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Biomedical subjects

Richard P Dutton

Publications and source records attributed to Richard P Dutton.

28 records · Page 2Linked to original sources
PubMed2004

Blood transfusion rates in the care of acute trauma.

BACKGROUND: Ten to 15 percent of all RBCs are used in the care of injury. Understanding patterns of RBC use is important. Routine resource allocation, planning for mass casualty situations, designing research, and optimizing triage all can be usefully informed. STUDY DESIGN AND METHODS: Blood Bank and Trauma Registry records were linked to produce a transfused blood product list for each patient directly admitted from the scene of injury to a large Level 1 trauma center in calendar year 2000. Categorical associations between demographic data, Injury Severity Score, transfused products, and outcome were sought. Special attention was paid to the groups receiving uncross-matched RBCs and more than 10 units of RBCs. RESULTS: Eight percent (479/5645) of acute trauma patients received RBCs, using 5219 units and sustaining an overall mortality of 27 percent. Sixty-two percent of RBCs were given in the first 24 hours of care. Three percent of patients (147 injured) received more than 10 units and received 71 percent of all RBCs given. Mortality in this cohort was 39 percent. Ninety percent of the patients who received more than 10 units of RBCs received plasma, and 71 percent received PLTs. CONCLUSIONS: A small number of patients receives most of the blood products used in the treatment of injury. Transfusion of more than 10 units of RBCs identifies a subgroup where most patients received plasma and PLTs to treat actual or anticipated dilutional coagulopathy. There is no clear threshold beyond which blood use is futile.

Acute Disease↗
PubMed2003

Recombinant factor VIIa for control of hemorrhage: early experience in critically ill trauma patients.

STUDY OBJECTIVE: To examine our institutional experience with recombinant Factor VIIa (rFVIIa) as a treatment for exsanguinating hemorrhage in critically ill trauma patients. DESIGN: Retrospective case review. SETTING: A specialized trauma and critical care hospital, serving as the quaternary referral center for trauma and surgical shock in the state of Maryland. PATIENTS: All patients with diffuse coagulopathy and impending exsanguination, given rFVIIa in an effort to control life-threatening hemorrhage. Patients were in the intensive care unit (ICU) or operating room (OR) and included both acute admissions and late-stage patients with multiple organ system failure. INTERVENTIONS: Patients of interest were those that had received rFVIIa. MEASUREMENTS: Examination of medical records, including pharmacy data, laboratory results, and the institutional trauma registry. MAIN RESULTS: Administration of rFVIIa contributed to successful control of hemorrhage in three of five patients. Failure in two patients was mostly likely due to overwhelming shock and acidosis. CONCLUSIONS: Administration of rFVIIa shows promise in the treatment of exsanguinating hemorrhage. Prospective, controlled clinical trials of this therapy are strongly recommended.

Abdominal Injuries↗
PubMed2003

Traumatic brain injury.

PURPOSE OF REVIEW: Management of the patient with traumatic brain injury is a rapidly advancing field, characterized in recent years by an improved understanding of intracranial pathophysiology and ways in which outcomes can be improved. Many traditional therapies, such as fluid restriction and hyperventilation, have been called into question and are no longer recommended. Other proposed therapies, such as deliberate hypothermia, remain controversial. This detailed review of the recent literature helps the reader come to an understanding of current scientific and evidence-based practices in this area, with emphasis on those therapies most likely to be of use to the practicing intensivist. RECENT FINDINGS: High-quality care of the traumatic brain injury patient demands the integrated activities of a number of different medical and nursing specialties. The best outcomes today are achieved by those systems that are able to focus as a team on the collective goal of minimizing secondary brain injury, and the respiratory therapist adjusting the patient's mechanical ventilation may be just as important to this effort as the attending neurosurgeon. Although the search for new diagnostic, prognostic, and therapeutic modalities continues (many of the more promising of which are reviewed in this article), it is clear that there exists no "silver bullet" therapy that will help all patients. Instead, it is the systematic integration and application of many small advances that will ultimately lead to better outcomes. SUMMARY: Some issues in traumatic brain injury have now been resolved, and specific recommendations can be made. Fluid therapy directed toward a euvolemic state is now universally recommended, for example, as is the role of intracranial pressure monitoring. Other areas, such as the use of hypertonic saline, remain controversial. In both cases the authors have made an effort to cite the most recent literature, so that readers can draw their own conclusions from the original source material.

Brain Injuries↗
PubMed2003

Impact of culture and policy on organ donation: a comparison between two urban trauma centers in developed nations.

BACKGROUND: The similarities and differences in organ donation policies, consent rates, and number of organs transplanted from patients declared "brain dead" after traumatic injury in different countries has not been previously reported. METHODS: An international trauma survey questionnaire was developed. Analysis of two responding centers with regard to organ donation practices between urban, free-standing adult trauma hospitals is presented: the R Adams Cowley Shock Trauma Center (STC) in Baltimore, Maryland, and the Lorenz Böhler Hospital (LBH) in Vienna, Austria. RESULTS: Hospital admissions resulting from traumatic brain injury (TBI) account for a significantly greater number of admissions at the STC than at the LBH (761 vs. 276), and the STC has a higher number of patients admitted with severe TBI (Glasgow Coma Scale score < 8). Of 39 medically suitable brain-dead patients at the STC, 18 went to organ donation. At the LBH, 16 patients were declared brain-dead, 7 were considered to be medically suitable, and all 7 went to donation. A "presumed consent" organ donation policy in Austria resulted in 100% of medically suitable patients going to donation at the LBH. With a volunteer donation policy at the STC, 46% of patients went to donation. Of those families who refused donation at the STC, 9 of 16 eligible African Americans (56%), 10 of 21 eligible Caucasians (48%), 1 Hispanic, and 1 Native American Indian family declined donation. CONCLUSION: "Presumed" organ donation in Austria led to 4 organs transplanted per trauma brain-death at the LBH, as compared with 3.8 organs per brain-death at the STC. The greater number of patients with severe TBI at the STC accounts for a similar organ donation rate compared with the LBH, despite the fact that the consent at the STC is voluntary and at the LBH is "presumed." A higher organ donation rate in the United States would result in a greater number of organ transplants from patients who die after traumatic injury and a resultant increase in potential lives saved. There does not appear to be a significant difference in ethnicity between families who accept and those who refuse organ donation after traumatic brain death declaration at the STC.

Adult↗
PubMed2003

Daily multidisciplinary rounds shorten length of stay for trauma patients.

PURPOSE: Efficient patient care depends on close communication between the trauma team, other surgical providers, nursing, physical therapy, and discharge planners. Communication is hampered by the number of services involved, the workload of each service, and the institution's training mission. We hypothesized that daily multidisciplinary "discharge rounds" would improve patient flow and increase readiness. METHODS: A senior trauma center physician leads discharge rounds, focusing on each patient's plan of care, including surgeries, diagnostic tests, and anticipated date of discharge or transfer. Present at rounds are the fellows leading each trauma team; an orthopedic surgeon; the hospital bed manager; the unit's discharge planner; the unit nursing staff; and physical, occupational, and speech therapists. RESULTS: Discharge rounds cover 90 inpatient trauma service beds in approximately 60 minutes each day. Discharge rounds have had a dramatic effect on patient flow. While maintaining the daily census, we have seen a 36% increase in patient volume and a 15% decrease in length of stay. "Bypass" status-inability to accept admissions-has been virtually eliminated. This effect has been sustained. CONCLUSION: By providing a forum for clear communications among all providers, discharge rounds have streamlined the care of complex trauma patients. As health care resources become ever more constrained, this sort of multidisciplinary effort is a viable option for senior physicians to directly impact hospital performance.

Humans↗
PubMed2002

Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality.

BACKGROUND: Traditional fluid resuscitation strategy in the actively hemorrhaging trauma patient emphasizes maintenance of a normal systolic blood pressure (SBP). One human trial has demonstrated improved survival when fluid resuscitation is restricted, whereas numerous laboratory studies have reported improved survival when resuscitation is directed to a lower than normal pressure. We hypothesized that fluid resuscitation titrated to a lower than normal SBP during the period of active hemorrhage would improve survival in trauma patients presenting to the hospital in hemorrhagic shock. METHODS: Patients presenting in hemorrhagic shock were randomized to one of two fluid resuscitation protocols: target SBP > 100 mm Hg (conventional) or target SBP of 70 mm Hg (low). Fluid therapy was titrated to this endpoint until definitive hemostasis was achieved. In-hospital mortality, injury severity, and probability of survival were determined for each patient. RESULTS: One hundred ten patients were enrolled over 20 months, 55 in each group. The study cohort had a mean age of 31 years, and consisted of 79% male patients and 51% penetrating trauma victims. There was a significant difference in SBP observed during the study period (114 mm Hg vs. 100 mm Hg, p < 0.001). Injury Severity Score (19.65 +/- 11.8 vs. 23.64 +/- 13.8, p = 0.11) and the duration of active hemorrhage (2.97 +/- 1.75 hours vs. 2.57 +/- 1.46 hours, p = 0.20) were not different between groups. Overall survival was 92.7%, with four deaths in each group. CONCLUSION: Titration of initial fluid therapy to a lower than normal SBP during active hemorrhage did not affect mortality in this study. Reasons for the decreased overall mortality and the lack of differentiation between groups likely include improvements in diagnostic and therapeutic technology, the heterogeneous nature of human traumatic injuries, and the imprecision of SBP as a marker for tissue oxygen delivery.

Adult↗
PubMed2002

Preliminary trial of a noninvasive brain acoustic monitor in trauma patients with severe closed head injury.

BACKGROUND: There is no simple way to assess the injured patient after a loss of consciousness. Computed tomographic scanning is required to rule out anatomic injuries, and invasive intracranial pressure monitoring is needed for the patient with severe traumatic brain injury (TBI). We hypothesized that a noninvasive acoustic monitoring system could provide useful clinical data on the severity and progression of TBI. METHODS: Twenty-eight consecutive patients with severe TBI and an indication for invasive intracranial pressure monitoring were studied using the Brain Acoustic Monitor (BAM). Monitoring occurred for 1- to 3-hour time periods on the day of enrollment and each day until the patient's condition stabilized. BAM signals were categorized on the basis of amplitude and positive-to-negative deflection ratio, and then compared with the patient's clinical outcome. RESULTS: BAM signal correlated very strongly with clinical outcome: in 27 of 29 sessions with a normal signal, patients were discharged at a Glasgow Coma Scale score > 13, whereas in 36 of 42 sessions with an abnormal signal, the patient either died or left the hospital with a Glasgow Coma Scale score < 9 (p < 0.00001). The correlation between clinical outcome and initial BAM reading was even stronger: 10 of 10 patients with a normal signal did well, as compared with 3 of 18 patients with an abnormal signal. CONCLUSION: Noninvasive monitoring of the injured brain can discriminate those patients who will have a poor clinical outcome from those who will do well. Further trials of the BAM are indicated.

Acoustics↗