Babak Sarani

Necrotizing Fasciitis: Current Concepts and Review of the Literature

M T b d d w f b a s i f t n ecrotizing soft-tissue infection (NSTI) was first described y Hippocrates circa 500 BC, when he wrote, “Many were ttacked by the erysipelas all over the body when the excitng cause was a trivial accident . . . flesh, sinews, and bones ell away in large quantities . . . there were many deaths.” espite many advances in our understanding of this disease nd great improvements in medical care, the mortality asociated with NSTI has not changed in the last 30 years and emains 25% to 35%. Mortality is directly proportional to ime to intervention. In addition, prevalence of this disase is such that the average practitioner will see only one or wo cases in his or her career. Physicians cannot be suffiiently familiar with NSTI to proceed rapidly with accurate iagnosis and the necessary management. The purpose of his article is to provide an evidence-based review of the icrobiology, pathophysiology, diagnosis, and treatment f NSTI. Because there are no adequately powered, ranomized, and blinded studies, the recommendations are ased on retrospective and nonblinded study data vailable. NSTI was described as “hospital gangrene” by British aval surgeons in the 18th and 19th century. Dr Joseph ones, a Confederate Army surgeon, was the first person to escribe this disorder in a large group of patients in 1871, hen he reported on 2,642 cases and found a mortality rate f 46%. In 1883, the French physician, Jean Alfred ournier, described a similar NSTI of the perineum in five ale patients—a process that continues to bear his name. It s now described in both male and female patients. In the nsuing years, many other terms, such as necrotizing erysiplas, streptococcal gangrene, and suppurative fasciitis, have een also been used. Because the gas-forming organism, lostridium perfringens, can be associated with this infecion, it has also been referred to as “Clostridial gangrene” or gas gangrene.” In 1951, Dr Wilson proposed the term necrotizing fascitis to include both gas-forming and non gas-forming ne-

Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection

Objective:To determine whether there is an association between transfusion of fresh frozen plasma and infection in critically ill surgical patients. Design:Retrospective study. Setting:A 24-bed surgical intensive care unit in a university hospital. Patients: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. Interventions:None. Measurements and Main Results: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). Conclusions:Transfusion of fresh frozen plasma is associated with an increased risk of infection in critically ill patients.

A Review of the Fundamental Principles and Evidence Base in the Use of Extracorporeal Membrane Oxygenation (ECMO) in Critically Ill Adult Patients

Extracorporeal membrane oxygenation (ECMO) comprises a commonly used method of extracorporeal life support. It has proven efficacy and is an accepted modality of care for isolated respiratory or cardiopulmonary failure in neonatal and pediatric populations. In adults, there are conflicting studies regarding its benefit, but it is possible that ECMO may be beneficial in certain adult populations beyond postcardiotomy heart failure. As such, all intensivists should be familiar with the evidence-base and principles of ECMO in adult population. The purpose of this article is to review the evidence and to describe the fundamental steps in initiating, adjusting, troubleshooting, and terminating ECMO so as to familiarize the intensivist with this modality.

Prospective Study Examining Clinical Outcomes Associated with a Negative Pressure Wound Therapy System and Barker’s Vacuum Packing Technique

BackgroundThe open abdomen has become a common procedure in the management of complex abdominal problems and has improved patient survival. The method of temporary abdominal closure (TAC) may play a role in patient outcome.MethodsA prospective, observational, open-label study was performed to evaluate two TAC techniques in surgical and trauma patients requiring open abdomen management: Barker’s vacuum-packing technique (BVPT) and the ABTheraTM open abdomen negative pressure therapy system (NPWT). Study endpoints were days to and rate of 30-day primary fascial closure (PFC) and 30-day all-cause mortality.ResultsAltogether, 280 patients were enrolled from 20 study sites. Among them, 168 patients underwent at least 48 hours of consistent TAC therapy (111 NPWT, 57 BVPT). The two study groups were well matched demographically. Median days to PFC were 9xa0days for NPWT versus 12xa0days for BVPT (pxa0=xa00.12). The 30-day PFC rate was 69xa0% for NPWT and 51xa0% for BVPT (pxa0=xa00.03). The 30-day all-cause mortality was 14xa0% for NPWT and 30xa0% for BVPT (pxa0=xa00.01). Multivariate logistic regression analysis identified that patients treated with NPWT were significantly more likely to survive than the BVPT patients [odds ratio 3.17 (95xa0% confidence interval 1.22–8.26); pxa0=xa00.02] after controlling for age, severity of illness, and cumulative fluid administration.ConclusionsActive NPWT is associated with significantly higher 30-day PFC rates and lower 30-day all-cause mortality among patients who require an open abdomen for at least 48xa0h during treatment for critical illness.

The Surgical Revolving Door: Risk Factors for Hospital Readmission

BACKGROUNDnUnplanned hospital readmissions increase healthcare costs and patient morbidity. We sought to identify risk factors associated with early readmission in surgical patients.nnnMATERIALS AND METHODSnAll admissions from a mixed surgical unit during 2009 were retrospectively reviewed and unplanned readmissions within 30 d of discharge were identified. Demographic data, length of stay, pre-existing diagnoses, and complications during the index admission were evaluated. T-tests and Fisher exact tests were used to examine the relationship of independent variables with readmission. Univariate and multivariate regression analysis were performed.nnnRESULTSnA total of 1808 index admissions occurred during the study period. In all, 51 (3%) patients were readmitted within 30 d of discharge. The majority of readmissions (53%) were for infectious reasons. On univariate analyses, DVT (P = 0.004) and acute renal failure (P = 0.002) were associated with increased risk of readmission. Readmitted patients were also more likely to have public insurance (63% versus 37%, P = 0.03) and have a longer stay in the hospital (8 d, range 4-14 d versus 3 d, range 2-7 d, P = 0.001). Initial admission after trauma evaluation was associated with a decreased risk of readmission (OR 0.374, P = 0.004). Other demographic variables and pre-existing conditions were not associated with increased readmission. On multivariate logistic regression only DVT (P = 0.039) and LOS (P = 0.014) remained significant.nnnCONCLUSIONSnIncreased LOS and the development of a DVT are risk factors for early unplanned hospital readmission. Admission following trauma is associated with a decreased risk of readmission, possibly due to proactive multidisciplinary discharge planning and geographically-based nurse practitioner involvement.

The effect and durability of a pregraduation boot cAMP on the confidence of senior medical student entering surgical residencies.

OBJECTIVEnMedical school does not specifically prepare students for surgical internship. Preinternship courses are known to increase confidence in multiple key areas. We examined the immediate effect and durability of effect of a surgical pregraduation preparatory course or boot camp on provider confidence in technical and medical management skills.nnnDESIGNnA 5-day boot camp was offered to senior medical students (SMS) entering surgical programs. SMS were anonymously surveyed before, after, and 6 months following the course. The same survey was given 6 months into internship to a control group of surgical interns who graduated from the same medical school but did not participate in boot camp before graduation. Data were compared between the time intervals and across cases and controls using the Wilcoxon rank-sum and signed-rank tests and the Student t test.nnnSETTINGnA joint effort between the University of Pennsylvania School of Medicine, the Department of Surgery at the Hospital of the University of Pennsylvania, and the Penn Medicine Simulation Center in Philadelphia, PA.nnnPARTICIPANTSnAll senior medical students set to graduate from a single institution entering general surgery or surgery subspecialties were offered the course. Twenty-nine students participated in the course.nnnRESULTSnPost-boot camp confidence scores of SMS were significantly greater in all areas except placement of a peripheral intravenous catheter compared with pre-boot camp scores. Six months into internship, the SMS boot camp group felt more confident than controls in their ability to perform a cricothyroidotomy (median 2.5 vs 1.0, p = 0.04) and to insert a chest tube (median 3.3 vs 1.0, p = 0.05). Otherwise, there was no residual difference in confidence levels between the boot camp group and the controls.nnnCONCLUSIONSnBoot camps can improve self-confidence in young doctors in many areas of perioperative care before enrolling in surgical residency. The effect is most durable in high risk, infrequently performed technical tasks. Future studies are under design to examine the impact of boot camps on the July Effect.

Complications following thoracic trauma managed with tube thoracostomy

INTRODUCTIONnTube thoracostomy is a common procedure used to treat traumatic chest injuries. Although the mechanism of injury traditionally does not alter chest tube management, complication rates may vary depending on the severity of injury. The purpose of this study was to investigate the incidence of and risk factors associated with chest tube complications (CTCs) following thoracic trauma.nnnMETHODSnA retrospective chart review of all trauma patients (≥16 years old) admitted to an urban level 1 trauma centre (1/2007-12/2007) was conducted. Patients who required chest tube (CT) therapy for thoracic injuries within 24 h of admission and survived until CT removal were included. CTCs were defined as a recurrent pneumothorax or residual haemothorax requiring CT reinsertion within 24 h after initial tube removal or addition of new CT >24 h after initial placement. Variables including demographic data, mechanism, associated injuries, initial vital signs, chest abbreviated injury score (AIS), injury severity score (ISS), Glasgow coma score (GCS) and length of stay (LOS) and CT-specific variables (e.g. indication, timing of insertion, and duration of therapy) were compared using the chi square test, Mann-Whitney test, and multivariate analysis.nnnRESULTSn154 patients were included with 22.1% (n=34) developing a CTC. On univariate analysis, CTCs were associated with longer ICU and hospital LOS (p=0.02 and p<0.001), increased chest AIS (p=0.01), and the presence of an extrathoracic injury (p=0.047). Results of the multivariate analysis indicated that only increased chest AIS (OR 2.49; p=0.03) was a significantly independent predictor of CTCs.nnnCONCLUSIONSnCTCs following chest trauma are common and are associated with increased morbidity. The severity of the thoracic injury, as measured by chest AIS, should be incorporated into the development of CT management guidelines in order to decrease the incidence of CTCs.

High-Frequency Oscillatory Ventilation (HFOV) and Airway Pressure Release Ventilation (APRV): A Practical Guide

Despite advances in ventilator management, 31% to 38% of patients with adult respiratory distress syndrome (ARDS) will die, some from progressive respiratory failure. Inability to adequately oxygenate patients with severe ARDS has prompted extensive efforts to identify what are now known as alternative modes of ventilation including high-frequency oscillatory ventilation and airway pressure release ventilation. Both modalities are based on the principles of the open-lung concept and aim to improve oxygenation by keeping the lung uniformly inflated for an extended period of time. Although a mortality benefit has not been proven, some patients may benefit from these alternative modes of ventilation as rescue measures while the underlying process resolves. The purpose of this article is to review the evidence and mechanisms underlying each modality and to describe the fundamental steps in initiating, adjusting, and terminating these modes of ventilation.

Transfer status: A risk factor for mortality in patients with necrotizing fasciitis

BACKGROUNDnNecrotizing fasciitis (NF) is a rapidly progressive disease that requires urgent surgical debridement for survival. Interhospital transfer (IT) may be associated with delay to operation, which could increase mortality. We hypothesized that mortality would be higher in patients undergoing surgical debridement for necrotizing fasciitis after IT compared to Emergency Department (ED) admission.nnnMETHODSnWe performed a retrospective cohort analysis from 2000-2006 using the Nationwide Inpatient Sample. Inclusion criteria were age >18 years, primary diagnosis of NF, and surgical therapy within 72 hours of admission. Logistic regression was used to assess the relationship between admission source, patient and hospital variables, and mortality.nnnRESULTSnWe identified 9,958 cases over the study period. Patients in the ED group were more likely to be nonwhite and of lower income when compared with patients in the IT group. Unadjusted mortality was higher in the IT group than ED group (15.5% vs 8.7%, P < .001). After adjusting for potential confounders, odds of mortality were still greater in the IT (OR 2.04, CI 95% 1.60-2.59, P < .001).nnnCONCLUSIONnInterhospital transfer is associated with increased risk of in-hospital mortality after surgical therapy for NF, a finding which persists after controlling for patient and hospital level variables.

Early hospital readmission in the trauma population: Are the risk factors different?

INTRODUCTIONnHospital readmission rates will soon impact Medicare reimbursements. While risk factors for readmission have been described for medical and elective surgical patients, little is known about their predictive value specifically in trauma patients.nnnPATIENTS AND METHODSnWe retrospectively identified all admissions after trauma resuscitation to our urban level 1 trauma centre from 1/1/2004 to 8/31/2010. All patients discharged alive were included. Data collected included demographics, Injury Severity Score (ISS), and length of stay (LOS). We analyzed these index admissions for the development of complications that have previously been shown to be associated with readmission. Readmissions that occurred within 30 days of index admission were identified. Univariable and multivariable analyses were performed. p<0.05 was considered significant.nnnRESULTSnWe identified 10,306 index admissions, with 447 (4.3%) early (within 30 days) readmissions. Mean ISS was 11.1 (SD 10.4). On multivariable analysis, African-American race (OR 1.3, p=0.009), pre-existing chronic obstructive pulmonary disease (COPD) (OR 1.5, p=0.02), and diabetes mellitus (OR 1.8, p<0.001) were associated with readmission, along with higher ISS (OR 1.01, p<0.001), ICU admission (OR 2.1, p<0.001), and increased LOS (OR 1.01, p<0.001). Among many in-hospital complications examined, only the development of surgical site infection (SSI) (OR 1.9, p=0.02) was associated with increased risk of readmission.nnnCONCLUSIONSnTrauma patients have a low risk of readmission. In contrast to elective surgical patients, the only modifiable risk factor for readmission in our trauma population was SSI. Other risk factors may present clinicians with opportunities for targeted interventions, such as proactive follow up or early phone contact. With future changes to health care policy, clinicians may have even greater motivation to prevent readmission.