Both groups A and AB plasma have been approved for emergency-release transfusion in acutely bleeding trauma patients before blood grouping being performed. The safety profile associated with this ...practice has not been well characterized, particularly in patients requiring massive transfusion.
This secondary analysis of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios trial examined whether exposure to group A emergency-release plasma (ERP) was noninferior to group AB ERP. We also examined patients whose blood groups were compatible with group A ERP versus patients whose blood groups were incompatible with group A ERP. Outcomes included 30-day mortality and complication rates including systemic inflammatory response syndrome, infection, renal injury, pulmonary dysfunction, and thromboembolism.
Of the 680 patients predicted to receive a massive transfusion, 584 (85.9%) received at least 1 U of ERP. Of the 584 patients analyzed, 462 (79.1%) received group AB and 122 (20.9%) received group A ERP. Using a hazard ratio (HR) of 1.35 as the noninferiority margin, transfusion with group A versus group AB ERP was not associated with increased thromboembolic rates (HR, 0.52; 95% confidence interval CI, 0.31-0.90). Mortality (HR, 1.15; 95% CI, 0.91-1.45) and nonfatal complication rates (HR, 1.24; 95% CI, 0.87-1.77) were inconclusive. In the subgroup analysis, transfusion with incompatible ERP (group B or AB patients receiving group A ERP) was not associated with increased nonfatal complications (HR, 1.02; 95% CI, 0.80-1.30). There were no reported hemolytic transfusion reactions.
The use of ERP is common in patients requiring massive transfusion and facilitates the rapid balanced resuscitation of patients who have sustained blood loss. Group A ERP is an acceptable option for patients requiring massive transfusion, especially if group AB ERP is not readily available.
Therapeutic/Care Management, level IV; Prognostic, level III.
Introduction
Injuries to the inferior vena cava (IVC), while uncommon, have a high mortality despite modern advances. The goal of this study is to describe the diagnosis and management in the largest ...available prospective data set of vascular injuries across anatomic levels of IVC injury.
Methods
The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November 2013 to January 2019. Demographics, diagnostic modalities, injury patterns, and management strategies were recorded and analyzed. Comparisons between anatomic levels were made using non-parametric Wilcoxon rank-sum statistics.
Results
140 patients from 19 institutions were identified; median age was 30 years old (IQR 23-41), 75% were male, and 62% had penetrating mechanism. The suprarenal IVC group was associated with blunt mechanism (53% vs 32%, P = .02), had lower admission systolic blood pressure, pH, Glasgow Coma Scale (GCS), and higher ISS and thorax and abdomen AIS than the infrarenal injury group. Injuries were managed with open repair (70%) and ligation (30% overall; infrarenal 37% vs suprarenal 13%, P = .01). Endovascular therapy was used in 2% of cases. Overall mortality was 42% (infrarenal 33% vs suprarenal 66%, P<.001). Among survivors, there was no difference in first 24-hour PRBC transfusion requirement, or hospital or ICU length of stay.
Conclusions
Current PROOVIT registry data demonstrate continued use of ligation extending to the suprarenal IVC, limited adoption of endovascular management, and no dramatic increase in overall survival compared to previously published studies. Survival is likely related to IVC injury location and total injury burden.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Acinetobacter organisms, which are a common cause of ventilator-associated pneumonia (VAP) in some health care centers, are becoming more resistant to such first-line agents as imipenem-cilastatin ...(Imi-Cil). Sulbactam has good in vitro activity against Acinetobacter organisms; thus, ampicillin-sulbactam (Amp-Sulb) may be a viable treatment alternative. The outcomes for critically ill trauma patients with Acinetobacter VAP treated with either Amp-Sulb or Imi-Cil were compared retrospectively. A total of 77 episodes in 75 patients were studied. Fourteen patients were treated with Amp-Sulb, and 63 patients were treated with Imi-Cil. Treatment efficacy was similar in the Amp-Sulb and Imi-Cil groups (93% vs. 83%, respectively; P > .05). No statistically significant differences between groups were noted with regard to associated mortality, duration of mechanical ventilation, or length of stay in the intensive care unit or hospital. However, adjunctive aminoglycoside therapy was used more often in the Amp-Sulb group. Patients generally received Amp-Sulb because of imipenem resistance. Amp-Sulb was effective in treating a small number of patients with Acinetobacter VAP; however, more data are needed.
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BFBNIB, NUK, PNG, UL, UM, UPUK
A microfluidic strategy has been used for the time- and labour-efficient evaluation of the relative efficiency and thermodynamic parameters of CO2 binding by three Lewis acid/base combinations, where ...efficiency is based on the amount of CO2 taken up per binding unit in solution. Neither tBu3P nor B(C6F5)3 were independently effective at CO2 capture, and the combination of the imidazolin-2-ylidenamino-substituted phosphine (NIiPr)3P and B(C6F5)3 was equally ineffective. Nonetheless, an archetypal frustrated Lewis pair (FLP) comprised of tBu3P and B(C6F5)3 was shown to bind CO2 more efficiently than either the FLP derived from tetramethylpiperidine (TMP) and B(C6F5)3 or the highly basic phosphine (NIiPr)3P. Moreover, the proposed microfluidic platform was used to elucidate the thermodynamic parameters for these reactions.
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IJS, KILJ, NUK, UL, UM, UPUK
Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of ventilator-associated pneumonia (VAP). This prospective, open-label, multicenter clinical trial compared the early ...microbiological efficacy of linezolid (LZD) therapy with that of vancomycin (VAN) therapy in patients with MRSA VAP.
A total of 149 patients with suspected MRSA VAP were randomized to receive either LZD, 600 mg, or VAN, 1 g every 12 h. Patients with baseline bronchoscopic BAL (BBAL) fluid quantitative culture findings that were positive for MRSA (≥ 104 cfu/mL) comprised the study population. The primary outcome was microbiological response (≤ 102 cfu/mL) in a second BBAL performed 72 to 96 h following the start of treatment.
Thirty LZD-treated patients and 20 VAN-treated patients had microbiologically confirmed MRSA at baseline; 23 and 19 patients, respectively, underwent repeat BBAL. While a greater number of LZD-treated patients than VAN-treated patients achieved a microbiological cure (56.5% vs 47.4%, respectively; p = 0.757; 95% confidence interval, −21.1 to 39.4), this difference was not statistically significant. Nonstatistically significant differences were also seen for LZD-treated patients vs VAN-treated patients in terms of clinical cure (66.7% vs 52.9%, respectively), survival rate (86.7% vs 70.0%, respectively), and the mean duration of ventilation (10.4 vs 14.3 d, respectively), hospitalization (18.8 vs 20.1 d, respectively), ICU stay (12.2 vs 16.2 d, respectively), and time spent alive and not receiving mechanical ventilation (15.5 vs 11.1 d, respectively). Three patients who had been extubated prior to undergoing repeat BBAL had been randomized to receive LZD therapy.
Early microbiological cure rates were not statistically significantly higher with LZD therapy than with VAN therapy despite trends in all secondary clinical outcomes favoring LZD therapy. These results suggest that any beneficial effect of LZD therapy may be due to factors other than increased bacterial clearance.
Clinicaltrials.gov Identifier: NCT00572559
Optimal management of exsanguinating pelvic fractures remains controversial. Our previous experience suggested that management decisions based on a defined algorithm were associated with a ...significant reduction in transfusion requirements and mortality. Based on these outcomes, a clinical pathway (PW) for the management of exsanguinating pelvic fractures was developed. The purpose of this study was to evaluate the impact of this PW on outcomes.
Consecutive patients over 10 years with blunt pelvic fractures subsequent to the implementation of the clinical PW were identified. Patients with hemodynamically unstable pelvic fractures are managed initially with a pelvic orthotic device. For those with continued hemodynamic instability and no extrapelvic source of hemorrhage, pelvic angiography was performed followed by elective pelvic fixation. Patients managed according to the PW were compared with those patients whose management deviated (DEV) from the PW.
There were 3,467 patients identified. Three hundred twelve (9%) met entry criteria: 246 (79%) comprised the PW group and 66 (21%) the DEV group. Injury severity, as measured by Injury Severity Score (35 vs. 36; p = 0.55), admission Glasgow Coma Scale (10 vs. 10; p = 0.58), admission BE (-7.4 vs. -6.4, p = 0.38), admission SBP (107 vs. 104, p = 0.53), and PRBC requirements during initial resuscitation (6.1 units vs. 6.6 units, p = 0.22) were similar between the groups. Pelvic orthotic device use was 48% in the DEV group (p < 0.001). Twenty-four percent of the PW group required angiography compared with 74% of the DEV group (p < 0.001). Forty-eight-hour transfusions (11 vs. 16, p = 0.01) and mortality (35% vs. 48%, p = 0.04) were reduced in the PW group compared with the DEV group. Pathway adherence was identified as an independent predictor of both decreased transfusions (β = -5.8, p = 0.002) via multiple linear regression and decreased mortality (hazard ratio, 0.74; 95% confidence interval, 0.42-0.98) via multivariable cox proportional hazards analysis.
Adherence to a defined clinical PW simplified the management of exsanguinating pelvic fractures and contributed to a reduction in both transfusion requirements and mortality.
Prognostic, level III.
Traumatic atlanto-occipital dissociation is considered highly unstable and was once believed to be uniformly fatal. With recent advances in prehospital care, coupled with early diagnosis and ...stabilization, these injuries are potentially survivable. The aim of this study was to identify potentially modifiable risk factors associated with improved outcomes after a traumatic atlanto-occipital dissociation.
Patients with traumatic atlanto-occipital dissociation over a 17-year period were identified and stratified by age, sex, injury severity, and severity of shock. Time to diagnosis, time to and method of stabilization, and mortality were compared. Multivariable logistic regression was performed to determine which factors were independent predictors of mortality.
Fifty-two patients were identified with a mean age of 44, an admission Glasgow Coma Score of 8, and an Injury Severity Score of 34; of these 52 patients, 38 (73%) underwent stabilization. Overall mortality was 33%. Of the survivors, 34 patients (97%) were discharged neurologically intact. One patient was discharged with neurologic deficits. Multivariable logistic regression identified admission Glasgow Coma Score (odds ratio 0.7; 95% confidence interval 0.552–0.877) as the only independent predictor of death after traumatic atlanto-occipital dissociation.
Traumatic atlanto-occipital dissociation remains a rare injury following blunt trauma. Clinical presentation is a predictor of mortality. Prompt diagnosis is crucial in promoting rapid stabilization and improving survivability. Survival to hospital discharge portends improved functional outcome.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Following venous injury, venorrhaphy can restore outflow, although it risks thrombosis and venous thromboembolism (VTE). Vein ligation is a faster option, although it potentially risks extremity ...edema. The purpose of this study was to evaluate the management of venous injury on VTE and extremity edema in patients with isolated lower-extremity venous injuries.
Patients with common iliac, external iliac, and femoral venous injuries over a 10-year period were stratified by age, shock, management of venous injury, injury severity, and timing and type of anticoagulation. Outcomes included development of extremity edema and VTE (pulmonary embolism, deep venous thrombosis). Outcomes were then evaluated to determine risk factors for symptomatic lower-extremity edema and VTE by the management of venous injuries.
Eighty-four patients were identified: 20 common iliac, 27 external iliac, 37 femoral. Forty-nine underwent vein repair and 35 underwent vein ligation. Ninety-three percent were male with a mean Injury Severity Score and Glasgow Coma Scale score of 17 and 14, respectively. Venous thromboembolism occurred in 18 (21%), 15 (18%) deep venous thrombosis, and 4 (5%) pulmonary embolisms. Thirty-two (38%) patients developed lower-extremity edema. Those who underwent vein ligation had a greater degree of shock on presentation (RBC transfusions, 14 vs. 8 units; p = 0.03) and were more likely to receive prophylactic fasciotomies (60% vs. 33%, p = 0.01). There was no difference in time to or type of chemoprophylaxis between patients who underwent vein repair and those who received vein ligation. However, patients with vein ligation had fewer episodes of VTE (9% vs. 31%, p = 0.02) with no difference in symptomatic lower-extremity edema (37% vs. 39%, p = 0.88) or amputation rates (0% vs. 2%, p = 0.99).
Vein repair had a higher incidence of VTE while providing no additional benefit in reducing symptomatic extremity edema compared to ligation in patients suffering venous injury. Ligation of most extremity venous injuries can be performed without increasing patient morbidity.
Therapeutic study, level IV.
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