H. Mathilda Horst

An Insulin Infusion Protocol in Critically Ill Cardiothoracic Surgery Patients

BACKGROUND: Critically ill cardiothoracic patients are prone to hyperglycemia and an increased risk of surgical site infections postoperatively. Aggressive insulin treatment is required to achieve tight glycemic control (TGC) and improve outcomes. OBJECTIVE: To examine and report on the performance of an insulin infusion protocol to maintain TGC, defined as a blood glucose level of 80–150 mg/dL, in critically ill cardiothoracic surgical patients. METHODS: A nurse-driven insulin infusion protocol was developed and initiated in postoperative cardiothoracic surgical intensive care patients with or without diabetes. In this before—after cohort study, 2 periods of measurement were performed: a 6–month baseline period prior to the initiation of the insulin infusion protocol (control group, n = 174) followed by a 6–month intervention period in which the protocol was used (TGC group, n = 168). RESULTS: Findings showed percent and time of blood glucose measurements within the TGC range (control 47% vs TGC 61%; p = 0.001), AUC of glucose exposure >150 mg/dL versus time for the first 24 hours of the insulin infusion (control 28.4 vs TGC 14.8; p < 0.001), median time to blood glucose <150 mg/dL (control 9.4 h vs TGC 2.1 h; p < 0.001), and percent blood glucose <65 mg/dL as a marker for hypoglycemia (control 9.8% vs TGC 16.7%; NS). CONCLUSIONS: An insulin infusion protocol designed to achieve a goal blood glucose range of 80–150 mg/dL efficiently and significantly improved TGC in critically ill postoperative cardiothoracic surgery patients without significantly increasing the incidence of hypoglycemia.

Necrotizing cellulitis caused by Legionella micdadei

Legionella micdadei is primarily considered a pathogen of the pulmonary tract of immunocompromised patients, the majority of whom have been renal transplant recipients. We report the case of a necrotizing soft tissue infection in a cadaveric renal transplant recipient resulting in amputation of the left arm. Only one other extrathoracic bacteriologically documented L. micdadei infection has been reported in the literature.

Hyperbilirubinemia: a risk factor for infection in the surgical intensive care unit.

BACKGROUNDnHyperbilirubinemia in intensive care unit (ICU) patients is common. We hypothesized that hyperbilirubinemia in the surgical ICU predisposes patients to infection.nnnMETHODSnPatients with bilirubin < or = 3 mg/dL were compared to patients with bilirubin > 3 mg/dL. We then compared the low bilirubin patients to high bilirubin patients who developed infection after their hyperbilirubinemia.nnnRESULTSnThere were 1,620 infections in 5,712 patients with low bilirubin (28%), compared with 284 in 409 patients in the high bilirubin group (69%, P < .001). After removing the patients in whom hyperbilirubinemia developed after infection, we found infection in 156 of 281 remaining patients (56%, P < .001). This group had a 3-fold increased risk of infection compared with low bilirubin (odds ratio [OR] 3.17, 95% confidence interval [CI] 2.48-4.03, P < .001).nnnCONCLUSIONSnThere is an increased susceptibility to infection among jaundiced surgical ICU (SICU) patients that persists even when sepsis-related hyperbilirubinemia patients are excluded.

Organ and tissue procurement in the acute care setting: Principles and practice — part 2

In this two-part series on organ and tissue procurement in the acute care setting, the procurement problem, cost-benefit analysis, organizational development and framework, approach to surviving relatives, public attitudes, and brain death certification were discussed in part 1 (January 1990). Part 2 examines evaluation, selection, maintenance, and management of the organ-tissue donor. It concludes with a discussion of disease transmission, controversial issues, and financial considerations relevant to the procurement process in the acute care setting.

A comparison of rigid -v- video thoracoscopy in the management of chest trauma

Between December 1, 1994 and April 1,1998, 44 thoracoscopic procedures were performed in 42 patients following chest injuries. Indications included exploration in 15, retained haemothorax in 10, continued bleeding after chest tube placement in 3, air leak in 5 and empyema in 11. Video thoracoscopy was used in 24 cases and rigid thoracoscopy in 20, including 14 patients in whom video thoracoscopy was contraindicated. There was no difference in the operative times, length of stay or incidence of complications. Two formal and 3 mini thoracotomies were used in the video thoracoscopy group. Three mini thoracotomies were required in the rigid thoracoscopy group. Rigid thoracoscopy is an effective tool that, in selected cases, increases the utility of thoracoscopy in the management of chest trauma and its complications.

Assessing Risk of Critical Care Complications and Mortality in the Elective Bariatric Surgery Population Using a Modified Frailty Index

BackgroundThe rate of surgical complications from bariatric procedures remains low despite an increase in volume. When serious complications occur, they are associated with an increased risk of mortality. The aim of this study is to determine if frail bariatric patients have an increased rate of Clavien level 4 and 5 complications. This study was conducted in participating hospitals in the National Surgical Quality Improvement Program (NSQIP).MethodsThe NSQIP participant use files were used to identify 104,952 patients undergoing elective bariatric procedures from 2005 to 2012. A previously described modified frailty index (mFI) was calculated based on available NSQIP variables, with a higher index suggesting more frail patients. Postoperative adverse events were stratified to Clavien levels 4 and 5 utilizing a pre-existing mapping scheme.ResultsOverall, 1xa0% of patients undergoing elective bariatric surgery experienced Clavien level 4 complications, and 0.2xa0% experienced a Clavien level 5 complication (mortality). Univariate analysis demonstrated that frailty was significant for both Clavien level 4 and 5 complications (pu2009<u20090.001). The mean mFI for those with Clavien level 4 complications, 0.15, was significantly higher than those without Clavien 4 complications, 0.09 (pu2009<u20090.001). Those experiencing mortality had a mean mFI of 0.17 compared to a mean mFI of 0.09 in those without mortality (pu2009<u20090.001). Frailty retained the highest odds ratio for both Clavien 4 and 5 complications in multivariate analysis compared to American Society of Anesthesiologist (ASA) class, age, sex, body mass index (BMI), and procedure type.ConclusionsFrailty may be used during patient selection to stratify bariatric surgery patients at high risk for critical care level complications.

Transfusion insurgency: practice change through education and evidence-based recommendations

BACKGROUNDnIn 2000, we implemented an evidence-based guideline in the surgical intensive care unit (SICU) using a transfusion threshold of hemoglobin <8 g/dL. We hypothesized that continual education on the transfusion protocol would decrease transfusions.nnnMETHODSnWe analyzed 2-month samples of admissions in even-numbered years from 1998 to 2006. Any infusion of packed red blood cells (PRBCs) was included.nnnRESULTSnWe analyzed data from 2,138 patients resulting in 5,130 transfusions. Thirty-six patients received >20 U of blood. The only difference between groups occurred in 2006 when renal failure increased. Transfusions decreased from 3.2 +/- 0.34 (SE) to 1.7 +/- 0.2. The number of patients who received blood also decreased. Mortality and length of stay (LOS) were not different among the groups. Every unit of blood transfused increased the mortality risk by 14%.nnnCONCLUSIONSnImplementation of an evidence-based transfusion guideline reduced the number of infused units and patients transfused without an increase in mortality.

Getting back to zero with nucleated red blood cells: following trends is not necessarily a bad thing.

BACKGROUNDnThe presence of nucleated red blood cells (NRBCs) has been identified as a poor prognostic indicator. We investigated the relationship of NRBC trends in patients with and without trauma.nnnMETHODSnWe retrospectively reviewed surgical intensive care unit admissions over 4 years, categorizing trauma and nontrauma patients and subdividing them into 3 groups: group A, all-zero NRBC; group B, positive NRBC value returning to zero; and group C, positive NRBC value that did not return to zero. We analyzed all groups for outcomes of length of stay and mortality.nnnRESULTSnGroup A was the largest and had the shortest length of stay and least mortality. Group C had the highest mortality rate. No statistical difference was observed with mortality.nnnCONCLUSIONSnAny positive NRBC was associated with poor outcome, and increasing NRBC was associated with increasing mortality. Trends in NRBC values showed that returning to zero was protective.

Preventative Antibiotics for Penetrating Abdominal Trauma - Single Agent or Combination Therapy?

SummaryIn this open, prospective, comparative study, 75 patients who sustained penetrating abdominal trauma were randomised to receive 1 of 3 antibiotic regimens preoperatively and for 3 to 5 days postoperatively. Group I received cefotaxime 2g 8-hourly, group II received cefoxitin 2g 6-hourly and group III received clindamycin (900mg 8-hourly) and gentamicin 3 to 5 mg/kg/day in divided doses 8-hourly. The 3 groups were not statistically different in terms of age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions or positive intra-operative cultures. Septic complications occurred in 8% of patients in group I, in 4% of group II patients and in 8% of group III patients. Cefotaxime was the least costly regimen, followed by cefoxitin, then clindamycin and gentamicin.It may be concluded that single agent therapy with a broad spectrum cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, less toxicity and lower costs.

Critical care education of surgical residents: a survey of general surgery residency programs

Abstract Critical care education may vary in general surgery residency programs because no specific guidelines for this type of training exist. In order to determine the current state of resident education in the ICU, a survey was sent to all general surgery program directors. Of the 217 programs responding, 90% had a dedicated ICU rotation. Surgical residents at the PGY-1 (27%) or PGY-2 (46%) level had a 1- (37%) or 2- (49%) month rotation in the ICU. Teaching formats included: bedside rounds (94% of programs), formal lectures (75%), patient problem-based reading (37%), assigned texts (34%), computers (20%), and videotapes (17%) or audiotapes (10%). Procedures were taught mainly by the senior house staff or faculty. Although the curriculum included a broad spectrum of critical care topics, ventilator management and respiratory failure were the only topics universally covered. Resident education in the ICU varies among general surgery programs. The data from this study establish a baseline for following the educational process as more uniform recommendations are developed and the use of novel educational techniques becomes more common.