Bedside insertion of inferior vena cava filters in the intensive care unit.

BACKGROUND: Injured patients are at significant risk for venous thromboembolic complications. Multiple studies have reported a benefit of prophylactic inferior vena cava filter (IVCF) insertion in selected high-risk trauma patients. Often, these high-risk patients reside in the intensive care unit (ICU) and require mechanical ventilation, intracranial pressure monitoring, multiple intravenous infusions, and other invasive monitoring modalities. This puts these patients at risk for transport from the ICU. METHODS: We prospectively studied a series of consecutive patients undergoing bedside preinsertion contrast cavagram and IVCF insertion in the ICU. RESULTS: Thirty-two patients received IVCF. There were no failures to insert IVCF. One insertion-site hematoma occurred; however, there were no documented insertion-site deep venous thromboses. One patient death was unrelated to the IVCF, and one potential contrast-related acute renal failure occurred in an unstable patient who underwent IVCF insertion for a pulmonary embolus. CONCLUSION: Bedside IVCF insertion with a preinsertion cavagram is a percutaneous procedure that can be safely performed in the ICU. Bedside insertion of IVCF avoids the potential complications of transporting critically ill patients and may reduce costs.

Preliminary results of bedside inferior vena cava filter placement: safe and cost-effective.

The use of inferior vena cava filters (IVCFs) is increasing in patients at high risk for venous thromboembolism; however, there is considerable controversy related to their cost. We inserted eight percutaneous IVCFs at the bedside. The hospital charges for bedside IVCF insertion were substantially lower compared with those for IVCF insertion performed in the Radiology Department or operating room. There was one death (unrelated to the procedure) and one asymptomatic caval occlusion believed to be caused by thrombus trapping. Bedside IVCF insertion is safe and cost-effective in selected patients. This practice averts the potential complications associated with transporting critically ill patients.

Octreotide versus pyloric exclusion in reducing gastrointestinal secretions entering the duodenum in a canine model.

Pyloric exclusion is advocated in the treatment of duodenal injury. The beneficial effect is thought to be due to diversion of gastric secretions and resultant reduction of biliary and pancreatic secretions. The long-acting somatostatin analog, Octreotide, makes the inhibitory actions of somatostatin on gastric, biliary, and pancreatic secretions a potential alternative to pyloric exclusion. We compared the effect of pyloric exclusion to the effect of Octreotide on the volume of gastrointestinal secretions entering the duodenum by creating a duodenal fistula using a canine model. Five animals had modified Thomas cannulas placed in the duodenum. Two animals had staple closure of the pylorus with a gastrojejunostomy in addition to the cannula. Gastrointestinal secretions were measured in 2- or 3-hour collection periods performed every third or fourth day. Animals were administered saline or Octreotide (100 micrograms/hour) intravenously during each collection. Up to 9 hours of collections under both saline and Octreotide (18 hours total) were done on each dog. Octreotide alone reduces gastrointestinal secretions entering the duodenum more than pyloric exclusion alone. Pyloric exclusion and Octreotide together offered no additional reduction in gastrointestinal secretions entering the duodenum over Octreotide alone.

Differential changes in intestinal permeability following burn injury.

Increased gut permeability (GP) following burn injury has been implicated in the predisposition to sepsis and multiple systems organ failure (MSOF). Since previous studies have identified only "global" alterations in GP, we examined the jejunum, ileum, and colon individually for GP using probes of two different sizes: fluorescein isothiocyanate-dextran-3 (FDEX, molecular weight 4387 d) and horseradish peroxidase (HRP, molecular weight 40,000 d). Animals were examined for GP at 1, 2, or 4 days following burn. The GP was significantly increased in all segments combined following burn injury to both the small probe (FDEX, p < 0.001) and the larger probe (HRP, p < 0.06) versus controls. The GP was significantly greater for FDEX versus HRP (p < 0.001). Jejunal permeability to FDEX and HRP increased most at 24 hours. Ileal and colonic GP to FDEX increased early also, but were higher at days 2 and 4. These results suggest that, following burn injury, there is differential GP that is size and site dependent, and that increased GP may last well beyond 24 hours postburn despite feeding.

The association of advanced life support training and decreased per capita trauma death rates: an analysis of 12,417 trauma deaths.

This study identified a number of significant predictors of per capita county trauma mortality rates: rurality, percentage nonwhite population, percentage unemployment, and Advanced Life Support (ALS) versus Basic Life Support (BLS) status. Of these, ALS versus BLS status is not only the most significant independent predictor, it is the only predictor readily amenable to change. The aspects of ALS clearly associated with decreased trauma death rates should be identified and, if possible, undergo widespread implementation.

The association of trauma death and alcohol use in a rural state.

This study documents the strong association of alcohol in trauma-related deaths. In a previous study alcohol was present in 62.8% of homicide victims, 48.6% of unintentional injury fatality victims, 35.3% of persons who committed suicide, and 14.4% of persons who died of natural causes. The present study uses the legal limit of 100 mg/100 mL to include patients as having an alcohol-associated trauma death. In addition the study includes patients who die up to 20 hours after injury. These features of our study result in the lower reported frequency rates. Our study confirms that alcohol is strongly associated with trauma deaths resulting from motor vehicle crashes. It also demonstrates a strong association between alcohol use and victims of all types of trauma mortality; specifically those victims of gunshot wounds, burns, stabbings, and falls all are frequently using alcohol. This information is of importance for those who treat such injured patients, since such tests as neurologic examination frequently will be compromised by the use of alcohol in the victims of major trauma. Perhaps most importantly this information can be of help in designing appropriate strategies in attacking this problem the best possible way--by prevention.

Prospective comparison of clinical judgment and APACHE II score in predicting the outcome in critically ill surgical patients.

Prospective identification of patients who will not survive has been proposed as a means of limiting utilization of medical resources including critical care. This study prospectively compared prediction of outcome for surgical ICU patients by clinical assessment and the APACHE II score. Five hundred seventy-eight patients were assessed within 24 hours of admission by the ICU attending physician and predicted to live or die. An APACHE II score was calculated in that same time period. All data were stored in a data base and compared with actual SICU outcome. There were 40 deaths in 578 patients (6.9%). The clinical assessment had an overall accuracy of 95.2% vs. 90.9% for APACHE II. The Pearson correlation coefficients for the two methods of prediction were 0.59 for clinical assessment and 0.44 for APACHE II. Predictive power was not greatly improved by combining both prediction methods. Over 40% of patients predicted to die by both methods actually survived. This study demonstrates that clinical assessment is superior to APACHE II in predicting outcome in this group of surgical patients, although the difference is small. In addition, this study suggests that neither clinical assessment nor the APACHE II score, when obtained within 24 hours of admission, is very reliable at predicting which surgical ICU patients will die.

Benefits, shortcomings, and costs of EEG monitoring.

A 5-year experience with 562 carotid endarterectomies, using electroencephalogram (EEG) monitoring and selective shunting, was reviewed. EEG changes occurred in 102 patients (18%). The frequency of EEG changes, as related to cerebral vascular symptoms, was as follows: transient ischemic attacks, seven per cent (19/259); completed strokes, 37% (36/98); vertebral basilar insufficiency, 24% (32/135); asymptomatic, 21% (15/71). Patients with contralateral carotid occlusion exhibited EEG changes in 37% (28/76) of operations. Fifteen patients suffered perioperative strokes (2.6%). Nine of the 15 were associated with a technical problem of either thrombosis of the internal carotid artery (five) or emboli (four). Technical problems were more common when shunts were used (five per cent) than when they were not (0.9%). Patients who suffered strokes prior to surgery were more at risk to develop a perioperative stroke (three per cent) than those not suffering prior strokes (0.3%). The EEG did not change in three patients who had lacunar infarcts prior to surgery and who awoke with a worsened deficit. Our series does not clearly establish the advantages of EEG monitoring, which is expensive (+375/patient) and may not detect ischemia in all areas of the brain. However, the use of shunts may introduce a risk of stroke due to technical error that is equal or greater than the risk of stroke due to hemodynamic ischemia. Since the need for protection is unpredictable by angiographic or clinical criteria, the benefit of EEG monitoring may be in reducing the incidence of shunting in those patients whose tracing remains normal after clamping. The decision to shunt, however, when there is electrical dysfunction after carotid clamping should be based not only on the EEG but also on the clinical signs and computed tomography (CT) scan. Our data does not show a net benefit in selective shunting unless the patient has sustained a stroke prior to surgery.

Toward strategies for cost containment in surgical patients.

The University of Rochester, Department of Surgery, in response to an experimental community-wide limit on hospital budgets, studied high-cost general surgical patients as a potential source of leverage for containment of hospital costs. It was found that a small number of patients impact significantly on hospital costs. In 1980, 3935 patients at Strong Memorial Hospital (SMH) had at least one contact with a general surgical patient care or intensive care unit; 261 patients (6.6%) had total 1980 charges of more than $20,000 each. They contributed 32% of the total of both general surgical charges and patient days. A subset of 2021 patients was selected to represent more precisely the general surgical patient. The 85 high-cost patients (4.2%) of this subset were chosen for intensive study. These patients generated a significant and disproportionate per cent of total (2021) general surgical charges (26.8%) and hospital days (27.6%). Average total charges were more than 8 times those of the complementary general surgical subset (1936). Nineteen of the 85 patients (22.3%) died in the hospital and 42 patients (49.4%) were dead within 2 1/2 years. Forty patients (of the 85) were then further identified as "complex", based on multiple, usually unrelated, illnesses and multiple annual admissions. Tending to be elderly with poor prognoses, 60% of them had died by April 1983. The major criterion of complexity was the lack of a well-focused medical problem; the cure for one problem simply relinquished primacy to another. A parallel study of hospital ancillary procedures disclosed a similar high-cost pattern. Of approximately 4000 ancillary procedures, 100 (2.5%) had annual charges of $100,000 or over, accounting for two-thirds of total 1980 ancillary charges. Roughly 20% of a single patient's ordered procedures accounted for 80% of the patient's ancillary charges, thus allowing concentrated study of a relatively small number of charges. Means for cost containment may be applied logically to the high-cost patient and particularly toward the complex patient. The complex patient is especially suited for consideration, since it is postulated that these patients are endemic to all general hospitals and to all clinical services. Strategies to be developed should include: 1) a managerial system in which physicians have an incentive to contain costs, 2) an online data system, 3) an accurate, efficient way to identify prospective high-cost and complex patients and, 4) awareness by physicians, patients, and society that less expensive modes of diagnosis and therapy are an appropriate response to rationed health resources.