Ventilator Associated Pneumonia in Pediatric Trauma Patients

Background: Ventilator associated pneumonia (VAP) is a common hospital-acquired infection found in intubated trauma patients. In previous adult studies, VAP has been associated with an increase in length of stay, cost, morbidity, mortality, and longer mechanical ventilation. There remains little examination of the risk factors, prognosis, and microbiology of VAP within the pediatric trauma population. This study aims to analyze factors associated with VAP in pediatric trauma patients. Methods: The Riley Hospital for Children Trauma Registry was utilized to identify intubated pediatric trauma patients from 2016-2020. Patients were excluded if intubated for less than 48 hours. VAP was defined as positive if patients met either Centers for Disease Control definition and or were clinically diagnosed with and treated for VAP. Univariate and multivariate modeling was performed. Results: A total of 171 patients met inclusion criteria and 43 (25%) were diagnosed with VAP. The median age was 8 years (2-13) and ISS was 26.5 (22-35). The median duration of intubation was 203.8 hours (117.3-331.3). The overall mortality was 55 (32.2%). While variables such as lower age and use of MTP resulted in a higher likelihood of mortality, VAP diagnosis was not associated with increased mortality. BAL analysis displayed that the most common cultured bacteria were H. influenzae, Staph. aureus, and Strep. Pneumoniae with most VAPs being diagnosed on day 2 of admission. When analyzing the impact of age, ISS, intubation hours, ICU days, and GI prophylaxis on VAP, only age was significantly associated with VAP: for each year the odds of VAP rose by 10%. Conclusions: A quarter of the pediatric trauma patients were diagnosed with VAP during the study period. No modifiable risk factors were found for VAP with only patient age demonstrating significance for the diagnosis. Further investigation into VAP definition and prevention in pediatric trauma patients should occur given it’s prevalence.

Improved Adherence to Best Practice Ventilation Management After Implementation of Clinical Practice Guideline (CPG) for United States Military Critical Care Air Transport Teams (CCATTs)

ABSTRACT Background Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically ill and injured patients in the combat theater to include mechanically ventilated patients. Previous research has demonstrated improved morbidity and mortality when lung protective ventilation strategies are used. Our previous study of CCATT trauma patients demonstrated frequent non-adherence to the Acute Respiratory Distress Syndrome Network (ARDSNet) protocol and a corresponding association with increased mortality. The goals of our study were to examine CCATT adherence with ARDSNet guidelines in non-trauma patients, compare the findings to our previous publication of CCATT trauma patients, and evaluate adherence before and after the publication of the CCATT Ventilator Management Clinical Practice Guideline (CPG). Methods We performed a retrospective chart review of ventilated non-trauma patients who were evacuated out of theater by Critical Care Air Transport Teams (CCATT) between January 2007 and April 2015. Data abstractors collected flight information, oxygenation status, ventilator settings, procedures, and in-flight assessments. We calculated descriptive statistics to determine the frequency of compliance with the ARDSNet protocol before and after the CCATT Ventilator CPG publication and the association between ARDSNet protocol adherence and in-flight events. Results We reviewed the charts of 124 mechanically ventilated patients transported out of theater via CCATT on volume control settings. Seventy percent (n = 87/124) of records were determined to be Non-Adherent to ARDSNet recommendations predominately due to excessive tidal volume settings and/or high FiO2 settings relative to the patient’s positive end-expiratory pressure setting. The Non-Adherent group had a higher proportion of in-flight respiratory events. Compared to our previous study of ventilation guideline adherence in the trauma population, the Non-Trauma population had a higher rate of non-adherence to tidal volume and ARDSNet table recommendations (75.6% vs. 61.5%). After the CPG was rolled out, adherence improved from 24% to 41% (P = 0.0496). Conclusions CCATTs had low adherence with the ARDSNet guidelines in non-trauma patients transported out of the combat theater, but implementation of a Ventilator Management CPG was associated with improved adherence.

Effects of the COVID-19 pandemic on pediatric trauma in Southern California

Purpose The COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders. Methods A multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019–6/30/2019 (CONTROL), 1/1/2020–3/18/2020 (PRE), 3/19/2020–6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses. Results 1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%, p = 0.219) and CONTROL (11.3 vs. 8.2%, p = 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days, p = 0.002) and CONTROL (2.4 vs. 3.4 days, p = 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all p > 0.05). Conclusions This multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS.

Does Time to Pelvic Fixation Influence Outcomes in Trauma Patients?

Background Pelvic fractures cause significant morbidity in the trauma population. Many factors influence time to fracture fixation. No previous study has determined the optimal time window for pelvic fixation. Methods A retrospective review of trauma patients with pelvic fractures from 2016 to 2020 was performed. Patients were stratified into EARLY and LATE groups, by time to fixation within 3 days or greater than 3 days whether from admission or from completion of a life-saving procedure. Unpaired Student’s t-test and Fisher’s exact test were performed with multiple linear regression for variables with P < .2 on univariate analysis. Results 287 patients were identified with a median fixation time of 3 days. There was no significant difference in demographics, incidence of preceding life-saving procedure, angioembolization, or mechanism of injury in the 2 groups ( P > .05). Length of stay in the EARLY group was significantly reduced at 11.9 +/− .7 days compared to 18.0 +/−1.2 days in the LATE group ( P < .001). There was no significant difference in rates of ventilator-associated pneumonia, deep vein thrombosis, pulmonary embolism (PE), acute kidney injury (AKI), pressure ulcer, or acute respiratory distress syndrome (ARDS) ( P > .05). There were significantly more SSIs (surgical site infections) in the LATE group. After multiple linear regression adjusting for covariates of age and ISS, the difference in hospital LOS was 5.5 days (95% CI −8.0 to −3.1, P < .001). Discussion Fixation of traumatic pelvic fractures within 3 days reduced LOS. Prospective multi-center studies will help identify additional factors to decrease time to surgery and improve patient outcomes.

Understanding Preventable Deaths in the Geriatric Trauma Population: Analysis of 3,452,339 Patients From the Center of Medicare and Medicaid Services Database

Background Patient safety indicators (PSIs) are avoidable complications that can impact outcomes. Geriatric patients have a higher mortality than younger patients with similar injuries, and understanding the etiology may help reduce mortality. We aim to estimate preventable geriatric trauma mortality in the United States and identify PSIs associated with increased preventable mortality. Methods A retrospective cohort study of patients aged ≥65 years, in the CMS database, 2017-second quarter of 2020. Risk-adjusted multivariable regression was performed to calculate observed-to-expected (O/E) mortality ratios for failure-to-prevent and failure-to-rescue PSIs with significance defined as P < .05. Results 3,452,339 geriatric patients were analyzed. Patients aged 75-84 years had 33% higher odds of preventable mortality (adjusted odds ratio [aOR] = 1.33 and 95% confidence interval [CI] = 1.31, 1.36), whereas patients aged ≥85 years had 91% higher odds of preventable mortality (aOR = 1.91 and 95% CI = 1.87, 1.94) compared to patients aged 65-74 years. Failure-to-prevent O/E were >1 for all PSIs evaluated with central line–related blood stream infection having a high O/E (747.93). Failure-to-rescue O/E were >1 for 10/11 (91%) PSIs with physiologic and metabolic derangements having the highest O/E (5.98). United States’ states with higher quantities of geriatric trauma patients experienced reduced preventable mortality. Conclusion Odds of preventable mortality increases with age. Perioperative venous thrombotic events, hemorrhage or hematoma, and postoperative physiologic/metabolic derangements produce significant preventable mortalities. United States’ states differ in their failure-to-prevent and failure-to-rescue PSIs. Utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy especially anticoagulation, ensuring operative and procedure-based competencies, and greater incorporation of inpatient geriatricians may serve to reduce preventable mortality in elderly trauma patients.