical spine fracture would be useful in emergency treatment decision making. METHODS: A search for patients with gunshot wounds to the head or neck potentially involving the cervical spine over a 13-year period was performed using a trauma registry. Individuals with cervical spine fractures were identified and their records reviewed in detail. Data collected included information about neurologic deficits, mental status, airway treatment, entrance wounds, fracture level/type, initial/definitive fracture treatment, and final disposition at hospital discharge. RESULTS: A total of 81 patients were identified; 19 had cervical spine fractures. There were 5 patients who were not examinable because of altered mental status (severe head trauma, hemorrhagic shock, or intoxication). All 5 patients had stable cervical spine fractures. There were 11 patients who had an acute spinal cord injury, 3 (30%) of whom underwent surgery for an unstable fracture. Of the 65 awake, alert patients without a neurologic deficit, only 3 (5%) had a fracture, none of which were unstable. CONCLUSIONS: Gunshot wounds to the head and neck had a high rate of concomitant cervical spine fracture. Neurologically intact patients have a lower rate of fracture than those presenting with a spinal cord injury or altered mental status. In this small series of patients, the only unstable cervical spine injuries were detected in patients with a spinal cord injury. The data suggest that spinal precautions and/or a hard cervical collar should not be maintained at the expense of delaying or hindering emergent life-saving airway or hemodynamically stabilizing procedures, particularly in awake, neurologically intact patients. However, the cervical collar and spinal precautions should be resumed after such procedures are completed and continued until a more definitive evaluation of spinal stability can be performed.