Mathematical modeling to define optimum operating room staffing for pediatric patients in trauma centers.

BACKGROUND: Adult trauma centers (TCs) in the United States may be verified with an on-call operating room team if the performance improvement program shows no adverse outcome. Using queuing and simulation methodology, this study attempts to add a volume guideline for injured children. METHODS: Data from 63 verified TCs identified demographic factors including specific information regarding the first pediatric trauma-related operation done between 11 pm and 7 am each month for 1 year. RESULTS: The annual pediatric admits correlated with the number of operations (383) done from 11 pm to 7 am (P < .001). The probability of operation within 30 minutes of arrival varies with the number of admits and the percent of penetrating vs blunt injuries. This likely number of operations from 11 pm to 7 am beginning within 30 minutes of patient arrival would be 3.45, 4.21, and 4.95 for TCs admitting 150, 250, and 350 injured children per year, respectively. The probability that 2 rooms would be occupied simultaneously is 0.074 and 0.109 for centers with 160 and 260 pediatric trauma admissions, respectively. CONCLUSION: Trauma centers performing less than 6 pediatric trauma operations per year from 11 pm to 7 am could conserve resources by using an on-call operating room team.

Kindness kills: the negative impact of pain as the fifth vital sign.

BACKGROUND: The current emphasis on pain assessment as the fifth vital sign and the use of unscientific pain scales is causing serious injury and death from overmedication. STUDY DESIGN: This premise was tested by reviewing the case reports of all trauma center site surveys performed by the authors for the American College of Surgeons Committee on Trauma verification program during 2 separate time periods: 1994 through 1998 and 2000 through 2004. A total of 2,907 and 2,282 reports summarized by one of the authors, plus a total of 53 and 50 other reviewers, respectively, were analyzed from the records of 120 and 94 trauma centers. Most patients were men (71% and 66%) and had sustained blunt injury (83% and 79%). Average age was 35 years for both periods, with a range of 3 weeks to 97 years and 3 days to 98 years, respectively. The most common injuries involved head (33% and 34%), chest (13% and 13%), abdominal (22% and 21%), orthopaedic (18% and 18%), or multiple (9% and 14%). There were 1,459 and 867 deaths, respectively; all had a multidisciplinary peer review. RESULTS: Overmedication with sedatives/narcotics, during the two periods, clearly contributed to deaths in 13 and 32 patients and probably contributed to deaths in 5 and 14 patients, respectively. This occurred in 17 and 43 patients, respectively, after blunt injury and in 1 and 3 patients, respectively, after penetrating injury. Two clinical scenarios predominated, ie, overmedication in preparation for an imaging study and overmedication after discharge from ICU to the floor. The sequel of hypotension and compromised airway requiring intubation initiated a cascade of negative events that led to death. One patient in each period died as a result of prehospital overmedication. CONCLUSIONS: The current assessment of pain by computer-stored pain scales is in a state of imbalance, with excessive emphasis on undermedication at the same time ignoring overmedication. This imbalance reflects pain-service attempts to comply with external accrediting agencies. This preventable cause of death and disability in trauma patients is also occurring in noninjured patients. Surgeons must correct this problem by insisting on a balanced assessment of overmedication versus undermedication.

Effect of albumin and Hespan on rodent hepatocyte function after hemorrhagic shock and sepsis.

BACKGROUND: Sepsis and hemorrhagic shock (HS) cause hypoalbuminemia, with extravascular albumin relocation. Prior studies on cultured rat hepatocytes showed a fall in albumin genesis when exposed to albumin and Hespan (HES) supplementation. This study assesses the effects of increased colloid osmotic pressure on albumin and urea genesis from hepatocytes exposed to HS or septic insult before harvesting. METHODS: Hepatocyte synthesis of albumin was measured in an in vitro collagen sandwich preparation with a seeding density of 1 million cells per dish in Dulbecco's modified Eagle's medium without additional colloid (control cultures). Study groups included control plus 2% bovine serum albumin (BSA), 4% BSA, 2% HES, and 4% HES. RESULTS: The albumin secretion in the control cultures of HS cells rose from 19.03 microg/d/10(6) cells on day 3 to 88.81 microg/d/10(6) cells by day 8 and remained constant. In contrast, albumin genesis in the 2% and 4% BSA groups rose from a significantly higher (p < 0.05) day 3 value of 39.83 microg/d/10(6) cells and 48.76 microg/d/10(6) cells, respectively, to 116.39 microg/d/10(6) cells and 118.76 microg/d/10(6) cells by day 8 and remained fairly constant. Albumin genesis from the HS cells after 2% HES and 4% HES was similar to control HS cells through day 8 but was significantly greater by day 12. Urea genesis from HS cells was greater in the 4% HES group compared with control and the 2% BSA and 4% BSA groups. The albumin genesis in the control cultures of septic cells was 9.32 microg/d/10(6) cells on day 3, rose to 81.46 microg/d/10(6) cells by day 8, and remained fairly constant. The BSA-supplemented septic cells had significantly higher albumin output than control cells early in the experiment, whereas the 2% HES group had higher albumin secretion than control cells throughout the study. CONCLUSION: HS and septic cultured hepatocytes respond to a rise in interstitial colloid osmotic pressure with a rise in albumin genesis, associated with morphologic changes typical of cellular injury. The mechanism remains cryptic; studies on human hepatocytes are needed.