Twenty-eight-day mortality in critically ill surgical patients is an imprecise temporal end-point measure for in-hospital mortality.

BACKGROUND: The purpose of this study was to determine the incidence of deaths occurring beyond 28 days in critically ill surgical patients and to identify the proportion of these deaths attributable to the original disease process. METHODS: Analysis of 1,360 subjects admitted to a surgical intensive care unit during a 2 year period. Demographics, indication(s) for admission, comorbidities, mortality rate, multiorgan failure development, and cause of death was obtained. RESULTS: Mortality rate in the surgical intensive care unit was 12%. Twenty % of deaths occurred more than 28 days after hospital admission with 76% of deaths related to admission diagnosis. By day 34, 95% of mortalities had occurred. CONCLUSIONS: The 28-day time period used to assess efficacy of therapeutic interventions and to define mortality in the context of quality audits should be questioned. If these findings are validated in other centers another temporal end point for in-hospital mortality should be considered.

Transcutaneous pressure of oxygen: a noninvasive and early detector of peripheral shock and outcome.

A noninvasive tool to recognize early shock would improve outcome by providing prompt recognition of tissue ischemia and precise resuscitation endpoint. The skin is the first tissue bed to vasoconstrict in shock states. Studies have demonstrated that transcutaneous partial pressure of oxygen (PtCO2) increases with higher FiO2 in nonshock states as arterial pressure of oxygen (PaO2) increases, but in shock situations, PtCO2 mirrors changes in cardiac output and oxygen delivery with minimum response to increasing FiO2 and PaO2. This study examined the relationship of hemodynamic variables and the degree of PtCO2 response to FiO2 of 1.0 (identified as the "oxygen challenge test") to mortality and organ failure. This prospective observational study examined 38 patients requiring at least 24 h of cardiac output monitoring for shock resuscitation in the Surgical Intensive Care Unit. Patients were resuscitated to the standard protocol of blood pressure, urine output, oxygen delivery (DO2), and mixed venous O2 (SvO2). Seventy-nine percent of the patients (30/38) with a mean age of 59 +/- 21 years had septic shock or severe sepsis with a 26% mortality (10/38). Measurements included hemodynamic variables, PtCO2, and outcome (mortality and organ failure). In this study, the ability of PtCO2 value to increase by 21 mmHg on a FiO2 of 1.0, at 24 h of resuscitation, divided survivors from nonsurvivors, P <.001. The PtCO2 response to FiO2 may provide an additional noninvasive method of detecting early shock as well as a specific endpoint of resuscitation.

Workload redistribution: a new approach to the 80-hour workweek.

BACKGROUND: The new Accreditation Council for Graduate Medical Education-mandated 80-hour resident work week has resulted in busy trauma services struggling to meet these strict guidelines, or face loss of accreditation. METHODS: Beginning in July 2003, our Level I trauma service began a policy of direct admission of isolated neurosurgical or orthopedic injuries to the specific subspecialty service after complete evaluation by the trauma service in the emergency department for associated injuries. Complications, missed injuries, delayed diagnoses, and admission rates were compared in two 6-month periods: PRE, before the policy change; and POST, after the new policy had been instituted. Resident work hours were likewise compared over the two time periods. RESULTS: Selected single-system injury admission to subspecialty services resulted in a 15% reduction in admissions to the trauma service. There were no significant differences in the overall complication rate, delayed diagnoses, or missed diagnoses between the PRE and POST time periods. Overall, there was a 9.7% reduction in resident work hours (p = 0.45; analysis of variance) between the PRE and POST periods, which allowed them, on average, to meet the Accreditation Council for Graduate Medical Education 80-hour workweek mandate. CONCLUSION: Direct admission of patients with isolated injuries to subspecialty services is safe and decreases the workload of residents on busy trauma services.

Uncompensated metabolic acidosis: an underrecognized risk factor for subsequent intubation requirement.

BACKGROUND: There are no published reports identifying an inadequate ventilatory response to metabolic acidosis as a predictor of impending respiratory failure. Metabolic acidosis should induce a respiratory alkalosis in which the partial pressure of carbon dioxide (Paco2) is (1.5 [HCO3-] + 8) +/- 2. This study examined the relation between inadequate ventilatory compensation and intubation among trauma patients. METHODS: A retrospective chart review was performed for trauma patients admitted between January 1999 and December 2000. Age, gender, Injury Severity Score and combined Trauma and Injury Severity Score, chest injury, history of cardiac or pulmonary disease, partial pressure of oxygen (Pao2), Paco2, Glasgow Coma Score, respiratory rate, systolic blood pressure, base deficit, and ability to compensate were analyzed with respect to intubation and need for ventilator support. RESULTS: Of 140 patients with metabolic acidosis, 45 ultimately were intubated. The mean Paco2 for the unintubated patients was 34 +/- 7 mm Hg, as compared with 41 +/- 11 mm Hg for the intubated patients (p < 0.001). Only injury severity and ability to compensate for metabolic acidosis were independent predictors of intubation. Patients with inadequate compensation were 4.2 times more likely to require intubation when control was used for the Injury Severity Score (95% confidence interval, 1.8-9.7; p < 0.001). CONCLUSIONS: Inability to mount an adequate hyperventilatory response to metabolic acidosis is associated with an increased likelihood of respiratory failure and a need for ventilatory support. Recognition of this relation should lead to closer monitoring of patients with this condition, and could help to avert unforeseen crisis intubations. This observation needs to be validated in a prospective study.