Khee-Siang Chan

Readmission to the intensive care unit: An indicator that reflects the potential risks of morbidity and mortality of surgical patients in the intensive care unit

PurposeTo investigate the characteristics and outcomes of surgical patients who were readmitted to the intensive care unit (ICU).MethodsThe data were collected for all readmissions to the surgical ICUs in a tertiary hospital in the year 2003.ResultsOf all the 945 ICU discharges, 110 patients (11.6%) were readmitted. They had a longer initial ICU stay (8.05 ± 7.17 vs 5.22 ± 4.95, P < 0.001) and were older and in a more severe condition than those not readmitted, but with a longer hospital stay and higher mortality rate (40% vs 3.6%, P < 0.001). A total of 26.4% of the readmission patients had an early readmission (<48 h), with a lower mortality rate than those with a late readmission (24.1% vs 45.7%, P = 0.049). A total of 46.4% of the patients were readmitted with the same diagnosis while the rest were readmitted with a new complication. Respiratory disease was the most common diagnosis for patients readmitted with a new complication (66.1%). The nonsurvivors had a significantly higher second Acute Physiology and Chronic Health Evaluation (APACHE II) score (22.1 ± 8.8 vs.14.6 ± 7.4, P < 0.001) and second Therapeutic Intervention Scoring System (TISS) score (30.1 ± 8.7 vs 24.7 ± 7.6, P = 0.001) and a longer stay in the first ICU admission (10.4 ± 9 days vs 6.4 ± 5 days, P = 0.010). A multivariate analysis showed that the first ICU length of stay and the APACHE II score at the time of readmission were the two risk factors for mortality.ConclusionThe mortality of surgical patients with ICU readmission was high with respiratory complications being the most important issue.

Antibiotic therapy for necrotizing fasciitis caused by Vibrio vulnificus: retrospective analysis of an 8 year period

OBJECTIVES To compare the effectiveness of a third-generation cephalosporin alone, a third-generation cephalosporin plus minocycline, and a fluoroquinolone in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus. METHODS A retrospective review of case notes was performed for 89 patients who presented with NF caused by V. vulnificus and underwent surgical intervention within 24 h of admission between 2003 and 2010. Data on comorbidities, clinical manifestations, laboratory studies, treatments and outcomes were extracted for analysis. These patients were grouped according to the antimicrobials prescribed: those who received only a third-generation cephalosporin (Group 1; n = 18); a third-generation cephalosporin plus minocycline (Group 2; n = 49); or a fluoroquinolone with/without minocycline (Group 3; n = 22). RESULTS The mean age of the 89 patients included in the study was 64.0 ± 12.0 years (range 33-89 years); 55% of the patients were male. There were no differences in age, sex or clinical characteristics among the three groups except that patients in Group 3 had a higher frequency of underlying chronic renal insufficiency than those in Groups 1 and 2 (P = 0.009). Groups 2 and 3 each had a significantly lower case fatality rate than Group 1 (61% in Group 1 versus 14% in Group 2, P = 0.0003; 61% in Group 1 versus 14% in Group 3, P = 0.0027), while no difference in case fatality rate was noted between Groups 2 and 3. CONCLUSIONS Our data suggested that, in addition to primary surgery, fluoroquinolones or third-generation cephalosporins plus minocycline are the best option for antibiotic treatment of NF caused by V. vulnificus.

Impact of timing of surgery on outcome of Vibrio vulnificus–related necrotizing fasciitis

BACKGROUND The aim of this study was to evaluate the impact of timing of surgery on mortality risk in patients with necrotizing fasciitis (NF) caused by Vibrio vulnificus infection. METHODS Medical records of 121 patients (mean age, 65.2 ± 11.6 years) with V vulnificus-related NF who underwent surgical intervention between July 1998 and June 2011 were collected and reviewed retrospectively. These patients were divided into 3 groups according to the time between admission and surgical treatment as follows: those who received surgical treatment less than 12 hours after admission, those who received treatment 12 to 24 hours after admission, and those who received treatment more than 24 hours after admission. Cox regression analysis was performed to assess the effect of the timing of surgery after admission on mortality risk across the 3 groups by adjusting for potential confounding covariates. RESULTS During their hospitalization, 35 patients died, yielding a case-fatality rate of 29%. After adjustment for potential confounding covariates (age, sex, duration of prodrome before admission, severity of illness on admission, the presence of primary septicemia, hepatic disorders, chronic renal insufficiency, blood pressure less than 90/60 mm Hg on admission, surgical and antibiotic modalities, and intensive care needed), patients who underwent surgery less than 12 hours after admission had a significantly lower mortality risk compared with those who had surgery either 12 to 24 hours after admission (adjusted hazard ratio [HR], .064; 95% confidence interval [CI], 1.6 × 10⁻⁷ to .25; P = .037) or more than 24 hours after admission (adjusted HR, .0043; 95% CI, 2.1 × 10⁻⁵ to .0085; P = .002). There was no difference in mortality risk between patients who underwent surgery 12 to 24 hours after admission and those who had surgery more than 24 hours after admission (P = .849). CONCLUSIONS Our data provide important clinically based evidence for the beneficial effects of surgical treatment within 12 hours of admission for V vulnificus-related NF.

The Laboratory Risk Indicator for Necrotizing Fasciitis score for discernment of necrotizing fasciitis originated from Vibrio vulnificus infections

BACKGROUND The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis (NF). Its application, however, is mainly for NF types I and II. The practical relevance of the LRINEC score for Vibro vulnificus–related skin and soft tissue infection (SSTI) was hardly ever investigated. The aim of this study was to assess the applicability of the LRINEC scoring system and to identify NF-predicting factors in patients with V. vulnificus–caused SSTI. METHODS A retrospective study was conducted, enrolling 125 consecutive patients diagnosed with V. vulnificus–related SSTI who were admitted to a teaching hospital between January 2003 and December 2011. Demographics, laboratory data, comorbidities, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic curve analyses were performed. RESULTS The mean (SD) age of the 125 patients was 63.0 (10.9) years; 58% of the patients were male. The mean (SD) LRINEC score at admission was 2.4 (1.9) points. Of the 125 patents, 72 (58%) had NF. Multivariate analysis revealed that the presence of hemorrhagic bullous lesions (p = 0.002) and higher LRINEC scores at admission (p < 0.0001) were significantly associated with the presence of NF. In addition, the area under the receiver operating characteristic curve for the LRINEC scoring model for detecting NF was 0.783 (p < 0.0001). An optimal cutoff LRINEC score of 2 or greater had a sensitivity of 71%, a specificity of 83%, and a positive predictive value of 85%, with an 11.9-fold increased risk for the presence of NF (p < 0.0001). CONCLUSION We have demonstrated that the LRINEC score and hemorrhagic bullous/blistering lesions are significant predictors of NF in patients with V. vulnificus–related SSTI. V. vulnificus–infected patients having hemorrhagic bullous/blistering lesions or with an LRINEC score of 2 or greater should be thoughtfully evaluated for the presence of NF. LEVEL OF EVIDENCE Diagnostic test study, level II.

Clinical outcomes and prognostic factors for patients with Vibrio vulnificus infections requiring intensive care: a 10-yr retrospective study.

Objective:Vibrio vulnificus infection is uncommon but potentially life-threatening. The aim of this study was to evaluate clinical outcomes and prognostic factors for patients with V. vulnificus infections admitted to an intensive care unit. Design:Retrospective study. Setting:Multidisciplinary intensive care unit in a 2300-bed teaching hospital. Patients:Eighty-five adult patients (≥18 yrs) with V. vulnificus infections who required intensive care were enrolled and reviewed during a 10-yr period. Interventions:None. Measurements and Main Results:Thirty-four of the 85 patients died, giving an intensive care unit mortality rate of 40%. The mean Acute Physiology and Chronic Health Evaluation II score on intensive care unit admission was 18.4 (95% confidence interval, 17.1–19.8). The most common underlying disease was hepatic disease (48%) followed by diabetes mellitus (22%). Multivariate analysis showed that risk factors for intensive care unit mortality were the presence of hemorrhagic bullous skin lesions/necrotizing fasciitis (relative risk, 2.4; 95% confidence interval, 1.3–4.5; p = .006), skin/soft tissue infections involving two or more limbs (relative risk, 2.5; 95% confidence interval, 1.1–5.7; p = .025), and higher Acute Physiology and Chronic Health Evaluation II scores on intensive care unit admission (relative risk, 1.2; 95% confidence interval, 1.1–1.3; p = .0001). In contrast, surgical treatment <24 hrs after arrival was inversely associated with intensive care unit mortality (relative risk, 0.35; 95% confidence interval, 0.15–0.79; p = .012). In addition, the area under the receiver operating characteristic curve for Acute Physiology and Chronic Health Evaluation II for predicting intensive care unit mortality was 0.945 (95% confidence interval, 0.873–0.983; p = .0001). An optimal cutoff Acute Physiology and Chronic Health Evaluation II score of ≥20 had a sensitivity of 97% and a specificity of 86% with a 41.4-fold increased risk of fatality (p = .0003). Conclusions:This study found that V. vulnificus-infected patients with hemorrhagic bullous skin lesions/necrotizing fasciitis, skin/soft tissue infections involving two or more limbs, or higher Acute Physiology and Chronic Health Evaluation II scores have high risks of intensive care unit mortality. However, patients receiving prompt surgical treatments within 24 hrs after admission have better prognoses.

Rapid Emergency Medicine Score as a main predictor of mortality in Vibrio vulnificus–related patients

OBJECTIVES Vibrio vulnificus causes potentially life-threatening and rapidly progressing infections. Therefore, the severity-of-illness assessment appears to be important for V vulnificus-infected patients at the time of admission. The aim of our study was to evaluate the performance of the severity-of-illness scoring model on admission in V vulnificus-infected patients. METHODS One hundred seventy-one consecutive patients (mean age: 63.1 ± 12.3 years) with V vulnificus infection who were admitted to a teaching hospital between January 1999 and June 2010 were included in the study. Demographic and clinical characteristics, illness severity on admission, treatment, and outcomes were collected for each patient and extracted for analysis. Logistic regression and receiver operating characteristic curve analyses were performed. RESULTS The mean Rapid Emergency Medicine Score (REMS) on admission was 6.5 ± 3.0 points. During hospitalization, 68 patients (40%) required intensive care. The overall case-fatality rate was 25%. In multivariate analysis, the presence of underlying liver disease (P = .002), hemorrhagic bullous lesions/necrotizing fasciitis (P = .012), and higher REMS values on admission (P < .0001) were associated with increased mortality risk; a time span <24 hours between arrival and surgical treatment was associated with a decreased mortality risk (P = .007). Additionally, the area under the receiver operating characteristic (ROC) curve for the REMS in predicting mortality risk was 0.895 (P < .0001). An optimal cut-off REMS ≥8 had a sensitivity of 81% and a specificity of 85%, with a 26.6-fold mortality risk (P < .0001) and a 12.5-fold intensive care unit admission risk (P < .0001). CONCLUSION The REMS could provide clinicians with an effective adjunct risk stratification tool for V vulnificus-infected patients.

Freestyle groin flaps: the real axial flap design and clinical application.

BackgroundThe groin flap represents a milestone in the history of flap development, since it was the first successful free cutaneous flap. Once widely used, it is currently less popular owing to the variations in vascular anatomy and the small, short pedicle. To enhance the clinical applications of the groin flap, its merits need to be promoted and its faults improved, including making some useful innovations. MethodsFrom February 2010 to February 2014, we successfully treated 35 patients with soft tissue defects in the extremities (28 patients), buttock (1 patient), and head (6 patients) using new designs in groin flaps: axial free (34 patients) or pedicle (1 patient) groin flaps. ResultsAll types of axial groin flaps survived successfully in the 2 to 38 months’ (mean, 15.6 months) follow-up. The branches of the superficial circumflex iliac artery used for the axial flap design were 2 to 4 (mean, 3.09). The flap size ranged from 1 × 1.5 cm to 11 × 30 cm. No significant complications developed in any of the patients, with the exception of 2 mildly bulky flaps. ConclusionsThis axial design of freestyle groin flaps not only preserves the earlier merits of the groin flap but also creates many new advantages: (1) reliability is greater, (2) ability to tailor the dimensions and flap paddles to the lesions, (3) options available to “lengthen” flap pedicles, and (4) local anesthesia usable with free flaps for reconstruction.

Transfusion-Associated Circulatory Overload: A Case Report

Transfusion-associated circulatory overload (TACO) may be the most under-recognized and life-threatening transfusion complication. During or within minutes to hours of transfusion, patients develop respiratory distress, and may develop orthopnea, cyanosis, tachycardia, and hypertension. Elevated blood pressure, tachycardia, and increased pulmonary wedge pressure are the typical stigmata. Treatment of TACO starts with discontinuing any ongoing transfusion and TACO usually responds to diuresis and ventilatory support.

Life-Threatening Metformin-Associated Lactic Acidosis: A Case Report

Metformin is a biguanide oral antihyperglycemic agent used to treat patients with non-insulin dependent diabetes mellitus (NIDDM). This medication is considered safe if not used in the presence of contraindications such as renal failure, liver disease, alcohol abuse, or congestive heart failure. The most significant adverse effect of metformin therapy is the development of lactic acidosis in the susceptible patients. We report a 62-year-old female with NIDDM and end stage renal disease on maintenance hemodialysis but metformin therapy was continued so life-threatening metformin-associated lactic acidosis (MALA) developed. Metformin is an effective and safe oral antihyperglycemic agent useful in the treatment of NIDDM but metformin use should be avoided in patients who have known contraindications to the agent.

The Investigation of Clinical Characteristics and Outcomes of ICU Readmission among Elderly Patients

Background: ICU readmission has been identified as a reliable performance indicator for intensive care. ICU readmission not only increases medical expenditure and prolongs the length of the hospital stay, but it also increases the mortality and morbidity of patients. However, ICU readmission of elderly patients has rarely been investigated. To address this issue, our aim was to delineate the clinical characteristics and outcomes of ICU readmission among elderly patients.Materials and Methods: Patients who were aged 65 years or above and admitted more than once to the ICU during the same hospitalization were retrospectively collected for the year 2003 from a medical ICU and a surgical ICU with a total of 79 beds at a tertiary care center. Clinical characteristics and outcomes were recorded. The risk factors associated with mortality on ICU readmission were evaluated.Results: The ICU readmission rate among the elderly patients was 12.0%. Eighty-three (56.5%) of these patients were male. The average age was 74.7 ± 6.1 years. Respiratory disease (46.3%) was the most common diagnosis among the elderly patients who were readmitted. The mortality rate was 38.1%. The non-survivors had significantly higher APACHE II scores (25.8 ± 9.5 vs. 19.1 ± 7.8, p=0.036) and therapeutic intervention scoring system (TISS) scores (29.3 ± 9.4 vs. 23.1 ± 6.7, p=0.019), but had a lower GCS (9.8 ± 5.1 vs. 11.7 ± 3.6, p＜0.001) during ICU readmission. The length of ICU stay was significantly longer for the ICU readmitted non-survivors group (11.6 ± 13.4 vs. 9.6 ± 6.7, p=0.002). In addition, the length of hospital stay was longer for the survivor group (55.4 ± 55.9 vs. 38.6 ±28.3, p=0.010). Multivariate analysis showed that the APACHE II scores (odds ratio 1.085, 95% confidence interval 1.003-1.172, p=0.041) and TISS scores (odds ratio 1.114, 95% confidence interval 1.040-1.193, p=0.002) on ICU readmission were the two risk factors associated with mortality.Conclusions: ICU readmission is associated with a high mortality and morbidity rate among elderly patients. The severity of the disease during readmission is correlated with the higher mortality of these patients. Respiratory disease was the major reason for ICU readmission. Strategies for reducing ICU readmission and improving the outcome among the elderly patients should be highlighted and studied further.