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INTRODUCTION: Delirium is an independent risk factor for prolonged hospital length of stay (LOS) and increased mortality. Several antipsychotics have been studied for the treatment of intensive care unit (ICU) delirium that has led to a high variability in prescribing patterns for these medications. We hypothesize that in clinical practice the documentation of delirium is lower than the incidence of delirium reported in prospective clinical trials. The objective of this study was to document the incidence of delirium diagnosed in ICU patients and to describe the utilization of antipsychotics in the ICU. METHODS: This was a retrospective, observational, cohort study conducted at 71 United States academic medical centers that reported data to the University Health System Consortium Clinical Database/Resource Manager. It included all patients 18 years of age and older admitted to the hospital between 1 January 2010 and 30 June 2010 with at least one day in the ICU. RESULTS: Delirium was diagnosed in 6% (10,034 of 164,996) of hospitalizations with an ICU admission. Antipsychotics were administered to 11% (17,764 of 164,996) of patients. Of the antipsychotics studied, the most frequently used were haloperidol (62%; n = 10,958) and quetiapine (31%; n = 5,448). Delirium was associated with increased ICU LOS (5 vs. 3 days, P < 0.001) and hospital LOS (11 vs. 6 days, P < 0.001), but not in-hospital mortality (8% vs. 9%, P = 0.419). Antipsychotic exposure was associated with increased ICU LOS (8 vs. 3 days, P < 0.001), hospital LOS (14 vs. 5 days, P < 0.001) and mortality (12% vs. 8%, P < 0.001). Of patients with antipsychotic exposure in the ICU, absence of a documented mental disorder (32%, n = 5,760) was associated with increased ICU LOS (9 vs. 7 days, P < 0.001), hospital LOS (16 vs. 13 days, P < 0.001) and in-hospital mortality (19% vs. 9%, P < 0.001) compared to patients with a documented mental disorder (68%, n = 12,004). CONCLUSIONS: The incidence of documented delirium in ICU patients is lower than that documented in previous prospective studies with active screening. Antipsychotics are administered to 1 in every 10 ICU patients. When administration occurs in the absence of a documented mental disorder, antipsychotic use is associated with an even higher ICU and hospital LOS, as well as in-hospital mortality.
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Antipsicóticos/uso terapêutico , Delírio/diagnóstico , Delírio/tratamento farmacológico , Unidades de Terapia Intensiva , Idoso , Estudos de Coortes , Delírio/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Sepsis is increasing in hospitalized patients. Our purpose is to describe its current epidemiology in a general surgery (GS) intensive care unit (ICU) where patients are routinely screened and aggressively treated for sepsis by an established protocol. METHODS: Our prospective, Institutional Review Board-approved sepsis research database was queried for demographics, biomarkers reflecting organ dysfunction, and mortality. Patients were grouped as sepsis, severe sepsis, or septic shock using refined consensus criteria. Data are compared by analysis of variance, Student's t test, and χ test (p<0.05 significant). RESULTS: During 24 months ending September 2009, 231 patients (aged 59 years ± 3 years; 43% men) were treated for sepsis. The abdomen was the source of infection in 69% of patients. Several baseline biomarkers of organ dysfunction (BOD) correlated with sepsis severity including lactate, creatinine, international normalized ratio, platelet count, and d-dimer. Direct correlation with mortality was noted with particular baseline BODs including beta natriuretic peptide, international normalized ratio, platelet count, aspartate transaminase, alanine aminotransferase, and total bilirubin. Most patients present with severe sepsis (56%) or septic shock (26%) each with increasing multiple BODs. Septic shock has prohibitive mortality rate (36%), and those who survive septic shock have prolonged ICU stays. CONCLUSION: In general surgery ICU patients, sepsis is predominantly caused by intra-abdominal infection. Multiple BODs are present in severe sepsis and septic shock but are notably advanced in septic shock. Despite aggressive sepsis screening and treatment, septic shock remains a morbid condition.
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Cirurgia Geral , Sepse/epidemiologia , APACHE , Adolescente , Adulto , Análise de Variância , Biomarcadores/análise , Distribuição de Qui-Quadrado , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Sepse/mortalidade , Estatísticas não Paramétricas , Texas/epidemiologiaRESUMO
BACKGROUND: Care of sepsis has been the focus of intense research and guideline development for more than two decades. With ongoing success of computer protocol (CP) technology and with publication of Surviving Sepsis Campaign (SSC) guidelines, we undertook protocol development for management of sepsis of surgical intensive care unit patients in mid-2006. METHODS: A sepsis protocol was developed and implemented in The Methodist Hospital (TMH) (Houston, TX) surgical intensive care unit (27 beds) together with a sepsis research database. We compare paper-protocol (PP) (2008) and CP (2009) performance and results of the SSC guideline performance improvement initiative (2005-2008). TMH surgical intensive care unit sepsis protocol was developed to implement best evidence and to standardize decision making among surgical intensivists, nurse practitioners, and resident physicians. RESULTS: The 2008 and 2009 sepsis protocol cohorts had very similar number of patients, age, % male gender, Acute Physiology and Chronic Health Evaluation scoring system II, and Sequential Organ Failure Assessment scores. The 2008 PP patients had greater baseline lactate concentration consistent with greater mortality rate. Antibiotic agents were administered to 2009 CP cohort patients sooner than 2008 PP cohort patients. Both cohorts received similar volume of intravenous fluid boluses. Comparing 6-hour resuscitation bundle compliance, the 2009 CP cohort was substantially greater than SSC eighth quarter and 2008 PP cohorts (79% vs. 31% vs. 29%), and mortality rate was much less when using the CP (14% vs. 31% vs. 24%). CONCLUSIONS: Our comprehensive sepsis protocol has enabled rapid and consistent implementation of evidence-based care, and, implemented as a bedside CP, contributed to decreased mortality rate for management of surgical sepsis.
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Protocolos Clínicos/normas , Cuidados Críticos/organização & administração , Processamento Eletrônico de Dados/métodos , Medicina Baseada em Evidências/métodos , Unidades de Terapia Intensiva/normas , Sepse/terapia , Centros Cirúrgicos , Medicina Baseada em Evidências/normas , Medicina Baseada em Evidências/estatística & dados numéricos , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sepse/diagnóstico , Sepse/epidemiologia , Índice de Gravidade de Doença , Taxa de Sobrevida , Texas/epidemiologiaRESUMO
Secondary causes of mania need to be considered when atypical features of mania are manifested. These would include those patients with a later onset and without a prior psychiatric history. This case series investigates the use of ziprasidone for the treatment of mania due to HIV, a complication that could develop in those patients with advanced stages of AIDS.
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Síndrome da Imunodeficiência Adquirida/psicologia , Antipsicóticos/uso terapêutico , Transtorno Bipolar/tratamento farmacológico , Transtorno Bipolar/etiologia , Piperazinas/uso terapêutico , Tiazóis/uso terapêutico , Antipsicóticos/administração & dosagem , Esquema de Medicação , Feminino , Humanos , Pessoa de Meia-Idade , Piperazinas/administração & dosagem , Tiazóis/administração & dosagem , Resultado do TratamentoRESUMO
BACKGROUND: Sepsis is the leading cause of mortality in noncoronary intensive care units. Recent evidence based guidelines outline strategies for the management of sepsis and studies have shown that early implementation of these guidelines improves survival. We developed an extensive logic-based sepsis management protocol; however, we found that early recognition of sepsis was a major obstacle to protocol implementation. To improve this, we developed a three-step sepsis screening tool with escalating levels of decision making. We hypothesized that aggressive screening for sepsis would improve early recognition of sepsis and decrease sepsis-related mortality by insuring early appropriate interventions. METHODS: Patients admitted to the surgical intensive care unit were screened twice daily by our nursing staff. The initial screen assesses the systemic inflammatory response syndrome parameters (heart rate, temperature, white blood cell count, and respiratory rate) and assigns a numeric score (0-4) for each. Patients with a score of > or = 4 screened positive proceed to the second step of the tool in which a midlevel provider attempts to identify the source of infection. If the patients screens positive for both systemic inflammatory response syndrome and an infection, the intensivist was notified to determine whether to implement our sepsis protocol. RESULTS: Over 5 months, 4,991 screens were completed on 920 patients. The prevalence of sepsis was 12.2%. The screening tool yielded a sensitivity of 96.5%, specificity of 96.7%, a positive predictive value of 80.2%, and a negative predictive value of 99.5%. In addition, sepsis-related mortality decreased from 35.1% to 23.3%. CONCLUSIONS: The three step sepsis screening tool is a valid tool for the early identification of sepsis. Implementation of this tool and our logic-based sepsis protocol has decreased sepsis-related mortality in our SICU by one third.
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Sepse/diagnóstico , Adolescente , Adulto , Criança , Pré-Escolar , Cuidados Críticos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Estudos Retrospectivos , Sepse/mortalidade , Adulto JovemRESUMO
PURPOSE OF REVIEW: Nutritional supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma, many areas of clinical nutrition remain controversial and not well defined. The benefit of early enteral nutrition in the care of injured patients has been well established, with further benefit derived by the administration of immune-enhancing formulas supplemented with glutamine, arginine, nucleotides, and omega-3-fatty acids. A new paradigm of pharmaconutrition has been developed that separates the administration of immunomodulatory nutrients from that of nutritional support. The optimal utilization and benefit of pharmaconutrients, however, remains unclear, as does the need for full caloric provision in the early postinjury phase. RECENT FINDINGS: Nutrition studies with the greatest reduction in morbidity and mortality are those utilizing specific nutrients. The use of pharmaconutrients to modulate the inflammatory and immune response associated with critical illness seems to provide benefit to critically ill and injured patients. Additionally, studies at least suggest that trauma patients derive comparable if not additional benefit from hypocaloric feeding during the acute phase of injury. SUMMARY: Building upon previous well performed studies in trauma patients, the current focus of nutritional investigations center on the use of pharmaconutrients to modulate the inflammatory response and the use of hypocaloric feeds. These practices will be reviewed and evidence presented for their use in critically ill and injured patients.
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Antioxidantes/administração & dosagem , Estado Terminal , Suplementos Nutricionais , Comportamento Alimentar , Alimentos Formulados , Estado Nutricional , Ferimentos e Lesões/complicações , Arginina/administração & dosagem , Ácidos Graxos Ômega-3/administração & dosagem , Glutamina/administração & dosagem , Humanos , Inflamação/complicações , Inflamação/etiologia , Nucleotídeos/administração & dosagem , Fatores de TempoRESUMO
BACKGROUND: The effect of adrenal replacement therapy (ART) with hydrocortisone on critical endpoints such as infection and mortality in critically ill patients with cirrhosis remains unclear. We evaluated our indications for ART in patients with cirrhosis with clinical symptoms of adrenal insufficiency (AI), and examined the rate of peri-transplant fungal colonization and mortality associated with ART. METHODS: Seventy-eight patients with cirrhosis admitted to our institution's surgical intensive care unit (ICU) over a 4-year period met criteria for AI by vasopressor requirement and baseline cortisol levels. Outcomes included disposition at 90-days, fungal colonization, and fungal infection in the presence or absence of ART. RESULTS: In total, 56 patients received hydrocortisone (HC+) while 22 did not (HC-). The HC+ and HC- groups had comparable median Model for End-stage Liver Disease (MELD) scores (26.5 vs. 25, respectively; p=0.93), median ICU lengths of stay (23 vs. 20 days, respectively; p=0.54) and median cortisol levels (18 µg/dL for both, p=0.87). Fungal cultures (FC) from blood, urine or bronchoalveolar lavage/sputum were positive for 44% of HC+, and 40.9% of HC- (p=0.77) had mortality rates between HC+ and HC- groups that were not significantly different (60.7% vs. 50%, respectively; p=0.39; α=0.05). The 90-day outcomes for HC+ vs. HC- (39.3% vs. 50% discharged, respectively; p=0.39; α=0.05) and those surviving to transplant (17.9% vs. 36.4%, respectively; p=0.08; α=0.05) were not significantly different between the two groups. CONCLUSION: In this small single-center series, we found that steroid administration for AI does not affect the rate of fungal colonization/infection or mortality. Further prospective studies are required to determine the utility of ART and factors affecting the rate of FC and mortality in these patients.
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BACKGROUND: Nucleated red blood cells (NRBCs) are present in certain non-oncologic disease states and are associated with a poor prognosis. The purpose of this study was to evaluate NRBCs as an early prognostic marker for death in patients with surgical sepsis. METHODS: Retrospective evaluation of data collected prospectively from 275 patients from our Investigational Review Board-approved surgical sepsis database over a 27-mo period. The NRBC values were correlated with patient outcomes. The χ(2) test was used for testing of categorical variables and the Mann-Whitney U was used for testing of continuous variables. The level of significance was set at 0.05. RESULTS: At sepsis recognition, 48 patients (17.5%) were NRBC-positive. The mortality rate was greater in patients who were NRBC positive while in the intensive care unit (ICU); (27% vs. 12%; p=0.007) and during the hospital stay (35.4% vs. 15%; p=0.001). When NRBC-values at all time points are considered, 116 patients (42.2%) were NRBC-positive. The mortality rate was greater in patients who were NRBC-positive in both the ICU (23.3% vs. 8.2%; p<0.001) and during the hospital stay (31% vs. 9.4%; p<0.001). In-hospital and ICU mortality rates increased with increasing NRBC-concentration. For the 153 patients with severe sepsis, NRBC positivity at any time was associated with a higher ICU mortality rate (20% vs. 3.2%; p=0.001). Significant mortality differences did not occur between NRBC-positive and NRBC-negative patients with sepsis (n=48) or septic shock (n=74). CONCLUSIONS: Surgical sepsis patients with detectable NRBCs are at higher risk of ICU and in-hospital death than those with non-detectable NRBCs. The mortality difference is underscored in surgical patients with severe sepsis. This study suggests NRBCs may be a biomarker of outcomes in patients with surgical sepsis.
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Eritroblastos/patologia , Complicações Pós-Operatórias/sangue , Sepse/sangue , Idoso , Distribuição de Qui-Quadrado , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos RetrospectivosRESUMO
BACKGROUND: Studies have documented a correlation between hypothyroxinemia and mortality in critically ill patients; however, there are limited data in sepsis. The objective of this study was to assess baseline thyroid function studies and their association with mortality in surgical sepsis. We hypothesized that the relatively decreased levels of free thyroxine (T4), decreased levels of triiodothyronine (T3), and increased thyrotropin-stimulating hormone levels would be associated with mortality. METHODS: This was a retrospective review of prospectively collected data in a surgical intensive care unit. Data evaluated included patient demographics, baseline thyroid function studies, and mortality. Patients were categorized as having sepsis, severe sepsis, or septic shock. A value of p < 0.05 was considered significant. RESULTS: Within 24 months, 231 septic patients were accrued. The mean age was 59 ± 3 years, and 43% were male. Thirty-nine patients were diagnosed as having sepsis, 131 as having severe sepsis, and 61 as having septic shock. There were no statistically significant differences between the T3, free T4, or thyrotropin-stimulating hormone levels at baseline and the different categorizations of sepsis.T4 levels were increased in all patients but to a significantly lesser extent in those who died. Similarly, T3 levels were significantly decreased in patients who died. CONCLUSION: In surgical sepsis, decreased T3 levels at baseline are associated with mortality. These data do not support the administration of levothyroxine (T4) because it is already elevated and would preferentially be converted to reverse T3 (inactive) in critical illness; however, replacement with liothyronine (T3) might be rational. LEVEL OF EVIDENCE: Epidemiologic study, level III.
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Síndromes do Eutireóideo Doente/diagnóstico , Sepse/complicações , Síndromes do Eutireóideo Doente/sangue , Síndromes do Eutireóideo Doente/etiologia , Síndromes do Eutireóideo Doente/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sepse/sangue , Sepse/fisiopatologia , Tireotropina/sangue , Tiroxina/sangue , Tri-Iodotironina/sangueRESUMO
Support for Acute Lung Injury (ALI) and Adult Respiratory Distress Syndrome (ARDS) in many ways represents the summation of all intensive care unit nutrition modalities. Basic tenets of management are based on those established for the general population of mechanically ventilated patients. As a marker of critical illness however, patients with ALI/ARDS suffer from other organ dysfunctions that require advanced support. Specific issues to be considered in this population include carbon dioxide production, prevention of aspiration, and modulation of the inflammatory response. These particular areas, with special attention paid to the role of lipids in ALI/ARDS, will be reviewed.
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Lesão Pulmonar Aguda/terapia , Lipídeos/uso terapêutico , Apoio Nutricional , Síndrome do Desconforto Respiratório/terapia , Adulto , Dióxido de Carbono/metabolismo , Humanos , Inflamação/terapia , Aspiração Respiratória/prevenção & controleRESUMO
BACKGROUND: The need for emergent colon surgery is a common cause of severe sepsis/septic shock and mortality among surgical patients. We wanted to benchmark our outcomes against those of the National Surgical Quality Improvement Program (NSQIP). We hypothesized that having acute care surgeons to provide comprehensive perioperative care and rapid source control surgery would improve outcome. METHODS: We queried the 2005 to 2007 NSQIP dataset and our prospective database for patients with severe sepsis/septic shock requiring emergency colon surgery. Demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained for all patients. RESULTS: Both cohorts were similar with regard to age and sex. The overall mortality rate for patients in our dataset was 28.3% compared with 40.1% in the NSQIP dataset (P = .06). The average Acute Physiology and Chronic Health Evaluation II score for our patients was 31 ± 8.2 with a predicted mortality rate of 73% (P < .0001 when compared with actual mortality rate of 28.3%). CONCLUSIONS: Patients with severe sepsis/septic shock requiring emergent colon surgery have a high mortality rate. Delivery of comprehensive emergency surgical care by acute care surgeons appears to improve survival.
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Benchmarking , Colectomia/mortalidade , Doenças do Colo/cirurgia , Cuidados Críticos/organização & administração , Acessibilidade aos Serviços de Saúde/tendências , Avaliação de Resultados em Cuidados de Saúde , Choque Séptico/cirurgia , Idoso , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Choque Séptico/etiologia , Choque Séptico/mortalidade , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The purpose of this study was to assess how surgical intensive care unit (SICU) patients and their families would perceive robotic telepresence. We hypothesized that they would view such technology positively. METHODS: This research was an Institutional Review Board-approved prospective observational study. Our robotic telepresence program augmented the SICU multidisciplinary team rounding process. We anonymously surveyed patients and their families on their perceptions. Those who interacted at least once with the robot served as our participant base. RESULTS: Twenty-four patients and 26 family members completed the survey. Ninety-two percent of respondents were comfortable with the robot, and 84% believed communication was "easy." Ninety percent did not perceive the robot as "annoying" and 92% did not believe that "the doctor cared less about them" because of the robot. Ninety-two percent of respondents supported the continued use of the robot. CONCLUSIONS: Robotic telepresence was viewed positively by patients and their families in the SICU. Furthermore, they believed the robot was beneficial to their care and indicated their support for its continued use.
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Estado Terminal/terapia , Família/psicologia , Unidades de Terapia Intensiva/provisão & distribuição , Avaliação de Resultados em Cuidados de Saúde , Robótica/métodos , Procedimentos Cirúrgicos Operatórios/métodos , Telemedicina/métodos , Desenho de Equipamento , Feminino , Humanos , Masculino , Estudos Prospectivos , Procedimentos Cirúrgicos Operatórios/psicologia , Estados UnidosRESUMO
BACKGROUND: B-type natriuretic peptide (BNP) is secreted in response to myocardial stretch and has been used clinically to assess volume overload and predict death in congestive heart failure. More recently, BNP elevation has been demonstrated with septic shock and is predictive of death. How BNP levels relate to cardiac function in sepsis remains to be established. STUDY DESIGN: Retrospective review of prospectively gathered sepsis database from a surgical ICU in a tertiary academic hospital. Initial BNP levels, patient demographics, baseline central venous pressure levels, and in-hospital mortality were obtained. Transthoracic echocardiography was performed during initial resuscitation per protocol. RESULTS: During 24 months ending in September 2009, two hundred and thirty-one patients (59 ± 3 years of age, 43% male) were treated for sepsis. Baseline BNP increased with initial sepsis severity (ie, sepsis vs severe sepsis vs septic shock, by ANOVA; p < 0.05) and was higher in those who died vs those who lived (by Fisher's exact test; p < 0.05). Of these patients, 153 (66%) had early echocardiography. Low ejection fraction (<50%) was associated with higher BNP (by Fisher's exact test; p < 0.05) and patients with low ejection fraction had a higher mortality (39% vs 20%; odds ratio = 3.03). We found no correlation between baseline central venous pressure (12.7 ± 6.10 mmHg) and BNP (526.5 ± 82.10 pg/mL) (by Spearman's ρ, R(s) = .001) for the entire sepsis population. CONCLUSIONS: In surgical sepsis patients, BNP increases with sepsis severity and is associated with early systolic dysfunction, which in turn is associated with death. Monitoring BNP in early sepsis to identify occult systolic dysfunction might prompt earlier use of inotropic agents.
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Peptídeo Natriurético Encefálico/sangue , Sepse/sangue , Sepse/fisiopatologia , Adolescente , Adulto , Idoso , Biomarcadores/sangue , Pressão Venosa Central/fisiologia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Sepse/mortalidade , Volume Sistólico/fisiologia , Adulto JovemRESUMO
OBJECTIVE: To document the incidence, mortality rate, and risk factors for sepsis and septic shock compared with pulmonary embolism and myocardial infarction in the general-surgery population. DESIGN: Retrospective review. SETTING: American College of Surgeons National Surgical Quality Improvement Program institutions. PATIENTS: General-surgery patients in the 2005-2007 National Surgical Quality Improvement Program data set. MAIN OUTCOME MEASURES: Incidence, mortality rate, and risk factors for sepsis and septic shock. RESULTS: Of 363 897 general-surgery patients, sepsis occurred in 8350 (2.3%), septic shock in 5977 (1.6%), pulmonary embolism in 1078 (0.3%), and myocardial infarction in 615 (0.2%). Thirty-day mortality rates for each of the groups were as follows: 5.4% for sepsis, 33.7% for septic shock, 9.1% for pulmonary embolism, and 32.0% for myocardial infarction. The septic-shock group had a greater percentage of patients older than 60 years (no sepsis, 40.2%; sepsis, 51.7%; and septic shock, 70.3%; P < .001). The need for emergency surgery resulted in more cases of sepsis (4.5%) and septic shock (4.9%) than did elective surgery (sepsis, 2.0%; septic shock, 1.2%) (P < .001). The presence of any comorbidity increased the risk of sepsis and septic shock 6-fold (odds ratio, 5.8; 95% confidence interval, 5.5-6.2) and increased the 30-day mortality rate 22-fold (odds ratio, 21.8; 95% confidence interval, 17.6-26.9). CONCLUSIONS: The incidences of sepsis and septic shock exceed those of pulmonary embolism and myocardial infarction. The risk factors for mortality include age older than 60 years, the need for emergency surgery, and the presence of any comorbidity. This study emphasizes the need for early recognition of patients at risk via aggressive screening and the rapid implementation of evidence-based guidelines.
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Cirurgia Geral/estatística & dados numéricos , Qualidade da Assistência à Saúde , Sepse/epidemiologia , Sepse/etiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Colectomia/efeitos adversos , Intervalos de Confiança , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Feminino , Humanos , Incidência , Intestino Delgado/cirurgia , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Razão de Chances , Pancreatectomia/efeitos adversos , Avaliação de Programas e Projetos de Saúde , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Sepse/mortalidade , Choque Séptico/epidemiologia , Choque Séptico/etiologia , Estados Unidos , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Adulto JovemRESUMO
BACKGROUND: The management of surgical sepsis is challenging because of the complexity of interventions. The authors therefore created a computerized clinical decision support program to facilitate this process, with the goal of improving abdominal sepsis mortality. METHODS: The authors evaluated a prospective database for all patients requiring surgery for abdominal sepsis. Patient demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained. Observed mortality was compared with predicted mortality using Fisher's exact test. RESULTS: Eighty-seven patients met the inclusion criteria. The average age was 59 ± 17.0 years, and 39% were men. The most common source of infection was the colon (45%). The average Acute Physiology and Chronic Health Evaluation II score was 27.6 ± 9.72. The overall actual mortality rate for the cohort was 24% compared with a predicted Acute Physiology and Chronic Health Evaluation II mortality of 62.5% (P < .0001). CONCLUSION: The use of computerized clinical decision support results in significantly improved survival in patients with intra-abdominal surgical sepsis.
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Abdome , Tomada de Decisões Assistida por Computador , Complicações Pós-Operatórias , Sepse/mortalidade , APACHE , Abdome/cirurgia , Medicina Baseada em Evidências , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Sepse/diagnóstico , Sepse/etiologia , Sepse/cirurgia , Síndrome de Resposta Inflamatória Sistêmica/etiologia , Síndrome de Resposta Inflamatória Sistêmica/mortalidadeRESUMO
BACKGROUND: We implemented a multidisciplinary electrolyte replacement protocol in a tertiary referral center surgical intensive care unit. The purpose of this study was to evaluate its efficacy. METHODS: This was a retrospective study. The electrolyte replacement protocol was designed for the replacement of potassium, magnesium, and phosphorous and was nurse driven. Data evaluated included patient demographics and details specific to electrolyte replacement. Univariate analyses were performed by using the Student t test and the Fisher exact test. A P value of <.05 was considered significant. RESULTS: After implementation of the protocol, overall electrolyte replacement improved from 70% to 79% (P = .03), and its overall effectiveness increased from 50% to 65% (P = .01). Individual electrolyte replacement, effectiveness, and dosing varied. CONCLUSIONS: The implementation of a multidisciplinary electrolyte replacement protocol in a tertiary referral center surgical intensive care unit significantly improved both overall electrolyte replacement and its effectiveness.
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Protocolos Clínicos , Hidratação/normas , Equipe de Assistência ao Paciente , Desequilíbrio Hidroeletrolítico/terapia , Estudos de Coortes , Feminino , Humanos , Hipopotassemia/terapia , Hipofosfatemia/terapia , Unidades de Terapia Intensiva , Magnésio/metabolismo , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
PURPOSE: Airway management occupies a crucial component of surgical education. As such, it can be difficult to provide adequate training within the hospital setting alone. To be facile in all aspects of nonsurgical airway management, the surgical resident must have thorough cognitive understanding of the process as well as technical mastery. The Department of Surgery at the Methodist Hospital in Houston has developed a curriculum for nonsurgical airway management that uses multiple modalities for education, reinforcement, and testing. Didactic lectures based on established national guidelines are provided as a foundation. This method is supplemented by hands-on group scenarios that use inanimate models. Throughout the course, faculty leaders provide guidance and skills assessment. Residents are tested for competency using core value checklists based on knowledge and technical proficiency. During its pilot year, the curriculum has proven its need and success in residency education. Future improvements include development of specific clinical scenarios as well as integration of more advanced educational equipment and models for use in nonsurgical airway management. DEVELOPMENT OF THE ACTIVITY AND MATERIALS: Materials used for this program include an article by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway, the New England Journal of Medicine article entitled "Videos in clinical medicine. Orotracheal intubation" by Kabrhel et al,(2) "Management of the difficult and failed airway" by Hung and Murphy,(3) the American Heart Association Airway Management course 2007,(4) and the Manual of Emergency Airway Management by Walls et al.(5) EVALUATION COMPONENT: Before participating in the module, residents completed a written pretest and performed an initial simulation to establish a baseline. Residents then worked through a series of skills that provided experience in both the cognitive and the procedural aspects of airway management. To complete the module successfully, residents were required to attend three 3-hour sessions. After supervised practice, residents were tested on the procedural techniques via a procedural checklist and cognitive aspects with respect to emergency, crash, difficult, and failed airway algorithms.(1,5) The simulations are based on the 2003 American Society of Anesthesiologists Task Force on Management of the Difficult Airway Algorithms(1) and emergency, crash, difficult, and failed airway algorithms.(2,5) PROPOSED OUTCOME MEASURES: Proposed long-term outcome measures will include evaluations from faculty on a resident's noninvasive airway management skills and the resident's self-evaluation in actual noninvasive airway management situations. Resident performance will be evaluated by faculty using standardized checklists, review of simulation parameters, and review of audio-video recording of the simulation. EXPERIENCE TO DATE: This article describes our first implementation in the evolution of this module. The module was introduced to residents at all postgraduate levels in September 2007. Scores on pretests and performance on initial simulations were similar in all postgraduate years, with minimally superior pretest and initial simulation performance from the senior residents. Correct procedural adoption occurred rapidly after prebriefing and initial hands-on demonstration and supervised practice in simulated patient scenarios on airway mannequins. CONCLUSIONS AND NEXT STEPS: Our preliminary experience with a nonsurgical airway management training module for surgical residents has shown that a need for training exists in this critical area. Correct procedural adoption occurred rapidly after a didactic and procedural hands-on experience. Time intervals needed for review to maintain competence will also be studied. Improvements to the proficiency criteria and simulations are underway.