James L Guzzo

University of Maryland Medical Center, Baltimore, Maryland, United States

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Publications (7)17.41 Total impact

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    ABSTRACT: To evaluate the effect of an online training course containing video clips of central venous catheter insertions on compliance with sterile practice. Prospective randomized controlled study. Admitting area of a university-based high-volume trauma center. Surgical and emergency medicine residents rotating through the trauma services. An online training course on recommended sterile practices during central venous catheter insertion was developed. The course contained short video clips from actual patient care demonstrating common noncompliant behaviors and breaks regarding recommended sterile practices. A 4-month study with a counterbalanced design compared residents trained by the video-based online training course (video group) with those trained with a paper version of the course (paper group). Residents who inserted central venous catheters but received neither the paper nor video training were used as a control group. Consecutive central venous catheter insertions from 12 noon to 12 midnight except Sundays were video recorded. Sterile-practice compliance was judged through video review by two surgeons blinded to the training status of the residents. Fifty residents inserted 73 elective central venous catheters (19, 31, and 23 by the video, paper, and control group operators, respectively) into 68 patients. Overall compliance with proper operator preparation, skin preparation, and draping was 49% (36 of 73 procedures). The training had no effect on selection of site and skin preparation agent. The video group was significantly more likely than the other two groups to fully comply with sterile practices (74% vs. 33%; odds ratio, 6.1; 95% confidence interval, 2.0-22.0). Even after we controlled for the number of years in residency training, specialty, number of central venous catheters inserted, and central venous catheter site chosen, the video group was more likely to comply with recommended sterile practices (p = .003). An online training course, with short video clips of actual patient care demonstrating noncompliant behaviors, improved sterile-practice compliance for central venous catheter insertion. Paper handouts with equivalent content did not improve compliance.
    Critical Care Medicine 06/2007; 35(5):1302-6. · 6.12 Impact Factor
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    ABSTRACT: Fournier's gangrene is an aggressive, polymicrobial soft tissue infection that specifically affects the genital and perineal region. Treatment requires early recognition, broad-spectrum intravenous antibiotics, and radical surgical debridement of all infected tissues. Optimal therapy may necessitate multiple debridements that leave the patient with large tissue defects that require skin grafting for scrotal and perineal reconstruction. The presence of other surgical emergencies, such as an incarcerated inguinal hernia, in the face of Fournier's gangrene presents a rare and challenging dilemma to the general surgeon. With the widespread acceptance of tension-free repair utilizing prosthetic mesh in uncomplicated hernia surgery, outcomes have been improved. However, surgical options for hernia repair may become limited in the face of a regional necrotizing soft tissue infection, for which mesh use in an open repair after debridement of infected tissues is generally contraindicated. In this report, the authors describe three consecutive cases of incarcerated inguinal hernia in the presence of concomitant Fournier's gangrene using a laparoscopic approach and natural biomaterial mesh for abdominal wall reinforcement.
    The American surgeon 02/2007; 73(1):93-5. · 0.92 Impact Factor
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    ABSTRACT: In the academic trauma unit during initial evaluation and resuscitation of trauma victims, central venous catheters are often placed by multiple operators. There are few data on compliance with accepted, standard sterile practices during such procedures. Prospective data were tabulated from video capture of 144 consecutive central venous catheterizations in a trauma resuscitation unit, during peak hours, by a team of trained video technicians. The physicians were surgical and emergency medicine residents. The number of primary operators (trainees) and secondary operators (mentors) for each line was recorded from the video analysis, as well as physician adherence to the use of maximum barrier precautions (MBP; sterile gown, gloves, full operative drape, cap, and mask). Procedures were stratified by level of urgency: Emergent (n = 7), semi-emergent (n = 20), and elective (n = 113). The subclavian vein was used for 73% of the elective catheter placements. For elective central venous catheters, 99 of 113 primary operators (88%) observed MBP, whereas only 31 of 45 secondary operators (69%) did so (p < or = 0.01). Among the 45 elective central venous catheters placed with a secondary operator, there were four instances of frank contamination (9%). Secondary operators, typically trauma surgery attendings, trauma/critical care fellows, or senior surgical residents, function as mentors in academic institutions and act as role models. Secondary operators participated in many of the studied cases, yet failed to demonstrate consistent use of MBP. In elective central venous catheter placement, those where there was the greatest opportunity to follow MBP, we observed a statistically significant difference in compliance rate between the primary and secondary operators. The study suggests the need to address the performance of the secondary operators and to educate them, as although they may be technically experienced in placing central venous catheters, they may comply less consistently with MBP.
    Surgical Infections 03/2006; 7(1):15-20. · 1.87 Impact Factor
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    ABSTRACT: Prediction of outcomes after injury has traditionally incorporated measures of injury severity, but recent studies suggest that including physiologic and shock measures can improve accuracy of anatomic-based models. A recent single-institution study described a mortality predictive equation [f(x) = 3.48 - .22 (GCS) - .08 (BE) + .08 (Tx) + .05 (ISS) + .04 (Age)], where GSC is Glasgow Coma Score, BE is base excess, Tx is transfusion requirement, and ISS is Injury Severity Score, which had 63% sensitivity, 94% specificity, (receiver operating characteristic [ROC] 0.96), but did not provide comparative data for other models. We have previously documented that the Physiologic Trauma Score, including only physiologic variables (systemic inflammatory response syndrome, Glasgow Coma Score, age) also accurately predicts mortality in trauma. The objective of this study was to compare the predictive abilities of these statistical models in trauma outcomes. Area under the ROC curve of sensitivity versus 1-specificity was used to assess predictive ability and measured discrimination of the models. The study cohort consisted of 15,534 trauma patients (80% blunt mechanism) admitted to a Level I trauma center over a 3-year period (mean age 37 +/- 18 years; mean Injury Severity Score 10 +/- 10; mortality 4%). Sensitivity of the new predictive model was 45%, specificity was 96%, ROC was 0.91, validating this new trauma outcomes model in our institution. This was comparable with area under the ROC for Revised Trauma Score (ROC 0.88), Trauma and Injury Severity Score (ROC 0.97), and Physiologic Trauma Score (ROC 0.95), but superior compared with admission Glasgow Coma Score (ROC 0.79), Injury Severity Score (ROC 0.79), and age (ROC 0.60). The predictive ability of this new model is superior to anatomic-based models such as Injury Severity Score, but comparable with other physiologic-based models such as Revised Trauma Score, Physiologic Trauma Score and Trauma, and Injury Severity Score.
    Journal of the American College of Surgeons 01/2006; 201(6):891-7. · 4.50 Impact Factor
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    ABSTRACT: The recognition of Helicobacter pylori infection as a cause of peptic ulcer disease, medical regimens to eradicate the organism, and the widespread use of proton pump inhibition to suppress gastric acid secretion have revolutionized the management of peptic ulcer disease. As a result, successful medical management of peptic ulcer disease has largely supplanted the need for gastric surgery by general surgeons. Surgery is reserved for complications of the disease, refractory disease, or rare causes of ulcer disease such as gastrinoma and Zollinger-Ellison syndrome. In this report, we describe a case of intractable peptic ulcer disease that progressed to gastric outlet obstruction despite maximal medical therapy. We review the diagnostic studies utilized to evaluate the potential etiologies of peptic ulcer disease and the difficulty in diagnosing gastrinoma and Zollinger-Ellison in the setting of potent medical acid suppression therapy.
    Digestive Diseases and Sciences 12/2005; 50(11):1999-2008. · 2.26 Impact Factor
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    ABSTRACT: To our knowledge, there is an absence of data evaluating the safety and efficacy of percutaneous endoscopic gastrostomy (PEG) placement in ICU patients with previous abdominal surgery. Our goals were to determine the complication rate of PEG in ICU patients who either had a recent or prior laparotomy compared to patients without any prior abdominal surgery. Prospective data was collected on 42 consecutive patients with prior abdominal surgery who underwent PEG placement in a university ICU setting during a 3-year period. These patients were further stratified by time of previous abdominal surgery: recent = abdominal surgery during the current hospitalization; old = abdominal surgery done prior to the current hospitalization and >30 days. Complications were defined as technical problems, local infection, tube dislodgment, and bleeding. This data was compared to results of 75 consecutive PEG placements in ICU patients with no previous abdominal surgery (NPAS) at the same institution. A total of 117 patients were included in the study. Sixty-two (58%) of the patients were trauma patients and 45 (42%) had other pathology. The mean age of the study population was 53 +/- 15 years and they were primarily male (75%). The overall complication rates were as follows: local wound = 18.7 per cent, technical problems = 4 per cent, PEG dislodgment = 7.4 per cent, and bleeding = 3 per cent. Of the 42 patients with prior abdominal surgery, 22 were recent, and 20 were old. Local wound complications were the most common complication when stratified by PEG category (virgin = 17.3%, recent = 18%, and old = 15%) followed by dislodgment (virgin = 6.7%, recent = 9%, and old = 5%). There were no significant differences in complication rates when comparing specific complications by PEG category as analyzed by chi2 analysis. PEG should be considered in all patients with previous laparotomy in need for long-term enteral access.
    The American surgeon 06/2005; 71(5):420-3. · 0.92 Impact Factor
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    ABSTRACT: Obesity is reaching epidemic proportions in the United States, and as patients at the extremes of morbid obesity come under the care of surgeons, routine procedures may become increasingly complex in the face of greater body mass. We prospectively evaluated the success rate of percutaneous endoscopic gastrostomy (PEG) placement in a group of morbidly obese patients outside the current classification systems used to stratify obesity. Patients with a body mass index (BMI) greater than 60 kg/m2 who presented for PEG over a one year period were prospectively enrolled. Each patient underwent attempted PEG placement using the pull method by a single surgeon. Outcome variables included: successful PEG, wound infection, tube dislodgement, or bleeding. Six patients with BMI > 60 kg/m2 presented for PEG. All patients were in a surgical critical care unit maintained on mechanical ventilation. All underwent successful PEG placement with standard techniques and sustained no post-procedural complications. In the hands of an experienced surgical endoscopist, percutaneous endoscopic gastrostomy can be safely performed in patients at the extremes of morbid obesity. Future studies are warranted to validate the results of our small series.
    JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 10(4):409-13. · 0.81 Impact Factor

Publication Stats

58 Citations
17.41 Total Impact Points

Institutions

  • 2006–2007
    • University of Maryland Medical Center
      • Department of Surgery
      Baltimore, Maryland, United States
  • 2005–2007
    • University of Maryland, Baltimore
      • • Department of Anesthesiology
      • • Department of Surgery
      Baltimore, MD, United States
    • Loyola University Maryland
      Baltimore, Maryland, United States