Joel R. Peerless

Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients

BACKGROUND Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients. METHODS One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment. RESULTS Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place. CONCLUSIONS The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.

Oxygen delivery is an important predictor of outcome in patients with ruptured abdominal aortic aneurysms.

OBJECTIVE The purpose of this study was to evaluate the relation of oxygen delivery (DO2) to the occurrence of multiple organ dysfunction (MOD) in patients with ruptured abdominal aortic aneurysms (AAA). SUMMARY BACKGROUND DATA Patients with ruptured AAA are at high risk for the development of MOD and death. Previous reports of high-risk general surgical patients have shown improved survival when higher levels of DO2 are achieved. METHODS Hemodynamic data were collected at 4-hour intervals on 57 consecutive patients (mean age, 70.5 years) who survived 24 hours after repair of infrarenal ruptured AAA. Patients were resuscitated to standard parameters of perfusion (pulse, blood pressure, urine output, normal base deficit). MOD was determined based on six organ systems. Standard parametric (analysis of variance, t tests) and nonparametric (chi square, Wilcoxon) tests were used to compare hemodynamic data, red blood cell requirements, colon ischemia, and organ failure for patients with and without MOD. RESULTS Patients who developed MOD had a significantly lower cardiac index and DO2 for the first 12 hours; the difference was most significant at 8 hours. Logistic regression analysis demonstrated that the strongest predictors of MOD were DO2, early onset of renal failure, and total number of red blood cells transfused. CONCLUSIONS DO2 is an earlier and better predictor of MOD after ruptured AAA than previously identified risk factors. Failure to achieve a normal DO2 in the first 8 hours after repair is strongly associated with the development of MOD and a high mortality. Strategies to restore normal DO2 may be useful to improve outcome in these high-risk patients.

Isolated cervical spine fractures in the elderly: a deadly injury.

BACKGROUND Traumatic injury in the elderly is an increasing problem and studies have shown that elderly patients (>/=65 years old) with cervical spine fractures and spinal cord injury (SCI) carry a mortality rate of 21% to 30%. However, little has been described with regard to outcomes for elderly patients with isolated cervical spine fractures (ICSF). HYPOTHESIS Outcomes for elderly patients with ICSF will be similar to elderly patients with cervical fractures and associated traumatic injuries (ATI) or SCI. METHODS A 9-year retrospective analysis was performed on all patients >/=65 years old admitted to a level I trauma center with any cervical spine fracture. Primary outcomes were defined as favorable (discharge to home or rehabilitation hospital) or unfavorable (death, discharge to a long-term acute care facility, or a skilled nursing facility). ICSF was defined as those fractures without ATI or SCI. Long-term mortality data were gathered using the Social Security Death Index. RESULTS A total of 177 patients with mean age of 78 +/- 1 and Injury Severity Score of 17 +/- 1 were evaluated. Fifty-six percent were men and falls were the most common mechanism (62%). An unfavorable outcome was seen in 56% of the study population with a mortality rate of 25%. ATIs were seen in 57% of the population and 22% had SCI. Patients with SCI had a significantly higher mortality compared with patients without SCI (38% vs. 22%, p = 0.032). However, there was no difference in unfavorable outcomes. Patients with ICSF had no differences in unfavorable outcomes compared with patients with SCI or ATI. Long-term survival analysis after discharge (mean = 2.8 years) demonstrated that patients with a favorable outcome had a significantly improved survival compared with patients with unfavorable outcomes (p < 0.001). CONCLUSION ICSFs were associated with an unfavorable outcome in the elderly population regardless of ATI or SCI. These unfavorable outcomes were also associated with long-term mortality. Strategies to reduce morbidity and mortality in this devastating injury will be essential to improve outcomes and maximize resource utilization.

Who is monitoring your infections: shouldn't you be?

BACKGROUND In the era of pay for performance and outcome comparisons among institutions, it is imperative to have reliable and accurate surveillance methodology for monitoring infectious complications. The current monitoring standard often involves a combination of prospective and retrospective analysis by trained infection control (IC) teams. We have developed a medical informatics application, the Surgical Intensive Care-Infection Registry (SIC-IR), to assist with infection surveillance. The objectives of this study were to: (1) Evaluate for differences in data gathered between the current IC practices and SIC-IR; and (2) determine which method has the best sensitivity and specificity for identifying ventilator-associated pneumonia (VAP). METHODS A prospective analysis was conducted in two surgical and trauma intensive care units (STICU) at a level I trauma center (Unit 1: 8 months, Unit 2: 4 months). Data were collected simultaneously by the SIC-IR system at the point of patient care and by IC utilizing multiple administrative and clinical modalities. Data collected by both systems included patient days, ventilator days, central line days, number of VAPs, and number of catheter-related blood steam infections (CR-BSIs). Both VAPs and CR-BSIs were classified using the definitions of the U.S. Centers for Disease Control and Prevention. The VAPs were analyzed individually, and true infections were defined by a physician panel blinded to methodology of surveillance. Using these true infections as a reference standard, sensitivity and specificity for both SIC-IR and IC were determined. RESULTS A total of 769 patients were evaluated by both surveillance systems. There were statistical differences between the median number of patient days/month and ventilator-days/month when IC was compared with SIC-IR. There was no difference in the rates of CR-BSI/1,000 central line days per month. However, VAP rates were significantly different for the two surveillance methodologies (SIC-IR: 14.8/1,000 ventilator days, IC: 8.4/1,000 ventilator days; p = 0.008). The physician panel identified 40 patients (5%) who had 43 VAPs. The SIC-IR identified 39 and IC documented 22 of the 40 patients with VAP. The SIC-IR had a sensitivity and specificity of 97% and 100%, respectively, for identifying VAP and for IC, a sensitivity of 56% and a specificity of 99%. CONCLUSIONS Utilizing SIC-IR at the point of patient care by a multidisciplinary STICU team offers more accurate infection surveillance with high sensitivity and specificity. This monitoring can be accomplished without additional resources and engages the physicians treating the patient.

Atrial septal lipomatous hypertrophy and ischemic heart disease: an unusual presentation

Lipomatous hypertrophy of the interatrial septum consists of the abnormal accumulation of fatty tissue. We report a patient with unsuspected massive lipomatous hypertrophy of the interatrial septum scheduled to undergo coronary artery surgery. This patient had experienced atrial arrhythmias and obstructive symptoms preoperatively that were ascribed to her coronary artery disease (CAD). The perioperative anesthetic and surgical management of patients with lipomatous hypertrophy of the interatrial septum and CAD is discussed.