Steven M. Steinberg

The gut origin septic states in blunt multiple trauma (ISS = 40) in the ICU.

The association between support elements (ventilator days = Vd, enteral protein = EnP, number of antibiotics per day = AB/d) and the magnitude of the septic state (SSS) and its bacteriologic manifestations (bacti. log) in 66 patients with blunt multiple trauma (mean HTI-ISS = 40) over 1649 days have been studied restrospectively. SSS is measured by summing the standard deviation units of change in the septic direction for the 16 measurements taken every day in the intensive care unit. Increasing Vd is tightly associated with an increasing SSS (r = +0.52), after day 10 an increasing bacti. log (r = +0.21 to +0.32), and an increasing AB/d (r = +0.26) (all p < 0.001, N = 1615–1626). The independent variables that best predicted Vd were delayed operations (DORS), day of rising EnP, and total positive blood cultures (TPC) (adj. R sq. = 0.84, F = 104, dF = 3/59). An increasing AB/d was associated with an increasing SSS (r = +0.38), increasing Vd (r = +0.26), and an increased bacti. log (r = +0.14 to +0.18) (all p < 0.001, N = 1615). Only an increased EnP was consistently associated with a reduced SSS (r = −0.38) and a reduction in bacti. log (r = −0.10 to −0.21) (all p < 0.001, N = 1626–1636). The independent variables Vd, EnP, AB/d, and TPC best predicted SSS for all surviving patients (adj. R sq. = 0.42, F = 268, dF = 4/1496). The patients who died of sepsis were not different in terms of bacti. log from those with equal Vd but were distinguished by zero EnP, high AB/d, and persistent ventilatory support. In conclusion, DORS is tightly associated with increased Vd, SSS, AB/d, and zero EnP. If Vd exceeds 10, there is an increasing bacti. log and evidence of infection probably from the gut. This responds only to increased EnP and not to AB/d. Death due to sepsis is not associated with increased bacti. log but with zero EnP and high AB/d and their consequences.

Pneumonia: incidence, risk factors, and outcome in injured patients.

One hundred thirty (44.2%) of 294 patients hospitalized for trauma and admitted to the Surgical Intensive Care Unit for mechanical ventilation developed hospital-acquired bacterial pneumonia. The predominant pathogens isolated were gram-negative enteric bacilli (72%), but there was not an increase in mortality associated with gram-negative pneumonia compared with similar patients without pneumonia. Of the seven admission risk factors univariately associated with the development of acquired bacterial pneumonia, only emergent intubation (p less than 0.001), head injury (p less than 0.001), hypotension on admission (p less than 0.001), blunt trauma as the mechanism of injury (p less than 0.001), and Injury Severity Score (p less than 0.001) remained significant after stepwise logistic regression. Not surprisingly, as mechanical ventilation is continued, the probability of pneumonia emerging increases. The consequences of hospital-acquired bacterial pneumonia are a significant seven-, five-, and two-fold increase in mechanically ventilated days, intensive care, and hospital stay, respectively. We conclude that the incidence of hospital-acquired pneumonia in injured patients admitted to the ICU for mechanical ventilation occurs in nearly half the patients, is associated with specific risk factors, and significantly increases morbidity but does not increase mortality.

Surgical Site Infection Prevention: The Importance of Operative Duration and Blood Transfusion—Results of the First American College of Surgeons–National Surgical Quality Improvement Program Best Practices Initiative

BACKGROUND Surgical site infections (SSI) continue to be a significant problem in surgery. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Best Practices Initiative compared process and structural characteristics among 117 private sector hospitals in an effort to define best practices aimed at preventing SSI. STUDY DESIGN Using standard NSQIP methodologies, we identified 20 low outlier and 13 high outlier hospitals for SSI using data from the ACS-NSQIP in 2006. Each hospital was administered a process of care survey, and site visits were conducted to five hospitals. Comparisons between the low and high outlier hospitals were made with regard to patient characteristics, operative variables, structural variables, and processes of care. RESULT Hospitals that were high outliers for SSI had higher trainee-to-bed ratios (0.61 versus 0.25, p < 0.0001), and the operations took significantly longer (128.3+/-104.3 minutes versus 102.7+/-83.9 minutes, p < 0.001). Patients operated on at low outlier hospitals were less likely to present to the operating room anemic (4.9% versus 9.7%, p=0.007) or to receive a transfusion (5.1% versus 8.0%, p=0.03). In general, perioperative policies and practices were very similar between the low and high outlier hospitals, although low outlier hospitals were readily identified by site visitors. Overall, low outlier hospitals were smaller, efficient in the delivery of care, and experienced little operative staff turnover. CONCLUSIONS Our findings suggest that evidence-based SSI prevention practices do not easily distinguish well from poorly performing hospitals. But structural and process of care characteristics of hospitals were found to have a significant association with good results.

Level I versus Level II trauma centers: an outcomes-based assessment.

OBJECTIVE Trauma centers improve outcomes compared with nontrauma centers, although the relative benefit of different levels of major trauma centers (Level I vs. Level II hospitals) remains unclear. We sought to determine whether there was a difference in the patient outcome in trauma victims taken to Level I versus Level II trauma centers. METHODS A multicenter, retrospective cohort analysis of all patients with trauma (>15 years), meeting State of Ohio trauma criteria, transported directly from the scene to a Level I or a Level II hospital (27 centers) between January 2003 and December 2006. Propensity score adjustment was used to adjust for nonrandom selection of hospital destination (I vs. II) and included age, emergency medical services (EMS) Glasgow Coma Score, comorbidities, EMS systolic blood pressure, injury type, injury severity, EMS procedures, emergency department procedures, gender, insurance status, and race. A propensity-adjusted multivariable logistic regression model was used to test the association between trauma center level and patient outcomes. Outcomes included in-hospital mortality and discharge destination (skilled nursing facility, rehabilitation center, home). RESULTS A total of 18,103 patients were included in the analysis; 10,070 (56%) were transported to a Level I center. Patients taken to Level I centers had more severe injuries, more penetrating injuries, more complications, yet similar unadjusted mortality compared with Level II centers. In adjusted analyses, patients taken to Level I hospitals had improved survival compared with Level II centers (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.56-0.98). Similar results were seen when restricting the analyses to patients with serious injuries (Injury Severity Score > 15; EMS Glasgow Coma Score < 9). Patients treated at Level I hospitals were more likely to be discharged home (OR 1.14, 95% CI 1.05-1.25), or a rehabilitation center or skilled nursing facility (OR 1.39, 95% CI 1.27-1.52). CONCLUSIONS Patients taken to Level I centers had improved survival and better functional outcomes compared with injured persons taken to Level II hospitals.

Esophageal Doppler ultrasound monitor versus pulmonary artery catheter in the hemodynamic management of critically ill surgical patients.

BACKGROUND The pulmonary artery (PA) catheter has been used to determine hemodynamic indices; however, it has recently been criticized. This study was undertaken to evaluate an esophageal Doppler monitor (EDM) as a possible replacement for PA catheter in critically ill, mechanically ventilated patients. METHODS EDM and PA catheters were placed in patients in the surgical intensive care units (n = 14, 118 matched sets of data). PA catheter and EDM measurements, including corrected flow time (FTc,) a measure of preload, were obtained. Pearson correlation (r) was analyzed to compare PA catheter and EDM measurements, and a nonlinear regression model was used to describe Starling Relationships. RESULTS Cardiac output correlated between EDM and PA catheter (r = 0.6; p < 0.001). FTc correlated more strongly with cardiac output than did pulmonary capillary wedge pressure. (FTc: r2 = 0.27; p < 0.001; cardiac output: r2 = 0.04; p = 0.06). CONCLUSION Corrected flow time is a better indicator of preload than pulmonary capillary wedge pressures. EDM seems to be at least as useful as PA catheter in managing the hemodynamic status of critically ill surgical patients.

Definitive control of mortality from severe pelvic fracture.

Within a group of 271 patients with pelvic fracture, 69 patients met criteria for severe hemorrhage. Sixty consecutive patients were treated by a combined multispecialty musculoskeletal trauma service using a protocol designed to control bleeding, rapidly diagnose and control associated injuries, as well as to prepare the patient for open reduction of the pelvic fracture, if appropriate. The pneumatic antishock garment, external fixation, and angiography were selectively used to control bleeding. Abdominal injuries were diagnosed using clinical examination and diagnostic peritoneal lavage. When lavage aspirate was grossly bloody, patients had no negative explorations. Microscopically positive lavages were associated with a 50% false-negative rate. Using the protocol, the mortality rate was 5%. Overall mortality rate was 10%. The combination of a trauma team approach and a specifically designed protocol reduces the number of deaths from pelvic fracture.

How early is early laparoscopic treatment of acute cholecystitis

BACKGROUND Despite the well-accepted success of laparoscopic cholecystectomy in elective treatment of symptomatic cholelithiasis, the efficacy and timing of this technique has been subject to some debate in the setting of acute cholecystitis. This study was undertaken to evaluate our institutions experience with early cholecystectomy as a safe, effective treatment of acute cholecystitis. METHODS Charts of all patients who had undergone laparoscopic cholecystectomy for the diagnosis of acute cholecystitis were reviewed. Patients were divided into two groups based on the length of time from onset of symptoms to surgical intervention: less than 48 hours in the early group (n = 14) and more than 48 hours in the late group (n = 31). RESULTS Comparing the two groups, the conversion rate to an open procedure was significantly less (0 versus 29%, P <0.04) in the early treated patients. Furthermore, the operative time (73 versus 96 minutes, P <0.004), postoperative hospitalization (1.2 versus 3.9 days, P <0.001), and total hospital stay (2.1 versus 5.4 days, P <0.004) were significantly reduced in patients undergoing early laparoscopic cholecystectomy. CONCLUSIONS Laparoscopic cholecystectomy performed by experienced surgeons is a safe, effective technique for treatment of acute cholecystitis. Patients treated within 48 hours of onset of symptoms experience a lower conversion rate to an open procedure, shorter operative time and reduced hospitalization.

Complications associated with pulmonary artery catheters: a comprehensive clinical review.

Care for the critically ill patient requires maintenance of adequate tissue perfusion/oxygenation. Continuous hemodynamic monitoring is frequently utilized to achieve these objectives. Pulmonary artery catheters (PAC) allow measurement of hemodynamic variables that cannot be measured reliably or continuously by less invasive means. Inherent to every medical intervention are risks associated with that intervention. This review categorizes complications associated with the PAC into four broad groups — Complications of central venous access; complications related to PAC insertion and manipulation; complications associated with short- or long-term presence of the PAC in the cardiovascular system; and errors resulting from incorrect interpretation/use of PAC-derived data. We will discuss each of these four broad categories, followed by in-depth descriptions of the most common and most serious individual complications.

Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies.

Given the increasing complexity of both the modern health care environment and the overall patient population, reduction of medical errors is a high priority task for health policy makers and medical/surgical community alike. The problem of retained surgical foreign bodies (RSFB) has existed ever since the humans first performed surgical procedures. Retained surgical foreign bodies continue to be a significant problem with an incidence between 0.3 and 1.0 per 1,000 abdominal operations. Retained surgical foreign bodies have the potential to cause harm to the patient and carry profound professional and medico-legal consequences to surgical trainees, surgical practitioners, hospitals, and health systems. Currently, there are no known methods of entirely eliminating the occurrence of RSFB. In this manuscript, the authors discuss the available evidence with regards to risk factors associated with RSFB as well as methods of minimizing the incidence of RSFB. Modern technological advances designed to decrease the incidence of RSFB (radio-frequency tagging of surgical sponges) and improved perioperative patient processing (multiple ‘checks and balances’ and better provider-to-provider communication) are reviewed. The authors also explore the relationship between RSFB and surgical training with emphasis on education in early recognition, prevention, and focus on teamoriented training strategies.

Retained Surgical Items: A Problem Yet to Be Solved

BACKGROUND Retained surgical items (RSI) continue to occur. Large RSI studies are few due to low RSI frequency in single institutions and the medicolegal implications. Consequently, RSI risks are not fully defined, with discrepancies persisting among published studies. The goals of this study were to better define risk factors for RSI, to clarify previously discrepant risk factors, and to evaluate other potential contributors to RSI occurrence, such as trainee presence during an operation. STUDY DESIGN Multicenter case-match study of RSI risk factors was conducted between January 2003 and December 2009. Cases complicated by RSI were identified at participating centers using clinical quality improvement and adverse event reporting data. Case match controls (non-RSI) were selected from same or similar-type cases performed at each respective institution. Retained surgical item risk factors were evaluated by univariate and multivariate conditional logistic regression. RESULTS Fifty-nine RSIs and 118 matched controls were analyzed (RSI incidence 1 in 6,975 or 59 in 411,526). Retained surgical items occurred despite use of confirmatory x-rays (13 of 27 instances) and/or radiofrequency tagging (2 of 32 instances). Among previously discrepant results, we confirmed that body mass index, unexpected intraoperative events, and procedure duration were associated with increased RSI risk. The occurrence of any safety variance, and specifically an incorrect count at any time during the procedure, was associated with elevated RSI risk. Trainee presence was associated with 70% lower RSI risk compared with trainee absence. CONCLUSIONS Longer duration of surgery, safety variances, and incorrect counts during the procedure result in elevated RSI risk. The possible positive influence of trainee presence on RSI risk deserves additional study. Our findings highlight the need for zero tolerance for safety omissions, continued study and development of novel approaches to RSI reduction, and establishing anonymous RSI reporting systems to better track both the incidence and risks associated with this problem, which has yet to be solved.