Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit.

Critically ill patients with requirement of continuous renal replacement therapy (CRRT) represent a growing intensive care unit (ICU) population. Optimal CRRT delivery demands continuous communication between stakeholders, iterative adjustment of therapy, and quality assurance systems. This Quality Improvement (QI) study reports the development, implementation and outcomes of a quality assurance system to support the provision of CRRT in the ICU. This study was carried out at the University of Kentucky Medical Center between September 2016 and June 2019. We implemented a quality assurance system using a step-wise approach based on the (a) assembly of a multidisciplinary team, (b) standardization of the CRRT protocol, (c) creation of electronic CRRT flowsheets, (d) selection, monitoring and reporting of quality metrics of CRRT deliverables, and (e) enhancement of education. We examined 34-month data comprising 1185 adult patients on CRRT (~ 7420 patient-days of CRRT) and tracked selected QI outcomes/metrics of CRRT delivery. As a result of the QI interventions, we increased the number of multidisciplinary experts in the CRRT team and ensured a continuum of education to health care professionals. We maximized to 100% the use of continuous veno-venous hemodiafiltration and doubled the percentage of patients using regional citrate anticoagulation. The delivered CRRT effluent dose (~ 30 ml/kg/h) and the delivered/prescribed effluent dose ratio (~ 0.89) remained stable within the study period. The average filter life increased from 26 to 31 h (p = 0.020), reducing the mean utilization of filters per patient from 3.56 to 2.67 (p = 0.054) despite similar CRRT duration and mortality rates. The number of CRRT access alarms per treatment day was reduced by 43%. The improvement in filter utilization translated into ~ 20,000 USD gross savings in filter cost per 100-patient receiving CRRT. We satisfactorily developed and implemented a quality assurance system for the provision of CRRT in the ICU that enabled sustainable tracking of CRRT deliverables and reduced filter resource utilization at our institution.

Clostridium perfringens sepsis following a molar pregnancy.

Clostridium perfringens sepsis is rare since the legalization of abortion in 1973. This is a 49 year old female who developed clostridial sepsis after suction dilation and curettage for a molar pregnancy. A hysterectomy was performed after prompt recognition, and the patient survived.

Are age cutoffs still used to identify candidates for invasive testing for chromosomal abnormalities?

OBJECTIVE: Our objective was to determine whether women > or = age 35 are more likely to undergo invasive testing after risk adjustment as compared with younger women at similar adjusted risk. STUDY DESIGN: Results of first-trimester combined aneuploidy risk assessment of singleton pregnancies from 2007-2008 were reviewed. For each level of adjusted risk, the rate of invasive testing (CVS or amniocentesis) was compared for those < age 35 and those > or = age 35. Spearman correlation, Fisher's exact test, and chi2 for trend were used for statistical comparison. RESULTS: For all categories except adjusted risk of 1 in < or = 250, women > or = age 35 were significantly more likely to undergo invasive testing as compared with younger women of similar risk. In women > or = age 35 with low adjusted risk, we observed a trend towards lower rates of invasive testing over time. CONCLUSION: The higher rate of invasive testing in those > or = 35 indicates that women are still being categorized based on age, though our data suggest this may be decreasing.

Embryonal rhabdomyosarcoma of the cervix and appendiceal carcinoid tumor.

BACKGROUND: Rhabdomyosarcomas, particularly those of gynecologic origin, are very rare in adults. As a result, there is little literature on the optimal staging procedure and treatment modalities for this population. CASE: A 43-year-old woman presented with a long-standing history of menorrhagia and was subsequently diagnosed with embryonal rhabdomyosarcoma of the cervix. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection, omentectomy, and appendectomy, which also revealed a synchronous tubular carcinoid tumor of appendiceal origin. Plans for treatment involve adjuvant chemotherapy with vincristine, dactinomycin, and cyclophosphamide. CONCLUSION: This case adds to the small body of literature surrounding cervical embryonal rhabdomyosarcoma in women over the age of 40 years and proposes that appendectomy be considered during surgical management.