Inter-facility transfers for burn patients with concomitant traumatic injuries.

Burn patients with concomitant traumatic injuries suffer increased morbidity and mortality. Complex care coordination is necessary for these patients, and the prevalence of resulting inter-facility transfers has not yet been quantified by literature. This study examined the outcomes for traumatically injured burn patients to identify the occurrence of trauma system transfers in this group. The National Trauma Data Bank was reviewed from the years 2007-2016 for 6,565,577 patients with traumatic, burn, and concomitant burn & traumatic injuries. There were 5068 patients with both traumatic and burn injuries, 145,890 patients with burn injuries, and 6,414,619 patients with traumatic injuries. Trauma/burn patients were more often admitted to the ICU from the ED at a rate of 35.5% compared to 27.1% for burn and 19.4% for trauma (P < 0.001). For disposition when discharged from the hospital, trauma/burn patients required more inter-facility transfers at a rate of 2.5% compared to 1.7% for burn and 1.3% for trauma (P < 0.001). For level I trauma centers, 5.5% of trauma/burn, 7.1% of burn, and 0.5% of trauma patients required inter-facility transfers. For level II trauma centers, 29.1% of trauma/burn, 47.0% of burn, and 2.8% of trauma patients required inter-facility transfers. Among level I and level II trauma centers, patients with only burns and burn patients with concomitant traumatic injuries required more inter-facility transfers, and level II trauma centers required more inter-facility transfers for all patients. Quantifying these findings is the first step toward improving triage decisions and allocation of health care resources while expediting appropriate care.

Coronavirus-Associated Coagulopathy After Trauma.

Coronavirus disease 2019 (COVID-19) is linked with a hypercoagulable state called COVID-19-associated coagulopathy (CAC). Due to elevated levels of factor VIII and fibrinogen as well as inflammation-linked hyperviscosity of blood, the risk for venous thromboembolism is increased in patients who have CAC. We report the case of a patient with recent COVID-19 infection and no other past medical history who presented after a motorcycle collision with left middle and distal femur fractures, who underwent retrograde intramedullary nailing, and then developed immediate massive bilateral pulmonary emboli. The patient was treated with tissue plasminogen activator administration via bilateral pulmonary artery thrombolysis catheters without improvement, and was then placed on venoarterial extracorporeal membrane oxygenation for subsequent cardiogenic shock. During a 58-day hospital stay, the patient recovered and was discharged with a good long-term prognosis. In this report, we discuss CAC, the role of surgical critical care in the management of the disease, and issues specific to this patient's disease process and treatment.

Implementation of a Surgical Intensivist Model Increases Palliative Care Consultation in the Care of Trauma ICU Patients.

OBJECTIVE: This study investigated patient outcomes of care before and after transitioning to a surgical intensivist-led trauma-intensive care unit (ICU) team. The intensivist team provided daily multidisciplinary rounds and continuity of care. Prior to an intensivist model, general surgeons cared for trauma patients admitted to the unit. METHODS: Outcomes of 1,078 trauma patients, admitted to the ICU at a Level II trauma center, under care of general surgeons (1/2011-8/2012, n = 449) were retrospectively compared with care managed by a surgical intensivist team (1/2013-5/2015, n = 629) by Pearson Chi-squared and Wilcoxon tests. A multivariable logistic regression technique was used to control for covariates. Demographics and injury severity were analyzed. The primary outcome was ICU mortality. The secondary outcomes were length of stay (LOS), ventilator-free and ICU-free days, and ICU readmission rate. Other data collected included palliative care consultation. Results: There were no statistically significant differences in ICU mortality (P = 0.055), hospital LOS (P = 0.481), ventilator-free days (P = 0.174), or ICU readmission rate (P = 0.587). The surgical intensivist team consulted palliative care more frequently (4.0% vs 13.5%, P < 0.001), while managing more trauma patients who were older than 65 years (P < 0.001) with lower Glasgow Coma Scale (P = 0.048) and higher injury severity (P = 0.025) and abbreviated injury scale (P < 0.001) scores. DISCUSSION: There were no differences in outcomes. However, incorporating palliative care consultation in the ICU is essential in the support of critically ill patients and their families. These data demonstrate that a surgical intensivist team utilized palliative care more often in the management of trauma patients admitted to the ICU.

Concomitant placement of dialysis and infusion catheters in the right internal jugular vein in the intensive care setting: Is it safe?

PURPOSE: This study examined the safety and efficacy of placing both a central venous dialysis catheter and a central venous catheter for infusion in the right internal jugular vein compared to only a central venous dialysis catheter. METHODS: We conducted a retrospective chart review for all adult patients who underwent the placement of the right internal jugular dialysis catheter by a single surgeon. Patients were grouped based on whether they received a tunneled dual lumen dialysis catheter alone or in combination with a central venous infusion catheter in the right internal jugular vein. Catheter-related thrombosis, line infections, line malfunctions, pneumothorax, and need for line replacement were evaluated. RESULTS: There were 97 patients in the dialysis catheter and central venous infusion line group and 63 patients in the dialysis catheter only group. The two groups were not different with regard to age (62.1 ± 16.3 years vs 57.9 ± 17.6 years) and gender (47.4% male vs 55.6% male). No significant differences were found in the incidence of thrombosis (1.0 % vs 0.0%, p > 0.999), line infection (2.1% vs 0.0%, p = 0.519), or line malfunctions (2.1% vs 0.0%, p = 0.516) in patients who did or did not have a central venous infusion catheter placed concomitantly with the dialysis catheter, respectively. No patients in either group had a pneumothorax. CONCLUSIONS: Although not currently utilized with frequency, these preliminary data indicate that placing both a dual lumen dialysis catheter and central venous infusion catheter in the right internal jugular simultaneously could be a viable option.

Hemodialysis patients have worse outcomes after infrageniculate revascularization procedures.

BACKGROUND: Hemodialysis (HD) has been shown to be an independent predictor of poor outcomes after femoropopliteal revascularization procedures in patients with chronic limb-threatening ischemia. However, HD patients tend to have isolated infrageniculate disease, an anatomic risk factor for inferior patency. We aimed to compare outcomes for HD versus non-HD patients after infrageniculate open lower extremity bypass (LEB) and endovascular peripheral vascular interventions (PVIs). METHODS: Data from the Society for Vascular Surgery Vascular Quality Initiative database (2008-2014) were analyzed. All patients undergoing infrageniculate LEB or PVI for rest pain or tissue loss were included. One-year primary patency (PP), secondary patency (SP), and major amputation outcomes were analyzed for HD versus non-HD patients stratified by treatment approach using both univariable and multivariable analyses. RESULTS: A total of 1688 patients were included, including 348 patients undergoing LEB (HD = 44 versus non-HD = 304) and 1340 patients undergoing PVI (HD = 223 versus non-HD = 1117). Patients on HD more frequently underwent revascularization for tissue loss (89% versus 77%, P < 0.001) and had ≥2 comorbidities (91% versus 76%, P < 0.001). Among patients undergoing LEB, 1-y PP (66% versus 69%) and SP (71% versus 78%) were similar for HD versus non-HD (P ≥ 0.25) groups, but major amputations occurred more frequently in the HD group (27% versus 14%; P = 0.03). Among patients undergoing PVI, 1-y PP (70% versus 78%) and SP (82% versus 90%) were lower and the frequency of major amputations was higher (27% versus 10%) for HD patients (all, P ≤ 0.02). After correcting for baseline differences between the groups, outcomes were similar for HD versus non-HD patients undergoing LEB (P ≥ 0.21) but persistently worse for HD patients undergoing PVI (all, P ≤ 0.006). CONCLUSIONS: HD is an independent predictor of poor patency and higher risk of major amputation after infrageniculate endovascular revascularization procedures for the treatment of chronic limb-threatening ischemia. The use of endovascular interventions in these higher risk patients is not associated with improved limb salvage outcomes and may be an inappropriate use of healthcare resources.

Evaluation of the effect of water-uptake on the impedance of dental resins.

UNLABELLED: Electrical impedance spectroscopy (EIS) offers a quantitative method of measuring the stability of resin films in aqueous solution over time. PURPOSE: The purpose of this study was to measure the EIS of five experimental dental adhesive films (ca. 17 microm thick) of increasing hydrophilicity (ranked by their Hoy's solubility parameters), and how much these values change over 3 weeks in aqueous buffer. METHODS: The resin films were placed in a U-shaped chamber and a pair of Ag-AgCl electrodes was used for EIS. The EIS results were confirmed by immersing the films in 50% AgNO3 for 24 h to trace the distribution of any water absorption into the resins by TEM observations. RESULTS: The resistance (Rr) of the resins 1-4 films increased most during the first day, and varied from 1x10(11) ohm for resin 1, to 40Omega for resin 5 at day 1. The day 1 Rr values of resins 1-4 were inversely proportional to their Hoy's solubility parameter for hydrogen bonding forces. Electrical impedance values of resins 1-3 and 5 varied widely but were relatively constant over time, while those of resin 4 decreased more than 99% from day 1 to 21 (p<0.05). Capacitance (Cr) of films of resins 1-4 all increased over the first day and then were relatively unchanged over the 20 days (except for resin 4 that continued to increase) and were between 0.01 and 1 nF. Silver uptake by TEM revealed the development of water-filled branching structures that formed in resins 4 and 5 over time.