Judith M. Jenkins

Primary graft infections

An amputation rate of 8% to 52% and a mortality rate of 13% to 58% make vascular prosthetic graft infections the most dreaded complication facing a vascular surgeon. In 1978 a randomized prospective double-blind study reported a statistically significant decrease in wound infections in patients treated with prophylactic antibiotics whereas the graft infection difference only approached statistical significance. The present study reviews 2614 arterial prosthetic grafts implanted from January 1975 through June 1986. Twenty-four patients were identified as having a prosthetic graft infection, yielding an overall infection rate of 0.92%. Staphylococcus aureus was the most common organism, occurring in one third of the cases. The most common graft material was polytetrafluoroethylene (PTFE) (33%) followed by Dacron (29%), composite PTFE and Dacron (20%), and umbilical vein grafts (9%). Diabetes was a common factor in one third of the patients. Symptoms of infection were present in 15 patients (63%) within 3 months of operation, with 11 patients showing symptoms within 30 days. The longest interval between operation and onset of symptoms was 48 months. Prophylactic antibiotics were administered to 22 of the 24 patients, but in only 7 of the 22 (29.5%) were they given according to our usual practice. All patients required removal of the infected prosthesis, with limb loss in 17% and death in 17%.

Infant survival after cesarean section for trauma

HYPOTHESIS Emergency cesarean sections in trauma patients are not justified and should be abandoned. SETTING AND DESIGN A multi-institutional, retrospective cohort study was conducted of level 1 trauma centers. METHODS Trauma admissions from nine level 1 trauma centers from January 1986 through December 1994 were reviewed. Pregnant women who underwent emergency cesarean sections were identified. Demographic and clinical data were obtained on all patients undergoing a cesarean section. Fetal distress was defined by bradycardia, deceleration, or lack of fetal heart tones (FHTs). Maternal distress was defined by shock (systolic blood pressure < 90) or acute decompensation. Statistical analyses were performed. RESULTS Of the 114,952 consecutive trauma admissions, more than 441 pregnant women required 32 emergency cesarean sections. All were performed for fetal distress, maternal distress, or both. Overall, 15 (45%) of the fetuses and 23 (72%) of the mothers survived. Of 33 fetuses delivered, 13 had no FHTs and none survived. Twenty infants (potential survivors) had FHTs and an estimated gestational age (EGA) of greater than or equal to 26 weeks, and 75% survived. Infant survival was independent of maternal distress or maternal Injury Severity Score. The five infant deaths in the group of potential survivors resulted from delayed recognition of fetal distress, and 60% of these deaths were in mothers with mild to moderate injuries (Injury Severity Score < 16). CONCLUSIONS In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.

Surgical adverse events, risk management, and malpractice outcome: Morbidity and mortality review is not enough

ObjectiveTo review all admissions (age > 13) to three surgical patient care centers at a single academic medical center between January 1, 1995, and December 6, 1999, for significant surgical adverse events. Summary Background DataLittle data exist on the interrelationships between surgical adverse events, risk management, malpractice claims, and resulting indemnity payments to plaintiffs. The authors hypothesized that examination of this process would identify performance improvement opportunities overlooked by standard medical peer review; the risk of litigation would be constant across the three homogeneous patient care centers; and the risk management process would exceed the performance improvement process. MethodsData collected included patient demographics (age, gender, and employment status), hospital financials (hospital charges, costs, and financial class), and outcome. Outcome categories were medical (disability: <1 month, 1–6 months, permanent/death), legal (no legal action, settlement, summary judgment), financial (indemnity payments, legal fees, write-offs), and cause and effect analysis. Cause and effect analysis attempts to identify system failures contributing to adverse outcomes. This was determined by two independent analysts using the 17 Harvard criteria and subdividing these into subsystem causative factors. ResultsThe study group consisted of 130 patients with surgical adverse events resulting in total liabilities of

Elective bedside surgery in critically injured patients is safe and cost-effective.

8.2 million. The incidence of adverse events per 1,000 admissions across the three patient care centers was similar, but indemnity payments per 1,000 admissions varied (cardiothoracic =

Cryopreserved saphenous vein allografts for below-knee lower extremity revascularization.

30, women’s health =

Cost-effective method for bedside insertion of vena caval filters in trauma patients

90, trauma =

The evolving surgical management of recurrent carotid stenosis

520). Patient demographics were not predictive of high-risk subgroups for adverse events or litigation. In terms of medical outcome, 51 patients had permanent disability or death, accounting for 98% of the indemnity payments. In terms of legal outcome, 103 patients received no indemnity payments, 15 patients received indemnity payments, four suits remain open, and in eight cases charges were written off (

Heart rate multiscale entropy at three hours predicts hospital mortality in 3,154 trauma patients.

0.121 million). To date, no cases have been adjudicated in court. Cause and effect analysis identified 390 system failures contributing to the adverse events (mean 3.0 failures per adverse event); there were 4.7 failures per adverse event in the 15 indemnity cases. Five categories of causes accounted for 75% of the failures (patient management, n = 104; communication, n = 89; administration, n = 33; documentation, n = 32; behavior, n = 23). The current medical review process would have identified 104 of 390 systems failures (37%). ConclusionsThis study demonstrates no rational link between the tort system and the reduction of adverse events. Sixty-three percent of contributing causes to adverse events were undetected by current medical review processes. Adverse events occur at the interface between different systems or disciplines and result from multiple failures. Indemnity costs per hospital day vary dramatically by patient care center (range

Cardiac uncoupling and heart rate variability stratify ICU patients by mortality : A study of 2088 trauma patients

3.60–97.60 a day). The regionalization of healthcare is in jeopardy from the burden of high indemnity payments.

Early Loss of Heart Rate Complexity Predicts Mortality Regardless of Mechanism, Anatomic Location, or Severity of Injury in 2178 Trauma Patients

OBJECTIVE The success of elective minimally invasive surgery suggested that this concept could be adapted to the intensive care unit. We hypothesized that minimally invasive surgery could be done safely and cost-effectively at the bedside in critically injured patients. SUMMARY BACKGROUND DATA This case series, conducted between October 1991 and June 1997 at a Level I trauma center, examined bedside dilatational tracheostomy (BDT), percutaneous endoscopic gastrostomy (PEG), and inferior vena cava (IVC) filter placement. All procedures had been performed in the operating room (OR) before initiation of this study. METHODS All BDTs and PEGs were performed with intravenous general anesthesia (fentanyl, diazepam, and pancuronium) administered by the surgical team. IVC filters were placed using local anesthesia and conscious sedation. BDTs were done using a Ciaglia set, PEGs were done using a 20 Fr Flexiflow Inverta-PEG kit, and IVC filters were placed percutaneously under ultrasound guidance. Cost difference (delta cost) was defined as the difference in hospital cost and physician charges incurred in the OR as compared to the bedside. RESULTS Of 16,417 trauma admissions, 379 patients (2%) underwent 472 minimally invasive procedures (272 BDTs, 129 PEGs, 71 IVC filters). There were four major complications (0.8%). Two patients had loss of airway requiring reintubation. Two patients had an intraperitoneal leak from the gastrostomy requiring operative repair. No patient had a major complication after IVC filter placement. Total delta cost was