Therapeutic hypothermia was investigated repeatedly as a tool to improve the outcome of severe traumatic brain injury (TBI), but previous clinical trials and meta-analyses found contradictory results. We aimed to determine the effectiveness of therapeutic whole-body hypothermia on the deaths of adult patients with severe TBI by using a novel approach of meta-analysis. We searched the PubMed, EMBASE, and Cochrane Library databases from inception to February 2017. The identified human studies were evaluated regarding statistical, clinical, and methodological designs to ensure interstudy homogeneity. We extracted data on TBI severity, body temperature, death, and cooling parameters; then we calculated the cooling index, an integrated measure of therapeutic hypothermia. Forest plot of all identified studies showed no difference in the outcome of TBI between cooled and not cooled patients, but interstudy heterogeneity was high. On the contrary, by meta-analysis of randomized clinical trials that were homogenous with regard to statistical, clinical designs, and precisely reported the cooling protocol, we showed decreased odds ratio for death in therapeutic hypothermia compared with no cooling. As independent factors, milder and longer cooling, and rewarming at <0.25°C/h were associated with better outcome. Therapeutic hypothermia was beneficial only if the cooling index (measure of combination of cooling parameters) was sufficiently high. We conclude that high methodological and statistical interstudy heterogeneity could underlie the contradictory results obtained in previous studies. By analyzing methodologically homogenous studies, we show that cooling improves the outcome of severe TBI, and this beneficial effect depends on certain cooling parameters and on their integrated measure, the cooling index.
BackgroundOrganism susceptibilities for trauma-associated pneumonia (TAP) differ from those in other groups of patients, including the critically ill. The purpose of this study was to identify common organisms and their susceptibilities in the respiratory isolates of trauma patients diagnosed with pneumonia within the first 7 days of hospital admission, and to create a disease-state antibiogram specific to TAP to guide empiric antibiotic therapy in this patient population.MethodsThis study was an IRB-approved, retrospective chart review of adult trauma patients with pneumonia admitted between September 1, 2015 and August 31, 2018 were evaluated. Patients included were diagnosed with and treated for pneumonia, with respiratory cultures drawn within the first 7 days of admission; both culture-positive and culture-negative patients were included. Subgroup antibiograms were made for a diagnosis made on days 1–3, 4–5, and 6–7.ResultsThere were 131 patients included with a median age of 45; 85% were male, and 31% were illicit drug users. The majority of patients (63%) had ventilator-associated pneumonia, and most respiratory samples (77%) were obtained via bronchiolar lavage. Cultures were positive in 109 patients and negative in 22. There were 144 total isolates; 54% were Gram-negative bacteria. The most common Gram-negative pathogens were Haemophilus influenzae (16%) and Klebsiella pneumoniae (15%). The most common Gram-positive pathogen was Staphylococcus aureus; 9% of all patients grew methicillin-resistant S. aureus. With culture-negative patients counted as susceptible, ceftriaxone monotherapy and ceftriaxone + vancomycin susceptibility were 85% and 94% of patients, respectively. Susceptibilities to cefazolin, ampicillin/sulbactam, cefepime, piperacillin/tazobactam, and levofloxacin were 49%, 69%, 91%, 90%, and 92%, respectively. Illicit drug use and day of pneumonia diagnosis did not appreciably affect antibiotic susceptibilities.ConclusionFor TAP diagnosed within the first 7 days of hospital admission, ceftriaxone monotherapy is adequate as empiric therapy, including in ventilated patients. The addition of vancomycin can be considered in patients with MRSA risk factors or who are critically ill.Disclosures
All authors: No reported disclosures.
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