A multicenter retrospective study evaluating the impact of desmopressin on hematoma expansion in patients with antiplatelet-associated intracranial hemorrhage.

INTRODUCTION: Antiplatelet medications interfere with hemostasis which can contribute to increased risk of hematoma expansion and potentially worse outcomes in patients presenting with intracranial hemorrhages (ICH). Current Neurocritical Care Society guidelines recommend desmopressin (DDAVP) in patients with antiplatelet-associated ICH with evidence limited by small cohorts. MATERIALS AND METHODS: Patients were included in our multi-center, retrospective study if they had computed tomographic (CT) scan confirmed ICH and were taking antiplatelet medications. Patients were excluded if hospital length of stay was <24 h, administered DDAVP dose was <0.3 µg/kg, no follow-up head CT scan was performed within the first 24 h after baseline, major neurosurgical intervention was performed in between CT scans, or the injury was an acute on chronic ICH. The primary outcome was incidence of hematoma expansion (defined as >20 % increase from baseline). Secondary outcomes were incidence of thrombotic complications within 7 days, largest absolute decrease in serum sodium within the first 24 h, and patient disposition. RESULTS: Among the 209 patients included in the study, 118 patients received DDAVP while 91 did not. The frequency of hematoma expansion was similar between patients who received DDAVP and those who did not (16.1 % vs 17.6 %; P = 0.78). No difference in secondary outcomes was observed between the two groups. CONCLUSIONS: These findings in conjunction with recently published literature may suggest minimal benefit or harm with DDAVP treatment. However, further study could elucidate any potential impact on long-term function outcomes.

Respiratory Therapists in an ICU Recovery Clinic: Two Institutional Experiences and Review of the Literature.

Post-intensive care syndrome is an increasingly recognized complication of critical illness, with patients reporting new problems in physical, mental health and/or psychosocial, and cognitive function for months to years after their acute illness. As a way of diagnosing and treating post-intensive care syndrome, many centers around the world have established ICU recovery clinics, which take a multidisciplinary approach to care after the ICU. Dyspnea and pulmonary dysfunction are frequently encountered concerns in the post-ICU population. Despite this, few ICU recovery clinics have described how respiratory therapists (RTs) can contribute to treating these symptoms. We reviewed the literature with regard to the roles of an RT in post-ICU follow-up, described our institutional experiences with having RTs as part of our ICU recovery clinics, and identified additional ways that RTs might contribute to a post-intensive care syndrome diagnosis and treatment. Although RTs can provide invaluable experience and contributions to an ICU recovery clinic, there are few articles in the published literature on the ways in which this can be accomplished. We, therefore, provide analogies to other multidisciplinary clinic models as well as our own experiences. Future studies should focus on examining the impact of respiratory therapy diagnostic testing and interventions in the ICU recovery clinic on both patient and provider outcomes.

Acute reversal of dabigatran with Idarucizumab for intravenous thrombolysis as acute stroke treatment.

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke (AIS) is contraindicated in patient taking either Factor Xa inhibitors or direct thrombin inhibitors. Idarucizumab completely reverses the biologic effect of dabigatran within minutes. Intravenous rt-PA treatment results in a significant benefit in functional outcome when administered 3-4.5 h after stroke onset or last seen normal time. There is little reported data and no large-scale studies of the reversal of dabigatran with Idarucizumab for the purpose of treating AIS with IV rt-PA. We describe the case of a 73 year old male with AIS and active dabigatran use. Idarucizumab was administered per an approved medical center protocol and the patient was subsequently treated with IV rt-PA. The patient had a severe stroke with no other contraindications to IV rt-PA other than dabigatran use. The patient was administered Idarucizumab and IV rt-PA was given. Within 24 h of treatment, the patient had minimal stroke deficits. Imaging revealed a right middle cerebral artery patchy infarct. The patient was restarted on dabigatran therapy for his atrial fibrillation and was discharged to a skilled nursing facility for rehabilitation. The patient did not experience any symptomatic or asymptomatic intracranial hemorrhage after treatment or through day 90. Though no randomized evidence exists for the risk of IV rt-PA after dabigatran reversal with Idarucizumab, the case experiences are mounting. This case of successful stroke treatment after reversal adds to the anecdotal literature and supports the study of dabigatran reversal with Idarucizumab for thrombolysis in AIS.

Evaluating vancomycin and piperacillin-tazobactam in ED patients with severe sepsis and septic shock.

STUDY OBJECTIVE: To determine the frequency and cause of inadequate initial antibiotic therapy with vancomycin and piperacillin-tazobactam in patients with severe sepsis and septic shock in the emergency department (ED), characterize its impact on patient outcomes, and identify patients who would benefit from an alternative initial empiric regimen. METHODS: Retrospective cohort study conducted between 2012 and 2015 in which 342 patients with culture-positive severe sepsis or septic shock who received initial vancomycin and piperacillin-tazobactam were reviewed to determine appropriateness of antimicrobial therapy, risk factors for inappropriate use, and outcome data. Univariate and multivariate regression analyses were determined to identify associations between inappropriate antibiotic use and outcomes and to identify risk factors that may predict which patients would benefit from an alternative initial regimen. RESULTS: Vancomycin and piperacillin-tazobactam were inappropriate for 24% of patients with severe sepsis or septic shock, largely due to non-susceptible infections, particularly ESBL organisms and Clostridium difficile. Risk factors included multiple sources of infection (OR 4.383), admission from a skilled nursing facility (OR 3.763), a history of chronic obstructive pulmonary disease (COPD) (OR 3.175), intra-abdominal infection (OR 2.890), and immunosuppression (OR 1.930). We did not find a mortality impact. CONCLUSION: Vancomycin and piperacillin-tazobactam were an inappropriate antibiotic combination for approximately 24% of patients with either severe sepsis or septic shock in the ED. Patients with known COPD, residence at a skilled nursing facility, a history concerning for Clostridium difficile, and immunosuppression would benefit from an alternative regimen. Future prospective studies are needed to validate these findings.

Immediate impact of an intensive one-week laparoscopy training program on laparoscopic skills among postgraduate urologists.

INTRODUCTION: Laparoscopic techniques are difficult to master, especially for surgeons who did not receive such training during residency. To help urologists master challenging laparoscopic skills, a unique 5-day mini-residency (M-R) program was established at the University of California, Irvine. The first 101 participants in this program were evaluated on their laparoscopic skills acquisition at the end of the 5-day experience. METHODS: Two urologists are accepted per week into 1 of 4 training modules: (1) ureteroscopy/percutaneous renal access; (2) laparoscopic ablative renal surgery; (3) laparoscopic reconstructive renal surgery; and (4) robot-assisted prostatectomy. The program consists of didactic lectures, pelvic trainer and virtual reality simulator practice, animal and cadaver laboratory sessions, and observation or participation in human surgeries. Skills testing (ST) simulating open, laparoscopic, and robotic surgery is assessed in all of the M-R participants on training days 1 and 5. Tests include ring transfer, suture threading, cutting, and suturing. Performance is evaluated by an experienced observer using the Objective Structured Assessment of Technical Skill (OSATS) scoring system. Statistical methods used include the paired sample t test and analysis of variance at a confidence level of P

InLine radiofrequency ablation-assisted laparoscopic liver resection: first experiment with stapling device.

BACKGROUND: In liver surgery, the increase in advancement of laparoscopic equipment has allowed the feasibility and safety of complex laparoscopic liver resection. However, blood loss and the potential risk of gas embolism seem to be the main obstacles. In this study, we successfully used the InLine radiofrequency ablation (RFA) device to carry out laparoscopic hand-assisted liver resection in pigs. METHODS: Under general anaesthesia with tracheal intubation, pigs underwent InLine RFA-assisted laparoscopic liver resection. After installation of Hand Port and trocars, the InLine RFA device was introduced through Hand Port system and inserted into the premarked resection line. Then the generator was turned on and the power was applied according to the power setting. The resection was finally carried out using diathermy or stapler. For the control group, resection was simply carried out by diathermy or stapler. RESULTS: Eight Landrace pigs underwent 23 liver resections. Blood loss was reduced significantly in the InLine group (P<0.001) when compared with control group in both surgical methods (diathermy and stapler). CONCLUSION: In this study, we successfully carried out InLine RFA-assisted laparoscopic liver resection in both stapled and diathermy group. We showed that there was a highly significant difference between InLine and other liver resection techniques laparoscopically.

A multicentre controlled study of the InLine radiofrequency ablation device for liver transection.

BACKGROUND: Surgical resection is the most effective therapy for liver cancer. Intraoperative blood loss during liver resection remains a major concern due to association with higher postoperative complications. The InLine radiofrequency ablation device (ILRFA) has achieved promising results in liver surgery with minimal blood loss and no increase of postoperative complications. In this multicentre controlled study, 108 patients undergoing liver resection were investigated. PATIENTS AND METHODS: A total of 108 patients underwent liver resections in 4 medical centres; the prospective sequential cohort study consisted of 54 ILRFA and 54 ultrasonic surgical aspirator transections as the control group. RESULTS: The type of liver resection performed was very similar in both groups. The median number of RFA deployments was 3 (range 1-12) with a median coagulation time of 9 (range 3-36) min. Median blood loss was 165+/-20 ml (range 5-675) in the ILRFA and 654+/-83 ml (range 80-3600) in the control group (p<0.001). The median transection time was 27 (2-219) min in the ILRFA group and 35 (5-62) min in controls. CONCLUSIONS: Our study indicates that ILRFA device for liver transection is effective in reducing blood loss and is safe. Precoagulation before parenchymal transection appears to be a valid concept in liver surgery. The avoidance of vascular inflow occlusion during parenchymal transection could also be of value.

Peritoneal carcinomatosis from colorectal cancer and small bowel cancer treated with peritonectomy.

BACKGROUND: This study aims to assess the survival of patients who underwent peritonectomy, to assess the morbidity and mortality associated with the procedure and to review the published reports on the survival of patients with peritoneal spread of colorectal cancer (CRC). METHODS: Peritonectomy involves resection of all visible peritoneal tumour and is followed by heated intraperitoneal chemotherapy. Peritonectomy with heated intraperitoneal chemotherapy is associated with a 3-year survival of 30-50% in patients with low peritoneal cancer index (PCI) with peritoneal carcinomatosis from CRC. There are approximately 1000 patients in phase 2 studies and a large survival advantage was shown in a randomized control trial. We have carried out over 100 peritonectomy procedures. This study describes 22 patients with peritoneal spread of gastrointestinal cancer treated with peritonectomy between 1996 and March 2005. Twenty of these patients had primary colorectal cancer and two patients had primary small bowel cancer. RESULTS: Of the 22 patients who underwent peritonectomy, 8 patients are now deceased. The median follow up is now 16.1 months. At 12 months, the survival was 61.5% and at 24 months the survival was 46.1%, which are creditable results comparable with the world published reports. We found that those patients with all macroscopic residual tumour removed at the end of the procedure (completeness of cancer resection, CCR O) had improved 24-month survival compared with patients in whom there was incomplete tumour resection (53.3% survival vs 22.2%, respectively, P = 0.024). Patients with a PCI score less than 13 had better survival (P = 0.0003). CONCLUSIONS: Peritonectomy for peritoneal carcinomatosis from CRC offers patients improved survival. Our results are consistent with the published data with respect to improved survival in patients with low PCI and complete cytoreduction.

Construct validity testing of a laparoscopic surgical simulator.

BACKGROUND: We present initial data on the construct, content, and face validity of the LAPMentor (Simbionix), virtual reality laparoscopic surgical simulator. STUDY DESIGN: Medical students (MS), residents and fellows (R/F), and experienced laparoscopic surgeons (ES), with < 30 laparoscopic cases per year (ES<30) and those with > 30 laparoscopic cases per year (ES>30), were tested on 9 basic skill tasks (SK) including manipulation of 0-degree and 30-degree cameras (SK1, SK2), eye-hand coordination (SK3), clipping (SK4), grasping and clipping (SK5), two-handed maneuvers (SK6), cutting (SK7), fulguration (SK8), and object-translocation (SK9). RESULTS: Mean MS (n=23), R/F (n=24), ES<30 (n=26), and ES>30 (n=30) ages were 26 years (range 21 to 32 years), 31 years (range 27 to 39 years), 49 years (range 31 to 70 years) and 47 years (range 34 to 69 years), respectively. In the lower level skill tasks (SK3, SK4, SK5, and SK6) the ES>30, ES<30, and R/F had similar scores, but were all substantially better than the MS scores. In the higher level skill tasks (SK7, SK8, and SK9), the ES>30 scores tended to be better than the R/F and ES<30, which were similar, and these, in turn, were markedly better than the MS. The ES>30 had notably higher SK8 scores than the R/F and ES<30, who had similar scores, and these had notably better scores than the MS. CONCLUSIONS: The noncamera skills (SK3 to 9) of the LAPMentor surgical simulator can distinguish between laparoscopically naive and ES. SK8 showed the highest level of construct validity, by accurately differentiating among the MS, R/F, ES<30 and ES>30.

A prospective study of in-line radiofrequency ablation in hepatic parenchymal transection--its efficacy and complications.

BACKGROUND: Bleeding during liver transection remains a potential hazard. This study aims to report the efficacy and complications of in-line radiofrequency ablation (ILRFA)-assisted liver resection. PATIENTS AND METHODS: The blood loss of 25 consecutive patients who underwent ILRFA-assisted liver resection was obtained by weighing swabs and measuring suction jar contents during liver resection and calculated in ml per cm(2) of the transection surface area. Postoperative complications were recorded. Five clinical variables, which might affect blood loss, were analyzed. RESULTS: The mean blood loss during parenchymal dissection for the ILRFA group was 3.4+/-3.2 ml/cm(2). Three patients had intra-abdominal collections, including one patient with bile leakage after ILRFA-assisted liver resection. Age, gender, extent of liver resection, liver quality and Pringle maneuver did not demonstrate significant impact on blood loss. CONCLUSIONS: This study showed that ILRFA-assisted liver resection was associated with very low blood loss. This is likely to improve the operative safety of liver resection for hepatic tumors. There were no significant postoperative sequelae.