Necrotizing pancreatitis: A review for the acute care surgeon.

BACKGROUND: Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients. METHODS: In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified. RESULTS: Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience. CONCLUSION: Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward.

Thoracoacromial artery injury after tube thoracostomy for pneumothorax.

In this case, a patient presented in a delayed fashion after blunt trauma is found to have a large left-sided pneumothorax, and tube thoracostomy is performed. After placement of the apically oriented tube, he developed haemothorax. CT imaging showed an area of questionable extravasation from the left subclavian artery, directly anterior to the thoracostomy tube. His haemothorax was refractory to adequate drainage with a new thoracostomy tube. He ultimately required angiography, coil embolisation and covered stent placement, followed by thoracoscopic evacuation of the haemothorax.

Sonographic Assessment of Intravascular Fluid Estimate (SAFE) Score by Using Bedside Ultrasound in the Intensive Care Unit.

OBJECTIVE: The objective of the study was to use an ultrasound-based numerical scoring system for assessment of intravascular fluid estimate (SAFE) and test its validity. METHODS: A prospective, observational study was carried out in the surgical intensive care unit (ICU) of an urban tertiary care teaching hospital. Patient's intravascular volume status was assessed using the standard methods of heart rate, blood pressure, central venous pressure, cardiac output, lactate and saturation of venous oxygen, and others. This was compared with assessment using bedside ultrasound evaluation of the cardiac function, inferior vena cava, lungs, and the internal jugular vein. Applying a numerical scoring system was evaluated by Fisher's exact testing and multinomial logistic model to predict the volume status based on ultrasound scores and the classification accuracy. RESULTS: 61 patients in the ICU were evaluated. 21 (34.4% of total) patients diagnosed with hypovolemia, and their ultrasound volume score was -4 in 14 (66.7%) patients, -3 in 5 (23.8%) patients, and 0 in 2 (9.5%) patients (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and -1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and -1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and -1 in 1 (5.6%) patient (p < 0.001). 18 (29.5% of total) patients diagnosed with euvolemia, and their ultrasound volume score was 0 in 11 (61.1%) patients, +1 in 4 (22.2%) patients, and -1 in 1 (5.6%) patient (. CONCLUSION: Using the SAFE scoring system to identify the IVV status in critically ill patients significantly correlates with the standard measures. A SAFE score of -4 to -2 more likely represents hypovolemia, -1 to +1 more likely represents euvolemia, and +2 to +4 more likely to be hypervolemia.

Association of Unplanned Reintubation with Higher Mortality in Old, Frail Patients: A National Surgical Quality-Improvement Program Analysis.

BACKGROUND: Unplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear. OBJECTIVE: To elucidate factors associated with increased mortality risk in patients with unplanned postoperative reintubation. DESIGN: Retrospective study. Patients older than 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Multiple regression models were used to examine the impact on mortality of factors that included the modified frailty index (mFI) we developed, American Society of Anesthesiologists (ASA) score, age decile, and days to reintubation. MAIN OUTCOME MEASURE: Mortality. RESULTS: A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). On postoperative day 1, 4434 patients were reintubated and 878 (19.8%) died. On postoperative day 7 and beyond, 6329 patients were reintubated and 2215 (35.0%) died. Increasing mFI resulted in increasing incidence of mortality (mFl of 0 = 20.5% mortality vs mFl of 0.37-0.45 = 41.7% mortality). As ASA score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality (40-49 years, 17.9% vs 80-89 years, 42.1%). After adjustment for confounding factors, mFI, ASA score, age decile, and increasing number of days to reintubation were independently and significantly associated with increased mortality in the study population. CONCLUSION: Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.

Inferior vena cava collapsibility loses correlation with internal jugular vein collapsibility during increased thoracic or intra-abdominal pressure.

PURPOSE: Point-of-care ultrasound evaluates inferior vena cava (IVC) and internal jugular vein (IJV) measurements to estimate intravascular volume status. The reliability of the IVC and IJV collapsibility index during increased thoracic or intra-abdominal pressure remains unclear. METHODS: Three phases of sonographic scanning were performed: spontaneous breathing phase, increased thoracic pressure phase via positive pressure ventilation (PPV) phase, and increased intra-abdominal pressure (IAP) phase via laparoscopic insufflation to 15 mmHg. IVC measurements were done at 1-2 cm below the diaphragm and IJV measurements were done at the level of the cricoid cartilage during a complete respiratory cycle. Collapsibility index was calculated by (max diameter - min diameter)/max diameter × 100 %. Chi square, t test, correlation procedure (CORR) and Fisher's exact analyses were completed. RESULTS: A total of 144 scans of the IVC and IJV were completed in 16 patients who underwent laparoscopic surgery. Mean age was 46 ± 15 years, with 75 % female and 69 % African-American. IVC and IJV collapsibility correlated in the setting of spontaneous breathing (r (2) = 0.86, p < 0.01). IVC collapsibility had no correlation with the IJV in the setting of PPV (r (2) = 0.21, p = 0.52) or IAP (r (2) = 0.26, p = 0.42). Maximal IVC diameter was significantly smaller during increased IAP (16.5 mm ± 4.9) compared to spontaneous breathing (20.6 mm ± 4.8, p = 0.04) and PPV (21.8 mm ± 5.6, p = 0.01). CONCLUSION: IJV and IVC collapsibility correlated during spontaneous breathing but there was no statistically significant correlation during increased thoracic or intra-abdominal pressure. Increased intra-abdominal pressure was associated with a significant smaller maximal IVC diameter and cautions the reliability of IVC diameter in clinical settings that are associated with intra-abdominal hypertension or abdominal compartment syndrome.

Feasibility of common carotid artery point of care ultrasound in cardiac output measurements compared to invasive methods.

BACKGROUND: Cardiac output (CO) measurement in the intensive care unit (ICU) requires invasive devices such as the pulmonary artery (PA) catheter or arterial waveform pulse contour analysis (PCA). This study tests the accuracy and feasibility of point of care ultrasound (POCUS) of the common carotid artery to estimate the CO non-invasively and compare it to existing invasive CO measurement modalities. METHODS: Patients admitted to the surgical and cardiothoracic ICU in a tertiary university-affiliated academic center during a 4-month period, with invasive hemodynamic monitoring devices for management, were included in this cohort study. Common carotid artery POCUS was performed to measure the CO and the results were compared to an invasive device. RESULTS: Intensivists and ICU fellows, using ultrasound of the common carotid artery, obtained the CO measurements. Images of the Doppler flow and volume were obtained at the level of the thyroid gland. Concurrent CO measured via invasive devices was recorded. The patient cohort comprised 36 patients; 52 % were females. The average age was 59 ± 13 years, and 66 % were monitored via PCA device and 33 % via PA catheter. Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect correlation (0.8152) between measurements of CO via ultrasound vs. invasive modalities. The ICC between POCUS and the invasive measurement via PCA was 0.84 and via PA catheter 0.74, showing substantial agreement between the ultrasound and both invasive modalities. CONCLUSIONS: Common carotid artery POCUS offers a non-invasive method of measuring the CO in the critically ill population.

Predictors of Clavien 4 Complications and Mortality After Necrosectomy: Analysis of the NSQIP Database.

BACKGROUND: Acute severe pancreatitis is one of the most common gastrointestinal reasons for admission to hospitals in the USA. Up to 20 % of these patients will progress to necrotizing pancreatitis requiring intervention. The aim of this study is to identify specific preoperative factors for the development of Clavien 4 complications and mortality in patients undergoing pancreatic necrosectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use files were reviewed from 2007 to 2012 to identify patients who underwent a pancreatic necrosectomy. Postoperative complications were stratified into Clavien 4 (ICU level complications) and Clavien 5 (mortality). Univariate and multivariate analyses were performed. RESULTS: A total of 1156 patients underwent a pancreatic necrosectomy from 2007 to 2012. Overall, 42 % of patients experienced a Clavien 4 complication. Mortality rate was 9.5 %. Nonindependent functional status and ASA class were highly significant (p < 0.001) in univariate analysis. Frailty and emergency surgery status (p < 0.001), as well as increased blood urea nitrogen (BUN) and alkaline phosphatase and decreased albumin (p < 0.05) demonstrated independent significance of Clavien 4 complications and mortality in multivariate analysis. CONCLUSION: This study identified specific preoperative variables that place patients at increased risk of Clavien 4 complications and mortality after necrosectomy. Identification of high-risk patients can aid in selection of appropriate treatment strategies and allow for informed preoperative discussion regarding surgical risk.

What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution.

OBJECTIVE: Technology currently exists for the application of remote guidance in the laparoscopic operating suite. However, these solutions are costly and require extensive preparation and reconfiguration of current hardware. We propose a solution from existing technology, to send video of laparoscopic cholecystectomy to the Blackberry Pearl device (RIM Waterloo, ON, Canada) for remote guidance purposes. This technology is time- and cost-efficient, as well as reliable. METHODS: After identification of the critical maneuver during a laparoscopic cholecystectomy as the division of the cystic duct, we captured a segment of video before it's transection. Video was captured using the laparoscopic camera input sent via DVI2USB Solo Frame Grabber (Epiphan Ottawa, Canada) to a video recording application on a laptop. Seven- to 40-second video clips were recorded. The video clip was then converted to an .mp4 file and was uploaded to our server and a link was then sent to the consultant via e-mail. The consultant accessed the file via Blackberry for viewing. After reviewing the video, the consultant was able to confidently comment on the operation. RESULTS: Approximately 7 to 40 seconds of 10 laparoscopic cholecystectomies were recorded and transferred to the consultant using our method. All 10 video clips were reviewed and deemed adequate for decision making. CONCLUSION: Remote guidance for laparoscopic cholecystectomy with existing technology can be accomplished with relatively low cost and minimal setup. Additional evaluation of our methods will aim to identify reliability, validity, and accuracy. Using our method, other forms of remote guidance may be feasible, such as other laparoscopic procedures, diagnostic ultrasonography, and remote intensive care unit monitoring. In addition, this method of remote guidance may be extended to centers with smaller budgets, allowing ubiquitous use of neighboring consultants and improved safety for our patients.

Renal dysfunction in trauma: even a little costs a lot.

BACKGROUND: Acute renal failure (ARF) is a devastating complication in critically ill patients. There is a paucity of data that describes the impact of ARF on the outcome of trauma patients admitted to the intensive care unit. METHODS: We studied trauma patients admitted to the surgical intensive care unit to determine the effect of increases in serum creatinine on the number of ventilator days, length of stay, mortality, and cost. We used the administrative database of the hospital and the trauma registry. Renal failure (RF) was defined as one or more of the following: creatinine >1.5 mg/dL, increase in creatinine of >50%, or increase of creatinine by 0.5 mg/dL. RESULTS: We obtained data on 1,033 patients. Two hundred and forty-six (23.8%) patients met at least one criterion for RF. Only 25 of these patients had one or more episodes of renal replacement therapy. The RF group had mortality of 24.4% compared with 2.3% in the no renal failure group (p < 0.0001). For each 1 mg/dL increase from the initial creatinine, length of stay increased by 2.21 days, ventilator days increased by 1.09 days, and the mortality risk increased by 1.83 times (CI, 1.47-2.29; p < 0.0001). For any diagnosis of renal dysfunction, the average cost increase was $3,088.00 and increased mortality risk was 7.19 times (CI, 4.11-12.58). CONCLUSION: Vigilance in preventing creatinine increases and ameliorating or removing potential causes should occur as soon as creatinine begins to rise to avoid worsening renal function, to reduce cost, and to improve patient outcome.