Background : Glycemic control is an important aspect of patient care in the surgical intensive care unit (SICU). This is a pilot study of a novel glycemic analysis tool - the glucogram. We hypothesize that the glucogram may be helpful in quantifying the clinical significance of acute hyperglycemic states (AHS) and in describing glycemic variability (GV) in critically ill patients. Materials and Methods: Serial glucose measurements were analyzed in SICU patients with lengths of stay (LOS) >30 days. Glucose data were formatted into 12-hour epochs and graphically analyzed using stochastic and momentum indicators. Recorded clinical events were classified as major or minor (control). Examples of major events include cardiogenic shock, acute respiratory failure, major hemorrhage, infection/sepsis, etc. Examples of minor (control) events include non-emergent bedside procedures, blood transfusion given to a hemodynamically stable patient, etc. Positive/negative indicator status was then correlated with AHS and associated clinical events. The conjunction of positive indicator/major clinical event or negative indicator/minor clinical event was defined as clinical "match". GV was determined by averaging glucose fluctuations (maximal - minimal value within each 12-hour epoch) over time. In addition, event-specific glucose excursion (ESGE) associated with each positive indicator/AHS match (final minus initial value for each occurrence) was calculated. Descriptive statistics, sensitivity/specificity determination, and student's t-test were used in data analysis. Results : Glycemic and clinical data were reviewed for 11 patients (mean SICU LOS 74.5 days; 7 men/4 women; mean age 54.9 years; APACHE II of 17.7 ± 6.44; mortality 36%). A total of 4354 glucose data points (1254 epochs) were analyzed. There were 354 major clinical events and 93 minor (control) events. The glucogram identified AHS/indicator/clinical event "matches" with overall sensitivity of 84% and specificity of 65%. We noted that while the mean GV was greater for non-survivors than for survivors (19.3 mg/dL vs. 10.3 mg/dL, P = 0.02), there was no difference in mean ESGE between survivors (154.7) and non-survivors (160.8, P = 0.67). Conclusions: The glucogram was able to quantify the correlation between AHS and major clinical events with a sensitivity of 84% and a specificity of 65%. In addition, mean GV was nearly two times higher for non-survivors. The glucogram may be useful both clinically (i.e., in the electronic ICU or other "early warning" systems) and as a research tool (i.e., in model development and standardization). Results of this study provide a foundation for further, larger-scale, multi-parametric, prospective evaluations of the glucogram.

Background : Neurosurgical patients including patients with severe head injury are at risk of developing respiratory complications. These can adversely affect the outcome and can result in poor survival. Many studies confirm that tracheostomy is a safe, effective method of airway management for patients with severe head, facial and multisystem organ trauma. Aims : To know the indications for performing early tracheostomy and its outcome. Settings and Design : Retrospective data analysis. Materials and Methods: The present study is a retrospective analysis of all patients who were admitted with the diagnosis of head injury between January 2007 and December 2009 and underwent tracheostomy at a rural tertiary care trauma center of Central India. Results : During the study period, a total of 40 patients with head injury underwent tracheostomy. All the patients sustained head injury in road traffic accidents. The mean age of the patients was 37.6 years (range 14-75 years, standard deviation 14 ± 14.9 years). Maximum number of patients were in their third decade of life, followed by those in the fifth and fourth decades. There were 36 males and 4 females. Tracheostomy was performed in 30 patients with severe head injury, 9 patients with moderate head injury and in only one case of mild head injury as the patient had multiple facial injuries compromising the airway. Conclusions : Neurocritical care is a relatively new field in India, and the facilities for critical neurosurgical patients are available only in a very few tertiary care centers mainly serving the urban areas. In the present study, we discuss our limited experience with tracheostomy in patients with head injury while facing the challenge of limited resources.

Background : Aminoglycosides are commonly used antibiotics in the intensive care unit (ICU), but are associated with nephrotoxicity. This study evaluated the development of aminoglycoside-associated nephrotoxicity (AAN) in a single surgical intensive care unit. Materials and Methods : Adult patients in our surgical ICU who received more than two doses of aminoglycosides were retrospectively reviewed for demographics, serum creatinine, receipt of nephrotoxins [angiotensin converting enzyme (ACE) inhibitors, angiotensin-II receptor blockers, diuretics, non-steroidal anti-inflammatory drugs, cyclosporine, tacrolimus, vasopressors, vancomycin and intravenous iodinated contrast] and the need for dialysis. AAN was defined as an increase in serum creatinine >0.5 mg/dL on at least 2 consecutive days. Univariate and multiple regression analyses were performed. Results : Sixty-one patients (43 males) receiving aminoglycoside were evaluated. Mean age, weight, initial serum creatinine, and duration of aminoglycoside therapy were 58.7 (±15) years, 83.3 (±24.4) kg, 0.9 (±0.5) mg/dL, and 4 (±2.3) days, respectively. Thirty-one (51%) aminoglycoside recipients also received additional nephrotoxins. Seven aminoglycoside recipients (11.5%) developed AAN, four of whom required dialysis and all had received additional nephrotoxins. Only concurrent use of vasopressors (P = 0.041) and vancomycin (P = 0.002) were statistically associated with AAN. Receipt of vasopressors or vancomycin were independent predictors of acute kidney insufficiency (AKI) with odds ratios of 19.9 (95% CI: 1.6-245, P = 0.019) and 49.8 (95% CI: 4.1-602, P = 0.002), respectively. Four patients (6.6%) required dialysis. Conclusions : In critically ill surgical patients receiving aminoglycosides, AAN occurred in 11.5% of the patients. Concurrent use of aminoglycosides with other nephrotoxins increased the risk of AAN.

Injury is the fourth leading cause of death in the US, and the leading cause of death in younger age. Trauma is primarily a disease of the young and accounts for more years of productive life lost than any other illness. Consequently, almost every health care provider encounters trauma patients from time to time. Many of these patients are critically ill and pose several challenges in the acute phase, including airway and ventilation, fluid management, intracranial pressure control, etc. In the last decade, several strategies and treatment options have been studied in trauma care along with improvement in technologies. In this review, we will discuss a few of the new developments and updates in trauma care.

Traumatic brain injury (TBI) is a major public health problem and the leading cause of death and disability worldwide. Despite the modern diagnosis and treatment, the prognosis for patients with TBI remains poor. While severity of primary injury is the major factor determining the outcomes, the secondary injury caused by physiological insults such as hypotension, hypoxemia, hypercarbia, hypocarbia, hyperglycemia and hypoglycemia, etc. that develop over time after the onset of the initial injury, causes further damage to brain tissue, worsening the outcome in TBI. Perioperative period may be particularly important in the course of TBI management. While surgery and anesthesia may predispose the patients to new onset secondary injuries which may contribute adversely to outcomes, the perioperative period is also an opportunity to detect and correct the undiagnosed pre-existing secondary insults, to prevent against new secondary insults and is a potential window to initiate interventions that may improve outcome of TBI. For this review, extensive Pubmed and Medline search on various aspects of perioperative management of TBI was performed, followed by review of research focusing on intraoperative and perioperative period. While the research focusing specifically on the intraoperative and immediate perioperative TBI management is limited, clinical management continues to be based largely on physiological optimization and recommendations of Brain Trauma Foundation guidelines. This review is focused on the perioperative management of TBI, with particular emphasis on recent developments.

Patients with actual or potential spinal cord injury (SCI) are frequently seen at adult trauma centers, and a large number of these patients require operative intervention. All polytrauma patients should be assumed to have an SCI until proven otherwise. Pre-hospital providers should take adequate measures to immobilize the spine for all trauma patients at the site of the accident. Stabilization of the spine facilitates the treatment of other major injuries both in and outside the hospital. The presiding goal of perioperative management is to prevent iatrogenic deterioration of existing injury and limit the development of secondary injury whilst providing overall organ support, which may be adversely affected by the injury. This review article explores the anesthetic implications of the patient with acute SCI. A comprehensive literature search of Medline, Embase, Cochrane database of systematic reviews, conference proceedings and internet sites for relevant literature was performed. Reference lists of relevant published articles were also examined. Searches were carried out in October 2010 and there were no restrictions by study design or country of origin. Publication date of included studies was limited to 1990-2010.

Prehospital trauma care developed over the last decades parallel in many countries. Most of the prehospital emergency medical systems relied on input or experiences from military medicine and were often modeled after the existing military procedures. Some systems were initially developed with the trauma patient in mind, while other systems were tailored for medical, especially cardiovascular, emergencies. The key components to successful prehospital trauma care are the well-known ABCs of trauma care: Airway, Breathing, Circulation. Establishing and securing the airway, ventilation, fluid resuscitation, and in addition, the quick transport to the best-suited trauma center represent the pillars of trauma care in the field. While ABC in trauma care has neither been challenged nor changed, new techniques, tools and procedures have been developed to make it easier for the prehospital provider to achieve these goals in the prehospital setting and thus improve the outcome of trauma patients.

Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.

Injuries are a major and growing public health problem, a leading cause of death and disabilities among people aged 1-44 years around the world. Each year, 5.8 million people die from injuries, accounting for 10% of the world's deaths. Road traffic injuries (RTIs), self-inflicted injuries and violence are the top three leading causes of all injury deaths, while RTIs, falls and drowning are the top three leading causes of unintentional injury death. In many high-income countries, trends of injury death have been decreasing as a result of prevention measures. In contrast, trends in low- and middle-income countries have been rising. In this article, we review the prevention strategies for RTIs, violence, falls and drowning developed over decades to disseminate the knowledge and inform health care providers, especially acute care physicians, about the importance of injury prevention.

The damage control concept is an essential component in the management of severely injured patients. The principles in sequence are as follows: (1) abbreviated surgical procedures limited to haemorrhage and contamination control; (2) correction of physiological derangements; (3) definitive surgical procedures. Although originally described in the management of major abdominal injuries, the concept has been extended to include thoracic, vascular, orthopedic, and neurosurgical procedures, as well as anesthesia and resuscitative strategies.

Ischemic colitis (IC) secondary to air embolism from decompression sickness or barotrauma during diving is an extremely rare condition. After extensive review of the available literature, we found that there has been only one reported case of IC secondary to air embolism from diving. Although air embolization from diving and the various medical complications that follow have been well documented, the clinical manifestation of IC from an air embolism during diving is very rare and thus far unstudied. Common symptoms of IC include abdominal pain, bloody or non-bloody diarrhea or nausea or vomiting or any combination. Emergency physicians and Critical Care specialists should consider IC as a potential diagnosis for a patient with the above-mentioned symptoms and a history of recent diving. We report a case of IC from air embolism after a routine dive to 75 feet below sea level in a 53-year-old White female who presented to a community Emergency Department complaining of a 2-day history of diffuse abdominal pain and nausea. She was diagnosed by colonoscopy with biopsies and treated conservatively with antibiotics, bowel rest, and a slow advancement in diet.

This is a case report of a 13-year old child diagnosed with hemophilia A. He reported with a bleeding wound in the middle part of the hard palate, due to trauma from a lead pencil. An intraoral palatal stent was planned to provide continuous pressure, stabilize the clot and allow local delivery of hemostatic agent. The stent was fabricated with a thermoplastic silicone rubber (biostar) under vacuum. The hemostatic agent used was one 500 mg capsule of tranxemic acid that was crushed and applied as a paste every 6 hourly. The patient was admitted under supervision for 3 days, where Recombinant factor VIII (rFVIII) intravenous infusion of 15-25 U/kg twice a day was given. Complete healing was observed in the traumatized area within 10 days. This article emphasizes on prenatal diagnosis, carrier screening and counseling of parents born with hemophilic children.

Propofol infusion syndrome (PRIS) is a rare but often fatal complication as a result of large doses of propofol infusion (4-5 mg/kg/hr) for a prolonged period (>48 h). It has been reported in both children and adults. Besides large doses of propofol infusion, the risk factors include young age, acute neurological injury, low carbohydrate and high fat intake, exogenous administration of corticosteroid and catecholamine, critical illness, and inborn errors of mitochondrial fatty acid oxidation. PRIS manifestation include presence of metabolic acidosis with a base deficit of more than 10 mmol/l at least on one occasion, rhabdomyolysis or myoglobinuria, acute renal failure, sudden onset of bradycardia resistant to treatment, myocardial failure, and lipemic plasma. The pathophysiology of PRIS may be either direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. We report a case of supermorbidly obese patient who received propofol infusion by total body weight instead of actual body weight and developed PRIS.