BACKGROUND:Traumatic injuries have increased risks for infection and progression to difficult-to-heal wounds. Often, they are inadequately treated with single-purpose dressings. Involving wound care specialists allows for integrating various advanced wound treatments. The objective of this report was to assess if healing rates correlated with using unique combination therapies. METHODS:An observational, prospective analysis was performed, reviewing patients with acute wounds from admission until healed. Systematic assessments were standardized, employing T.I.M.E. (tissue, infection /inflammation, moisture balance, edge/periwound). Key outcomes included wound progression, dimensions, treatments, healing time, and health care utilization metrics. RESULTS:A total of 124 patients with acute wounds up to 1120 cm3 healed using multimodal therapy. Median time to wound specialist consultation was 2 days. It was determined that all patients were treated with a pure hypochlorous acid-based wound cleanser combined with negative pressure wound therapy, collagen, silver, manuka honey, and/or foam dressings. Median healing time was 19 days. Delays were associated with smoking, immunocompromise, and inability to obtain wound care supplies. CONCLUSIONS:Optimizing advanced therapeutic combinations with innovative dressings, including pHA and other beneficial components, has shown reduced health care utilization of acute wound patients by shortening healing time. The resulting decrease in dressing changes, follow-up appointments, and home care could increase patient satisfaction and improve outcomes.

INTRODUCTION:The management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non-intensive care unit (ICU) setting after stratifying them using the mBIG criteria. METHODS:A retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3. RESULTS:Of the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups. CONCLUSIONS:Select patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

Introduction: There are limited data on how patients with pre-existing psychiatric disorders fare after sustaining a traumatic brain injury (TBI). The purpose of this study was to evaluate the impact of pre-existing psychiatric illness on clinical outcomes after TBI. Methods: A retrospective review was conducted at a regional level 1 trauma center of patients who suffered a TBI between 2012 and 2020. Propensity scores were used to match patients with psychiatric disorder 1:1 to controls. The matched population was used in analyses. Results: Totally, 5343 patients sustained TBI in the study period of which, 977 (18%) had a pre-existing psychiatric disorder. These patients had 1.6 times longer hospital length of stay (LOS) and 1.2 times longer ICU LOS, though days on a ventilator were not longer. TBI readmission, unrelated to the initial head injury, which was more frequent for patients with psychiatric disorder (OR= 2.6 [1.5, 4.6]). Conclusion: In patients sustaining a TBI, having a pre-existing psychiatric disorder is an independent risk factor for increased LOS, and TBI readmission. Identifying psychiatric patients as being of higher risk may allow for targeted modifications toward head injury prevention.

Importance:Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown.Objective:To determine whether adding sigh breaths improves clinical outcomes.Design, Setting, and Participants:A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours.Interventions:Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished.Main Outcomes and Measures:The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality.Results:Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]).Conclusions and Relevance:In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes.Trial Registration:ClinicalTrials.gov Identifier: NCT02582957.

Liou, Jesse; Doherty, Daniel; Gillin, Tom; Emberger, John; Yi, Yeonjoo; Cardenas, Luis; Benninghoff, Michael; Vest, Michael; Deitchman, Andrew Author Information

OBJECTIVES:. Acute respiratory distress syndrome is treated by utilizing a lung protective ventilation strategy. Obesity presents with additional physiologic considerations, and optimizing ventilator settings may be limited with traditional means. Transpulmonary pressure (PL) obtained via esophageal manometry may be more beneficial to titrating positive end-expiratory pressure (PEEP) in this population. We sought to determine the feasibility and impact of implementation of a protocol for use of esophageal balloon to set PEEP in obese patients in a community ICU. DESIGN:. Retrospective cohort study of obese (body mass index [BMI] ≥ 35 kg/m2) patients undergoing individualized PEEP titration with esophageal manometry. Data were extracted from electronic health record, and Wilcoxon signed rank test was performed to determine whether there were differences in the ventilatory parameters over time. SETTING:. Intensive care unit in a community based hospital system in Newark, Delaware. PATIENTS:. Twenty-nine mechanically ventilated adult patients with a median BMI of 45.8 kg/m2 with acute respiratory distress syndrome (ARDS). INTERVENTION:. Individualized titration of PEEP via esophageal catheter obtained transpulmonary pressures. MEASUREMENTS AND MAIN RESULTS:. Outcomes measured include PEEP, oxygenation, and driving pressure (DP) before and after esophageal manometry at 4 and 24 hr. Clinical outcomes including adverse events (pneumothorax and pneumomediastinum), increased vasopressor use, rescue therapies (inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and new prone position), continuous renal replacement therapy, and tracheostomy were also analyzed. Four hours after PEEP titration, median PEEP increased from 12 to 20 cm H2O (p < 0.0001) with a corresponding decrease in median DP from 15 to 13 cm H2O (p = 0.002). Subsequently, oxygenation improved as median Fio2 decreased from 0.8 to 0.6 (p < 0.0001), and median oxygen saturation/Fio2 (S/F) ratio improved from 120 to 165 (p < 0.0001). One patient developed pneumomediastinum. No pneumothoraces were identified. Improvements in oxygenation continued to be seen at 24 hr, compared with the prior 4 hr mark, Fio2 (0.6–0.45; p < 0.004), and S/F ratio (165–211.11; p < 0.001). Seven patients required an increase in vasopressor support after 4 hours. Norepinephrine and epinephrine were increased by 0.05 (± 0.04) µg/kg/min and 0.02 (± 0.01) µg/kg/min on average, respectively. CONCLUSIONS:. PL-guided PEEP titration in obese patients can be used to safely titrate PEEP and decrease DP, resulting in improved oxygenation.

Introduction Negative-pressure wound therapy (NPWT) with instillation and dwell time is an accepted adjunct therapy for infected wounds. A study was conducted to assess whether the use of hypochlorous acid preserved wound cleanser (HAPWOC) (Vashe, Urgo Medical North America, Fort Worth, TX, USA) as the irrigant would reduce the cost of care in comparison to 0.9% saline (NaCl). Method A comparative, observational, retrospective analysis assessed 27 serious and infected wounds in 24 patients. The lesions were of different and complex etiologies, including necrotizing fasciitis and stage IV diabetic foot ulcers. NPWT was used as part of the overall multimodal treatment regimen. The only variance in the treatment protocol was the use of saline (N=8) or HAPWOC (N=19) as the irrigant. Results When compared to NaCl, wounds treated with HAPWOC trended toward fewer operating room (OR) visits versus NaCl (3.3 versus 4.1) and a shorter length of hospital stay (LOS) (24.3 days versus 37.9 days). The Orlando Health Transparency guide shows the cost of OR debridement as $ 2,525. Thus, debridement for HAPWOC-treated wounds ($8,332) costs $2,020 (24%) less than for NaCl-treated wounds ($10,352). Using the 2016 Kaiser Health data (average daily hospital cost, excluding all interventions: $2,052), the cost of HAPWOC and NaCl instill translates to $49,864 and $77,771, respectively, a difference of $27,906 (56%) more for NaCl treatment. The Agency for Healthcare Research and Quality (AHRQ) 2012 data indicate an average daily cost of hospital stay, including all interventions, of $10,400. Thus, HAPWOC treatment cost translates to $252,720 versus NaCl-related costs of $394,160; in these calculations, using NaCl costs $141.440 (+56%) more per patient than HAPWOC. Conclusion The use of NPWT with HAPWOC versus NaCl as instillation in NPWT reduces the number of visits to the operating room and LOS. This has a significant impact on lowering the cost of care when HAPWOC is used.

BACKGROUND:Standardized treatment of split-thickness skin graft (STSG) donor sites is not established. Bleeding can necessitate premature dressing changes, interrupting the healing process and increasing pain.PURPOSE:A collagen/oxidized regenerated cellulose (C/ORC) dressing was used on the donor site. The authors hypothesized that the collagen matrix could decrease bleeding-related complications, reduce pain, and foster epithelialization.METHODS:The C/ORC matrix was applied to the donor site after hemostasis was achieved. Dressings were removed between postoperative days 4 and 7, and the patients' pain levels, bleeding complications, and percentage healed were recorded.RESULTS:Thirty-nine patients were treated with the C/ORC donor site dressing. Of these, 35 patients (89.7%) were receiving at least prophylactic anticoagulation, and no bleeding complications were recorded. The average area of donor sites was 123.8 cm2 (range, 20-528 cm2). Utilizing the Numerical Rating Scale, 25 patients (64.1%) reported no pain with dressing removal while 5 (12.8%) reported a decrease in pain. The percentage of epithelialization as assessed by treating clinician was at least equivalent to other modalities.CONCLUSIONS:The application of a C/ORC matrix to STSG donor wound sites resulted in no bleeding complications and excellent pain control while promoting epithelialization in the patients studied. Following this study, the C/ORC dressing has been incorporated into the authors' standard protocol.

BACKGROUND:Necrotizing soft tissue infection (NSTI) is rare and characterized by rapid onset and spread of inflammation and necrosis. The infection starts within the fascia but can rapidly progress to include musculature, subcutaneous fat, and overlying skin. Its presentation is considered a surgical emergency. Persons who use intravenous or subcutaneous opioids are at higher risk of NSTIs.PURPOSE:The purpose of this case report is to describe the positive clinical outcome after consulting with wound specialists and using a dressing regimen to expedite more rapid wound healing, shortened time to skin graft, and improved pain tolerance in a patient with a history of intravenous and subcutaneous heroin use.CASE REPORT:The patient presented with an NSTI that required extensive debridement of the bilateral upper extremities. The acute surgical wound service was consulted. A dressing regimen consisting of hypochlorous acid-preserved wound cleansing, followed by carboxymethylcellulose fiber with 1.2% ionic silver covered by hydrocellular foam to promote a moist healing environment, was used to facilitate granulation.RESULTS:Healthy granulation tissue was noted 6 days after debridement. The improved rate of granulation and the patient's tolerance to dressing changes secondary to decreased pain from these dressings significantly expedited the time to graft and wound healing. The patient underwent split-thickness skin grafting 10 days after debridement. There was 100% uptake of the grafts on postgraft day 8.CONCLUSION:The favorable clinical outcome suggests that early consultation with wound specialists and implementation of the dressing regimen were effective in this patient regarding improved pain control and healing. However, because the patient left against medical advice on hospital day 20, the clinical course could not be followed beyond the first few postoperative weeks.

INTRODUCTION:Modern wound management continues to present new challenges. Many patients elect to forego operative debridement secondary to high risk, fear, cost concerns, and personal ideologies on healing. Although operative debridement has long been a tenet of proper wound care, alternative innovative approaches to wound management must be considered.OBJECTIVE:This case series describes the successful outcomes of 12 patients with dissimilar wounds who were managed with medical-grade honey (active Leptospermum honey [ALH]) as an alternative to surgery.MATERIALS AND METHODS:A case series was identified from clinical experience, chart review, and photographic documentation of all patients evaluated by the acute wound care service. To be included, patients had to decline the recommendation of operative debridement or skin grafting, utilize ALH as an alternative to surgery, and have regular follow-up visits.RESULTS:Twelve patients with complex wounds were identified and included in this case series. Five patients were considered high risk for surgery due to comorbidities. Seven patients were at low risk for surgery but desired to avoid operative procedures. The use of ALH facilitated autolytic debridement and healing without surgery or hospital readmission.CONCLUSIONS:The properties of ALH include autolytic debridement, bacterial growth inhibition, anti-inflammatory mediation, and cytokine release, making it a viable option for wound management for patients with contraindications to surgery. However, surgical debridement should remain a tenet of wound care in appropriate patients.

Wound care continues to be a major issue for all stages of medical care. Despite acute wounds being more prevalent, the vast majority of advancements and standardizations have focused on chronic wounds, most of which present initially as simple acute traumatic wounds in patients with multiple comorbidities.1 The challenge is to proactively recognize and initiate appropriate wound therapy. Most of the acute wounds are often treated with simple techniques and require minimal follow-up, but these methods may not provide the highest quality of care or appropriately decrease resource utilization and cost. There is a growing need for the standardization of acute wound management and for health-care providers to close the present knowledge gap of available resources and advanced wound care methodologies. With a growing emphasis on evidence-based medicine, it is unfortunate that many acute wound decisions fall to providers who may not be up to date with current recommendations. As of 2014, only 7 of 55 medical schools in the United States had established a formal wound care curriculum, and only one had a focus on surgical interventions for acute wounds.2 Even when wound care education is provided, information tends to be outdated. For example, the importance of a moist wound environment was established in 1962, but it took more than 50 years for it to be acknowledged. Consequently, wet-to-dry wound dressing is still commonplace teaching in both medical schools and residency programs.3 Algorithms have successfully been used in many studies to provide guidance for clinicians performing wound care, including when encountering unique situations. By making these algorithms available online, the most updated recommendations are easily accessed by providers. Some countries have developed web-based tools to assist with care decisions in areas of limited resources. Some have focused on specific frequently asked questions, whereas others have used pictures to guide nonexperts. In Nova Scotia, an evidence-based algorithm tool was implemented in 1995 that focused predominantly on chronic wounds but also contained surgical and burn wound management. The tool demonstrated both clinical and economic improvements and was so well received that the protocol eventually became a policy for the province and remains available for public access today.4 In this study, we attempted to integrate a web-based resource to enhance competency in acute surgical wound management, optimize patient outcomes, and reduce wound care spending while presenting appropriate treatment options with the corresponding supportive evidence, rather than limiting providers to a specific algorithm. It was our hypothesis that if such a resource was made readily available, clinicians would use it to enhance their care and ultimately improve patient outcomes. We developed a web-based tool and implemented it at a large, 1000-bed regional Level I trauma center. This institution also has an Acute Surgical Wound Service (ASWS) dedicated to the management of acute wounds resulting from trauma, infection, and surgery or wounds that require multiple surgical interventions, have a higher potential for loss of limb(s), and/or involve high resource care. Prior approval was obtained from the Institutional Review Board. A customized, comprehensive web-based wound care guideline resource tool was developed by institutional experts for health-care providers and implemented after an initial questionnaire. The completed database contained descriptions and images of all wound care products and therapies available at this institution with evidence-based algorithms based within manufacture indications. The overarching categories of the tool included wound care guidelines with hyperlinks to identified therapies; dressing information with mechanisms Address correspondence and reprint requests to Michael Steven Farrell, M.D., M.B.S., Surgical Resident, Department of General Surgery, Christiana Care Health System, 4755 Ogletown-Stanton Road, Suite 2E70B, Newark, DE 19718. E-mail: mfarrellmd@ gmail.com.