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Biomedical subjects

Richard P Dutton

Publications and source records attributed to Richard P Dutton.

At least 19 recordsLinked to original sources
PubMed2007

Sublingual capnometry for rapid determination of the severity of hemorrhagic shock.

BACKGROUND: Sublingual capnometry (SLCO2) is a rapid, minimally invasive bedside test of focal tissue perfusion. We hypothesized that SLCO2 could diagnose hemorrhagic shock and monitor adequacy of resuscitation. We compared the ability of SLCO2, serum lactate (LAC), and base deficit (BD) to predict outcome in hypotensive trauma patients. METHODS: Prospective, observational trial at two Level I trauma centers was performed. Inclusion criteria were blunt or penetrating trauma patients, age > or =16 years, with hypotension (systolic blood pressure < or =90 mm Hg). SLCO2, LAC, and BD were measured in each patient at admission, at the end of active hemorrhage, and at 6, 24, and 48 hours. Data are reported as means (+/-SD). RESULTS: A total of 86 patients were enrolled: mean age 35 (+/-17) years, 80% male, 51% blunt trauma, Injury Severity Score score 20 (+/-14). Twenty patients died. SLCO2 at admission was 52.4 (+/-13.3) in survivors versus 87.9 (+/-35.6) in nonsurvivors (p < 0.001). Receiver operating characteristic (ROC) curves showed that SLCO2, LAC, and BD were all good predictors of mortality. The area under each ROC curve was as follows: SLCO2 (0.82; 95% CI 0.70-0.96; p < 0.001), LAC (0.80; 95% CI 0.69-0.91; p < 0.001), BD (0.87; 95% CI 0.77-0.98; p < 0.001). There was no significant difference (p > 0.05) in the areas under the three curves. CONCLUSIONS: SLCO2 predicted survival in hypotensive trauma patients. It had equivalent diagnostic ability to LAC and BD. This rapid test may supplement standard, more invasive measures of hemorrhagic shock.

Adolescent↗
PubMed2006

The use of factor VIIa in haemorrhagic shock and intracerebral bleeding.

Factor VIIa is a revolutionary new pharmaceutical that promises to change the anaesthesia and critical care approach to major trauma. It is an extremely potent pro-coagulant agent, and while it enables haemostasis at the site of tissue injury, it also has the possibility of producing life-threatening thromboembolic complications. New data regarding FVIIa use is published almost every month, leading to a rapidly evolving clinical understanding of the potential indications, and potential pitfalls, of off-label use. Determination of appropriate practice, including the ability to judge the risks and benefits of FVIIa therapy for individual cases, is still some years in the future, and will depend in large part on clinical trials which are just getting underway.

Blood Coagulation Disorders↗
PubMed2006

Traumatic hemoptysis treated with recombinant human factor VIIa.

Blunt thoracic trauma resulting in massive hemoptysis is rare. Although there are several indications for the administration of recombinant factor VIIa, we are unaware of a report of its utilization in the treatment of hemoptysis following chest trauma. We report a case of the successful use of factor VIIa in the treatment of life-threatening hemoptysis secondary to blunt force thoracic injury and traumatic coagulopathy.

Adult↗
PubMed2006

Mentors decrease compliance with best sterile practices during central venous catheter placement in the trauma resuscitation unit.

BACKGROUND: In the academic trauma unit during initial evaluation and resuscitation of trauma victims, central venous catheters are often placed by multiple operators. There are few data on compliance with accepted, standard sterile practices during such procedures. METHODS: Prospective data were tabulated from video capture of 144 consecutive central venous catheterizations in a trauma resuscitation unit, during peak hours, by a team of trained video technicians. The physicians were surgical and emergency medicine residents. The number of primary operators (trainees) and secondary operators (mentors) for each line was recorded from the video analysis, as well as physician adherence to the use of maximum barrier precautions (MBP; sterile gown, gloves, full operative drape, cap, and mask). Procedures were stratified by level of urgency: Emergent (n = 7), semi-emergent (n = 20), and elective (n = 113). RESULTS: The subclavian vein was used for 73% of the elective catheter placements. For elective central venous catheters, 99 of 113 primary operators (88%) observed MBP, whereas only 31 of 45 secondary operators (69%) did so (p < or = 0.01). Among the 45 elective central venous catheters placed with a secondary operator, there were four instances of frank contamination (9%). CONCLUSIONS: Secondary operators, typically trauma surgery attendings, trauma/critical care fellows, or senior surgical residents, function as mentors in academic institutions and act as role models. Secondary operators participated in many of the studied cases, yet failed to demonstrate consistent use of MBP. In elective central venous catheter placement, those where there was the greatest opportunity to follow MBP, we observed a statistically significant difference in compliance rate between the primary and secondary operators. The study suggests the need to address the performance of the secondary operators and to educate them, as although they may be technically experienced in placing central venous catheters, they may comply less consistently with MBP.

Catheterization, Central Venous↗
PubMed2006

Database predictors of transfusion and mortality.

Transfusion is a cornerstone of early trauma care, but little is known regarding the consistency of transfusion practice in different regions of the world. We examined data available in the German Trauma Registry, the University of Miami Trauma Registry, and the Registry of the Shock Trauma Center in Baltimore to learn more regarding this question. We sought to identify the rate of transfusion of trauma patients during the resuscitative phase, the volume of transfusion administered, and the correlation of various levels of transfusion with clinical outcomes such as mortality, hospital length of stay, and the incidence of organ system failure. Mortality associated with transfusion was remarkably similar in all three systems, making it clear that the volume of blood received during early resuscitation is a strong predictor of outcome for patients presenting in hemorrhagic shock.

Adult↗
PubMed2005

Recombinant activated factor VIIa and hemostasis in critical care: a focus on trauma.

In this article we describe the current use of recombinant activated factor VII (rFVIIa; NovoSeven) in trauma patients. Emphasis is placed on current uses as defined by key studies, efficacy data, and safety data. Most published studies in trauma patients are retrospective case studies and reports, although an international, double-blind, randomized, controlled, phase II study has been conducted that reported on the efficacy of rFVIIa in reducing the amount of blood products transfused in blunt trauma patients. That study demonstrated the efficacy and safety profile of this hemostatic agent as compared with placebo as adjunctive therapy in the management of severe bleeding associated with trauma. Further prospective, randomized, and placebo-controlled clinical trials will yield more information on the role of rFVIIa in the management of traumatic bleeding.

Blood Coagulation↗
PubMed2005

Who needs blood?

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APACHE↗
PubMed2005

Characterizing the need for mechanical ventilation following cervical spinal cord injury with neurologic deficit.

BACKGROUND: Patients who sustain cervical spinal cord injury (C-SCI) with neurologic deficit may require a definitive airway and/or prolonged mechanical ventilation. The purpose of this study was to characterize factors associated with a high risk for respiratory failure and/or the need for mechanical ventilation in C-SCI patients. METHODS: Patients with C-SCI and neurologic deficit admitted to a Level I Trauma Center between July 1, 2000 and June 30, 2002 were retrospectively reviewed for demographics, level and completeness of neurologic deficit, need for definitive airway, need for tracheostomy, need for mechanical ventilation at hospital discharge (MVDC), and outcomes. The level and completeness of injury were defined by American Spinal Injury Association standards. RESULTS: One hundred nineteen patients with C-SCI and neurologic deficit were identified over this period. Of these, 45 were identified as complete C-SCI: 12 (27%) patients had levels of C1 to C4; 19 (42%) had a level of C5; and 14 (31%) had levels of C6 and below. There were 37 males and 8 females. There were 36 blunt and 9 penetrating injuries. The average age of these patients was 40 +/- 21, and the average ISS was 45+/-22. Eight of the patients with complete C-SCI died, for a mortality of 18%. Of the 37 survivors, 92% received a definitive airway, 81% received tracheostomy, and 51% required MVDC. All patients with complete injuries at the C5 level and above required a definitive airway and tracheostomy, and 71% of survivors required MVDC. Of the patients with complete injuries of C6 and below, 79% received a definitive airway, 50% required tracheostomy, and 15% of survivors required MVDC. Only 35% of incomplete injuries required a definitive airway, and only 7% required tracheostomy. CONCLUSIONS: The need for definitive airway control, tracheostomy, and ventilator dependence is significant, especially for patients with high complete C-SCI. Based on these results we recommend consideration of early intubation and tracheostomy for patients with complete C-SCI, especially for those with levels of C5 and above.

Adult↗
PubMed2005

Safety of uncrossmatched type-O red cells for resuscitation from hemorrhagic shock.

BACKGROUND: Uncrossmatched type-O packed red blood cells (UORBC) are recommended for immediate transfusion in hemorrhaging trauma patients. The potential for alloimmunization with this technique is controversial, and has been reported to be as high as 80%. We examined a 1-year experience with UORBC transfusion to determine the incidence of allergic reaction and alloimmunization. METHODS: Blood Bank and Trauma Registry databases for the year 2000 were linked to determine the incidence of UORBC use and the characteristics of patients, including the incidence of transfusion reactions and seroconversion of Rh-patients. Ten units of type-O, Rh+ blood (and two units of O-blood for women of childbearing age) were available for immediate transfusion, 30 to 45 minutes sooner than type-specific or crossmatched red blood cells. UORBC were administered to any patient with signs of severe hemorrhagic shock, at the discretion of the attending physician. RESULTS: In all, 480 trauma patients (out of 5,623 admitted) received transfusions of RBC, totaling 5,203 units. Five hundred eighty-one units of UORBC were given to 161 patients. Average Injury Severity Score in the UORBC cohort was 33.8. Patients receiving UORBC received an average of 16.9 total units of red blood cells, 14 units of plasma, and 10 units of platelets. Seventy-three patients died (45%). There were no acute hemolytic transfusion reactions observed in the patients who received UORBC. Four Rh-women received UORBC, all O-. Ten Rh-men received O+ blood, and only one developed antibodies to the Rh antigen. CONCLUSION: The need for UORBC is associated with significant injury and the need for subsequent massive transfusion. In this largest reported trauma series, the use of UORBC enabled rapid administration of red cells to hemorrhaging patients, without discernible risk for transfusion-related complications. The rate of seroconversion of Rh-patients is lower than reported in the literature, perhaps due to immune suppression associated with hemorrhagic shock.

ABO Blood-Group System↗
PubMed2005

An algorithm for processing vital sign monitoring data to remotely identify operating room occupancy in real-time.

We developed an algorithm for processing networked vital signs (VS) to remotely identify in real-time when a patient enters and leaves a given operating room (OR). The algorithm addresses two types of mismatches between OR occupancy and VS: a patient is in the OR but no VS are available (e.g., patient is being hooked up), and no patient is in the OR but artifactual VS are present (e.g., because of staff handling of sensors). The algorithm was developed with data from 7 consecutive days (122 cases) in a 6 OR trauma center. The algorithm was then tested on data from another 7 consecutive days (98 cases), against patient in- and out-times captured by OR surveillance videos. When pulse oximetry, electrocardiogram, and temperature readings were used, OR occupancy was correctly identified 96% (95% confidence interval [CI] 95%-97%) and OR vacancy >99% of the time. Identified patient in- and out-times were accurate within 4.9 min (CI 4.2-5.7) and 2.8 min (CI 2.3-3.5), respectively, and were not different in accuracy from times reported by staff on OR records. The algorithm's usefulness was demonstrated partly by its continued operational use. We conclude that VS can be processed to accurately report OR occupancy in real-time.

Algorithms↗
PubMed2005

Determinants of futility of administration of recombinant factor VIIa in trauma.

BACKGROUND: "Off-label" use of human coagulation factor VIIa (FVIIa) is presently restricted to patients in extremis at our institution. Although bleeding will diminish in most patients, some will still die early as a result of irreversible shock and/or rebleeding. Futile administration of FVIIa significantly increases the economic burden of this expensive therapy and therefore limits its availability. On the basis of both human and in vitro studies, profound acidosis may be expected to predict lack of response. In addition, the depth of hemorrhagic shock, as defined by the degree of hypoperfusion over a given period of time, may be predictive of failure of FVIIa administration. We hypothesized that retrospective review of FVIIa use would identify variables associated with clinical futility. METHODS: Characteristics of patients receiving FVIIa for acute traumatic hemorrhage were identified. Patients were retrospectively stratified into two groups; those who died as a result of acute hemorrhagic shock (nonresponders) and those in whom hemostasis was achieved and sustained (responders). Demographics, laboratory values, transfusion requirements, and outcomes were recorded for all patients. Data were analyzed using the Student's t test to identify the clinical characteristics of nonresponders and stepwise logistic regression was then used to identify independently predictive factors. A classification and regression tree analysis was conducted to develop a decision tree on the basis of our results. RESULTS: Eighty-one patients received FVIIa therapy over a 3-year period. Among the 46 patients treated for acute hemorrhage, there were 26 with blunt and 20 with penetrating mechanisms of trauma. Average age was 35 +/- 15 years, 72% were male, and the average Injury Severity Score was 36 +/- 15. Revised Trauma Score (RTS), lactate, and preadministration prothrombin time (PT) each predicted lack of response (p < 0.05 for each). RTS and PT were independently predictive of failure of response. An RTS of less than 4.09 and a PT of greater than or equal to 17.6 seconds were significantly associated with futile administration of FVIIa. Age was a significant factor in patients with a PT greater than or equal to 17.6 seconds, whereas ISS was significant in patients with an RTS greater than or equal to 4.09. CONCLUSION: Profound acidosis and coagulopathy may predict failure of FVIIa therapy. Depth of hemorrhagic shock, as described by the RTS, was also associated with futile administration. These variables should be considered as potential contraindications to the use of FVIIa. Earlier administration of FVIIa, before the development of massive blood loss and severe shock, may increase the rate of clinical response.

Adult↗
PubMed2004

Controlled hypotension for spinal surgery.

Controlled, deliberate hypotension during anesthesia for major spinal surgery reduces intraoperative blood loss and transfusion requirement. Hypotension may be achieved with increased doses of volatile anesthetic agents or by continuous infusion of vasodilating drugs. Safe application of this technique requires knowledge of the physiology of hemorrhagic shock and close intraoperative monitoring to avoid vasoconstriction and end-organ ischemia.

Anesthetics, Inhalation↗
PubMed2004

Uses of recombinant factor VIIa in trauma.

PURPOSE OF REVIEW: Despite advances in the care of the injured, the morbidity and mortality of traumatic hemorrhage remain a significant problem. Traumatologists continue to look for ways to treat bleeding and prevent the sequelae of hemorrhagic shock. Recombinant factor VIIa, developed for the treatment of patients with hemophilia, has been used with some success in acute bleeding associated with injuries. RECENT FINDINGS: The mechanism of action is via a tissue factor-dependent effect and/or platelet activation. Coagulation occurs at the site of tissue injury, where tissue factor is exposed. Case series have described the beneficial effects of recombinant factor VIIa in the treatment of acute hemorrhage, early treatment of traumatic brain injury, and reversal of premorbid anticoagulation. In addition, there have been numerous reports of recombinant factor VIIa use in acute bleeds secondary to other causes as well as some evidence that recombinant factor VIIa may be efficacious when used prophylactically in high-risk patients and for high-risk procedures. Typical doses range from 50 to 100 microg/kg as a single bolus. Although there has been concern over the risk of inappropriate thrombosis with recombinant factor VIIa administration, this complication has seldom been described in published series. SUMMARY: Although case experience is encouraging, no level 1 evidence has been published that demonstrates clinical or economic benefit of the use of recombinant factor VIIa in trauma patients. Many questions remain to be answered, ideally through randomized, prospective clinical trials. In particular, the issues of patient selection, ideal dosing, and factors associated with futile administration need to be elucidated.

Algorithms↗
PubMed2004

Decompressive laparotomy to treat intractable intracranial hypertension after traumatic brain injury.

INTRODUCTION: Increases in intra-abdominal pressure (IAP) can cause increases in intracranial pressure (ICP). Recently, we noticed that abdominal fascial release could be useful in treating intracranial hypertension (ICH) after traumatic brain injury (TBI). We added this as an option in our treatment of TBI. METHODS: In our institution, ICH is treated with an algorithm using osmolar therapy, CSF drainage and barbiturates. Patients with refractory ICH have routine measurement of IAP. If elevated, consideration is given to decompressive laparotomy. We retrospectively reviewed all patients admitted from January 2000 through July 2003 who had abdominal decompression to treat refractory ICH. RESULTS: From 1/00 to 7/03, 17 patients underwent decompressive laparotomy for intractable ICH. Thirteen male and 4 females all sustained blunt injury. All had failed maximal therapy including 14 who had had decompressive craniectomy. Mean ICP was 30 +/- 8.1 mmHg (range 20-40 mmHg) before decompression. No patients had evidence of abdominal compartment syndrome (ACS). Before decompression mean IAP was 27.5 (+/- 5.2) mmHg (range 21-35 mmHg). After abdominal decompression ICP dropped precipitously by at least 10 mmHg to a mean of 17.5 (+/- 3.2) mmHg (range 10-25 mmHg). In 6 patients the decrease in ICP was transient. All died. The remaining 11 had sustained decreases in ICP. All survived, made neurologic recovery and were discharged to a rehabilitation facility. CONCLUSION: Decompressive laparotomy can be a useful adjunct in the treatment of ICH failing maximal therapy following TBI. More work will need to be done to precise the exact indications for this therapy.

Adolescent↗
PubMed2004

Factor VIIa for correction of traumatic coagulopathy.

INTRODUCTION: Activated factor VIIa (FVIIa) was developed to treat hemophiliacs with high-titer antibodies to factor VIII. FVIIa initiates thrombin formation by binding with exposed tissue factor. Anecdotal reports have described the utility of FVIIa in correcting coagulopathy from trauma, but no large series exists. We present our experience with 81 coagulopathic trauma patients treated using FVIIa in years 2001-2003, compared with "control" patients matched from the trauma registry from the same time period. METHODS: Use of FVIIa was restricted to active hemorrhage with clinical coagulopathy. We recorded the cause of coagulopathy, dose of FVIIa administered, effect on clinical coagulation, pertinent laboratory values, length of stay, number and type of blood products administered, and patient outcome. For the same time period we also examined outcomes in coagulopathic patients who did not receive FVIIa. RESULTS: Causes of coagulopathy were diverse, and included acute traumatic hemorrhage (46 patients), traumatic brain injury (20), warfarin use (9), congenital Factor VII deficiency (2), and other acquired hematologic defects (4). Coagulopathy was reversed in 61/81 cases (75%), with an associated reduction in PT from 19.6 to 10.8 (p=0.000018). 34 patients (42%) survived to hospital discharge (20/46 traumatic hemorrhage, 5/20 TBI, 4/9 on warfarin, 2/2 factor deficient, 3/4 other). Patients died from irreversible shock, multiple organ system failure, or traumatic brain injury. FVIIa patients had a higher mortality than coagulopathic controls matched by specific anatomic injuries, admission lactate value, and predicted probability of survival. Only a group identified by all three characteristics had a similar mortality to the FVIIa cohort, but the number of patients that could be matched this way was too small to be meaningful. CONCLUSION: FVIIa therapy lead to an immediate reduction in coagulopathic hemorrhage in most cases, accompanied by a significant improvement in laboratory measures. Application of FVIIa as a therapy of last resort makes the identification of equivalent control patients difficult. Use of FVIIa should be considered for any patient with coagulopathic hemorrhage in which surgically-accessible bleeding has been controlled. Prospective trials of FVIIa in patients with traumatic coagulopathy are strongly indicated, and should focus on appropriate patient selection and the dose and timing of therapy.

Adolescent↗