Treatment of Strongyloides stercoralis hyperinfection-associated septic shock and acute respiratory distress syndrome with drotrecogin alfa (activated) in a renal transplant recipient.

We report a case of Strongyloides stercoralis hyperinfection syndrome in a renal transplant recipient complicated by septic shock, acute respiratory distress syndrome, and Klebsiella pneumoniae superinfection. The patient was treated successfully with drotrecogin alfa (activated), parenteral ivermectin, albendazole, and piperacillin/tazobactam. This outcome suggests that drotrecogin alfa (activated) may be useful therapy for transplant recipients who develop severe sepsis or septic shock secondary to potentially lethal opportunistic infections.

Management of severe sepsis of abdominal origin.

Severe sepsis is a life-threatening condition that may occur as a sequela of intra-abdominal infections (IAIs) of all types. Diagnosis of IAIs is predicated upon the combination of physical examination and imaging techniques. Diffuse peritonitis usually requires urgent surgical intervention. In the absence of diffuse peritonitis, abdominal computed tomography remains the most useful test for the diagnosis of IAIs, and is essential to both guide therapeutic interventions and evaluate suspected treatment failure in the critically ill patient. Parameters most consistently associated with poor outcomes in patients with IAIs include increased illness severity, failed source control, inadequate empiric antimicrobial therapy, and healthcare-acquired, as opposed to community-acquired infection. Whereas community-acquired IAI is characterized predominantly by enteric gram-negative bacilli and anaerobes that are susceptible to narrow-spectrum agents, healthcare-acquired IAI (e.g., anastomotic dehiscence, postoperative organ-space surgical site infection) frequently involves at least one multi-drug resistant pathogen, necessitating broad-spectrum therapy guided by both culture results and local antibiograms. The cornerstone of effective treatment for abdominal sepsis is early and adequate source control, which is supplemented by antibiotic therapy, restoration of a functional gastrointestinal tract (if possible), and support of organ dysfunction. Furthermore, mitigation of deranged immune and coagulation responses via therapy with recombinant human activated protein C may improve survival significantly in severe cases complicated by septic shock and multiple organ dysfunction syndrome.

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.

Beneficial effects of chest tube drainage of pleural effusion in acute respiratory failure refractory to positive end-expiratory pressure ventilation.

BACKGROUND: As part of an ongoing prospective evaluation of the response of acute respiratory failure (ARF) to ventilation with titrated amounts of positive end-expiratory pressure (PEEP), a subset of patients with a poor response to the initial application of PEEP and radiographic evidence of pleural effusion was identified. The effusion(s) were treated by tube thoracostomy (TT) to test the hypothesis that drainage would have a favorable effect on oxygenation and compliance in critically ill patients with substantial pulmonary dysfunction. METHODS: Consecutive patients with ARF underwent a titrated progressive application of PEEP if arterial oxygen saturation was less than 90% on fraction of inspired oxygen less than 0.5. One or two thoracostomy tubes (TT) were placed afterward in patients with radiologic evidence of effusion who had a poor response to PEEP therapy. The lung injury score (LIS), PaO2:FiO2 (P:F), peak airway pressure, dynamic compliance, and TT output were recorded. Changes over time were analyzed by one-way analysis of variance with repeated measures. RESULTS: Nineteen of 199 patients needed TT. LIS was 3.0 +/- 0.1. Maximum PEEP was 16.6 +/ 1.0 cm H2O. TT drainage was 863 +/- 164 ml in the first 8 hours. Mortality was 63% (12 of 19) but only 41% (74 of 180) in the patients who did not require TT (p = 0.11). TT improved oxygenation and compliance immediately after insertion in 17 of 19 patients, and P:F remained statistically higher (245 +/- 29 versus 151 +/- 13, p < 0.01) 24 hours after TT drainage. There was no correlation between the volume of fluid removed and P:F either immediately (R2, 0.16) or 24 hours after TT (R2, 0.07). CONCLUSIONS: Drainage of pleural fluid resulted in a significant improvement in oxygenation in ARF patients with pleural effusions who were refractory to treatment with mechanical ventilation and PEEP. TT represents a simple and safe alternative for aggressive management of selected patients, obviating the inherent risk of pneumothorax with thoracentesis and possibly avoiding the need for more complex forms of support in this critically ill patient population.

Alterations of pulmonary gas exchange after superimposed carbon monoxide poisoning in acute lung injury.

BACKGROUND: Smoke inhalation injury produces substantial morbidity and mortality caused both by immediate catastrophic pulmonary failure and by the subsequent development of pneumonia. Although carbon monoxide (CO) poisoning is present to a degree in nearly all instances of smoke inhalation, the importance of CO in the pathogenesis of smoke inhalation injury remains controversial because smoke contains numerous other potential pulmonary toxins such as aldehydes, chlorine gas, and hydrochloric acid. This study was performed to determine whether CO poisoning acts as a cofactor in the evolution of inhalation injury. METHODS: Four groups of anesthetized dogs received ventilation with 1% CO in room air alone, intratracheal instillation of 2.0 ml/kg 0.1 N hydrochloric acid (HCl) alone, or acid either immediately or 30 minutes before CO. Ventilation/perfusion relationships were measured for 4 hours thereafter with the multiple inert gas elimination technique. RESULTS: Acid instillation established 30 minutes before CO poisoning resulted in significantly decreased carboxyhemoglobin concentrations after ventilation with 1% CO in air for 10 minutes. However, CO elimination was markedly delayed in both acid-challenged groups ventilated with CO. Moreover, acid instillation immediately before CO poisoning significantly exacerbated the development of ventilation/perfusion inequality caused by the acid, because the development of shunt was accelerated. CONCLUSIONS: CO poisoning is an important cofactor in the development of inhalation injury by acceleration of the development of ventilation/perfusion inequality after inhalation.

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 enterectomy on peripheral tissue glutamine efflux in critically ill patients.

Glutamine and alanine are dominant nitrogen carriers from skeletal muscle stores to splanchnic organs. In addition, these amino acids may also serve as a primary energy source for the gastrointestinal tract during injury. To investigate these contributions, we studied extremity amino acid efflux during hypocaloric dextrose feedings and during total parenteral nutrition in a population of normal volunteers (NL VOL) (n = 9), a group of patients with sepsis who had undergone laparotomy without bowel resection and were in the intensive care unit (ICU) (n = 7), and patients with sepsis after laparotomy (PT) (n = 2) who had recently undergone greater than 80% bowel resection. Circulating alanine and glutamine levels were significantly lower in the patients compared with NL VOL under both feeding conditions. The peripheral output of alanine was higher in the ICU group than in the NL VOL during hypocaloric feedings. Glutamine efflux, however, was independent of either the counterregulatory hormone or substrate background. By contrast, enterectomy was associated with a marked decrease of extremity glutamine efflux compared with NL VOL or the ICU patients who did not undergo enterectomy (-62 +/- 9 nmol/min/dl tissue in the PT vs -265 +/- 32 nmol/min/dl tissue in the NL VOL and -311 +/- 58 nmol/min/dl tissue in the ICU group) during the dextrose feedings; this difference persisted during subsequent total parenteral nutrition (+12 +/- 13 nmol/min/dl tissue in PT vs -178 +/- 56 nmol/min/dl tissue in the NL VOL and -287 +/- 81 nmol/min/dl tissue in the ICU group). These data suggest that distinct mechanisms regulate peripheral alanine and glutamine balance and that the gastrointestinal tract provides a feedback signal to peripheral tissues to maintain glutamine mobilization under both nonstressed and stressed conditions.

Advances in critical care monitoring.

A critical evaluation of monitoring in critical illness must recognize first that there are many different types of monitoring that may take place, and that each type of monitor may be evaluated appropriately by different standards. Monitoring may occur with imaging devices, analyzers that require the permanent removal of tissue or fluid for analysis, or monitors that observe physiology with either invasive or noninvasive methods without requiring an ex vivo sample.

Improved survival after intraoperative cardiac arrest in noncardiac surgical patients.

OBJECTIVE: To test the hypothesis that improvements in intraoperative and perioperative critical care are resulting in an improved outcome after intraoperative cardiac arrest. DESIGN: A retrospective consecutive series of patients who experienced an intraoperative cardiac arrest during noncardiothoracic surgical procedures between January 1986 and June 1994. SETTING: A tertiary care university-based hospital. PARTICIPANTS: Twenty-four consecutive patients who experienced an intraoperative arrest among 162,661 noncardiothoracic surgical procedures during the designated period. INTERVENTION: Advanced cardiac life support and advanced trauma life support methods were used appropriately. Postarrest pharmacologic and mechanical cardiopulmonary support were used as needed in the setting of a surgical intensive care unit. MAIN OUTCOME MEASURES: Survival out of the operating room and survival to discharge. RESULTS: Fifteen patients (62%) were resuscitated in the operating room and taken to the surgical intensive care unit or recovery room. Nine patients (38%) survived to discharge from the hospital. Twelve arrests (50%) were primarily cardiac in origin. Predictors of mortality included a need for pressor or inotropic support (P < .001) and duration of the arrest greater than 15 minutes (P < .001). CONCLUSION: Survival from an intraoperative cardiac arrest in a noncardiothoracic surgical patient is much improved over rates in historical controls who experienced in-hospital and out-of-hospital cardiac arrest. Rapid identification and aggressive correction of mechanical and metabolic derangements is warranted.

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.

Minimally invasive and noninvasive diagnosis and therapy in critically ill and injured patients.

In this review, both the newer noninvasive (ie, those that pose no breach of an epithelial barrier) and minimally invasive techniques relevant to the treatment of the critically ill or injured patient will be discussed. In some cases, the development of the technology is so recent that published data describing their clinical applications may be scant. The emphasis herein is on newer technologies; therefore, the discussion of certain established noninvasive techniques, such as pulse oximetry, and minimally invasive therapies, such as percutaneous abscess drainage, will be deferred.

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.

Relationship of systemic inflammatory response syndrome to organ dysfunction, length of stay, and mortality in critical surgical illness: effect of intensive care unit resuscitation.

BACKGROUND: A systemic proinflammatory response has been implicated in the pathogenesis of organ dysfunction. The effects of surgery, surgical stress, anesthesia, and subsequent intensive care unit (ICU) resuscitation may affect the components of the systemic inflammatory response syndrome (SIRS) score (temperature, heart rate, respiratory rate, and white blood cell count). Any SIRS scores calculated within 24 hours after surgery or at the onset of nonoperative resuscitation may overestimate the proinflammatory response itself, making quantitation of SIRS at that time potentially too sensitive. We hypothesized that SIRS attributable to ICU resuscitation can be quantitated, and that SIRS after the first day of therapy in the ICU correlates with several outcomes. METHODS: Prospective analysis of 2300 surgical ICU admissions during a 49-month period. Acute Physiology and Chronic Health Evaluation III (APACHE III) scores were recorded after 24 hours. Daily and cumulative multiple organ dysfunction scores (0-4 points for each of 6 organs, 24 points total) and SIRS scores (1 point for each parameter, 4 points total) were recorded. Defined end points were hospital mortality, days in the ICU, and organ dysfunction. RESULTS: On day 1, 49.4% of patients had SIRS (score > or =2), whereas 34.5% of patients who remained in the ICU had SIRS (score > or =2) on day 2 (P<.001). The SIRS score decreased by a mean of 0.8 points from day 1 to day 2, regardless of the type of admission. A SIRS score that decreased on day 2, in comparison with the score on day 1, resulted in less mortality than a unchanged or higher score on day 2 (11% vs. 18% vs. 22%, P<.001). Systemic inflammatory response scores were higher for nonsurvivors than survivors on each of the first 7 days in the ICU. The day 2 SIRS score correlated well with the admission APACHE III score (P<.001) and all defined end points (all P<.001). The day 2 SIRS score also correlated with the day 2 multiple organ dysfunction score (P<.001). By multiple logistic regression, APACHE III (P<.001), day 2 SIRS score (P<.01) (but not day 1 SIRS score, P = .99), and day 2 multiple organ dysfunction score (P<.001) (but not day 1 multiple organ dysfunction score, P = .81) predicted mortality. CONCLUSIONS: Systemic inflammatory response syndrome attributable to surgery or surgical stress can be quantitated. Twenty-four hours of ICU resuscitation results in a decline in the SIRS score. The magnitude of the proinflammatory response on the second ICU day may be a useful predictor of outcome in critical surgical illness.

Gender-based differences in outcome in patients with sepsis.

HYPOTHESIS: Among factors postulated to affect outcome in sepsis is the gender of the patient, with a suggestion that females may have lower mortality. This study tested the hypothesis that female patients admitted to the surgical intensive care unit with a documented infection have a lower mortality rate. DESIGN: Retrospective analysis of a prospectively collected data set. SETTING: Surgical intensive care unit of a university hospital medical center. METHODS: Analysis of a consecutive series of 1348 patients who had signs of systemic inflammatory response syndrome on admission to a surgical intensive care unit. A cohort of 443 patients (32.9%) admitted with documented infection--and who therefore had sepsis, severe sepsis, or septic shock--constituted the study population. For each patient, APACHE (Acute Physiology and Chronic Health Evaluation) II and III scores, systemic inflammatory response syndrome score, gender, age, and hospital mortality were recorded. Chi2 With Fisher exact test was performed to compare mortality rates between males and females. Univariate analysis of variance was used to compare continuous variables in discrete populations. Multivariate analysis of variance was used to determine which factors independently predicted mortality. PRIMARY OUTCOME MEASURES: Mortality, intensive care unit length of stay, hospital length of stay, and maximal multiple organ dysfunction score. Outcomes stratified by gender. RESULTS: Patients had mean +/- SEM age of 67+/-1 years; mean +/- SEM APACHE II and III scores of 20.1+/-0.4 and 67.7+/-1.0 points, respectively. There were no demographic differences between genders. Overall, 104 (23.5%) of 443 patients with sepsis died. The difference in mortality rates between female and male patients was not significant, except in octogenarians (P = .05). Multivariate analysis of variance, APACHE III (P<.001), maximal multiple organ dysfunction score (P<.001), and female gender (P =.02) predicted mortality. In females, APACHE III (P = .03) and maximal multiple organ dysfunction score (P<.001) predicted mortality, but age did not. CONCLUSION: Female gender is an independent predictor of increased mortality in critically ill surgical patients with documented infection.

Utility of routine chest radiographs in the surgical intensive care unit. A prospective study.

OBJECTIVES: To correlate patient condition and reasons for obtaining chest radiographs (CXRs) with the utility of CXRs in critical illness and to determine the potential impact of stricter criteria for obtaining a CXR in a surgical intensive care unit (ICU). DESIGN: Inception cohort study of 1003 CXRs examined prospectively. PATIENTS AND SETTING: A total of 157 consecutive patients admitted to the general surgical ICU of a 780-bed, urban, university-affiliated, tertiary care hospital. INTERVENTION: Nothing was done to influence the ordering of CXRs. OUTCOME MEASURES: Influence of CXR findings on clinical management. RESULTS: The likelihood of a clinically important finding was 17% for CXRs obtained for no clear clinical indication (routine), 26% for those obtained to verify the position of a medical device, and 30% for those obtained for suspected clinical conditions. By univariate analysis, suspected pathophysiologic condition, admission APACHE II (Acute Physiology and Chronic Health Evaluation II) score, presence of a central venous or Swan-Ganz catheter, and length of ICU stay were all predictors of a significant finding. By multivariate analysis, the only independent predictor of a finding was a suspected clinical condition, and the only indwelling medical device that was an independent predictor of a finding was a Swan-Ganz catheter. If the criterion that routine CXRs should only be obtained in patients with Swan-Ganz catheters had been used, 200 CXRs would have been avoided during the 3-month study period. The only findings missed by not obtaining those CXRs would have been two malpositioned nasogastric tubes and one malpositioned central venous catheter. CONCLUSIONS: Chest radiographs should only be obtained on surgical ICU patients for specific indications. Routine CXRs for ICU patients are justified only for patients with indwelling Swan-Ganz catheters.

Enterococcal burn sepsis. A highly lethal complication in severely burned patients.

A retrospective study was undertaken to examine the incidence and clinical significance of enterococcal bacteremia in burned patients with enterococcal burn-wound infections. During a 26-month period from 1983 to 1985, 38 patients were found to have enterococcal burn-wound infections. Twenty of these patients developed positive blood cultures for enterococcus with no other identifiable source for the bacteremia. Cases occurred sporadically during the study period without evidence of a specific epidemic. Ten patients died within ten days of the bacteremia, while nine others eventually died from other complications. Only one patient survived to discharge. Prior antibiotic therapy did not appear to increase the risk for enterococcal infection, and specific therapy against the enterococcus after the bacteremia was identified appeared to have no effect on mortality. Mortality was significantly greater for bacteremic patients than for patients with enterococcal wound infection alone or for burned patients without enterococcal infections. Although previously not considered pathogenic, enterococcal burn-wound infections should prompt aggressive therapy to prevent the development of enterococcal sepsis with its associated high mortality.

Surgical Infection Society intra-abdominal infection study. Prospective evaluation of management techniques and outcome.

This prospective, open, consecutive, nonrandomized trial examined management techniques and outcome in severe peritonitis. A total of 239 patients with surgical infection in the abdomen and an APACHE (acute physiology and chronic health evaluation) II score greater than 10 were studied. Seventy-seven patients (32%) died. Reoperation had a 42% mortality rate (35 of 83 patients died) compared with a 27% mortality rate (42 of 156 died) in patients who did not undergo reoperation. Forty-six patients underwent one reoperation; 15, two reoperations; 10, three reoperations; five, four reoperations; and seven, five reoperations, with mortality rates of 43%, 40%, 30%, 40%, and 57%, respectively. There was no significant difference in mortality between patients treated with a "closed-abdomen technique" (31% mortality) and those treated with variations of the "open-abdomen" technique (44% mortality). Logistic regression analysis showed that a high APACHE II score, low serum albumin level, and high New York Heart Association cardiac function status were significantly and independently associated with death. Low serum albumin level, youth, and high APACHE II score were significantly and independently associated with reoperation.

Multivariate analysis of 9 disease-associated variables for outcome prediction in patients with sepsis.

OBJECTIVE: To assess the ability of 9 clinical or biological variables to predict outcome (survival or nonsurvival) using multiple regression and classification analyses. DESIGN: Prospective, descriptive cohort study with no interventions. SETTING: Surgical intensive care unit of a tertiary care hospital and a medical school research laboratory. PATIENTS: Eighteen patients with a documented source of infection who met currently accepted criteria for sepsis syndrome or septic shock. MAIN OUTCOME MEASURES: Prediction of survival or nonsurvival based on analysis of clinical (Multiple Organ Dysfunction score, Acute Physiology and Chronic Health Evaluation III scores) and biological (plasma levels of cortisol, interleukin 6, interleukin 10, phospholipase A2, soluble tumor necrosis factor receptor p75, and monocyte membrane tumor necrosis factor receptor levels) variables, with comparison of predicted and actual outcomes. RESULTS: Plasma interleukin 6, interleukin 10, and phospholipase A2 concentrations were not significantly (P>.05) different between survivors and nonsurvivors. By standard, forward stepwise, and backward stepwise multiple regression analyses, only monocyte membrane tumor necrosis factor receptor levels measured at the onset of sepsis significantly predicted outcome in all 3 analyses. However, by both standard and backward stepwise analyses, Multiple Organ Dysfunction scores based on evaluation at the onset of sepsis and 24 hours later were also significant predictors of outcome. Classification analysis showed that assignment to outcome group was statistically significant when based on monocyte membrane tumor necrosis factor receptor levels determined at the onset of sepsis or on Multiple Organ Dysfunction scores assessed 24 hours after sepsis was diagnosed. CONCLUSION: Although these findings were based on a relatively small cohort, both multiple regression and classification analyses indicated that only monocyte membrane tumor necrosis factor receptor levels are able to discriminate survivors from nonsurvivors at the onset of sepsis.

Assessment of hepatitis B virus immunization status among North American surgeons.

OBJECTIVE: We hypothesized that many surgeons have not been vaccinated against hepatitis B virus (HBV), despite the existence of effective recombinant vaccines. Prevalence of HBV vaccination among surgeons, attitudes of those not vaccinated, estimated HBV infection rates, and respondents' knowledge of the epidemiology of HBV exposure were determined. DESIGN: Survey conducted by mail just before implementation of mandatory HBV vaccination for health care workers. SETTING: Private and academic general surgical, trauma and transplantation practices. PARTICIPANTS: Two thousand one hundred twenty-five surgeons received the survey. Response rates are as follows: in the Surgical Infection Society, 196 (50%) of 393 surgeons; in the American Association for the Surgery of Trauma, 223 (52%) of 433 surgeons; in the American Society of Transplant Surgeons, 194 (44%) of 438 surgeons; and among the Fellows of the American College of Surgeons, 403 (47%) of 861 surgeons. MAIN OUTCOME MEASURES: Prevalence of HBV exposure and active immunization by specialty and society. RESULTS: Prevalence of HBV exposure was 19.6%, was higher among trauma and transplantation surgeons compared with general surgeons (P < .0001), and increased significantly with age in all groups (P < .05). Despite greater exposure, probable immunity was lower at an older age because young surgeons (age, < 46 years) are more likely to be vaccines (P < .05). Most surgeons (55%) were vaccinated more than 5 years ago; many recipients of recombinant vaccines (26%) received an inadequate amount of vaccine or were improperly vaccinated. Knowledge of the epidemiology was uniformly poor, with rates of correct responses to the three questions below 50%. CONCLUSIONS: Vaccination does not equal immunity. Between 38% and 50% of practicing surgeons may not have adequate immunity to HBV.