Outcomes in Patients with Known Contrast Allergy Undergoing Contrast-Enhanced Endourologic Procedures: A Retrospective Cohort Study.

Background: Intravenous (IV) administration of iodinated contrast agents carries the risk of allergic reaction, yet this risk is unclear with administration into the urinary tract. We sought to evaluate patients with known contrast, iodine, or shellfish allergies for allergic response when undergoing urologic imaging requiring intraluminal urinary tract contrast administration. Materials and Methods: We retrospectively reviewed consecutive patients undergoing endourologic procedures from 2010 to 2015 at our institution. Clinical records were reviewed for demographics, medical history, allergies, procedure details, fluids administered, anesthetic and pharmacologic agents administered, and continuous monitoring parameters. Patients with known allergies to iodine, shellfish, and/or contrast were identified and evaluated for clinical or hemodynamic signs of allergy. A convenience sample of 50 patients without allergy history was used as a comparison group. Results: We identified 1405 procedures involving 1000 consecutive patients. Procedures included retrograde pyelograms and antegrade nephrostograms. Eighty-six cases involving 58 patients with contrast, iodine, or shellfish allergies were identified. Of those with contrast allergy history, 18 (20.1%) cases involved patients with a history of anaphylactic reaction. Of these, 11 (61%) received steroid prophylaxis. No patients in either group (Allergy, No Allergy) were identified as having an allergic reaction during the procedure. There were no statistically significant differences in intraoperative IV fluids (p = 0.931), procedure duration (p = 0.747), or vasopressor use (p = 0.973) between groups. Owing to the zero event rate of contrast allergy, we used the Hanley and Lippman-Hand method, which places true population risk (95% confidence interval) of a significant event at <3.5%. Conclusions: In 86 cases involving patients with a history of contrast allergy, we found no evidence of clinically significant allergic reaction to intraluminal endourologic contrast administration under continuous anesthesia monitoring. The risk of significant reactions to contrast administered within the urinary tract appears to be low in these patients, regardless of prophylaxis.

Chemoprophylaxis Use and Risk of Venous Thromboembolism and Death in Adult Patients following Orthotopic Liver Transplantation.

BACKGROUND: Coagulation abnormalities in end-stage liver disease may preclude patients from receiving venous thromboembolism (VTE) prophylaxis immediately following orthotopic liver transplantation. METHODS: To identify risk factors for VTE and death following liver transplantation, a retrospective chart review was conducted in adult liver transplant recipients from January 1, 2001, to October 1, 2011. RESULTS: In 716 transplantations in 701 patients, the overall incidence of VTE was 2.1%. The incidence was 3.6% in patients who received chemoprophylaxis compared to 1.4% in those without chemoprophylaxis (P = .06). Most patients (69.5%) did not receive chemoprophylaxis postsurgery during their hospitalization. Multivariate logistic regression modeling revealed no association between the use of chemoprophylaxis (adjusted odds ratio [OR] 1.5 [0.45-4.7], P = .53) and VTE. A significant positive association was observed between the use of chemoprophylaxis (adjusted OR 3.2 [1.3-8.0], P = .01) and death. CONCLUSION: Use of chemoprophylaxis and increasing amounts of blood products following orthotopic liver transplant was associated with increased mortality. A significant positive association was observed between blood product administration and VTE, while chemoprophylaxis use was not significantly associated with VTE. Larger prospective studies are necessary to further examine the significance of this finding.

Patient repositioning and pressure ulcer risk--monitoring interface pressures of at-risk patients.

Repositioning patients regularly to prevent pressure ulcers and reduce interface pressures is the standard of care, yet prior work has found that standard repositioning does not relieve all areas of at-risk tissue in nondisabled subjects. To determine whether this holds true for high-risk patients, we assessed the effectiveness of routine repositioning in relieving at-risk tissue of the perisacral area using interface pressure mapping. Bedridden patients at risk for pressure ulcer formation (n = 23, Braden score <18) had their perisacral skin-bed interface pressures recorded every 30 s while they received routine repositioning care for 4-6 h. All participants had specific skin areas (206 +/- 182 cm(2)) that exceeded elevated pressure thresholds for >95% of the observation period. Thirteen participants were observed in three distinct positions (supine, turned left, turned right), and all had specific skin areas (166 +/- 184 cm(2)) that exceeded pressure thresholds for >95% of the observation period. At-risk patients have skin areas that are likely always at risk throughout their hospital stay despite repositioning. Healthcare providers are unaware of the actual tissue-relieving effectiveness (or lack thereof) of their repositioning interventions, which may partially explain why pressure ulcer mitigation strategies are not always successful. Relieving at-risk tissue is a necessary part of pressure ulcer prevention, but the repositioning practice itself needs improvement.

Inspiratory muscle strength training improves weaning outcome in failure to wean patients: a randomized trial.

INTRODUCTION: Most patients are readily liberated from mechanical ventilation (MV) support, however, 10% - 15% of patients experience failure to wean (FTW). FTW patients account for approximately 40% of all MV days and have significantly worse clinical outcomes. MV induced inspiratory muscle weakness has been implicated as a contributor to FTW and recent work has documented inspiratory muscle weakness in humans supported with MV. METHODS: We conducted a single center, single-blind, randomized controlled trial to test whether inspiratory muscle strength training (IMST) would improve weaning outcome in FTW patients. Of 129 patients evaluated for participation, 69 were enrolled and studied. 35 subjects were randomly assigned to the IMST condition and 34 to the SHAM treatment. IMST was performed with a threshold inspiratory device, set at the highest pressure tolerated and progressed daily. SHAM training provided a constant, low inspiratory pressure load. Subjects completed 4 sets of 6-10 training breaths, 5 days per week. Subjects also performed progressively longer breathing trials daily per protocol. The weaning criterion was 72 consecutive hours without MV support. Subjects were blinded to group assignment, and were treated until weaned or 28 days. RESULTS: Groups were comparable on demographic and clinical variables at baseline. The IMST and SHAM groups respectively received 41.9 ± 25.5 vs. 47.3 ± 33.0 days of MV support prior to starting intervention, P = 0.36. The IMST and SHAM groups participated in 9.7 ± 4.0 and 11.0 ± 4.8 training sessions, respectively, P = 0.09. The SHAM group's pre to post-training maximal inspiratory pressure (MIP) change was not significant (-43.5 ± 17.8 vs. -45.1 ± 19.5 cm H2O, P = 0.39), while the IMST group's MIP increased (-44.4 ± 18.4 vs. -54.1 ± 17.8 cm H2O, P < 0.0001). There were no adverse events observed during IMST or SHAM treatments. Twenty-five of 35 IMST subjects weaned (71%, 95% confidence interval (CI) = 55% to 84%), while 16 of 34 (47%, 95% CI = 31% to 63%) SHAM subjects weaned, P = .039. The number of patients needed to be treated for effect was 4 (95% CI = 2 to 80). CONCLUSIONS: An IMST program can lead to increased MIP and improved weaning outcome in FTW patients compared to SHAM treatment. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00419458.

Effects of turning on skin-bed interface pressures in healthy adults.

AIM: This paper is a report of a study of the effects of lateral turning on skin-bed interface pressures in the sacral, trochanteric and buttock regions, and its effectiveness in unloading at-risk tissue. BACKGROUND: Minimizing skin-support surface interface pressure is important in pressure ulcer prevention, but the effect of standard patient repositioning on skin interface pressure has not been objectively established. METHODS: Data were collected from 15 healthy adults from a university-affiliated hospital. Mapped 24-inch x 24-inch (2304 half-inch sensors) interface pressure profiles were obtained in the supine position, followed by lateral turning with pillow or wedge support and subsequent head-of-bed elevation to 30 degrees . RESULTS: Raising the head-of-bed to 30 degrees in the lateral position statistically significantly increased peak interface pressures and total area > or = 32 mmHg. Comparing areas > or = 32 mmHg from all positions, 93% of participants had skin areas with interface pressures > or = 32 mmHg throughout all positions (60 +/- 54 cm(2)), termed 'triple jeopardy areas'. The triple jeopardy area increased statistically significantly with wedges as compared to pillows (153 +/- 99 cm(2) vs. 48 +/- 47 cm(2), P < 0.05). CONCLUSION: Standard turning by experienced intensive care unit nurses does not reliably unload all areas of high skin-bed interface pressures. These areas remain at risk for skin breakdown, and help to explain why pressure ulcers occur despite the implementation of standard preventive measures. Support materials for maintaining lateral turned positions can also influence tissue unloading and triple jeopardy areas.

Exit of catheter lock solutions from double lumen acute haemodialysis catheters--an in vitro study.

BACKGROUND: Double lumen dialysis catheters are routinely heparin or citrate 'locked' to maintain patency. Heparin lock-related bleeding episodes and antibiotic lock-related toxicity have been reported. The aim of this study is to quantify the amount of leak during 'lock' procedures and to compare leakage for different double lumen dialysis catheters. METHODS: In an experimental, in vitro study at a University research laboratory, five different double lumen dialysis catheters were tested using three different lock volumes. RESULTS: Using the catheter flush volume, leak ratios for Flexxicon II 15 cm and 20 cm catheters were greater than that seen in the Arrow 16 cm catheter (P < 0.05). Using 20% less than the catheter flush volume, the Flexxicon II 20 cm catheter had greater leak than the Duo-flow 15 and 20 cm catheters and Arrow 16 cm catheter (P < 0.05). The Flexxicon II 15 cm catheter had greater leak than the Duo-flow 15 cm and Duo-flow 20 cm catheters with 20% less locking volume (P < 0.05). Using 20% greater than the catheter flush volume, the Duo-flow 20 cm catheter had significantly less leak ratio than the Flexxicon II 20 cm catheter (P < 0.05). There were no other significant differences in leak ratios between the catheters. CONCLUSION: All double lumen dialysis catheters we tested have a substantial amount of leak even when the catheter 'lock' volumes were used, and leak ratio increases significantly with 20% overfill. There is a leak even when using 20% less 'lock' volume. The amount of leak can be clinically important and may explain the reports of bleeding episodes after heparin lock and antibiotic toxicity after antibiotic and anticoagulant combination lock. Some devices have lower leak ratios than others, likely related to catheter design.

Utilization of intensive care resources in bariatric surgery.

BACKGROUND: Obese patients occasionally require either elective or emergency critical care services following bariatric surgery. We describe this subgroup of patients. METHODS: From July 1, 1991 to July 31, 2004, we performed 1,279 bariatric operations; 241 (19%) required admission to the surgical critical care service. We retrospectively reviewed medical records for gender, body mass index (BMI), age, whether the operation was initial or revisional, and whether critical care admission was elective or emergent. 3 complication clusters (thromboembolic, pulmonary, and anastomotic) were identified using discharge ICD-9 codes. The costs and length of stay of these subpopulations was calculated. RESULTS: Patients were on average 46+/-10 years old, with BMI 59+/-13. Critical care admission was emergent in 52.7% (n=127) of cases. Revisional cases did not differ from the initial cases in BMI (56.4 vs 59.2, P=0.42) and they were no more likely to require emergent critical care admission than initial cases (P=0.16). Revisional cases were hospitalized longer (27.2+/-25.6 vs 12.5+/-18.7 days, P=0.003); had higher total hospital costs (US$ 60,631+/-78,337 vs 27,697+/-52,351, P=0.025); and were more likely to die from their complications (revisional surgery mortality 6.5% vs 1.9% for initial surgery [P=0.002]). CONCLUSIONS: An increasing number of surgical revisions will likely accompany the recent increase in popularity of bariatric surgery. In our experience, these patients require significant critical care services, and have longer, complicated, and more costly hospitalizations.

Oxidant injury occurs rapidly after cardiac arrest, cardiopulmonary resuscitation, and reperfusion.

OBJECTIVE: Investigations conducted in cellular models show that reperfusion of ischemic tissue is associated with a burst of reactive oxidant species within minutes after reperfusion. Oxidant injury may play a role in the poor outcome typical of people resuscitated from cardiac arrest. The objective of the present study was to determine the presence and timing of oxidant injury in an in vivo model of cardiac arrest. DESIGN: Randomized controlled. SETTING: University medical center laboratory. SUBJECTS: Domestic swine. INTERVENTIONS: We evaluated oxidant injury during and after 8 mins of cardiac arrest using a gas chromatography/mass spectrometry F2-isoprostane assay and compared these results with a matched control group. MEASUREMENTS AND MAIN RESULTS: Baseline mean arterial, venous, and brain tissue F2-isoprostane levels were not significantly different when the cardiac arrest group was compared with the control group. However, in the group subjected to cardiac arrest and cardiopulmonary resuscitation we found significant (p < .0006) two- to three-fold increases in venous and arterial F2-isoprostane levels, which peaked between 15 and 30 mins after reperfusion and returned to baseline within 90 mins (p < .0006). Overall mean (+/- SE) brain tissue F2-isoprostane levels increased significantly to 370 +/- 60 vs. 140 +/- 60 ng/g tissue in the cardiac arrest group compared with the control group (p = .026). CONCLUSION: This study shows that F2-isoprostane measurement could be used to assess oxidant injury in an animal model of cardiac arrest and that oxidant injury occurs rapidly after cardiac arrest and reperfusion.

Too much lactate or too little liver?

We describe a 67-year-old woman with cholangiocarcinoma who was scheduled for cholecystectomy, trisegmentectomy, bile duct resection, and regional lymphadenectomy. Her case was complicated by hyperlactatemia, sepsis, and multiorgan failure. The discussion reviews the possible causes of the hyperlactatemia and reviews measures that could be used to reduce this risk.

Paradoxical vocal cord motion: an often misdiagnosed cause of postoperative stridor.

This conference reports a case of acute functional airway obstruction occurring in the postoperative anesthesia care unit, which was diagnosed by fiberoptic laryngoscopy and successfully treated with intravenous midazolam after other more common causes of stridor were ruled out. The presentation, etiology, diagnosis, and treatment of paradoxical vocal cord motion as it relates to the care of the postoperative patient are discussed.

Burn injuries.

PURPOSE OF REVIEW: To summarize new advances and research findings that relate to the treatment of burn victims. RECENT FINDINGS: Recent advances in burn resuscitation and critical care reflect a better understanding of the acute phase pathophysiology of severe burns. Aggressive management of the unstable burn airway is always the most important clinical priority. Emphasis has been placed on the early identification of inhalation injury and its impact on fluid resuscitation, as well as on a protective lung strategy to reduce the development of pulmonary edema, acute lung injury and pneumonia, and to reduce the risk of barotrauma. New blood markers, such as serum cholinesterase and inflammatory cytokines, have been introduced to assist in the prognosis of morbidity and mortality, beyond the traditional vital signs. At this time, however, these are available only for research purposes. Finally, early burn wound excision and coverage with new biodegradable materials results in less pain and more rapid healing for the patient. SUMMARY: The combination of innovative approaches and a dedicated burn team is expected to continue to improve survival in the next few years even in the most severe cases.