Ruben J. Azocar

The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients.

Objective:Previously, delirium has been identified as an independent risk factor for mortality in critically ill medical patients. We undertook this study to examine the relationships among medication usage, delirium, and clinical outcomes in a critically ill surgical/trauma population. Design:Prospective, multicentered, observational study. Setting:Two surgical intensive care units in level 1 trauma centers. Patients:One hundred thirty-four consecutive surgical adult patients requiring mechanical ventilation (MV) for greater than 24 hours. Interventions:Daily delirium assessment with the Confusion Assessment Method-Intensive Care Unit tool, outcomes assessment, and prospective data collection. Measurement and Main Results:Of the 134 patients who met inclusion criteria, 84 patients (63%) developed delirium at some point during their intensive care unit (ICU) stay. Delirium was associated with more MV days (9.1 vs. 4.9 days, p < 0.01), longer ICU stay (12.2 vs. 7.4 days, p < 0.01), longer hospital stay (20.6 vs. 14.7 days, p < 0.01). Additionally, greater cumulative lorazepam dose (p = 0.012), and higher cumulative fentanyl dose (p = 0.035) were administered in the delirium group. Conclusions:Delirium in the surgical/trauma ICU cohort is independently associated with more days requiring MV, longer ICU length of stay, and longer hospital length of stay. Additionally, greater amounts of lorazepam and fentanyl were administered to patients with delirium.

Persistent left superior vena cava identified after cannulation of the right subclavian vein.

IMPLICATIONS We report the case of a patient with a chest radiograph suggestive of intraarterial placement of a central venous catheter. On investigation, the catheter was located in a previously undiagnosed persistent left superior vena cava.

Acute trauma and multiple injuries in the elderly population

Purpose of review Traumatic injuries in the rapidly growing elderly population pose a significant challenge to the healthcare community. These injuries are associated with significant morbidity and mortality, and as a result cause a financial burden on the medical system. Although normal decline in physiologic reserve can provide some explanation for these poor outcomes, there is significant room for improvement. This review will summarize recent literature around the evaluation and management of elderly trauma patients with a particular focus on those with hip fractures. Recent findings It is becoming increasingly evident that customized evaluation and management of elderly trauma patients is a key factor in improving outcomes. Geriatric-specific triage and assessment criteria have been developed and initial results are encouraging. In particular, the use of frailty as an assessment tool in these patients has been shown to be an independent predictor of outcomes. Further, assessment of these tools in elderly trauma patients with hip fractures has provided a wealth of information about their use and limitations. Summary Differentiated, geriatric-specific triaging, assessment and treatment pathways in the care of elderly trauma patients will ultimately lead to improvements in outcomes. These improvements have already started to be seen in the realm of orthogeriatrics.

Conversion of an oral to nasal orotracheal intubation using an endotracheal tube exchanger.

References 1. Wilkes NJ, Woolf R, Mutch M, et al. The effects of balanced versus saline-based hetastarch and crystalloid solutions on acid base and electrolyte status and gastric mucosal perfusion in elderly surgical patients. Anesth Analg 2001;93:811–6. 2. Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg 1995;130:423–9. 3. Gan TJ, Mythen MG, Glass PSA. Intraoperative gut hypoperfusion may be a risk factor for postoperative nausea and vomiting. Brit J Anaesth 1997;78:476. 4. Wilcox CS. Regulation of renal blood flow by plasma chloride. J Clin Invest 1983;71:726–35. 5. Hansen PB, Jensen BL, Skott O. Chloride regulates afferent arteriolar contraction in response to depolarization. Hypertension 1998;32:1066–70.

Dexmedetomidine and ketamine show distinct patterns of cell degeneration and apoptosis in the developing rat neonatal brain

Abstract Objective: Early exposure to common anesthetic and sedative agents causes widespread brain cell degeneration and apoptosis in the developing rat brain, associated with persistent learning deficits in rats. This study was designed to determine whether the α2 adrenergic receptor agonist, dexmedetomidine, produces brain cell degeneration and apoptosis in postnatal day-7 rats in the same brain areas when compared to ketamine. Methods: Systemic saline, ketamine 20 mg/kg, or dexmedetomidine at 30 or 45 μg/kg were given six times to postnatal day 7 rats (n  =  6/group) every 90 min. Twenty-four hours after the initial injection, brain regions were processed and analyzed for cell degeneration using the silver stain and for apoptosis using activated caspase-3 immunohistochemistry. Results: Exposure to ketamine resulted in significant cellular degeneration and apoptosis in limbic brain regions, but nonsignificant changes in primary sensory brain regions. In contrast, dexmedetomidine produced significant cellular degeneration and apoptosis in primary sensory brain regions, but nonsignificant changes in limbic regions. Conclusions: These data show that ketamine and dexmedetomidine result in anatomically distinct patterns of cell degeneration and apoptosis in the brains of 7-day-old rat pups. The meaning and the clinical significance of these findings remain to be established.

Spontaneous pneumothorax during laparoscopic adrenalectomy secondary to a congenital diaphragmatic defect

Despite its obvious benefits, laparoscopic surgery is not free of complications. It may cause significant physiologic changes and technical mishaps. Pneumothorax has been described as a complication of almost any type of laparoscopic surgery. We report a case of tension pneumothorax during laparoscopic adrenalectomy secondary to a congenital diaphragmatic defect and describe our treatment.

Elevated Red Cell Distribution Width Is Associated With Decreased Ventilator-Free Days in Critically Ill Patients.

Introduction: Elevated red cell distribution width (RDW) is associated with mortality in a variety of respiratory conditions. Recent data also suggest that RDW is associated with mortality in intensive care unit (ICU) patients. Although respiratory failure is common in the ICU, the relationship between RDW and pulmonary outcomes in the ICU has not been previously explored. Therefore, our goal was to investigate the association of admission RDW with 30-day ventilator-free days (VFDs) in ICU patients. Methods: We performed a retrospective analysis from an ongoing prospective, observational study. Patients were recruited from medical and surgical ICUs of a large teaching hospital in Boston, Massachusetts. The RDW was assessed within 1 hour of ICU admission. Poisson regression analysis was used to investigate the association of RDW (normal: 11.5%-14.5% vs elevated: >14.5%) with 30-day VFD, while controlling for age, sex, race, body mass index, Nutrition Risk in the Critically Ill score, the presence of chronic lung disease, Pao2/Fio2 ratio, and admission levels of hemoglobin, mean corpuscular volume, phosphate, albumin, C-reactive protein, and creatinine. Results: A total of 637 patients comprised the analytic cohort. Mean RDW was 15 (standard deviation 4%), with 53% of patients in the normal range and 47% with elevated levels. Median VFD was 16 (interquartile range: 6-25) days. Poisson regression analysis demonstrated that ICU patients with elevated admission RDW were likely to have 32% lower 30-day VFDs compared to their counterparts with RDW in the normal range (incidence rate ratio: 0.68; 95% confidence interval: 0.55-0.83: P < .001). Conclusions: We observed an inverse association of RDW and 30-day VFD, despite controlling for demographics, nutritional factors, and severity of illness. This supports the need for future studies to validate our findings, understand the physiologic processes that lead to elevated RDW in patients with respiratory failure, and determine whether changes in RDW may be used to support clinical decision-making.

Geriatrics and the Perioperative Surgical Home

An ever-changing health care system with a constantly increasing aging surgical population creates both opportunities for providing improved health care as well as significant challenges. Coordinated health care initiatives are needed if one is to adequately balance the need for evidence-based improved patient outcomes and the often-associated increased costs. In this article the authors postulate that a protocol-driven, multidisciplinary approach may be a pathway for implementing an effective triple aim to health care, especially in a frail geriatric population.

Critical care and trauma considerations in the geriatric patient.

The rapid growth of the elderly population has had a significant impact on health care delivery. Critical care services have been especially affected, as admissions of older adults to intensive care units (ICU) continue to become increasingly common. Importantly, this trend is a worldwide phenomenon. Blot et al reported that admissions of patients older than the age of 75 to an ICU in a Dutch institution increased by 33% when comparing the periods between 1992 and 1996 and 2002 and 2006. Similarly, looking at data from 57 ICUs in Australia and New Zealand, Bagshaw et al found that in patients older than the age of 80 there was a 6% increase per year in ICU admissions between 2000 and 2005 and this segment of the population represented 14% of all ICU admissions. In the United States, approximately 42% to 52% of ICU admissions are geriatric patients and 60% of all intensive care days are attributed to this group. In addition, 11% of the Medicare recipients spend an average of 8 days in the ICU during the final 6 months of their lives, and about 40% of the Medicare recipients who die are admitted to the ICU during their terminal illness. These ICU stays represent approximately 25% of total Medicare expenditures. Furthermore, analysis of ICU bed utilization demonstrates that those patients older than the age of 65 occupy 25% to 50% of all beds. This larger utilization of critical care services by older adults combined with the limited

Trauma and the Geriatric Patient

Traumatic injuries to patients over the age of 65 are a major public health concern. In 2007, the Center for Disease Control and Prevention found that accidental injuries are the fifth overall cause of death in all age groups and the ninth leading cause of death in older adults. For geriatric patients there are important issues to be considered that may not apply to younger victims of traumatic injury.