Jack Jordan

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.

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

BACKGROUND Hyperbilirubinemia in intensive care unit (ICU) patients is common. We hypothesized that hyperbilirubinemia in the surgical ICU predisposes patients to infection. METHODS Patients 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. RESULTS There 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). CONCLUSIONS There is an increased susceptibility to infection among jaundiced surgical ICU (SICU) patients that persists even when sepsis-related hyperbilirubinemia patients are excluded.

Octogenarian Abdominal Surgical Emergencies: Not So Grim a Problem With the Acute Care Surgery Model?

BACKGROUND As the aging population continues to increase, the surgical needs of the elderly will increase. The acute care surgery model has been developed in which the trauma team also manages all general surgical emergencies to improve patient outcomes. We retrospectively reviewed our elderly acute care surgery population during the past 5 years to determine the variables affecting major abdominal surgery outcomes. METHODS Patients aged 80 years and older who received an emergent major abdominal operation by our Acute Care Surgery team between July 2000 and November 2006 were included. We assessed after-hours operations, length of stay, duration of operation, gender, comorbidities, and mortality. Administrative, operating room, and corporate databases were used for demographics, comorbidities, admission logistics, American Society of Anesthesiologists (ASA) score, and mortality. We performed SPSS, chi2, and logistic regression analyses. RESULTS A total of 183 operations were performed with a mortality of 15%. Significant predictors were ASA score and female gender, with increasing ASA scores leading to worse outcomes and women faring worse than men as an independent variable. Neither operative duration nor off-hours surgery was associated with increased mortality. CONCLUSIONS This is the first study to report mortality data and expected survival curves for major abdominal surgery in the octogenarian population. Our data prove that it is safer than previously thought to operate on the elderly. Our mortality data and survival curves provide real data for the surgeon to be able to risk stratify and discuss predicted outcomes with consultants, patients, and families.

Acute renal failure in cardiothoracic surgery patients: what is the best definition of this common and potent predictor of increased morbidity and mortality

BACKGROUND Universal agreement on criteria for acute renal failure (ARF) is lacking. The purpose of the current study was to determine which of 6 definitions for ARF best predicted clinical outcomes in postoperative cardiothoracic surgery (CTS) patients. METHODS Criteria for ARF were retrospectively applied to 1,085 CTS patients. General linear models analyzed length of stay (LOS) and ventilator days with logistic regression for mortality. RESULTS Thirty-seven percent of patients met at least 1 of 6 definitions of ARF. For each 1-mg/dL increase from the initial creatinine, LOS increased by 6.96 days, ventilator days increased by 3.58 days, and mortality increased by 2.23 times (P < .0001). CONCLUSIONS One definition that best predicted ARF was not found. ARF was a significant independent predictor of increased mortality, LOS, and ventilator days. Even small increases in creatinine correlate with clinically significant worsening of expected outcomes.

Implementation of the National Surgical Quality Improvement Program: critical steps to success for surgeons and hospitals.

The National Surgical Quality Improvement Program (NSQIP), as administered by the American College of Surgeons, became available to private sector hospitals across the United States in 2004. The program works to improve surgical outcomes by providing high-quality, risk-adjusted data to surgeons at a given hospital to stimulate discussion and define target areas for improvement. Although the NSQIP began in the early 1990s with Veterans Administration hospitals and expanded to private sector hospitals nearly 5 years ago, the “how to” process for NSQIP implementation has been left to individual institutions to manage on their own. The NSQIP was instituted at a large tertiary hospital in 2005, identifying through experience 12 critical steps to help surgeons and hospitals implement the NSQIP. (Am J Med Qual 2009;24:474-479)

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

BACKGROUND In 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. METHODS We analyzed 2-month samples of admissions in even-numbered years from 1998 to 2006. Any infusion of packed red blood cells (PRBCs) was included. RESULTS We 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%. CONCLUSIONS Implementation of an evidence-based transfusion guideline reduced the number of infused units and patients transfused without an increase in mortality.

Using Procedural Codes to Supplement Risk Adjustment: A Nonparametric Learning Approach

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program collects information related to procedures in the form of the work relative value unit (RVU) and current procedural terminology (CPT) code. We propose and evaluate a fully automated nonparametric learning approach that maps individual CPT codes to perioperative risk. STUDY DESIGN National Surgical Quality Improvement Program participant use file data for 2005-2006 were used to develop 2 separate support vector machines (SVMs) to learn the relationship between CPT codes and 30-day mortality or morbidity. SVM parameters were determined using cross-validation. SVMs were evaluated on participant use file data for 2007 and 2008. Areas under the receiver operating characteristic curve (AUROCs) were each compared with the respective AUROCs for work RVU and for standard CPT categories. We then compared the AUROCs for multivariable models, including preoperative variables, RVU, and CPT categories, with and without the SVM operation scores. RESULTS SVM operation scores had AUROCs between 0.798 and 0.822 for mortality and between 0.745 and 0.758 for morbidity on the participant use file used for both training (2005-2006) and testing (2007 and 2008). This was consistently higher than the AUROCs for both RVU and standard CPT categories (p < 0.001). AUROCs of multivariable models were higher for 30-day mortality and morbidity when SVM operation scores were included. This difference was not significant for mortality but statistically significant, although small, for morbidity. CONCLUSIONS Nonparametric methods from artificial intelligence can translate CPT codes to aid in the assessment of perioperative risk. This approach is fully automated and can complement the use of work RVU or traditional CPT categories in multivariable risk adjustment models like the National Surgical Quality Improvement Program.

Perioperative tight glycemic control: the challenge of bariatric surgery patients and the fear of hypoglycemic events.

BACKGROUND Tight glycemic control (TGC) is rapidly becoming a standard of care for all hospitalized patients. However, fear of hypoglycemia has proven a potent barrier to adoption of such initiatives by physicians and medical staff. Henry Ford Hospital has pursued aggressive glycemic control for all hospital patients. Because the initial standard TGC protocol (TGCP) was insufficient to improve glycemic control in our bariatric surgery patients, we hypothesized that a more intensive protocol would be necessary to improve glycemic control for this group. METHODS As part of an institutional quality control project involving TGC, we reviewed medical records for the bariatric surgery patients at our hospital. We divided the populations into three subgroups: prior to TGC (A), initial hospital rollout TGC (B), and intensive bariatric TGC protocol (C). Patient populations were compared using hospital administrative databases and clinical chart review. Metrics for successful glycemic control included percent hypoglycemia (glucose <50 mg/dL), in-range percent (glucose 80-150 mg/dL), mild hyperglycemia (glucose 151-250 mg/dL), and major hyperglycemia (glucose >250 mg/dL). RESULTS The percent in range for group C improved to 71% but was not statistically different from the values for groups A and B. The incidence of hyperglycemia was significantly decreased in group C as compared with groups A and B at both the minor (20% vs 31% and 27%) and major levels (1% vs 4% and 2%) (p < 0.001).There were no differences in the rates of hypoglycemia. CONCLUSION As an ongoing quality improvement process, our institution has pursued TGC for all of its patients. Glucose control in bariatric surgery patients is resistant to standard TGCPs. An initial intensive TGCP can be safely implemented in bariatric surgery patients with no increase in the number of hypoglycemic events. This work represents follow-up of several plan, do, check, act (PDCA) cycles related to improvement with a hospital-wide TGCP.

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

BACKGROUND The 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. METHODS We 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. RESULTS Group 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. CONCLUSIONS Any 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.

The differential effects of surgical harm in elderly populations. Does the adage: “they tolerate the operation, but not the complications” hold true?

BACKGROUND Elderly patients are thought to tolerate surgical complications poorly because of low physiologic reserve. The purpose of the study was to evaluate the differential effects of surgical harm in patients over 80 years old. METHODS Three years of data from a harm-reduction campaign were used to identify inpatient surgeries performed on patients older than 50. The rates of harm, death, cost, and length of stay (LOS) were analyzed using SPSS 21 (IBM, New York, NY). RESULTS A total of 22,710 patients were identified. Rates of harm and mortality increased with increasing age. Harmed patients over age 80 had increased mortality (9.5% vs 7%), but lower cost, intensive care unit days, and LOS versus those aged 50 to 80. Linear regression showed increased cost with harm (