Nanakram Agarwal

Limitations of the TRISS method for interhospital comparisons : A multihospital study

The value of the TRISS method for interhospital comparisons of trauma care was studied using data for 5,616 consecutive patients from three trauma centers and five community hospitals. Z-scores were used to compare mortality rates. Three limitations of the method were documented: 1) the lack of homogeneity within the patient subcategory of penetrating injuries, specifically between patients with gunshot versus stab wounds; 2) the inability of the TRISS method to predict the survival rate of patients suffering low falls; and 3) the inability of the TRISS method to account for multiple severe injuries to a single body part. Remedies to the first two of these limitations can be addressed within the present TRISS method. A remedy for the third requires a new method.

Routine prophylactic antifungal agents (clotrimazole, ketoconazole, and nystatin) in nontransplant/nonburned critically ill surgical and trauma patients.

A prospective, randomized study was conducted to determine if prophylactic antifungal agents prevented yeast colonization (YC) or yeast sepsis (YS), or if they diminished mortality in 292 critically ill adult (nontransplant/nonburned) surgical and trauma patients admitted to the SICU for 48 hours or longer. Patients were randomized to receive (group I) no therapy, (group II) clotrimazole 10 mg three times a day, (group III) ketoconazole 200 mg per day, or (group IV) nystatin 2 million units every 6 hours. For comparison patients were stratified by the criteria of Slotman and Burchard into high risk (> or = 3 risk factors) and low risk (< 3 risk factors). Fifty patients (17%) had yeast colonization, nine (3.1%) had yeast sepsis, and 41 (14%) died. Stepwise logistic regression analysis of yeast colonization and sepsis using the variables APACHE II scores > 10, need for ventilator support > 48 hours, and 14 risk factors (Slotman and Burchard) showed that treatment with three or more antibiotics, APACHE II > 10, and ventilatory support > 48 hours were the only three variables that were significant predictors of yeast colonization and sepsis. There was no significant difference between the four groups with regard to YC (23%, 18%, 12%, and 15%, respectively), YS (3%, 1%, 2%, and 7%, respectively), or mortality (15%, 14%, 6%, and 20%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Manipulation of ascitic fluid pressure in cirrhotics to optimize hemodynamic and renal function

Intra-abdominal pressure (IAP), measured via a transurethral catheter, hemodynamic, and renal functions were evaluated in 25 cirrhotic patients admitted to ICU with variceal bleeding, tense ascites, and peripheral edema. In patients with an IAP > 25 cm H2O, a paracentesis was performed to decrease the IAP by 10 cm H2O. After paracentesis, a decrease in the IAP from 33.47 to 19.06 cm H2O (p < 0.001) resulted in a decrease in total peripheral resistance (TPR) (p < 0.01) and a significant increase in cardiac index (CI) (p < 0.001), stroke index (p < 0.001), left ventricular stroke work (LVSW) (p < 0.01), and right ventricular stroke work (p < 0.01). The therapeutic effects of paracentesis on renal function were: a decrease in BUN and serum creatinine (p < 0.001) and an increase in the creatinine clearance (Ccr) (p < 0.001), urine volume (p < 0.001), osmolar clearance (Cosm) (p < 0.001), and urine creatinine (p < 0.001) values. The IAP correlated directly with the TPR (r = +0.35, p < 0.01) and inversely with the CI (r = −0.39, p < 0.001) and LVSW (r = −0.37, p < 0.001) in the 126 studies of IAP performed with the 25 patients. IAP also correlated directly with BUN (r = 0.40, p < 0.001), serum creatinine (r = 0.28, p < 0.01), and free water clearance (CH2O) (r = 0.3, p < 0.001); IAP correlated negatively with Ccr (r = −0.54, p < 0.001) and Cosm (r = −0.43, p < 0.001). In critically ill cirrhotic patients, IAP, when measured noninvasively via a bladder catheter, is an accurate and useful method to follow manipulation of ascitic fluid pressure quantitatively in order to optimize hemodynamic and renal function.

Experience with 115 civilian venous injuries.

Retrospective analysis of 115 patients with venous injuries managed at Lincoln Hospital in a 7-year period disclosed a total mortality of 15%. Retrohepatic caval injury was uniformly fatal; infrarenal caval injury was not. Fifty-six per cent of victims of truncal venoarterial injuries died. Isolated venous injury of the extremity was never lethal. Ligation of injured veins of the neck and upper extremities was well tolerated. Ligation of external iliac, or common femoral, or superficial femoral veins resulted in edema in 50% of the patients compared to 7% after repair (p less than 0.05). Venoarterial injuries of iliac or femoral-level veins resulted in 37% incidence of compartment syndrome against 5% in isolated arterial injuries (p less than 0.01). Therapeutic fasciotomy after the onset of clinically evident compartment syndrome did not prevent foot drop in any patient. We advocate that all major veins of the lower extremities be repaired with the same care as arterial injuries. Prophylactic fasciotomy for all patients with iliac or femoral venoarterial injuries should be considered as strongly as with popliteal venoarterial injuries. The caliber and patency of repaired veins must be assessed by venography at operation, and again before discharge from the hospital.

Physiologic profile monitoring in burned patients.

Physiologic profile monitoring was performed on 18 elderly patients (mean age, 71.3 +/- 11.7 years) with major burns (mean, 49% +/- 17% BSA) on days 1 to 4. Nine had associated inhalation injury. Ten patients survived more than 10 days. Degree of myocardial dysfunction in response to burn injury is unpredictable. Sixteen of the total 18 patients needed inotropic support. Cardiac output is probably a more accurate means of assessing efficacy of resuscitation than hourly urine output. Maintenance of cardiac index at higher than normal levels is a physiologic necessity. Failure of cardiac index to remain high after 3 days predicted nonsurvival in this group of patients. In presence of combined cutaneous and inhalation burn injury fluid requirement is unpredictable, and the optimum resuscitation in these patients merits further definition. Physiologic profile monitoring in these older patients is a very useful guide to the precise management of fluid resuscitation, early detection, and treatment of ventricle dysfunction, and results in improved survival.

Penetrating Injuries of the Neck: Criteria for Exploration

One hundred thirty-six patients with penetrating injuries of the neck over a 4-year period were studied prospectively. Seventy-two patients (52.9%) had no major physical signs on admission, 56 were observed without complications, and 16 had a negative exploration. Injuries below the level of the cricoid cartilage were associated with a very high mortality (12.12%). We recommend a policy of selective conservatism in the management of penetrating neck injuries.

Increased risk of colorectal cancer following breast cancer.

Identification of population groups at increased risk for colorectal cancer is important for deriving maximum benefit from screening procedures. A retrospective analysis of 7605 patients with cancer treated between 1958 to 1982 revealed that the colorectum was the site of metachronous primary in 38 patients (15 males and 23 females). The risk factor of developing the metachronous multiple primary cancer was determined by comparing the observed number of second primary malignancy with the expected number based on person years of observation, age, sex, and site specific incidence rates. Incidence of metachronous colonic cancer was twice the expected number and was the highest following a primary in the breast. This increased risk (2.0) is of equal magnitude as noted following primary colon cancer (1.7). Advanced metachronous colonic lesions were seen more often following breast cancer than following colon cancer. Since carcinoma of the breast is the leading cancer in women, it is urged that the follow-up management of such patients include the same aggressive screening program as that recommended for those with colorectal cancer.

Fatality Analysis Reporting System demonstrates association between trauma system initiatives and decreasing death rates.

BACKGROUND Trauma registries frequently do not include the deaths of patients who do not get to trauma centers (TCs). Thus, complementary methods of monitoring the impact of trauma system initiatives should be considered. The objective of this study is to use National Highway Safety Traffic Administrations Fatality Analysis Reporting System (FARS) and New York State Department of Motor Vehicles data and to study the impact of state and regional initiatives over a 10-year period in the seven-county Hudson Valley New York (HV) region with one regional TC in Westchester County (WC) and to assess its face validity. METHODS FARS data for the United States (US), New York State (NY), the HV region, and WC were analyzed from 1987 to 1996. Trauma system initiatives included the following. Statewide: (1) TC standards (1989), (2) TC designation and funding (1990), (3) State Trauma Advisory Committee (1991), (4) BLS triage protocol and trauma registry (1993), and (5) quality improvement site surveys (1994). Regional: (1) one regional and two area TCs (1990), (2) helicopter services (1992 and 1994), (3) two additional area TCs, and (4) E 911 in all three counties (1995). The results were presented to the New York State Trauma Advisory Committee. RESULTS Although nationally motor vehicle crash deaths/100,000 persons have plateaued since 1991, trauma system initiatives have been temporally associated with death rates continuing to diminish in New York, the HV, and WC. From 1987 to 1996, the HV death rate dropped from 17.00 to 9.45, a 44% drop; and the WC rate dropped from 12.51 to 7.05, a 44% drop compared with United States death rate drop of 16% (p < 0.005). The percentage of seriously injured trauma patients going to the trauma centers increased from 53% in 1990 to 72% in 1995 (p < 0.001). The STAC felt that the data reflected in part effects of New York State trauma system initiatives. CONCLUSION The drops in motor vehicle crash death rates may reflect injury prevention as well as trauma system initiatives. Thus, although FARS and New York State Department of Motor Vehicles data cannot establish cause and effect relationships, it can monitor the aggregated impact of multiple initiatives. Taken together with increasing percentages of seriously injured trauma patients going to trauma centers and comparisons with national FARS data, the association of decreasing deaths with the implementation of a trauma system seems to have face validity.

Factors influencing DRG 210 (Hip fracture) reimbursement

The effect of prospective payment system (PPS) on reducing cost and quality of care is still unknown. Fifty-two patients (mean +/- SD, 82.0 +/- 6.5 years) with hip fracture classified as DRG 210 (hip and femur procedures except major joint, age greater than 69 years and/or complication and/or comorbidity), treated by compression nail were separated into four groups: Group I--no comorbidity, no complications; Group II--no comorbidity but had complications; Group III--with comorbidity but no complications; and Group IV--with both comorbidity and complications. Compared to length of stay (LOS) in Groups I, II and III (mean 26 days), Group IV had significantly increased LOS (mean, 61.5 days) and 81% of the 16 who were day outliers (L.O.S. greater than 40 days). Patients without comorbidity (I & II) even if they did develop complications were not financial losers. Those with comorbidity appear to be high-cost patients as they invariably end up with complications (78%), and reimbursement for Group IV was significantly less, resulting in net loss of this DRG. Our finding demonstrates the importance of preventing complications in patients with comorbidity. Present DRG reimbursement guidelines do not provide sufficient attention to LOS implications of both comorbidity and complications. Ideally, they should be considered as separate factors within the DRG category.

The metabolic cost of breathing in critical surgical patients.

Twenty ventilator-dependent patients, 14 male and six female, age 47.9 +/- 14, status post polytrauma (14), emergency surgery (three), and coronary artery bypass (three) were evaluated to compare measured energy expenditure (MEE) between the intermittent mandatory ventilation mode (IMV) and assist mode ventilation (AMV) utilizing indirect calorimetry. The MEE was then compared to the predicted basal energy expenditure (PEE) utilizing the Harris-Benedict equation (HBE) and appropriate correction factors dependent on disease and injury status (mean 1.65 +/- 0.24). The mean oxygen consumption (VO2) (IMV) was 347.5 +/- 54.6 ml/min; (VO2) (AMV) was 307.1 +/- 51.4 ml/min (p less than 0.001). The mean MEE (IMV) was 2,380 +/- 369 kcal/day; MEE (AMV) was 2,128 +/- 342 kcal/day (p less than 0.05). The mean predicted energy expenditure (PEE) was 2,731 +/- 416 kcal/day. The IMV mode required 11.6% more pulmonary work when compared to AMV (VO2 IMV - VO2 AMV). The PEE overestimated caloric needs in ventilator-dependent patients by 12.8% on IMV and 22.1% on AMV. The MEE (IMV) required 10.7% more energy than MEE (AMV). Assist mode ventilation resulted in decreased work of breathing and decreased energy expenditure, and the (HBE) inaccurately predicted caloric needs in ventilator dependent patients.