AAST Annual Meeting 2012

Post-trauma deep vein thrombosis and pulmonary embolism diagnoses in severely injured blunt trauma patients were associated with different clinical risk factors, leading researchers to consider that the two "may represent distinct pathophysiologic entities."

At the meeting, Dr. Scott C. Brakenridge also pointed to other recent findings, including a study that found that more than half of pulmonary embolism (PE) cases are diagnosed within the first few days of injury (Am. J. Surg. 2011;201:209-15).

"We believe these findings bring into question whether the conventional wisdom of peripheral thrombosis and subsequent embolism is an oversimplification of thromboembolic pathophysiology after injury," said Dr. Brakenridge, a trauma/surgical critical care and vascular surgery fellow, at Harborview Medical Center and the University of Washington, Seattle.

In the multicenter prospective observational study, he and his coinvestigators compared clinical risk factors for deep vein thrombosis (DVT) and PE in 1,822 severely injured blunt trauma patients with evidence of hemorrhagic shock, treated at one of five urban trauma centers from 2002 to 2011. Most were male, their median age was 41 years, and the median injury severity score was 33; they received a mean of 6 U of packed red blood cells and 12 L crystalloid resuscitation over the first 24 hours.

Within 28 days of injury, 95 patients (5.1%) were diagnosed with a DVT and 83 (3.9%) were diagnosed with a PE; the total number of patients diagnosed with the traditional composite end point of venous thromboembolism (VTE) was 159 (8.5%). Of the 159 patients with VTE, only 6% (9 patients) were diagnosed with both DVT and PE.

Risk factors for the composite end point VTE resembled those from other studies. However, when analyzed individually, DVT and PE exhibited differences in their risk-factor profiles. The independent risk factors identified among those diagnosed with a DVT were failure to initiate prophylaxis within the first 48 hours, a thoracic abbreviated injury score of 3 or more, and body mass index above 28 kg/m². Independent risk factors for PE were serum lactate greater than 5 mmol/L and male gender. The median times to diagnosis of DVT and PE were similar at approximately 10 days.

These results indicate that the risk factors for a clinical DVT diagnosis after severe blunt trauma "appear to represent the inability to initiate prompt pharmacologic prophylaxis, overall injury burden and obesity, while risk factors for PE are gender specific and consistent with a severe shock state." Dr. Brakenridge said.

Mechanistically, he and his associates are suggesting that while a predisposition to DVT and PE may share "a postinjury hypercoagulopathic state ... their discordance may be secondary to differences in local factors such as tissue injury, stasis, and endothelial damage, as well as systemic influences such as a severe shock state," he added.

The study had limitations, including a lack of standardized DVT screening protocols, and more prospective studies that evaluate the pathophysiology, diagnosis, and treatment of DVT and PE early after injury are needed, Dr. Brakenridge said. "If borne out in future prospective studies, this could have significant implications for the diagnosis, and treatment of postinjury DVT and PE," he added.

Dr. Brakenridge and his coinvestigators reported having no disclosures.

Post-trauma deep vein thrombosis and pulmonary embolism diagnoses in severely injured blunt trauma patients were associated with different clinical risk factors, leading researchers to consider that the two "may represent distinct pathophysiologic entities."

At the meeting, Dr. Scott C. Brakenridge also pointed to other recent findings, including a study that found that more than half of pulmonary embolism (PE) cases are diagnosed within the first few days of injury (Am. J. Surg. 2011;201:209-15).

"We believe these findings bring into question whether the conventional wisdom of peripheral thrombosis and subsequent embolism is an oversimplification of thromboembolic pathophysiology after injury," said Dr. Brakenridge, a trauma/surgical critical care and vascular surgery fellow, at Harborview Medical Center and the University of Washington, Seattle.

In the multicenter prospective observational study, he and his coinvestigators compared clinical risk factors for deep vein thrombosis (DVT) and PE in 1,822 severely injured blunt trauma patients with evidence of hemorrhagic shock, treated at one of five urban trauma centers from 2002 to 2011. Most were male, their median age was 41 years, and the median injury severity score was 33; they received a mean of 6 U of packed red blood cells and 12 L crystalloid resuscitation over the first 24 hours.

Within 28 days of injury, 95 patients (5.1%) were diagnosed with a DVT and 83 (3.9%) were diagnosed with a PE; the total number of patients diagnosed with the traditional composite end point of venous thromboembolism (VTE) was 159 (8.5%). Of the 159 patients with VTE, only 6% (9 patients) were diagnosed with both DVT and PE.

Risk factors for the composite end point VTE resembled those from other studies. However, when analyzed individually, DVT and PE exhibited differences in their risk-factor profiles. The independent risk factors identified among those diagnosed with a DVT were failure to initiate prophylaxis within the first 48 hours, a thoracic abbreviated injury score of 3 or more, and body mass index above 28 kg/m². Independent risk factors for PE were serum lactate greater than 5 mmol/L and male gender. The median times to diagnosis of DVT and PE were similar at approximately 10 days.

These results indicate that the risk factors for a clinical DVT diagnosis after severe blunt trauma "appear to represent the inability to initiate prompt pharmacologic prophylaxis, overall injury burden and obesity, while risk factors for PE are gender specific and consistent with a severe shock state." Dr. Brakenridge said.

Mechanistically, he and his associates are suggesting that while a predisposition to DVT and PE may share "a postinjury hypercoagulopathic state ... their discordance may be secondary to differences in local factors such as tissue injury, stasis, and endothelial damage, as well as systemic influences such as a severe shock state," he added.

The study had limitations, including a lack of standardized DVT screening protocols, and more prospective studies that evaluate the pathophysiology, diagnosis, and treatment of DVT and PE early after injury are needed, Dr. Brakenridge said. "If borne out in future prospective studies, this could have significant implications for the diagnosis, and treatment of postinjury DVT and PE," he added.

Dr. Brakenridge and his coinvestigators reported having no disclosures.

Post-trauma deep vein thrombosis and pulmonary embolism diagnoses in severely injured blunt trauma patients were associated with different clinical risk factors, leading researchers to consider that the two "may represent distinct pathophysiologic entities."

At the meeting, Dr. Scott C. Brakenridge also pointed to other recent findings, including a study that found that more than half of pulmonary embolism (PE) cases are diagnosed within the first few days of injury (Am. J. Surg. 2011;201:209-15).

"We believe these findings bring into question whether the conventional wisdom of peripheral thrombosis and subsequent embolism is an oversimplification of thromboembolic pathophysiology after injury," said Dr. Brakenridge, a trauma/surgical critical care and vascular surgery fellow, at Harborview Medical Center and the University of Washington, Seattle.

In the multicenter prospective observational study, he and his coinvestigators compared clinical risk factors for deep vein thrombosis (DVT) and PE in 1,822 severely injured blunt trauma patients with evidence of hemorrhagic shock, treated at one of five urban trauma centers from 2002 to 2011. Most were male, their median age was 41 years, and the median injury severity score was 33; they received a mean of 6 U of packed red blood cells and 12 L crystalloid resuscitation over the first 24 hours.

Within 28 days of injury, 95 patients (5.1%) were diagnosed with a DVT and 83 (3.9%) were diagnosed with a PE; the total number of patients diagnosed with the traditional composite end point of venous thromboembolism (VTE) was 159 (8.5%). Of the 159 patients with VTE, only 6% (9 patients) were diagnosed with both DVT and PE.

Risk factors for the composite end point VTE resembled those from other studies. However, when analyzed individually, DVT and PE exhibited differences in their risk-factor profiles. The independent risk factors identified among those diagnosed with a DVT were failure to initiate prophylaxis within the first 48 hours, a thoracic abbreviated injury score of 3 or more, and body mass index above 28 kg/m². Independent risk factors for PE were serum lactate greater than 5 mmol/L and male gender. The median times to diagnosis of DVT and PE were similar at approximately 10 days.

These results indicate that the risk factors for a clinical DVT diagnosis after severe blunt trauma "appear to represent the inability to initiate prompt pharmacologic prophylaxis, overall injury burden and obesity, while risk factors for PE are gender specific and consistent with a severe shock state." Dr. Brakenridge said.

Mechanistically, he and his associates are suggesting that while a predisposition to DVT and PE may share "a postinjury hypercoagulopathic state ... their discordance may be secondary to differences in local factors such as tissue injury, stasis, and endothelial damage, as well as systemic influences such as a severe shock state," he added.

The study had limitations, including a lack of standardized DVT screening protocols, and more prospective studies that evaluate the pathophysiology, diagnosis, and treatment of DVT and PE early after injury are needed, Dr. Brakenridge said. "If borne out in future prospective studies, this could have significant implications for the diagnosis, and treatment of postinjury DVT and PE," he added.

Dr. Brakenridge and his coinvestigators reported having no disclosures.

An approach to sedating intubated patients in the intensive care unit, designed to minimize continuous analgesic and sedative infusions, was associated with better outcomes than was the sedation interruption regimen previously used, according to a retrospective study of almost 1,500 patients.

The new approach resulted in a nearly 80% reduction in the overall use of sedatives and narcotics, as well as fewer infections and days spent on a ventilator – with no increase in patient discomfort, falls, or unintended extubations, Brenton J. LaRiccia, RPA, lead physician assistant in the Kessler Family Burn Trauma Intensive Care Unit (BTICU) at Strong Memorial Hospital, Rochester, N.Y., reported at the annual meeting of the American Association for the Surgery of Trauma.

Courtesy Kessler Trauma Center

Protocols that address the worse outcomes associated with oversedation of mechanically ventilated patients include sedation interruption (SI) regimens. While the interruption regimens have been shown to reduce sedation use in medical ICUs, their regimens in trauma ICUs have been unclear, said Mr. LaRiccia, who is also in the division of acute care surgery at the University of Rochester (N.Y.).

In 2011, a protocol designed to minimize the use of continuous infusions was implemented at the BTICU at Strong Memorial Hospital, which he described as "aggressive upfront bolus dosing" of analgesic and sedative medications during the first hour of admission, continuous infusions if the bolus dosing was not effective, followed by "nursing-driven regimented weaning of all medications," both intermittently dosed and continuous medications.

The study compared outcomes associated with this approach among 749 patients admitted to the trauma ICU in 2011 with outcomes among 743 patients in 2009, when the SI protocol was still used. The patients (average age 55-57 years) were all ventilated and had similar APACHE II scores; burn patients and those who required hourly neurologic checks were not included.

Compared with the SI regimen, the new regimen was associated with significantly fewer sedation days (a total of 344 vs. 1,784 days) and significantly fewer days on a ventilator (an average of 6.2 vs. 8.4 days ). In addition, about one-fourth of those on the new protocol never required a continuous infusion of a sedative or analgesic, which "was in stark contrast to our prior sedation interruption–based practice where almost all intubated patients were placed on continuous infusions on arrival to the BTICU," Mr. LaRiccia said. (Among those on the SI protocol, 11% never required continuous sedatives and 13% never required continuous narcotics, compared with 25% and 27%, respectively, of those on the new protocol, statistically significant differences).

Mortality (18%-19%) and the average ICU length of stay (almost 10 days), as well as pain scores and the total number of falls and self-extubation rates, were similar between the two groups. Limitations of the study include the retrospective analysis, the single ICU setting, and the relatively small sample size and lack of long-term data, and more studies are needed to confirm these results, he pointed out.

The results indicate that an analgesia-based protocol implemented on ICU admission, which "focuses on front loading analgesia with upfront use of intermittent pain medications and sedation medications, instead of continuous infusions with sedation, greatly decreases ICU sedation use," and is well-tolerated by patients, reduces ICU infection rates and ventilator days without significant complications, Mr. LaRiccia concluded.

"By moving beyond the sedation interruption mindset, we change our goal from being ‘When can this sedation be stopped?’ to ‘Does this sedation even need to be started?’ – thereby truly optimizing patient care," he added, emphasizing that a multidisciplinary effort is needed to ensure that the protocol is implemented properly.

He and his coinvestigators reported having no relevant financial conflicts.

An approach to sedating intubated patients in the intensive care unit, designed to minimize continuous analgesic and sedative infusions, was associated with better outcomes than was the sedation interruption regimen previously used, according to a retrospective study of almost 1,500 patients.

The new approach resulted in a nearly 80% reduction in the overall use of sedatives and narcotics, as well as fewer infections and days spent on a ventilator – with no increase in patient discomfort, falls, or unintended extubations, Brenton J. LaRiccia, RPA, lead physician assistant in the Kessler Family Burn Trauma Intensive Care Unit (BTICU) at Strong Memorial Hospital, Rochester, N.Y., reported at the annual meeting of the American Association for the Surgery of Trauma.

Courtesy Kessler Trauma Center

Protocols that address the worse outcomes associated with oversedation of mechanically ventilated patients include sedation interruption (SI) regimens. While the interruption regimens have been shown to reduce sedation use in medical ICUs, their regimens in trauma ICUs have been unclear, said Mr. LaRiccia, who is also in the division of acute care surgery at the University of Rochester (N.Y.).

In 2011, a protocol designed to minimize the use of continuous infusions was implemented at the BTICU at Strong Memorial Hospital, which he described as "aggressive upfront bolus dosing" of analgesic and sedative medications during the first hour of admission, continuous infusions if the bolus dosing was not effective, followed by "nursing-driven regimented weaning of all medications," both intermittently dosed and continuous medications.

The study compared outcomes associated with this approach among 749 patients admitted to the trauma ICU in 2011 with outcomes among 743 patients in 2009, when the SI protocol was still used. The patients (average age 55-57 years) were all ventilated and had similar APACHE II scores; burn patients and those who required hourly neurologic checks were not included.

Compared with the SI regimen, the new regimen was associated with significantly fewer sedation days (a total of 344 vs. 1,784 days) and significantly fewer days on a ventilator (an average of 6.2 vs. 8.4 days ). In addition, about one-fourth of those on the new protocol never required a continuous infusion of a sedative or analgesic, which "was in stark contrast to our prior sedation interruption–based practice where almost all intubated patients were placed on continuous infusions on arrival to the BTICU," Mr. LaRiccia said. (Among those on the SI protocol, 11% never required continuous sedatives and 13% never required continuous narcotics, compared with 25% and 27%, respectively, of those on the new protocol, statistically significant differences).

Mortality (18%-19%) and the average ICU length of stay (almost 10 days), as well as pain scores and the total number of falls and self-extubation rates, were similar between the two groups. Limitations of the study include the retrospective analysis, the single ICU setting, and the relatively small sample size and lack of long-term data, and more studies are needed to confirm these results, he pointed out.

The results indicate that an analgesia-based protocol implemented on ICU admission, which "focuses on front loading analgesia with upfront use of intermittent pain medications and sedation medications, instead of continuous infusions with sedation, greatly decreases ICU sedation use," and is well-tolerated by patients, reduces ICU infection rates and ventilator days without significant complications, Mr. LaRiccia concluded.

"By moving beyond the sedation interruption mindset, we change our goal from being ‘When can this sedation be stopped?’ to ‘Does this sedation even need to be started?’ – thereby truly optimizing patient care," he added, emphasizing that a multidisciplinary effort is needed to ensure that the protocol is implemented properly.

He and his coinvestigators reported having no relevant financial conflicts.

An approach to sedating intubated patients in the intensive care unit, designed to minimize continuous analgesic and sedative infusions, was associated with better outcomes than was the sedation interruption regimen previously used, according to a retrospective study of almost 1,500 patients.

The new approach resulted in a nearly 80% reduction in the overall use of sedatives and narcotics, as well as fewer infections and days spent on a ventilator – with no increase in patient discomfort, falls, or unintended extubations, Brenton J. LaRiccia, RPA, lead physician assistant in the Kessler Family Burn Trauma Intensive Care Unit (BTICU) at Strong Memorial Hospital, Rochester, N.Y., reported at the annual meeting of the American Association for the Surgery of Trauma.

Courtesy Kessler Trauma Center

Protocols that address the worse outcomes associated with oversedation of mechanically ventilated patients include sedation interruption (SI) regimens. While the interruption regimens have been shown to reduce sedation use in medical ICUs, their regimens in trauma ICUs have been unclear, said Mr. LaRiccia, who is also in the division of acute care surgery at the University of Rochester (N.Y.).

In 2011, a protocol designed to minimize the use of continuous infusions was implemented at the BTICU at Strong Memorial Hospital, which he described as "aggressive upfront bolus dosing" of analgesic and sedative medications during the first hour of admission, continuous infusions if the bolus dosing was not effective, followed by "nursing-driven regimented weaning of all medications," both intermittently dosed and continuous medications.

The study compared outcomes associated with this approach among 749 patients admitted to the trauma ICU in 2011 with outcomes among 743 patients in 2009, when the SI protocol was still used. The patients (average age 55-57 years) were all ventilated and had similar APACHE II scores; burn patients and those who required hourly neurologic checks were not included.

Compared with the SI regimen, the new regimen was associated with significantly fewer sedation days (a total of 344 vs. 1,784 days) and significantly fewer days on a ventilator (an average of 6.2 vs. 8.4 days ). In addition, about one-fourth of those on the new protocol never required a continuous infusion of a sedative or analgesic, which "was in stark contrast to our prior sedation interruption–based practice where almost all intubated patients were placed on continuous infusions on arrival to the BTICU," Mr. LaRiccia said. (Among those on the SI protocol, 11% never required continuous sedatives and 13% never required continuous narcotics, compared with 25% and 27%, respectively, of those on the new protocol, statistically significant differences).

Mortality (18%-19%) and the average ICU length of stay (almost 10 days), as well as pain scores and the total number of falls and self-extubation rates, were similar between the two groups. Limitations of the study include the retrospective analysis, the single ICU setting, and the relatively small sample size and lack of long-term data, and more studies are needed to confirm these results, he pointed out.

The results indicate that an analgesia-based protocol implemented on ICU admission, which "focuses on front loading analgesia with upfront use of intermittent pain medications and sedation medications, instead of continuous infusions with sedation, greatly decreases ICU sedation use," and is well-tolerated by patients, reduces ICU infection rates and ventilator days without significant complications, Mr. LaRiccia concluded.

"By moving beyond the sedation interruption mindset, we change our goal from being ‘When can this sedation be stopped?’ to ‘Does this sedation even need to be started?’ – thereby truly optimizing patient care," he added, emphasizing that a multidisciplinary effort is needed to ensure that the protocol is implemented properly.

He and his coinvestigators reported having no relevant financial conflicts.