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Sirtuins (SIRT), first discovered in yeast as NAD+ dependent epigenetic and metabolic regulators, have comparable activities in human physiology and disease. Mounting evidence supports that the seven-member mammalian sirtuin family (SIRT1–7) guard homeostasis by sensing bioenergy needs and responding by making alterations in the cell nutrients. Sirtuins play a critical role in restoring homeostasis during stress responses. Inflammation is designed to “defend and mend” against the invading organisms. Emerging evidence supports that metabolism and bioenergy reprogramming direct the sequential course of inflammation; failure of homeostasis retrieval results in many chronic and acute inflammatory diseases. Anabolic glycolysis quickly induced (compared to oxidative phosphorylation) for ROS and ATP generation is needed for immune activation to “defend” against invading microorganisms. Lipolysis/fatty acid oxidation, essential for cellular protection/hibernation and cell survival in order to “mend,” leads to immune repression. Acute/chronic inflammations are linked to altered glycolysis and fatty acid oxidation, at least in part, by NAD+ dependent function of sirtuins. Therapeutically targeting sirtuins may provide a new class of inflammation and immune regulators. This review discusses how sirtuins integrate metabolism, bioenergetics, and immunity during inflammation and how sirtuin-directed treatment improves outcome in chronic inflammatory diseases and in the extreme stress response of sepsis.

Background Elderly trauma patients are at risk for undertriage, resulting in substantial morbidity and mortality. The objective of this study was to determine whether implementation of geriatric-specific trauma team activation (TTA) protocols appropriately identified severely-injured elderly patients. Methods This single-center retrospective study evaluated all severely injured (injury severity score [ISS] >15), geriatric (≥65 years) patients admitted to our Level 1 tertiary-care hospital between January 2014 and September 2017. Undertriage was defined as the lack of TTA despite presence of severe injuries. The primary outcome was all-cause in-hospital mortality; secondary outcomes were mortality within 48 hours of admission and urgent hemorrhage control. A multivariable logistic regression analysis was performed to identify predictors of appropriate triage in this study. Results Out of 1039 severely injured geriatric patients, 628 (61%) did not undergo TTA. Undertriaged patients were significantly older and had more comorbidities. In-hospital mortality was 5% and 31% in the undertriaged and appropriately triaged groups, respectively (P < .0001). One percent of undertriaged patients needed urgent hemorrhage control, compared to 6% of the appropriately triaged group (P < .0001). One percent of undertriaged patients died within 48 hours compared to 19% in the appropriately triaged group (P < .0001). Predictors of appropriate triage include GCS, heart rate, systolic blood pressure, lactic acid, ISS, shock, and absence of dementia, stroke, or alcoholism. Discussion Geriatric-specific TTA guidelines continue to undertriage elderly trauma patients when using ISS as a metric to measure undertriage. However, undertriaged patients have much lower morbidity and mortality, suggesting the geriatric-specific TTA guidelines identify those patients at highest risk for poor outcomes.

Rhabdomyolysis is a clinical condition characterized by destruction of skeletal muscle with release of intracellular contents into the bloodstream. Intracellular contents released include electrolytes, enzymes, and myoglobin, resulting in systemic complications. Muscle necrosis is the common factor for traumatic and non-traumatic rhabdomyolysis. The systemic impact of rhabdomyolysis ranges from asymptomatic elevations in bloodstream muscle enzymes to life-threatening acute kidney injury and electrolyte abnormalities. The purpose of this clinical consensus statement is to review the present-day diagnosis, management, and prognosis of patients who develop rhabdomyolysis.

Table 1 Contamination considerations Type of contamination Antibiotic recommendations Additional considerations Water contamination Short course, 3–5 days Salt water Doxycycline and ceftazidime Fluoroquinolone Freshwater Ciprofloxacin Levofloxacin Third or fourth-generation cephalosporin Vibrio Aeromonas Pseudomonas Soil contamination Short course, 3–5 days High-dose penicillin Clostridium sp Farm-related injuries Mammalian bites (human, dog, or cat) Short course, 3–5 days Amoxicillin-clavulanate Clindamycin plus trimethoprim-sulfamethoxazole for penicillin-allergic patients Table 2 Summary of antibiotic recommendations Injury Antibiotic recommendations Additional considerations Face and scalp Open or contaminated facial fractures Prophylactic antibiotics 24 h or less Cefazolin—coverage against GP bacteria Ceftriaxone—broader GN coverage and CNS penetration Ampicillin/sulbactam—broader GN and anaerobic coverage Clindamycin—for penicillin-allergic patients Frontal sinus fracture that involves the posterior table Contaminated fractures Open mandible fractures Closed or non-contaminated operative facial fractures Preoperative antibiotics Cefazolin—coverage against GP bacteria Ceftriaxone—broader GN coverage and CNS penetration Ampicillin/sulbactam—broader GN and anaerobic coverage Clindamycin—for penicillin-allergic patients No postoperative antibiotics Fractures of the upper one-third of the face Frontal sinus fractures that do not involve the posterior table Fractures of the middle one-third of the face (LeFort, zygomaticomaxillary complex, orbital, maxillary sinus, nasal bone) Fractures of the lower one-third of the face (non-dentate segments of mandible) Non-operative facial fractures No prophylactic antibiotics Orbital fractures Upper face fractures Mid-face fractures Mandibular fractures Facial and scalp lacerations Prophylactic antibiotics 24 h or less if complex or high-risk patient Amoxicillin-clavulanate Clindamycin—for penicillin-allergic patients Communication to oral cavity High infection risk: significant tissue destruction, large dead space, extensive contamination, underlying medical problems that place a patient at high risk (diabetes, immunosuppression, steroids, extremes of age, obesity, etc) Nasal packing No prophylactic antibiotics Central nervous system Pneumocephalus No prophylactic antibiotics Associated with open skull fracture and communication to the sinuses CSF leaks No prophylactic antibiotics Associated with basilar skull fractures Penetrating brain injury Short course of prophylactic antibiotics, <3 days Cefazolin Clindamycin - for penicillin-allergic patients Visible contamination—add metronidazole Penetrating spine injury Short course of prophylactic antibiotics, no more than 48 h First and second-generation cephalosporins Ampicillin-sulbactam Piperacillin-tazobactam Clindamycin with second-generation cephalosporin Gastrointestinal involvement, specifically transcolonic Extremity Closed extremity fractures No prophylactic antibiotics if non-operative management Preoperative antibiotics within 1 h of incision First-generation cephalosporin Clindamycin—for penicillin-allergic patients Open extremity fractures Prophylactic antibiotics 24 h or less Types I and II should be treated with GP coverage First-generation cephalosporin Clindamycin - for penicillin allergic patients Type III should be treated with GP and GN coverage First-generation cephalosporin and aminoglycoside Piperacillin/tazobactam Ceftriaxone Antibiotics should be initiated within 1 h of injury and continued for 24 h Washout and debridement should take place within 24 h of injury Soft tissue injury Soft tissue Lacerations/stab wounds Prophylactic antibiotics 24 h or less if complex or high-risk patient First-generation cephalosporin Clindamycin—for penicillin-allergic patients High-risk infection Specific wound-related concerns (presence of significant contamination, crush injury, or specific at-risk anatomic sites) Underlying patient factors that would increase the risk or worsen the outcome of infection GSW Prophylactic antibiotics 24 h or less if complex or high-risk patient First-generation cephalosporin Clindamycin—for penicillin-allergic patients Surgical debridement of devitalized tissue if needed Consideration of low-energy vs. high-energy mechanism Burn injury No prophylactic antibiotics Providers should take into account their institutional antibiogram when choosing antibiotics for prophylaxis and/or treatment. Iterative selection of studies was not performed as in a systematic review, and the methodology of the literature search was at the discretion of the authors. Freshwater wounds should be managed with ciprofloxacin, levofloxacin, or a third-generation or fourth-generation cephalosporin.1 Potential clostridial contamination, such as farm-related injuries, requires high-dose penicillin irrespective of the fracture type.2 A full review of the treatment of bite injuries is beyond the scope of this document, but wounds caused by human, cat, and dog bites (the most common bite wounds encountered) are often treated with antibiotics due to the high load of more variable pathogens found in the oral cavity and the wound mechanism, with punctures that make both natural movement of the bacteria and adequate irrigation difficult.3 A course of 3–5 days of amoxicillin-clavulanate is a suggested regimen, with clindamycin plus trimethoprim-sulfamethoxazole two times per day as an alternative for patients with a penicillin allergy.4 5 While there is increasing question in the literature about the benefit of treating bite injuries with empiric antibiotics, there seems to be general consensus that injuries in high-risk locations (specifically hands, and over cartilage) and in high-risk patients should be treated.4–6 Rabies treatment should also be considered and addressed with any mammalian bite wounds (table 1). [...]there is tremendous variability in practice patterns among treating surgeons, and many providers continue antibiotic prophylaxis longer than proposed, which leads to overuse of antibiotics in this patient population.7 8 The Surgical Infection Society (SIS) recently published a guideline for prophylactic antibiotic use in patients with traumatic facial fractures.9 The authors of the SIS guidelines defined prophylactic antibiotics as antibiotics administered for more than 24 hours.

ObjectivesThe American Association for the Surgery of Trauma (AAST) Critical Care Committee chose handoffs and transitions of care in the intensive care unit (ICU) as a clinically relevant topic for review. This clinical consensus document aims to provide practical guidance to the surgical intensivist on the best practices for patient handoffs and transitions of care.MethodsA working group was formed from the committee-at-large to complete this work. The members of the working group were each assigned a subtopic to review using research to date. The research on which the recommendations are based was compiled at the discretion of the working group. Any topic with discrepant or minimal supporting literature was reviewed by the AAST Critical Care Committee through an anonymous survey.ResultsRecommendations for healthcare handovers include formally recognized handoffs at dedicated times, an interactive verbal exchange including all patients with a focus on what to anticipate or what is needs to be completed, tools to record and maintain information, and training to new providers on the handoff process and technology.ConclusionAs clinicians, we strive to provide the best evidence-based care to our patients. It is essential to study these high states, ICU handoffs to enhance the safety, efficiency, and effectiveness of patient care transitions, ultimately leading to better patient outcomes and provider satisfaction.Level of evidenceV.

A 59-year old woman presented to the emergency department (ED) after sustaining injuries in a head-on motor vehicle collision. A supraglottic airway was placed in the field secondary to a depressed Glasgow Coma Scale score and airway protection. The patient initially presented to the ED with hemodynamic instability, as defined by tachycardia (153 beats/min) and hypotension (87/67 mm Hg). During the primary and secondary surveys, the supraglottic airway was exchanged for an endotracheal tube; a left-sided chest tube for large pneumothorax was placed; the pelvis was sheeted; and the patient received whole blood. Following these interventions, her heart rate was 87 beats/min with a blood pressure of 106/81 mm Hg. Focused assessment with sonography for trauma exam was positive for fluid in the right upper quadrant. Physical examination was significant for crepitus along the left chest wall, and venous oozing was identified from a vaginal laceration. Pelvic radiography showed multiple pelvic fractures.

Emergent operations are thought to carry higher morbidity and mortality than nonemergent cases. However, there is a lack of specific outcomes data for emergent general surgery procedures. The objective of our study was to assess and quantify postoperative morbidity and mortality for emergency versus nonemergency general surgery operations. All general surgery inpatients were identified in the American College of Surgeons National Surgical Quality Improvement Program 2008 database. Preoperative, intraoperative, and postoperative clinical metrics and occurrences were assessed. A total of 25,770 emergent and 98,867 nonemergent cases were identified. Postoperative morbidity was significantly worse in the emergent group, including ventilation more than 48 hours, bleeding requiring transfusion, deep vein thrombosis, renal failure, and need for reoperation. Overall, emergent cases had significantly more postoperative complications (22.8% vs 14.2%) and higher mortality rates (6.5% vs 1.4%). General surgery patients who undergo emergent operations have significantly poorer outcomes when compared with nonemergent patients; our analysis has quantified these differences. Emergent patients seem to manifest unique clinical, pathophysiologic, and inflammatory responses to their surgical disease. This data suggests that there is a need for improvement in both methods and systems of care for the emergent population.

The use of prophylactic measures, including perioperative antibiotics, for the prevention of surgical site infections is a standard of care across surgical specialties. Unfortunately, the routine guidelines used for routine procedures do not always account for many of the factors encountered with urgent/emergent operations and critically ill or high-risk patients. This clinical consensus document created by the American Association for the Surgery of Trauma Critical Care Committee is one of a three-part series and reviews surgical and procedural antibiotic prophylaxis in the surgical intensive care unit. The purpose of this clinical consensus document is to provide practical recommendations, based on expert opinion, to assist intensive care providers with decision-making for surgical prophylaxis. We specifically evaluate the current state of periprocedural antibiotic management of external ventricular drains, orthopedic operations (closed and open fractures, silver dressings, local, antimicrobial adjuncts, spine surgery, subfascial drains), abdominal operations (bowel injury and open abdomen), and bedside procedures (thoracostomy tube, gastrostomy tube, tracheostomy).

Abstract Rationale Accurate, early identification of patients at risk for developing acute lung injury (ALI) provides the opportunity to test and implement secondary prevention strategies. Objectives To determine the frequency and outcome of ALI development in patients at risk and validate a lung injury prediction score (LIPS). Methods In this prospective multicenter observational cohort study, predisposing conditions and risk modifiers predictive of ALI development were identified from routine clinical data available during initial evaluation. The discrimination of the model was assessed with area under receiver operating curve (AUC). The risk of death from ALI was determined after adjustment for severity of illness and predisposing conditions. Measurements and Main Results Twenty-two hospitals enrolled 5,584 patients at risk. ALI developed a median of 2 (interquartile range 1–4) days after initial evaluation in 377 (6.8%; 148 ALI-only, 229 adult respiratory distress syndrome) patients. The frequency of ALI varied according to predisposing conditions (from 3% in pancreatitis to 26% after smoke inhalation). LIPS discriminated patients who developed ALI from those who did not with an AUC of 0.80 (95% confidence interval, 0.78–0.82). When adjusted for severity of illness and predisposing conditions, development of ALI increased the risk of in-hospital death (odds ratio, 4.1; 95% confidence interval, 2.9–5.7). Conclusions ALI occurrence varies according to predisposing conditions and carries an independently poor prognosis. Using routinely available clinical data, LIPS identifies patients at high risk for ALI early in the course of their illness. This model will alert clinicians about the risk of ALI and facilitate testing and implementation of ALI prevention strategies. Clinical trial registered with www.clinicaltrials.gov (NCT00889772).

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.