Heidi J. Hansen

Survey of intensive care physicians on the recognition and management of intra-abdominal hypertension and abdominal compartment syndrome*

Objective:To assess current understanding and clinical management of intra-abdominal hypertension and abdominal compartment syndrome among critical care physicians. Design:A ten-question, written survey. Setting:University health sciences center. Subjects:Physician members of the Society of Critical Care Medicine (SCCM). Interventions:The survey was sent to 4,538 SCCM members with a response rate of 35.7% (1622). Measurements and Main Results:Primary training, intensive care unit type, and methods for management of abdominal compartment syndrome were assessed. Surgically trained intensivists managed the highest number of abdominal compartment syndrome cases (47% managed 4–10 cases, 16% managed >10 cases). No cases were seen by 25% of medically trained and pediatric trained intensivists. Respondents agreed that bladder pressures and clinical variables were needed to diagnose abdominal compartment syndrome (70%) vs. bladder pressure (7%) or clinical variables (20%) alone. Two percent of surgical intensivists were unaware of a bladder pressure measurement procedure compared with 24% (p < .0001) of pediatric and 23% (p < .0001) of medical intensivists. Forty-two percent of respondents believed bladder pressures of 20–27 mm Hg may cause physiologic compromise. However, 25–27% of pediatric, medicine, or anesthesia trained intensivists believed that compromise occurs between 12 and 19 mm Hg compared with 18% of surgeons. No respondent believed that physiologic compromise occurred at <8 mm Hg. Thirty-eight percent of pediatric intensivists believed that physiologic compromise was patient dependent vs. 7–17% from other specialties (p < .0001; all comparisons). In managing intra-abdominal hypertension, 33% of pediatric intensivists and 19.6% of medical intensivists would never use decompression laparotomy to treat abdominal compartment syndrome compared with 3.6% of intensivists with surgical training (p < .0001; both comparisons). Conclusions:Significant variation across medical training exists in the management of intra-abdominal hypertension and abdominal compartment syndrome. A significant percentage of intensivists may be unaware of current approaches to abdominal compartment syndrome management including monitoring bladder pressures and decompression laparotomy. Future research and education are necessary to establish clear diagnostic criteria and standards for treatment of this relatively common life-threatening disease process.

Intravenous bisphosphonate–related osteonecrosis of the jaw: Long-term follow-up of 109 patients

OBJECTIVE We report long-term follow-up of patients with intravenous bisphosphonate-related osteonecrosis of the jaw (BRONJ). STUDY DESIGN Medical and dental histories, including type and duration of bisphosphonate treatment and comorbidities, were analyzed and compared with clinical course of 109 patients with BRONJ at Memorial Sloan-Kettering Cancer Center Dental Service. RESULTS Median onset of BRONJ in months was 21 (zoledronic acid), 30 (pamidronate), and 36 (pamidronate plus zoledronic acid), with a significant difference between the pamidronate plus zoledronic acid and zoledronic acid groups (P = .01; Kruskal-Wallis). The median number of doses for BRONJ onset was significantly less with zoledronic acid (n = 18) than pamidronte plus zoledronic acid (n = 36; P = .001), but not pamidronate alone (n = 29). An association between diabetes (P = .05), decayed-missing-filled teeth (P = .02), and smoking (P = .03) and progression of BRONJ was identified through χ(2) test. CONCLUSIONS This long-term follow-up of BRONJ cases enhances the literature and contributes to the knowledge of BRONJ clinical course.

Dosimetric distribution to the tooth-bearing regions of the mandible following intensity-modulated radiation therapy for base of tongue cancer

OBJECTIVES Osteoradionecrosis is a significant complication following head and neck radiotherapy. The purpose of this study was to determine the intensity-modulated radiation therapy (IMRT) dosages delivered to the tooth-bearing regions of the mandible. STUDY DESIGN A total of 28 patients with base of tongue cancer with the following stages: T1-2/N2-3 (n = 10), T3-4/N2-3 (n = 10), and T1-4/N0 (n = 8), treated with IMRT, were included. Average mean and maximum doses were calculated for the anterior, premolar, and molar regions. RESULTS Lower doses were seen in anterior bone with smaller tumors. Large tumors, regardless of laterality, resulted in high doses to the entire mandible, with anterior bone receiving more than 6000 cGy. CONCLUSIONS Tumor size is important in preradiation dental treatment planning. This information is important in planning pre- and postradiation dental extractions. Dosimetric analyses correlating mean and maximum point dose with clinical presentation and outcomes are needed to determine the best predictor of osteoradionecrosis risk.

Antibiotic prophylaxis in the placement of totally implanted central venous access ports

BACKGROUND Antibiotic prophylaxis during placement of implanted central venous access ports (CVAP) has not been studied. This retrospective review compared the rate of catheter-related infections (CRIs) with and without perioperative antibiotics. METHODS This was a single-center study that compared patients treated with and without a single dose of antibiotics during CVAP placement. CRIs were defined as a patient treated with antibiotics for port site induration, positive blood cultures, or suspicion of infection that led to port removal within 30 days of placement. RESULTS CVAP were placed in 459 patients, 103 of whom (22.4%) received antibiotic prophylaxis. Surgical technique and patient demographics were similar to those patients not receiving antibiotics (356). All 9 (2%) CRIs occurred in the non-prophylactic antibiotic group (P = .218), with 5 infections resulting in port removal. CONCLUSIONS Single-dose perioperative antibiotics may decrease CVAP infection rates and should be studied further in a prospective randomized trial.

A comparison of infusion volumes in the measurement of intra-abdominal pressure

Bladder pressure measurement through a foley catheter is the current standard in monitoring for intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Accurate pressure transduction requires a continuous fluid column with a small volume of transducing medium at the tip of the catheter. Infusing excessive fluid volume can falsely elevate the measured intra-abdominal pressure (IAP) due to bladder overdistention and can lead to intrinsic muscular contraction. This effect can be seen with volumes as low as 60 mL. Recent expert consensus has recommended 25 mL as the maximal infusion volume; however, 50 mL is the most commonly cited volume of infusion in the literature. The purpose of this analysis was to determine the variance between IAP values using a range of volume infusions between 10 and 60 mL. Eighteen adult, surgical intensive care unit (SICU) patients who were undergoing IAP measurement for IAH or clinically indicated monitoring were enrolled in a prospective, nontreatment study. Intra-abdominal pressure measurements were obtained with stepwise increases of injectate volume from 10 to 60 mL (in 10 mL increments). Bland-Altman analyses and receiver operating characteristic (ROC) curves were used for analysis. After analysis accounting for data correlation within patients, means and standard deviations were generated for differences between 50 mL and 10, 20, 30, 40, and 60 mL bladder infusion volumes. Bland-Altman analyses showed good agreement between measurements and no significant difference in variance (mean ≤1.35 mm Hg) between volume comparisons. The ROC curve generated for each test volume using a diagnostic pressure value for IAH (!12 mm Hg) showed that a value between 11 and 12 mm Hg gave the best combination of sensitivity and specificity for all test volumes. In SICU patients, with a clinical indication for IAP monitoring, bladder infusion volumes between 10 mL and 60 mL provide consistent IAP measurements.

Selective use of intraoperative sentinel lymph node pathological evaluation in breast cancer

BACKGROUND In breast cancer staging, the need for intraoperative sentinel lymph (SLN) evaluation is not well established. This study compares intraoperative use of touch preparation (TP), frozen section (FS), and factors that may influence the selective use of intraoperative SLN analysis. METHODS Breast cancer patients (1998-2007) undergoing SLN evaluation were retrospectively reviewed. RESULTS Of 205 SLN procedures, 157 cases underwent intraoperative evaluation, 43% (FS) and 57% (TP) with positive pathology in 21% and 20%, respectively. The false negative case rate was 16% for TP versus 12% for FS. Of T1, low-grade tumors, 9% were intraoperatively positive, versus 43% of T2-3, moderate- to high-grade tumors (P = .006). Additional positive axillary nodes were found in 43% of the higher risk patients versus 0% in the lower risk groups. CONCLUSIONS Both TP and FS are accurate for intraoperative SLN evaluation and can be selectively applied to breast cancer staging in low- and high-risk groups.

A comparison of postoperative outcomes utilizing a continuous preperitoneal infusion versus epidural for midline laparotomy

BACKGROUND Postoperative pain management with a continuous preperitoneal infusion (CPI) for locoregional anesthesia has been shown to have improved postoperative outcomes. This is the first direct comparison of CPI versus epidural infusion (EPI), both in conjunction with systemic analgesia. METHODS A retrospective review was performed of midline laparotomy cases, comparing the use of CPI with systemic patient-controlled analgesia to EPI with systemic patient-controlled analgesia for postoperative outcomes. RESULTS A total of 240 cases from 2007 to 2009 were reviewed. There were 41.3% using CPI and 58.7% with EPI. There were no differences with respect to age, body mass index, or American Society of Anesthesiologists score between CPI and EPI cases. In a multivariate model, total hospital stay was 2 days shorter for the CPI group (P < .001), and the total admission cost was less for CPI (by

Comparison of intraoperative versus delayed enteral feeding tube placement in patients undergoing a Whipple procedure

6,164; P < .001). CONCLUSIONS The use of CPI results in decreased length of hospital stay, decreased number of days with a Foley catheter, and lower hospital costs, compared with EPI use. These findings show that the routine use of CPI for pain management after laparotomy is a safe alternative to EPI.

Success in sentinel lymph node procedures in obese patients with breast cancer

BACKGROUND The intraoperative placement of an enteral feeding tube (FT) during pancreaticoduodenectomy (PD) is based on the surgeons perception of need for postoperative nutrition. Published preoperative risk factors predicting postoperative morbidity may be used to predict FT need and associated intraoperative placement. METHODS A retrospective review of patients who underwent PD during 2005-2011 was performed by querying the National Surgical Quality Improvement Program (NSQIP) database with specific procedure codes. Patients were categorized based on how many of 10 possible preoperative risk factors they demonstrated. Groups of patients with scores of ≤ 1 (low) and ≥ 2 (high), respectively, were compared for FT need, length of stay (LoS) and organ space surgical site infections (SSIs). RESULTS Of 138 PD patients, 82 did not have an FT placed intraoperatively, and, of those, 16 (19.5%) required delayed FT placement. High-risk patients were more likely to require a delayed FT (29.3%) compared with low-risk patients (9.8%) (P = 0.026). The 16 patients who required a delayed FT had a median LoS of 15.5 days, whereas the 66 patients who did not require an FT had a median LoS of 8 days (P < 0.001). CONCLUSIONS In this analysis, subjects considered as high-risk patients were more likely to require an FT than low-risk patients. Assessment of preoperative risk factors may improve decision making for selective intraoperative FT placement.

Does Ultrasonic Energy for Surgical Dissection Reduce the Incidence of Renal Transplant Lymphocele

BACKGROUND Sentinel lymph node (SLN) biopsy for axillary staging in breast cancer is technically more demanding but of added benefit in obese patients. This retrospective review compares variables and outcomes of SLN staging in obese and nonobese women. METHODS From 235 total SLN cases, demographics and clinical and procedural variables were collected and compared in obese (body mass index [BMI] of ≥ 35, n = 28) and nonobese (BMI ≤ 25 [n = 84]) patients. RESULTS Overall, the intraoperative false-negative rate was 13.6% and failure to identify SLN occurred in 2 cases (.85%). Although no differences in patient or tumor characteristics were found, obese patients had significantly lower external hotspot counts, first sentinel node counts, and fewer sentinel nodes recovered when compared with the nonobese. CONCLUSIONS SLN procedures are successful and accurate for axillary staging in obese women and avoid the added morbidity of axillary lymph node dissection in this higher risk population.