Supply Chain Delays in Antimicrobial Administration After the Initial Clinician Order and Mortality in Patients With Sepsis.

OBJECTIVES: There is mounting evidence that delays in appropriate antimicrobial administration are responsible for preventable deaths in patients with sepsis. Herein, we examine the association between potentially modifiable antimicrobial administration delays, measured by the time from the first order to the first administration (antimicrobial lead time), and death among people who present with new onset of sepsis. DESIGN: Observational cohort and case-control study. SETTING: The emergency department of an academic, tertiary referral center during a 3.5-year period. PATIENTS: Adult patients with new onset of sepsis or septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We enrolled 4,429 consecutive patients who presented to the emergency department with a new diagnosis of sepsis. We defined 0-1 hour as the gold standard antimicrobial lead time for comparison. Fifty percent of patients had an antimicrobial lead time of more than 1.3 hours. For an antimicrobial lead time of 1-2 hours, the adjusted odds ratio of death at 28 days was 1.28 (95% CI, 1.07-1.54; p = 0.007); for an antimicrobial lead time of 2-3 hours was 1.07 (95% CI, 0.85-1.36; p = 0.6); for an antimicrobial lead time of 3-6 hours was 1.57 (95% CI, 1.26-1.95; p < 0.001); for an antimicrobial lead time of 6-12 hours was 1.36 (95% CI, 0.99-1.86; p = 0.06); and for an antimicrobial lead time of more than 12 hours was 1.85 (95% CI, 1.29-2.65; p = 0.001). CONCLUSIONS: Delays in the first antimicrobial execution, after the initial clinician assessment and first antimicrobial order, are frequent and detrimental. Biases inherent to the retrospective nature of the study apply. Known biologic mechanisms support these findings, which also demonstrate a dose-response effect. In contrast to the elusive nature of sepsis onset and sepsis onset recognition, antimicrobial lead time is an objective, measurable, and modifiable process.

Intussusception: an anatomical perspective with review of the literature.

Originally described over 300 years ago, the clinical scenario of intussusception remains incompletely understood. Intussusception is now one of the conditions that can be, most of the time, preoperatively diagnosed and treated with success. This article reviews the literature regarding this pathological state of the abdomen and discusses what is known regarding the presentation, diagnosis, embryology, and anatomy of intussusception.

The prefixed and postfixed brachial plexus: a review with surgical implications.

The definition of a pre and postfixed brachial plexus is varied in the literature, which results in inconsistent conclusions for various studies. As anatomical variation is important both during clinical evaluation and surgical procedures of the brachial plexus, a review of this literature was performed. Based on our review, variation in the contribution to the brachial plexus is more the rule than the exception. These variations may lead to deviation from the expected dermatome distribution as well as differences in the motor innervation of muscles of the upper limb. Such variations may predispose patients to certain pathology such as thoracic outlet syndrome and may alter surgical approaches to the brachial plexus.

Clinical outcomes of isolated lower extremity or foot burns in diabetic versus non-diabetic patients: a 10-year retrospective analysis.

INTRODUCTION: The incidence of diabetes mellitus (DM) in the United States is expected to increase from 8 per 1000 in 2008 to 15 per 1000 by 2050 [20]. As a result, DM patients will constitute a large proportion of Burn Center admissions, with burns typically due to contact burn or scalding. Peripheral vascular disease (PVD) and peripheral neuropathy (PN) are far more common in DM patients, particularly in those with poorly controlled disease, and are often associated with worse outcomes than non-diabetic (nDM) burn patients. This study sought to analyze whether the outcome of isolated leg and foot burns among DM and nDM individuals differed significantly. MATERIALS AND METHODS: Retrospective data on 207 consecutive patients (>18 years old) admitted to a Burn Center with isolated leg or foot burns between 1999 and 2009 was collected and analyzed for this study. Age, gender, ethnicity, total body surface area (TBSA), degree of burn, etiology, hospital and burn intensive care unit (ICU), length of stay (LOS), and status at discharge were reviewed. Patients were grouped as diabetic (DM) or non-diabetic (nDM). Differences were analyzed using either the Student's t-test or Chi-square. RESULTS: 43 DM and 164 nDM patients with isolated lower extremity or foot burns were treated during the study period (1999-2009). The mean age of DM and nDM patients was 54.6 and 43.7 years, respectively (p<0.001). The most common burn etiology was scalding, flame, or contact burn. Percentage of total body surface area (TBSA) burn in DM patients averaged±standard deviation 1.8±1.3% compared to 1.8±1.6% in nDM (p<0.9). Among DM patients, 86% (N=37) of patients suffered third degree burns and 14% (N=6) of patients had second degree burns compared to 76% (N=125) of patients and 24% (N=39) of patients among nDM patients, respectively (p<0.16). The DM group had significantly higher burn ICU admission rates, 16.3% of patients versus 8.5% of patients (p<0.001), total length of hospital stay (mean±standard deviation), 14.1±10 versus 9.8±9.3 days (p<0.01) and renal failure, 4.7% of patients versus 0.6% of patients (p<0.05) compared to the nDM group. 93% of DM patients were discharged to home without further medical attention while 4.7% of patients underwent further treatment. In comparison, 85.4% of the nDM patients were discharged home with no further treatment while 8.5% of patients received home care (p<0.01). CONCLUSION: DM patients who suffer isolated burns to the feet or lower extremities have poorer clinical outcomes and more complicated and protracted hospital courses when compared to nDM patients with similar burns. Although diabetics in the current study did not experience larger or more severe burns than nDM patients, they were nearly twice as likely to be admitted to the ICU, spent an average of four days longer in the hospital, and had a higher likelihood of developing renal failure compared to nDM patients.