Norman Snow

Readmission of patients to the surgical intensive care unit: patient profiles and possibilities for prevention

Because experience is lacking regarding the profile of patients readmitted to a surgical ICU (SICU), we retrospectively reviewed total admissions, readmissions, patient profiles, and characteristics of illness requiring readmission to a multidisciplinary SICU. During a 1-yr period, the 721 recorded admissions included 68 readmissions for 57 patients (9.4% of the total). Eight patients had multiple readmissions. Seventy-five percent of the original admissions in these 57 patients occurred postoperatively, 9% were due to trauma, and 16% were caused by nonsurgical illness. Mortality for readmitted patients was 26%.Although 53 (78%) discharges were deemed appropriate, 62% of the patients manifested one or more of a retrospectively selected group of warning signs which might have alerted the responsible physician to alter the treatment plan. In half of these patients the reason for readmission was related to the warning sign.Readmission was related to the original disease in 65% of the incidents, while a new patient problem initiated readmission in 38%. The most common new problems were cardiopulmonary insufficiency and infection. All but one patient readmitted with pulmonary problems displayed retrospective evidence of clear warning signs before the original discharge.Recognition of SICU readmission patterns will allow more precise discharge planning: to delay discharge, to effect a lateral transfer, or to initiate a stepdown unit which may be able to help prevent costly and potentially lethal patient outcomes.

Odontogenic infection leading to cervical emphysema and fatal mediastinitis

Abstract A case of fatal mediastinitis following an odontogenic infection has been presented. The anatomic pathways through fascial planes from the mouth to the mediastinum have been reviewed. The causes of cervical emphysema when the oral cavity is an entry site have been discussed. Usually this process is benign, but the possibility that gas-forming anaerobes could be present in the emphysema and that insidious mediastinitis could concurrently occur is stressed. The presence of Bacteroides asaccharolyticus in the anaerobic cultures from the submandibular and chest abscesses, and the recovery of aerobic organisms, leads to speculation about a synergistic action between these organisms.

Aortoesophageal Fistula Secondary to Reflux Esophagitis

Abstract The case reports of 2 patients with exsanguinating hemorrhage from aortoesophageal fistula secondary to reflux esophagitis are presented. One patient underwent closure of the fistula, esophageal diversion, and subsequent esophageal substitution. A high index of suspicion based on the patients history, results of esophagoscopy, and the rate of bleeding should prompt early left thoracotomy and obliteration of the fistulous tract along with esophageal diversion.

Use of the Rhomboid Major Muscle Flap for Esophageal Repair

A 16-year-old boy sustained vehicular blunt trauma with delayed esophageal rupture that resulted in empyema and an esophagopleurocutaneous fistula. Diverting esophagostomy, gastrotomy, and transpyloric jejunostomy were performed, and these procedures permitted satisfactory nutritional support of the patient. Staged direct closure of the esophagus buttressed by a rhomboid muscle flap preserved normal esophageal function. Both clinical application and cadaver dissections have demonstrated that the rhomboid flap has an excellent blood supply and that it can be used to repair lesions on either side in the upper half of the esophagus. Because this flap is extrathoracic, it is not usually distorted by intrathoracic sepsis or previous thoracic incisions. The rhomboid major muscle flap is an excellent alternative to conventional autogenous grafts for esophageal repair.

Elimination of Lead Dislodgement by the Use of Tined Transvenous Electrodes

Pacemaker lead dislodgement has accounted for a large proportion of the postoperative complications seen after transvenous pacemaker insertion. Ninety‐two patients underwent implantation of a tined transvenous electrode over a three‐year period without a single dislodgement. Excellent thresholds were obtained and no difficulties related to electrode insertion were encountered. Tined transvenous pacemaker leads are preferred for routine use at this time. (PACE, Vol. 5, July‐August, 1982)

Tracheocarotid fistula with life-threatening hemorrhage: Report of case

Every surgical procedure carries certain potential risks and complications. Perhaps none is as dramatic or as devastating as a delayed, massive hemorrhage caused by a fistula between the trachea and a major vessel following tracheostomy. Exsanguinating hemorrhage from such an injury can occur within seconds.1 Koerte in 1879 was the first to report such a fatality in a 5-year-old patient who suffered an exsanguinating hemorrhage from a ruptured innominate (brachiocephalic) artery.2 Schlaepfer in 1924 and Brantigan in 1973 both found that the innominate artery was the vessel most frequently involved in this complication (75%).1,3 A little-known variant of this problem is involvement of the right common carotid artery. It occurs in approximately 5% of the cases. The purpose of this article is to report a case of near fatal, delayed hemorrhage from a tracheocarotid fistula in a patient with a history of laryngectomy and radiation therapy, its immediate management, and subsequent surgical repair.

Effect of sodium nitroprusside on postoperative blood loss in the cardiac surgical patient

Sodium nitroprusside (SNP) is known to inhibit platelet aggregation and has been implicated in postoperative hemorrhagic complications. Because it is a useful agent for treating postoperative hypertension and low cardiac output in the cardiac surgical patient, the authors retrospectively reviewed the course of 53 patients undergoing open heart procedures on cardiopulmonary bypass.Twenty-three patients received SNP and 30 did not. There were no differences in baseline hematological or clotting profiles, liver functions, bypass or cross-clamp times or heparin/protamine requirements between the two groups.Analysis revealed no significant differences between the groups in blood product requirements, actual mediastinal drainage, or postoperative measurements of routine clotting parameters.Although biochemical inhibition of platelet aggregation can be demonstrated, the use of SNP in the cardiac surgical patient has no apparent clinical effects which should detract from its utility in treating hypertension or low cardiac output.

Modification of myocardial test probe for epicardial pacemaker insertion.

Modification of the myocardial test probe has proven voluable in reducing the danger of myocardial laceration and has improved the reliability of epicardial threshold measurements during epicordial pacemaker insertion. Angulation of the stylet to 30° and 60° allows application of the probe at an angle perpendicular to the epicardial surface of the heart, thus reducing readoul variotion and epicardiaJ trauma.

MANAGEMENT OF NECROTIZING TRACHEOSTOMY INFECTIONS

Management of three patients with necrotizing tracheostomy infections resulting in tracheal dissolution was reviewed with respect to presentation, cause, and management. Loss of tracheal substance led to difficulty in ventilation because of a large air leak. The stomal area cavitated in two patients, denuding the right common carotid artery in one. Purulent peristomal drainage was present in all three patients. Common factors of possible etiologic significance included necrotizing polymicrobial gram-negative tracheobronchial infections caused by Pseudomonas, Enterobacter, and Klebsiella species. Also of possible importance were suture fixation of the appliance, history of neurologic injury, and closure of the incision. Immediate therapy consisted of oral intubation for ventilatory purposes and a regimen of hourly application of 1% neomycin dressings. Seven to 21 days were necessary to allow formation of sufficient granulation tissue to support replacement of the tracheostomy appliance for continued mechanical ventilation. Once spontaneous ventilation was possible, a Montgomery T-tube was inserted for long-term tracheal stenting prior to reconstruction. The two patients treated by tracheal stenting are long-term survivors. Avoidance of suture fixation of the appliance, aggressive treatment of bronchopulmonary infection, and adequate stomal toilet may help to avoid this devastating complication.