Failure events in transition of care for surgical patients.

BACKGROUND: Unexpected clinical deterioration (failure events) in surgical patients on standard nursing units (WARDs) could have a significant impact on eventual survival. We sought to investigate failure events requiring intensive care (surgical ICU [SICU]) transfer of surgical patients on WARDs in a single-center academic setting. STUDY DESIGN: Surgical patients admitted to WARDs over a 12-month period, who developed failure events, were retrospectively reviewed. Time to deterioration since WARD arrival, clinical factors, notification chain, and outcomes were identified. A physician review panel determined the preventability of failure events. RESULTS: Ninety-eight patients experienced 111 failure events requiring SICU transfer. Most patients (85%) were emergency admissions. Of 111 events, 90% had been previously discharged from an SICU or a postanesthesia care unit (PACU). Recognition of failure was by nursing (54%) and on routine physician rounds (34%). Rapid response or code blue alone was less common (12%). A second physician notification was needed in 29%, with delays due to failure to identify severity of illness. Most commonly, respiratory events prompted notification (77 of 111, 69%). Overall mortality was 26 of 98 (27%). Median time to failure was 2 days and was associated with early transfer from the SICU or PACU. Rapid response or code blue activation was associated with higher mortality than physician notification. CONCLUSIONS: Patients most at risk for WARD failures were those with acute surgical emergencies or recently discharged from the SICU or PACU. Respiratory complications were the most common cause of WARD failure events. Many early failures may have been due to premature transfer from the SICU or PACU. Failure events on WARDs can have lethal consequences. Awareness, monitoring, and communication are important components of preventative measures.

Microfluidics-based capture of human neutrophils for expression analysis in blood and bronchoalveolar lavage.

Gene expression analysis can be a powerful tool in predicting patient outcomes and identifying patients who may benefit from targeted therapies. However, isolating human blood polymorphonuclear cells (PMNs) for genomic analysis has been challenging. We used a novel microfluidic technique that isolates PMNs by capturing CD66b(+) cells and compared it with dextran-Ficoll gradient isolation. We also used microfluidic isolation techniques for blood and bronchoalveolar lavage (BAL) samples of patients with acute respiratory distress syndrome (ARDS) to evaluate PMN genomic alterations secondary to pulmonary sequestration. PMNs obtained from ex vivo lipopolysaccharide (LPS)-stimulated or -unstimulated whole blood from five healthy volunteers were isolated by either dextran-Ficoll gradient, microfluidics capture, or a combination of the two techniques. Blood and BAL fluid PMNs were also isolated using microfluidics from seven hospitalized patients with ARDS. Gene expression was inferred from extracted RNA using Affymetrix U133 Plus 2.0 GeneChips. All methods of PMN isolation produced similar quantities of high-quality RNA, when adjusted for recovered cell number. Unsupervised analysis and hierarchical clustering indicated that LPS stimulation was the primary factor affecting gene expression patterns among all ex vivo samples. Patterns of gene expression from blood and BAL PMNs differed significantly from each other in the patients with ARDS. Isolation of PMNs by microfluidics can be applied to both blood and BAL specimens from critically ill, hospitalized patients. Unique genomic expression patterns are obtained from the blood and BAL fluid of critically ill patients with ARDS, and these differ significantly from genomic patterns seen after ex vivo LPS stimulation.

All-terrain vehicle safety in Florida: is legislation really the answer?

Florida is among the nation's leaders in all-terrain vehicle (ATV)-related injuries and fatalities. We hypothesized that patients sustaining injuries while in compliance with ATV laws would demonstrate less severe injury patterns and improved outcomes when compared with noncompliant patients. We reviewed patients treated for ATV-related injuries over a 36-month period. We grouped patients according to conformity with Florida statutes and compared demographics, admission status, injuries sustained, and outcome measures. Three hundred seventy-seven patients were treated for ATV-related injuries. In 294 cases, sufficient data existed to assess compliance with Florida's statutes regarding ATV rider safety: safety helmet use for persons younger than age 16 years and prohibition of ATV operation on roadways. Forty-three per cent (n = 126) had violated one or both statutes; 57 per cent (n = 168) had violated neither. The group in violation was younger (15 vs 24 years, P < 0.001) and wore helmets less often (6 vs 34%, P < 0.001). Groups required admission at similar rates (62% violators vs 60% nonviolators, P = 0.770), showed similar injury patterns, and had comparable mortality rates (2% violators vs 5% nonviolators, P = 0.451). Current Florida laws are inadequate to prevent ATV-related injuries and their sequelae. This issue should be addressed through an increased focus on safety education for ATV operators.

A new dosing protocol reduces dexmedetomidine-associated hypotension in critically ill surgical patients.

BACKGROUND: Although no ideal sedative exists, dexmedetomidine is unique because it produces sedation and analgesia without decreasing the respiratory drive. Hemodynamic responses to dexmedetomidine are variable and dependent on the patient population. Our initial experience was associated with an unacceptable incidence of hypotension and bradycardia. We evaluated occurrence of hypotension and bradycardia in critically ill surgical patients receiving dexmedetomidine before and after implementation of a dosing protocol. METHODS: This is a retrospective chart review of all admissions to a university medical center-based, 44-bed surgical intensive care unit pre and post protocol implementation. RESULTS: Forty-four patients received dexmedetomidine including 19 historic controls and 25 dosed via protocol. Both groups had comparable demographics and initial and maximum dosages of dexmedetomidine. Use of the dosing protocol resulted in fewer dosage changes (mean +/- standard deviation, 4.8 +/- 3.8 compared to 7.8 +/- 3.9; P = .014) and fewer episodes of hypotension (16% vs 68.4%; P = .0006) but did not influence bradycardic episodes (20% vs 15.5%; P > .99). CONCLUSION: We found that use of a protocol that increases the time interval between dosage adjustments may reduce dexmedetomidine-associated hypotension.

Endovascular treatment of traumatic thoracic aortic injuries.

BACKGROUND: Although a large proportion of patients with traumatic thoracic aortic injury die before undergoing definitive repair, those who survive still face ongoing risk of death and morbidity. Endovascular therapy may offer a minimally invasive alternative in the repair of the aortic injury. STUDY DESIGN: We reviewed our experience with endovascular repair of traumatic aortic injuries using medical records, imaging studies, and a prospectively maintained endovascular and institutional trauma database. RESULTS: Twenty-two patients underwent thoracic endovascular repair (TEVAR) of traumatic aortic injuries over 44 months. The mean (SD) age was 34+/-12 years and 68% were men. Among the 16 patients registered with our trauma database, the mean Injury Severity Score was 33+/-16 (range, 13 to 45). All injuries were sustained from blunt trauma; 95% of patients had nonaortic thoracic injuries, and 64% and 55% had extremity and abdominal injuries, respectively. Intraoperatively, 91% were repaired under general anesthesia, the mean procedure time was 80+/-52 minutes, and mean blood loss was 219+/-72 mL. The mean fluoroscopy time was 13+/-5 minutes and contrast volume 98+/-23 mL. Twenty-one patients (95%) required coverage of the left subclavian artery to achieve an adequate proximal landing zone. There were no in-hospital or 30-day deaths. The median length of stay was 8 days (range, 1 to 62 days), and 11 (50%) patients were able to be discharged home (versus to another extended care facility). At a mean followup of 7.7 months (range, 0 to 40 months) there were 2 patients (9%) who required endograft-related reintervention at 1 and 6 months. One was an access-related complication, and the second was complete device collapse with acute aortic occlusion, resulting in the patient's death. CONCLUSIONS: Although patients who undergo endovascular repair of traumatic thoracic aortic transections typically have significant concomitant injuries, the procedure itself is well tolerated and can be performed rapidly with minimal blood loss and contrast administration. But close followup is necessary given the risk of late complications.

Blunt splenic injuries: have we watched long enough?

BACKGROUND: Nonoperative management (NOM) of blunt splenic injuries (BSIs) has been used with increasing frequency in adult patients. There are currently no definitive guidelines established for how long BSI patients should be monitored for failure of NOM after injury. METHODS: This study was performed to ascertain the length of inpatient observation needed to capture most failures, and to identify factors associated with failure of NOM. We utilized the National Trauma Data Bank to determine time to failure after BSI. RESULTS: During the 5-year study period, 23,532 patients were identified with BSI, of which 2,366 (10% overall) were taken directly to surgery (within 2 hours of arrival). Of 21,166 patients initially managed nonoperatively, 18,506 were successful (79% of all-comers). Patients with isolated BSI are currently monitored approximately 5 days as inpatients. Of patients failing NOM, 95% failed during the first 72 hours, and monitoring 2 additional days saw only 1.5% more failures. Factors influencing success of NOM included computed tomographic injury grade, severity of patient injury, and American College of Surgeons designation of trauma center. Importantly, patients who failed NOM did not seem to have detrimental outcomes when compared with patients with successful NOM. No statistically significant predictive variables could be identified that would help predict patients who would go on to fail NOM. CONCLUSIONS: We conclude that at least 80% of BSI can be managed successfully with NOM, and that patients should be monitored as inpatients for failure after BSI for 3 to 5 days.

Pulmonary cytomegalovirus reactivation causes pathology in immunocompetent mice.

OBJECTIVE: Cytomegalovirus (CMV) is a ubiquitous herpes virus that persists in the host in a latent state following primary infection. We have recently observed that CMV reactivates in lungs of critically ill surgical patients and that this reactivation can be triggered by bacterial sepsis. Although CMV is a known pathogen in immunosuppressed transplant patients, it is unknown whether reactivated CMV is a pathogen in immunocompetent hosts. Using an animal model of latency/reactivation, we studied the pathobiology of CMV reactivation in the immunocompetent host. DESIGN: Laboratory study. SETTING: University laboratory. SUBJECTS: Cohorts of immunocompetent BALB/c mice with or without latent murine CMV (MCMV+/MCMV-). INTERVENTIONS: Mice underwent cecal ligation and puncture. Lung tissue homogenates were evaluated after cecal ligation and puncture for tumor necrosis factor-alpha, interleukin-1beta, neutrophil chemokine KC, and macrophage inflammatory protein-2 messenger RNA by polymerase chain reaction and real-time quantitative reverse transcription-polymerase chain reaction. Because pulmonary tumor necrosis factor-alpha expression is known to cause pulmonary fibrosis, trichrome-stained sections of lung tissues were analyzed using image analysis to quantitate pulmonary fibrosis. In a second experiment, a cohort of MCMV+ mice received ganciclovir (10 mg/kg/day subcutaneously) following cecal ligation and puncture. Tumor necrosis factor-alpha messenger RNA and pulmonary fibrosis were evaluated as described previously. MEASUREMENTS AND MAIN RESULTS: All MCMV+ mice had CMV reactivation beginning 2 wks after cecal ligation and puncture. Following reactivation, these mice had abnormal tumor necrosis factor-alpha, interleukin-1beta, neutrophil chemokine KC, and macrophage inflammatory protein-2 messenger RNA expression compared with controls. Image analysis showed that MCMV+ mice had significantly increased pulmonary fibrosis compared with MCMV- mice 3 wks after cecal ligation and puncture. Ganciclovir treatment following cecal ligation and puncture prevented MCMV reactivation. Furthermore, ganciclovir-treated mice did not demonstrate abnormal pulmonary expression of tumor necrosis factor-alpha messenger RNA. Finally, ganciclovir treatment prevented pulmonary fibrosis following MCMV reactivation. CONCLUSIONS: This study shows that CMV reactivation causes abnormal tumor necrosis factor-alpha expression, and that following CMV reactivation, immunocompetent mice have abnormal pulmonary fibrosis. Ganciclovir blocks MCMV reactivation, thus preventing abnormal tumor necrosis factor-alpha expression and pulmonary fibrosis. These data may explain a mechanism by which critically ill surgical patients develop fibroproliferative acute respiratory distress syndrome. These data suggest that human studies using antiviral agents during critical illness are warranted.

Occult herpes family viral infections are endemic in critically ill surgical patients.

OBJECTIVE: Herpes family viruses have been recognized as pathogens for many years in immunosuppressed transplant or human immunodeficiency virus patients, but they have garnered little attention as potential pathogens in the nonimmunosuppressed critically ill. The objective of this study was to define the prevalence of and risk factors for development of herpes family virus infection in chronic critically ill surgical patients. DESIGN: Prospective epidemiologic study. SETTING: A 38-bed surgical intensive care unit in a major university hospital. PATIENTS: Nonimmunosuppressed intensive care unit patients in intensive care unit for >/=5 days. INTERVENTIONS: None; patients received no antiviral treatment during the study. MEASUREMENTS AND MAIN RESULTS: Weekly cultures for cytomegalovirus (CMV) and herpes simplex virus, viral serologies, and T-cell counts were performed. The prevalence (95% confidence interval) of positive respiratory cultures for herpes simplex or CMV was 35% (22-49%); 15% (5-25%) cultured positive for CMV, 23% (11-35%) cultured positive for herpes simplex virus, and one patient's respiratory secretions culturing positive for both CMV and herpes simplex virus. The prevalence of CMV viremia was only 5.8% (1-10%). CMV+ patients had longer hospital admissions, intensive care unit admissions, and periods of ventilator dependence than CMV- patients, despite having comparable severity of illness scores. CMV+ patients also had significantly higher numbers of blood transfusions, prevalence of steroid exposure, and prevalence of hepatic dysfunction, and all were immunoglobulin G positive at the beginning of the study. In contrast, herpes simplex virus-positive patients had lengths of hospital admissions, lengths of intensive care unit admissions, and periods of ventilator dependence comparable with patients without viral infections (p >.05). CONCLUSIONS: There is a significant prevalence (22-49%) of occult active herpes family viruses in chronic critically ill surgical patients. The clinical significance of these viral infections is unknown, although CMV+ patients have significantly higher morbidity rates than CMV- patients. Several factors suggest pathogenicity, but further study is needed to define causality.

Transthoracic echocardiography is not cost-effective in critically ill surgical patients.

BACKGROUND: Echocardiography has been shown to be valuable in critically ill surgical patients. Transthoracic echocardiography (TTE) often fails to provide adequate imaging in critically ill patients, necessitating subsequent transesophageal echocardiography (TEE). The objective of this study was to determine and quantify factors associated with failure of transthoracic echocardiography (TTE) in critically ill surgical patients, and to define a cost-effective strategy for echocardiography in these patients. METHODS: Demographic and clinical data were collected retrospectively and evaluated to determine which factors were associated with failure of TTE to provide adequate imaging. In addition, models were developed to estimate costs for echocardiography in critically ill surgical patients. RESULTS: TTE has a high failure rate in critically ill surgical patients. This failure rate increases significantly in patients who gain > 10% body weight from admission weight, who are supported with > or = 15 cm H(2)O positive end-expiratory pressure, and in those with chest tubes. As a result, the use of TTE in critically ill surgical patients is not cost-effective. TEE, however, is highly effective in this group of patients, and is more cost-effective than TTE in evaluating those critically ill surgical patients requiring echocardiography. CONCLUSION: The routine use of TTE to initially evaluate all critically ill surgical patients who require echocardiography should be abandoned because it is not cost-effective. TEE appears to be the most cost-effective echocardiographic modality in the surgical intensive care unit.