Nasoenteric tube complications.

The use of nasoenteric tubes (NETs) is ubiquitous, and clinicians often take their placement, function, and maintenance for granted. NETs are used for gastrointestinal decompression, enteral feeding, medication administration, naso-biliary drainage, and specialized indications such as upper gastrointestinal bleeding. Morbidity associated with NETs is common, but frequently subtle, mandating high index of suspicion, clinical vigilance, and patient safety protocols. Common complications include sinusitis, sore throat and epistaxis. More serious complications include luminal perforation, pulmonary injury, aspiration, and intracranial placement. Frequent monitoring and continual re-review of the indications for continued use of any NET is prudent, including consideration of changing goals of care. This manuscript reviews NET-related complications and associated topics.

The glucogram: A new quantitative tool for glycemic analysis in the surgical intensive care unit.

BACKGROUND: Glycemic control is an important aspect of patient care in the surgical intensive care unit (SICU). This is a pilot study of a novel glycemic analysis tool - the glucogram. We hypothesize that the glucogram may be helpful in quantifying the clinical significance of acute hyperglycemic states (AHS) and in describing glycemic variability (GV) in critically ill patients. MATERIALS AND METHODS: Serial glucose measurements were analyzed in SICU patients with lengths of stay (LOS) >30 days. Glucose data were formatted into 12-hour epochs and graphically analyzed using stochastic and momentum indicators. Recorded clinical events were classified as major or minor (control). Examples of major events include cardiogenic shock, acute respiratory failure, major hemorrhage, infection/sepsis, etc. Examples of minor (control) events include non-emergent bedside procedures, blood transfusion given to a hemodynamically stable patient, etc. Positive/negative indicator status was then correlated with AHS and associated clinical events. The conjunction of positive indicator/major clinical event or negative indicator/minor clinical event was defined as clinical "match". GV was determined by averaging glucose fluctuations (maximal - minimal value within each 12-hour epoch) over time. In addition, event-specific glucose excursion (ESGE) associated with each positive indicator/AHS match (final minus initial value for each occurrence) was calculated. Descriptive statistics, sensitivity/specificity determination, and student's t-test were used in data analysis. RESULTS: Glycemic and clinical data were reviewed for 11 patients (mean SICU LOS 74.5 days; 7 men/4 women; mean age 54.9 years; APACHE II of 17.7 ± 6.44; mortality 36%). A total of 4354 glucose data points (1254 epochs) were analyzed. There were 354 major clinical events and 93 minor (control) events. The glucogram identified AHS/indicator/clinical event "matches" with overall sensitivity of 84% and specificity of 65%. We noted that while the mean GV was greater for non-survivors than for survivors (19.3 mg/dL vs. 10.3 mg/dL, P = 0.02), there was no difference in mean ESGE between survivors (154.7) and non-survivors (160.8, P = 0.67). CONCLUSIONS: The glucogram was able to quantify the correlation between AHS and major clinical events with a sensitivity of 84% and a specificity of 65%. In addition, mean GV was nearly two times higher for non-survivors. The glucogram may be useful both clinically (i.e., in the electronic ICU or other "early warning" systems) and as a research tool (i.e., in model development and standardization). Results of this study provide a foundation for further, larger-scale, multi-parametric, prospective evaluations of the glucogram.

Complications associated with pulmonary artery catheters: a comprehensive clinical review.

Care for the critically ill patient requires maintenance of adequate tissue perfusion/oxygenation. Continuous hemodynamic monitoring is frequently utilized to achieve these objectives. Pulmonary artery catheters (PAC) allow measurement of hemodynamic variables that cannot be measured reliably or continuously by less invasive means. Inherent to every medical intervention are risks associated with that intervention. This review categorizes complications associated with the PAC into four broad groups--complications of central venous access; complications related to PAC insertion and manipulation; complications associated with short- or long-term presence of the PAC in the cardiovascular system; and errors resulting from incorrect interpretation/use of PAC-derived data. We will discuss each of these four broad categories, followed by in-depth descriptions of the most common and most serious individual complications.

Early clinical results of long coronary arteriotomy, endarterectomy and reconstruction combined with multiple bypass grafting for severe coronary artery disease.

Within a 2.5-year period between 1985 and 1988, long coronary arteriotomy, endarterectomy and reconstruction (principally left anterior descending artery) and multiple bypass grafting (mean graft rate was 9) were performed in 130 of 329 patients (40%) with severe diffuse coronary artery disease to ensure complete myocardial revascularization. Ninety-two percent of the patients who underwent exercise testing had abnormal (greater than 1 mm ST) depression and/or positive results on scintigraphy. Long coronary arteriotomy (5 to 12 cm), endarterectomy and reconstruction of the left anterior descending artery and its branches, were performed in 121 patients; of the left circumflex artery and its branches in 13 patients; and of the right coronary artery and its branches beyond the crux in 18 patients. Single endarterectomy and reconstruction was performed in 109 patients, double in 20 and triple in 1. The operative mortality was 2.3% and the perioperative infarction was 1.5%. Twenty-four patients (among them 38% who had undergone greater than 1 previous bypass operation) were randomly selected and studied within 20 days after surgery. This group comprised a total of 69 coronary conduits of which 68 (99%) were patent, and a total of 206 coronary anastomoses of which 202 (98%) were patent. Thirty-two of 33 conduits (97%) to endarterectomized and reconstructed arteries were patent. One hundred and twenty-six of 127 patients were followed up for a mean of 20 months; 120 of the 121 patients (99%) were in angina class I by Canadian Cardiovascular Society classification, and 63 of 71 patients (89%) had a normal treadmill exercise stress test.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative use of cold blood potassium cardioplegia in coronary bypass patients necessitating long (2.5-6 h) versus short (less than 1.5 h) aortic cross-clamp times.

In symptomatic patients with severe diffuse multivessel coronary disease undergoing bypass surgery, complete revascularization with multiple bypass grafts using saphenous vein and internal mammary conduits, and multiple endarterectomies may be necessary. Such complex surgeries may require long aortic cross-clamp times in excess of 2.5 h. To evaluate the myocardial preservation provided by cold potassium blood cardioplegia, two groups of consecutive patients using nearly similar surgical techniques were compared. Group A consisted of 100 patients who received an average of 3.8 grafts per patient and had a mean aortic cross-clamp time of 66 (range 15-90) min. Group B was comprised of 100 patients who received an average of 9.3 grafts per patient and had a mean cross-clamp time of 187 (range 150-351) min. Operative mortality and perioperative myocardial infarction were low (0-2%) and were not significantly different between the groups. In addition, the postoperative creatine kinase-MB isoenzyme levels, use of pharmacologic and/or mechanical (i.e., intra-aortic balloon) support, and follow-up exercise treadmill tests were not significantly different in the two groups. These findings suggest that cold potassium blood cardioplegia is equally protective of the myocardium during surgical revascularization in patients with short aortic cross-clamp times (less than 1.5 h) as in those with severe diffuse multivessel coronary artery disease requiring long cross-clamp times exceeding 2.5 h and up to 6 h.

Multiple (more than eight) bypass grafts in severe diffuse coronary disease: improved exercise tolerance and functional classification in seventy-seven consecutive patients.

During a 43-month period (May 1981 to December 1984), 77 consecutive patients underwent multiple (eight or more) coronary artery bypass procedures using saphenous vein conduits for severe diffuse triple-vessel coronary artery disease. Patients received from 8 to 14 grafts (average 9). All coronary arteries and branches that were at least 1.5 mm in diameter and greater than 50% obstructed were bypassed. The operative mortality rate was 1.3%. Seventy-six of 77 (98.7%) patients are alive at a mean follow-up of 2 years. According to the Canadian Cardiovascular Society Angina Criteria, before surgery 5 patients (6%) were classified class I, 8 (10%) class II, 43 (56%) class III, and 21 (27%) class IV. After surgery all 76 patients were class I. Of 59 patients who had undergone bypass surgery who were followed by exercise testing according to the modified Bruce protocol, 47 exercised to greater than or equal to 85% heart rate. Among these patients, 44 (94%) had a normal exercise test result and only 3 had greater than or equal to 1 mm ST segment depression. Thus, patients with severe diffuse coronary disease can undergo multiple (eight or more) bypass grafting procedures with low mortality rates and improved exercise tolerance and functional classification.

Sternal dehiscence: pericostal guy wires equals sternal stability.

Our five-year clinical experience with 11 patients treated with pericostal guy wires has uniformly established sternal stability, primary bone healing, and rapid resolution of infection. The stable anterior chest wall helps abolish cardiopulmonary complications (i.e., progressive pulmonary insufficiency, atelectasis, and low cardiac output) commonly associated with sternal dehiscence.

Improved stress test results after multiple coronary grafting.

Compared with previous reports that have addressed the issue of preoperative and postoperative stress testing in coronary artery bypass grafting, our results show a 30 percent improvement in the conversion rate from abnormal to normal. In a group of patients with severe coronary artery disease, we have been able to obtain normal stress test results postoperatively. Modern surgical techniques, including the use of blood cardioplegia and other methods of myocardial preservation, have allowed for safety in doing adequate grafting. From our population, we identified a select group of patients (approximately 30 percent) who require 6 or more grafts for complete revascularization. Although our follow-up of 30 months is relatively short, we are encouraged by the results so far. We believe that more than 90 percent of patients can be converted to normal postoperative stress test results after adequate coronary artery bypass grafting.