Soumitra R. Eachempati

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Clinical Practice Guideline: Endpoints of Resuscitation

STATEMENT OF THE PROBLEM Severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock (defined as inadequate tissue oxygenation to meet tissue O2 requirements), including appropriate fluid resuscitation and rapid hemostasis. Inadequate tissue oxygenation leads to anaerobic metabolism and resultant tissue acidosis. The depth and duration of shock leads to a cumulative oxygen debt. Resuscitation is complete when the oxygen debt has been repaid, tissue acidosis eliminated, and normal aerobic metabolism restored in all tissue beds. Many patients may appear to be adequately resuscitated based on normalization of vital signs, but have occult hypoperfusion and ongoing tissue acidosis (compensated shock), which may lead to organ dysfunction and death. Use of the endpoints discussed in this guideline may allow early detection and reversal of this state, with the potential to decrease morbidity and mortality from trauma. Without doubt, resuscitation from hemorrhagic shock is impossible without hemostasis. Fluid resuscitation strategies before obtaining hemostasis in patients with uncontrolled hemorrhage, usually victims of penetrating trauma, remain controversial. Withholding fluid resuscitation may lead to death from exsanguination, whereas aggressive fluid resuscitation may disrupt the clot and lead to more bleeding. “Limited,” “hypotensive,” and/or “delayed” fluid resuscitation may be beneficial, but clinical trials have yielded conflicting results. This clinical practice guideline will focus on resuscitation after achieving hemostasis and will not address the issue of uncontrolled hemorrhage further. Use of the traditional markers of successful resuscitation, including restoration of normal blood pressure, heart rate, and urine output, remain the standard of care per the Advanced Trauma Life Support Course. When these parameters remain abnormal, i.e., uncompensated shock, the need for additional resuscitation is clear. After normalization of these parameters, up to 85% of severely injured trauma victims still have evidence of inadequate tissue oxygenation based on findings of an ongoing metabolic acidosis or evidence of gastric mucosal ischemia. This condition has been described as compensated shock. Recognition of this state and its rapid reversal are critical to minimize risk of MODS or death. Consequently, better markers of adequate resuscitation for severely injured trauma victims are needed. This guideline committee sought to evaluate the current state of the literature regarding use of potential markers and related goals of resuscitation, focusing on those that have been tested in human trauma victims. This manuscript is part of an ongoing process of guideline development that includes periodic (every 3–4 years) review of the topic and the recommendations in light of new data. The goal is for these guidelines to assist clinicians in assuring adequate resuscitation of trauma patients, ultimately improving patient outcomes.

Factors influencing the development of decubitus ulcers in critically ill surgical patients.

IntroductionDecubitus ulcers confer significant morbidity to critically ill patients. We sought to determine which patient factors contributed to the formation of decubitus ulcers in our critically ill patients, and hypothesized that these ulcers occurred most often in elderly patients with lengths of stay >7 days and high severity of illness. MethodsThis study was conducted prospectively in two phases. Phase I provided an initial analysis of patients who developed decubitus ulcers in the surgical intensive care unit (ICU) of New York Weill Cornell Center from January 1, 1993, to June 1, 1997. In phase II of the study, a comparison study was made for patients with ICU length of stay (ULOS) >7 days admitted to the same ICU from January 1, 1998, to August 31, 1998. Age, APACHE III score, systemic inflammatory response syndrome (SIRS score), multiple organ dysfunction syndrome (MODS) score, admission status, days without nutrition, ULOS, mortality, days to formation of decubitus ulcers, Cornell ulcer risk score, and other demographic features were recorded. Univariate and multivariate analysis of variance were performed to analyze independent risk factors for development of decubitus ulcers;p < .05. ResultsIn phase I, 2,615 patients were admitted to surgical ICU over the study period. One hundred and one decubitus ulcers occurred (incidence 3.8%) during phase I, but the incidence of decubitus ulcers increased significantly over time to 9% (p < .01). Thirty-three decubitus ulcers occurred among the 412 patients (incidence 8.0%) during phase II. Multivariate analysis revealed that emergent admission (odds ratio [OR] 36.00, 95% confidence interval [CI] CI 0.2290–0.7694), age (OR 1.08, 95% CI 0.0026–0.0131), days in bed (OR 1.05, 95% CI −0.0013–0.0156, and days without nutrition (OR 0.51, 95% CI −0.1095–−0.0334) were independent predictors of a decubitus ulcer. ConclusionsThe incidence of decubitus ulcers is increasing in critically ill patients. Emergency ICU admission and ULOS >7 days in elderly patients confer significant risk for the formation of decubitus ulcers. Specific interventions targeting this high-risk population that may be instituted to decrease the incidence of decubitus ulcers include early nutrition, early mobilization, and possibly less noxious bedding surfaces.

Blunt vascular injuries of the head and neck: is heparinization necessary?

BACKGROUND Blunt vascular injuries to the head and neck (BHVI) represent some of the most devastating and morbid injuries seen by a trauma surgeon. This series reviewed the experience of a single institution to determine if diagnostic and therapeutic guidelines can be established for these uncommon injuries. In particular, the utility of anticoagulation in the treatment of these injuries is examined. METHODS The institutional trauma registry of a single state-designated Level I trauma center was examined for patients with BHVI. Patients were identified and their charts reviewed individually with regard to multiple data points including the type of injury, its presentation, the treatment of the injury, and the functional outcome of the patient. RESULTS Twenty-nine BHVI in 23 patients were reviewed from 1989 to 1997. No mortalities were noted. Among the injuries noted were 14 internal carotid artery dissections and 8 carotid artery tears. Thirteen patients had accompanying closed head injuries. Ten patients were diagnosed after an abnormal neurologic examination, and eight others were diagnosed after having carotid canal fractures. Heparin was started within 48 hours of injury in 4 patients (17%) and was used in a total of 12 patients (52%). No patient worsened neurologically after diagnosis independent of the use of heparin. Thirteen patients (57%) had no or minimal deficits upon discharge. CONCLUSION BHVI represent a serious cause of morbidity in the patient with multiple injuries. Patients with closed head injuries and carotid canal fractures appear most at risk. A multicenter, randomized trial involving antiplatelet therapy, full systemic anticoagulation, or observation with a long-term functional assessment is indicated to determine the optimal management of these injuries.

Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients?

BACKGROUND Ventilator-associated pneumonia (VAP) is a leading cause of mortality in critically ill patients. Although previous studies have shown that de-escalation therapy (DT) of antibiotics may decrease costs and the development of resistant pathogens, minimal data have shown its effect in surgical patients or in any patients with septic shock. We hypothesized that DT for VAP was not associated with an increased rate of recurrent pneumonia (RP) or mortality in a high acuity cohort of critically ill surgical patients. METHODS All surgical intensive care unit (SICU) patients from January 2005 to May 2007 with VAP diagnosed by quantitative bronchoalveolar lavage with a positive threshold of 10,000 CFU/mL were identified. Data collected included age, gender, Acute Physiologic and Chronic Health Evaluation Score III (A3), type of bacterial or other pathogen, antibiotics used for initial and final therapy, mortality, RP, and appropriateness of initial therapy (AIT). Patients were designated as receiving AIT, DT, or escalation of antibiotic therapy based on microbiology for their VAP. RESULTS One hundred thirty-eight of 1,596 SICU patients developed VAP during the study period (8.7%). For VAP patients, the mean Acute Physiologic and Chronic Health Evaluation III score was 82.7 points with a mean age of 63.8 years. The RP rate was 30% and did not differ between patients receiving DT (27.3%) and those who did not receive DT (35.1%). Overall mortality was 37% (55% predicted by A3 norms) and did not differ between those receiving DT (33.8%) or not (42.1%). The most common pathogens for primary VAP were methicillin-resistant Staphylococcus aureus (14%), Escherichia coli (11%), and Pseudomonas aeruginosa (9%) whereas P. aeruginosa was the most common pathogen in RP. The AIT for all VAP was 93%. De-escalation of therapy occurred in 55% of patients with AIT whereas 8% of VAP patients required escalation of antibiotic therapy. The most commonly used initial antibiotic choice was vancomycin/piperacillin-tazobactam (16%) and the final choice was piperacillin-tazobactam (20%). Logistic regression demonstrated no specific parameter correlated with development of RP. Higher A3 (Odds ratio, 1.03; 95% confidence interval, 1.01-1.05) was associated with mortality whereas lack of RP (odds ratio, 0.31; 95% confidence interval, 0.12-0.80), and AIT reduced mortality (odds ratio, 0.024; 95% confidence interval, 0.007-0.221). Age, gender, individual pathogen, individual antibiotic regimen, and the use of DT had no effect on mortality. CONCLUSION De-escalation therapy did not lead to RP or increased mortality in critically ill surgical patients with VAP. De-escalation therapy was also shown to be safe in patients with septic shock. Because of its acknowledged benefits and lack of demonstrable risks, de-escalation therapy should be used whenever possible in critically ill patients with VAP.

Defining the current negative appendectomy rate: For whom is preoperative computed tomography making an impact?

BACKGROUND Historically, the negative appendectomy rate (NAR) for patients operated on for acute appendicitis (AA) has exceeded 20%. We sought to define the current NAR with increased use of computed tomography (CT) and laparoscopy. METHODS Records of 1425 consecutive patients undergoing appendectomy for suspicion of AA during the past 7 years at a single institution were reviewed. The NAR was calculated and compared with earlier data from this institution (1995-1999). Statistical methods included the Fisher exact test and the Student t test; differences of P < .05 were considered statistically significant. RESULTS The overall NAR was 7.65% compared to 16.3% over the period 1995-1999 (P = .0001), without a change in the perforation rate. Concurrently, the rate of preoperative CT increased from 32% to 95%. CT was associated with a lesser NAR only among adult females (7.6% vs 20.8%, P = .005) but not among adult males or children. No difference in NAR was noted in comparing laparoscopic and open appendectomy. Patients without AA had a greater mean duration of symptoms and lower white blood cell count at presentation than those with AA. Most patients undergoing negative appendectomy had a CT, and more than 50% had CT interpretations that were positive for, or could not exclude, AA. CONCLUSIONS The NAR in our hospital has decreased progressively to approximately 5%. Although preoperative CT is used in almost all patients, it is only associated with a lesser NAR among adult females. False-positive CTs may contribute to the residual NAR, and further data are needed to determine whether subgroups of male or pediatric patients benefit from preoperative CT.

The Relationships of Hypocholesterolemia to Cytokine Concentrations and Mortality in Critically Ill Patients with Systemic Inflammatory Response Syndrome

BACKGROUND Decreased concentrations of total cholesterol, lipoproteins, and lipoprotein cholesterols occur early in the course of critical illness. Low cholesterol concentrations correlate with high concentrations of cytokines such as interleukin (IL)-6 and IL-10, and may be due to decreased synthesis or increased catabolism of cholesterol. Low cholesterol concentrations have been associated clinically with several adverse outcomes, including the development of nosocomial infections. The study was performed to test the hypothesis that a low cholesterol concentration predicts mortality and secondarily predicts the development of organ dysfunction in critical surgical illness. METHODS A prospective study was undertaken of 215 patients admitted to a university surgical ICU with systemic inflammatory response syndrome (SIRS). Serial blood samples were collected within 24 h of admission, as well as on the morning of days 2, 4, and 7 of the ICU stay for as long as the patients were in the ICU. Demographic data and predetermined outcomes were noted. RESULTS One hundred nine patients had at least two samples drawn and form the population for analysis. Sixty-two of the patients had three samples obtained, whereas 42 patients had four samples obtained. By univariate analysis, non-survivors were more severely ill on admission (APACHE III), more likely to have been admitted to the ICU as an emergency, more likely to develop a nosocomial infection, and more likely to develop severe organ dysfunction (MODS) (all, p < 0.05). Death was associated on day 1 with increased concentrations of sIL2R, IL-6, IL-10, and sTNFR-p75 (all, p < 0.01), but there were initially no differences in serum lipid concentrations. However, by day 2, concentrations of IL-6, IL-10, and cholesterol had decreased significantly (all, p < 0.05) from day 1 in non-survivors but not in survivors; the difference in serum cholesterol concentration persisted to day 7 (p < 0.05). Persistently elevated concentrations of IL-6 and IL-10 were observed in patients who developed severe MODS. By logistic regression, increased APACHE III score, development of a nosocomial infection, and decreased cholesterol concentration were independently associated with mortality. CONCLUSIONS Decreased serum cholesterol concentration is an independent predictor of mortality in critically ill surgical patients. Repletion of serum lipids is a feasible therapeutic approach for the management of critical illness.

Randomized, double-blind, placebo-controlled trial of effects of enteral iron supplementation on anemia and risk of infection during surgical critical illness.

BACKGROUND Critical illness is characterized by hypoferremia, iron-deficient erythropoiesis (IDE), and anemia. The relative risks and benefits of iron supplementation in this setting are unknown. METHODS Anemic, critically ill surgical patients with an expected intensive care unit length of stay (ULOS) >or= 5 days were randomized to either enteral iron supplementation (ferrous sulfate 325 mg three times daily) or placebo until hospital discharge. Outcomes included hematocrit, iron markers (i.e., serum concentrations of iron, ferritin, and erythrocyte zinc protoporphyrin [eZPP]), red blood cell (RBC) transfusion, transfusion rate (mL RBC/study day), nosocomial infection, antibiotic days, study length of stay (LOS), ULOS, and death. Iron-deficient erythropoiesis was defined as an elevated eZPP concentration. RESULTS Two hundred patients were randomized; 97 received iron, and 103 received placebo. Socio-demographics, baseline acuity, hematocrit, and iron markers were similar in the two groups. No differences were observed between the iron and placebo groups with respect to either hematocrit or iron markers following up to 28 days. However, patients treated with iron were significantly less likely to receive an RBC transfusion (29.9% vs. 44.7%, respectively; p = 0.03) and had a significantly lower transfusion rate (22.0 mL/day vs. 29.9 mL/day; p = 0.03). Subgroup analysis revealed that these differences were observed in patients with baseline IDE only. Iron and placebo groups did not differ with respect to incidence of infection (46.8% vs. 48.9%; p = 0.98), antibiotic days (14 vs. 16; p = 0.45), LOS (14 vs. 16 days; p = 0.24), ULOS (12 vs. 14 days; p = 0.69), or mortality rate (9.4% vs. 9.9%; p = 0.62). CONCLUSIONS Enteral iron supplementation of anemic, critically ill surgical patients does not increase the risk of infection and may benefit those with baseline IDE by decreasing the risk of RBC transfusion. A trial comparing enteral and parenteral iron supplementation in this setting is warranted (ClinicalTrials.gov number, NCT00450177).

Accuracy of short-duration creatinine clearance determinations in predicting 24-hour creatinine clearance in critically ill and injured patients.

BACKGROUND We hypothesized that measured 2-hour (CrCl2), 6-hour (CrCl6), and 16-hour (CrCl16) urine creatinine clearance accurately reflect measured (CrCl24meas) and calculated 24-hour CrCl (CrCl24calc) in critical illness. METHODS Urine was collected in consecutive specimens from 7 am to 9 am (CrCl2), 9 am to 3 pm (CrCl6), and 3 pm to 7 am (CrCl16) at surgical intensive care unit admission and weekly thereafter. CrCl2 and CrCl6 were added to obtain CrCl8, which was then added to CrCl16 to obtain CrCl24meas. CrCl24calc was estimated using the Cockcroft-Gault equation. RESULTS One hundred patients (45 with trauma) had 131 sets of CrCl2, CrCl6, and CrCl16. Trauma patients were younger; had a lower mean body surface area; and had higher CrCl2, CrCl6, and CrCl16 (all p < 0.0001). Correlation percentages (r2) comparing CrCl2, CrCl6, CrCl8, CrCl16, and CrCl24calc with CrCl24meas in trauma patients were 0.597, 0.760, 0.815, 0.958, and 0.670, respectively. In nontrauma patients, r2 values were 0.516, 0.693, 0.807, 0.946, and 0.649, respectively. CONCLUSION CrCl2, CrCl6, and CrCl24calc are unreliable for clinical decision making. A minimum collection period of at least 8 hours is recommended for determination of urine creatinine clearance.