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Critique of hyperglycemia
and surgical site infection
To the Editor:
Richards 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 hyper-
glycemia was associated with surgical site
infection in this prospective observational
cohort of stable nondiabetic patients with or-
thopedic 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 signif-
icant difference between nonhyperglycemic
and hyperglycemic patients in terms of age
(p= 0.03) and American Society of Anesthe-
siologists (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 non-
hyperglycemic 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 orthope-
dic injuries.
*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 infec-
tion in stable nondiabetic adults with orthope-
dic injuries. J Trauma Acute Care Surg. 2014;
76(4):1070Y1075.
Pediatric casualties
in the war zone
To the Editor:
Edwards et al.
1
report particularly interest-
ing and uncommon data about war pediatric
blast injuries. They highlight the specifications
of surgical procedures performed for this par-
ticular 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 Sever-
ity Score (ISS) of 25.2 (range, 12Y43) and a
mean Trauma and Injury Severity Score
(TRISS) of 9.96% (range, 0.9Y46.9%) illus-
trate the severity of the injuries in these pa-
tients, with an in-hospital mortality of 5%.
Thus, approximately 100 pediatric anesthetic
and surgical procedures (damage control sur-
gery and repeated procedures) were performed
monthly. These data enhance those collected by
Edwards et al. during a period of 8 years (1,213
patients e15 years) and the relevance of the
questions concerning pediatric operative re-
sources 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 limit-
ations of their study due to the lack of data
before the admission of the wounded children
in Role 3. We can highlight this topic differ-
ently thanks to in-press data, collected in 2011
by Frenchmilitary physicians in Region Com-
mand East (Kapisa), for each French Role 1
MTF (prehospital echelon of care). They de-
scribe 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 pa-
tients. Among injuries, 59% were directly re-
lated to explosions (improvised explosive device,
mortar, or other exploding munitions) or to
gunshot wounds. Physicians and paramedics
performed tactical care and medical proce-
dures: tourniquets and hemostatic dressings,
venous or intraosseous access, orotracheal intu-
bation, and sedation. The severity, assessed by
a mean Pediatric Trauma Score
2
of 7.2 (range,
j4 to +11), wasillustratedby injury locations
(limbs, 50%; head and neck, 18%; abdomen,
thorax, and perineum, 20%). Eighty-two pedi-
atric 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 (Interna-
tional 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 high-
light the extent of the issue of severe war pedi-
atric injuries. The awesome series of Edwards
et al. is probably a terrible, but represen-
tative, 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. Surgi-
cal interventions for pediatric blast injury: an
analysis from Afghanistan and Iraq 2002 to
2010. JTraumaAcuteCareSurg. 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:
Iread with interest the article by Ekeh et al.
titled ‘‘Successful placement of intracrani-
al pressure monitors by trauma surgeons,’’
since we have recently published an article
on the safe placement of intracranial pres-
sure 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
LETTERS TO THE EDITOR
J Trauma Acute Care Surg
Volume 77, Number 3 521
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
