Transient hypoadrenalism during surgical critical illness.

OBJECTIVE: To report the cortisol levels in 6 patients during and after severe inflammation. DESIGN: Patients with severe inflammatory disease had basal and stimulated (cosyntropin) serum cortisol levels determined at the time of severe and less severe inflammation. SETTING: Intensive care unit and wards of a tertiary care center. PATIENTS: Six patients with continued evidence of severe inflammation, despite aggressive management of the underlying inflammatory disease. INTERVENTIONS: Five of 6 patients received hydrocortisone at "physiologic" doses. MAIN OUTCOME MEASURES: Basal and stimulated serum cortisol levels. RESULTS: The mean+/-SD cortisol data for these patients were as follows: baseline cortisol level during inflammation, 350+/-121 nmol/L (n=6); stimulated cortisol level during inflammation, 571+/-326 nmol/L (n=6); baseline cortisol level with less inflammation, 833+/-339 nmol/L (P=.03 vs baseline level during inflammation) (n=5); and stimulated cortisol level with less inflammation, 1090+/-295 nmol/L (P=.03 vs stimulated level during inflammation) (n=4). Manifestations of inflammation decreased with hydrocortisone administration. CONCLUSIONS: Severe inflammation may result in lower-than-expected serum cortisol levels, which then increase significantly as the inflammation decreases. Transient hypoadrenalism may aggravate the adverse effects of severe inflammation. These effects may be ameliorated by administering physiologic rather than pharmacologic doses of hydrocortisone.

Short-term outcome after mesh or shouldice herniorrhaphy: a randomized, prospective study.

BACKGROUND: Retrospective analyses have shown that long-term recurrence rates after Lichtenstein mesh and Shouldice herniorrhaphies are low. Therefore differences in short-term outcome may be important determinants of one's choice of repair. Although proponents of the mesh repair claim that their methods is less morbid, to our knowledge no prospective comparative studies of short-term morbidity have been reported. METHODS: One hundred five adult patients were randomized to undergo either a mesh or Shouldice inguinal hernia repair. Postoperative pain, narcotic use, and time to resumption of usual activities and employment were recorded. Patients were blinded to the type of repair received until all data were collected. RESULTS: There was no difference between the herniorrhaphy methods with respect to postoperative pain, duration of narcotic use, and time to resumption of usual activity and employment. Recovery was rapid for both groups of patients. By 3 days after operation, 50% of patients rated their pain as very mild or less and no longer required narcotic analgesics. Patients in both groups returned to usual activity and work by a median of 9 days after operation. CONCLUSION: Both of these well-established methods can be used to repair inguinal hernias with local anesthetics in an outpatient setting with minimal morbidity. Despite the "tension-free" design of the mesh repair, short-term outcomes of mesh and Shouldice repairs of inguinal hernias do not differ.

Surgical perspective on invasive Candida infections.

Invasive and disseminated Candida infections have become a major source of morbidity and mortality in the modern surgical intensive care unit. The most common risks for invasion and dissemination are the use of antibiotics, central venous lines, total parenteral nutrition, burns, immunosuppression, and other markers for severity of illness (APACHE > 10, ventilatory use for > 48 hours). Data suggest that colonization can be a late predictor of invasive disease in today's critically ill surgical patient and that prophylaxis or early treatment in high risk patients is warranted, particularly before invasive/disseminated disease becomes life-threatening. When advanced disease is present, the diagnosis of invasive or disseminated Candida infection is often prompted by clinical suspicion and supported by consistent clinical data; laboratory tests alone lack sufficient sensitivity and specificity to direct therapeutic decision-making. Once the diagnosis of invasive or disseminated Candida infection is ascertained, early systemic treatment, along with treatment of localized infection, is as fundamental as with any other serious infectious disease. Reported toxicity and efficacy supports the use of fluconazole for most patients with invasive/disseminated Candida infections. For the most critically ill surgical patient amphotericin B remains the treatment of choice. Prophylaxis and early treatment strategies with minimally toxic agents may diminish the need to use more toxic therapy in the most severely ill patients.

Communication effectiveness training improves surgical resident teaching ability.

BACKGROUND: An important educational objective of academic surgical programs is to train surgical teachers. Whether formal instruction of surgery residents in general principles of teaching has a role in the achievement of this objective is unproven. STUDY DESIGN: We tested whether the teaching ability of surgery residents could be improved by two different interventions: (A) a lecture on communication effectiveness plus home study of their own videotaped lectures and (B) a critical review of their own videotaped lectures with a teaching consultant. Each resident taught four sessions. There was no intervention between sessions 1 and 2; intervention A occurred between sessions 2 and 3; and intervention B, between sessions 3 and 4. Each of the four videotaped sessions was graded for communication effectiveness using a standardized scoring form. RESULTS: There were no significant differences between scores from lectures 1 and 2 (no intervention) or lectures 2 and 3 (intervention A). Intervention B (individualized feedback) resulted in significant improvement in all scores from session 4 compared with sessions 1 and 2: content 3.40 versus 2.98 (p = 0.01), language 3.43 versus 3.22 (p = 0.03), delivery 3.25 versus 2.87 (p = 0.002), and overall 3.43 versus 2.88 (p = 0.002). CONCLUSIONS: Surgical resident teaching ability can be improved by communication effectiveness teaching. Individualized feedback is more effective than a lecture combined with self-study.

Continuous arteriovenous hemofiltration attenuates polymorphonuclear leukocyte phagocytosis in porcine intra-abdominal sepsis.

BACKGROUND: Activation of circulating polymorphonuclear leukocytes (PMN) is a characteristic of systemic inflammation and may contribute to organ malfunction. Continuous arteriovenous hemofiltration (CAVH) has been reported to improve organ malfunction during severe systemic inflammation. This study postulates that the CAVH effects may be linked to alterations in PMN activation. METHODS: Sixteen pigs that underwent cecal ligation and rupture were randomized to receive CAVH or no CAVH for 24 hours. The PMN phagocytosis of Candida was measured prior to the insult and at 24, 48, and 72 hours. Temperature, total leukocyte count (WBC), hemodynamic, blood gas, microbiologic, and ionized calcium data were also collected. RESULTS: All animals developed increased temperature, heart rate, and WBC, and positive blood and peritoneal cultures. Hemodynamic, pulmonary, and ionized calcium changes were not different between the CAVH and no CAVH groups. Phagocytosis of PMN increased in the no CAVH group at 24 hours, but not in the CAVH group. After discontinuing CAVH, phagocytosis increased to the no CAVH rate at 48 and 72 hours. CONCLUSIONS: Continuous arteriovenous hemofiltration attenuates the upregulation of PMN phagocytosis of Candida; this effect disappears after CAVH is discontinued. Hemofiltration does not affect many other manifestations of sepsis, which implies that these manifestations may not be related to PMN phagocytosis capacity.

Fungal infection in surgical patients.

Invasive fungal infections have become a major source of morbidity and mortality in the modern surgical intensive care unit. Patients at risk for invasion and dissemination are common, and are not as ill as thought previously. Severity of illness (APACHE II score > 10, ventilator use for >48 hours), antibiotics, central venous lines, total parenteral nutrition, burns, and immunosuppression are the most common risk factors. Recognition of these risk factors should arouse a high index of suspicion for the diagnosis of invasion or dissemination. Unfortunately, laboratory tests alone lack sensitivity and specificity. Therefore, the diagnosis of invasion and dissemination in the majority of cases requires the acquisition and proper interpretation of clinical evidence. Once the diagnosis is made, early systemic treatment is warranted. Reported toxicity and efficacy supports the use of fluconazole for most patients with invasive fungal infections. However, for the most critically ill patients amphotericin B remains the treatment of choice.

Severe pancreatitis. Determinants of mortality in a tertiary referral center.

OBJECTIVE: To determine factors associated with mortality in patients with severe pancreatitis. DESIGN: Retrospective review. SETTING: University tertiary referral center intensive care unit (ICU). PATIENTS: Thirty patients admitted to the ICU with the primary diagnosis of pancreatitis from 1986 to 1995. MAIN OUTCOME MEASURE: Survival vs nonsurvival. RESULTS: Twenty-seven patients were transferred from another institution. At the time of ICU admission, subsequent death was not associated with the following: systolic blood pressure, pulse rate, hemoglobin level, leukocyte count, platelet count, or serum calcium concentration. The patients who died during the study were older at admission (age [mean+/-SD] of those who lived, 47+/-17 years; age of those who died, 64+/-8 years; P=.01) and their serum creatinine concentrations were higher (creatinine concentrations [mean +/-SD] of those who lived, 150+/-90 micromol/L [1.7+/-1.0 mg/dL]; creatinine concentrations of those who died, 410+/-250 micromol/L [4.6+/-2.8 mg/dL]; P=.001). Clinical events not associated with mortality included respiratory failure, insulin use, positive blood cultures, positive pancreatic cultures, and abdominal surgery for pancreatitis and infected pancreatic necrosis. Death was associated with the use of inotropic and/or vasopressor support (P=.05) and renal failure (creatinine, >170 micromol/L[>2.0 mg/dL]) at any time during the ICU stay (P=.01). Patients with renal failure were no older than the patients without, but were admitted later after the onset of pancreatitis (mean+/-SD, 5.9+/-7.2 days vs 1.5+/-1.1 days; P=.03; median, 2 days vs 1 days). CONCLUSIONS: After hospital transfer to a teritiary referral center, only older age, use of inotropic and/or vasopressor support, and evidence of renal malfunction are associated with death. Prompt recognition of severe pancreatitis, especially in older patients, aggressive hemodynamic management, and/or earlier transfer to a tertiary care center may diminish the incidence of renal failure and mortality in severe pancreatitis.

A surgery oral examination: interrater agreement and the influence of rater characteristics.

BACKGROUND: Poor interrater reliability is a common objection to the use of oral examinations. METHOD: In 1990 the authors measured the agreement of 140 U.S. and Canadian surgical raters and the influences, if any, of age, years in practice, and experience as an examiner on individual oral examination scores. Eight actor examinees memorized transcripts of actual oral examinations and were videotaped using a single examiner. Examinee verbal style, dress, content of answers, and gender were purposefully adjusted. A repeated-measures analysis of variance was used for data analysis. RESULTS: Three aspects of examinee performance influenced scores (verbal style, dress, and content of answers). No rater characteristic significantly affected scores. Raters showed high agreement (86%) when rating "good" performances but less agreement (67%) when rating "poor" performances. CONCLUSION: The oral examination scores were not influenced by rater selection. The raters ranked good performances more consistently than poor performances. Therefore, more than one examiner appears necessary to confirm a poor performance during an examination.

Long-term morbidity following jejunoileal bypass. The continuing potential need for surgical reversal.

OBJECTIVE: To review the late sequelae of jejunoileal bypass (JIB) and the potential role of late surgical reversal in ameliorating morbidity and mortality following JIB. DESIGN: Patients who underwent JIB between 1965 and 1977 were contacted and pertinent health-event information was gathered. Early sequelae were defined as disorders occurring within the first 2 years after JIB; late sequelae were those occurring after 2 years. Health events occurring between 0 and 23 years after JIB were documented. SETTING: A private, tertiary referral center. PATIENTS: Patients underwent JIB for morbid obesity that had failed medical and/or psychiatric interventions. MAIN OUTCOME MEASURES: Body mass index (BMI) (weight kilograms divided by the square of the height in meters), diarrhea, electrolyte imbalance, acute, and chronic liver disease, renal disease, JIB reversal, reason for JIB reversal, death, and cause of death. RESULTS: A total of 453 morbidity obese patients underwent JIB. By 2 years following JIB, the mean (+/- SD) BMI dropped from 49.3 +/- 8.1 to 31.1 +/- 0.8 and remained at this level until year 15, after which weight gradually increased (BMI, 35.4 +/- 3.1). The most severe early complication was acute liver failure, which occurred in 7% of patients and caused seven deaths. At 15 years, the actuarial probability of the most common serious late complications related to JIB were renal disease (37%), with two deaths; diarrhea (29%); and liver disease (10%), with three deaths. One hundred thirty-eight patients (31%) had a bypass reversal. The most common indications for reversal were diarrhea and electrolyte disturbance (29%), renal disease (19%), and liver disease (17%). Fifty-six patients died more than 30 days after JIB: 64% before JIB reversal, 13% at the time of reversal, and 23% subsequently. CONCLUSIONS: Jejunoileal bypass is associated with progressive accrual of serious, sometimes life-threatening complications. Lifelong follow-up for early diagnosis and surgical reversal before life is threatened should reduce the morbidity and mortality associated with this procedure.

Fungal sepsis.

Immunocompromise can result from trauma, burns, cancer, cancer chemotherapy, and immunosuppressive therapy. Immunocompromise increases the risk of invasive infection from opportunistic fungi. The key to successful management of these infections is early recognition, aggressive therapy, and when indicated, surgical therapy. This article describes the common opportunistic fungal infections aspergillosis, zygomycosis, and candidiasis, which may arise in surgical patients or which may require surgical intervention for diagnosis or therapy.

Hypocalcemia during sepsis. Relationship to resuscitation and hemodynamics.

The ionized calcium (IC) and parathyroid hormone response to polymicrobial intra-abdominal sepsis and the relationship between IC and hemodynamic alterations with and without crystalloid resuscitation were investigated. Thirty swine underwent cecal ligation and incision (n = 19) or sham laparotomy (n = 11), with seven animals that had cecal ligation and incision administered Ringer's solution (50 mL/kg) after each set of measurements recorded on days 0, 1, 2, 4, and 8. An early decrease in mean arterial pressure and cardiac index in animals that had cecal ligation and incision reversed with resuscitation. The IC also fell early and parathyroid hormone level increased in both the unresuscitated and resuscitated septic groups. However, correlation coefficients of mean arterial pressure and cardiac index with IC ranged from .034 to .287 in the septic animals and were lower in the group that had sham laparotomy. We conclude that polymicrobial intra-abdominal sepsis results in decreased IC and an elevated parathyroid hormone level. Hemodynamics do not correlate with IC levels, and resuscitation can be achieved without calcium administration.

Patterns of liver test abnormalities in patients with surgical sepsis.

The progression of changes in biochemical liver test results during moderate and severe sepsis (SS) was studied prospectively in 43 patients admitted to a surgical intensive care unit. Using predetermined criteria, severity of sepsis was assessed by physicians blinded to the liver test results. Linear regression analysis showed that bilirubin levels increased at a rate approximating 0.95 mg/dl/day in patients with SS, whereas alkaline phosphatase levels did not rise initially in these patients. Following peak hyperbilirubinemia, however, alkaline phosphatase levels increased at approximately 4 IU/L/day. In patients with moderate sepsis (MS), bilirubin levels increased slowly (approximately 0.4 mg/dl/day) but alkaline phosphatase levels increased rapidly (approximately 29 IU/L/day). Following peak hyperbilirubinemia, alkaline phosphatase levels did not change. These data define patterns of liver test abnormalities of clinical importance. Rapidly rising bilirubin levels with little change in alkaline phosphatase levels are associated with SS, whereas markedly elevated alkaline phosphatase levels may indicate MS or resolution of SS. In critically ill surgical patients subjected to many potential hepatic insults, recognition of liver dysfunction with these patterns should alert the clinician to the possibility of underlying sepsis.

Intraabdominal sepsis: enhanced autooxidative effect on polymorphonuclear leukocyte cell surface receptor expression.

We investigated the effects of untreated intraabdominal sepsis on the interrelationship between PMN oxidative metabolism and cell surface receptor expression. Female swine underwent either sham laparotomy (n = 7) or cecal ligation and incision (n = 9) with assays conducted on postoperative days (POD) 0, 1, 4, and 8. Superoxide anion production, intracellular H2O2 production, and the cell surface expression of Fc gamma RII, III, CR1, and CR3 were measured. In addition, phagocytosis of serum-opsonized zymosan was used as a multivalent ligand for CR3 and subsequently Fc gamma RII, III, and CR1 expression were assayed to determine if intraabdominal sepsis induces a linkage between complement and Fc gamma receptor expression. Superoxide anion production increased between POD 0 and 4 and fell between POD 4 and 8 in animals with untreated intraabdominal sepsis. Intracellular H2O2 production rose between POD 0 and 1 and then fell progressively in animals with untreated intraabdominal sepsis. Simulation of the oxidative burst using glucose/glucose oxidase reduced Fc gamma RII and III expression in both sets of animals with a greater reduction seen by POD 4 in animals with intraabdominal sepsis. CR1/CR3 expression was increased with glucose/glucose oxidase by POD 4 in the presence of intraabdominal sepsis. Xanthine/xanthine oxidase did not alter cell surface receptor expression. Phagocytosis of serum-opsonized zymosan decreased subsequent Fc gamma RII expression in animals with intraabdominal sepsis by POD 4.(ABSTRACT TRUNCATED AT 250 WORDS)

Transesophageal echocardiography. Preliminary results in patients with traumatic aortic rupture.

Eleven patients with blunt chest trauma at risk for traumatic aortic rupture underwent transesophageal echocardiography to image the descending aorta. Diagnoses were compared with the results of radiographic studies. Ten of the 11 patients underwent arch aortography, with positive results in six cases. In one patient, the results of a computed tomographic scan were interpreted as consistent with aortic rupture. The results of transesophageal echocardiography were positive for ruptured descending aorta in three of six patients with positive aortographic findings, and negative in eight patients. All three patients with positive findings had the diagnosis of ruptured descending aorta confirmed at surgery. The remaining eight patients demonstrated no aortic morbidity. These preliminary findings suggest that transesophageal echocardiography is a useful technique for the diagnosis of ruptured descending aorta following blunt chest trauma.

Role of gastric colonization in the development of pneumonia in critically ill trauma patients: results of a prospective randomized trial.

Critically ill trauma patients were entered in a prospective, randomized trial to determine the role of gastric colonization in the development of pneumonia. Trauma patients admitted to the SICU were randomized to receive antacids (n = 27), continuous IV cimetidine (n = 32), or sucralfate (n = 30). Quantitative nasogastric tube (NGT) cultures were obtained biweekly and correlated with gastric pH, the incidence of pneumonia, and the incidence of pneumonia caused by an organism previously isolated from the stomach (percentage of gastric source of pneumonia--% GSP). Patients receiving antacids had a significantly greater pH than those receiving cimetidine (5.6 +/- 1.03 vs. 4.7 +/- 1.03; p = 0.006). However, there was no significant difference between the overall incidence of pneumonia, the percentage of NGT isolates greater than 10(6)/ml, or the % GSP. The gastric bacteriology of the three subgroups was nearly identical, with Candida albicans, Enterococci, and beta-hemolytic Streptococci being the most frequently isolated organisms. Gastric growth of organisms preceding their appearance in the blood occurred in 5 of 89 (5.6%) patients. These results suggest that 1) in trauma patients, the incidence of pneumonia is not increased by the use of stress ulcer prophylactic agents that elevate gastric pH; 2) increases in gastric pH progressively increased the number of intragastric bacteria but this did not correlate with an increased incidence of % GSP; and 3) while organisms in the upper intestinal tract may be pathogens for pneumonia, they are uncommonly a source of bacteremia in seriously injured patients.

Influence of effective communication by surgery students on their oral examination scores.

This study investigated the influences of specific elements of surgery students' verbal and nonverbal communication on evaluators' "objective" ratings of several categories of the students' performances on oral examinations. Three actors and two actresses, dressed as surgery students in a wide range of attire, were videotaped as they reenacted five transcripts of actual students' responses in their oral examinations. For each examination, the actors portrayed the students' responses to the same examining surgeon in two formats, one using direct eye contact with a moderate response rate (Style A) and the other using indirect eye contact with a slower response rate (Style B). All transcripts were taped at least twice. The resulting 255 videotaped "examinations" were randomly distributed in 1988 to 78 clinical surgery faculty representing 46 institutions throughout the United States and Canada. These faculty viewed the reenactments (under the impression they were actual examinations) and rated the "students" performances overall and in ten categories concerning different aspects of the students' knowledge, clinical decision-making skills, and personal characteristics. The performances done in Style A were rated significantly higher than those done in Style B (1) in every performance category except decision making and (2) when the scores were classified by the content of the responses and how professionally dressed the students were. There were also a significant relationship between scores on communication skills and the overall all scores on examinations. These findings suggest that regardless of the content of a student's responses on an oral examination, evaluators are strongly influenced by how well the student communicates.

Splenic artery ligation for splenic salvage: clinical experience and immune function.

Documentation of overwhelming post-splenectomy sepsis, characterized by infection from encapsulated organisms, has led to development of surgical techniques for preservation of the injured spleen to maintain splenic clearance of encapsulated, opsonized organisms from the circulation. In this study splenic artery ligation (SAL) was performed as an adjunct to successful splenorrhaphy in 20 adults suffering blunt splenic injury. There were no deaths and no reoperations. Twenty units of blood were transfused in ten patients. Splenic removal of blood-borne opsonized particles was measured as the clearance of anti-Rh-antibody-coated 51Cr-radiolabeled autologous red blood cells from the circulation in five SAL patients and nine normal volunteers. The clearance of opsonized red cells 120 minutes after injection was not different (40 +/- 7% of injected dose in controls, 40 +/- 4% in SAL patients). These results demonstrate that SAL can safely be applied as an adjunct to splenorrhaphy and that SAL does not diminish splenic clearance of opsonized particles from the circulation.

Altered polymorphonuclear leukocyte Fc gamma R expression contributes to decreased candicidal activity during intraabdominal sepsis.

We investigated the effects of untreated intraabdominal sepsis on polymorphonuclear leukocyte (PMN) candicidal activity. Two groups of swine were studied. Group I (n = 6) underwent sham laparotomy, group II (n = 7) underwent cecal ligation and incision. Untreated intraabdominal sepsis resulted in a progressive decrease in PMN candicidal activity. Concomitant rosetting and phagocytosis assays demonstrated a decrease in both the attachment and phagocytosis of Candida albicans opsonized with both normal and septic swine serum by PMNs in group II. Iodine 125-labeled swine immunoglobulin G (IgG) and fluorescein isothioalanate (FITC)-labeled swine IgG were used to investigate Fc gamma receptor ligand interactions. Scatchard analyses demonstrated a progressive decline in both the binding affinity constant and number of IgG molecules bound per PMN. Stimulation of the oxidative burst markedly reduced 125I-labeled IgG binding in both group I and group II, with a greater decrement being seen in animals with intraabdominal sepsis. Further, in group II, PMN recycling of the Fc gamma receptor to the cell surface after generation of the oxidative burst was reduced by postoperative day 4. Binding of monoclonal antibodies to Fc gamma receptor II, but not Fc gamma receptor I/III markedly reduced intracellular candicidal activity. Immunofluorescence studies revealed a homogeneous pattern of FITC-IgG uptake by nearly all group I PMNs, whereas by postoperative day 8 a substantial number of PMNs from group II failed to internalize the FITC-IgG. These studies suggest that untreated intraabdominal sepsis reduces PMN candicidal activity and that this is due, in part, to altered PMN Fc gamma receptor ligand interactions.