Executive Summary Introduction Methodology Used to Prepare the Guideline Epidemiology Incidence Etiology Major Epidemiologic Points Pathogenesis Major Points for Pathogenesis Modifiable Risk Factors Intubation and Mechanical Ventilation Aspiration, Body Position, and Enteral Feeding Modulation of Colonization: Oral Antiseptics and Antibiotics Stress Bleeding Prophylaxis, Transfusion, and Glucose Control Major Points and Recommendations for Modifiable Risk Factors Diagnostic Testing Major Points and Recommendations for Diagnosis Diagnostic Strategies and Approaches Clinical Strategy Bacteriologic Strategy Recommended Diagnostic Strategy Major Points and Recommendations for Comparing Diagnostic Strategies Antibiotic Treatment of Hospital-acquired Pneumonia General Approach Initial Empiric Antibiotic Therapy Appropriate Antibiotic Selection and Adequate Dosing Local Instillation and Aerosolized Antibiotics Combination versus Monotherapy Duration of Therapy Major Points and Recommendations for Optimal Antibiotic Therapy Specific Antibiotic Regimens Antibiotic Heterogeneity and Antibiotic Cycling Response to Therapy Modification of Empiric Antibiotic Regimens Defining the Normal Pattern of Resolution Reasons for Deterioration or Nonresolution Evaluation of the Nonresponding Patient Major Points and Recommendations for Assessing Response to Therapy Suggested Performance Indicators

Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia the official statement of the American Thoracic Society and the Infectious Disease Society of America (特集 救急診療ガイドライン) -- (海外のガイドライン)

The importance of the gut-brain axis in maintaining homeostasis has long been appreciated. However, the past 15 yr have seen the emergence of the microbiota (the trillions of microorganisms within ...

The Microbiota-Gut-Brain Axis

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

/pdf/the-european-guideline-on-management-of-major-bleeding-and-50g3zxrre8.pdf

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

Objective To observe the effect of intensive insulin therapy on the critically ill patients with stress hyperglycemia in ICU.Methods One hundred and ten critically ill patients in ICU were randomly divided into two groups,the intensive insulin therapy group(n=55) and control group(n=55).The blood glucose in the intensive insulin therapy group was controlled at 4.4 to 6.1 mmol/L,and the blood glucose in control group was controlled at 10.0 to 11.1 mmol/L.The two groups were observed and compared the days in the ICU,the numbers of patients requiring mechanical ventilation,the days of mechanical ventilation,the incidences of infection in hospital,the days of using antibiotics,Acute Physiology and Chronic Health Evaluation Ⅱ score of the last day in ICU,the morbidity of multiple organ failure,the morbidity of hypoglycemia and mortality.Results All the above indices except morbidity of hypoglycemia were significantly lower in the intensive insulin therapy group than those in control group(P0.05 or P0.01).Conclusion Intensive insulin therapy and keeping blood glucose at 4.4 to 6.1 mmol/L can improve the clinical curative effect and reduce the mortality for the critically ill patients with stress hyperglycemia,

Intensive insulin therapy for the critically ill patients with stress hyperglycemia

노인 통증사정을 위한 한국어 판 Short-form McGill Pain Questionnaire [SF-MPQ]의 신뢰도와 타당도

Background: The cytotoxic effects of antiseptics on pivotal cell types of the healing process have been well documented. The purpose of our investigation was to explore the ability of subcytotoxic levels of antiseptics to interfere with fibroblast function. Methods: Cell proliferation assays were performed by culturing fibroblasts in the presence of commonly used antiseptics. Migration was evaluated using scratch assays in which monolayers were “wounded” and cellular movement was monitored by digital photography. Matrix metalloproteinase (MMP) release was analyzed by zymography. Results: H2O2 and povidone-iodine reduced both migration and proliferation of fibroblasts in a dose-dependent fashion.Treatmentwithsilver-containing antiseptics and chlorhexidine exhibited reductions in proliferation at high concentrations, but enhanced growth at lower doses. Silver-containing compounds and chlorhexidine also proved to be the least detrimental to migration in these assays. metalloproteinase release from the cells was differently affected depending on the dosage and class of antiseptic applied. Conclusions: When debridement of the wound bed is not sufficient to reduce bacterial loads, the application of broadspectrum antiseptics maybe indicated. Our data would suggest that H2O2 and iodine are poor choices, potentially retarding the contribution of fibroblasts to the healing process. Silver sulfadiazine and chlorhexidine, at levels still proven to be bactericidal, had fewer detrimental effects on fibroblast activity in these assays. The silver-containing antiseptics may even increase the proliferative potential of these cells in culture.

Mechanisms of delayed wound healing by commonly used antiseptics.

Importance The Glasgow Coma Scale (GCS) is used frequently to define the extent of neurologic injury in patients with a traumatic brain injury (TBI). Whether age affects the predictive ability of the GCS for severity of TBI (determined by the Abbreviated Injury Scale [AIS] score) remains unknown. Objective To investigate the effect of age on the association between the GCS and anatomic TBI severity. Design, Setting, and Participants We examined all patients with a TBI, defined by diagnostic codes 850 to 854 from the International Classification of Diseases, Ninth Revision, Clinical Modification , who were admitted to 2 level I trauma centers from January 1, 2008, through December 31, 2012. Exposures We compared elderly (≥65 years) and younger (18-64 years) adults with TBI. Main Outcomes and Measures We examined differences by age in GCS category (defined by emergency department GCS as severe [3-8], moderate [9-12], or mild [13-15]) at each level of TBI severity (head AIS score, 1 [minor] to 5 [critical]). Cochran-Armitage χ 2 trend tests and stepwise multivariate linear and logistic regression models were used. Results During the study period, 6710 patients had a TBI (aged P  ≤ .01 for all). In particular, among patients with an AIS score of 5, most of the elderly patients (56.33%) had a mild neurologic deficit (GCS score, 13-15), whereas most of the younger patients (63.28%) had a severe neurologic deficit (GCS score, 3-8). After adjustment, the younger adults had increased odds of presenting with a severe neurologic deficit (GCS score, 3-8) at each of the following AIS scores: 1, 4.2 (95% CI, 1.0-17.6; P  = .05); 2, 2.0 (1.0-3.7; P  = .04); 3, 2.0 (1.2-3.5; P  = .01); 4, 4.6 (2.8-7.5; P P P  = .005). Conclusions and Relevance Age affects the relationship between the GCS score and anatomic TBI severity. Elderly TBI patients have better GCS scores than younger TBI patients with similar TBI severity. These findings have implications for TBI outcomes research and for protocols and research selection criteria that use the GCS.

https://jamanetwork.com/journals/jamasurgery/articlepdf/1876615/soi140002.pdf

The effect of age on Glasgow Coma Scale score in patients with traumatic brain injury.

Traditional vital signs (TVS), including systolic blood pressure (SBP), heart rate (HR) and their composite, the shock index, may be poor prognostic indicators in geriatric trauma patients. The purpose of this study is to determine whether lactate predicts mortality better than TVS. We studied a large cohort of trauma patients age ≥ 65 years admitted to a level 1 trauma center from 2009-01-01 - 2011-12-31. We defined abnormal TVS as hypotension (SBP 120 beats/min), an elevated shock index as HR/SBP ≥ 1, an elevated venous lactate as ≥ 2.5 mM, and occult hypoperfusion as elevated lactate with normal TVS. The association between these variables and in-hospital mortality was compared using Chi-square tests and multivariate logistic regression. There were 1987 geriatric trauma patients included, with an overall mortality of 4.23% and an incidence of occult hypoperfusion of 20.03%. After adjustment for GCS, ISS, and advanced age, venous lactate significantly predicted mortality (OR: 2.62, p < 0.001), whereas abnormal TVS (OR: 1.71, p = 0.21) and SI ≥ 1 (OR: 1.18, p = 0.78) did not. Mortality was significantly greater in patients with occult hypoperfusion compared to patients with no sign of circulatory hemodynamic instability (10.67% versus 3.67%, p < 0.001), which continued after adjustment (OR: 2.12, p = 0.01). Our findings demonstrate that occult hypoperfusion was exceedingly common in geriatric trauma patients, and was associated with a two-fold increased odds of mortality. Venous lactate should be measured for all geriatric trauma patients to improve the identification of hemodynamic instability and optimize resuscitative efforts.

/pdf/a-retrospective-analysis-of-geriatric-trauma-patients-venous-2g01480w2s.pdf

A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs

The cobalt-albumin binding assay: insights into its mode of action.

The amount of oxidative stress in patients with an isolated traumatic brain injury (ITBI) can be estimated by measuring several biochemical parameters, such as total antioxidants, lipid peroxidation, protein oxidation, and others. Unfortunately, measuring these parameters is time-consuming, impractical in a clinical setting, and may miss important factors contributing to the overall redox balance. Here we suggest that the overall oxidative status in ITBI patients can be assessed by measuring plasma oxidation-reduction potential (ORP). Daily whole blood samples were obtained from severe ITBI patients (abbreviated injury score [AIS] >or=3, n = 32), and demographically similar non-head injury traumatized patients (n = 26) until discharge. Whole blood was also collected from patients with minor to moderate ITBI (AIS <or= 2, n = 18) and healthy volunteers (n = 22). Admission plasma ORP was significantly elevated in all traumatized patients compared to controls. Maximum ORP was detected on day 6 for severe ITBI and non-head injury traumatized patients. However, maximum ORP values were significantly higher (p < 0.05) in the severe ITBI group (+8.5 mV +/- 3.4 SEM) compared to the non-head injury group (-5.2 mV +/- 2.9 SEM). Additionally, a significantly higher oxidation of human serum albumin (HSA) was measured in all trauma patients compared to controls. These results demonstrate the presence of an oxidative environment in the plasma of traumatized patients, specifically in severe ITBI patients. Therefore monitoring ORP is a potentially useful tool for assessing the degree of oxidative stress, inflammation, severity of injury, and potential efficacy of treatment in ITBI patients.

Charles W. Mains

Papers

Mechanisms of delayed wound healing by commonly used antiseptics.

The effect of age on Glasgow Coma Scale score in patients with traumatic brain injury.

A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs

The cobalt-albumin binding assay: insights into its mode of action.

Plasma oxidation-reduction potential and protein oxidation in traumatic brain injury.