Thomas Wasser

Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation.

BACKGROUND The purpose of this study was to determine the predictive value of an endotracheal tube cuff leak for the development of postextubation stridor and the need for reintubation. STUDY DESIGN Consecutive trauma patients who required intubation at a level I trauma center from July 1997 to July 1998 were studied prospectively. Pediatric patients and those who did not meet the standard weaning protocol criteria established by the Division of Trauma and Surgical Critical Care were excluded. Injury Severity Score, endotracheal tube size, reason for intubation, and the number of days intubated before the initial extubation attempt were recorded. At the time of extubation, the difference in exhaled tidal volume from before to after endotracheal tube cuff deflation was calculated. This number was then divided by the exhaled tidal volume before cuff deflation and was recorded as the percent cuff leak. Patients were followed for 24 hours after extubation for the development of stridor or need for reintubation. Statistical analysis to compare subgroups of patients was performed using ANOVA with Scheffé post hoc analysis. RESULTS Among the 110 patients analyzed, the most common reason for intubation was closed-head injury. Seven patients (6.4%) developed stridor alone and had a mean cuff leak of 5 8 mL (8.4% of tidal volume before cuff deflation). Six patients (5.5%) experienced stridor that required reintubation and had a mean cuff leak of 68 mL (9.2% of tidal volume before cuff deflation). Patients who developed stridor or needed reintubation had been intubated for a significantly greater length of time than those not developing stridor or requiring reintubation (2.6 versus 3.0 days, p < 0.001). There were no differences in Injury Severity Score, endotracheal tube size, or reason for intubation between these groups. CONCLUSIONS A cuff leak of less than 10% of tidal volume before cuff deflation is useful in identifying patients at risk for stridor or reintubation (96% specificity). It appears that the amount of cuff leak decreases after intubation for more than 3 days, increasing the risk of stridor and need for reintubation. This information may be helpful in identifying those patients who need treatment for laryngotracheal edema, ie, use of steroids or anesthesia during extubation, the efficacy of which remains to be determined.

Using Innovative Simulation Modalities for Civilian-Based, Chemical, Biological, Radiological, Nuclear, and Explosive Training in the Acute Management of Terrorist Victims: A Pilot Study

OBJECTIVES Chemical, biological, radiological, nuclear, and explosive (CBRNE) incidents are low frequency, high impact events that require specialized training outside of usual clinical practice. Educational modalities must recreate these clinical scenarios in order to provide realistic first responder/receiver training. METHODS High fidelity, mannequin-based (HFMB) simulation and video clinical vignettes were used to create a simulation-based CBRNE course directed at the recognition, triage, and resuscitation of contaminated victims. The course participants, who consisted of first responders and receivers, were evaluated using a 43-question pre- and post-test that employed 12 video clinical vignettes as scenarios for the test questions. The results of the pre-test were analyzed according to the various medical training backgrounds of the participants to identify differences in baseline performance. A Scheffe post-hoc test and an ANOVA were used to determine differences between the medical training backgrounds of the participants. For those participants who completed both the pre-course and post-course test, the results were compared using a paired Students t-test. RESULTS A total of 54 first responders/receivers including physicians, nurses, and paramedics completed the course. Pre-course and post-course test results are listed by learner category. For all participants who took the pre-course test (n = 67), the mean value of the test scores was 53.5 +/- 12.7%. For all participants who took the post-course test (n = 54), the mean value of the test scores was 78.3 +/-10.9%. The change in score for those who took both the pre- and post-test (n = 54) achieved statistical significance at all levels of learner. CONCLUSIONS The results suggest that video clinical vignettes and HFMB simulation are effective methods of CBRNE training and evaluation. Future studies should be conducted to determine the educational and cost-effectiveness of the use of these modalities.

Outcome of blunt thoracic aortic injury in a level I trauma center: an 8-year review.

BACKGROUND The purpose of this study was to evaluate our experience with blunt thoracic aortic injury and identify factors predictive of outcome. METHODS Hospital charts, trauma registry data, and autopsies of 64 patients with blunt thoracic aortic injury from 1988 to 1995 were reviewed. RESULTS Patients were identified and segregated based on admission physiology. Group 1 patients (n = 19) arrived in arrest. Group 2 patients (n = 10) arrived in shock with systolic BP 90. Group 3 patients (n = 35) arrived with systolic BP>90. All patients in groups 1 and 2 expired. Injury Severity Scores for nonsurvivors in group 3 (n = 12) were significantly higher than survivors. There were no significant differences when comparing time of injury to repair or arrival between groups, or in mortality or paralysis comparing repair techniques or clamp/bypass times. Double lumen endotracheal tubes caused significant operative delays compared to single lumen tubes. CONCLUSIONS Predictors of survivability were hemodynamic stability on arrival and lower Injury Severity Scores. In thoracic aortic injury patients arriving hemodynamically stable, Injury Severity Score correlated with mortality but not paralysis.

Alcohol level at head injury and subsequent psychotropic treatment during trauma critical care

Alcohol intoxication at the time of traumatic brain injury (TBI) presents many complications for critical care treatment. This is the first reported data on psychotropic dosages administered to TBI patients in the critical care setting. In this study, the blood alcohol level (BAL)-positive patients (n = 14) tended to be older (P = 0.095), have lower admission Glascow Coma Scores (P = 0.031), and spent more days on respirators (P = 0.125) than the BAL-zero patients (n = 21). The BAL-positive group received more days of narcotics and benzodiazepines with markedly higher average daily doses, not statistically significant. These results are a basis for studying relationships between medication, treatment variables, and outcomes for TBI patients and then developing specific medication guidelines.

Evidence for the Will Rogers Phenomenon in Migration of Employees to Managed Care Plans

Employees have increasing opportunities to enroll in managed care plans, and employers tend to favor these plans because of their lower costs. However, lower costs may be the result of selection of healthier patients into managed care plans. This study measured differences in health care utilization across an indemnity plan and a managed care plan, and for all employees together. We found that apparent increases in utilization in both indemnity and managed care plans disappeared when the plans were viewed together, reflecting the migration of sicker patients from indemnity plans to managed care plans.

Is early analgesia associated with delayed treatment of appendicitis

PURPOSE We sought to investigate the relationship between delay in treatment of appendicitis and early use of analgesia. BASIC PROCEDURES We designed a matched case-control study, with patients having delayed treatment of appendicitis as the cases and patients with no delay in treatment of appendicitis as controls matched for age, sex, Alvarado score, and date of diagnosis. Of 957 patients with appendicitis, there were 103 delayed cases. Matching patients were identified yielding 103 controls. MAIN FINDINGS In comparing cases and controls for early opiate use (26/103 cases, 24/103 controls), there was no association with delayed treatment (odds ratio, 1.11; P = .745; 95% confidence interval, 0.59-3.89). When comparing cases and controls for early NSAID use (29/103 cases, 17/103 controls), an association was found with delayed treatment (odds ratio, 1.98; P = .045; 95% confidence interval, 1.01-3.89). CONCLUSION For early analgesia in appendicitis, we did not find an association with delayed treatment for opiate analgesia, but there did appear to be an association with nonsteroidal anti-inflammatory analgesia.

A software program to calculate Goodman and Kruskal's gamma: a method to monitor surgical-site infection rates.

Several studies have described a need for a valid statistical methodology to facilitate interhospital and intrahospital infection rates for their operative procedures. Physician awareness of postoperative surgical-site infection rates has been demonstrated as an effective means to reduce infection rates in both high- and low-risk surgical patients. This article presents a new software program that allows for simple data entry and provides results including the gamma statistic, sample size, variance, standard error, and Z value and P value of the gamma result. This software also provides a data interpretation table, allowing infectious disease department physicians or staff to determine if a significant relation exists between operative procedure infection rates and patient risk factors.

Morbidity of Post-Coronary Artery Bypass Surgery Patients with Atrial Fibrillation Treated with Rate Control versus Sinus-Restoring Therapy

Background: Atrial fibrillation (AF) is the most common dysrhythmia encountered in the post-coronary artery bypass (post-CABG) patient, reported to occur with a frequency of 20–40%. To date, with the exception of amiodarone, there is no evidence that prophylactic therapy or therapy to restore and maintain sinus rhythm reduces the risk of adverse events associated with AF. Objective: To determine whether rate control alone is an effective method of managing post-CABG AF. Method: Prospective nonrandomized observational pilot study to assess the outcome of patients with post-CABG AF managed with rate control (group 1) or a combination of rate control and sinus-restoring therapy (group 2). Adverse events, postoperative length of stay, and persistence of AF were assessed in both groups at discharge and 30 days post-discharge. Results: Post-CABG AF was observed in 101 patients. Among the 39 patients in group 1 and 62 patients in group 2, there was an 87% spontaneous conversion rate to sinus rhythm at discharge (p = 0.99). The surgical length of stay was 6.3 days in group 1, and 8.3 days in group 2 (p = 0.01). Adverse events were observed in 2 patients (5.1%) in group 1, and 7 patients (11.3%) in group 2 (p = 0.29). Conclusion: Rate control appears to be an effective method of management of post-CABG AF patients, reducing length of hospital stay without increasing the rate of adverse events. Similar proportions of patients from both groups were in sinus rhythm at time of discharge, irrespective of therapeutic techniques.