Discharge against Medical Advice in Surgical Patients with Posttraumatic Stress Disorder: A Case Report Series Illustrating Unique Challenges.

Discharge against medical advice (DAMA) can have detrimental effects on patient outcomes. Recently, the diagnosis of posttraumatic stress disorder (PTSD) has been linked with DAMA in the mental health setting. However, PTSD as a risk factor for DAMA in surgical patients has not received much consideration, although such patients may be at risk for triggering or amplification of PTSD symptoms perioperatively. We present the first case report series of three surgical patients with PTSD who left the hospital AMA. These cases differ markedly from DAMA in non-PTSD patients. In all three subjects, the stress of feeling misunderstood by clinicians and the distress of public detainment by hospital security in the setting of chronic PTSD led to aggressive and risky behavior. All three subjects represented a risk to themselves and to others at the time of DAMA. Finally, all three subjects were difficult to contact for follow-up or medical care and missed appointments.

Serotonin Syndrome Following an Uncomplicated Orthopedic Surgery in a Patient With Post-Traumatic Stress Disorder.

Serotonin syndrome (SS) is a potentially life-threatening adverse drug reaction that may occur in patients treated with serotonin agonist medications. Medications responsible for serotonin syndrome include commonly prescribed antidepressants, anxiolytics, analgesics, and antiemetics. Veterans with post-traumatic stress disorder (PTSD) are at risk for polypharmacy with serotoninergic medications, given their psychological comorbidities and service-related musculoskeletal injuries. The perioperative period is a particularly vulnerable time owing to the use of high-dose anxiolytics and antiemetics frequently administered in this period, and places PTSD patients at higher risk of SS. Herein, we present the first case of SS in a young veteran with combat-related PTSD following an uncomplicated L5-S1 revision discectomy that highlights the unique set of clinical challenges and dilemmas faced when treating SS in a patient with severe postsurgical pain. As we are likely to encounter increasing numbers of veterans treated for PTSD who require multiple surgical procedures to treat their service-related injuries, health care providers need to be familiar with prevention, recognition, and the clinical challenges in the management of SS in the postoperative period.

Invasive Mechanical Ventilation in California Over 2000-2009: Implications for Emergency Medicine.

INTRODUCTION: Patients who require invasive mechanical ventilation (IMV) often represent a sequence of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most populous state, little information exists to define patterns of IMV use within the state of California. METHODS: We examined data from the masked Patient Discharge Database of California's Office of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV during their stay were identified using the International Classification of Diseases 9th Revision and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age strata (18-34 yr, 35-64 yr, and >65 yr). Using descriptive statistics and regression analyses, for IMV discharges during the study period, we quantified the number of ED vs. non-ED based admissions; changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV; determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96 hr); and projected the number of IMV discharges and ED-based admissions by year 2020. RESULTS: There were 696,634 IMV discharges available for analysis. From 2000-2009, IMV discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868 (328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35-64 year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by 29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for younger patients (ages 18-34 yr), non-whites, and publicly insured patients. Some of the strongest predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites; and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED. CONCLUSION: Based on sustained growth over the past decade, by the year 2020, we project a further increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed capacities, ongoing increases in the number and type of IMV patients have the potential to adversely affect California EDs that often admit patients to ICUs.

Development of a Veterans Affairs hybrid operating room for transcatheter aortic valve replacement in the cardiac catheterization laboratory.

IMPORTANCE: Transcatheter aortic valve replacement (TAVR) revolutionized the treatment of aortic stenosis. Developing a TAVR program with a custom-built hybrid operating room (HOR) outside the surgical operating room area poses unique challenges in Veterans Affairs (VA) institutions. OBJECTIVE: To present the process by which the San Francisco VA Medical Center developed a VA-approved TAVR program, in which an HOR exists in a cardiac catheterization laboratory, as a guideline for future programs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of each required approval process for developing an HOR in a cardiac catheterization laboratory in a VA designated for complex surgery. Participants included San Francisco VA Medical Center health care professionals and individuals responsible for new program initiation in VA institutions. EXPOSURES: External reviews by industry vendors, the VA Central Office, and the Office for Construction, Facilities, and Management and an internal Healthcare Failure Mode and Effect Analysis. MAIN OUTCOMES AND MEASURES: The timeline for each process. RESULTS: Developing a TAVR program required vetting and approval from industry vendors, who provided training and expertise. Architectural plans for construction of the HOR began in 2010-2011, followed by approval from Edwards Lifesciences, Inc, in 2012 and fundamentals training on February 8 and 9, 2013. Following a pilot launch of the first VA TAVR program at the Houston VA Medical Center, subsequent programs were required to submit a plan to the VA Central Office for proposed restructuring of their clinical programs. After the San Francisco VA Medical Center proposal submission on February 3, 2013, a site visit consisting of a National Chief of Catheterization Laboratory Managers, a cardiac surgeon, and an interventional cardiologist with TAVR experience was conducted on April 12, 2013. During construction, HOR plans were inspected by the Office for Construction, Facilities, and Management followed by on-site inspection on August 8, 2013, to assess the adequacy of the HOR, newly built restricted corridors, equipment storage areas, and altered staff and patient flow patterns. Last, a Healthcare Failure Mode and Effect Analysis was performed to mitigate any negative effects of the HOR not being colocated in the surgical operating room area. Approval was then granted on November 13, 2013. Our first 10 TAVR cases were successfully completed as of April 2, 2014. CONCLUSIONS AND RELEVANCE: The primary factor for development of a successful TAVR program is integration of the heart valve team. Particular adaptations to the cardiac catheterization laboratory environment are required to accommodate an uncompromised HOR in which cardiac and vascular surgeons can be as comfortable as their interventional cardiology colleagues.

Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System.

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I. OBJECTIVE: To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I. DESIGN: A retrospective cohort study. SETTING: Veterans Affairs (VA) Healthcare System. PATIENTS: A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE-I who underwent inpatient surgery from calendar years 1999 to 2012. INTERVENTION: None. MEASUREMENTS: We classified surgical admissions based upon the timing of postoperative resumption of an ACE-I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30-day mortality data. We evaluated the relationship between 30-day mortality and the nonresumption of an ACE-I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient- and hospital-level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models. RESULTS: Twenty-five percent of our cohort did not resume an ACE-I during the 14 days following surgery. Nonresumption of an ACE-I within postoperative day 0 to 14 was independently associated with increased 30-day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30-3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship. CONCLUSIONS: Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated.

Perioperative ß-blockade: atenolol is associated with reduced mortality when compared to metoprolol.

BACKGROUND: The Atenolol study of 1996 provided evidence that perioperative ß-blockade reduced postsurgical mortality. In 1998, the indications for perioperative ß-blockade were codified as the Perioperative Cardiac Risk Reduction protocol and implemented at the San Francisco Veterans Affairs Medical Center. The current study tested the following hypothesis: Is there a difference in mortality rates between patients receiving perioperative atenolol and metoprolol? METHODS: Epidemiologic analysis of the operations performed at the San Francisco Veterans Affairs Medical Center since 1996 was performed. High-risk inpatients with perioperative ß-blockade were divided into two groups: patients who received perioperative atenolol only and those who received metoprolol only. Patients who switched between the two chronic oral ß-blocker medications were excluded. IV administration of ß-blockers was ignored. Propensity matching analysis was used to correct for population differences in risk factors. RESULTS: There were 38,779 operations performed from 1996 to 2008, with 24,739 inpatient procedures. Based on analysis of inpatient medication use, 3,787 patients received atenolol only (1,011) or metoprolol only (2,776). Thirty-day mortality (atenolol 1% vs. metoprolol 3%, P < 0.0008) and 1-yr mortality (atenolol 7% vs. metoprolol 13%, P < 0.0001) differed between the two ß-blockers. Analysis based on inpatient and outpatient ß-blocker use showed a similar pattern. Propensity matching that corrected for multiple cardiac risk factors found an odds ratio (OR) of 2.1 [95% CI 1.5-2.9], P < 0.0001 for increased 1-yr mortality with metoprolol for inpatient use. CONCLUSION: Perioperative ß-blockade using atenolol is associated with reduced mortality compared with metoprolol.

Predictors of early postdischarge mortality in critically ill patients: a retrospective cohort study from the California Intensive Care Outcomes project.

PURPOSE: Existing intensive care unit (ICU) mortality measurement systems address in-hospital mortality only. However, early postdischarge mortality contributes significantly to overall 30-day mortality. Factors associated with early postdischarge mortality are unknown. METHODS: We performed a retrospective study of 8484 ICU patients. Our primary outcome was early postdischarge mortality: death after hospital discharge and 30 days or less from ICU admission. Cox regression models assessed the association between patient, hospital, and utilization factors and the primary outcome. RESULTS: In multivariate analyses, the hazard for early postdischarge mortality increased with rising severity of illness and decreased with full-code status (hazard ratio [HR], 0.33; 95% confidence interval [CI], 0.21-0.49). Compared with discharges home, early postdischarge mortality was highest for acute care transfers (HR, 3.18; 95% CI, 2.45-4.12). Finally, patients with very short ICU length of stay (<1 day) had greater early postdischarge mortality (HR, 1.86; 95% CI; 1.32-2.61) than those with longest stays (≥7 days). CONCLUSIONS: Early postdischarge mortality is associated with patient preferences (full-code status) and decisions regarding timing and location of discharge. These findings have important implications for anyone attempting to measure or improve ICU performance and who rely on in-hospital mortality measures to do so.

The effect of race and ethnicity on outcomes among patients in the intensive care unit: a comprehensive study involving socioeconomic status and resuscitation preferences.

OBJECTIVE: We sought to determine whether race or ethnicity is independently associated with mortality or intensive care unit length of stay among critically ill patients after accounting for patients' clinical and demographic characteristics including socioeconomic status and resuscitation preferences. DESIGN: Historical cohort study of patients hospitalized in intensive care units. SETTING: Adult intensive care units in 35 California hospitals during the years 2001-2004. PATIENTS: A total of 9,518 intensive care unit patients (6,334 white, 655 black, 1,917 Hispanic, and 612 Asian/Pacific Islander patients). MEASUREMENTS AND MAIN RESULTS: The primary outcome was risk-adjusted mortality and a secondary outcome was risk-adjusted intensive care unit length of stay. Crude hospital mortality was 15.9% among the entire cohort. Asian patients had the highest crude hospital mortality at 18.6% and black patients had the lowest at 15.0%. After adjusting for age and gender, Hispanic and Asian patients had a higher risk of death compared to white patients, but these differences were not significant after additional adjustment for severity of illness. Black patients had more acute physiologic derangements at intensive care unit admission and longer unadjusted intensive care unit lengths of stay. Intensive care unit length of stay was not significantly different among racial/ethnic groups after adjustment for demographic, clinical, and socioeconomic factors and do-not-resuscitate status. In an analysis restricted only to those who died, decedent black patients averaged 1.1 additional days in the intensive care unit (95% confidence interval, 0.26-2.6) compared to white patients who died, although this was not statistically significant. CONCLUSIONS: Hospital mortality and intensive care unit length of stay did not differ by race or ethnicity among this diverse cohort of critically ill patients after adjustment for severity of illness, resuscitation status, socioeconomic status, insurance status, and admission type. Black patients had more acute physiologic derangements at intensive care unit admission and were less likely to have a do-not-resuscitate order. These results suggest that among intensive care unit patients, there are no racial or ethnic differences in mortality within individual hospitals. If disparities in intensive care unit care exist, they may be explained by differences in the quality of care provided by hospitals that serve high proportions of minority patients.

Association of the pattern of use of perioperative ß-blockade and postoperative mortality.

BACKGROUND: The 1996 atenolol study provided evidence that perioperative ß-adrenergic receptor blockade (ß-blockade) reduced postsurgical mortality. In 1998, the indications for perioperative ß-blockade were codified as the Perioperative Cardiac Risk Reduction protocol and implemented at the San Francisco Veterans Administration Medical Center, San Francisco, California. The present study analyzed the association of the pattern of use of perioperative ß-blockade with perioperative mortality since introduction of the Perioperative Cardiac Risk Reduction protocol. METHODS: Epidemiologic analysis of the operations undertaken since 1996 at the San Francisco Veterans Administration Medical Center was performed. The pattern of use of perioperative ß-blockade was divided into four groups: None, Addition, Withdrawal, and Continuous. Logistic regression, survival analysis, and propensity analysis were performed. RESULTS: A total of 38,779 operations were performed between 1996 and 2008. In patients meeting Perioperative Cardiac Risk Reduction indications for perioperative ß-blockade, Addition is associated with a reduction in 30-day (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33 to 0.83; P = 0.006) and 1-yr mortality (OR, 0.64; 95%, CI 0.51 to 0.79; P < 0.0001). Continuous is associated with a reduction in 30-day (OR, 0.68; 95% CI, 0.47 to 0.98; P = 0.04) and 1-yr mortality (OR, 0.82; 95% CI, 0.67 to 1.0; P = 0.05). Withdrawal is associated with an increase in 30-day (OR 3.93, 95% CI, 2.57 to 6.01; P less than 0.0001) and 1-yr mortality (OR, 1.96; 95% CI, 1.49 to 2.58; P < 0.0001). CONCLUSION: Perioperative ß-blockade administered according to the Perioperative Cardiac Risk Reduction protocol is associated with a reduction in 30-day and 1-yr mortality. Perioperative withdrawal of ß-blockers is associated with increased mortality.

Mortality probability model III and simplified acute physiology score II: assessing their value in predicting length of stay and comparison to APACHE IV.

BACKGROUND: To develop and compare ICU length-of-stay (LOS) risk-adjustment models using three commonly used mortality or LOS prediction models. METHODS: Between 2001 and 2004, we performed a retrospective, observational study of 11,295 ICU patients from 35 hospitals in the California Intensive Care Outcomes Project. We compared the accuracy of the following three LOS models: a recalibrated acute physiology and chronic health evaluation (APACHE) IV-LOS model; and models developed using risk factors in the mortality probability model III at zero hours (MPM(0)) and the simplified acute physiology score (SAPS) II mortality prediction model. We evaluated models by calculating the following: (1) grouped coefficients of determination; (2) differences between observed and predicted LOS across subgroups; and (3) intraclass correlations of observed/expected LOS ratios between models. RESULTS: The grouped coefficients of determination were APACHE IV with coefficients recalibrated to the LOS values of the study cohort (APACHE IVrecal) [R(2) = 0.422], mortality probability model III at zero hours (MPM(0) III) [R(2) = 0.279], and simplified acute physiology score (SAPS II) [R(2) = 0.008]. For each decile of predicted ICU LOS, the mean predicted LOS vs the observed LOS was significantly different (p

Retrograde cerebral perfusion and delayed hyperbaric oxygen for massive air embolism during cardiac surgery.

We report a case of massive air embolism from a ventricular vent line during cardiac surgery successfully treated with emergent retrograde cerebral perfusion and delayed hyperbaric oxygen therapy. The etiologies of this rare but potentially devastating complication are discussed along with prevention and treatment options.

Effects of hospital procedure volume and resident training on clinical outcomes and resource use in radical retropubic prostatectomy surgery in the Department of Veterans Affairs.

PURPOSE: In this retrospective cohort study we used data from the National Surgical Quality Improvement Program of the Veterans Health Administration to examine the effect of case volume and resident participation on radical retropubic prostatectomy outcomes. MATERIALS AND METHODS: The study population included 5,736 patients who underwent radical retropubic prostatectomy in Veterans Administration hospitals between October 1, 2001 and September 30, 2004. Resource related outcomes included operative times and length of stay. Clinical outcomes included blood transfusion, complications, readmissions and reoperations. Hierarchical multivariate regression models were developed to predict outcomes. Risk adjustment was performed using patient chronic health factors and results of preoperative laboratory testing. RESULTS: A total of 5,070 radical retropubic prostatectomy surgeries met inclusion criteria. After adjustment for case mix, academic training institutions had longer operative times (3.2 vs 2.4 hours, p <0.01) but shorter length of stay (3.4 vs 4.2 days, p <0.01). Surgery at academic institutions was not associated with greater risk of transfusion (p = 0.36), reoperation (p = 0.93), complications (p = 0.53) or readmissions (p = 0.97). However, among the academic institutions low vs high hospital radical retropubic prostatectomy volume was associated with longer length of stay (3.7 vs 3.1 days, p = 0.02) and higher transfusion rate (29.6% vs 18.2%, p = 0.02). Substantial clustering of outcomes at the hospital level was observed. CONCLUSIONS: Within the Veterans Administration system academic training institutions have longer operative times for radical retropubic prostatectomy, but shorter length of stay. Among the same institutions, high volume hospitals tend to have lower transfusion rates and shorter length of stay. Clustering of outcomes at the hospital level suggests that unmeasured institutional factors are key determinants of clinical and resource related outcomes.

Isoflurane-induced dilation of porcine coronary microvessels is endothelium dependent and inhibited by glibenclamide.

BACKGROUND: Isoflurane has been reported to cause dose-dependent constriction in isolated coronary microvessels. However, these results are inconsistent with data from in situ and in vivo heart preparations which show that isoflurane dilates the coronary vasculature. To clarify the direct effects of isoflurane on coronary tone, we measured the response of isolated porcine resistance arterioles (ID, 75 +/- 4.0 microm; range, 41-108 microm) to isoflurane in the presence and absence of adenosine triphosphate-sensitive and Ca2+-activated potassium channel blockers and also after endothelial removal. METHODS: Subepicardial arterioles were isolated, cannulated, and pressurized to 45 mmHg without flow in a 37 degrees C vessel chamber filled with MOPS buffer (pH = 7.4). After all vessels developed spontaneous (intrinsic) tone, dose-dependent (0.17-0.84 mm; approximately 0.5-2.5 minimum alveolar concentration) isoflurane-mediated effects on vessel ID were studied in the presence and absence of extraluminal glibenclamide (1 microm; an adenosine triphosphate-sensitive channel blocker) or iberiotoxin (100 nm; a Ca2+-activated potassium channel blocker) or before and after endothelial denudation using the nonionic detergent CHAPS (0.4%). Vessel ID was measured using an inverted microscope and videomicrometer, and vasomotor responses were analyzed by normalizing changes in arteriole ID to the dilation observed after exposure to 10-4 m sodium nitroprusside, which causes maximal dilation. RESULTS: Isoflurane caused dose-dependent dilation of all coronary arterioles. This vasodilation was 6.0 +/- 0.7 microm at an isoflurane concentration of 0.16 mm (approximately 0.5 minimum alveolar concentration) and 25.3 +/- 2.1 microm at 0.75 mm (approximately 2.5 minimum alveolar concentration). These values represent 18.1 +/- 1.7% and 74.1 +/- 3.3%, respectively, of that observed with 10-4 sodium nitroprusside (34 +/- 3 microm). Glibenclamide, but not iberiotoxin, exposure affected arteriolar dilation in response to isoflurane. Glibenclamide caused a downward displacement of the isoflurane dose-response curve, reducing isoflurane-mediated dilation by an average of 36%. Denuded arterioles showed a marked (approximately 70%) reduction in their ability to dilate in response to isoflurane. CONCLUSIONS: The authors conclude that isoflurane dilates coronary resistance arterioles in a dose-dependent manner, and that this dilation is partially mediated by adenosine triphosphate-sensitive channels and is highly dependent on the presence of a functioning endothelium.