Persistent exit-site/tunnel infection and subcutaneous cuff removal in PD patients.

The purpose of our study was to investigate catheter outcome of persistent exit-site/tunnel infections (ESI/TIs) in peritoneal dialysis (PD) patients. The patients underwent removal of subcutaneous cuff due to persistent ESI/TI from January 1989 to December 1996 in a tertiary referral university hospital. Two hundred and twenty-three patients (138 male, 85 female) underwent 244 double-cuff coiled Swan neck catheter implantations surgically. Twenty-nine patients (11.8%) had persistent ESI/TI for more than 6 months with the same organism. Sixteen patients (52%) underwent subcutaneous cuff excision. Thirteen (48%) patients refused and were managed conservatively. Two hundred and forty-three episodes of ESI/TI were observed over 4970 patient-months with a rate of 0.58 episodes/patient/year. Twenty-nine patients (11.8%) had persistent ESI/TI with S. aureus in 19, Pseudomonas aeruginosa in 9 (31%), and Serratia marcescens in one (3%) patient. Fourteen (88%) persistent ESI/TIs resolved after subcutaneous cuff excision. None of the patients with ESI/TI responded to conservative treatment. ESI/TI-related peritonitis decreased from 11 episodes to 5 episodes after cuff excision. In contrast, episodes of peritonitis increased from one to 9 with conservative management during a follow-up of mean 18 months (4-38 months). Four (31%) catheters were lost in the conservative group, while 3 (19%) were lost after cuff excision. ESI/TI-related peritonitis decreased after subcutaneous cuff excision but increased with conservative management for ESI/TI. ESI/TI resolved in 88% of the patients after cuff excision, while none resolved with conservative treatment.

Endogenous peritonitis and related outcome in peritoneal dialysis patients.

Our objective was to study endogenous peritonitis and related catheter outcome in peritoneal dialysis (PD) patients. The study was designed to investigate endogenous peritonitis and related catheter loss in all end-stage renal disease (ESRD) patients who started peritoneal dialysis from January, 1989 to September, 1995. In a tertiary-referral university hospital, 192 ESRD patients (117 male, 75 female) who entered the home program from 1/89 to 9/95 were studied. Sixteen episodes of endogenous peritonitis occurred in 15 PD patients (7 male, 8 female) with a mean age of 63 years (range 33-81 years). Five patients were diabetic. Two hundred and seventeen episodes of peritonitis in 192 patients occurred over 4149 patient-months, resulting in one episode/19.1 patient-months. Sixteen episodes of endogenous peritonitis were encountered in 15 patients, accounting for 7% of all episodes of peritonitis. The mean duration of PD before contracting endogenous peritonitis was 24.2 months (range 7-52 months). Eleven episodes were related to diverticular leak/perforation, three to sigmoidoscopy/colonoscopy/PEG procedures, one to unknown etiology, and one to cholecystitis. During 11 episodes, severe constipation preceded. All the patients were initially treated conservatively with antibiotics. Five episodes (31%) responded to antibiotic therapy alongside antifungal prophylaxis and continued PD. One episode (6%) required cholecystectomy without catheter removal and resumed PD. Six episodes (38%) required catheter removal due to subsequent fungal peritonitis in a mean of 11 days (range 3-24 days): 4 patients transferred to hemodialysis and 2 patients resumed PD. Three patients underwent catheter removal along with colectomy and colostomy: 2 patients transferred to hemodialysis and 1 patient died in ten days. One patient refused surgery and died in 16 days. Endogenous peritonitis resulted in a high incidence of catheter loss and dropout from PD. Peritonitis due to bowel leak without frank bowel perforation can be managed with antibiotic therapy and antifungal prophylaxis. Aggressive management of constipation may decrease endogenous peritonitis.

Efficacy of albumin supplementation in the surgical intensive care unit: a prospective, randomized study.

OBJECTIVE: To determine the efficacy of supplemental 25% albumin in reducing morbidity and mortality rates in the surgical intensive care unit (ICU). DESIGN: Prospective, randomized, unblinded clinical study. SETTING: Surgical ICU in a community hospital. PATIENTS: Two hundred nineteen patients with admission circulating albumin concentrations of < 3.0 g/dL (< 30 g/L). The groups were well matched regarding age, sex, Acute Physiology and Chronic Health Evaluation II scores and initial circulating albumin concentrations. INTERVENTIONS: The treatment group (n = 116) received 37.5 g/day of albumin until the circulating albumin concentration increased to > 3.0 g/dL (> 30 g/L). The control group (n = 103) received no supplemental albumin. Both groups received standard nutritional support. MEASUREMENTS AND MAIN RESULTS: The complication rate was 44% in the albumin group vs. 36.9% in the controls (p = .29). The albumin patients had a mortality rate of 10.3% vs. 5.8% in the control group (p = .22). There were no significant differences between the groups in the number of days spent receiving mechanical ventilation or in the tolerance to tube feedings. CONCLUSIONS: Routine supplemental administration of 25% albumin is expensive and offers no apparent outcome advantage and should be abandoned in the treatment of patients in the surgical ICU.

Complication of the intracolonic bypass. Report of a case.

The intracolonic bypass has been used both experimentally and clinically to avoid high-risk primary colonic anastomosis in the face of peritonitis. Experimental and clinical data have established the Coloshield as safe, with few clinical complications reported. This is a review of the literature and a case report of a complication of an intracolonic bypass that was found to have eroded through the colon in the early postoperative period.

Efficacy of preadmission testing in ambulatory surgical patients.

A retrospective study was done with 325 patients who had preadmission testing prior to ambulatory surgery. At least one laboratory abnormality was noted in 84% of the patients. The serial multiple analysis (SMA)-7 was abnormal 63% of the time. Abnormalities were seen in 54% of the SMA-12 panels and 38% of the urinalyses performed. Twenty-four percent of the patients treated had an abnormal electrocardiogram (ECG). An abnormal chest roentgenogram was found in 19% of the patients. Only three (1%) patients potentially benefited from preadmission testing. Ninety-six percent of the abnormal laboratory results were ignored by the attending physicians. Therefore, we conclude that preadmission testing should be done on a selective basis. Patients older than 50 years of age should have an ECG. A hematocrit should be obtained only if major blood loss is anticipated. All other tests should be ordered based on the history and physical examination.