Trauma/Critical Care
Teixeira PGR et al. Civilian prehospital tourniquet use is associated with improved survival in patients with peripheral vascular injury . J Am Coll Surg. 2018;226(5):769-76.
Dr. Krista Kaups
The use of tourniquets for hemorrhage control in trauma patients has been widely condemned in the past because of concerns regarding complications and potential limb loss. However, evidence from liberal tourniquet use in combat situations documenting survival benefits has continued to accumulate. Prompt hemorrhage control in trauma patients, including the use of tourniquets where applicable, has been validated by recent combat zone studies but improved survival hasn’t yet been shown in the civilian setting. In this multicenter, retrospective study of 1,026 patients with peripheral vascular injuries, only a relatively small number (17.6%) had pre-hospital tourniquets applied, yet multivariable analysis showed a significant survival benefit (odds ratio, 5.86). Importantly, no difference was seen in delayed amputation rates, of approximately 1% in both groups. This study helps to emphasize the importance of the Stop the Bleed (STB) campaign which includes education on the effective and safe use of tourniquets for prehospital hemorrhage. The STB program offers surgeons the opportunity to educate members of their own communities in effective bystander first aid.
Pileggi C et al. Ventilator bundle and its effects on mortality among ICU patients: A meta-analysis. Crit Care Med. 2018;46(7):1167-74.
Critically ill patients requiring mechanical ventilation are at risk for a number of complications, including ventilator-associated pneumonia (VAP) (now a subset of ventilator-associated events (VAE) which prolong ventilator and ICU time and contribute to further complication. Ventilator “bundles,” incorporating simple measures such as elevation of the head of the bed; daily “sedation holidays”; and evaluation of readiness for extubation, peptic ulcer, and DVT prophylaxis have been widely used in ICUs for nearly 20 years. Effective implementation has also emphasized multidisciplinary teamwork. Reductions in ventilator-associated pneumonia (VAP) incidence have been widely demonstrated but mortality benefits have been inconsistent. In this meta-analysis of 13 studies, 6 in Europe, 6 in the US and 1 in Brazil, an overall reduction in mortality (odds ratio, 0.9) was demonstrated. The effect was even larger when limited to studies with patients with VAP (OR, 0.71). This study both validates the effectiveness of relatively simple and inexpensive measures and emphasizes the benefits of a team approach to the care of ICU patients.
Krista L. Kaups, MD, FACS