Intra-Abdominal Hypertension Is More Common Than Previously Thought: A Prospective Study in a Mixed Medical-Surgical ICU. Murphy PB, Parry NG, Sela N, Leslie K, Vogt K, Ball I. Crit Care Med. 2018 Jun;46(6):958-964.
Intra-abdominal hypertension (IAH) and intra-abdominal compartment syndrome are known to contribute to patient morbidity and mortality. However, there is contradictory information on the significance of intra-abdominal hypertension This study by Murphy et al. applied the WSACS definitions to determine the prevalence of intra-abdominal hypertension and its association with patient outcome.
Murphy et al. examined consecutively admitted patients to a mixed surgical-medical ICU at a tertiary care center. A total of 386 patients were admitted in the ICU over the study period and 285 patients were included in the final analysis. The prevalence of IAH at admission at 24 hours was 30%, and an additional 15% developed IAH during their ICU stay. The overall prevalence was 45%. Those diagnosed with IAH had worse outcomes including higher mortality and longer LOS. Overall ICU mortality was found to be 20% and was significantly higher in patients diagnosed with IAH. In a multivariable model attempting to predict ICU mortality, IAH was an independent predictor of ICU mortality (OR, 3.33; 95% CI, 1.46–7.57; p = 0.004). The most common cause of death for all patients was withdrawal of care (73%), followed by cardiorespiratory death (23%) and brain death (2%). Factors associated with development of IAH included sepsis, obesity, a positive fluid balance, and mechanical ventilation.
Murphy at al. demonstrate that IAH was equally distributed among medical, surgical, and trauma admissions, confirming the hypothesis that intra-abdominal pathology is not required for the development of IAH. The study shows a clear association between IAH and ICU mortality. Further studies are needed to study the effect of early interventions on clinical outcome.
Indications and outcomes of extracorporeal life support in trauma patients. Swol J, Brodie D, Napolitano L, Park PK, Thiagarajan R, Barbaro RP, Lorusso R, McMullan D, Cavarocchi N, Hssain AA, Rycus P, Zonies D; Extracorporeal Life Support Organization (ELSO). J Trauma Acute Care Surg. 2018 Jun;84(6):831-837.
The use of extracorporeal life support (ECLS) in the trauma population remains controversial and has been reported only in small cohort studies. Advances in ECLS have increased its role in trauma care. Swol et al. performed a multi-institutional retrospective study to assess the indications and outcomes of ECLS in trauma.
Two hundred seventy-nine trauma patients were identified (0.92% of 30,273 adult ECLS patients). Extracorporeal life support increased significantly in the last 5 years (173 in 2011–2016, 62%) compared with 106 in the prior 18 years. Thoracic injury was the most common diagnosis; acute respiratory distress syndrome was the most common indication. Extracorporeal life support duration was 8.8 ± 9.5 days and was longer for respiratory support (9.3 ± 9.3 days) vs. cardiac support (4.1 ± 4.5 days) and ECLS-supported cardiopulmonary resuscitation (6.5 ± 16.8 days). Overall survival from ECLS was 70% and survival to hospital discharge was 61%in the total cohort, similar to survival rates in other ELSO registry cohorts. More than 80% of patients had a reported complication during ECLS support. The most common complication was cardiovascular (51%) followed by hemorrhage (29%). The most common cause of death was multisystem organ failure (15.4%).
Swol et al. demonstrate reasonable survival among trauma patients undergoing ECLS. With growing experience and improved safety profile, trauma should not be considered a contraindication for ECLS. Further studies are needed to identify appropriate trauma candidates to optimize outcomes.
Reinventing the wheel: Impact of prolonged antibiotic exposure on multidrug-resistant ventilator-associated pneumonia in trauma patients. Lewis RH, Sharpe JP, Swanson JM, Fabian TC, Croce MA, Magnotti LJ. J Trauma Acute Care Surg. 2018 Aug;85(2):256-262.
Multidrug-resistant (MDR) strains of both Acinetobacter baumannii (AB) and Pseudomonas aeruginosa (PA) as causative ventilator-associated pneumonia (VAP) pathogens are becoming increasingly common. Magnotti et al. prospectively examined the changing sensitivity patterns of these pathogens over ten years and studied which risk factors for MDR in trauma patients with VAP.
Three hundred ninety-seven patients were identified with AB or PA VAP. There were 173 episodes of AB (91 sensitive and 82 MDR) and 224 episodes of PA (170 sensitive and 54 MDR). The incidence of MDR VAP did not change over the period (p = 0.633). Groups were clinically similar except for 24-hour transfusions (14 vs. 19 units, p = 0.009) and extremity Abbreviated Injury Scale (AIS) score (1 vs. 3, p < 0.001), both were significantly increased in the MDR group. Antibiotic exposure as well as multiple episodes of inadequate empiric antibiotic therapy (mIEAT) (63% vs. 81%, p < 0.001) were significantly increased in the MDR group. Multivariable logistic regression identified prophylactic antibiotic days (odds ratio, 23.1; 95% confidence interval, 16.7–28, p < 0.001) and mIEAT (odds ratio, 18.1; 95% confidence interval, 12.2–26.1, p = 0.001) as independent predictors of MDR.
Magnotti et al. demonstrate prolonged exposure to unnecessary antibiotics remains one of the strongest predictors for the development of antibiotic resistance. Limiting prophylactic antibiotic days is the only potentially modifiable risk factor for the development of MDR VAP in trauma patients.