trauma patients

Reducing acute kidney injury due to vancomycin in trauma patients

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Supratherapeutic vancomycin trough levels are common after trauma and associated with both increased acute kidney injury (AKI) and mortality. We sought to limit the adverse effects of vancomycin in trauma patients through more frequent trough monitoring.

METHODS: Beginning in January 2011, trauma patients treated with vancomycin had trough levels (VT) monitored daily until steady state was reached. Trauma patients admitted from January 2011 to May 2015 (POST) were compared with those admitted from January 2006 to December 2010 (PRE). Inclusion criteria required administration of intravenous vancomycin, admission serum creatinine (SCr), and SCr within 72 hours of highest VT. Acute kidney injury was defined as an increase in SCr of at least 0.3 mg/dL or 50% from admission to post–vancomycin administration. Those in the POST group were prospectively followed up until discharge or death.

RESULTS: Two hundred sixty-three patients met inclusion criteria in the PRE-phase and 115 in the POST-phase. The two groups were similar in age, gender, race, body mass index, pre-existing comorbidities, admission systolic blood pressure, Glasgow Coma Scale, and head Abbreviated Injury Scale. Injury Severity Score was higher in the POST cohort (18 PRE vs. 25 POST, p < 0.001). Compared with PRE, the POST cohort had lower rates of supratherapeutic VT (>20 mg/L) (34.6% PRE vs. 22.6% POST, p = 0.02) and AKI (30.4% PRE vs. 19.1% POST, p = 0.026). After adjusting for confounders, the POST group had a significantly lower risk of AKI with an adjusted odds ratio of 0.457 (p = 0.027). There was a trend toward decreased mortality in the POST cohort, but this did not reach significance (10% PRE vs. 5.2% POST, p = 0.162).

CONCLUSIONS: A reduction in AKI was observed in trauma patients with daily vancomycin trough levels monitored until steady state. Increased awareness regarding closer surveillance of VT in trauma patients may limit the incidence of vancomycin-related nephrotoxicity.

Simple, Reliable Sepsis Screening Tool Improves Mortality in Trauma Patients

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Abstract

Learning Objectives The recent update to the Surviving Sepsis Campaign Guidelines advocates for the use of routine sepsis screening. We have previously shown that sepsis screening improves outcomes in surgical patients but data are lacking in the trauma population. The purpose of this prospective, observational study was to determine the utility of a novel screening tool for the early identification of sepsis in trauma patients.

Methods Patients admitted to the trauma service were screened for sepsis twice daily using our sepsis screening tool which assesses a patient’s white blood cell count, respiratory rate, temperature, and heart rate and assigns a numeric score (0 to 4) for each. Patients with a score of ≥4 screened positive. ACCP/SCCM Consensus definitions were used to diagnose sepsis. Sensitivity and specificity were calculated using a standard two by two table. Chi square analysis was used for categorical data. Values are expressed as mean ± standard deviation.

Results 10,201 screens were completed on 1,637 trauma patients admitted to a Level 1 Trauma Center. The incidence of sepsis was 7.3%. The sepsis screening tool had a sensitivity of 92.5%, specificity of 97.4%, positive predictive value of 73.5% and negative predictive value of 99.4%. There was no difference in the age (43.3±18.15 vs. 42.7±19.1, p= 0.74) or gender (74.1% male vs. 68.7% male, p=0.22) of patients with sepsis and without sepsis. Patients that developed sepsis had higher injury severity scores (23.3±12.3 vs.12.7±9.3, p<0.0001), increased hospital length of stay (31.1±26.7 vs. 8.5±8.4, p <0.0001), increased intensive care unit (ICU) length of stay (16.4±16.3 vs. 1.7±3.9, p<0.0001), and fewer ICU free days (14.7±19.4 vs. 6.9±7.1, p <0.0001). Thirty-day ICU mortality decreased from 13% to 8% (p=0.08) after implementing the sepsis screening tool.

Conclusions Sepsis in trauma patients has a significant impact on patient outcomes. Our sepsis screening tool accurately identifies sepsis in trauma patients with a high sensitivity and specificity. The implementation of routine screening was associated with improved ICU mortality rates.