Charity H. Evans

Treatment of bacteriobilia decreases wound infection rates after pancreaticoduodenectomy

BACKGROUND Although mortality following pancreaticoduodenectomy is decreasing, postoperative morbidity remains high. It was hypothesized that culture-directed treatment of bacteriobilia would decrease the incidence of infectious complications following pancreaticoduodenectomy. METHODS In a retrospective study of 197 pancreaticoduodenectomy patients, those in the control group (n = 128, 2005-2009) were given perioperative prophylactic antibiotics, whereas those in the treatment group (n = 69, 2009-2011) were continued on antibiotics until intraoperative bile culture results became available. Patients with bacteriobilia received 10 days of antibiotic treatment, which was otherwise discontinued in patients without bacteriobilia. Various complication rates were compared using Fishers exact test for categorical variables, Wilcoxon rank sum test for ordinal variables, and a two-sample t-test for continuous variables. RESULTS Demographics, comorbidities, baseline clinical characteristics, and intraoperative and postoperative variables were similar between the two groups. There were higher incidences of elevated creatinine (19% versus 4%; P = 0.004) and preoperative hyperglycaemia (18% versus 7%; P = 0.053) in the control group. Fewer patients in the control group underwent preoperative biliary stenting (48% versus 67%; P = 0.017) and intraperitoneal drains were placed at the time of resection more frequently in the control group (85% versus 38%; P < 0.001). Bacteriobilia was found in 59% of patients. Treatment of bacteriobilia was associated with a decrease in the rate of postoperative wound infections (12% in the control group versus 3% in the treatment group; P = 0.036) and overall complication severity score (1 in the control group versus 0 in the treatment group; P = 0.027). CONCLUSIONS Prolonged antibiotic therapy for bacteriobilia may decrease postoperative wound infection rates after pancreaticoduodenectomy. A randomized prospective trial is warranted to provide evidence to further support this practice.

Optimal Glucose Management in the Perioperative Period

Hyperglycemia is a common finding in surgical patients during the perioperative period. Factors contributing to poor glycemic control include counterregulatory hormones, hepatic insulin resistance, decreased insulin-stimulated glucose uptake, use of dextrose-containing intravenous fluids, and enteral and parenteral nutrition. Hyperglycemia in the perioperative period is associated with increased morbidity, decreased survival, and increased resource utilization. Optimal glucose management in the perioperative period contributes to reduced morbidity and mortality. To readily identify hyperglycemia, blood glucose monitoring should be instituted for all hospitalized patients.

Enteral albuterol decreases the need for chronotropic agents in patients with cervical spinal cord injury-induced bradycardia

BACKGROUND Cervical spinal cord injury (CSCI) is often complicated by autonomic instability and life-threatening bradycardia. &bgr;-adrenergic receptors offer a potential target for modulating cardiac vagal activity and heart rate. Enteral albuterol may mitigate symptomatic bradycardia in CSCI patients. The purpose of this study was to examine the effect of enteral albuterol on the frequency of symptomatic bradycardia and the need for rescue therapy in CSCI patients. METHODS The charts of CSCI patients admitted to a Level I trauma center from February 2008 through March 2012 were reviewed for demographics, episodes of symptomatic bradycardia (defined as heart rate < 60 beats per minute and systolic blood pressure < 90 mm Hg), use of enteral albuterol, hospital days requiring chronotropic use, and total atropine administered. In the albuterol group, patients received scheduled enteral albuterol after experiencing symptomatic bradycardia, with chronotropic agents used as needed for rescue treatment. In the no-albuterol group, only chronotropic agents were used as needed for rescue treatment. The albuterol and no-albuterol groups were compared using independent-samples Kruskal-Wallis test for total number of bradycardic episodes, hospital days requiring chronotropic use, and total atropine administered. RESULTS Eighteen patients with CSCI-induced bradycardia were identified. Eight patients received treatment with enteral albuterol, and 10 patients did not. The median age did not differ significantly between the two groups. However, the median Injury Severity Score (ISS) was higher in the albuterol group (median ISS, 36.5; interquartile range, 35–66.5 vs. median ISS 26; interquartile range, 27–37.25 in no-albuterol group). Patients receiving albuterol experienced 1.8 symptomatic bradycardic episodes versus 4.3 episodes in those patients not receiving albuterol (p = 0.08). Hospital days on chronotropic agents were significantly less in the albuterol group (1.8 vs. 8.6, p = 0.01). One patient, in the no-albuterol group, required pacemaker placement. CONCLUSION Enteral albuterol may reduce the frequency of symptomatic bradycardia in patients with CSCI, resulting in less rescue therapy using chronotropic agents. LEVEL OF EVIDENCE Therapeutic study, level IV.

No one has ever drowned in sweat.

expressing his belief that hard work is needed to achieve success. Many older surgeons echo the coach’s sentiments with regards to surgical training. But do today’s medical students intending a career in surgery feel the same way? Since the inception of resident duty hour limits and its application to medical students through the Liaison Committee on Medical Education, surgeons have engaged in an ongoing debate if those entering and exiting surgical residency are as dedicated as generations past. Albeit biased, it is human nature to think that the younger generation is not as hard working as the older generation recalls. The millennial medical student starts the surgery clerkshipwithadifferentsetofdemands,expectations,andvalues than that of learners in years past. The millennial learner prefers active learning methods over lectures, does not value information for information’s sake, requires relevance, obliges rationale for complying, and prefers a less formal learning environment with ample contact with their educators. 2 The learner has changed and so has the environment.

Ultrasound Imaging for the Surgical Intensivist

Ultrasound imaging technology and techniques have rapidly advanced over the past decade and are now at the point where they should be considered a standard and critical component of critical care practice. All current and future intensivists should be thoroughly familiar with the myriad of applications of point-of-care ultrasound (POCUS) for assisting in the assessment, diagnostic workup, and therapeutic interventions in the intensive care unit (ICU) setting. POCUS differs from comprehensive ultrasound (US) in its intent and use. POCUS is performed bedside by a clinician, employed to detect acute and often life-threatening conditions to facilitate treatment or to guide performance of an invasive procedure. It is quick and usually only focuses on a single or limited set of organs. Its clinical applications can be viewed as procedural guidance, diagnostics, monitoring, or resuscitation, with guidelines for the appropriate use of bedside ultrasound in the ICU set forth by the Society of Critical Care Medicine. By following evidence-based recommendations regarding the appropriate use of ultrasound in the ICU, clinicians can provide selected patients with effective and efficient care. This chapter will review the key points and strategies for ICU physicians to incorporate POCUS into their day-to-day practice.

The eye of the master

Surgical tasks are performed in a dynamic, ever changing, anxiety-provoking environment that continuously tests the limits of human performance. The ability to maintain control and focus on attention is universally accepted as a key to success. In the operating room, there are many actions going on simultaneously, often distracting the novice learner. It begs the question – what exactly should surgical trainees focus on to acquire skills and produce anxiety-free performances? If we were in the business of training ball players, we would teach them to keep their eye on the ball. This is the advice passed on by my coaches at every level, but can we apply this same advice to students learning surgical skills? The answer is a resounding yes. In the preceding work by Causer et al, Dr Vickers has expanded her ground-breaking work from improving athletic performance into the operating room. This method of teaching has the potential of completely revolutionizing the way we teach surgical skills. While their manuscript is well written and important, it fails to provide the background information and supporting evidence that would excite surgical educators to completely rethink the way technical skills are traditionally taught. Dr Vickers pioneered the concept of the ‘‘Quiet Eye’’ (QE), which is the final visual fixation or tracking gaze located on a specific area in the visuomotor workspace within 3 of visual angle for a minimum of 100 ms. During this period, the performer sets the final parameters which