Aminoglycoside Dosing and Volume of Distribution in Critically Ill Surgery Patients.

Background: At a tertiary referral and Level I trauma center, current institutional guidelines suggest initial aminoglycoside doses of gentamicin or tobramycin 4 mg/kg and amikacin 16 mg/kg for patients admitted to surgical intensive care units (SICUs) with suspected gram-negative infection. The objective of this study was to evaluate initial aminoglycoside dosing and peak serum drug concentrations in critically ill surgery patients to characterize the aminoglycoside volume of distribution (Vd) and determine an optimal standardized dosing strategy. Methods: This retrospective, observational, single-center study included adult SICU patients who received an aminoglycoside for additional gram-negative coverage. Descriptive statistics were used to evaluate the patient population, aminoglycoside dosing, and Vd. Multivariable linear regression was applied to determine variables associated with greater aminoglycoside Vd. The mortality rate was compared in patients who achieved adequate initial peak concentrations versus those who did not. Results: One hundred seventeen patients received an aminoglycoside in the SICUs, of whom 58 had an appropriately timed peak concentration measurement. The mean Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score was 27.8 ± 8.9. The Vd in patients receiving gentamicin, tobramycin, and amikacin was 0.49 ± 0.10, 0.41 ± 0.09, and 0.53 ± 0.13 L/kg, respectively. Together, the mean aminoglycoside Vd was 0.50 ± 0.12 L/kg. Gentamicin or tobramycin 5 mg/kg achieved goal peak concentrations in 24 patients (63.2%), and amikacin 20 mg/kg achieved the desired concentrations in nine patients (50.0%). Net fluid status, Body Mass Index, and vasopressor use were not predictive of Vd. There was no difference in the in-hospital mortality rate in patients who achieved adequate peak concentrations versus those who did not (26.8% versus 26.7%; p = 0.99). Conclusion: High aminoglycoside doses are needed in critically ill surgery patients to achieve adequate initial peak concentrations because of the high Vd. Goal peak concentrations were optimized at doses of gentamicin or tobramycin 5 mg/kg, and amikacin 20 mg/kg.

Effect of epsilon aminocaproic acid on red-cell transfusion requirements in major spinal surgery.

STUDY DESIGN: : Randomized, placebo-controlled trial. OBJECTIVE: : To evaluate the efficacy of epsilon aminocaproic acid (EACA) to reduce the number of red-cell (RBC) transfusions in adult patients undergoing major spinal surgery. SUMMARY OF BACKGROUND DATA: : Reconstructive spinal surgery is associated with significant blood loss. The number of studies evaluating the efficacy of EACA in adult patients undergoing spinal surgery remains scarce and limited. METHODS: : EACA (100 mg/kg) or placebo was administered to 182 adult patients after the induction of anesthesia followed by an infusion that was continued for 8 hours after surgery. Primary end points included total allogeneic RBC transfusions through postoperative day 8 and postoperative allogeneic plus autologus RBC transfusions through postoperative day 8. RESULTS: : Mean total allogeneic RBC transfusions were not statistically different between the groups (5.9 units EACA vs. 6.9 units placebo; P = 0.17). Mean postoperative RBC transfusions in the EACA group was less (2.0 units vs. 2.8 units placebo; P = 0.03). There was no significantdifference in mean estimated intraoperative estimated-blood loss (2938 cc EACA vs. 3273 cc placebo; P = 0.32). Mean intensive care unit length of stay was decreased (EACA: 1.8 days vs. 2.8 days placebo; P = 0.04). The incidence of thromboembolic complications was similar (2.2% EACA vs. 6.6% placebo; P = 0.15). CONCLUSION: : The difference in total allogeneic RBC transfusions between the groups was not statistically significant. EACA was associated with a 30% (0.8 units) reduction in postoperative RBC transfusions and a 1-day reduction in ICU LOS, without an increased incidence of thromboembolic events. EACA may be considered for patients undergoing major spinal surgery. Larger studies are needed to evaluate the relationship between EACA and total RBC requirements.

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.

PURPOSE: The aim of this study is to determine if patient safety incidents and the system-related factors contributing to them systematically differ for medical versus surgical patients in intensive care units. MATERIALS AND METHODS: We conducted a multicenter prospective study of 646 incidents involving adult medical patients and 707 incidents involving adult surgical patients that were reported to an anonymous patient safety registry over a 2-year period. We compared incident characteristics, patient harm, and associated system factors for medical versus surgical patients. RESULTS: The proportion of safety incidents reported for medical versus surgical patients differed for only 3 of 11 categories: equipment/devices (14% vs 19%; P = .02), "line, tube, or drain" events (8% vs 13%; P = .001), and computerized physician order entry (13% vs 6%; P < or = .001). The type of patient harm associated with incidents also did not differ. System factors were similar for medical versus surgical patients, with training and teamwork being the most important factors in both groups. CONCLUSIONS: Medical and surgical patients in the intensive care unit experience very similar types of safety incidents with similar associated patient harm and system factors. Common initiatives to improve patient safety for medical and surgical patients should be undertaken with a specific focus on improving training and teamwork among the intensive care team.

Association between venous thromboembolism and perioperative allogeneic transfusion.

HYPOTHESIS: Perioperative allogeneic blood product transfusion would be associated with venous thromboembolic complications in surgical patients. DESIGN: Observational study using a state discharge database. SETTING: Nonfederal acute care hospitals in Maryland performing colorectal cancer resections between January 1, 1994, and December 31, 2000. PATIENTS: We obtained data on 14 014 adult patients having a primary diagnosis code for colorectal cancer and a primary procedure code for colorectal resection. MAIN OUTCOME MEASURES: The primary outcome variable was a discharge diagnosis of venous thromboembolism (VTE). RESULTS: Venous thromboembolism occurred in 1% of patients and was associated with an adjusted 3.8-fold increase in mortality (odds ratio, 3.8; 95% confidence interval, 2.1-6.8), a 61% increase in mean hospital length of stay, and a 72% increase in mean total hospital charges. Risk factors for VTE after adjustment included transfusion, female sex, age 80 years or older, moderate to severe liver disease vs no liver disease, admission through the emergency department, and low annual surgeon case volume. Transfusion was associated with an increase in the odds of developing VTE in women (odds ratio, 1.8; 95% confidence interval, 1.2-2.6) but not in men (odds ratio, 0.9; 95% confidence interval, 0.5-1.9). In the absence of transfusion, female compared with male sex was not associated with an increased risk of VTE (odds ratio, 1.2; 95% confidence interval, 0.8-1.7). CONCLUSIONS: In this large observational study of patients undergoing colorectal cancer resection, perioperative allogeneic blood transfusion was associated with an increased risk of VTE in women but not in men. Given the substantial morbidity and mortality associated with VTE and the implication that this finding has for postoperative management in women, this association must be confirmed in independent studies.

Toward learning from patient safety reporting systems.

PURPOSE: To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety. MATERIALS AND METHODS: Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm. RESULTS: Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm. CONCLUSIONS: The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

Clinical and economic outcomes of hospital acquired pneumonia in intra-abdominal surgery patients.

OBJECTIVE: To measure the clinical and economic impact of postoperative hospital-acquired pneumonia (HAP) and to identify risk factors for the development of HAP. SUMMARY BACKGROUND DATA: Although postoperative HAP is recognized to be an major risk associated with surgery, little is known about the overall outcomes of patients whose hospital stay is complicated by HAP following surgery. METHODS: We studied 618,495 patients who underwent an intra-abdominal operation from the National Inpatient Sample database over a 1-year period (January 2000 to December 2000) using CPT codes and discharge diagnoses identified by the Clinical Classification Software. Data collected included demographic characteristics, type of operation, in-hospital mortality, discharge disposition, length of stay, and hospital charges. RESULTS: Of the 13,292 patients with HAP following intra-abdominal surgery, 1421 died prior to discharge (mortality = 10.7%) compared with 7217 deaths in the control group of patients without HAP following intra-abdominal surgery (mortality = 1.2%) (P < 0.001). HAP was independently associated with a 4.13-fold (95% confidence interval = 3.94-4.34) increase in risk to be discharged to a skilled nursing facility. The mean length of hospital stay for intra-abdominal patients who developed HAP was significantly greater compared with intra-abdominal surgery patients who did not develop HAP (17.10 days versus 6.07 days, P < 0.001). After adjusting for patient characteristics, HAP was independently associated with a 75% (28,160.95 dollars; 95% confidence interval, 27,543.76 dollars - 28,778.13 dollars) mean increase in total hospital charges. CONCLUSIONS: Given the high incidence and significant impact of HAP on patient outcomes, early preventive strategies and interventions to reduce HAP should be a priority.

Integrating the intensive care unit safety reporting system with existing incident reporting systems.

BACKGROUND: Voluntary incident reporting systems that identify risks can be integrated into existing hospital reporting systems and can improve patient safety. FINDINGS: A voluntary and anonymous Web-based intensive care unit safety reporting system (ICUSRS) was implemented in a cohort of intensive care units (ICUs). The reporting system was integrated into hospitals' reporting systems after the adverse event reporting structures were investigated. Reporting systems were classified as mandatory or voluntary and internal or external; the extent of formal training was identified and the trajectory of completed adverse events in the exisiting systems were tracked. Information from reported incidents was sent back monthly to the hospital ICUs through case discussions and a quarterly newsletter. RESULTS: All seven hospitals had internal reporting systems and two also used external reporting systems. In general, the majority of incident reports were completed by registered nurses and were reported to the nursing chain of command. Many of the sites had little knowledge or understanding of their existing reporting systems. CONCLUSION: Voluntary external reporting systems such as the ICUSRS hold promise for improving patient safety.

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

OBJECTIVE: To analyze the system factors related to "line, tube, and drain" (LTD) incidents in the intensive care unit (ICU). DESIGN: Voluntary, anonymous Web-based patient safety reporting system. SETTING: Eighteen ICUs in the United States. PATIENTS: Incidents reported by ICU staff members during a 12-month period ending June 2003. INTERVENTIONS: None. MEASUREMENTS: Characteristics of the incidents (defined as events that could/did cause harm), patients, and patient harm were described. Separate multivariable logistic regression analyses of contributing, limiting, and preventive system factors for LTD vs. non-LTD incidents were reported. MAIN RESULTS: Of the 114 reported LTD incidents, >60% were considered preventable. One patient death was attributed to an LTD incident. Of patients experiencing LTD incidents, 56% sustained physical injury, and 23% had an anticipated increased hospital stay. Factors contributing to LTD incidents included occurrence in the operating room (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.25-9.83), occurrence on a holiday (OR, 3.65; 95% CI, 1.12-11.9), patient medical complexity (OR, 3.68; 95% CI, 2.28-5.92), and age of 1-9 yrs (OR, 7.95; 95% CI, 3.29-19.2). Factors related to team communication were less likely to limit LTD incidents (OR, 0.28; 95% CI, 0.11-0.68), while clinician knowledge and skills helped prevent LTD incidents (OR, 1.80; 95% CI, 1.09-2.97). CONCLUSIONS: Patients are harmed by preventable LTD incidents. Relative to non-LTD events, these incidents occur more frequently during holidays and in medically complex patients and children. Focusing on these contributing factors and clinician knowledge and skills is important for reducing and preventing these hazardous events.

Number needed to treat and cost of recombinant human erythropoietin to avoid one transfusion-related adverse event in critically ill patients.

OBJECTIVE: To calculate the absolute risk reduction of transfusion-related adverse events, the number of patients needed to treat, and cost to avoid one transfusion-related adverse event by using erythropoietin in critically ill patients DESIGN: Number needed to treat with sensitivity analysis. SETTING: Teaching hospital. PATIENTS: Hypothetical cohort of critically ill patients who were candidates to receive erythropoietin. INTERVENTIONS: Using vs. not using erythropoietin to reduce the need for packed red blood cell transfusions. MEASUREMENTS AND MAIN RESULTS: We used published estimates of known transfusion risks: transfusion-related acute lung injury, transfusion-related errors, hepatitis B and C, human immunodeficiency virus, human T-cell lymphotropic virus, and bacterial contamination, stratified by severity. Based on the estimated risk and frequency of transfusions with and without erythropoietin, we calculated the absolute risk reduction of transfusion-related adverse events, the number needed to treat, and cost to avoid one transfusion-related adverse event by using erythropoietin. The estimated incidence of transfusion-related adverse event was 318 permillion units transfused for all transfusion-related adverse events, 58 per million for serious transfusion-related adverse events, and 21 per million for likely fatal transfusion-related adverse events. The routine use of erythropoietin resulted in an absolute risk reduction of 191 per million for all transfusion-related adverse events, 35 per million for serious transfusion-related adverse events, and 12 per million for likely fatal transfusion-related adverse events. The number needed to treat was 5,246 to avoid one transfusion-related adverse event, 28,785 to avoid a serious transfusion-related adverse event, and 81,000 for a likely fatal transfusion-related adverse event. The total cost was $4,700,000 to avoid one transfusion-related adverse event, $25,600,000 to avoid one serious transfusion-related adverse event, and $71,800,000 to avoid a likely fatal transfusion-related adverse event. The magnitude of these results withstood extensive sensitivity analysis. CONCLUSIONS: From the perspective of avoidance of adverse events, erythropoietin does not appear to be an efficient use of limited resources for routine use in critically ill patients.

Platelet gene polymorphisms and cardiac risk assessment in vascular surgical patients.

BACKGROUND: Current perioperative cardiac risk assessment tools use historic and surgical factors to stratify patient risk. Polymorphisms in platelet glycoprotein (GP) IIIa and GPIbalpha are associated with myocardial ischemic risk in nonsurgical settings, but their relation to perioperative ischemia is unclear. The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors. METHODS: One hundred ninety-six patients who underwent infrainguinal, abdominal aortic, or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia. Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIbalpha. Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis. RESULTS: Sixty-five patients (33%) experienced one or more ischemic endpoints (2% death, 5% myocardial infarction, 20% troponin+, 22% electrocardiogram+). The Pro33 (adjusted odds ratio [OR], 2.4 [95% confidence interval, 1.2-6.2]) and Met145 (OR 3.4 [1.4-9.3]) genotypes were independent predictors of composite ischemic outcome by multivariate regression, as were diabetes mellitus (OR 4.0 [1.7-12.5]), abdominal aortic surgery (OR 4.1 [1.7-14.4]), and thoracoabdominal aortic surgery (OR 6.4 [2.7-23.8]). The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 13.5, P < 0.001) of an ischemia prediction model. The derived risk assessment tool had a receiver operator characteristic curve of 0.73 (0.65-0.81) compared with 0.64 (0.57-0.74) for a model excluding genetic factors (P = 0.04). A significant relation between the GPIbalpha polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint. CONCLUSIONS: Platelet polymorphisms are independent risk factors for postoperative myocardial ischemia and improve a risk prediction model when added to historic and surgical risk factors.

A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS).

OBJECTIVE: To evaluate the contributing and limiting factors for airway events reported in the Intensive Care Unit Safety Reporting System (ICUSRS) developed in partnership with the Society of Critical Care Medicine. DESIGN: Analysis of system factors in airway vs. nonairway events reported to a voluntary, anonymous, Web-based patient safety reporting system (the ICUSRS). SETTING: Sixteen adult and two pediatric intensive care units (ICU) across the United States. PATIENTS: Incidents reported during the 12-month period ending June 30, 2003. INTERVENTIONS: None MEASUREMENTS: Descriptive characteristics of incidents (defined as events that could have, or did, cause harm), patients, and patient harm; separate multivariable logistic regression analyses of contributing and limiting factors for airway vs. nonairway events. MAIN RESULTS: There were 78 airway and 763 nonairway events reported. More than half of airway events were considered preventable. One patient death was attributed to an airway event. Physical injury, increased hospital length of stay, and family dissatisfaction occurred in at least 20% of airway events. Important factors contributing to reported airway events (odds ratio (OR), 95% confidence interval (CI)) included patients' medical condition (5.24, 3.07-8.95) and age <1 yr old (4.15, 1.79-9.59). Factors limiting the impact of airway events (OR, 95% CI) included adequate ICU staffing (3.60, 1.71-7.56) and use of skilled assistants (3.20, 1.62-6.32). CONCLUSIONS: Patients are harmed by unintended and preventable incidents involving airway management. Prevention efforts should focus on critically ill infants and patients with complex medical conditions. Managers should ensure appropriate ICU staffing to limit the impact of airway events when they occur.

Sensitivity of routine intensive care unit surveillance for detecting myocardial ischemia.

OBJECTIVE: To assess the effectiveness of routine intensive care unit surveillance compared with frequent 12-lead electrocardiogram monitoring for detecting electrocardiogram evidence suggestive of prolonged myocardial ischemia in vascular surgery patients. DESIGN: Prospective cohort trial. SETTING: Intensive care unit. PARTICIPANTS: We studied 149 patients undergoing elective infrainguinal or aortic vascular surgery who were admitted to the intensive care unit postoperatively. INTERVENTIONS: Patients were simultaneously monitored with a 10-electrode/12-lead electrocardiogram obtained every 2 mins (criterion standard) and routine intensive care unit surveillance that included standard monitoring (five-electrode/two-lead electrocardiogram with ST segment trends and routine 12-lead electrocardiogram) and clinical assessment for detecting myocardial ischemia. The results of the criterion standard were not available to the caregivers. MEASUREMENTS AND MAIN RESULTS: We measured the ability of routine intensive care unit surveillance to detect the first 20 mins of electrocardiogram evidence suggestive of myocardial ischemia, defined as ST segment depression or elevation of >/=1 mm in two consecutive leads, during the first postoperative day. Seventeen patients (11%) had electrocardiogram evidence suggestive of prolonged myocardial ischemia, the majority of which occurred in leads V2-V4. The sensitivity of routine intensive care unit surveillance for detecting the first episode of electrocardiogram evidence suggestive of prolonged myocardial ischemia in a patient was 12% (95% confidence interval, 7-17%), and the specificity was 98% (95% confidence interval, 95-100%) with a positive predictive value of 40% (95% confidence interval, 32-48%), a negative predictive value of 90% (95% confidence interval, 85-94%), a positive likelihood ratio of 6, and a negative likelihood ratio of 1. The sensitivity of routine intensive care unit surveillance for detecting all episodes was 3% (95% confidence interval, 2-3%) and the specificity 99% (95% confidence interval, 99-100%) per 20-min monitoring interval, with a positive predictive value of 17% (95% confidence interval, 16-18%), negative predictive value of 95% (95% confidence interval, 95-96%), positive likelihood ratio of 3, and negative likelihood ratio of 1. CONCLUSIONS: Routine intensive care unit surveillance has low sensitivity for detecting electrocardiogram evidence suggestive of prolonged myocardial ischemia compared with frequent 12-lead electrocardiograms. Because detecting electrocardiogram evidence suggestive of prolonged postoperative myocardial ischemia is important, physicians should consider alternative strategies to detect myocardial ischemia.

Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999-2000.

OBJECTIVE: The epidemiology of aspiration pneumonia and its impact on clinical and economic outcomes in surgical patients are poorly defined. We sought to identify preoperative patient characteristics and surgical procedures that are associated with an increased risk for aspiration pneumonia and to determine the clinical and economic impact in hospitalized surgical patients. DESIGN: Observational study using a state discharge database. SETTING: All hospitals in Maryland. PATIENTS: We obtained discharge data for 318,880 adult surgical patients in 52 Maryland hospitals from January 1, 1999, through December 31, 2000. MEASUREMENTS AND MAIN RESULTS: The primary outcome variable was a discharge diagnosis of aspiration pneumonia. Unadjusted and adjusted analyses were performed to identify patient characteristics and surgical procedures associated with an increased risk for aspiration pneumonia and to determine the impact on intensive care unit admission, in-hospital mortality, hospital length of stay, and total hospital charges. The overall prevalence of aspiration pneumonia was 0.8%. The prevalence varied among hospitals (range, 0% to 1.9%) and by surgical procedure (range, <0.1% to 19.1%). Patient characteristics independently associated with an increased risk included: male sex, nonwhite race, age of >60 yrs vs. 18-29 yrs, dementia, chronic obstructive pulmonary disease, renal disease, malignancy, moderate to severe liver disease, and emergency room admission. In patients undergoing procedures other than tracheostomy, aspiration pneumonia was independently associated with an increased risk for admission to the intensive care unit (odds ratio, 4.0; 95% confidence interval, 3.0-5.1), in-hospital mortality (odds ratio, 7.6; 95% confidence interval, 6.5-8.9), longer hospital length of stay (estimated mean increase of 9 days; 95% confidence interval, 8-10), and increased total hospital charges (estimated mean increase of 22,000 US dollars; 95% confidence interval, 19,000 US dollars-25,000 US dollars). CONCLUSIONS: Aspiration pneumonia occurs in approximately 1% of surgical patients and is associated with significant morbidity, mortality, and costs of care. Given that the rate of aspiration pneumonia varies among hospitals, we can improve the quality and reduce the costs of care by implementing strategies to reduce the rate of aspiration pneumonia.

Improving communication in the ICU using daily goals.

BACKGROUND: Clear communication is imperative if teams in any industry expect to make improvements. An estimated 85% of errors across industries result from communication failures. PURPOSE: The purpose of this study was to evaluate and improve the effectiveness of communication during patient care rounds in the intensive care unit (ICU) using a daily goals form. DESIGN: We conducted a prospective cohort study in collaboration with the Volunteer Hospital Association (VHA), Institute for Healthcare Improvement (IHI), and Johns Hopkins Hospital's (JHH) 16-bed surgical oncology ICU. All patients admitted to the ICU were eligible. Main outcome variables were ICU length of stay (LOS) and percent of ICU residents and nurses who understood the goals of care for patients in the ICU. Baseline measurements were compared with measurements of understanding after implementation of a daily goals form. RESULTS: At baseline, less than 10% of residents and nurses understood the goals of care for the day. After implementing the daily goals form, greater than 95% of nurses and residents understood the goals of care for the day. After implementation of the daily goals form, ICU LOS decreased from a mean of 2.2 days to 1.1 days. CONCLUSION: Implementing the daily goals form resulted in a significant improvement in the percent of residents and nurses who understood the goals of care for the day and a reduction in ICU LOS. The use of the daily goals form has broad applicability in acute care medicine.

Sepsis alert and diagnostic system: integrating clinical systems to enhance study coordinator efficiency.

Screening patients for clinical studies is time-consuming for researchers. Inefficiencies from human-based eligibility screening cause delay in scientific breakthroughs and are costly. We sought to determine the reliability of an automated computer-based real-time eligibility screening tool. A time-motion diary study was conducted in two university-based intensive care units using a cohort-controlled design. Time saved by automated eligibility screening and the positive and negative predictive values of the integrated eligibility screening system were compared with the gold standard of manual chart review. Sepsis Alert and Diagnostic System sensitivity and specificity were 82% and 95%, respectively. Positive and negative predictive values were 87.5% and 93%, respectively. During evaluation, Sepsis Alert and Diagnostic System saved a minimum of 137 minutes for the study coordinator. Sepsis Alert and Diagnostic System serves as a reliable tool for real-time eligibility screening in an intensive care unit setting. Time efficiencies through use of Sepsis Alert and Diagnostic System may translate into cost savings for funding agencies. The concept and methodology deployed in this study are applicable to any facility with electronic medical record capacity, as long as the data within that system are granular enough to support the specific query.

Preoperative predictors of blood transfusion in colorectal cancer surgery.

Transfusion is associated with multiple risks and morbidities. Little is known, however, about preoperative predictors of transfusion in gastrointestinal surgery patients. To identify factors that influence transfusion practices, we analyzed hospital discharge data from colorectal cancer surgery patients in Maryland between 1994 and 2000 (n = 14,052). The primary outcome variable was whether or not patients received a blood product ("Any Transfusion"). Characteristics independently associated with an increased risk of receiving Any Transfusion included: advanced age (>80 yr: OR 2.3; 95% CI 1.9-2.9; 70-79 yr: OR 1.6; 95% CI 1.4-2.0 vs. <60 yr), moderate to severe liver disease (OR 2.5; 95% CI 1.5-4.2), mild liver disease (OR 2.1; 95% CI 1.5-2.9), diabetes with complications (OR 2.1; 95% CI 1.6-2.6), chronic renal disease (OR 2.1; 95% CI 1.4-3.0), female gender (OR 1.3; 95% CI 1.2-1.5), chronic pulmonary disease (COPD) (OR 1.3; 95% CI 1.1-1.4), and metastatic disease (OR 1.2; 95% CI 1.1-1.4). Patients at hospitals with an annual case volume in the highest quartile were at an increased risk for receiving Any Transfusion (OR 2.1; 95% CI 1.3-3.4) and those with surgeons in the highest volume quartile (>12 cases/yr) were at a decreased risk (OR 0.8; 95% CI 0.6-0.99). The association between greater surgeon case volume and low transfusion rates was seen in all but the very high volume hospitals (>74 cases/yr). Blood product transfusion was associated with a 2.5-fold (95% CI 2.1-3.1) increased mortality, 3.7 day (95% CI 2.1-3.1) increase in hospital length of stay, and a 7120 dollars (95% CI 6472 dollars-7769 dollars) increase in total charges compared to patients that did not receive Any Transfusion. This data can be used by providers in discussions with patients regarding the risks for transfusion and in identifying patients in whom strategies to reduce transfusions should be evaluated.

Cardiac troponin I predicts short-term mortality in vascular surgery patients.

BACKGROUND: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for myocardial injury that predicts outcomes in patients with acute coronary syndromes. Cardiovascular complications are the leading cause of morbidity and mortality in patients who have undergone vascular surgery. However, postoperative surveillance with cardiac enzymes is not routinely performed in these patients. We evaluated the association between postoperative cTnI levels and 6-month mortality and perioperative myocardial infarction (MI) after vascular surgery. METHODS AND RESULTS: Two hundred twenty-nine patients having aortic or infrainguinal vascular surgery or lower extremity amputation were included in this study. Blood samples were analyzed for cTnI immediately after surgery and the mornings of postoperative days 1, 2, and 3. An elevated cTnI was defined as serum concentrations >1.5 ng/mL in any of the 4 samples. Twenty-eight patients (12%) had postoperative cTnI >1.5 ng/mL, which was associated with a 6-fold increased risk of 6-month mortality (adjusted OR, 5.9; 95% CI, 1.6 to 22.4) and a 27-fold increased risk of MI (OR, 27.1; 95% CI, 5.2 to 142.7). Furthermore, we observed a dose-response relation between cTnI concentration and mortality. Patients with cTnI >3.0 ng/mL had a significantly greater risk of death compared with patients with levels < or =0.35 ng/mL (OR, 4.9; 95% CI, 1.3 to 19.0). CONCLUSIONS: Routine postoperative surveillance for cTnI is useful for identifying patients who have undergone vascular surgery who have an increased risk for short-term mortality and perioperative MI. Further research is needed to determine whether intervention in these patients can improve outcome.

Phase I collaborative pilot study: Waste anesthetic gas levels in the PACU.

The National Institute of Occupational Safety and Health (NIOSH) recommends that exposure to waste anesthetic gas (WAG) be minimized to the greatest extent possible. Current recommendations include 2 parts per million (ppm) for 1 hour sample to halogenated agents level or 25 ppm based on nitrous oxide level or combination of 0.5 ppm for halogenated agents and 25 ppm nitrous oxide. The Occupational Safety Health Administration requires that work practices and engineering controls be implemented so that occupational exposure to WAG is controlled. This pilot study was conducted to (1) evaluate the level of WAG in the PACU, (2) analyze the relationship between nurse exposure and self-reported symptoms, and (3) test methods used to describe occupational exposure of PACU staff to WAG. Air sampling to measure levels of WAG in the patient and PACU nurse environment was performed with MIRAN SapphRE (Foxboro Company, Foxboro, MA), a nondispersive infrared spectrophotometer. A personal sampling method was used to measure the level of nurse exposure to WAG on 2 separate days. Self-report of 9 health symptoms using a 10-cm visual analogue scale was obtained before and after the shift from 6 (PACU) nurses. Three nurses from the Medical Intensive Care Unit (MICU) served as a control. Descriptive statistics summarized exhaled gas level and staff exposure. The highest concentrations of nitrous oxide were 283 to 295 ppm in the patient's breathing zone, whereas halogenated agents were below the limit of detection. Staff exposure to nitrous oxide ranged from 2.9 to 8.2 ppm, averaged over the work shift. T test of the pre- and postshift symptoms showed no significant difference in both PACU and MICU nurses. This pilot study identified the potential for staff exposure to WAG in the PACU setting. The methods to detect this exposure were also evaluated. It is recommended that further study be conducted to evaluate PACU staff exposure to WAG. Modifications in some of the measurement methods tested here are also suggested, including the use of procedures to measure the efficacy of air exchange and other engineering controls related to staff exposure.

Predictors of transfusion for spinal surgery in Maryland, 1997 to 2000.

BACKGROUND: The purpose of this study was to identify preoperative patient, hospital, and surgeon characteristics associated with transfusion for spinal surgery. STUDY DESIGN AND METHODS: Discharge data were obtained from 39 Maryland hospitals for adult patients (n = 3988) who had a primary procedure code for spinal surgery between July 1997 through June 2000, and with these codes, surgeons and hospitals were characterized by annual patient volume. Outcome variables included any allogeneic transfusion, any transfusion, RBCs, autologous blood, FFP, or platelet transfusion. Logistic regression was used for univariate and multivariate analyses. RESULTS: Characteristics independently associated with an increased risk of receiving any allogeneic transfusion (n = 786) included age >54 (OR, 1.6; 95% CI, 1.3-2.1), age >66 (OR, 2.7; 95% CI, 2.0-3.5), female sex (OR, 1.6; 95% CI, 1.2-2.0), diabetes with chronic complications (OR, 2.5; 95% CI, 1.3-4.9), and metastatic tumor (OR, 4.9; 95% CI, 2.3-10.5), emergency room admission (OR, 2.3; 95% CI, 1.4-3.8), and greater hospital volume (OR, 4.0; 95% CI, 1.8-8.6). Characteristics independently associated with increased autologous transfusions (n = 574) included white race (OR, 1.7; 95% CI, 1.2-2.4), female sex (OR, 1.4; 95% CI, 1.1-1.8), and greater surgeon volume (OR, 3.5; 95% CI, 1.4-9.1). DISCUSSION: This information can be used to provide informed risk-benefit discussions with patients regarding the risk for blood transfusion as well as to target high-risk patients and institutions for interventions to reduce the risk of exposure to blood components.