James M. Hurst

Cardiac Prognosis in Noncardiac Geriatric Surgery

Predictors of perioperative complications, including cardiac death, ventricular tachycardia or fibrillation, and heart failure or myocardial infarction, were assessed in an initial study of 100 patients aged 65 years or older scheduled for elective abdominal or noncardiac thoracic surgery. Preoperative history, results of physical examination, chest roentgenogram, electrocardiogram, laboratory data, Dripps (American Society of Anesthesiologists) class, and Goldman cardiac risk index were compared with rest and exercise radionuclide ventriculograms. Thirteen patients had perioperative cardiac complications, and 6 died. Multivariate analysis showed that an inability to do 2 minutes of bicycle exercise in the supine position to raise the heart rate above 99 beats/min (sensitivity 85%, specificity 64%) gave predictive information not available from clinical or radionuclide data. On prospective testing involving 55 additional geriatric patients, inability to exercise was the only independent predictor of perioperative complications (p less than 0.05). Data from rest and exercise radionuclide ventriculography added little information for predicting perioperative cardiac risk.

Prediction of cardiac and pulmonary complications related to elective abdominal and noncardiac thoracic surgery in geriatric patients.

PURPOSE Major cardiac and pulmonary complications associated with abdominal and noncardiac thoracic surgery are a common cause of mortality and serious morbidity in elderly patients. We postulated that a simple, inexpensive bicycle exercise test could provide objective documentation of cardiopulmonary reserve and, therefore, predict perioperative pulmonary as well as cardiac complications. PATIENTS AND METHODS Prior to elective surgery, 177 patients aged 65 years or older had assessment of the clinical history, results of physical examination, electrocardiogram, chest radiograph, blood chemistries, pulmonary function test findings, supine exercise test results, Dripps classification, and Goldman cardiac risk factors. Observations in patients with and without major perioperative cardiac and/or pulmonary complications were compared using univariate analysis followed by a multivariate logistic regression procedure. RESULTS Major perioperative complications were pulmonary in 24 patients, cardiac in 25 patients, and either cardiac or pulmonary in 39 patients. By multivariate analysis, inability to perform two minutes of supine bicycle exercise raising the heart rate above 99 beats/minute was the best predictor of perioperative pulmonary, cardiac, and combined cardiopulmonary complication (p less than 0.0005). Among 108 patients who were able to achieve these exercise criteria, cardiac or pulmonary complications occurred in 10 patients (9.3%), with one death (0.9%). Among 69 patients unable to exercise satisfactorily, cardiac or pulmonary complications occurred in 29 patients (42%), with five total deaths (7.2%). CONCLUSION Objective measurement of exercise capacity by supine bicycle ergometry appears to be of clinical value for preoperative risk stratification for both pulmonary and cardiac complications prior to major elective abdominal or noncardiac thoracic surgery in elderly patients.

Prospective, Randomized Comparison of Epidural Versus Parenteral Opioid Analgesia in Thoracic Trauma

OBJECTIVE To evaluate systemic versus epidural opioid administration for analgesia in patients sustaining thoracic trauma. SUMMARY BACKGROUND DATA The authors have previously shown that epidural analgesia significantly reduces the pain associated with significant chest wall injury. Recent studies report that epidural analgesia is associated with a lower catecholamine and cytokine response in patients undergoing elective thoracotomy compared with patient-controlled analgesia (PCA). This study compares the effect of epidural analgesia and PCA on pain relief, pulmonary function, cathechol release, and immune response in patients sustaining significant thoracic trauma. METHODS Patients (ages 18 to 60 years) sustaining thoracic injury were prospectively randomized to receive epidural analgesia or PCA during an 18-month period. Levels of serum interleukin (IL)-1beta, IL-2, IL-6, IL-8, and tumor necrosis factor-alpha (TNF-alpha) were measured every 12 hours for 3 days by enzyme-linked immunosorbent assay. Urinary catecholamine levels were measured every 24 hours. Independent observers assessed pulmonary function using standard techniques and analgesia using a verbal rating score. RESULTS Twenty-four patients of the 34 enrolled completed the study. Age, injury severity score, thoracic abbreviated injury score, and length of hospital stay did not differ between the two groups. There was no significant difference in plasma levels of IL-1beta, IL-2, IL-6, or TNF-alpha or urinary catecholamines between the two groups at any time point. Epidural analgesia was associated with significantly reduced plasma levels of IL-8 at days 2 and 3, verbal rating score of pain on days 1 and 3, and maximal inspiratory force and tidal volume on day 3 versus PCA. CONCLUSIONS Epidural analgesia significantly reduced pain with chest wall excursion compared with PCA. The route of analgesia did not affect the catecholamine response. However, serum levels of IL-8, a proinflammatory chemoattractant that has been implicated in acute lung injury, were significantly reduced in patients receiving epidural analgesia on days 2 and 3. This may have important clinical implications because lower levels of IL-8 may reduce infectious or inflammatory complications in the trauma patient. Also, tidal volume and maximal inspiratory force were improved with epidural analgesia by day 3. These results demonstrate that epidural analgesia is superior to PCA in providing analgesia, improving pulmonary function, and modifying the immune response in patients with severe chest injury.

Airway pressure release ventilation during acute lung injury: a prospective multicenter trial.

ObjectiveTo evaluate the feasibility of airway pressure release ventilation (APRV) in providing ventilatory support to patients with acute lung injury of diverse etiology and mild-to-moderate severity. DesignProspective, multicenter, nonrandomized crossover trial. SettingICUs in six major referral hospitals. PatientsFifty adult patients with respiratory failure requiring mechanical ventilation and positive end-expiratory airway pressure. InterventionsAfter optimization of continuous positive airway pressure (CPAP), conventional ventilation and APRV were administered sequentially for 30 mins. During APRV, the CPAP level and airway pressure release level were adjusted to prevent hypoxemia, while the degree of ventilatory support was adjusted by altering the frequency of pressure release. Measurements and Main ResultsCirculatory and ventilatory pressures, arterial blood gases and pH, heart rate, and respiratory rate were measured. Alveolar ventilation was augmented adequately in 47 of 50 patients by APRV. Adjustment of APRV required an increase in mean CPAP from 13 ± 3 (SD) to 21 ± 9 cm H2O and a release pressure of 6 ± 5 cm H2O. This airway pressure pattern produced a mean airway pressure comparable to that pressure achieved during conventional ventilation. Failure of APRV in three patients could be attributed to an inadequate level of CPAP or an inadequate APRV rate. While maintaining oxygenation of arterial blood and circulatory function, APRV allowed a substantial (55 ± 17%; p < .0001) reduction in peak airway pressure compared with conventional positive pressure ventilation adjusted to deliver a comparable or lower level of ventilatory support. ConclusionsAPRV is a feasible alternative to conventional mechanical ventilation for augmentation of alveolar ventilation in patients with acute lung injury of mild-to-moderate severity.

Blunt carotid artery injuries

BACKGROUND Blunt carotid artery trauma remains a rare but potentially devastating injury. Early detection and treatment remain the goals of management. Our objective was to identify patients sustaining blunt carotid injuries at a regional trauma center and report on the incidence, demographics, diagnostic workup, management, and outcome. STUDY DESIGN A retrospective chart review was performed of patients sustaining blunt carotid artery injury between 1990 and 1996. RESULTS Twenty patients were identified during the 7-year period. All patients suffered blunt trauma, with motor vehicle accidents being the most common mechanism, and the internal carotid the most frequently injured vessel. Associated injuries were present in all patients, with head (65%) or chest (65%) injuries being the most common. The combination of head and chest trauma (45%) was found to be associated with a 14-fold increase in the likelihood of carotid injury. Cerebral angiography was diagnostic in all patients and the majority were treated nonoperatively with anticoagulation. Twenty percent of patients were discharged with a normal neurologic exam, while 45% left with a significant neurologic deficit. Overall mortality was 5%. CONCLUSIONS Blunt carotid injuries are rare but are associated with significant morbidity and mortality. The combination of craniofacial and chest wounds should raise the index of suspicion for blunt carotid injury. Anticoagulation was associated with the least morbidity.

Cost and complications during in-hospital transport of critically ill patients : a prospective cohort study

We prospectively studied transport of a group of 100 surgery/trauma patients and a matched control group in the ICU. APACHE II scores for the two groups were 23 +/- 6 and 20 +/- 8. During transport both groups had ECG, heart rate, blood pressure, and oxygen saturation continuously monitored. We also determined the cost and results of transport for those patients requiring diagnostic testing. There were six diagnostic tests performed: CT scan of the abdomen (39%), CT scan of the head (31%), CT scan of the chest (8%), CT scan of the cervical spine (4%), angiography (14%), and tomography (4%). Average transport time was 74 +/- 16 minutes with a range of 20-225 minutes. Physiologic changes defined as a BP +/- 20 mm Hg, heart rate +/- 20 beats/min, respiratory rate +/- 5 breaths/min, or oxygen saturation +/- 5% for 5 minutes duration occurred in 66% of transported patients and 60% of ICU patients. There were no differences in arterial blood gas levels before and during transport. In 39% of transports, the results of diagnostic testing produced a change in patient management within 48 hours. Abdominal CT scanning and angiography were associated with the highest percentage of tests leading to a management change (51% and 57%). The average charge to the patient was

Comparison of conventional mechanical ventilation and high-frequency ventilation. A prospective, randomized trial in patients with respiratory failure.

612.00 and the average cost to the hospital

Comparison of Blood Gases during Transport Using Two Methods of Ventilatory Support

452.00. Our results suggest that while physiologic changes are frequent during transport, they are also frequent in ICU patients as a consequence of the severity of illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Institutional and Individual Learning Curves for Focused Abdominal Ultrasound for Trauma: Cumulative Sum Analysis

Acute respiratory failure (ARF) following trauma or sepsis has a mortality rate of 50% to 85%. The mainstays of treatment are mechanical ventilation and positive end-expiratory pressure (PEEP). In the past decade, many reports have claimed superiority of high frequency ventilation (HFV) in the treatment of ARF. We structured a prospective randomized trial of HFV versus conventional mechanical ventilation (CMV) in the treatment of acute respiratory failure. All patients admitted to the Surgical Intensive Care Unit (SICU) were eligible for the study. On admission patients identified for being at risk of developing acute respiratory failure were randomized to receive either HFV or CMV. Patients were treated to the same therapeutic endpoint (pH greater than 7.35, PaCO2 35 to 45 torr, PaO2/FIO2 greater than 225). Daily ventilatory support, fluid and drug requirements, and cardiopulmonary variables were recorded. One hundred thirteen patients were entered into the study. Of these, 100 completed the study (HFV n = 52, CMV n = 48) and 60 developed acute respiratory failure (HFV n = 32, CMV n = 28). Patients on HFV reached the therapeutic endpoint at a lower level of continuous positive airway pressure and mean airway pressure; however there were no differences in mortality, SICU days, hospital days, incidence of barotrauma, number of blood gases, or cardiovascular interventions. This report suggests that HFV offers no concrete advantages over CMV when applied in a prospective fashion for the treatment of acute respiratory failure.

Techniques of Emergency Ventilation: A Model to Evaluate Tidal Volume, Airway Pressure, and Gastric Insufflation

Transportation of critically ill patients requiring ventilatory support represents a common, yet difficult, problem faced by clinicians. We examined 28 patients requiring transport in a prospective, randomized fashion, comparing manual ventilation with ventilation provided by a transport ventilator. Patients were ventilated to their destination with one method and returned with the alternate method. After manual ventilation, all patients showed a marked respiratory alkalosis (pH increased from 7.39 to 7.51 and PaCO2 decreased from 39 to 30 torr). After ventilation with the transport ventilator, no appreciable changes in pH or PaCO2 were seen. Oxygenation remained stable with both methods. No patient suffered hemodynamic instability, although two patients in the manual ventilation group developed cardiac arrhythmias. We conclude that when ventilatory support is required during transport, a transport ventilator produces reliable control of ventilation.