Faculty Bibliography

BACKGROUND: The Rothman index (RI) is a numerical score calculated hourly from 26 data points in the electronic medical record by a commercial software package. Although it is purported to serve as an indicator of change in a patient's condition, it has not been extensively evaluated in the literature. Our objective was to determine whether the RI can be used to predict early surgical intensive care unit (SICU) readmissions. METHODS: This is a single-institution, retrospective 12-month period review of all patients transferred from the SICU to the surgical floor. Patients readmitted to the SICU within 48 hours were compared with patients who did not require readmission during this time (control). Demographics and continuous RI scores were collected at admission, 24 hours before SICU transfer, and for the first 48 hours on the surgical floor or until readmission to the SICU. RESULTS: A total of 1,152 SICU patients were transferred to the surgical floor; 27 patients were readmitted within 48 hours of transfer. Demographics were similar in both groups. The SICU length of stay was longer in the readmission group (mean [SD], 4.7 [8.1] vs. 16.5 [15.2]; p < 0.001). The RI immediately before SICU transfer was higher in the control group (70.4 [20.3] vs. 49.1 [20.9], p < 0.001) and was uniformly improved from the RI at the initial SICU admission. In comparison, readmitted patients had more variable RI trends from admission to SICU transfer (mean Delta, 6.51; range, -54.10 to 48.6), and 40.74% of readmitted patients actually had a decreased RI score on transfer. No patient with a RI score greater than 82.90 required readmission within 48 hours. CONCLUSION: An increased RI score or a score greater than 82.90 correlates with appropriateness for SICU transfer to the surgical floor. A decreased RI score is strongly associated with SICU readmission within 48 hours and should be explored as a potential quality metric. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

BACKGROUND: Pneumatosis intestinalis (PI) is associated with numerous adult conditions, ranging from benign to life threatening. To date, series of PI outcomes consist of case reports and small retrospective series. METHODS: We conducted a retrospective multicenter study, involving eight centers, of PI from January 2001 to December 2010. Demographics, medical history, clinical presentation, and outcomes were collected. Primary outcome was the presence of pathologic PI defined as confirmed transmural ischemia at surgery or the withdrawal of clinical care and subsequent mortality. Forward logistic regression and a regression tree analysis was used to generate a clinical prediction rule for pathologic PI. RESULTS: During the 10-year study period, 500 patients with PI were identified. Of this number, 299 (60%) had benign disease, and 201 (40%) had pathologic PI. A wide variety of variables were statistically significant predictors of pathologic PI on univariate comparison. In the regression model, a lactate of 2.0 or greater was the strongest independent predictor of pathologic PI, with hypotension or vasopressor need, peritonitis, acute renal failure, active mechanical ventilation, and absent bowel sounds also demonstrating significance. Classification and regression tree analysis was used to create a clinical prediction rule. In this tree, the presence of a lactate value of 2.0 or greater and hypotension/vasopressor use had a predictive probability of 93.2%. CONCLUSION: Discerning the clinical significance of PI remains a challenge. We identified the independent predictors of pathologic PI in the largest population to date and developed of a basic predictive model for clinical use. Prospective validation is warranted. LEVEL OF EVIDENCE: Epidemiologic study, level III.

BACKGROUND: The surgical intensive care unit (SICU) is increasingly used as a surrogate operating room (OR). This study seeks to characterize a Level I trauma center's operative undertakings in the SICU versus OR for trauma and emergency general surgery patients. METHODS: Operative and ICU databases were queried for all operative procedures as a function of procedure type (CPT code) and location (OR, ICU) from August 2002 through June 2009. Mode of ventilation, type of anesthesia used, and adverse outcomes were recorded. Data were divided into 2002-2006 versus 2007-2009 because of MD staffing and service structure changes. Time frames were compared via Student's t-test or chi(2) as appropriate; significance for p < 0.05 (*) versus 2002-2006. RESULTS: Trauma service-admitted patient volume increased from 2002-2003 (n = 1,293) to 2006-2007 (n = 1,577) and again in 2008-2009 (n = 1,825). Emergency general surgery total operative cases increased from 2002-2003 (n = 246) to 2005-2006 (n = 468). Case volume further increased in 2006-2007 (n = 767*), 2007-2008 (n = 1,071*), and 2008-2009 (n = 875*) compared with 2002-2003 or 2005-2006. Relaparotomy and temporary abdominal closure procedures were significantly increased in 2007-2008 (n = 109*) and 2008-2009 (n = 128*) versus 2002-2006 (n = 6) and 2006-2007 (n = 10). ICU cases were 11.5% of total cases (OR + ICU) spanning 2002-2006 and significantly increased to 24.3%* in 2007-2008 and 36%* in 2008-2009. Advanced ventilation was used in 15% of ICU cases in 2002-2003 and significantly increased to 40% in 2006-2007 and 78%* in 2008-2009. Neuromuscular blockade was rare; most cases (93.9%) were performed under deep sedation. CONCLUSION: Our ICU is increasingly used for surgical procedures traditionally reserved for the OR. Advanced ventilation management may influence the choice of operative location. The ICU may be safely used as an operative location for the critically ill and injured. LEVEL OF EVIDENCE: Epidemiologic study, level III.

BACKGROUND: Small-bowel obstruction (SBO) represents as many as 16% of surgical admissions and more than 300,000 operations annually in the United States. The optimal strategies for the diagnosis and management of SBO continue to evolve secondary to advances in imaging techniques, critical care, and surgical techniques. This updated systematic literature review was developed by the Eastern Association for the Surgery of Trauma to provide up-to-date evidence-based recommendations for SBO. METHODS: A search of the National Library of Medicine MEDLINE database was performed using PubMed interface for articles published from 2007 to 2011. RESULTS: The search identified 53 new articles that were then combined with the 131 studies previously reviewed by the 2007 guidelines. The updated guidelines were then presented at the 2012 annual EAST meeting. CONCLUSION: Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management. Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration. The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO. Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes. Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

BACKGROUND: Airway pressure release ventilation (APRV) is used both as a rescue therapy for patients with acute lung injury and as a primary mode of ventilation. Unlike assist-control volume (ACV) ventilation that uses spontaneous breathing trials, APRV weaning consists of gradual decreases in supporting pressure. We hypothesized that the APRV weaning process increases total ventilator days compared with those of spontaneous breathing trials-based weaning. METHODS: A retrospective review of a Level I trauma center's database identified trauma admissions from January 1, 2007, to December 31, 2010, which required mechanical ventilation for more than 24 hours and survived. Demographics, injuries, in-hospital complications, ventilation mode(s), and total ventilator days were abstracted. RESULTS: A total of 362 patients fulfilled study entry criteria; 53 patients with more than one ventilator mode change were excluded. Seventy-five patients were successfully liberated from mechanical ventilation on APRV and 234 on ACV. The APRV and ACV groups, respectively, were similar in age (46.1 vs. 44.6 years) and sex (72% vs. 73% male) but differed in Injury Severity Score (20.8 vs. 17.5; p = 0.03). Patients on APRV had higher rates of abdominal compartment syndrome (6.7% vs. 0.8%, p = 0.003) and were more likely to have a higher chest Abbreviated Injury Scale (AIS) score >/=3 (57.3% vs. 30.8%, p < 0.001). Ventilator days were significantly greater in the APRV group (19.6 vs. 10.7 days, p < 0.001). Multiple regression was performed to adjust for the clinical differences between the two groups, identifying APRV as an independent predictor for increased number of ventilator days (B = 6.2 +/- 1.5, p < 0.001) in addition to male sex, abdomen AIS score of 3 or higher, spine AIS score of 3 or higher, acute renal failure, and sepsis. CONCLUSION: APRV is frequently used for patients who are more severely injured or who develop in-hospital complications such as pneumonia. However, after controlling for potential confounding factors in a multiple regression model, the APRV mode itself seems to increase ventilator days.

BACKGROUND: Multi-drug-resistant organisms (MDRO) complicate care increasingly on the general ward and in the emergency department, operating room, and intensive care unit (ICU). Whereas barrier precautions are important in limiting transmission of MDRO between patients, few tactics have been defined that reduce the genesis of MDRO. METHOD: Review of pertinent English-language literature. RESULTS: Antibiotic heterogeneity practices, as part of an overall antimicrobial drug stewardship program, offer one readily deployable means to reduce selection pressure for MDRO development in the ICU. The data underpinning this approach and data derived from its use indicate that, especially in surgical ICUs, heterogeneity of antibiotic prescribing can preserve or restore microbial ecology, reduce the prevalence of MDRO and the incidence of infections caused thereby, and facilitate the implementation and effectiveness of other antibiotic-sparing tactics, such as de-escalation. CONCLUSION: Heterogeneity of antibiotic prescribing is effective in preventing the dissemination of MDRO pathogens.

For surgical patients, appropriate selection and administration of fluids can mitigate against organ failure, whereas improper dosing can exacerbate already injured systems. Fluid and electrolyte goals and deficiencies must be defined for individual patients to provide the appropriate combination of resuscitation and maintenance fluids. Specific electrolyte abnormalities should be anticipated, identified, and corrected to optimize organ functions. Using the strong-ion approach to acid-base assessment, delivered fluids that contain calculated amounts of electrolytes will interact with the patient's plasma charge and influence the patient's pH, allowing the clinician to achieve a more precise end point.

With the shift toward nonoperative management, most hepatic injuries are managed nonoperatively. On the other hand, up to two-thirds of high-grade hepatic injuries require laparotomy; these cases are technically difficult and challenging. Damage-control approaches, understanding of liver anatomy, and advances in technology have dramatically changed the approach to hepatic trauma, with improved outcomes. Anatomic or nonanatomic liver resection is required in 2% to 5% of liver injuries. Mortality with liver injury following resection is 9% with current advances.