Outcomes in Traumatic Brain Injury Patients on Preinjury Anticoagulation and Antiplatelet Agents

Traumatic brain injury (TBI) affects an estimated 1.7 million people a year. Around 75% of these cases are mild. Falls and motor vehicle accidents are among the leading causes for TBI, with falls accounting for 60.7% of occurrences in populations 65 years or older1. As the general population continues to expand both in age and in size, the risk of falls will increase. This poses a problem particularly in light of the pervasive use of anticoagulants and antiplatelet agents for this population, both of which increase the bleeding risk. Anticoagulants and antiplatelet agents are used for a variety of conditions, including deep venous thrombosis, atrial fibrillation, pulmonary embolism and coronary artery disease. They are also given postoperatively for prosthetic heart valves or stent placement. An estimated 597,689 deaths in 2010 were due to cardiovascular disease, with 80% above the age of 652. Stroke caused 129,476 deaths. The use of anticoagulants and antiplatelet agents for prevention of cardiovascular and cerebrovascular events is irrefutable, but little literature has touched on its effects on morbidity and mortality in those with traumatic brain injury. This article summarizes the current literature on the pre-TBI use of anticoagulants and antiplatelet agents and the associated morbidity and mortality

Intraoperative Vancomycin Use in Spinal Surgery: Single Institution Experience and Microbial Trends.

Study Design. Retrospective Case Series.Objective. To demonstrate the microbial trends of spinal surgical site infections(SSI) in patients who had previously received crystallized vancomycin in the operative bed.Summary of Background Data. Prior large, case control series demonstrate the significant decrease in SSI with the administration of vancomycin in the wound bed.Methods. A single institution, electronic database search was conducted for all spinal surgery patients who had received prophylactic crystalline vancomycin powder in the wound bed. Patient\u27s with a prior history of wound infection, intrathecal pumps, or spinal stimulators were excludedResults. 981 consecutive patients (494 male, 487 female, mean age 59.4 years, range 16-95 years) were identified from January 2011 to June 2013. The average dose of vancomycin powder was 1.13 grams(range: 1-6 grams). 66 patients (6.71%) were diagnosed with a SSI of which 51 patients had positive wound cultures (5.2%). Of the 51 positive cultures the most common organism was Staphylococcus aureus. The average dose of vancomycin was 1.3 grams in the 38 cases where a gram-positive organism was cultured. A number of gram-negative infections were encountered such as Serratia marcescens, Enterobacter aerogenes, Bacteroides fragilis, Enterobacter cloacae, Citrobacter koseri and Pseudomonas aeruginosa. The average dose of vancomycin was 1.2 grams in 23 cases where a gram negative infection was cultured. 15 of the 51 (29.4%) positive-cultures were polymicrobial. 8 (53%) of these 15 polymicrobial cultures contained three or more distinct organisms.Conclusion. Prophylactic intraoperative vancomycin use in the wound bed in spinal surgery may increase the incidence of gram-negative or polymicrobial spinal infections. The use of intraoperative vancomycin may correlate with postoperative seromas, due to the high incidence of non-positive cultures. Large, randomized, prospective trials are needed to demonstrate causation and dose-response relationship