James Rucinski

Antibiotic Administration in Patients Undergoing Common Surgical Procedures in a Community Teaching Hospital: The Chaos Continues

Abstract. The influence of recently published guidelines by the Surgical Infection Society (SIS) on current surgical practice are not well documented. The appropriateness of antibiotic administration in a cohort of surgical patients undergoing elective and emergency surgery in a department of surgery in an urban, community-based, private, 560-bed teaching hospital was retrospectively reviewed. The following were the criteria defining administration as appropriate as modified from SIS guidelines: Prophylactic use: (1) started prior to operation; (2) spectrum appropriate to the specific operation; (3) duration ≤ 24 hours. Therapeutic use: (1) started prior to operation; (2) spectrum appropriate to pathology; (3) Duration ≤ 24 hours for contamination or “resectable” infection and ≤ 5 days for established infection in the absence of clinical evidence of persisting infection. Any switchover from an appropriate agent to another appropriate or inappropriate agent in the same patient in the absence of microbiologic or clinical indication was considered inappropriate administration. We reviewed the charts of 211 randomly selected patients who underwent elective (n= 132) or emergency (n= 79) procedures during 1996. The operations included gastrectomy (n= 22), appendectomy (n= 27), open (n= 5) or laparoscopic (n= 27) cholecystectomy, colectomy (n= 28), hysterectomy (n= 8), laparotomy for intestinal obstruction (n= 11), mastectomy (n= 26), and ventral hernia repair (n= 37). A total of 17 antibiotics were used for prophylaxis and 21 for therapy. In 156 patients (74%) the administration was considered inappropriate. Eight patients in the inappropriate group developed diarrhea (two cases of Clostridium difficile-induced colitis) compared to two cases of diarrhea in the appropriate group (nonsignificant). The average duration of administration after elective and emergency operations was 3.3 and 5.7 days, respectively. The total expense for excessive duration of administration was

A technique for transplantation of ovarian cortical strips to the forearm

18,533. Many surgeons are not familiar with the spectrum of antimicrobials and often do not distinguish between prophylactic and therapeutic administration. Antibiotic usage in current surgical practice is often inappropriate, excessive, and chaotic.

Liver Enzymes Are Commonly Elevated following Laparoscopic Cholecystectomy: Is Elevated Intra-Abdominal Pressure the Cause?

OBJECTIVE To describe a forearm heterotopic ovarian transplantation technique. DESIGN Case study. SETTING Academic medical center. PATIENT(S) One patient with stage IIIB squamous cell cervical carcinoma and one patient with recurrent benign ovarian cysts. INTERVENTION(S) Preparation of thin ovarian cortical slices and transplantation under the skin of the forearm. MAIN OUTCOME MEASURE(S) Follicular development and oocyte retrieval; cyclical estradiol (E(2)) and progesterone (P(4)) production; restoration of serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels to reproductive age range. RESULT(S) Both patients were menopausal immediately after oophorectomy. The first patient developed a dominant follicle 10 weeks after transplantation, and her gonadotropin levels decreased to nonmenopausal levels. Percutaneous aspiration of ovarian follicles yielded a metaphase I (M-I) oocyte that was matured to metaphase II (M-II). The first patients graft was functional for at least 21 months. In the second patient, ovarian follicle development was detected 6 months after transplantation, and periodic menstruation occurred thereafter. Spontaneous ovulation was confirmed by a midluteal increase in her P(4) levels. Menstruation and follicle development continued for more than 2 years after the transplant. CONCLUSION(S) Heterotopic transplantation of ovarian tissue to the forearm is a simple and promising technique to restore ovarian function in women who become menopausal due to chemotherapy, surgery, or radiation.

Effect of renal function loss on NT-proBNP level variations

Background: A previous study disclosed ‘unexplained’ disturbances in postoperative liver function tests (LFTs) in up to 80% of 67 patients undergoing laparoscopic cholecystectomy (LC). No cause for these elevations was documented. Our objective was to assess the incidence, cause and clinical significance of ‘unexplained’ disturbances in liver enzymes following LC. Patients and Methods: A retrospective chart review of 270 patients who underwent LC and 64 patients undergoing open cholecystectomy (OC) was conducted. Exclusion criteria: any preoperative abnormality in bilirubin or liver enzyme levels, history of chronic liver disease, gallbladder empyema, gangrene or perforation, any evidence or suggestion of choledocholithiasis or other ductal pathology on preoperative or intraoperative imaging or surgical exploration. Preoperatively and on postoperative day 1, alanine transaminase (ALT), alkaline phosphatase and bilirubin levels were measured. There ‘unexplained’ disturbances were defined as a 50% increase from preoperative values and/or above the normal range. At LC the pneumoperitoneum was maintained at a pressure not exceeding 15 mm Hg. Results: In the groups undergoing OC and LC the respective early elevations in bilirubin occurred in 5 and 9% of patients (NS), and in alkaline phosphatase in 0 and 4% patients (NS). Postoperative ALT was elevated in 15% of patients following OC and in 34% after LC (p = 0.004). ‘Unexplained’ LFT disturbances were not associated with any morbidity. Conclusions: ‘Unexplained’ disturbances in ALT following LC occur in 34% of the patients and appear to be clinically nonsignificant. It is suggested that the reason for this phenomenon is the pneumoperitoneum-related intra-abdominal hypertension; the only variable not present in the OC group.

A systematized interdisciplinary nutritional care plan results in improved clinical outcomes

OBJECTIVE NT-proBNP level is used for the detection of acute CHF and as a predictor of survival. However, a number of factors, including renal function, may affect the NT-proBNP levels. This study aims to provide a more precise way of interpreting NT-proBNP levels based on GFR, independent of age. METHODS This study includes 247 pts in whom CHF and known confounders of elevated NT-proBNP were excluded, to show the relationship of GFR in association with age. The effect of eGFR on NT-proBNP level was adjusted by dividing 1000 x log(NT-proBNP) by eGFR then further adjusting for age in order to determine a normalized NT-proBNP value. RESULTS The normalized NT-proBNP levels were affected by eGFR independent of the age of the patient. CONCLUSION A normalizing function based on eGFR eliminates the need for an age-based reference ranges for NT-proBNP.

Measurement of granulocyte maturation may improve the early diagnosis of the septic state.

OBJECTIVE This study investigated identification and treatment of patients at-risk for malnutrition and extended inpatient length of stay. DESIGN Data were collected retrospectively from the medical records for a period of 6 months. The records were reviewed for (1) adherence to RD recommendation, (2) decreasing serum albumin during hospital stay, (3) length of hospital stay, (4) readmission within 30 days, (5) age, (6) gender, (7) past medical history, (8) primary and secondary diagnoses, (9) the presence or absence of a diet order and (10) medications. SUBJECTS AND PARTICIPANTS Medical records were reviewed for diagnoses associated with nutrition-related complications. Patients records were excluded for length of stay less than 4 days, or in-hospital death. RESULTS The mean LOS was 10 days shorter when the advice was followed (p=0.0074). CONCLUSIONS Patients at high nutritional risk have a shorter LOS and have fewer complications when the RD advice is followed.

The abdominal compartment syndrome in the critically ill patient

Abstract Background: Sepsis is a costly diagnosis in hospitalized patients. Failure to diagnose sepsis in a timely manner creates a potential financial and safety hazard. The use of transthyretin, C-reactive protein and procalcitonin measurement as early markers of systemic inflammatory response syndrome (SIRS) and sepsis in association with admission of emergency department patients to the intensive care unit (ICU) has been studied. In these studies the SIRS criteria as well as the use of an elevated neutrophil count with granulocyte precursors (left shift) have proved to be problematic. Despite the validity of procalcitonin measurement (PCT, Brahms) in the early diagnosis of SIRS the cost and time for testing are limiting considerations. Immature granulocyte (IG) measurement has been proposed as a more readily available indicator of the presence of granulocyte precursors (left shift). Methods: This study calibrates and validates the measurement of granulocyte maturation [Immature granulocytes (IG)] to the identification of sepsis, a study carried out on a Sysmex Analyzer, model XE 2100 (Kobe, Japan). The Sysmex IG parameter is a crucial measure of immature granulocyte counts and includes metamyelocytes and myelocytes, but not band neutrophils. Results and conclusions: We found agreement with previous work that designated an IG measurement cut-off of 3.2 as optimal. The analysis was then carried a step further with a multivariable discriminator.

C-Reactive Protein for the Enhanced Evaluation of the Systemic Inflammatory Response Syndrome (SIRS)

A large body of knowledge supports the concept that elevated intra-abdominal pressure (IAP) can impair physiology and organ function by producing an abdominal compartment syndrome. Complex, adverse physiologic consequences of increased IAP develop as IAP is transmitted onto adjacent spaces and cavities, affecting cardiac output, pulmonary ventilation, renal function, visceral perfusion, and cerebrospinal pressure. In the presence of raised IAP, cardiac filling pressures are elevated but transmural readings remain normal. At the bedside, IAP is best measured using the urinary-bladder catheter. Deleterious consequences of raised IAP appear gradually. At an IAP of less than 10 mm Hg, cardiac output and blood pressure are normal but hepatic arterial blood flow falls significantly. An IAP of 15 mm Hg produces adverse cardiovascular changes; an IAP of 20 mm Hg may cause renal dysfunction and oliguria; and an increase in IAP to 40 mm Hg induces anuria. In an individual patient, the effects of increased IAP are not isolated but are usually superimposed on multiple underlying and coexistent factors, most notably hypovolemia, which aggravates the effects of increased IAP. Clinical abdominal compartment syndrome in the ICU consists of a need for increased ventilatory pressure and the presence of decreased cardiac and urinary output despite apparently “normal” or increased cardiac filling pressures (ie, central venous pressure or “wedge” pressure), in association with abdominal distention. Cardiovascular, respiratory, and renal dysfunction become progressively difficult to manage unless IAP is reduced. The decision to decompress the abdomen should not be made on the basis of isolated measurements of IAP without considering the whole clinical picture. Decompression of the abdomen promptly restores normal physiology when performed in the well-resuscitated patient.

Delayed presentation of penetrating carotid injury: Two cases and a review of the literature

Introduction: An elevation in the CRP may provide an early indication of developing SIRS with progression to sepsis that is more sensitive than the standard clinical criteria of fever (or hypothermia), tachypnea, tachycardia, and leukocytosis with neutrophilia (or neutropenia). The problem of false positive rate for SIRS resides mainly in the common occurance of tachypnea and tachycardia in presenting patients, and in the confounding presence of neutrophilia without reference to good measures of a left shift. The objective of this study was to investigate how using CRP as a marker to confirm the presence of early sepsis might reduce the false positive rate inherent in the defining SIRS criteria. Materials and Methods: One hundred sixty eight patients with leukocytosis greater than 12,000 associated with a high absolute neutrophil count were studied. Those that met the inclusion criteria were analyzed for CRP response. Results: A linear correlation between CRP elevation and the defining criteria for SIRS was found except there was no correlation with absolute neutrophil count.

Blunt traumatic transection of the right common carotid artery

Background Carotid injuries secondary to a penetrating mechanism of trauma can present immediately, weeks, or even years after the initial injury. Although uncommon, these injuries are associated with significant morbidity and mortality. We present two cases of delayed presentation of carotid injury after penetrating neck trauma, both of which were managed surgically. Case report A 57-year-old male presented with a symptomatic left facial artery pseudoaneurysm two weeks after sustaining a Zone III laceration at angle of mandible. He underwent successful left neck exploration and repair of pseudoaneurysm with complete resolution of his symptoms post-operatively. A 33-year-old female with a history of penetrating right neck trauma repaired primarily 10 years prior in Russia presented with new onset left upper extremity weakness and tingling. Outpatient diagnostic workup revealed a right common carotid aneurysm which was repaired with a polytetrafluoroethylene interposition graft. The patient was discharged without residual neurologic deficits. She represented several years later with neurologic symptoms and an occluded graft. She underwent successful ligation of her graft and was discharged with complete resolution of her symptoms. Conclusion Penetrating carotid injuries can manifest in an immediate or delayed fashion. Computerized tomographic angiography appears to be an appropriate diagnostic tool. Once diagnosed, either endovascular or surgical repair may be valid treatment options.