Background: Although the association of neutrophil proportions with mortality in trauma patients has recently been shown, there is a paucity of research on the association with other outcomes. We sought to investigate the association of neutrophil proportions with organ failure in critically-ill trauma patients. Methods: We reviewed a randomly-selected group of trauma patients admitted to our level-1 trauma intensive care unit between July 2007 and December 2016. Data collected included demographics, injury mechanism and severity (ISS), neutrophil-to-lymphocyte ratio (NLR) at admission and at 24 and 48 hours and organ failure data. NLR patterns during the first 48 hours were divided into two trajectories identified by applying factor and cluster analysis to longitudinal measures. Logistic regression was performed for the association between NLR trajectories and any organ failure; negative binomial regression was used to model the number of organ failures and stage of kidney failure measured by KDIGO classification. Results: 207 patients had NLR data at all three time points. The average age was 44.9 years with mean ISS of 20.6. Patients were 72% male and 23% had penetrating trauma. The 74 patients (36%) with Trajectory 1 had a mean NLR at admission of 3.6, which increased to 14.7 at 48 hours. The 133 (64%) patients in Trajectory 2 had a mean NLR at admission of 8.5 which decreased to 6.6 at 48 hours. Mean NLR was different between the two groups at all three time points (all p < 0.01). There was no significant difference in ISS, age or gender between the two trajectory groups. Models adjusted for age, gender and ISS showed that relative to those with trajectory 2, patients with the trajectory 1 were more likely to have organ failure OR 2.96 (1.42–6.18; p < 0.01), higher number of organ failures IRR 1.50 (1.13–2.00, p < 0.01), and degree of AKI IRR 2.06 (1.04–4.06, p = 0.04). In all cases, the estimated associations were higher among men vs. women, and all were significant among men, but not women. Conclusions: Trauma patients with an increasing NLR trajectory over the first 48 hours had increased risk, number and severity of organ failures. Further research should focus on the mechanisms behind this difference in outcome.

Antimicrobial resistance in the intensive care unit is an ongoing global healthcare concern associated with high mortality and morbidity rates and high healthcare costs. Select groups of bacterial pathogens express different mechanisms of antimicrobial resistance. Clinicians face challenges in managing patients with multidrug-resistant bacteria in the form of a limited pool of available antibiotics, slow and potentially inaccurate conventional diagnostic microbial modalities, mimicry of non-infective conditions with infective syndromes, and the confounding of the clinical picture of organ dysfunction associated with sepsis with postoperative surgical complications such as hemorrhage and fluid shifts. Potential remedies for antimicrobial resistance include specific surveillance, adequate and systematic antibiotic stewardship, use of pharmacokinetic and pharmacodynamic techniques of therapy, and antimicrobial monitoring and adequate employment of infection control policies. Novel techniques of combating antimicrobial resistance include the use of aerosolized antibiotics for lung infections, the restoration of gut microflora using fecal transplantation, and orally administered probiotics. Newer antibiotics are urgently needed as part of the armamentarium against multidrug-resistant bacteria. In this review we discuss mechanisms and patterns of microbial resistance in a select group of drug-resistant bacteria, and preventive and remedial measures for combating antibiotic resistance in the critically ill.

Evidence exists on the morbiduty and mortality associated with both massive blood loss and transfusion in cardiac surgical patients. Monitoring of the vesicoelastic properties of blood using rotational thromboelastometry and thromboelsatography (TEG) has been a major step towards ameliorating the risks associated with these 2 evils by providing trageted goal-directed blood product resuscitation. Point of care ROTEM and TEG overcome many of the current limitatons of conventional laboratory coagulation testing. Despite the peaking interest and widespread use there is a lack of consensus whetehr the use of these devices to guide blood product resucistation is associated with a reduction in mortality. Also, both ROTEM and TEG suffer from some limitations resulting in a lack of agreement on the duperiority of one device versus the other. In this concise review we discuss the operational charecteristics of both devices and the pro-side of the use of ROTEM in cardiac surgery backed with the most recent evidence.

The association of gender with mortality in trauma remains a subject of debate. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of gender with mortality in a group of geriatric trauma patients presenting to an academic level 1 trauma center (trauma center designated by New York State capable of handling the most severe injuries and most complex cases). Methods: We performed a retrospective review of geriatric trauma patients who were admitted to our trauma center between January 2018 and December 2020. Data collected included vital signs, demographics, injury, and clinical characteristics, laboratory data and outcome measures. The study controlled for co-morbidities, injury severity score (ISS), and systolic blood pressure (SBP) in the ED. Multivariable logistic regression analysis was performed to evaluate the association of gender and mortality. Results: 4432 geriatric patients were admitted during the study period, there were 1635 (36.9%) men and 3859 (87.2%) were White with an average age of 81 ± 8.5 years. The mean ISS was 6.7 ± 5.4 and average length of stay was 6 ± 6.3 days. There were 165 deaths. Male gender (OR 1.94, 95% CI 1.38 to 2.73), ISS (OR 1.12, 95% CI 1.09 to 1.14), Emergency Department SBP less than 90 mmHg (OR 6.17, 95% CI 3.17 to 12.01), and having more than one co-morbidity (OR 2.28, 95% CI 1.55 to 3.35) were independently predictive of death on multivariable logistic regression analysis. Conclusion: Male gender, Emergency Department systolic blood pressure less than 90 mmHg, having more than one co-morbidity, and injury severity are independent predictors of mortality among geriatric trauma patients.

There is no current consensus on the follow up of kidney function in patients undergoing cardiopulmonary bypass (CPB). The main objectives of this pilot study is to collect preliminary data on kidney function decline encountered on the first postoperative visit of patients who have had CPB and to identify predictors of kidney function decline post hospital discharge. Design: Retrospective chart review. Adult patients undergoing open heart procedures utilizing CPB. Patient demographics, type of procedure, pre-, intra-, and postoperative clinical, hemodynamic echocardiographic, and laboratory data were abstracted from electronic medical records. Acute kidney disease (AKD), and chronic kidney disease (CKD) were diagnosed based on standardized criteria. Interval change in medications, hospital admissions, and exposure to contrast, from hospital discharge till first postoperative visit were collected. AKD, and CKD as defined by standardized criteria on first postoperative visit. 83 patients were available for analysis. AKD occurred in 27 (54%) of 50 patients and CKD developed in 12 (42%) out of 28 patients. Older age was associated with the development of both AKD and CKD. Reduction in right ventricular cardiac output at baseline was associated with AKD (OR: 0.5, 95% CI: 0.3, 0.79, P = 0.01). Prolongation of transmitral early diastolic filling wave deceleration time was associated with CKD (OR: 1.02, 95% CI: 1.01, 1.05, P = 0.03). In-hospital acute kidney injury (AKI) was a predictor of neither AKD nor CKD. AKD and CKD occur after CPB and may not be predicted by in-hospital AKI. Older age, right ventricular dysfunction and diastolic dysfunction are important disease predictors. An adequately powered longitudinal study is underway to study more sensitive predictors of delayed forms of kidney decline after CPB.