Gaurav Sachdev

Complications of bariatric surgery: the acute care surgeon's experience.

BACKGROUND Complications of bariatric surgeries are common, can occur throughout the patients lifetime, and can be life-threatening. We examined bariatric surgical complications presenting to our acute care surgery service. METHODS Records were reviewed from January 2007 to June 2013 for patients presenting with a complication after bariatric surgery. RESULTS Laparoscopic Roux-en-Y gastric bypass was the most common index operation (n = 20), followed by open Roux-en-Y gastric bypass (n = 6), laparoscopic gastric band (n = 4), and vertical banded gastroplasty (n = 3). Diagnoses included internal hernia (n = 10), small bowel obstruction (n = 5), lap band restriction (n = 4), biliary disease (n = 3), upper GI bleeding or ulcer (n = 3), ischemic bowel (n = 2), marginal ulcer (n = 2), gastric outlet obstruction (n = 2), perforated ulcer (n = 2), intussusception (n = 1), and incarcerated ventral hernia (n = 1). Operations were required in 91% of the patients. Laparoscopic outcomes were similar to open; however, open cases were more emergent (23.5% vs 69.2%) and had longer hospital length of stay (4.8 ± 3.5 vs 11.0 ± 10.3 days, P < .05). All patients survived. CONCLUSIONS The acute care surgeon will encounter complications of bariatric surgery. Internal hernias or obstructive etiologies are the most common presentations and often require emergent or urgent surgery.

Failure of lorazepam to treat alprazolam withdrawal in a critically ill patient

Management of sedation in the critical care unit is an ongoing challenge. Benzodiazepines have been commonly used as sedatives in critically ill patients. The pharmacokinetic and pharmacodynamic properties that make benzodiazepines effective and safe in critical care sedation include rapid onset of action and decreased respiratory depression. Alprazolam is a commonly used benzodiazepine that is prescribed for anxiety and panic disorders. It is frequently prescribed in the outpatient setting. Its use has been reported to result in a relatively high rate of dependence and subsequent withdrawal symptoms. Symptoms of alprazolam withdrawal can be difficult to recognize and treat in the critical care setting. In addition, other benzodiazepines may also be ineffective in treating alprazolam withdrawal. We present a case of alprazolam withdrawal in a critically ill trauma patient who failed treatment with lorazepam and haloperidol. Subsequent replacement with alprazolam resulted in significant improvement in the patients medication use and clinical status.

Outcomes of acute kidney injury in patients with severe ARDS due to influenza A(H1N1) pdm09 virus

Background The incidence and long‐term outcomes of acute kidney injury in patients with severe acute respiratory distress syndrome (ARDS) due to influenza A(H1N1) pdm09 virus (pH1N1) have not been examined. Objective To assess long‐term renal recovery in patients with acute kidney injury and severe ARDS due to pH1N1. Methods A retrospective observational cohort study of adults with severe pH1N1‐associated ARDS admitted to a tertiary referral center. Baseline characteristics, acute kidney injury stage, continuous renal replacement therapy (CRRT), intermittent hemodialysis, extracorporeal membrane oxygenation, survival, and renal recovery (defined as dialysis independence) were evaluated. Results Fifty‐seven patients, most with stage 3 acute kidney injury, were included. The 53% mortality rate among the 38 patients requiring CRRT was significantly higher than the 0% mortality rate among the 19 patients not requiring CRRT or intermittent hemodialysis. Increased duration of CRRT was not significantly associated with decreased survival. Fifteen CRRT patients required transition to intermittent hemodialysis. Of the CRRT patients who survived, 94% experienced renal recovery. Extracorporeal membrane oxygenation was instituted in 17 patients; 15 of these patients required CRRT. Conclusions Acute kidney injury is common in patients with severe ARDS caused by pH1N1 infection. CRRT is a significant risk factor for increased mortality, but most patients who survived experienced full renal recovery.

1274: IMPACT OF MULTIPROFESSIONAL ROUNDS ON OUTCOMES IN A SURGICAL INTENSIVE CARE UNIT

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Multi-professional rounds (MPR) represent a mechanism for the coordination of care in critical ill patients. Herein, we examined the impact of MPR implementation in our surgical ICU (ICU) on ventilator days (Vent-day) and ICU length of stay (LOS). Methods: A multi-professional team developed guidelines, including an organ system-based daily goal checklist, and MPR began in February 2016. Patients admitted from November 2015 to January 2017 with ICU LOS greater than 5 hours were included. Severity of illness was determined using APACHE IVa scores. Outcome data, consisting of Vent-day and ICU LOS, were captured via electronic medical record. Linear regression models were constructed to observe the impact of MPR, by month after implementation, on ICU outcomes. Data are reported as mean and observed/ expected ratios (O/E), calculated by a risk-stratified proprietary methodology. Results: There were a total of 1,892 patients, with a mean APACHE IVa score of 61.3. For patients on mechanical ventilation, MPR led to a reduction in Vent-day, from 3.7 to 2.6 days; and the O/E ratio decreased from 0.93 to 0.78. The mean ICU LOS decreased from 3.5 to 2.9 days, with O/E ratio decreased from 0.64 to 0.50. Conclusions: Implementation of MPR in our surgical ICU, with an organ system-based daily goal checklist, was associated with a reduction in use of ICU resources.

285: FACTORS IMPEDING ENTERAL NUTRITION DELIVERY IN CRITICALLY ILL TRAUMA PATIENTS

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) PN was initiated, and the indication for the use of PN. Utilizing our electronic medical record, those medical record numbers were then used to determine the admitting team. Only those patients admitted by the SICU team and who were initiated on PN during their ICU stay were included in data analysis. Results: A total of 102 ventilated SICU patients were started on PN during their ICU stay. Of those, 29 (28.4%) were started on or after day 7 or, if started prior to day 7, had signs of malnutrition documented. The average total duration of PN therapy was 13.6 days. There were 16 patients (15.7%) who received PN therapy for less than 5 days. The most common reasons for the use of PN were GI complications (including, but not limited to, short gut and bowel discontinuity), TBI with assumed ileus and the use of vasopressor therapy. Conclusions: The initiation of PN in most SICU patients was due to major GI procedures and/or complications. While arguments can be made to support the use of PN in those patients, we found many reasons for PN therapy that do not fit within the recommended guidelines.