Consumer-driven cholecystectomy: myth or reality?

OBJECTIVE: To discover if a consumer-driven process is fueling the high rate of cholecystectomies in the laparoscopic era. DESIGN: A 12-question survey. SETTING: A 1000-bed, university-affiliated hospital. PATIENTS: Patients admitted for elective cholecystectomies. MAIN OUTCOME MEASURES: Survey responses suggesting positive perceptions about laparoscopic cholecystectomy persuade patients to undergo gallbladder surgery. RESULTS: Patients' symptoms persisted for a mean of 20.7 months, range zero to 204. Mean time between diagnosis and surgery was ten months, range 0.1-312. Ninety-five and three-tenths percent knew their gallbladder would be removed; 1.7 percent thought it would be opened to extract stones. Ninety-one and four-tenths percent correctly identified the procedure as "laparoscopic cholecystectomy." Fifty and four-tenths percent believed they would fully recover within a week, 24.1 percent within two weeks, and 14.7 percent within two days. Eighty-three and two-tenths percent knew laparoscopic cholecystectomy required less cutting; 33.6 percent thought a laser was used. Forty-four and eight-tenths percent assumed laparoscopy was the safer method. Sixty-two and one-tenth percent were referred for surgery by family physicians; Seven percent approached surgeons themselves. When asked who first suggested the laparoscopic procedure, 43.1 percent indicated family doctor, 41.4 percent, surgeon, and three percent requested laparoscopy themselves. Twenty-four and one-tenth percent who delayed surgery despite more than 12 months of symptoms indicated escalating pain as their reason for seeking surgery now; 0.9 percent cited the newer procedure. CONCLUSIONS: We found no clear evidence that consumer awareness of laparoscopy has encouraged more cholecystectomies. Misconceptions exist about the procedure's execution and safety. Education about risks, especially bile duct injury, is needed. More frequent referral by family doctors probably plays a role in the higher incidence of cholecystectomies.

Safety and efficacy of propofol with EDTA when used for sedation of surgical intensive care unit patients.

OBJECTIVE: To compare propofol with disodium edetate (EDTA) and propofol without EDTAwhen used for the sedation of critically ill surgical intensive care unit (ICU) patients. DESIGN: Prospective, randomised, multicentre trial. PATIENTS: A total of 122 surgical ICU patients who required intubation and mechanical ventilation. INTERVENTIONS: Patients were randomised to receive either propofol or propofol plus EDTA (propofol EDTA) by continuous infusion for sedation. MEASUREMENTS AND RESULTS: The addition of EDTA to propofol had no effect on calcium or magnesium homeostasis, renal function, haemodynamic function, or efficacy when used for the sedation of surgical patients in the ICU. The most common adverse events were hypotension, atrial fibrillation, and hypocalcaemia. In this trial, a greater number of serious adverse events and adverse events leading to withdrawal occurred in the propofol group relative to the propofol EDTA group. There was a significantly lower crude mortality rate at 7 and 28 days for the propofol EDTA group compared with the propofol group. There were no statistically significant differences between groups with respect to depth of sedation. CONCLUSION: The propofol EDTA formulation had no effect on calcium or magnesium homeostasis, renal function, or sedation efficacy compared with propofol alone when used for sedation in critically ill surgical ICU patients. There was a significant decrease in mortality in the propofol EDTA group compared with the propofol group. Further investigations are needed to validate this survival benefit and elucidate a possible mechanism.

Propofol in the treatment of moderate and severe head injury: a randomized, prospective double-blinded pilot trial.

OBJECT: Sedation regimens for head-injured patients are quite variable. The short-acting sedative-anesthetic agent propofol is being increasingly used in such patients, yet little is known regarding its safety and efficacy. In this multicenter double-blind trial, a titratable infusion of 2% propofol accompanied by low-dose morphine for analgesia was compared with a regimen of morphine sulfate in intubated head-injured patients. In both groups, other standard measures of controlling intracranial pressure (ICP) were also used. METHODS: Forty-two patients from 11 centers were evaluated to assess both the safety and efficacy of propofol: 23 patients in the propofol group (mean time of propofol usage 95+/-87 hours) and 19 patients in the morphine group (mean time of morphine usage 70+/-54 hours). There was a higher incidence of poor prognostic indicators in the propofol group than in the morphine group: patient age older than 55 years (30.4% compared with 10.5%, p < 0.05), initial Glasgow Coma Scale scores of 3 to 5 (39.1% compared with 15.8%, p < 0.05), compressed or absent cisterns on initial computerized tomography scanning (78.3% compared with 57.9%, p < 0.05), early hypotension and/or hypoxia (26.1% compared with 10.5%, p = 0.07). During treatment there was a trend toward greater use of vasopressors in the propofol group. However, the mean daily ICP and cerebral perfusion pressure were generally similar between groups and, on therapy Day 3, ICP was lower in the propofol group compared with the morphine group (p < 0.05). Additionally, there was less use of neuromuscular blocking agents, benzodiazepines, pentobarbital, and cerebrospinal fluid drainage in the propofol group (p < 0.05). At 6 months postinjury, a favorable outcome (good recovery or moderate disability) was observed in 52.1% of patients receiving propofol and in 47.4% receiving morphine; the mortality rates were 17.4% and 21.1%, respectively. Patients who received the highest doses of propofol for the longest duration tended to have the best outcomes. There were no significant differences between groups in terms of adverse events. CONCLUSIONS: Despite a higher incidence of poor prognostic indicators in the propofol group, ICP therapy was less intensive, ICP was lower on therapy Day 3, and long-term outcome was similar to that of the morphine group. These results suggest that a propofol-based sedation and an ICP control regimen is a safe, acceptable, and, possibly, desirable alternative to an opiate-based sedation regimen in intubated head-injured patients.

Multicenter study of noninvasive monitoring systems as alternatives to invasive monitoring of acutely ill emergency patients.

BACKGROUND: Recent reports showed lack of effectiveness of pulmonary artery catheterization in critically ill medical patients and relatively late-stage surgical patients with organ failure. Since invasive monitoring requires critical care environments, the early hemodynamic patterns may have been missed. Ideally, early noninvasive hemodynamic monitoring systems, if reliable, could be used as the "front end" of invasive monitoring to supply more complete descriptions of circulatory pathophysiology. OBJECTIVES: To evaluate the accuracy and reliability of noninvasive hemodynamic monitoring consisting of a new bioimpedance method for estimating cardiac output combined with arterial BP, pulse oximetry, and transcutaneous PO2 and PCO2; we compared this system of noninvasive monitoring with simultaneous invasive measurements to evaluate circulatory deficiencies in acutely ill patients shortly after hospital admission where invasive monitoring was not readily available. We also preliminarily explored early differences in temporal hemodynamic patterns of survivors and nonsurvivors. DESIGN AND SETTING: Prospective comparison of simultaneous invasive and noninvasive measurements of circulatory function with retrospective analysis of data in university-run county hospitals, university hospitals and affiliated teaching hospitals, and a community private hospital. PATIENTS: We studied 680 patients, including 139 severely injured or hemorrhaging patients in the emergency department (ED), 129 medical (nontrauma) patients on admission to the ED, 274 high-risk surgical patients intraoperatively, and 138 patients recently admitted to the ICU. RESULTS: A new noninvasive impedance device provided cardiac output estimations under conditions in which invasive thermodilution measurements were not usually applied. There were 2,192 simultaneous bioimpedance and thermodilution cardiac index measurements; the correlation coefficient, r = 0.85, r2 = 0.73, p < 0.001. The precision and bias was -0.124+/-0.75 L/min/m2. Both invasive and noninvasive monitoring systems provide similar information and identified episodes of hypotension, low cardiac index, arterial hemoglobin desaturation, low transcutaneous O2, high transcutaneous CO2, and low oxygen consumption before and during initial resuscitation. The limitations of noninvasive systems were described. CONCLUSIONS: Noninvasive monitoring systems gave continuous displays of physiologic data that provided information allowing early recognition of low flow and poor tissue perfusion that were more pronounced in the nonsurvivors. Noninvasive systems may be acceptable alternatives where invasive monitoring is not available.

An evaluation of serum troponin T and signal-averaged electrocardiography in predicting electrocardiographic abnormalities after blunt chest trauma.

OBJECTIVE: Despite multiple inquiries, there are no available tests to definitively detect blunt myocardial injury. The evaluation of patients with chest wall injuries without other indications for intensive care unit (ICU) admission has ranged from a single emergency department electrocardiogram (ECG) to 72 hours of continuous electrocardiographic monitoring. Recently, signal-averaged ECG and serum cardiac troponin T have demonstrated clinical utility in the evaluation of ischemic heart disease. The purpose of this study is to determine the ability of these diagnostic tests to predict the occurrence of significant electrocardiographic rhythm disturbances for patients with chest wall injuries and no other indication for ICU admission. METHODS: We prospectively evaluated 71 consecutive adult patients admitted to a regional Level I trauma center with chest wall injuries not requiring ICU admission. We obtained admission signal-averaged ECG, serum troponin T level, standard ECG, and creatine phosphokinase (CPK-MB) level. Patients received continuous electrocardiographic monitoring, follow-up 12-lead electrocardiography, and serial monitoring of troponin and CPK-MB. Echocardiography was performed for patients with abnormal CPK-MB levels. Electrocardiographic events were graded as normal, abnormal but clinically insignificant, or clinically significant. Multiple stepwise logistic regression analysis was used to evaluate predictors for the development of clinically significant electrocardiographic events. RESULTS: On admission, 17 of 71 patients (23.9%) had normal sinus rhythm; 13 (18.3%) had a clinically significant finding. For 50 patients, follow-up ECG was abnormal; for 26, the findings were clinically significant. Of 17 patients with normal initial ECGs, 7 (41%) developed a clinically significant abnormality. Six patients received intervention for ECG findings. Eleven of 71 patients (16%) had positive troponin T; 5 of 71 (7%) had positive CPK-MB; 15 of 71 (21%) had positive signal-averaged ECG; and 4 of 13 had positive echocardiograms. Initial electrocardiographic abnormalities and a troponin T level > 0.20 microg/L were the only variables found to predict clinically significant electrocardiographic events. Sensitivity and specificity of troponin T in predicting clinically significant abnormalities were 27 and 91%, respectively. CONCLUSIONS: 1. The best predictors for the development of significant electrocardiographic changes are an admission ECG abnormality and an elevated serum troponin T level. 2. Both tests have high specificity with low to moderate sensitivity. 3. Patients with normal ECGs may develop clinically significant events. 4. CPK-MB and echocardiograms continue to be poor predictors of significant electrocardiographic events.

Impact of a two-tiered trauma response in the emergency department: promoting efficient resource utilization.

OBJECTIVE: The purpose of this prospective study was to assess the impact of a two-tiered trauma response protocol on the expediency of identification, evaluation, and treatment of trauma patients in the Emergency Department. MATERIALS AND METHODS: At a Level I Trauma Center serving a suburban/urban population of approximately one million people, Emergency Department length of stay was tabulated for all consecutive Trauma Service admissions 6 months before and 6 months after implementation of a two-tiered trauma response protocol. This protocol, which uses specific triage criteria, consisted of the standard Surgery-supervised trauma code response and an additional Emergency Medicine-supervised trauma alert response. RESULTS: Trauma Service admissions numbered 532 in the pre-protocol period and 512 in the period after implementation of the protocol. In the first period, the Emergency Department length of stay was 289 minutes; in the second period, it was 241 minutes. Of the 512 patients in the post-protocol period, 183 were triaged to the new trauma alert group, reducing the number of Trauma Service consultations and decreasing Emergency Department length of stay by 139 minutes. The two levels of trauma response allowed accurate identification of the most seriously injured patients and improved the ability to predict those patients who would require direct disposition to the operating room or intensive care unit. CONCLUSIONS: Implementation of a two-tiered trauma response significantly decreased Emergency Department length of stay, allowed Emergency Medicine physicians to more rapidly identify, evaluate, and treat trauma patients requiring hospitalization, improved identification of patients requiring operating room or intensive care unit resources, and was time efficient and resource efficient.

Tracheobronchial disruption following low-energy trauma.

A case is reported of a patient who sustained a tracheobronchial tear as a result of an assault rather than the typical crushing trauma associated with such an injury. A review of tracheobronchial injuries is presented.

Traumatic blindness after airbag deployment: bilateral lenticular dislocation.

Airbags have been shown to save lives and reduce head, neck, and upper torso trauma associated with motor vehicle crashes. However, airbags have also been implicated as the source of facial and orbital injury. We report the case of a patient who suffered bilateral lenticular subluxation, anterior chamber hemorrhages, and minor facial lacerations as the result of airbag deployment.

Internal mammary artery injury, anterior mediastinal hematoma, and cardiac compromise after blunt chest trauma.

A rare case of blunt chest trauma resulting in internal mammary artery hemorrhage and cardiac tamponade is presented. Thoracotomy revealed anterior mediastinal hemorrhage but no pericardial hematoma. The significance of chest wall vessel hemorrhage as a cause of widened mediastinum is reiterated. The importance of accurate angiographic assessment and vigilant care of victims of blunt chest trauma who present with a widened mediastinum is emphasized.

Neuroleptic malignant syndrome in a trauma patient.

Neuroleptic malignant syndrome is a rare complication of antipsychotic medications. This paper describes the case of a trauma patient who received haloperidol and droperidol for severe agitation, developed neuroleptic malignant syndrome, and was treated successfully with dantrolene sodium, and also provides a review of the literature.