Trauma team utilization of universal precautions: if you see something, say something.

PURPOSE: The risks deriving from the lack of compliance with universal safety precautions (USPs) are unequivocal. However, the adoption of these prophylactic precautions by healthcare providers remains unacceptably low. We hypothesized that trauma teams are not routinely adhering to USPs and that a brief educational intervention, followed by real-time peer feedback, would substantially improve compliance rates. METHODS: This before-and-after interventional study took place in the resuscitation bay of a Level I Trauma Center during trauma team activations. Six USPs were examined: hand washing (before and after patient contact), use of gloves, gowns, eye protection, and masks. Surgery and Emergency Medicine attending physicians, residents, and nurses, who had direct patient contact, were included. Following 162 baseline observations, an educational intervention in the form of brief lectures was conducted, emphasizing the danger to self from dereliction of USPs. Subsequently, 167 post-intervention observations were made after a one-month period of knowledge decay. Finally, real-time feedback was provided by trauma team leaders and study staff. Adherence to prophylactic measures was recorded again. RESULTS: Baseline compliance rates were dismal. Only hand washing prior to patient interaction, the use of eye protection, and the use of masks improved significantly (p < 0.05) after the educational initiative. However, compliance rates remained suboptimal. No difference was noted regarding the three other USPs. Impressively, following real-time behavioral corrections, compliance improved to nearly 90 % for all USPs (p < 0.05). CONCLUSIONS: Compliance with OSHA-required USPs during trauma team activations is unacceptably low, but can be dramatically improved through simple educational interventions, combined with real-time peer feedback.

Sample entropy predicts lifesaving interventions in trauma patients with normal vital signs.

INTRODUCTION: Heart rate complexity, commonly described as a "new vital sign," has shown promise in predicting injury severity, but its use in clinical practice is not yet widely adopted. We previously demonstrated the ability of this noninvasive technology to predict lifesaving interventions (LSIs) in trauma patients. This study was conducted to prospectively evaluate the utility of real-time, automated, noninvasive, instantaneous sample entropy (SampEn) analysis to predict the need for an LSI in a trauma alert population presenting with normal vital signs. METHODS: Prospective enrollment of patients who met criteria for trauma team activation and presented with normal vital signs was conducted at a level I trauma center. High-fidelity electrocardiogram recording was used to calculate SampEn and SD of the normal-to-normal R-R interval (SDNN) continuously in real time for 2 hours with a portable, handheld device. Patients who received an LSI were compared to patients without any intervention (non-LSI). Multivariable analysis was performed to control for differences between the groups. Treating clinicians were blinded to results. RESULTS: Of 129 patients enrolled, 38 (29%) received 136 LSIs within 24 hours of hospital arrival. Initial systolic blood pressure was similar in both groups. Lifesaving intervention patients had a lower Glasgow Coma Scale. The mean SampEn on presentation was 0.7 (0.4-1.2) in the LSI group compared to 1.5 (1.1-2.0) in the non-LSI group (P < .0001). The area under the curve with initial SampEn alone was 0.73 (95% confidence interval [CI], 0.64-0.81) and increased to 0.93 (95% CI, 0.89-0.98) after adding sedation to the model. Sample entropy of less than 0.8 yields sensitivity, specificity, negative predictive value, and positive predictive value of 58%, 86%, 82%, and 65%, respectively, with an overall accuracy of 76% for predicting an LSI. SD of the normal-to-normal R-R interval had no predictive value. CONCLUSIONS: In trauma patients with normal presenting vital signs, decreased SampEn is an independent predictor of the need for LSI. Real-time SampEn analysis may be a useful adjunct to standard vital signs monitoring. Adoption of real-time, instantaneous SampEn monitoring for trauma patients, especially in resource-constrained environments, should be considered.

Bougie insertion: A common practice with underestimated dangers.

INTRODUCTION: Esophageal perforation after bariatric operations is rare. We report two cases of esophageal perforation after bariatric operations indicating the dangers of a common practice - like insertion of esophageal tubes - and we describe our management of that complication. PRESENTATION OF CASE: A 56 year old woman who underwent laparoscopic sleeve gastrectomy and a 41 year old woman who underwent laparoscopic adjustable gastric banding respectively. In both operations a bougie has been used and led to esophageal perforation. DISCUSSION: The insertion of bougie and especially of inflated bougie is a common practice. It is an invasive procedure that in most cases is performed by the anesthesiologist team. CONCLUSION: Bougie insertion is an invasive procedure with risks and should always be attempted under direct supervision of surgical team or should be inserted by a surgeon.

Primary hydatidosis of the gluteus muscles: report of three cases.

BACKGROUND: Hydatid disease caused by the tapeworm Echinococcus granulosus is a worldwide problem especially in sheep and cattle raising countries. AIMS: Muscle involvement is most commonly encountered as recurrence of previously treated disease or concurrently with primary lesions of the liver or lung. Furthermore, the rarity of muscle hydatidosis has unique implications in diagnosis and management. METHODS: We report on three cases of primary echinococcus of the gluteus muscles presented in our clinic during a 10-year period. RESULTS: We have administered albendazole for one cycle of 28 days in two of our patients based on the size and appearance of the cyst. All patients underwent total pericystectomy without cyst rupture. We have not found any recurrences after minimum follow up of 12 months. CONCLUSIONS: Muscle echinococciasis respond well to surgical intervention. Complete and intact removal of the cyst in primary muscular hydatidosis should be considered curative.

Preoperative levosimendan in heart failure patients undergoing noncardiac surgery.

BACKGROUND: Heart failure (HF) is a major cause of perioperative morbidity and mortality in noncardiac surgery. Preoperative optimisation of these patients is, thus, of utmost importance. Levosimendan seems promising for patients undergoing cardiac surgery; however, its safety and efficacy in HF patients undergoing noncardiac surgery have not been evaluated. OBJECTIVE: To evaluate the effects of prophylactic preoperative levosimendan administration on left ventricular function in HF patients undergoing noncardiac surgery. METHODS: HF patients with ejection fraction <30%undergoing elective noncardiac surgery in 2005 were included in this prospective study. Patients were admitted to our surgical intensive care unit one day preoperatively. Under continuous haemodynamic monitoring, the treatment protocol consisted of an initial loading dose (24 microg/kg) for ten minutes followed by a continuous 24-hour infusion (0.1 microg/kg/min) at the end of which patients underwent surgery. Echocardiography was performed before infusion (day 0) and on the 7th postinfusion day (day 7). Measurements included left ventricular ejection fraction (LVEF), velocity time integral(VTI), pre-ejection period (PEP), ejection time (ET),maximum (Pmax) and minimum P(min) transvalvular aortic pressure gradient, and maximum (Vmax) and minimum V(min) aortic velocity. RESULTS: Twelve consecutive patients were enrolled. Levosimendan resulted in a significant increase in LVEF,VTI, P(max), P(min), V(max), and V(min) (p<0.01) and, moreover, a significant reduction in PEP, ET, and PEP/ET (p=0.04) on day 7 compared with day 0 values. No adverse reactions,complications or mortality occurred during 30-day follow-up. CONCLUSION: Prophylactic preoperative levosimendan treatment may be safe and efficient for perioperative optimisation of heart failure patients undergoing noncardiac surgery.

Refractory septic shock: efficacy and safety of very high doses of norepinephrine.

The aim of this study was to evaluate the safety, efficacy, and effects of administration of very high doses of norepinephrine (> 4 microg kg(-1) min(-1)) in catecholamine-resistant septic shock. We reviewed the charts of all patients with nonresponding to commonly used norepinephrine doses (< or = 4 microg kg(-1) min(-1)) septic shock from January 1999 to December 2002 in our Surgical Intensive Care Unit. All patients were treated with high norepinephrine doses (> 4 microg kg(-1) min(-1)), after initial resuscitation, so as to achieve a mean arterial pressure higher than or equal to 65 mmHg. During this 4-year period, 12 consecutive patients with catecholamine-resistant septic shock were included in our study. When compared with the values obtained prior to the administration of very high norepinephrine doses, the values of mean arterial pressure (p = 0.003) and systemic vascular resistance (p = 0.002) significantly increased after the administration of such doses, and additionally, lactate concentrations (p = 0.003) decreased. In contrast, no significant changes were observed regarding mean central venous pressure, pulmonary capillary wedge pressure, and pulmonary arterial pressure. Administration of high norepinephrine doses in our patients resulted in a survival rate of 33.4%. Management of catecholamine-resistant septic shock patients poses a challenging problem. Administration of very high norepinephrine doses is safe and effective and may improve survival of these patients with otherwise extremely high mortality rates.