Bruce W. Bonnell

Duty-hour restrictions and the work of surgical faculty: results of a multi-institutional study.

Purpose To examine whether duty-hour restrictions have been consequential for various aspects of the work of surgical faculty and if those consequences differ for faculty in academic and nonacademic general surgery residency programs. Method Questionnaires were distributed in 2004 to 233 faculty members in five academic and four nonacademic U.S. residency programs in general surgery. Participation was restricted to those who had been faculty for at least one year. Ten items on the questionnaire probed faculty work experiences. Results include means, percentages, and t-tests on mean differences. Of the 146 faculty members (63%) who completed the questionnaire, 101 volunteered to be interviewed. Of these, 28 were randomly chosen for follow-up interviews that probed experiences and rationales underlying items on the questionnaire. Interview transcripts (187 single-spaced pages) were analyzed for main themes. Results Questionnaire respondents and interviewees associated duty-hour restrictions with lowered faculty expectations and standards for residents, little change in the supervision of residents, a loss of time for teaching, increased work and stress, and less satisfaction. No significant differences in these perceptions (p ≪ .05) were found for faculty in academic and nonacademic programs. Main themes from the interviews included a shift of routine work from residents to faculty, a transfer of responsibility to faculty, more frequent skill gaps at night, a loss of time for research, and the challenges of controlling residents’ hours. Conclusions Duty-hour restrictions have been consequential for the work of surgical faculty. Faculty should not be overlooked in future studies of duty-hour restrictions.

Pulmonary artery catheterization. A prospective study of internal jugular and subclavian approaches

We compared complications of pulmonary artery catheter (PAC) insertion and maintenance at internal jugular (IJ) vs. subclavian (SC) sites. Patients were randomized into groups using an IJ or SC route, and insertions were timed. An air-permeable dressing and anticontamination shield were used. Catheters were removed 72 h after insertion. If PAC monitoring was still needed, a new catheter was either inserted over a guidewire at the initial insertion site or inserted at a new site. On removal, the catheter tip, introducer-sheath tip, and catheter within the shield were submitted for semiquantitative culture. Sixty-six catheters were initially inserted, and 26 were changed. No determinative differences in the time for venous cannulation were found, but the IJ route was slightly faster. In 3% of the catheterizations, serious complications arose. The infection rate was 2% for initial catheters, 8% for second catheters placed over a guidewire, and 15% for second catheters placed at a new site. These differences were not consequential. No local infection or catheter-related sepsis occurred. Thus, using a standard, sterile-insertion technique and a catheter-maintenance protocol yielded a low risk of insertion and infectious complications at either the IJ or SC site. Our data indicated that PACs can be changed safely over a guidewire at 72 h, avoiding further insertion risks without increasing infectious complications.

Percutaneous Thrombin Injection of Splanchnic Artery Aneurysms: Two Case Reports

JVIR 2000; 11:469–472 THE diagnosis and management of splanchnic artery aneurysms is difficult. The first reported splanchnic artery aneurysm was discovered while Beaussier was injecting a cadaver for anatomic demonstration in 1770 (1). Since then, more than 3,000 cases of splanchnic artery aneurysms have been documented in the literature. However, the incidence of such aneurysms is not known. Although rare, these lesions are clinically important. Nearly 22% of all splanchnic artery aneurysms present as clinical emergencies. Of these, 8.5% result in death (2). The majority of aneurysms (63%) are symptomatic at the time of presentation and 23.9% present with rupture (3). The treatment of choice of splanchnic artery aneurysms classically has been operative ligation or resection. With the advancement of interventional radiology, percutaneous transcatheter embolization has been effective (4). Unfortunately, not all aneurysms can be successfully cannulated with these catheters (4). In 1986, Cope and Zeit described the successful treatment of pseudoaneurysms of the peripheral arteries by direct percutaneous injection of thrombin (5). In 1989, Rothbarth et al reported a case in which they successfully treated a large intraparenchymal hepatic artery aneurysm by percutaneously injecting thrombin after embolization with coils had failed (6). The purpose of this article is to describe the use of percutaneous thrombin injection for the treatment of ruptured aneurysms involving branches of the superior mesenteric artery. Two patients presented to our institution with symptoms related to rupture of splanchnic artery aneurysms.

The first 72 hours of brain tissue oxygenation predicts patient survival with traumatic brain injury.

BACKGROUND: Utilization of brain tissue oxygenation (pBtO2) is an important but controversial variable in the treatment of traumatic brain injury. We hypothesize that pBtO2 values over the first 72 hours of monitoring are predictive of mortality. METHODS: Consecutive, adult patients with severe traumatic brain injury and pBtO2 monitors were retrospectively identified. Time-indexed measurements of pBtO2, cerebral perfusion pressure (CPP), and intracranial pressure (ICP) were collected, and average values over 4-hour blocks were determined. Patients were stratified according to survival, and repeated measures analysis of variance was used to compare pBtO2, CPP, and ICP. The pBtO2 threshold most predictive for survival was determined. RESULTS: There were 8,759 time-indexed data points in 32 patients. The mean age was 39 years ± 16.5 years, injury severity score was 27.7 ± 10.7, and Glasgow Coma Scale score was 6.6 ± 3.4. Survival was 68%. Survivors consistently demonstrated higher pBtO2 values compared with nonsurvivors including age as a covariate (F = 12.898, p < 0.001). Individual pBtO2 was higher at the time points 8 hours, 12 hours, 20 hours to 44 hours, 52 hours to 60 hours, and 72 hours of monitoring (p < 0.05). There was no difference in ICP (F = 1.690, p = 0.204) and CPP (F = 0.764, p = 0.389) values between survivors and nonsurvivors including age as a covariate. Classification and regression tree analysis identified 29 mm Hg as the threshold at which pBtO2 was most predictive for mortality. CONCLUSION: The first 72 hours of pBtO2 neurologic monitoring predicts mortality. When the pBtO2 monitor remains below 29 mm Hg in the first 72 hours of monitoring, mortality is increased. This study challenges the brain oxygenation threshold of 20 mm Hg that has been used conventionally and delineates a time for monitoring pBtO2 that is predictive of outcome. LEVEL OF EVIDENCE: III, prognostic study.

Characterizing the practice of surgical critical care fellowship graduates: What's a fellow to do?

Abstract In order to characterize further the developing field of surgical critical care, we mailed letters to surgical critical care fellowship directors requesting the addresses of their graduates. We then mailed out surveys to the graduates and analyzed their responses. Resident teaching is a prominent feature for 85% of the graduates, with 94% of them teaching surgical critical care and 84% teaching general surgery residents. Sixty-five percent of the respondents spend at least 25% of their time providing surgical critical care, and 56% actively practice some aspects of general surgery as well. Not surprisingly, trauma care is a large part of the surgical intensivists practice, with 74% also spending at least 25% of their clinical time caring for trauma patients. With this mix of responsibilities, the respondents performed an average of 148 operations annually. Of the surgeons who responded to the survey, 66% have academic practices. Over 75% were salaried, with 95% earning over

Early tracheostomy versus late tracheostomy in the surgical intensive care unit.

100,000 annually and 40% earning in excess of

Recombinant factor VIIa for the treatment of severe postoperative and traumatic hemorrhage.

150,000. Practice arrangements and patient mix varied substantially within the field. Several issues regarding the career choice of surgical critical care have been raised in previous studies, and the current survey helps to clarify several of these issues. Further surveys and follow-up studies are urgently needed to better characterize the career profile for surgical critical care.