LETTERS
Critique of hyperglycemia and surgical site infection To the Editor: ichards et al.1 have done an excellent study on stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries and found that stress hyperglycemia was associated with surgical site infection in this prospective observational cohort of stable nondiabetic patients with orthopedic injuries. We have tried several times to prove this hypothesis but gave up halfway because of the difficulty in getting enough qualified cases. However, we find a shortcoming in the study of Richards et al. through our limited experience, which is that there was a significant difference between nonhyperglycemic and hyperglycemic patients in terms of age (p = 0.03) and American Society of Anesthesiologists (ASA) class (p = 0.006). As we know, patients with more severe comorbid medical disease, as defined by ASA Class 3 or 4, were more likely to be hyperglycemic, and they also have low resistance to disease, which lead to high risk for postoperative infection. At the same time, the younger patients usually have good hyperglycemia reaction to stress and also have low risk for postoperative infection. Thus, there is no significant difference between nonhyperglycemic and hyperglycemic patients in terms of age, and ASA class is the prerequisite for study on stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries. We hope that there will be such a study in large-scale clinical centers that can meet the prerequisites and give us the exact results about the relationship between stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries.
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*The authors declare no conflicts of interest. Yueju Liu, MD Han Li, MD Third Hospital of Hebei Medical University and Key Orthopaedic Biomechanics Laboratory of Hebei Province Shijiazhuang, China
REFERENCE 1. Richards JE, Hutchinson J, Mukherjee K, et al. Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries. J Trauma Acute Care Surg. 2014; 76(4):1070Y1075.
TO THE
EDITOR
Pediatric casualties in the war zone To the Editor: dwards et al.1 report particularly interesting and uncommon data about war pediatric blast injuries. They highlight the specifications of surgical procedures performed for this particular population admitted to a US Department of Defense Medical Treatment Facility (MTF) at the Role 3 (combat hospital) echelon of care, named ‘‘Role 3,’’ during a period of 8 years of war in Iraq and Afghanistan. They emphasize the requirements in pediatric operative resources and expertise but also point out the restrictions on humanitarian admissions in this context. We would like to subjoin two comments. First, data collected by French military physicians in Kabul multinational Role 3, under French command, from 2010 to 2014, showed that pediatric patients (defined as e15 years) could account for one third of emergency or surgical care. In 1 year, up to 60 children were admitted to the intensive care unit, in 88% of cases for penetrating trauma (shrapnels, gunshot wounds) with at least two associated major injuries. A mean Injury Severity Score (ISS) of 25.2 (range, 12Y43) and a mean Trauma and Injury Severity Score (TRISS) of 9.96% (range, 0.9Y46.9%) illustrate the severity of the injuries in these patients, with an in-hospital mortality of 5%. Thus, approximately 100 pediatric anesthetic and surgical procedures (damage control surgery and repeated procedures) were performed monthly. These data enhance those collected by Edwards et al. during a period of 8 years (1,213 patients e 15 years) and the relevance of the questions concerning pediatric operative resources and expertise in Role 3 MTF. They highlight the question of trauma rehabilitation and long-term outcome of these patients in war zone. Besides, the authors point out the limitations of their study due to the lack of data before the admission of the wounded children in Role 3. We can highlight this topic differently thanks to in-press data, collected in 2011 by French military physicians in Region Command East (Kapisa), for each French Role 1 MTF (prehospital echelon of care). They describe their complete prehospital trauma care activity, including 90 wounded children (mean age, 9.4 years; range, 8 months to 15 years), that is, 25% (349) of the overall wounded patients. Among injuries, 59% were directly related to explosions (improvised explosive device, mortar, or other exploding munitions) or to gunshot wounds. Physicians and paramedics
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performed tactical care and medical procedures: tourniquets and hemostatic dressings, venous or intraosseous access, orotracheal intubation, and sedation. The severity, assessed by a mean Pediatric Trauma Score2 of 7.2 (range, j4 to +11), was illustrated by injury locations (limbs, 50%; head and neck, 18%; abdomen, thorax, and perineum, 20%). Eighty-two pediatric patients needed further urgent surgical procedures: 3 died before evacuation, and the 50 more severely injured were transferred to an ISAF Role 3 (61%), through ISAF (International Security and Assistance Force) tactical medical evacuation. The others, 29 casualties transported to local hospitals and 8 discharged to home, were not followed up. These limited prehospital data highlight the extent of the issue of severe war pediatric injuries. The awesome series of Edwards et al. is probably a terrible, but representative, part of the reality for children in those countries. *The authors declare no conflicts of interest.
Pierre-Fran0ois Wey, MD Fabrice Petitjeans, MD Pascal Precloux, MD Anesthesia and Intensive Care Department Desgenettes French Military Teaching Hospital Lyon, France
REFERENCES 1. Edwards MJ, Lustik M, Carlson T, et al. Surgical interventions for pediatric blast injury: an analysis from Afghanistan and Iraq 2002 to 2010. J Trauma Acute Care Surg. 76:854Y858. 2. Tepas JJ, Mollitt DL, Talbert JL, Bryant M. The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg. 1987;22:14Y18.
Nonsuperiority does not imply equivalence To the Editor: read with interest the article by Ekeh et al. titled ‘‘Successful placement of intracranial pressure monitors by trauma surgeons,’’ since we have recently published an article on the safe placement of intracranial pressure monitors by midlevel practitioners.1 However, I wish to point out two major flaws in the design and interpretation of the study by Ekeh et al. In their study, they do not specify the study design or adequately explain their statistical analysis. On the basis of the
I
J Trauma Acute Care Surg Volume 77, Number 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
521
Critique of hyperglycemia and surgical site infection To the Editor: ichards et al.1 have done an excellent study on stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries and found that stress hyperglycemia was associated with surgical site infection in this prospective observational cohort of stable nondiabetic patients with orthopedic injuries. We have tried several times to prove this hypothesis but gave up halfway because of the difficulty in getting enough qualified cases. However, we find a shortcoming in the study of Richards et al. through our limited experience, which is that there was a significant difference between nonhyperglycemic and hyperglycemic patients in terms of age (p = 0.03) and American Society of Anesthesiologists (ASA) class (p = 0.006). As we know, patients with more severe comorbid medical disease, as defined by ASA Class 3 or 4, were more likely to be hyperglycemic, and they also have low resistance to disease, which lead to high risk for postoperative infection. At the same time, the younger patients usually have good hyperglycemia reaction to stress and also have low risk for postoperative infection. Thus, there is no significant difference between nonhyperglycemic and hyperglycemic patients in terms of age, and ASA class is the prerequisite for study on stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries. We hope that there will be such a study in large-scale clinical centers that can meet the prerequisites and give us the exact results about the relationship between stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries.
R
*The authors declare no conflicts of interest. Yueju Liu, MD Han Li, MD Third Hospital of Hebei Medical University and Key Orthopaedic Biomechanics Laboratory of Hebei Province Shijiazhuang, China
REFERENCE 1. Richards JE, Hutchinson J, Mukherjee K, et al. Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries. J Trauma Acute Care Surg. 2014; 76(4):1070Y1075.
TO THE
EDITOR
Pediatric casualties in the war zone To the Editor: dwards et al.1 report particularly interesting and uncommon data about war pediatric blast injuries. They highlight the specifications of surgical procedures performed for this particular population admitted to a US Department of Defense Medical Treatment Facility (MTF) at the Role 3 (combat hospital) echelon of care, named ‘‘Role 3,’’ during a period of 8 years of war in Iraq and Afghanistan. They emphasize the requirements in pediatric operative resources and expertise but also point out the restrictions on humanitarian admissions in this context. We would like to subjoin two comments. First, data collected by French military physicians in Kabul multinational Role 3, under French command, from 2010 to 2014, showed that pediatric patients (defined as e15 years) could account for one third of emergency or surgical care. In 1 year, up to 60 children were admitted to the intensive care unit, in 88% of cases for penetrating trauma (shrapnels, gunshot wounds) with at least two associated major injuries. A mean Injury Severity Score (ISS) of 25.2 (range, 12Y43) and a mean Trauma and Injury Severity Score (TRISS) of 9.96% (range, 0.9Y46.9%) illustrate the severity of the injuries in these patients, with an in-hospital mortality of 5%. Thus, approximately 100 pediatric anesthetic and surgical procedures (damage control surgery and repeated procedures) were performed monthly. These data enhance those collected by Edwards et al. during a period of 8 years (1,213 patients e 15 years) and the relevance of the questions concerning pediatric operative resources and expertise in Role 3 MTF. They highlight the question of trauma rehabilitation and long-term outcome of these patients in war zone. Besides, the authors point out the limitations of their study due to the lack of data before the admission of the wounded children in Role 3. We can highlight this topic differently thanks to in-press data, collected in 2011 by French military physicians in Region Command East (Kapisa), for each French Role 1 MTF (prehospital echelon of care). They describe their complete prehospital trauma care activity, including 90 wounded children (mean age, 9.4 years; range, 8 months to 15 years), that is, 25% (349) of the overall wounded patients. Among injuries, 59% were directly related to explosions (improvised explosive device, mortar, or other exploding munitions) or to gunshot wounds. Physicians and paramedics
E
performed tactical care and medical procedures: tourniquets and hemostatic dressings, venous or intraosseous access, orotracheal intubation, and sedation. The severity, assessed by a mean Pediatric Trauma Score2 of 7.2 (range, j4 to +11), was illustrated by injury locations (limbs, 50%; head and neck, 18%; abdomen, thorax, and perineum, 20%). Eighty-two pediatric patients needed further urgent surgical procedures: 3 died before evacuation, and the 50 more severely injured were transferred to an ISAF Role 3 (61%), through ISAF (International Security and Assistance Force) tactical medical evacuation. The others, 29 casualties transported to local hospitals and 8 discharged to home, were not followed up. These limited prehospital data highlight the extent of the issue of severe war pediatric injuries. The awesome series of Edwards et al. is probably a terrible, but representative, part of the reality for children in those countries. *The authors declare no conflicts of interest.
Pierre-Fran0ois Wey, MD Fabrice Petitjeans, MD Pascal Precloux, MD Anesthesia and Intensive Care Department Desgenettes French Military Teaching Hospital Lyon, France
REFERENCES 1. Edwards MJ, Lustik M, Carlson T, et al. Surgical interventions for pediatric blast injury: an analysis from Afghanistan and Iraq 2002 to 2010. J Trauma Acute Care Surg. 76:854Y858. 2. Tepas JJ, Mollitt DL, Talbert JL, Bryant M. The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg. 1987;22:14Y18.
Nonsuperiority does not imply equivalence To the Editor: read with interest the article by Ekeh et al. titled ‘‘Successful placement of intracranial pressure monitors by trauma surgeons,’’ since we have recently published an article on the safe placement of intracranial pressure monitors by midlevel practitioners.1 However, I wish to point out two major flaws in the design and interpretation of the study by Ekeh et al. In their study, they do not specify the study design or adequately explain their statistical analysis. On the basis of the
I
J Trauma Acute Care Surg Volume 77, Number 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
521
