The economic burden of Clostridium difficile.

Although Clostridium difficile (C. difficile) is the leading cause of infectious diarrhoea in hospitalized patients, the economic burden of this major nosocomial pathogen for hospitals, third-party payers and society remains unclear. We developed an economic computer simulation model to determine the costs attributable to healthcare-acquired C. difficile infection (CDI) from the hospital, third-party payer and societal perspectives. Sensitivity analyses explored the effects of varying the cost of hospitalization, C. difficile-attributable length of stay, and the probability of initial and secondary recurrences. The median cost of a case ranged from $9179 to $11 456 from the hospital perspective, $8932 to $11 679 from the third-party payor perspective, and $13 310 to $16 464 from the societal perspective. Most of the costs incurred were accrued during a patient's primary CDI episode. Hospitals with an incidence of 4.1 CDI cases per 100 000 discharges would incur costs ≥$3.2 million (hospital perspective); an incidence of 10.5 would lead to costs ≥$30.6 million. Our model suggests that the annual US economic burden of CDI would be ≥$496 million (hospital perspective), ≥$547 million (third-party payer perspective) and ≥$796 million (societal perspective). Our results show that C. difficile infection is indeed costly, not only to third-party payers and the hospital, but to society as well. These results are consistent with current literature citing C. difficile as a costly disease.

Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study.

UNLABELLED: Metabolic acidosis and changes in serum osmolarity are consequences of 0.9% normal saline (NS) solution administration. We sought to determine if these physiologic changes influence patient outcome. Patients undergoing aortic reconstructive surgery were enrolled and were randomly assigned to receive lactated Ringer's (LR) solution (n = 33) or NS (n = 33) in a double-blinded fashion. Anesthetic and fluid management were standardized. Multiple measures of outcome were monitored. The NS patients developed a hyperchloremic acidosis and received more bicarbonate therapy (30 +/- 62 mL in the NS group versus 4 +/- 16 mL in the LR group; mean +/- SD), which was given if the base deficit was greater than -5 mEq/L. The NS patients also received a larger volume of platelet transfusion (478 +/- 302 mL in the NS group versus 223 +/- 24 mL in the LR group; mean +/- SD). When all blood products were summed, the NS group received significantly more blood products (P = 0.02). There were no differences in duration of mechanical ventilation, intensive care unit stay, hospital stay, and incidence of complications. When NS was used as the primary intraoperative solution, significantly more acidosis was seen on completion of surgery. This acidosis resulted in no apparent change in outcome but required larger amounts of bicarbonate to achieve predetermined measurements of base deficit and was associated with the use of larger amounts of blood products. These changes should be considered when choosing fluids for surgical procedures involving extensive blood loss and requiring extensive fluid administration. IMPLICATIONS: Predominant use of 0.9% saline solution in major surgery has little impact on outcome as assessed by duration of mechanical ventilation, intensive care unit stay, hospital stay, and postoperative complications, but it does appear to be associated with increased perioperative blood loss.

Bedside diagnostic laparoscopy and peritoneal lavage in the intensive care unit.

BACKGROUND: Early diagnosis and treatment of intra-abdominal pathology in critically ill intensive care unit (ICU) patients remains a clinical challenge. The objective of this study is to assess the feasibility of portable, bedside diagnostic laparoscopy (DL) in the ICU for patients suspected of intra-abdominal pathology, and to contrast its accuracy with diagnostic peritoneal lavage (DPL). METHODS: All adult ICU patients for whom a general surgery consultation was requested were eligible. Patients with a recent laparotomy or obvious peritonitis were excluded. All procedures were performed in the ICU. RESULTS: Over a consecutive 16-month period, 12 patients underwent DPL/DL. Ages ranged from 28 to 88 (mean, 72) years. Causative findings were disclosed by DL in five patients, (42%) including intestinal ischemia in two. Perforated diverticulitis, thickened terminal ileum, and nonpurulent peritonitis were found in one patient each. All patients with findings by DL had a positive DPL (WBC > 200 cells/mm3), and one negative laparoscopy was positive by lavage. The average length of time to perform DPL was 14 min, and to complete DL 19 min. One patient underwent laparotomy based on DPL/DL and survived along with three others with negative DPL/DL. Eight patients died (67%), four from their surgically untreated intra-abdominal pathology. One patient sustained a procedure-related complication of bradycardia and high ventilatory airway pressures. Peak airway pressures increased an average of 8 mmHg and were significantly higher (p < 0. 001) than pre-DL pressures without any significant change in end-tidal CO2 or pCO2. There were no statistically significant hemodynamic changes based on mean arterial pressure (MAP), central venous pressure (CVP), or pulmonary artery diastolic pressure (PADP). CONCLUSIONS: Bedside laparoscopy can be performed rapidly and safely in the ICU. In predicting the need for laparotomy, DL was more accurate than DPL.

The impact of do-not-resuscitate orders on nursing workload in an ICU.

BACKGROUND: The meaning of do-not-resuscitate orders and their impact on nursing care have been a source of confusion, and the results of the few studies that have examined nursing care of ICU patients with these orders have been conflicting. OBJECTIVES: To assess nursing workload associated with caring for patients with do-not-resuscitate orders and to better understand the patients and selected events associated with these orders. METHOD: Sixty patients from medical, surgical, and neuroscience ICUs met the criteria for the study. The Medicus Systems Corporation InterAct 2000 Workload and Productivity System was used to classify patients by type; the results reflected the number of hours of nursing care required per 24 hours. Data on patient type for 1 day before and 1 day after do-not-resuscitate orders were written were available for 31 of the 60 patients. These data were analyzed. RESULTS: The number of hours of nursing care required 1 day before and 1 day after a do-not-resuscitate order did not change. The amount of nursing care remained the same or increased for 74% (23/31) of the patients after the order was written. Patients were classified as types IV (n = 8), V (n = 20), and VI (n = 3) after the order was written. CONCLUSIONS: A high level of nursing care was required for this group of critically ill patients, and the do-not-resuscitate order did not alter the number of hours of nursing care required after the order was written.

Nasal bridle revisited: an improvement in the technique to prevent unintentional removal of small-bore nasoenteric feeding tubes.

OBJECTIVE: To demonstrate the efficacy and safety of an updated version of the nasal "bridle," which is used to prevent the accidental removal of small-bore nasoenteric feeding tubes. DESIGN: A descriptive study. SETTING: Surgical intensive care unit in a tertiary care hospital. PATIENTS: Twenty-six critically ill patients without nasotracheal tubes or facial trauma or fractures who received enteral nutrition and either had removed or were at risk for removing their properly positioned nasoenteric feeding tubes. INTERVENTIONS: A length of one-eighth inch (3.2 mm) umbilical tape is looped around the nasal septum and vomer by serially attaching the ends of the umbilical tape to a suction catheter, passing the catheter through the nostrils, into the oropharynx, and retrieving the ends from the oropharynx. The properly positioned umbilical tape loops into one nostril around the vomer, and out the other nostril. The feeding tube is then anchored to the umbilical tape with a central venous catheter fastener clamp. MEASUREMENTS AND RESULTS: Communicative patients denied discomfort, and there were no episodes of bleeding, infection, sinusitis, or nasal septal trauma caused by the umbilical tape bridle. Five patients had the bridle in place >30 days. There were only two cases in which the bridle failed to prevent removal of a feeding tube. One of these cases occurred because the fastener clamp anchor failed, but this patient had had the same bridle and feeding tube for 170 consecutive days. CONCLUSIONS: An umbilical tape bridle with a central venous catheter fastener clamp anchor is a safe and effective method to prevent the accidental removal of nasoenteric feeding tubes in critically ill patients. We recommend its use in confused or uncooperative patients, or when the risk of unintentional feeding tube removal is high.

The role of MR imaging in determining surgical eligibility for pelvic exenteration.

OBJECTIVE: The purpose of this study was to evaluate the role of MR imaging in the preoperative assessment of candidates for pelvic exenteration. Specifically, we sought to determine if MR imaging was reliable in selecting patients with pelvic cancer for surgical exenteration. MATERIALS AND METHODS: MR images of the pelvis were retrospectively evaluated in 23 patients with proved pelvic cancer. These images were analyzed for (1) presence and location of the primary or recurrent tumor; (2) tumor extension to the bladder, rectum, or pelvic sidewall; and (3) presence and location of lymphadenopathy. On the basis of the MR findings, we determined suitability for pelvic exenteration by using generally accepted contraindications to surgery (involvement of the pelvic sidewall muscles or metastatic lymphadenopathy). In addition, tumor involvement of the bladder or rectum was evaluated to help determine the type of exenteration indicated. Surgical and/or histologic confirmation was available in all 23 cases. RESULTS: The accuracy of MR imaging in selecting patients was 83% (19 of 23), with a positive predictive value of 56% and a negative predictive value of 100%. In evaluating tumor involvement of the pelvic sidewall and lymph nodes, the negative predictive values were 100% and 95%, respectively. Tumor extension into the pelvic sidewall was overestimated in four patients, in three of whom it was not possible to distinguish radiation changes from tumor on MR images. For assessing extension of these pelvic tumors into the bladder and rectum, MR imaging had an accuracy of 81% and 85%, respectively. CONCLUSION: MR imaging may provide an accurate means of selecting patients considered for pelvic exenteration. MR accurately determined which patients should undergo the surgery, by demonstrating absence of sidewall abnormalities or adenopathy. Radiation changes could not be reliably distinguished from tumor involvement in those patients with sidewall abnormalities, however, especially in the first 6 to 12 months after treatment.

CT of intracranial cryptococcosis.

CT scans of 35 patients with intracranial cryptococcal infection were reviewed retrospectively. Studies were normal in 43% of the patients. Positive findings in others included diffuse atrophy in 34%, mass lesions (cryptococcoma) in 11%, hydrocephalus in 9%, and diffuse cerebral edema in 3%. Two unusual types of cryptococcoma were encountered, namely gelatinous pseudocysts and an intraventricular cryptococcal cyst. All findings were nonspecific for CNS cryptococcosis. The results suggest that CNS cryptococcosis should be considered in all patients at risk for the disease who have these abnormal CT findings, no matter what their initial clinical presentation. In addition, MR demonstration of gelatinous pseudocysts in one patient indicates that this technique may be helpful in locating cryptococcal mass lesions not visualized on CT.

CT of intracranial cryptococcosis.

CT scans of 35 patients with intracranial cryptococcal infection were reviewed retrospectively. Studies were normal in 43% of the patients. Positive findings in others included diffuse atrophy in 34%, mass lesions (cryptococcoma) in 11%, hydrocephalus in 9%, and diffuse cerebral edema in 3%. Two unusual types of cryptococcoma were encountered, namely gelatinous pseudocysts and an intraventricular cryptococcal cyst. All findings were nonspecific for CNS cryptococcosis. The results suggest that CNS cryptococcosis should be considered in all patients at risk for the disease who have these abnormal CT findings, no matter what their initial clinical presentation. In addition, MR demonstration of gelatinous pseudocysts in one patient indicates that this technique may be helpful in locating cryptococcal mass lesions not visualized on CT.