Caitlin Fitzgerald Wins Georgia ACS Day of Trauma Resident Paper Competition

August 2017

Caitlin Fitzgerald, MD, an Emory general surgery resident on research sabbatical, received the Day of Trauma's Top Resident Paper Award at the 2017 Annual Meeting of the Georgia Society of the American College of Surgeons, held at the King and Prince Beach Resort, St. Simons Island, Georgia, from August 18 through August 20. Dr. Fitzgerald was first author of the paper, and Christopher Dente, MD, program director of the acute care surgery fellowship, was senior author.

The focus of the paper was the incidence of acute kidney injury in a Level 1 trauma center, with the center in this case being located at Grady Memorial Hospital. Acute kidney injury (AKI) is a common problem caused by multiple factors in critically ill patients, and is associated with a significantly high morbidity and mortality. Its manifestation can range from a small increase in serum creatinine, to critical, anuric renal failure (inability to pass urine) requiring emergent renal replacement therapy. Despite advances in the management of critically ill trauma patients, Drs. Fitzgerald and Dente state that the incidence of AKI remains high in the trauma population, and that they hope to identify the potential reasons behind this excessive rate and to develop new clinical care guidelines designed to diminish AKI in trauma patients.

The study was conducted via a retrospective chart review of all patients that presented to Grady's trauma center from July 1, 2015 through September 30, 2016, and that subsequently developed AKI. Acute Kidney Injury Network (AKIN) criteria was used to determine each patient's eventual AKI stage. Data collected included patient demographics, medications given, intensive-care unit (ICU) and hospital length of stay (LOS), fluid requirements, the duration of renal replacement therapy, and other complications.

The team found that a total of 80 patients met the study's inclusion criteria, and that overall mortality was 42.5% (34/80). The majority of patients were male (82.5%, 66/80) and suffered from a blunt mechanism of trauma (72.5%, 58/80). Continuous renal replacement therapy (CRRT) was utilized in 43.8% (35/80) of all patients with an average duration of 8.5±16.3 days. Forty-five patients (55%) progressed to stage three AKI, and eight (10%) required hemodialysis after discharge. When considering hospital management, patients underwent an average of 3.1±3.2 trips to the operating room and received 200.3±196.6 mL of intravenous contrast. Fluid requirements within the first 24 hours were 6295.4±7463.3 mL, and urine output was 1774.6±1307.6 mL. The most common medications given were piperacillin/tazobactam (46.3%, 37/80), vancomycin (80.0%, 64/80), and a combination of vancomycin and piperacillin/tazobactam (56.1%, 37/66). Sepsis (55%, 44/80) and pneumonia (48.8%, 39/80) were the most frequent complications.

Drs. Fitzgerald and Dente concluded that AKI in the trauma population is a complex problem that not only affects in-patient mortality, but also leads to increased morbidity outside of the hospital since patients are at increased risk of developing chronic kidney disease and subsequent dialysis dependence. In the study's trauma patients, infectious complications and the administration of nephrotoxic medications appear to have contributed to the high incidence of AKI. The team proposed that the next logical step in reducing this problem would be to design and implement new patient management protocols aimed at lowering the incidence of AKI.

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