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ABSTRACT: The evaluation and management of hemodynamically stable patients with penetrating neck injury has evolved considerably over the previous four decades. Algorithms developed in the 1970s focused on anatomic neck "zones" to distinguish triage pathways resulting from the operative constraints associated with very high or very low penetrations. During that era, mandatory endoscopy and angiography for Zone I and III penetrations, or mandatory neck exploration for Zone II injuries, became popularized, the so-called "selective approach." Currently, modern sensitive imaging technology, including computed tomographic angiography (CTA), is widely available. Imaging triage can now accomplish what operative or selective evaluation could not: a safe and noninvasive evaluation of critical neck structures to identify or exclude injury based on trajectory, the key to penetrating injury management. In this review, we discuss the use of CTA in modern screening algorithms introducing a "No Zone" paradigm: an evidence-based method eliminating "neck zone" differentiation during triage and management. We conclude that a comprehensive physical examination, combined with CTA, is adequate for triage to effectively identify or exclude vascular and aerodigestive injury after penetrating neck trauma. Zone-based algorithms lead to an increased reliance on invasive diagnostic modalities (endoscopy and angiography) with their associated risks and to a higher incidence of nontherapeutic neck exploration. Therefore, surgeons evaluating hemodynamically stable patients with penetrating neck injuries should consider departing from antiquated, invasive algorithms in favor of evidence-based screening strategies that use physical examination and CTA.
The American surgeon 01/2013; 79(1):23-9. · 1.28 Impact Factor
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ABSTRACT: Necrotising soft tissue infection (NSTI) presents unique challenges in diagnosis and management. The key to a successful outcome is a high index of suspicion in appropriate clinical settings. Type II NSTI tends to occur on an extremity in younger, healthier patients with a history of known trauma, and to be monomicrobial. Type I NSTI tends to occur on the trunk of older, less healthy patients without an obvious history of trauma, and tends to be polymicrobial. Other, rarer types exist as well. The pathophysiology of both types involves superantigen acticivty, as well as a number of microbial byproducts which collectively decrease the viscosity of pus, facilitating its spread along deep tissue planes and ultimately causing diffuse deep thrombosis and aggressive systemic sepsis. The most important physical finding is tenderness to palpation beyond the area of redness, and the lack of crepitus should not be seen as a reassuring sign. Suspected cases should undergo early surgical exploration for diagnosis, which may be performed at bedside through a small incision. Most imaging techniques are not sufficiently specific to warrant a delay in surgical exploration. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) shows promise as a tool for excluding suspected cases. Successful outcomes in cases of NSTI require early and aggressive serial debridement and a multidisciplinary critical care approach.
Journal of Intensive Care Medicine 10/2012;
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Stanislaw P A Stawicki,
Susan D Moffatt-Bruce,
Hesham M Ahmed,
Harry L Anderson,
Tara M Balija,
Irina Bernescu,
Liza Chan,
Laurie Chowayou,
James Cipolla,
Susette M Coyle, Vicente H Gracias,
Oliver L Gunter,
Raffaele Marchigiani,
Niels D Martin,
Jigar Patel,
Mark J Seamon,
Eileen Vagedes,
E Christopher Ellison,
Steven M Steinberg,
Charles H Cook
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ABSTRACT: BACKGROUND: Retained surgical items (RSI) continue to occur. Large RSI studies are few due to low RSI frequency in single institutions and the medicolegal implications. Consequently, RSI risks are not fully defined, with discrepancies persisting among published studies. The goals of this study were to better define risk factors for RSI, to clarify previously discrepant risk factors, and to evaluate other potential contributors to RSI occurrence, such as trainee presence during an operation. STUDY DESIGN: Multicenter case-match study of RSI risk factors was conducted between January 2003 and December 2009. Cases complicated by RSI were identified at participating centers using clinical quality improvement and adverse event reporting data. Case match controls (non-RSI) were selected from same or similar-type cases performed at each respective institution. Retained surgical item risk factors were evaluated by univariate and multivariate conditional logistic regression. RESULTS: Fifty-nine RSIs and 118 matched controls were analyzed (RSI incidence 1 in 6,975 or 59 in 411,526). Retained surgical items occurred despite use of confirmatory x-rays (13 of 27 instances) and/or radiofrequency tagging (2 of 32 instances). Among previously discrepant results, we confirmed that body mass index, unexpected intraoperative events, and procedure duration were associated with increased RSI risk. The occurrence of any safety variance, and specifically an incorrect count at any time during the procedure, was associated with elevated RSI risk. Trainee presence was associated with 70% lower RSI risk compared with trainee absence. CONCLUSIONS: Longer duration of surgery, safety variances, and incorrect counts during the procedure result in elevated RSI risk. The possible positive influence of trainee presence on RSI risk deserves additional study. Our findings highlight the need for zero tolerance for safety omissions, continued study and development of novel approaches to RSI reduction, and establishing anonymous RSI reporting systems to better track both the incidence and risks associated with this problem, which has yet to be solved.
Journal of the American College of Surgeons 10/2012; · 4.55 Impact Factor
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ABSTRACT: Emergency general surgery (EGS) is increasingly being provided by academic trauma surgeons in an acute care surgery model. Our tertiary care hospital recently changed from a model where all staff surgeons (private, subspecialty academic, and trauma academic) were assigned EGS call to one in which an emergency surgery service (ESS), staffed by academic trauma faculty, cares for all EGS patients. In the previous model, many surgeries were "not covered" by residents because of work-hour restrictions, conflicting needs, or private surgeon preference. The ESS was separate from the trauma service. We hypothesize that by creating a separate ESS, residents can accumulate needed and concentrated operative experience in a well-supervised academic environment.
A prospectively accrued EGS database was retrospectively queried for the 18-month period: July 2010 to June 2011. The Accreditation Council for Graduate Medical Education (ACGME) databases were queried for operative numbers for our residency program and for national resident data for 2 years before and after creating the ESS. The ACGME operative requirements were tabulated from online sources. ACGME requirements were compared with surgical cases performed.
During the 18-month period, 816 ESS operations were performed. Of these, 307 (38%) were laparoscopy. Laparoscopic cholecystectomy and appendectomy were most common (138 and 145, respectively) plus 24 additional laparoscopic surgeries. Each resident performed, on average, 34 basic laparoscopic cases during their 2-month rotation, which is 56% of their ACGME basic laparoscopic requirement. A diverse mixture of 70 other general surgical operations was recorded for the remaining 509 surgical cases, including reoperative surgery, complex laparoscopy, multispecialty procedures, and seldom-performed operations such as surgery for perforated ulcer disease. Before the ESS, the classes of 2008 and 2009 reported that only 48% and 50% of cases were performed at the main academic institution, respectively. This improved for the classes of 2010 and 2011 to 63% and 68%, respectively, after ESS creation.
An ESS rotation is becoming essential in large teaching hospitals by helping to fulfill ACGME requirements and by providing emergent general surgical skills an efficient and well-supervised academic environment. Movement toward concentrating EGS on a single service can enhance resident education and may decrease the need to supplement certain aspects of general surgery education with away rotations.
The journal of trauma and acute care surgery. 09/2012; 73(3):599-604; discussion 604.
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ABSTRACT: Meta-analytic costeffectiveness analysis.
Our goal was to compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries.
We performed a structured literature review related to cervical spine trauma, radiographic clearance techniques (plain radiography, flexion/extension, CT, and MRI), and complications associated with semirigid collar use.
Meta-analytic techniques were used to pool data from multiple sources to calculate pooled mean estimates of sensitivities and specificities of imaging techniques for cervical spinal clearance, rates of complications from various clearance strategies and from empirical use of semirigid collars. A decision analysis model was used to compare outcomes and costs among these strategies.
Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%-60%). Sensitivities for CT and MRI alone were 83% (82%-84%) and 87% (84%-89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low.
As currently used, neuroimaging studies for cervical spinal clearance in clinically unevaluable patients are not cost-effective compared with empirical immobilization in a semirigid collar.
Spine 08/2010; 35(18):1721-8. · 2.08 Impact Factor
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ABSTRACT: The object of this study was to determine whether brain tissue oxygen (PbtO(2))-based therapy or intracranial pressure (ICP)/cerebral perfusion pressure (CPP)-based therapy is associated with improved patient outcome after severe traumatic brain injury (TBI).
Seventy patients with severe TBI (postresuscitation GCS score < or = 8), admitted to a neurosurgical intensive care unit at a university-based Level I trauma center and tertiary care hospital and managed with an ICP and PbtO(2) monitor (mean age 40 +/- 19 years [SD]) were compared with 53 historical controls who received only an ICP monitor (mean age 43 +/- 18 years). Therapy for both patient groups was aimed to maintain ICP < 20 mm Hg and CPP > 60 mm Hg. Patients with PbtO(2) monitors also had therapy to maintain PbtO(2) > 20 mm Hg.
Data were obtained from 12,148 hours of continuous ICP monitoring and 6,816 hours of continuous PbtO(2) monitoring. The mean daily ICP and CPP and the frequency of elevated ICP (> 20 mm Hg) or suboptimal CPP (< 60 mm Hg) episodes were similar in each group. The mortality rate was significantly lower in patients who received PbtO(2)-directed care (25.7%) than in those who received conventional ICP and CPP-based therapy (45.3%, p < 0.05). Overall, 40% of patients receiving ICP/CPP-guided management and 64.3% of those receiving PbtO(2)-guided management had a favorable short-term outcome (p = 0.01). Among patients who received PbtO(2)-directed therapy, mortality was associated with lower mean daily PbtO(2) (p < 0.05), longer durations of compromised brain oxygen (PbtO(2) < 20 mm Hg, p = 0.013) and brain hypoxia (PbtO(2) < 15 mm Hg, p = 0.001), more episodes and a longer cumulative duration of compromised PbtO(2) (p < 0.001), and less successful treatment of compromised PbtO(2) (p = 0.03).
These results suggest that PbtO(2)-based therapy, particularly when compromised PbtO(2) can be corrected, may be associated with reduced patient mortality and improved patient outcome after severe TBI.
Journal of Neurosurgery 04/2010; 113(3):571-80. · 2.96 Impact Factor
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ABSTRACT: Volume status assessment is an important aspect of patient management in the surgical intensive care unit (SICU). Echocardiologist-performed measurement of IVC collapsibility index (IVC-CI) provides useful information about filling pressures, but is limited by its portability, cost, and availability. Intensivist-performed bedside ultrasonography (INBU) examinations have the potential to overcome these impediments. We used INBU to evaluate hemodynamic status of SICU patients, focusing on correlations between IVC-CI and CVP.
Prospective evaluation of hemodynamic status was conducted on a convenience sample of SICU patients with a brief (3 to 10 minutes) INBU examination. INBU examinations were performed by noncardiologists after 3 hours of didactics in interpreting and acquiring two-dimensional and M-mode images, and > or =25 proctored examinations. IVC-CI measurements were compared with invasive CVP values.
Of 124 enrolled patients, 101 had CVP catheters (55 men, mean age 58.3 years, 44.6% intubated). Of these, 18 patients had uninterpretable INBU examinations, leaving 83 patients with both CVP monitoring devices and INBU IVC evaluations. Patients in three IVC-CI ranges (<0.20, 0.20 to 0.60, and >0.60) demonstrated significant decrease in mean CVP as IVC-CI increased (p = 0.023). Although <5% of patients with IVC-CI <0.20 had CVP <7 mmHg, >40% of this group had a CVP >12 mmHg. Conversely, >60% of patients with IVC-CI >0.6 had CVP <7 mmHg.
Measurements of IVC-CI by INBU can provide a useful guide to noninvasive volume status assessment in SICU patients. IVC-CI appears to correlate best with CVP in the setting of low (<0.20) and high (>0.60) collapsibility ranges. Additional studies are needed to confirm and expand on findings of this study.
Journal of the American College of Surgeons 08/2009; 209(1):55-61. · 4.55 Impact Factor
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ABSTRACT: To better define the reliability of left ventricular ejection fraction (LVEF) and left ventricular filling, as determined by either hand-carried ultrasound (HCU) or formal transthoracic echocardiography (TTE), in the critically ill surgical patient.
Prospective cross-sectional study of 80 surgical intensive care unit patients with concomitant (<30 minutes apart) formal TTE and clinician-performed cardiac HCU. Visual estimates of LVEF and left ventricular filling ("underfilled" vs "normally filled") were recorded, both by clinicians performing HCU and fellowship-trained echocardiographers.
Bland-Altman plot analysis of LVEF estimates revealed good interobserver agreement between HCU and formal TTE (% LVEF mean bias, -2.2; with 95% limits of agreement, +/-22.1). This was similar to agreement between independent echocardiography observers (% LVEF mean bias, 1.3; with 95% limits of agreement, +/-21.0). However, assessments of left ventricular filling demonstrated only fair to moderate interobserver agreement (kappa = 0.22-0.40). Of note, a greater percentage of the 5 standard acoustic windows were obtainable using formal TTE (72% vs 56%).
Formal TTE offers no advantage over HCU for determination of LVEF in critically ill surgical patients, even though the former allows for a more complete examination. However, estimations of left ventricular filling only demonstrate fair to moderate interrater agreement and thus should be interpreted with care when used as markers of volume responsiveness.
Journal of critical care 02/2009; 24(3):470.e1-7. · 2.13 Impact Factor
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ABSTRACT: The additional impact of development of acute lung injury on mortality in severely-injured trauma patients beyond baseline severity of illness has been questioned. We assessed the contribution of acute lung injury to in-hospital mortality in critically ill trauma patients.
Prospective cohort study. The contribution of acute lung injury to in-hospital mortality was evaluated in two ways. First, multivariable logistic regression models were used to test the independent association of acute lung injury with in-hospital mortality while adjusting for baseline confounding variables. Second, causal pathway models were used to estimate the amount of the overall association of baseline severity of illness with in-hospital mortality that is attributable to the interval development of acute lung injury.
Academic level 1 trauma center.
Two hundred eighty-three critically ill trauma patients without isolated head injury and with an Injury Severity Score > or = 16 were evaluated for development of acute lung injury in the first 5 days after trauma.
Of the 283 patients, 38 (13.4%) died. The unadjusted mortality rate was nearly three-fold greater in the acute lung injury group (23.9% vs. 8.4%; odds ratio = 3.36; 95% confidence interval 1.67-6.77; p = 0.001). Acute lung injury remained an independent risk factor for death after adjustment for age, baseline Acute Physiologic and Chronic Health Evaluation III score, Injury Severity Score, and blunt mechanism of injury (odds ratio = 2.87; 95% confidence interval 1.29-6.37; p = 0.010). Forty percent of the total association of the baseline Acute Physiologic and Chronic Health Evaluation III score with mortality occurred via an indirect association through acute lung injury, and the remaining 60% via a direct effect.
Development of acute lung injury in critically ill trauma patients without isolated head injury contributes independently to in-hospital mortality beyond baseline severity of illness measures. In addition, a significant portion of the association between baseline illness severity and risk of death in these patients might be explained by the interval development of acute lung injury.
Critical care medicine 09/2008; 36(8):2309-15. · 6.37 Impact Factor
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ABSTRACT: Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its use in documenting cardiac disorders has long been recognized. Since the introduction of 2-dimensional TTE, the right-sided heart chambers have become amenable to fairly accurate analysis, enabling the evaluation of morphologic and functional abnormalities associated with many cardiopulmonary diseases, including pulmonary embolism (PE). The availability of small, portable echocardiographic units combined with an increasing number of intensive care specialists trained in echocardiography makes TTE an attractive modality for the diagnosis of PE in the intensive care unit (ICU). In the ICU setting, prompt decision-making and appropriate triage of critically ill patients can facilitate early institution of therapy for PE while awaiting patient stabilization and further definitive testing. Although several prior reviews incorporate TTE in the overall approach and clinical decision algorithms pertaining to the diagnosis and treatment of pulmonary embolism, no dedicated review exists that focuses purely on TTE. We attempt to fill that gap by reviewing the available literature pertaining to use of TTE in the diagnosis of suspected PE, and by better defining the use of TTE in the ICU setting. Emphasis is placed on the use of TTE as a clinical triage tool for suspected PE.
Journal of Clinical Ultrasound 07/2008; 36(5):291-302. · 0.81 Impact Factor
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ABSTRACT: Systemic inflammatory response can be associated with clinically significant and, at times, refractory hypotension. Despite the lack of uniform definitions, this condition is frequently called vasoplegia or vasoplegic syndrome (VS), and is thought to be due to dysregulation of endothelial homeostasis and subsequent endothelial dysfunction secondary to direct and indirect effects of multiple inflammatory mediators. Vasoplegia has been observed in all age groups and in various clinical settings, such as anaphylaxis (including protamine reaction), sepsis, hemorrhagic shock, hemodialysis, and cardiac surgery. Among mechanisms thought to be contributory to VS, the nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) pathway appears to play a prominent role. In search of effective treatment for vasoplegia, methylene blue (MB), an inhibitor of nitric oxide synthase (NOS) and guanylate cyclase (GC), has been found to improve the refractory hypotension associated with endothelial dysfunction of VS. There is evidence that MB may indeed be effective in improving systemic hemodynamics in the setting of vasoplegia, with reportedly few side effects. This review describes the current state of clinical and experimental knowledge relating to MB use in the setting of VS, highlighting the potential risks and benefits of therapeutic MB administration in refractory hypotensive states.
Mini Reviews in Medicinal Chemistry 06/2008; 8(5):472-90. · 2.53 Impact Factor
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ABSTRACT: To determine whether there is an association between transfusion of fresh frozen plasma and infection in critically ill surgical patients.
Retrospective study.
A 24-bed surgical intensive care unit in a university hospital.
A total of 380 non-trauma patients who received fresh frozen plasma from 2004 to 2005 were compared with 2,058 nontrauma patients who did not receive fresh frozen plasma.
None.
We calculated the relative risk of infectious complication for patients receiving and not receiving fresh frozen plasma. T-test allowed comparison of average units of fresh frozen plasma transfused to patients with and without infectious complications to describe a dose-response relationship. We used multivariate logistic regression analysis to evaluate the association between fresh frozen plasma and infectious complication, controlling for the effect of red blood cell transfusion, Acute Physiology and Chronic Health Evaluation II, and patient age. A significant association was found between transfusion of fresh frozen plasma and ventilator-associated pneumonia with shock (relative risk 5.42, 2.73-10.74), ventilator-associated pneumonia without shock (relative risk 1.97, 1.03-3.78), bloodstream infection with shock (relative risk 3.35, 1.69-6.64), and undifferentiated septic shock (relative risk 3.22, 1.84-5.61). The relative risk for transfusion of fresh frozen plasma and all infections was 2.99 (2.28-3.93). The t-test revealed a significant dose-response relationship between fresh frozen plasma and infectious complications (p = .02). Chi-square analysis showed a significant association between infection and transfusion of fresh frozen plasma in patients who did not receive concomitant red blood cell transfusion (p < .01), but this association was not significant in those who did receive red blood cells in addition to fresh frozen plasma. The association between fresh frozen plasma and infectious complications remained significant in the multivariate model, with an odds ratio of infection per unit of fresh frozen plasma transfused equal to 1.039 (1.013-1.067). This odds ratio resembled that noted for each unit of packed red blood cells, 1.074 (1.043-1.106).
Transfusion of fresh frozen plasma is associated with an increased risk of infection in critically ill patients.
Critical care medicine 05/2008; 36(4):1114-8. · 6.37 Impact Factor
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ABSTRACT: Hypertonic saline (HTS) may decrease intracranial pressure (ICP) in severe traumatic brain injury (STBI) and effectively resuscitates hypotensive patients. No data exist on institutional standardization of HTS for hypotensive patients with STBI. It remains unclear how HTS affects brain tissue oxygenation (PbtO2) in STBI. We hypothesized HTS could be safely standardized in patients with STBI and would lower ICP while improving cerebral perfusion pressure (CPP) and PbtO2. Under institutional guidelines in a Level I trauma center, 12 hypotensive STBI intensive care unit subjects received HTS. Inclusion criteria included mean arterial pressure (MAP) < or = 90 mmHg, Glasgow Coma Scale (GCS) < or = 8, ICP > or = 20 mmHg, and serum [Na+] <155 mEq/L. All patients underwent ICP monitoring. Hemodynamics, CPP, ICP, and PbtO2 data were collected before and hourly for 6 hours after HTS infusion. Guideline criteria compliance was greater than 95 per cent. No major complications occurred. Mean ICP levels dropped by 45 per cent (P < 0.01) and this drop persisted for 6 hours. CPP levels increased by 20 per cent (P < 0.05). PbtO2 remained persistently elevated for all time points after HTS infusion. Institutional use of HTS in STBI can be safely implemented in a center caring for neurotrauma patients. HTS infusion in hypotensive STBI reduces ICP and raises CPP. Brain tissue oxygenation tends to improve after HTS infusion.
The American surgeon 04/2008; 74(3):253-9. · 1.28 Impact Factor
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ABSTRACT: Use of transthoracic echocardiography (TTE) in documenting cardiac disorders is well accepted. This study reviews institutional experience with TTE in the clinical setting of pulmonary embolism (PE).
Retrospective review of surgical ICU patients who underwent TTE within 72 hours of diagnosis of PE, from January 2005 to March 2007. Collected data included symptoms, clinical suspicion of PE, preexisting conditions, operative procedures, TTE findings, presence of deep venous thrombosis, and treatments used for PE. Preexisting TTEs, when available, were compared with those obtained after acute PE. TTEs subsequent to the first post-PE study were analyzed for change in severity of findings.
Thirty-one patients (12 men, 19 women, mean age 66 years, APACHE II 18.1) were included. Twenty-two had high, and nine had moderate, clinical suspicion for PE. Radiographic diagnosis of PE was made by computed tomography (25 of 31) and by ventilation-perfusion scans (6 of 31). Twelve of 31 patients had extremity deep venous thrombosis by duplex ultrasonography. Tricuspid regurgitation was the most common TTE finding (28 of 31), followed by pulmonary hypertension (24), dilated right ventricle (23), right heart strain (19), and underfilled, hyperdynamic left ventricle (17). Seventeen patients had previous or "baseline" echocardiograms, and when compared with the post-PE TTE, all patients demonstrated worsening in at least one TTE finding.
This study identified findings that can be used in prospective evaluation of TTE for suspected PE. The importance of baseline TTE has also been emphasized. Additional prospective evaluation of TTE in diagnosis of suspected PE in the ICU is warranted.
Journal of the American College of Surgeons 02/2008; 206(1):42-7. · 4.55 Impact Factor
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ABSTRACT: A damage control (DC) approach was developed to improve survival in severely injured trauma patients. The role of DC in acute surgery (AS) patients who are critically ill, as a result of sepsis or overwhelming haemorrhage continues to evolve. The goal of this study was to assess morbidity and mortality of AS patients who underwent DC, and to compare observed and predicted morbidity and mortality as calculated from APACHE II and physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scores.
Consecutive acute surgery patients who underwent DC from 2002 to 2004 were included. Retrospectively collected data included patient demographics, physiological parameters, surgical indications and procedures, mortality, morbidity, as well as volumes of crystalloid and colloid (plasma and red blood cell) resuscitation. Observed mortality and complications were compared to those calculated from APACHE II and POSSUM scores. Data were analysed using the Mann-Whitney test for median values, chi-square and Fisher's exact tests for proportions.
Sixteen patients (mean age 53 years, seven men, nine women) underwent DC. The most common indications for DC included abdominal sepsis (6/15), intraoperative bleeding (5/15), and bowel ischaemia (3/15). The mean intraoperative blood loss during the index procedure was 2060mL. There were 2.4 average procedures per patient. At the end of DC II (36.5h), mean infusion of crystalloid was 17L, packed red blood cells was 3.6L, and plasma was 3L. Eight of 16 patients required vasopressor administration during resuscitation. At 28 days, there were five unexpected survivors as predicted by POSSUM and three by APACHE II (observed mortality seven, predicted mortality by the two methods: 12 (P=0.074), and 10 (P=0.24), respectively). Five patients died prior to definitive abdominal closure. Split thickness skin grafting (4/16) and primary fascial closure (4/16) constituted the most common methods of abdominal closure. Surgical morbidity predicted by POSSUM (98%) and actual morbidity (100%) were similar.
Although the morbidity and mortality of AS patients undergoing DC is high, the application of DC principles in this group may reduce mortality compared to that predicted by POSSUM or APACHE II. In order to adequately demonstrate this contention, large, multi-institutional studies of DC in AS patients need to be performed. The POSSUM score appears to accurately estimate the high morbidity in general surgery DC patients, and supports the importance of team management of these complex patients by acute care surgery specialists.
Injury 02/2008; 39(1):93-101. · 1.98 Impact Factor
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The Journal of trauma 12/2007; 63(5):1155-8. · 2.48 Impact Factor
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ABSTRACT: Bedside transthoracic echocardiography (TTE) performed by emergency physicians (EPs) is valuable in the rapid assessment and treatment of critically ill patients. We sought to determine the preferred cardiac window for left ventricular ejection fraction (LVEF) estimation by EP sonographers in a critically ill patient population.
Prospective investigator-blinded study of focused bedside TTE in a convenience sample of surgical intensive care patients. Investigators were faculty, fellows, or residents from an academic emergency medicine department. Five standard cardiac views were performed: parasternal long axis (PSLA), parasternal short axis (PSSA), subxiphoid 4-chamber, subxiphoid short axis, and apical 4-chamber (AFC). LVEF was determined using at least 1 cardiac view. Investigators rated their preference for each cardiac view on a 5-point Likert scale.
A total of 70 studies were performed on 70 patients during a 6-month period. Users rated the PSLA as the most useful view for estimation of LVEF (mean 4.23; 95% confidence interval, 3.95-4.51). Pairwise comparisons of cardiac ultrasound views revealed PSLA was preferred over all other views (P < .05) except PSSA (P = .23). Complete 5 view examinations were not achieved in all patients (PSLA in 98%, PSSA in 96%, apical 4-chamber in 74%, subxiphoid 4-chamber in 35%, and subxiphoid short axis in 18%). Interobserver correlation of LVEF estimation was good (r = 0.86, r2 = 0.74, P < .0001).
Parasternal long axis and PSSA are the preferred echocardiographic windows for EP estimation of LVEF using focused bedside TTE in critical care patients. This may be an important consideration in patients who often have physical barriers to optimal echocardiographic evaluation, are relatively immobile, and have unstable conditions requiring rapid assessment and intervention.
The American journal of emergency medicine 10/2007; 25(8):894-900. · 1.54 Impact Factor
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ABSTRACT: Estimation of volume status in the high-acuity surgical population can be challenging. The use of intensivist bedside ultrasound (INBU) to rapidly assess volume status in the surgical intensive care unit (SICU) was hypothesized to be feasible and as accurate as invasive measures.
Clinician sonographers (CSs) were trained to perform basic cardiac ultrasound and sonographic assessment of the inferior vena cava (IVC). A convenience sample of general surgery and trauma patients was enrolled in the SICU. The CS interpreted IVC and cardiac parameters and then categorized the subject as hypovolemic or not hypovolemic. Intensivists caring for the patients were blinded to the INBU findings and made a real-time expert clinical judgment (ECJ) of the patient's volume status (hypovolemic vs. not hypovolemic) using all available traditional data.
A total of nine CSs performed 70 studies; three of the CSs performed the majority of the studies (86%). Adequate ultrasound (US) views for cardiac and IVC assessment were obtained in 96% and 89% of studies, respectively. The ECJ was considered to be the standard to which comparisons were made. The concordance rate between ECJ and central venous pressure was 62%. ECJ concordance with sonographic measures were similar (cardiac US = 75%, IVC US = 67%, and IVC collapse index = 65%). All pairwise comparisons against the ECJ/CVP agreement were not significantly different.
INBU is feasible in the SICU and is equivalent to central venous pressure in assessing volume status. Noninvasive methods to assess volume status may decrease the need for invasive procedures.
The Journal of trauma 10/2007; 63(3):495-500; discussion 500-2. · 2.48 Impact Factor
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ABSTRACT: Esophageal Doppler monitoring (EDM) is utilized in numerous clinical settings. This study examines the relationship between pulmonary artery catheter (PAC) and EDM-derived hemodynamic parameters, concentrating on gender- and age-related EDM measurement biases.
Prospective study of EDM use in ventilated surgical ICU patients. Parameters examined included demographics, diagnosis, resuscitation endpoints, cardiac output (CO) and stroke volume from both devices, number of personnel and time needed to place equipment, time to data acquisition, duration of use, complications of placement.
Fifteen patients (11 men, 4 women, mean age 47 years) were included. Most common diagnoses included trauma (7/15) and sepsis (4/15). Insertion time and time to data acquisition were shorter for EDM than for PAC (P<0.001). The EDM required an average of 1.1 persons to place (2.4 for PAC, P=0.002). Mean EDM utilization time was 12.4 h. There was a fair CO correlation between EDM and PAC (r = 0.647, P<0.001). Overall, the EDM underestimated CO relative to PAC (bias -1.42 +/- 2.08, 95% CI: -5.58-2.74), with more underestimation in women (mean bias difference of -1.16, P<0.001). No significant age-related measurement bias differences between PAC and EDM were noted. Significant reductions in lactate and norepinephrine requirement were noted following EDM monitoring periods.
This study found that the EDM significantly underestimated cardiac output in women when compared to PAC. Clinicians should be aware of this measurement bias when making therapeutic decision based on EDM data. Significant reductions in lactate and norepinephrine requirement during EDM monitoring periods support the clinical usefulness of EDM technology.
Annals of Thoracic Medicine 10/2007; 2(4):148-53. · 1.62 Impact Factor
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ABSTRACT: Pneumonia occurs commonly in intubated patients and is morbid and occasionally mortal. Pneumonia prevention strategies have been successful in the intensive care unit and are favorably regarded, cost effective, and efficacious. Trauma patients are often intubated emergently in the prehospital or emergency department (ED) setting. Nationwide, hospital crowding has resulted in prolonged ED length of stay (LOS). We sought to study the association between prolonged ED LOS and rates of pneumonia.
This was a 2-year retrospective case-control study of pneumonia risk among blunt trauma patients presenting to an urban Level I trauma center who were emergently intubated. The trauma registry was queried for demographic and clinical information. All patients who were intubated prehospital or in the ED and developed pneumonia were identified as cases. A group of matched controls with equivalent age, injury severity score, abbreviated injury score (AIS) chest, and AIS head who did not develop pneumonia were identified. A comparison of ED LOS between the two groups was assessed using conditional logistic regression.
We identified 509 emergently intubated blunt trauma patients. Of these, 33 developed pneumonia and could be matched with comparable controls. The case subjects had a mean age of 44.6 (+/-24.3), a mean injury severity score of 32.7 (+/- 9.4), a mean chest AIS of 1.5 (+/-1.6), and a mean head AIS of 4.4 (+/-1.2). The ED LOS for the cases was significantly longer than that for the controls (281.3 minutes vs. 214.0 minutes, p < 0.05). Each hour increased the risk of developing pneumonia by approximately 20%.
In blunt trauma patients who are emergently intubated, increased ED LOS is an independent risk factor for pneumonia. Ventilator associated pneumonia interventions, successful in the intensive care unit, should be implemented early in the hospital course, and efforts should be made to minimize hospital crowding and ED LOS.
The Journal of trauma 08/2007; 63(1):9-12. · 2.48 Impact Factor
