Factors influencing outcome of prolonged norepinephrine therapy for shock in critical surgical illness.

Several studies indicate that norepinephrine (NE) may be more effective than dopamine for the treatment of septic shock. Nonetheless, many consider dopamine to be the pressor of choice for shock refractory to volume resuscitation. Owing to fear of excessive vasoconstriction, accentuated end-organ hypoperfusion, and the development of multiple organ dysfunction syndrome (MODS), it is contended that NE may be deleterious. We analyzed the duration of NE use and the variables that predict mortality in a consecutive cohort of 406 surgical intensive care unit patients treated with NE for shock. Study parameters included age, acute physiology and chronic health evaluation (APACHE) II and APACHE III scores, hospital (HLOS) and intensive care unit (ULOS) length of stay, maximal and daily multiple organ dysfunction (MOD) scores, MOD score minus cardiovascular points (MOD-CV), duration of NE infusion, and survival. The duration of NE infusion was stratified into six subsets (1, 2, 3-5, 6-10, 11-20, and > or =21 days). An age- and APACHE II and III score-matched cohort of 195 patients, in whom NE was not utilized, was identified retrospectively for comparison. The prevalence of NE use was 10.9%. NE patients developed MODS to a greater degree (11.7 +/- .3 vs. 5.9 +/- .4 points, p < .0001). NE patients had a greater degree (p < .0001) of noncardiovascular MOD as well. When stratified by survival, a greater degree of MOD occurred in both nonsurvivors and survivors of NE (both, p < .0001) compared with comparably ill patients without pressor-dependent shock. MOD scores, ULOS, and HLOS increased progressively with prolonged NE therapy (all, p < .0005), whereas mortality increased significantly only when the duration of NE infusion exceeded 10 days (p = .05). By multivariate analysis of variance (ANOVA), MOD score (p < .0001), and APACHE III (p < .01) predicted mortality, but notably the duration of NE therapy failed to attain predictive value (p = .3192). Only the MOD score was predictive of HLOS (p = .0001) and ULOS (p = .003). Daily MOD scores revealed that nonsurvivors of NE therapy were admitted to the intensive care unit with a greater degree of baseline organ dysfunction than NE survivors (7.5 +/- .4 vs. 5.1 +/- .2 for survivors, p < .0001). In addition, whereas survivors showed significant improvement by Day 5 (p < .01), MOD amongst nonsurvivors remained unchanged (p = .993). Although critically ill surgical patients requiring NE support have significantly greater degrees of organ dysfunction than patients not requiring pressors, much of the organ dysfunction is present on admission. The data contradict the notion that NE facilitates the development of MODS.

Interpretation of computed tomography does not correlate with laboratory or pathologic findings in surgically confirmed acute appendicitis.

BACKGROUND: Computed tomography (CT) is used increasingly to diagnose acute appendicitis, despite variable technique and interpretation. We hypothesized that CT interpretation would not reflect actual clinical-pathologic findings in all demographic patient groups. METHODS: A prospective university hospital database of 625 consecutive patients (1995-1999), all of whom were operated on for appendicitis (261, or 41.8%, within 24 hours of discretionary CT), was reviewed. CT and pathology data were obtained from final, written reports. CT criteria included free fluid or air, appendiceal visualization, mesenteric fat stranding, and blurred pericecal fat. Appendix pathology included acute, gangrenous, and perforated organs. Statistics were performed with the Fisher exact test (coordinate data) and univariate analysis of variance (continuous data); multivariate analysis of variance for independent effects on dependent variable (positive CT or pathology; P <.05). RESULTS: The mean age was 35 +/- 1 years with 46.6% being female patients. CT was done more often in women and after 1997 (both P <.05). The sensitivity and specificity of CT were 96.1% and 16.1%, respectively. The positive predictive value (PPV) and accuracy rate (A) were 90%, and 88%, respectively. After CT, the incidence of finding a normal appendix was lower (19.3% vs 12.3%, P <.05), especially if the white blood cell count (WBC) was normal (< or = 11K/microL, 6.1% vs 23.2%, P <.001). If the WBC was < or = 11K/microL with positive CT, PPV/A was 73. 7%/71.3%, whereas with WBC > 11K/microL and positive CT, PPV/A was 99.4%/93.3%. Multivariate analysis of variance showed that none of the individual variables used by the radiologist to determine a positive CT scan correlated with outcome determined by surgical pathology. A healthy appendix was predicted by a CT interpreted as negative and younger age (both P <.05), and especially by lower WBC (P <.0001), but not by gender or surgeon. CONCLUSIONS: Although the negative appendectomy rate was decreased by CT, there was no correlation between CT findings and pathologically proved disease. Other factors such as more precise patient selection by clinical criteria may also be improving outcome. A positive CT scan in a patient with a normal WBC should be interpreted with caution.

Influence of multiple organ dysfunction syndrome on duration of critical illness and hospitalization.

BACKGROUND: Multiple organ dysfunction syndrome (MODS) is the leading cause of death in the general surgery intensive care unit (SICU). The development of MODS is a powerful predictor of prolonged SICU stay in survivors and nonsurvivors of critical illness, but its relation to less severe illness and briefer duration of care is unknown. OBJECTIVES: To determine the relation between modest degrees of MODS and length of stay in the SICU and hospital and whether daily MOD score calculations can distinguish survivors from nonsurvivors before the SICU stay becomes prolonged. SETTING: An SICU of a university tertiary care medical center. DESIGN: Prospective inception-cohort study. Illness severity data were collected in retrospect only for the calendar year 1991. PATIENTS: Of 2646 consecutive patients studied, 115 stayed in the SICU more than 21 days. METHODS: Acute Physiology and Chronic Health Evaluation (APACHE) II and III scores were calculated after 24 hours, with daily and cumulative MOD scores (0-4 points for 6 organs, 24 points maximum). Patients were followed up until hospital discharge or death. Data analysis was performed by unpaired 2-tailed t test, exact contingency analysis for multiple groups, univariate 1- or 2-way analysis of variance with repeated measures, or linear or polynomial regression tests as appropriate, alpha = .05. RESULTS: The mean (+/-SEM) age of the patients was 65 +/- 1 years; mean (+/-SEM) APACHE II score, 13.8 +/- 0.2; APACHE III score, 44.2 +/- 0.7; incidence of MODS, 1173 of 2646 patients, 44.3%; and hospital mortality rate, 9.2%. Cumulative MOD scores correlated closely with SICU length of stay in survivors, especially for SICU stays of less than 10 days (R2 = 0.99, P < .001). Similar correlations existed between the prevalence of MODS related to the increasing length of the SICU stay (R2 = 0.98, P < .001) and between the length of hospital stay and the cumulative MOD score (R2 = 0.79, P < .05). Daily MOD scores in patients whose SICU stay was more than 21 days distinguished survivors from nonsurvivors by day 2 of the SICU stay (P < .05) and thereafter. CONCLUSIONS: Modest degrees of MODS correlate closely with the duration of care in less severely ill patients. Early identification and daily quantitation of MODS may help identify patients at risk for prolonged illness and death. Prevention of outcomes that contribute to organ dysfunction is critical for reduction of length of stay and cost of care.

Comparison of APACHE II and III scoring systems for mortality prediction in critical surgical illness.

OBJECTIVE: To determine whether the Acute Physiology and Chronic Health Evaluation III (APACHE III), an updated version of APACHE II that contains a larger number of postoperative patients in the normative database, offers better prediction in critical surgical illness. DESIGN: Prospective cohort study. SETTING: Surgical intensive care unit of an urban, tertiary-care university hospital. PARTICIPANTS: Eight hundred forty-four consecutive patients in the surgical intensive care unit. Overall scores were determined, as well as scores for survivor, nonsurvivor, trauma, nontrauma, postoperative, and nonoperative patient subgroups. MAIN OUTCOME MEASURES: Survival to hospital discharge, and survival compared with published normative APACHE II and III databases. RESULTS: Mean age was 65.1 +/- 0.5 years. Overall mortality was 7.0% in the surgical intensive care unit and 9.1% in the hospital. The relationship between APACHE II and APACHE III scores for individual patients was linear and correlated significantly (P < .0001) (range of correlation coefficients, .72 to .86) overall and in all subgroups. Both scoring systems overestimated our mortality, but estimations made by APACHE III were significantly (P < .01) higher overall and in all subgroups. CONCLUSIONS: In institutions or groups of patients where APACHE II underestimates mortality, APACHE III may be corrective. However, the differences are subtle and may be difficult to detect in smaller studies.

Development of multiple organ dysfunction syndrome in critically ill patients with perforated viscus. Predictive value of APACHE severity scoring.

OBJECTIVE: To determine whether scoring on the Acute Physiology and Chronic Health Evaluation (APACHE) III at admission can predict the development of multiple organ dysfunction syndrome and mortality in critically ill surgical patients. DESIGN: Prospective, inception-cohort study. SETTING: Surgical intensive care unit of an urban, tertiary-care hospital. PATIENTS: One hundred fourteen critically ill patients with surgically treated perforated gastrointestinal viscus. INTERVENTIONS: Calculation of APACHE II and APACHE III scores 24 hours after admission to the surgical intensive care unit and serial quantitation of organ dysfunction for the duration of critical care according to two different predefined scoring systems. Patients were stratified by survival, the development of organ dysfunction, and colon vs noncolonic perforation. MAIN OUTCOME MEASURES: Hospital mortality, length of stay in the surgical intensive care unit, and the development of organ dysfunction or overt organ failure. RESULTS: The mean (+/- SEM) APACHE II and APACHE III scores were 17.4 +/- 0.6 (range, 6 to 37) and 59.0 +/- 2.2 (range, 15 to 141), respectively. The incidence of organ dysfunction was 73% (64% in survivors). All severity scores were identical for colon perforation and noncolonic perforation subgroups. Nonsurvivors invariably had organ dysfunction. Overall length of stay in the intensive care unit was 12.0 +/- 1.6 days (8.7 +/- 1.2 days for survivors and 22.7 +/- 5.0 days for nonsurvivors). The APACHE scores and organ dysfunction or failure scores were significantly higher in nonsurvivors, and APACHE scores were higher in survivors with organ dysfunction than in those without it. Significant linear relationships were identified for APACHE II vs APACHE III scores (R2 = .66) and for all four combinations of APACHE scores and organ dysfunction or failure scores (R2 = .43 to .52). By multivariate analysis of variance, independent predictors of organ dysfunction or failure were APACHE III, increased age, and a prolonged stay in the surgical intensive care unit, but not the type of perforation. Neither APACHE II or APACHE III predicted mortality independently. CONCLUSIONS: The development of multiple organ dysfunction syndrome correlated with higher APACHE III scores but was independent of the type of perforation. Only the development of overt multiple organ failure predicted death. Combined use of APACHE III and the multiple organ dysfunction score provides improved prediction of multiple organ dysfunction syndrome, but further enhancements are needed before prediction of outcome in individual patients is reliable.

Epidemiology of multiple organ dysfunction syndrome in critical surgical illness.

Multiple organ dysfunction syndrome (MODS) is a major cause of morbidity and mortality in surgical intensive care units (SICUs). Multiple organ dysfunction syndrome remains the most important factor associated with mortality in the SICU. Illness severity scores such as the Acute Physiology and Chronic Health Evaluation-III (APACHE III) and the magnitude of the systemic inflammatory response syndrome (SIRS) at the time of SICU admission are useful in stratifying patients at risk for MODS and subsequent mortality. Assessment of key organ systems shows that mortality correlates with the overall severity of organ dysfunction and the number of involved organ systems, as well as to individual organs that fail. Despite the prognostic utility of SIRS/MODS, definitions of dysfunction of individual organs have shortcomings. The problem with quantitating MODS lies in the inability to adequately define organ dysfunction, especially of the gastrointestinal tract, liver, and central nervous system. Biological indicators of organ dysfunction may prove to be better markers for MODS in the future.

A prospective evaluation of the use of emergency department computed tomography for suspected acute appendicitis.

BACKGROUND: Computed tomography (CT) is used increasingly to evaluate suspected cases of acute appendicitis (AA) in the emergency department (ED). This prospective study was performed to test the hypothesis that the evaluation of AA by CT in the ED remains suboptimal and that erroneous interpretation diminishes its utility. METHODS: Consecutive patients 18 years of age or older were enrolled prospectively if AA was among the first three differential diagnoses listed in the record of patients undergoing evaluation of abdominal pain in the ED. Imaging of the abdomen and pelvis was obtained at the discretion of the ED staff or consultant surgeon. Initial CT interpretation was by a radiology resident or fellow along with the surgical staff, but final review by an attending radiologist occurred later. Age, gender, presenting symptoms, white blood cell (WBC) count, final CT results, and final pathology (for patients undergoing operation) were recorded. X +/- SEM, p < 0.05 by chi(2), ANOVA, or MANOVA was used for statistical analysis as appropriate. RESULTS: A CT scan was performed in 104 patients (83% of those meeting entry criteria), 35 of whom were male (mean age, 37 +/- 2 years) and 69 of whom were female (mean age, 39 +/- 3 years). Thirty-five patients had pathologically proved appendicitis, 28 of whom were diagnosed prospectively by CT. There were seven false-negative scans. Sensitivity, specificity, and positive predictive value for the initial CT reading were 80%, 91%, and 82%, respectively. Gender (p < 0.03), WBC count (p < 0.0002), and a positive initial CT reading (p < 0.0001) correlated with operative management. However, although final CT interpretation did correlate with pathologic confirmation of AA (p < 0.0001), initial CT interpretation did not correlate with the presence of AA (p = 0.52). CONCLUSION: The ability of CT to predict AA is dependent on the interpretative skill of the individual interpreting the images. Widespread use of CT in the evaluation of patients for AA should be implemented with caution until institution-specific protocols are validated.

The use of computed tomography for the diagnosis of acute appendicitis in children does not influence the overall rate of negative appendectomy or perforation.

BACKGROUND: Computed tomography (CT) has been used more frequently to diagnose acute appendicitis in children. The purpose of this study was to determine whether the use of CT has any influence on negative appendectomy or perforation rates. METHODS: Review of a prospective database of children having appendectomy for suspected acute appendicitis. Negative appendectomy and perforation rates were determined by correlation with final pathology reports. RESULTS: Eighty-five consecutive patients underwent appendectomy for the suspicion of acute appendicitis. The overall negative appendectomy rate was 17.6%, being 19.4% in females and 16.6% in males (p = 0.75). The overall accuracy, sensitivity and positive predictive value of CT were 75%, 91%, and 81%, respectively. Patients that had CT did not have a significantly lower rate of negative appendectomy (17.9% vs. 19.3%, p > 0.99) or perforation (26% vs. 17%; p = 0.53). CONCLUSIONS: The use of CT for the diagnosis of appendicitis in children does not change the negative appendectomy rate. Results of studies performed in adults may not be extrapolated to the evaluation of children with suspected acute appendicitis.

Learning to not know: results of a program for ancillary cost reduction in surgical critical care.

OBJECTIVE: Compelling internal and external influences are stimulating global re-evaluations of care standards for efficacy and cost. Critical care uses huge amounts of resources despite widespread shortages of beds and nurses. This study tested the hypothesis that ancillary expenditures can be decreased without compromising care. METHODS: Costs for laboratory tests, radiographs, blood products, nutritional supplements, and drugs were compared prospectively for all surgical intensive care unit care for two 4-month periods (January 1 to April 30, 1994 and January 1 to April 30, 1995) at a urban university center. A systematic, multidisciplinary cost-reduction program began May 1, 1994, with emphasis on laboratory and radiographic testing and procedures, and blood product, nutritional, and drug therapies. Cohorts were compared by age, Acute Physiology and Chronic Health Evaluation (APACHE) II and III admission scores, and case mix. Outcome variables were hospital mortality, days in the intensive care unit and hospital, the development of multiple organ dysfunction syndrome, and expenditures. Cost data were taken weekly from the hospital's clinical information system. No new equipment was introduced during the study period except for pumps for patient-controlled analgesia, and there were no new critical pathways or other patient care guidelines. RESULTS: Case mix and all noncost variables were identical. Overall costs were reduced by 29% when normalized by the number of patient-days in each period. Laboratory testing was reduced in frequency by 24 to 32%, and cost by 26 to 28%. Comparable reductions in the cost of blood products (32%) were exceeded by the reductions in expenditures for nutritional supplements (49%) and pharmaceuticals (45%) (all, p < 0.01 or less). Modestly increased (2%) x-ray charges in 1995 were owing entirely to insertion of prophylactic inferior vena cava filters (each, $2,800, n = 5) and computed tomography scans for sinusitis (each, $350, n = 5), although the 7% reduction in portable chest radiographs that was achieved did not meet expectations. CONCLUSIONS: Substantial reductions in physician-ordered ancillary expenditures are possible without compromising the standard of care of critically ill patients, or the support of an elaborate framework of defined care plans. With additional experience, incremental savings may accrue from refinement of successful strategies and new approaches to intractable problems.

Lessons learned: durability and progress of a program for ancillary cost reduction in surgical critical care.

OBJECTIVE: Modern surgical care must meet high standards of quality but must also be cost-effective. Critical care uses huge amounts of resources, and strategies for effective use of scarce, expensive intensive care unit beds must be implemented. Previously, we demonstrated that ancillary expenditures can be decreased without compromising care. The present study was performed to determine whether our cost-containment strategies were durable and could be extended to areas, such as chest roentgenography, where savings previously proved elusive. METHODS: Costs for laboratory tests, radiographs, and drugs were determined prospectively for all surgical intensive care unit care for a 34-month period (January 1, 1994-October 31, 1996) at an urban university center. A systematic, multidisciplinary cost-reduction program began on May 1, 1994, with emphasis on laboratory and radiographic testing and procedures and drug therapies. Calendar-year cohorts were compared by age and Acute Physiology and Chronic Health Evaluation II and III admission scores. Outcome variables were hospital mortality, days in the intensive care unit and hospital, and expenditures. Cost data were taken weekly from the hospital's clinical information system. RESULTS: All admission noncost variables were identical. There were significant reductions in intensive care unit and hospital length of stay, and there was a trend (p = 0.07) toward decreased hospital mortality. Normalized by the number of patient-days per week, arterial blood gas determinations were reduced 46% between 1994 and 1996, and nonarterial blood gas laboratory tests were reduced by 29% (both p < 0.0001). Within the latter group, electrolyte determinations decreased by 38% and serum creatinine determinations decreased by 32%. Chest roentgenograms decreased by 34%, but pharmaceutical costs decreased by a remarkable 73%. CONCLUSION: Durable reductions in physician-ordered ancillary expenditures are possible without compromising the standard of care of critically ill patients, but active management and daily reinforcement are necessary to the process. Shorter length of stay and lower costs benefit the patient, the surgeon, the intensivist, and the institution.

A prospective comparison of two multiple organ dysfunction/failure scoring systems for prediction of mortality in critical surgical illness.

Multiple organ failure (MOF) is the primary cause of death in surgical intensive care units (SICU). Mortality increases with an increasing number of failed organs, but it has been recognized that lesser degrees of organ dysfunction occur commonly. Such gradations of the multiple organ dysfunction syndrome (MODS) are postulated to provide more descriptive and predictive power. We analyzed and compared two different MODS/MOF scoring systems and determined the utility of gradations of organ dysfunction for prediction of mortality in MODS/MOF. One of the scoring systems defines organ failure as an all-or-nothing phenomenon for each organ, whereas the other scoring system describes increasing organ dysfunction on a 24-point scale. Each scoring system assesses the same six organs. Admission APACHE II (AII) and AIII scores were calculated as independent estimates of mortality. In 867 consecutive SICU admissions, 261 patients (30%) had some degree of organ dysfunction, of whom 142 patients (54%) met criteria for single or multiple organ failure. The mean admission AII score was 19 (25 for nonsurvivors), and the AIII score was 62 (91 for nonsurvivors). Overall mortality was 5.8%, but among those patients with organ dysfunction, mortality was 19%. Death was equally likely for comparable degrees of organ dysfunction and failure. Mortality increased (p < 0.01, ANOVA) with higher scores in both systems. In patients with 9-12 organ dysfunction points, the number of failed organs was 1.5 +/- 0.2 in 34 survivors, versus 2.9 +/- 0.3 in the 14 nonsurvivors (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Utility of illness severity scoring for prediction of prolonged surgical critical care.

OBJECTIVE: To determine whether APACHE III and multiple organ dysfunction syndrome scores can predict a prolonged length of stay for critically ill surgical patients in the intensive care unit. DESIGN: Prospective, inception-cohort study. SETTING: Surgical intensive care unit (SICU) of an urban, tertiary care hospital. PATIENTS: 2,295 consecutive admissions for critical surgical illness, postoperative complications, or postoperative monitoring in 2,058 patients. INTERVENTIONS: Calculation of Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores 24 hours after admission to the SICU. Serial quantitation of organ dysfunction for the duration of hospitalization according to the multiple organ dysfunction score. Patients were stratified by survival and time intervals for the duration of critical care, and followed until discharge or death. MAIN OUTCOME MEASURES: Hospital mortality and length of stay in the SICU. RESULTS: The mean APACHE II and APACHE III scores were 14.0 +/- 0.2 and 45.2 +/- 0.6 points, respectively (mean +/- SEM). The incidence of organ dysfunction was 43%, and the hospital mortality was 9.7%. The mean ICU length of stay was 6.1 +/- 0.2 days, but decreased progressively from 6.8 +/- 0.5 days in 1991 to 5.3 +/- 0.6 days in 1995 (p < 0.01) with no change in either illness severity or the number of admissions. By univariate analysis, increased length of stay in the ICU was associated with increasing APACHE scores, an increased incidence of emergency admissions, and the incidence and magnitude of organ dysfunction (all p < 0.01). Severity indices appeared to plateau in magnitude in patients whose ICU stay ultimately exceeded 21 days. By multivariate analysis of variance (MANOVA), independent predictors of a prolonged stay in the SICU were APACHE III (p = 0.0023), emergency admission (p = 0.0007), and the magnitude of organ dysfunction (p < 0.00001), but not APACHE II. Only an emergency admission (p = 0.0005) and the magnitude of organ dysfunction (p < 0.00001) predicted a prolonged stay independently in survivors. In contrast, only the admission APACHE III score(p = < 0.0001) and the magnitude of organ dysfunction (p = 0.0001) were independently predictive of mortality by MANOVA. CONCLUSIONS: The development of multiple organ dysfunction syndrome is a powerful predictor of a prolonged ICU course in critical surgical illness, even in survivors. Increased risk of a prolonged stay in the ICU plateaued at 21 days, making 21 days an appropriate definition of prolonged care for future studies. Predictive models should account for organ dysfunction and very long stays in future estimations. The combined use of APACHE III and the multiple organ dysfunction score may provide improved prediction of a prolonged stay in the ICU, but further enhancements are needed before prediction of outcome in individual patients is reliable.

Factors influencing the development of decubitus ulcers in critically ill surgical patients.

INTRODUCTION: Decubitus ulcers confer significant morbidity to critically ill patients. We sought to determine which patient factors contributed to the formation of decubitus ulcers in our critically ill patients, and hypothesized that these ulcers occurred most often in elderly patients with lengths of stay >7 days and high severity of illness. METHODS: This study was conducted prospectively in two phases. Phase I provided an initial analysis of patients who developed decubitus ulcers in the surgical intensive care unit (ICU) of New York Weill Cornell Center from January 1, 1993, to June 1, 1997. In phase II of the study, a comparison study was made for patients with ICU length of stay (ULOS) >7 days admitted to the same ICU from January 1, 1998, to August 31, 1998. Age, APACHE III score, systemic inflammatory response syndrome (SIRS score), multiple organ dysfunction syndrome (MODS) score, admission status, days without nutrition, ULOS, mortality, days to formation of decubitus ulcers, Cornell ulcer risk score, and other demographic features were recorded. Univariate and multivariate analysis of variance were performed to analyze independent risk factors for development of decubitus ulcers; p <.05. RESULTS: In phase I, 2,615 patients were admitted to surgical ICU over the study period. One hundred and one decubitus ulcers occurred (incidence 3.8%) during phase I, but the incidence of decubitus ulcers increased significantly over time to 9% (p <.01). Thirty-three decubitus ulcers occurred among the 412 patients (incidence 8.0%) during phase II. Multivariate analysis revealed that emergent admission (odds ratio [OR] 36.00, 95% confidence interval [CI] CI 0.2290-0.7694), age (OR 1.08, 95% CI 0.0026-0.0131), days in bed (OR 1.05, 95% CI -0.0013-0.0156, and days without nutrition (OR 0.51, 95% CI -0.1095--0.0334) were independent predictors of a decubitus ulcer. CONCLUSIONS: The incidence of decubitus ulcers is increasing in critically ill patients. Emergency ICU admission and ULOS >7 days in elderly patients confer significant risk for the formation of decubitus ulcers. Specific interventions targeting this high-risk population that may be instituted to decrease the incidence of decubitus ulcers include early nutrition, early mobilization, and possibly less noxious bedding surfaces.

Factors associated with mortality in patients with penetrating abdominal vascular trauma.

OBJECTIVE: Prehospital transport, resuscitation, and operative intervention are all critical to the care of the penetrating trauma victim. We determined which factors most affected mortality in patients with penetrating abdominal vascular injuries. METHODS: Consecutive patients with penetrating abdominal vascular injuries from an urban Level I trauma center from January 1993 to December 1998 were identified from the trauma registry and their charts reviewed. All patients who died prior to operative intervention were excluded. Data collected included mortality, age, scene time (ST), EMS transport time (TT), time in the emergency department (ED), initial systolic blood pressure in the ED (BP), operating time, intraoperative estimated blood loss (EBL), and worst base deficit in the first 24 h (BD). These variables were compared between nonsurvivors and survivors by univariate ANOVA. Multivariate ANOVA (MANOVA) determined independent effects on mortality. RESULTS: Forty-six penetrating abdominal vascular injuries were identified in 31 patients, 11 of whom died (38.7%). Examining prehospital parameters, mean ST averaged 16.5 +/- 3.6 min, while TT was 31.8 +/- 7.1 min. For ED parameters, initial BP was 94.8 +/- 6.4 mm Hg and initial heart rate was 109 +/- 7 beats per minute. Mean operative EBL for all patients was 3518 +/- 433 ml. The mean BD for all patients was -12.9 +/- 1.8. Significant differences were noted in the univariate analysis between survivors and nonsurvivors for BD (P < 0.0001), BP (P = 0.0062) and EBL (P = 0.0002). MANOVA revealed that only base deficit (P < 0.0001) had an independent effect on mortality. CONCLUSIONS: In patients with penetrating abdominal vascular injuries who survive their ED stay, adverse physiologic parameters reflecting the adequacy of resuscitation are more predictive of mortality than identifiable prehospital parameters.

Hypothermia during elective abdominal aortic aneurysm repair: the high price of avoidable morbidity.

PURPOSE: Adverse outcomes apparently associated with hypothermia led us to examine patients undergoing elective abdominal aortic aneurysm (AAA) repairs to test the hypothesis that hypothermia (temperature less than 34.5 degrees C) is associated with increased morbidity and excess mortality rates. METHODS: Two hundred sixty-two elective AAA repairs were retrospectively reviewed for preoperative and intraoperative risk factors. Core temperature, age, Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores (raw and temperature-adjusted), fluid resuscitation, and perioperative organ dysfunction were recorded prospectively. Outcome measures included lengths of stay in the intensive care unit and in the hospital, and hospital mortality rates. RESULTS: Except for a higher risk of hypothermia in women (p < 0.05), by univariate analysis, preoperative risk factors were similar in patients in the hypothermic and normothermic groups. After operation, patients with hypothermia had significantly greater APACHE scores (p < 0.0001), and patients in the hypothermic nonsurvivor group took significantly longer to rewarm (p < 0.05), suggesting marked hypoperfusion. Patients with hypothermia had significantly greater fluid (p < 0.05), transfusion (p < 0.01), vasopressor (p < 0.05), and inotrope (p < 0.05) requirements, resulting in significantly higher incidences of organ dysfunction (53.0% vs 28.7%, p < 0.01) and death (12.1% vs 1.5%, p < 0.01) and markedly prolonged lengths of stay in the unit (9.2 +/- 2.0 vs 5.3 +/- 0.6, p < 0.05) and in the hospital (24.3 +/- 2.9 vs 15.0 +/- 0.08, p < 0.01). By multivariate analysis, female gender (p = 0.004) was the only predictor of intraoperative hypothermia, whereas initial hypothermia was significantly predictive of both prolonged hypothermia and development of organ failure (p < 0.05). Organ failure (p < 0.05) and acute myocardial infarction (p < 0.01) were independent predictors of death. CONCLUSIONS: After AAA repair, patients with hypothermia have multiple physiologic derangements associated with adverse outcomes. Although multiple etiologic factors are interacting, body temperature is one variable that should be controlled during aortic surgery.

High-risk intrahospital transport of critically ill patients: safety and outcome of the necessary "road trip".

OBJECTIVE: Intrahospital transport of critically ill patients is often necessary for optimal patient care. However, transport of intensive care unit (ICU) patients within the hospital has been associated with a high rate of potentially detrimental complications. This study was designed to determine the occurrence rate of transport-related complications and to determine if these complications have any effect on patient morbidity and mortality. DESIGN: Prospective, cohort-matched study. SETTING: A 780-bed urban, university teaching hospital. PATIENTS: Seven hundred fifty-nine surgical ICU patients. INTERVENTIONS: One hundred seventy-five patients were transported out of the surgical ICU for diagnostic testing or operative interventions deemed necessary by their surgical or critical care team. MEASUREMENTS AND MAIN RESULTS: Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores were determined 24 hrs after admission. Transport patients were stratified into low-risk and high-risk transport groups. Patients were considered a high-risk transport if they required positive end-expiratory pressure of > 5 cm H2O, a continuous infusion of dobutamine, or a continuous infusion of norepinephrine. The high-risk group was further stratified into three groups based on the number of defined treatment regimens required to maintain the patient during transport. The patients were then followed during their transport for any potentially detrimental complications, such as a need for an increased dose of vasoactive medications, loss of intravenous access, a need for additional ventilatory support, or cardiopulmonary arrest. APACHE-matched control cohorts were identified as patients who did not leave the surgical ICU. The overall occurrence rate of complications was similar in the two groups (low-risk group, 6.3%; high-risk group, 5.5%). The mortality rate for all transport patients was 28.6%, which was statistically higher (p < .01) than the mortality rate for all control patients (11.4%). However, there was no mortality as a direct result of a transport. The overall mortality rate (10.9%) of the low-risk group was not significantly different from the APACHE-matched controls (6.0%). The overall mortality rate (51.4%) in the high-risk group was significantly higher (p < .01) than the APACHE-matched controls, but was not statistically higher than predicted mortality (p = .416). Both the low-risk and the high-risk groups stayed in the surgical ICU three times as long as the APACHE-matched control cohorts. CONCLUSIONS: Intrahospital transport of critically ill patients is safe and carries a low risk of detrimental complications. Although patients requiring "high-risk" interventions experienced a higher mortality rate than did APACHE-matched controls, the increase in mortality does not appear to be directly related to the intrahospital transport. Patients requiring transport out of the surgical ICU are a more critically ill group of patients. These patients require a greater length of stay in the surgical ICU and may experience an increased mortality rate by virtue of the severity of their illness.

Clinical features and outcome of patients admitted to the intensive care unit after plastic surgical procedures: implications for cost reduction and quality of care.

Recent interest in cutting cost and improving utilization and delivery of perioperative services has prompted surgeons to identify patient populations that would benefit from care in an intensive care unit as opposed to intermediate or standard care. The purpose of this study was to evaluate patients admitted to the surgical intensive care unit (SICU) after major plastic/reconstructive surgical procedures in order to determine appropriate perioperative management strategies for these patients. We reviewed retrospectively the data from 2,805 consecutive admissions to the SICU between 1990 and 1996. Forty-two patients (1.5%) who had undergone major plastic/reconstructive procedures were identified. Outcomes (mortality, length of stay in the SICU and hospital, and the degree of organ dysfunction) were compared between this population, an illness severity-matched (Acute Physiology and Chronic Health Evaluation [APACHE]-II and APACHE III) population of patients recovering from vascular surgical procedures, and a similarly matched population of SICU patients who were randomly assigned to serve as a second control group. The hospital mortality of the plastic surgical patient population (9.5%) was significantly higher than the zero mortality of the random cohort (p < 0.05). A second analysis compared the SICU plastics group to a case-controlled group of patients who were admitted to the postanesthesia care unit (PACU) for at least 24 hours of perioperative monitoring. SICU patients had significantly higher APACHE II scores (10.9) when compared to PACU patients (7.2; p < 0.01). Based on severity of illness scoring and eventual mortality, patients admitted to our SICU after major reconstructive surgery were selected appropriately for that setting. In contrast, the patients who stayed in the PACU for perioperative monitoring did not require life-supporting therapy and, therefore, were overmonitored. Care could be provided in a specialized unit with dedicated nursing specifically trained for that purpose.

Alterations of preliminary readings on radiographic examinations minimally affect outcomes of trauma patients discharged from the emergency department.

BACKGROUND: We hypothesized that trauma patients could be discharged safely from the emergency department (ED) before the availability of official readings for their radiologic examinations. We also sought to determine whether trauma patients were more prone to alterations of preliminary interpretations than other ED patients. METHODS: Alterations of preliminary readings (PR) for patients discharged from the ED were reviewed. If the official readings conflicted with the PR used for the patient's disposition, attempts were made to contact the patient and provide the appropriate follow-up. Data recorded included the type of radiographic examination, the presence of a missed injury, and the follow-up. By using institutional data, the incidence of inaccurate PR were compared for trauma patients and other ED patients (chi2 test, Fisher exact test, p < 0.05). RESULTS: Between January of 1998 and December of 1998, 102 of 38,260 discharged ED patients had official readings differing from PR. Forty-three of the changed readings involved 42 of the 1,073 discharged trauma patients, who were more likely to harbor inaccurate PR (<0.0001) than other discharged ED patients. Twenty-eight altered readings involved plain films and 15 involved computed tomographic scans. The most common altered readings involved computed tomographic scans of the head and face (n = 13). Twelve missed injuries were detected, most commonly related to a missed injury of the extremity (7 cases). Nine other cases involved the detection of incidental pathologic conditions. Eight patients required repeat ED visits for clinical and radiographic evaluation, and one patient required subsequent hospital admission. CONCLUSION: Discharged trauma patients are more likely to harbor alterations of preliminary interpretations than other ED patients. Although the official readings for these trauma patients will occasionally reveal previously undetected pathologic conditions, the majority of such cases can be managed with outpatient follow-up.