Empiric antimicrobial therapy for early-onset pneumonia in severe trauma patients

Abstract Background Hybrid emergency room (ER) systems, consisting of an angiography-computed tomography (CT) machine in a trauma resuscitation room, are reported to be effective for reducing death from exsanguination in trauma patients. We aimed to investigate the cost-effectiveness of a hybrid ER system in severe trauma patients without severe traumatic brain injury (TBI). Methods We conducted a cost-utility analysis comparing the hybrid ER system to the conventional ER system from the perspective of the third-party healthcare payer in Japan. A short-term decision tree and a long-term Markov model using a lifetime time horizon were constructed to estimate quality-adjusted life years (QALYs) and associated lifetime healthcare costs. Short-term mortality and healthcare costs were derived from medical records and claims data in a tertiary care hospital with a hybrid ER. Long-term mortality and utilities were extrapolated from the literature. The willingness-to-pay threshold was set at $47,619 per QALY gained and the discount rate was 2%. Deterministic and probabilistic sensitivity analyses were conducted. Results The hybrid ER system was associated with a gain of 1.03 QALYs and an increment of $33,591 lifetime costs compared to the conventional ER system, resulting in an ICER of $32,522 per QALY gained. The ICER was lower than the willingness-to-pay threshold if the odds ratio of 28-day mortality was < 0.66. Probabilistic sensitivity analysis indicated that the hybrid ER system was cost-effective with a 79.3% probability. Conclusion The present study suggested that the hybrid ER system is a likely cost-effective strategy for treating severe trauma patients without severe TBI.

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Splanchnic Hypoperfusion-Directed Therapies in Trauma: A Prospective, Randomized Trial

The American Surgeon ◽

10.1177/000313480507100317 ◽

2005 ◽

Vol 71 (3) ◽

pp. 252-260 ◽

Cited By ~ 7

Author(s):

Stephen M. Cohn ◽

Orlando Kirton ◽

Margaret Brown ◽

S. Morad Hameed ◽

...

Keyword(s):

Randomized Trial ◽

Injury Severity ◽

Ischemia Reperfusion ◽

Unit Group ◽

Severe Trauma ◽

Prospective Randomized Trial ◽

Gastric Tonometry ◽

Trauma Patients ◽

Splanchnic Perfusion ◽

Splanchnic Hypoperfusion

Splanchnic hypoperfusion as reflected by gastric intramucosal acidosis has been recognized as an important determinant of outcome in shock. A comprehensive splanchnic hypoperfusion-ischemia reperfusion (IRP) protocol was evaluated against conventional shock management protocols in critical trauma patients. The study was a prospective randomized trial comparing three therapeutic approaches to hypoperfusion after severe trauma in 151 trauma patients admitted to the intensive care unit. Group 1 patients received hemodynamic support based on conventional indicators of hypoperfusion. In group 2, resuscitation was further guided by gastric tonometry-derived estimates of splanchnic hypoperfusion and included more invasive hemodynamic monitoring and additional administration of colloid or crystalloid solutions, or inotropic support. Group 3 patients additionally received therapies specifically aimed at optimizing splanchnic perfusion and minimizing oxidant-mediated damage from reperfusion. The three groups were similar based on age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II Scores. There were no statistically significant differences in mortality rates, organ dysfunction, ventilator days, or length of stay between any of the interventions. Techniques of optimization of splanchnic perfusion and minimization of oxidant-mediated reperfusion injury evaluated in this study were not advantageous relative to standard resuscitation measures guided by conventional or tonometric measures of hypoperfusion in the therapy of occult and clinical shock in trauma patients.

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Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury

The American Surgeon ◽

10.1177/000313481508101231 ◽

2015 ◽

Vol 81 (12) ◽

pp. 1272-1278 ◽

Cited By ~ 1

Author(s):

Yann-Leei L. Lee ◽

Jon D. Simmons ◽

Mark N. Gillespie ◽

Diego F. Alvarez ◽

Richard P. Gonzalez ◽

...

Keyword(s):

Injury Severity ◽

Capillary Flow ◽

Severe Trauma ◽

Dark Field ◽

Serum Lactate ◽

Microvascular Perfusion ◽

Trauma Patients ◽

Sidestream Dark Field ◽

Trauma Population ◽

Severity Scores

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

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Multicentre randomised controlled trial to investigate the usefulness of continuous pneumatic regulation of tracheal cuff pressure for reducing ventilator-associated pneumonia in mechanically ventilated severe trauma patients: the AGATE study protocol

BMJ Open ◽

10.1136/bmjopen-2017-017003 ◽

2017 ◽

Vol 7 (8) ◽

pp. e017003 ◽

Cited By ~ 4

Author(s):

Nicolas Marjanovic ◽

Denis Frasca ◽

Karim Asehnoune ◽

Catherine Paugam ◽

Sigismond Lasocki ◽

...

Keyword(s):

Cuff Pressure ◽

Invasive Mechanical Ventilation ◽

Severe Trauma ◽

Control Group ◽

Trauma Patients ◽

Intermittent Control ◽

Ventilator Associated Pneumonia ◽

Pneumatic Device ◽

Randomised Controlled ◽

Tracheal Cuff

IntroductionSevere trauma represents the leading cause of mortality worldwide. While 80% of deaths occur within the first 24 hours after trauma, 20% occur later and are mainly due to healthcare-associated infections, including ventilator-associated pneumonia (VAP). Preventing underinflation of the tracheal cuff is recommended to reduce microaspiration, which plays a major role in the pathogenesis of VAP. Automatic devices facilitate the regulation of tracheal cuff pressure, and their implementation has the potential to reduce VAP. The objective of this work is to determine whether continuous regulation of tracheal cuff pressure using a pneumatic device reduces the incidence of VAP compared with intermittent control in severe trauma patients.Methods and analysisThis multicentre randomised controlled and open-label trial will include patients suffering from severe trauma who are admitted within the first 24 hours, who require invasive mechanical ventilation to longer than 48 hours. Their tracheal cuff pressure will be monitored either once every 8 hours (control group) or continuously using a pneumatic device (intervention group). The primary end point is the proportion of patients that develop VAP in the intensive care unit (ICU) at day 28. The secondary end points include the proportion of patients that develop VAP in the ICU, early (≤7 days) or late (>7 days) VAP, time until the first VAP diagnosis, the number of ventilator-free days and antibiotic-free days, the length of stay in the ICU, the proportion of patients with ventilator-associated events and that die during their ICU stay.Ethics and disseminationThis protocol has been approved by the ethics committee of Poitiers University Hospital, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.Trial registrationClinical TrialsNCT02534974

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A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

European Geriatric Medicine ◽

10.1007/s41999-021-00546-9 ◽

2021 ◽

Author(s):

Y. Kalbas ◽

M. Lempert ◽

F. Ziegenhain ◽

J. Scherer ◽

V. Neuhaus ◽

...

Keyword(s):

Length Of Stay ◽

Injury Severity ◽

Descriptive Analysis ◽

Patient Characteristics ◽

Severe Trauma ◽

Diagnostic Tools ◽

Trauma Patients ◽

Treatment Algorithms ◽

Injured Patients ◽

Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

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Abstract 287: Plasma PCSK9 Concentrations in Critically Ill Patients

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.32.suppl_1.a287 ◽

2012 ◽

Vol 32 (suppl_1) ◽

Author(s):

Bertrand Cariou ◽

Maëlle Le Bras ◽

Antoine Roquilly ◽

Fanny Feuillet ◽

Véronique Sebille ◽

...

Keyword(s):

Multiple Trauma ◽

Injury Severity ◽

Ldl Receptor ◽

Plasma Lipid ◽

Severity Of Illness ◽

Inverse Correlation ◽

Severe Trauma ◽

Trauma Patients ◽

Intensive Care Patients ◽

Pearson Coefficient

Objective. Pro-protein convertase subtilisin/kexin type 9 (PCSK9) is a circulating protein that impairs LDL clearance by promoting the LDL receptor (LDLR) degradation. Plasma lipid parameters (LDL-C and HDL-C) are related to severity of illness and survival in intensive care patients. Here, we aimed to determine whether circulating PCSK9 concentrations were correlated to the severity of illness in patients with multiple trauma. Methods/Results. Plasma PCSK9 were measured, at day 0 and 8 after admission, by ELISA in 111 patients hospitalized in ICU for severe trauma. Patients were included in the HIPOLYTE study and were randomly assigned to hydrocortisone therapy or placebo. Plasma PCSK9 levels were significantly increased by 161% at day 8 compared to day 0 (481 ± 227 vs 231 ± 117 ng/ml, P=0.0001). Hydrocortisone therapy did not alter PCSK9 concentrations at day 8 compared to placebo (451 ± 216 vs 511 ± 239ng/ml, P=0.33). In the whole population of the study, PCSK9 was positively associated with LDL-C (Pearson coefficient : 0.26, p=0.007) at day 0, but not with markers of severity illness. At day 8, an inverse correlation was found between PCSK9 and HDL-C (β =-653 ; P=0.004). Interestingly, PCSK9 concentrations at day 8 were related to markers of severity illness as injury severity score (β =6.17 ; P=0.0007), length of stay in ICU (β =6.14 ; P=0.0001), duration of both mechanical ventilation (β =8.26 ; P=0.0001) and cathecolamines infusion (β =18.57; P=0.015). Conclusion. PCSK9 appears as a late biomarker of severity illness in patients hospitalized for multiple trauma in ICU. These results open new perspectives for a role of PCSK9 in critical illness.

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Appropriateness of empiric antimicrobial therapy with imipenem/colistin in severe septic patients: observational cohort study

Annals of Clinical Microbiology and Antimicrobials ◽

10.1186/s12941-018-0292-7 ◽

2018 ◽

Vol 17 (1) ◽

Author(s):

Ahlem Trifi ◽

Sami Abdellatif ◽

Cyrine Abdennebi ◽

Foued Daly ◽

Rochdi Nasri ◽

...

Keyword(s):

Cohort Study ◽

Antimicrobial Therapy ◽

Observational Cohort Study ◽

Empiric Antimicrobial Therapy ◽

Observational Cohort

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Impact of Inactive Empiric Antimicrobial Therapy on Inpatient Mortality and Length of Stay

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00466-06 ◽

2006 ◽

Vol 50 (10) ◽

pp. 3355-3360 ◽

Cited By ~ 27

Author(s):

Kimberly K. Scarsi ◽

Joe M. Feinglass ◽

Marc H. Scheetz ◽

Michael J. Postelnick ◽

Maureen K. Bolon ◽

...

Keyword(s):

Length Of Stay ◽

Antimicrobial Therapy ◽

Medical Center ◽

Academic Medical Center ◽

Bloodstream Infections ◽

Empiric Therapy ◽

Inpatient Mortality ◽

In Vitro Susceptibility ◽

Empiric Antimicrobial Therapy

ABSTRACT The consequences of inactive empiric antimicrobial therapy are not well-described and may cause prolonged hospitalization or infection-related mortality. In vitro susceptibility results for 884 patients hospitalized at an academic medical center with gram-negative bloodstream infections (GNBI) from 2001 to 2003 were matched to antimicrobial orders within 24 h of culture. Clinical characteristics, organism, inpatient mortality, and length of stay after culture for patients with GNBI were compared between patients receiving active versus inactive empiric antimicrobial therapy. A total of 14.1% of patients with GNBI received inactive empiric therapy, defined as no antimicrobial therapy within 24 h of the culture active against the identified organism based on in vitro microbiology reports. Patients who received inactive therapy were more likely to be younger, to be infected with Pseudomonas aeruginosa, to have a nosocomial infection, and to receive antimicrobial monotherapy but less likely to be bacteremic with Escherichia coli or to have sepsis (P < 0.05). There were no significant differences in mortality between patients receiving active versus inactive empiric therapy (16.1% versus 13.6%, respectively) or in length of stay after positive culture (11.5 days versus 12.6 days, respectively). Only 45 patients had greater than 2 days of exposure to inactive therapy; however, 8/30 patients (26.7%) who never received active antimicrobial therapy died while in the hospital. Inactive empiric therapy was more common in healthier patients. Inactive antimicrobial therapy in the first 24 h did not significantly impact average outcomes for GNBI among hospitalized patients but may have caused harm to specific individuals.

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