Surgery News - January 2008 - (Page 10) 10 TRAUMA When the study period was divided into two halves, the VAP rate dropped from 9.2 cases/1,000 ventilator days in the first half to 1.4 in the latter months. In the trauma/surgical ICU, the VAP rate was 13.7 cases/1,000 ventilator days in the first half and 11.6 in the second half, a nonsignificant difference. The VAP rate in the cardiac and pulmonary ICU went from 6.2 to 3.0 cases/1,000 ventilator days. Discussant Dr. Gregory J. Jurkovich said these results support the notion that the pneumonia commonly seen in trauma patients differs from that encountered in medical or coronary ICUs. “Rather than calling it ventilator-associated pneumonia in these trauma patients, perhaps we should call it CTAP—chest trauma–associated pneumonia; or IAP— injury-associated pneumonia; or RAP—resuscitation-associated pneumonia,” added Dr. Jurkovich, an ACS Fellow, professor of surgery at the University of Washington, SURGERY NEWS • J A N U A RY 2 0 0 8 VAP Rates Rose in Surgical Patients Ventilator • from page 1 rounds together. The hospital introduced the four-pronged ventilator bundle—the same as that advocated in the 5 Million Lives Campaign of the Institute for Healthcare Improvement—as a quality improvement initiative in August 2005. Prior to implementation, ICU nurses and respiratory therapists received several months of intensive education. Compliance with the ventilator bundle was tracked daily, and VAP diagnosis was based upon the Centers for Disease Control and Prevention definition. The VAP rate in the medical ICU fell from 7.8 cases/1,000 ventilator days at baseline to 2.0/1,000 ventilator days in the seventh quarter with the ventilator bundle. But the rate increased slightly in the trauma/surgical ICU from 10 to 11.9 cases. mance, as seems highly likely, then those bundles need to be revised and made more relevant to trauma/surgical patients so hospitals and surgeons aren’t unfairly penalized, Dr. Offner said. Ventilator-associated pneumonia (VAP) is the most common ICU-acquired infection and accounts for substantial morbidity, mortality, and health care cost. Numerous medical centers have reported success in sustaining extremely low VAP rates since introducing ventilator bundles. But these reports emanate from medical ICUs, not trauma/surgical ICUs, he said. St. Anthony is a busy urban tertiary referral center with just under 3,000 trauma admissions per year. The hospital has trauma surgeons and critical care medicine physicians are on site 24/7, and they do and chief of the trauma service at Harborview Medical Center, Seattle. “The four strategies in the ventilator bundle are advocated by the medicinedominated critical care societies,” he continued. “This type of work [by Dr. Offner] is important as we become more beholden to national norms and practice guidelines.” Asked which of the four bundle elements had the poorest compliance, Dr. Offner said it was, to his considerable surprise, elevating the bed head. “I thought that would be the one that would be easiest to implement. But the nurses worry about pressure ulcers, the patient sliding out of the bed, things like that,” he said. He and his colleagues are considering incorporating into their ventilator bundle rigorous hand hygiene, routine use of a secretory tube for suction, and early tracheostomy in selected patients. ■ Transfusion Ratio Reexamined for Role in Multiorgan Failure BY BRUCE JANCIN Else vier Global Medical Ne ws C O L O R A D O S P R I N G S — Early transfusion of fresh frozen plasma in the resuscitation of patients with early post- injury coagulopathy appears to be independently associated with an increased risk of subsequent multiorgan failure, according to a prospective cohort study of critically injured patients. Moreover, the increasingly popular prac- At U.S. trauma centers, FFP is increastice of delivering units of fresh frozen plasma (FFP) and packed red blood cells ingly being delivered together with RBCs (RBCs) in a fixed 1:1 ratio also may be in a fixed 1:1 ratio. Much of the impetus counterproductive in patients with early for this strategy comes from highly favorpostinjury coagulopathy and shock. This able reports by U.S. combat surgeons who strategy needs to be reexamined, accord- use this protocol in Iraq and Afghanistan. But when Dr. Johnson and ing to Dr. Jeffrey L. Johnson, an coworkers plotted 30-day surACS Fellow and director of the vival of the Denver cohort surgical ICU at Denver Health against the ratio of FFP to Medical Center. RBCs administered, they found He presented his study of a U-shaped curve. Mortality the relationship between transwas highest at ratios of 1:5 and fusion and postinjury multiorabove, lowest with ratios of 1:2 gan failure (MOF) at the annuand 1:3, but also high at 1:1. al meeting of the Western They also identified an inSurgical Association. The study teraction between the volumes involved 1,415 Denver Health Patients given of FFP and RBCs that were givICU patients who had survived 10 U of fresh more than 48 hours after they frozen plasma had en. The risk of MOF associatsustained critical injuries dur- a sevenfold higher ed with FFP was significantly greater in patients who reing 1992-2004. adjusted risk of Their mean age was 37 years, multiorgan failure. ceived 6 U of RBCs or fewer, compared with those who got and all were older than age 15. DR. JOHNSON more. For example, the adjustBlunt trauma was the mechanism of injury in three-quarters of cases. ed risk of MOF increased nearly sevenfold The mean Injury Severity Score was 30. in patients who got 10 U of FFP but fewTwenty-four percent of patients devel- er than 6 U of RBCs, while the risk of MOF oped MOF. Overall 30-day mortality in the attributable to FFP merely doubled in those who received more than 6 U of RBCs. study population was 8%. In contrast, platelet transfusion was not In an earlier influential 1997 study, the Denver Health group demonstrated a lin- associated with MOF. These new findings underscore how litear relationship between the number of units of RBCs given in the first 12 hours tle is understood about the early biology after injury and the risk of subsequent of trauma, Dr. Johnson said. His study prompted several audience MOF. Those who got more than 20 units had an MOF incidence in excess of 50%. members to vow that they would examine That study helped trigger a widespread the impact of early use of FFP in a 1:1 rachange in trauma practice, with greater tio with RBCs on their own institutional early use of FFP and less use of RBCs. But MOF rates. Dr. Stephen Cohn, an ACS Fellow and the pendulum may now have swung too far in the other direction, since FFP de- chair of the surgery department at the velops biologically active metabolites dur- University of Texas at San Antonio, coming storage that can exacerbate the im- mended Dr. Johnson for “challenging the munologic dysfunction that can result in current sacred cow” of the 1:1 FFP to RBC ratio. MOF, according to Dr. Johnson. On the other hand, Dr. David W. MerIndeed, when he and his coinvestigators plotted the number of units of FFP given cer, an ACS Fellow, vice chairman of the in the first 12 hours against the incidence surgery department, and chief of general of MOF in the Denver cohort, they found surgery, trauma, and critical care at the the odds of MOF increased in a nearly lin- University of Texas at Houston, remarked ear fashion after adjustment for patient age that surgeons there have shown a signifiand Injury Severity Score. Patients who re- cant reduction in mortality since moving ceived 10 U had a sevenfold increased risk. to a 1:1 ratio in the past year. ■ http://www.ce-university.org/surgery
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