Chasen A. Croft

A protocol for the management of adhesive small bowel obstruction

BACKGROUND Differentiating between partial adhesive small bowel obstruction (aSBO) likely to resolve with medical management and complete obstruction requiring operative intervention remains elusive. We implemented a standardized protocol for the management of aSBO and reviewed our experience retrospectively. METHODS Patients with symptoms of aSBO were admitted for intravenous fluid resuscitation, bowel rest, nasogastric tube decompression, and abdominal examinations every 4 hours. Laboratory values and a computed tomography scan of the abdomen and pelvis with intravenous contrast were obtained. Patients with peritonitis or computed tomography scan findings suggesting bowel compromise were taken to the operating room for exploration following resuscitation. All other patients received 80 mL of Gastroview (GV) and 40 mL of sterile water via nasogastric tube. Abdominal plain films were obtained at 4, 8, 12, and 24 hours. If contrast did not reach the colon within 24 hours, then operative intervention was performed. RESULTS Over 1 year, 91 patients were admitted with aSBO. Sixty-three patients received GV, of whom 51% underwent surgery. Twenty-four patients went directly to the operating room because of clinical or imaging findings suggesting bowel ischemia. Average time to surgery was within 1 day for the no-GV group and 2 days for the GV group. Patients passing GV to the colon within 5 hours of administration had a 90% rate of resolution of obstruction. There was a direct relationship between the duration of time before passing GV to the colon and hospital length of stay (HLOS) (r2 = 0.459). Patients who received GV and did not require surgery had lower HLOS (3 days vs. 11 days, p < 0.0001). CONCLUSION The GV protocol facilitated early recognition of complete obstruction. Administration of GV had diagnostic and therapeutic value and did not increase HLOS, morbidity, or mortality. LEVEL OF EVIDENCE Therapeutic study, level V. Epidemiologic study, level V.

Computer versus paper system for recognition and management of sepsis in surgical intensive care.

BACKGROUND A system to provide surveillance, diagnosis, and protocolized management of surgical intensive care unit (SICU) sepsis was undertaken as a performance improvement project. A system for sepsis management was implemented for SICU patients using paper followed by a computerized system. The hypothesis was that the computerized system would be associated with improved process and outcomes. METHODS A system was designed to provide early recognition and guide patient-specific management of sepsis including (1) modified early warning signs–sepsis recognition score (MEWS-SRS; summative point score of ranges of vital signs, mental status, white blood cell count; after every 4 hours) by bedside nurse; (2) suspected site assessment (vascular access, lung, abdomen, urinary tract, soft tissue, other) at bedside by physician or extender; (3) sepsis management protocol (replicable, point-of-care decisions) at bedside by nurse, physician, and extender. The system was implemented first using paper and then a computerized system. Sepsis severity was defined using standard criteria. RESULTS In January to May 2012, a paper system was used to manage 77 consecutive sepsis encounters (3.9 ± 0.5 cases per week) in 65 patients (77% male; age, 53 ± 2 years). In June to December 2012, a computerized system was used to manage 132 consecutive sepsis encounters (4.4 ± 0.4 cases per week) in 119 patients (63% male; age, 58 ± 2 years). MEWS-SRS elicited 683 site assessments, and 201 had sepsis diagnosis and protocol management. The predominant site of infection was abdomen (paper, 58%; computer, 53%). Recognition of early sepsis tended to occur more using the computerized system (paper, 23%; computer, 35%). Hospital mortality rate for surgical ICU sepsis (paper, 20%; computer, 14%) was less with the computerized system. CONCLUSION A computerized sepsis management system improves care process and outcome. Early sepsis is recognized and managed with greater frequency compared with severe sepsis or septic shock. The system has a beneficial effect as a clinical standard of care for SICU patients. LEVEL OF EVIDENCE Therapeutic study, level III.

Temporary abdominal closure for trauma and intra-abdominal sepsis: different patients, different outcomes.

BACKGROUND Temporary abdominal closure (TAC) after damage control surgery (DCS) for injured patients has been generalized to septic patients. However, direct comparisons between these populations are lacking. We hypothesized that patients with intra-abdominal sepsis would have different resuscitation requirements and lower primary fascial closure rates than trauma patients. STUDY DESIGN We performed a 3-year retrospective cohort analysis of patients managed with TAC for trauma (n = 77) or intra-abdominal sepsis (n = 147). All patients received negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-hour intervals. RESULTS At presentation, trauma patients had higher rates of hypothermia (31% vs. 18%), severe acidosis (27% vs. 14%), and coagulopathy (68% vs. 48%), and septic patients had higher vasopressor infusion rates (46% vs. 27%). Forty-eight hours after presentation, septic patients had persistently higher vasopressor infusion rates (37% vs. 17%), and trauma patients had received more red blood cell transfusions (6.0 U vs. 0.0 U), fresh frozen plasma (5.0 U vs. 0.0 U), and crystalloid (8,290 vs. 7,159 ml). Among patients surviving to discharge, trauma patients had higher primary fascial closure (PFC) rates (90% vs. 76%). For trauma patients, independent predictors of failure to achieve PCF were ≥2.5 L NPWT output at 48 hours, ≥10 L crystalloid administration at 48 hours, and ≥10 U PRBC + FFP at 48 hours. For septic patients, relaparotomy within 48 hours predicted successful PFC; requirement for ≥3 diagnostic/therapeutic laparotomies predicted failure to achieve PFC. CONCLUSIONS Traumatic injury and intra-abdominal sepsis are associated with distinct pathophysiologic insults, resuscitation requirements, and outcomes. Failure to achieve primary fascial closure in trauma patients was attributable to the triad of hypothermia, acidosis, and coagulopathy; failure to achieve fascial closure in septic patients was dependent upon operative course. Indications and optimal techniques for TAC may differ between these populations. LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic study, level III.

Acute Kidney Injury Following Exploratory Laparotomy and Temporary Abdominal Closure.

Background: Acute kidney injury (AKI) following exploratory laparotomy and temporary abdominal closure (TAC) is poorly understood but clinically significant. We hypothesized that the prevalence of AKI would be highest 96 h following TAC, early hypoxemia would predict AKI, and that AKI would be an independent predictor of mortality. Methods: We performed a retrospective analysis of 251 acute care surgery patients managed with TAC by negative pressure wound therapy (NPWT). Kidney Disease: Improving Global Outcomes AKI stages were assessed on admission, initial TAC, and following TAC at 48 h, 96 h, and 7 d. Multivariate regression was performed to identify risk factors for AKI and inpatient mortality. Results: Fifty-seven percent of all patients developed AKI within 7 days of laparotomy (stage 1: 14%, 2: 21%, 3: 22%). The prevalence of AKI peaked 48 h following TAC, and stage correlated with inpatient mortality (stage 0: 7%, 1: 13%, 2: 19%, 3: 37%, P < 0.001). Overall mortality was 14%. Factors predictive of stage 2 or 3 AKI at 48 h included age >65 years (OR 2.6 [95% CI 1.4–4.9]), NPWT output >30 mL/h from first TAC to 48 h (2.0 [1.1–3.9]), and three parameters at initial laparotomy: mean arterial pressure <60 mm Hg (2.9 [1.0–8.5]), temperature <36°C (2.1 [1.1–3.8]), and anion gap >21 mEq/L (1.9 [1.0–3.7]). AKI was an independent predictor of inpatient mortality (5.5 [2.5–11.8]). Conclusions: AKI is common following TAC, reaches greatest prevalence 48 h after initial laparotomy, and is associated with increased mortality. NPWT fluid loss is a risk factor for AKI that is unique to TAC patients.

Predicting appendiceal tumors among patients with appendicitis.

BACKGROUND As nonoperative management of appendicitis gains popularity, vigilance for appendiceal tumors becomes increasingly important. We hypothesized that, among patients presenting with acute appendicitis, those with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis would be more likely to have underlying appendiceal tumors. METHODS We performed a 4-year retrospective cohort analysis of 677 consecutive adult patients who underwent appendectomy for appendicitis at our tertiary care center. Patients with an appendiceal tumor on their final pathology report were compared to patients with no tumor. Conditions present on admission were used to create a multivariate logistic regression model to predict appendiceal tumor. Risk factors were reported as odds ratio (OR) [95% CI]. Model strength was assessed by area under the receiver operating characteristic curve. RESULTS Seventeen patients (2.5%) had an appendiceal tumor. Within this group. 14 underwent immediate appendectomy, two initially had nonoperative management but failed to improve on antibiotics and underwent appendectomy during the initial admission, and one had successful nonoperative management and elective appendectomy 19 days after discharge. Four variables contributed to the multivariate model to predict the presence appendiceal tumor: age ≥ 50 (OR 3.6 [1.1–11.4]), outpatient steroid/immunosuppressant use (OR 12.1 [2.0–72.5]), the absence of migratory right lower quadrant pain (OR 4.7 [1.2–18.1]), and the appearance of a phlegmon on CT scan (OR 7.0 [1.6–30.2]); model area under the receiver operating characteristic curve: 0.860 [0.705–0.969]. CONCLUSION For patients presenting with acute appendicitis, conditions present on admission may predict underlying appendiceal tumor. Patients with advanced age, multiple comorbidities, atypical presentation, and complicated appendicitis should be considered for appendectomy during the index admission or at earliest convenience if nonoperative management is necessary. LEVEL OF EVIDENCE Prognostic study, level III.

Chronic Critical Illness: Application of What We Know

Over the last decade, chronic critical illness (CCI) has emerged as an epidemic in intensive care unit (ICU) survivors worldwide. Advances in ICU technology and implementation of evidence-based care bundles have significantly decreased early deaths and have allowed patients to survive previously lethal multiple organ failure (MOF). Many MOF survivors, however, experience a persistent dysregulated immune response that is causing an increasingly predominant clinical phenotype called the persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The elderly are especially vulnerable; thus, as the population ages the prevalence of this CCI/PICS clinical trajectory will undoubtedly grow. Unfortunately, there are no proven therapies to prevent PICS, and multimodality interventions will be required. The purpose of this review is to: (1) discuss CCI as it relates to PICS, (2) identify the burden on healthcare and poor outcomes of these patients, and (3) describe possible nutrition interventions for the CCI/PICS phenotype.

Routine surveillance cholangiography after percutaneous cholecystostomy delays drain removal and cholecystectomy

Introduction Percutaneous cholecystostomy (PC) is often performed for patients with acute cholecystitis who are at high risk for operative morbidity and mortality. However, the necessity for routine cholangiography after PC remains unclear. We hypothesized that routine surveillance cholangiography (RSC) after PC would provide no benefit compared to on-demand cholangiography (ODC) triggered by signs or symptoms of biliary pathology. Methods We performed a 3-year retrospective cohort analysis of patients managed with PC for acute cholecystitis at two tertiary care hospitals. Patients who had routine surveillance cholangiography (RSC, n = 43) were compared to patients who had on-demand cholangiography (ODC, n = 41) triggered by recurrent biliary disease. Results RSC and ODC groups were similar by severity of acute cholecystitis, presence of gallstones, systemic inflammatory response syndrome (SIRS) criteria at the time of PC, SIRS criteria 72 hours after PC, and hospital length of stay. Two patients in the ODC group developed clinical indications for cholangiography. All 44 RSC patients had cholangiography, and 67 total cholangiograms were performed in this group. Surveillance cholangiography identified six patients (14%) with cystic duct filling defect and seven patients (16%) with a common bile duct filling defect, all of whom were asymptomatic. Fifteen patients (35%) in the RSC group had 32 ERCP procedures; five patients (12%) in the ODC group had 7 ERCPs (p = 0.021). The ODC group had fewer days to drain removal (35 vs. 61, p < 0.001) and days to cholecystectomy (39 vs. 81, p = 0.005). Rates of recurrent cholecystitis, cholangitis, gallstone pancreatitis, drain removal, and cholecystectomy were similar between groups. Conclusion RSC after PC for acute cholecystitis identified biliary pathology in asymptomatic patients and propagated further testing, but did not provide clinical benefit. ODC was associated with earlier drain removal, earlier cholecystectomy, and decreased resource utilization. Level of Evidence Prognostic study, level III; therapeutic study, level IV.

Characterization of hypoalbuminemia following temporary abdominal closure

BACKGROUND The purpose of this study was to characterize associations among serum proteins, negative-pressure wound therapy (NPWT) fluid loss, and primary fascial closure (PFC) following emergent laparotomy and temporary abdominal closure (TAC). We hypothesized that high levels of C-reactive protein (CRP) and NPWT output would be associated with hypoalbuminemia and failure to achieve PFC. METHODS We performed a retrospective analysis of 233 patients managed with NPWT TAC. Serum proteins and resuscitation indices were assessed on admission, initial laparotomy, and then at 48 hours, 96 hours, 7 days, and discharge. Correlations were assessed by Pearson coefficient. Multivariable regression was performed to identify predictors of PFC with cutoff values for continuous variables determined by Youden index. RESULTS Patients who failed to achieve PFC (n = 55) had significantly higher CRP at admission (249 vs. 148 mg/L, p = 0.003), initial laparotomy (237 vs. 154, p = 0.002), and discharge (124 vs. 72, p = 0.003), as well as significantly lower serum albumin at 7 days (2.3 vs. 2.5 g/dL, p = 0.028) and discharge (2.5 vs. 2.8, p = 0.004). Prealbumin (in milligrams per deciliter) was similar between groups at each time point. There was an inverse correlation between nadir serum albumin and total milliliters of NPWT output (r = −0.33, p < 0.001). Exogenous albumin administration (in grams per day) correlated with higher serum albumin levels at each time point: 48 hours: r = 0.26 (p = 0.002), 96 hours: r = 0.29 (p = 0.002), 7 days: r = 0.40 (p < 0.001). Albumin of less than 2.6 g/dL was an independent predictor of failure to achieve PFC (odds ratio, 2.59; 95% confidence interval, 1.02–6.61) in a multivariate model including abdominal sepsis, body mass index of greater than 40 kg/m2, and CRP of greater than 250 mg/L. CONCLUSIONS Early and persistent systemic inflammation and high NPWT output were associated with hypoalbuminemia, which was an independent predictor of failure to achieve PFC. The utility of exogenous albumin following TAC requires further study. LEVEL OF EVIDENCE Prognostic study, level III; Therapeutic study, level IV.

Early bronchoalveolar lavage for intubated trauma patients with TBI or chest trauma

Purpose: To evaluate the efficacy of an early bronchoalveolar lavage (E‐BAL) protocol. BAL was performed within 48 h for intubated patients with traumatic brain injury or chest trauma. We hypothesized that E‐BAL would decrease antibiotic use and improve outcomes compared to late BAL (L‐BAL) triggered by clinical signs of pneumonia. Methods: Retrospective cohort analysis of 132 patients with quantitative BAL and ≥1 risk factor: head Abbreviated Injury Score ≥2, ≥3 rib fractures, or radiographic signs of aspiration or pulmonary contusion. E‐BAL (n = 71) was compared to L‐BAL (n = 61). Pneumonia was defined as ≥104 organisms on BAL or Clinical Pulmonary Infection Score >6. Results: There were no significant differences in age, injury severity, initial Pao2:Fio2, or smoking status between E‐BAL and L‐BAL groups. 52% and 61% of the E‐BAL and L‐BAL cultures were positive, respectively. E‐BAL patients had fewer antibiotic days (7.3 vs 9.2, P = .034), ventilator days (11 vs 15, P = .002), tracheostomies (49% vs 75%, P = .002), and shorter intensive care unit and hospital length of stay (13 vs 17 days (P = .007), 18 vs 22 days (P = .041)). Conclusions: More than half of all E‐BAL patients had pneumonia present early after admission. E‐BAL was associated with fewer days on antibiotics and better outcomes than L‐BAL. HighlightsEarly BAL (E‐BAL) was performed within 48 h for high risk intubated trauma patientsE‐BAL was compared to late BAL (L‐BAL) triggered by signs of pneumonia52% of E‐BAL cultures were positive, identifying pneumonia present on admissionE‐BAL patients had fewer antibiotics days and better outcomes than L‐BAL patients

Large Bowel Obstruction

Acute large bowel obstruction (LBO) refers to any condition which blocks the flow of enteric contents through the colon and rectum. It is a condition which is encountered frequently by the acute care surgeon. Large bowel obstruction has many etiologies including mechanical causes such as colorectal malignancies and volvulus, as well as physiological causes due to disruption of normal peristalsis. As such, an astute surgeon must expeditiously make the diagnosis and implement the correct treatment strategy so as to limit the high morbidity and mortality associated with acute colonic obstruction. This chapter describes the etiologies, clinical presentation, workup, and treatment options for both mechanical and physiological causes of acute bowel obstruction in the adult population.