Colonization and infection in surgical intensive care patients--a prospective study.

Nosocomial infections are a major problem in intensive care patients. Thirty-nine patients, requiring intensive care for 5 days or more (mean 15.8 days) were prospectively investigated, to determine the relation between colonisation and nosocomial infection. Thrice weekly, cultures from the oropharynx, respiratory and digestive tract were obtained. Colonization with aerobic gram-negative microorganisms of the oropharynx, respiratory and digestive tract significantly increased during the stay in the Intensive Care Unit. In 29 patients (74%) 78 nosocomial infections were diagnosed. The most frequent nosocomial infections were pneumonia (26 patients, 66.6%), catheter-related bacteraemia (11 patients, 28.2%), and wound infections (7 patients, 17.9%). In 59 instances (75.6%), colonization with the same potential pathogenic microorganism preceded the nosocomial infection. The overall mortality was 25.6% (10 patients), bacteraemia with aerobic gram-negative microorganisms being the cause of death in 7 patients.

Fulminant acute pancreatitis and infected necrosis: results of open management of the abdomen and "planned" reoperations.

BACKGROUND: Controversy still surrounds the management of fulminant acute necrotizing pancreatitis. Because mortality rates continue to be high, especially in patients with fulminant acute pancreatitis and infected necrosis, aggressive surgical techniques, such as open management of the abdomen and "planned" reoperations, seem to be justified. STUDY DESIGN: From 1988 through 1995, 28 patients with fulminant acute pancreatitis and infected necrosis were treated with open management of the abdomen followed by planned reoperations at our surgical intensive care unit. RESULTS: All patients had infected necrosis with severe clinical deterioration: 12 patients had an Acute Physiology and Chronic Health Evaluation (APACHE) II score > or = 20 and 16 patients had a Simplified Acute Physiology Score (SAPS) > or = 15. Nineteen patients suffered from severe multiorgan failure; the remaining 9 patients needed only ventilatory and inotropic support. The mean number of reoperations was 17. In 14 patients, major bleeding occurred; fistula developed in 7. Later, 9 abscesses were drained percutaneously. The hospital mortality rate was 39%. Longterm morbidity in survivors was substantial, especially concerning abdominal-wall defects. CONCLUSIONS: Open management of the abdomen followed by planned reoperations is an aggressive but reasonably successful surgical treatment strategy for patients with fulminant acute pancreatitis and infected necrosis. Morbidity and mortality rates were high, but in these critically ill patients, such high rates could be expected. Because management and clinical surveillance require specific expertise, management of these patients is best undertaken in specialized centers.

An outbreak of Serratia marcescens traced to a contaminated bronchoscope.

An outbreak of colonization and infection with Serratia marcescens in a surgical Intensive Care Unit is described. A case-control study pointed to a bronchoscope as the source of the epidemic strain, and cultures of washing effluent of the incriminated bronchoscope yielded S. marcescens. Discontinuation of the use of the instrument and the implementation of recommendations for future use of bronchoscopes ended the outbreak.

[Necrotising fasciitis and myositis as serious complications after liposuction]. / Necrotiserende fasciitis en myositis als ernstige complicaties na liposuctie.

Three days after liposuction of the lower abdomen, a 41-year-old woman was admitted for toxic shock-like syndrome with necrotising fasciitis and myositis, caused by Lancefield-group-A beta-haemolytic streptococci. The patient was treated by radical debridement of the skin, subcutis, fasciae and part of the pectoral muscle, plus antibiotics. Postoperatively she required artificial respiration for respiratory insufficiency. One week after the operation the wound was covered by transplantation of autologous skin. The patient survived, but was seriously disfigured. Necrotising fasciitis is a progressive soft-tissue infection, characterised by widespread necrosis of the superficial and deep fascia, often associated with severe systemic toxic reactions. Unless quickly recognised and aggressively treated, the course is often fatal. Due to the absence of cutaneous findings in the early stages, diagnosis is difficult. Important diagnostic aids are routine laboratory tests, contrast-MRI and a combination of the finger test and frozen-section biopsy. Treatment consists of early radical debridement, broad-spectrum antibiotics and supportive care. In a later stage, soft-tissue reconstruction with autografts or artificial skin grafts and skin transposition can be performed.

Traumatic hemipelvectomy: Improvements in the last decennia illustrated by 2 case reports.

INTRODUCTION: In this article we present two cases of young men who sustained a traumatic hemipelvectomy. PRESENTATION OF CASE: The first case occurred more than 10 years ago and the second case happened less than 1 year ago. Changes in the management for resuscitation, surgical intervention, and in postoperative treatment are detailed. Goal of this article is to evaluate the changes over time in the treatment of trauma in general and this specific injury in particular. DISCUSSION: Maximum survival chance could be achieved by an aggressive resuscitation (following a massive transfusion protocol-ratio of 1:1:1 unit of blood-products), starting pre-hospitally and continued in the emergency department, immediate control of the haemorrhage and direct surgical intervention. Early and frequent re-explorations are necessary to prevent complications as sepsis and to minimize the chance for complications such as disturbed wound healing and fistula formation. The use of the Vacuum-Assisted Closure therapy nowadays gives the patient an earlier recover and lesser chance at developing complications. Early consultation with plastic surgeons needs to be done in order to achieve an adequate definitive wound-closure (reconstructive surgery). CONCLUSION: A traumatic hemipelvectomy is a catastrophic and mutilating injury, seldom survivable. Maximum survival chance could be achieved by an aggressive resuscitation, frequent re-explorations, the use of VAC therapy and early consultation with a plastic surgeon for reconstructive surgery.

Prognostic factors in surgery for duodenal ulcer.

A 5 to 12 year follow-up study of 132 patients with nonobstructive duodenal ulcer treated by HSV without a drainage procedure was done. The results of pre- and postoperative gastric emptying studies and pre- and postoperative acid secretion studies were related to recurrent ulceration and postoperative complaints. The almost 9 percent of instances of recurrent ulceration were found in the group of patients with preoperative PPAO values greater than 40 mmol/hr. In all 13 patients with preoperative PPAO values greater than 60 mmol/hr, HSV was considered a failure. It was concluded that at least the latter group should be excluded from HSV. In 4.3 percent of patients serious gastric stasis after HSV was cause for reoperation. In spite of meticulous denervation and peroperative open pH metry, inadequate vagotomy, defined as percent reduction of PIAO values after HSV less than 75 percent, was found in 33 out of 117 patients. In an experimental study, vascular occlusion alone also gives a positive Grassi test. From both facts the relative value of this test can be concluded. Symptoms after inadequate vagotomy were again clearly related to preoperative PPAO values.

Effect of dopexamine on outcome after major abdominal surgery: a prospective, randomized, controlled multicenter study. European Multicenter Study Group on Dopexamine in Major Abdominal Surgery.

OBJECTIVE: To test the hypothesis that dopexamine reduces postoperative mortality and morbidity in high-risk, major abdominal surgery patients, when given to fluid-resuscitated patients starting before the operation and continued for 24 hrs after surgery. DESIGN: Prospective, randomized, controlled, double-blind multicenter trial. SETTING: Intensive care units in 13 hospitals from six European countries. PATIENTS: A total of 412 patients with predefined high-risk criteria, undergoing major abdominal surgery with an expected duration of at least 1.5 hrs. INTERVENTIONS: The patients received placebo (n = 140), dopexamine at 0.5 microg/kg/min (n = 135), or dopexamine at 2.0 microg/kg/ min (n = 137) starting after preoperative hemodynamic stabilization and continued for 24 hrs after surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome variable was mortality at 28 days. Analysis was by intention to treat. Dopexamine had no effect on mortality (at 28 days, 13%, 7%, and 15%, for the groups receiving placebo, dopexamine at 0.5 microg/kg/ min, and dopexamine at 2.0 microg/kg/min, respectively), despite the expected dose-dependent hemodynamic responses. No effect was observed on the occurrence of organ dysfunction, duration of intensive care unit stay, or length of hospital stay. CONCLUSION: We conclude that dopexamine in doses that result in increased cardiac output and oxygen delivery after preoperative stabilization with fluids does not improve outcome after major abdominal surgery compared with fluids alone. Based on post hoc subgroup analysis and stratification according to the number of risk factors, we suggest that the concept should be further tested in patients at higher risk of complications or undergoing emergency surgery.

Prognostic scoring systems to predict outcome in peritonitis and intra-abdominal sepsis.

BACKGROUND: Early classification of patients presenting with peritonitis and intra-abdominal sepsis by means of objective scoring systems is desirable to select patients for 'aggressive' surgery and to compare results of different treatment regimens. However, none of the existing scoring systems has fulfilled all expectations. METHODS: Evaluation of the value of various scoring systems (Acute Physiology And Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score, Sepsis Severity Score, Multiple Organ Failure, Mannheim Peritonitis Index (MPI), Ranson and Imrie) was performed in 50 patients. Additionally, scoring systems were combined to obtain a 'combined score' for the prediction of peritonitis-related in-hospital death. Hazard ratios were calculated in a univariate and multivariate analysis. RESULTS: In the univariate analysis all scoring systems, except Ranson and Imrie, predicted the primary outcome. In the multivariate analysis, only the APACHE II score (hazard ratio 6.7) and the MPI (hazard ratio 9.8) contributed independently to the prediction of outcome. All patients with an APACHE II score of 20 or more and a MPI of 27 or more died in hospital. CONCLUSION: Combination of the APACHE II and the MPI provides the best scoring system fitting clinical goals.

The effect of secretin on peripheral arterial blood flow.

Arterial blood flow was measured in 18 arteries leading to nearly all major organs in the anesthetized dog, to obtain information about the specificity of the blood flow effects caused by secretin. This gastro-intestinal hormone was administered intravenously in a sequence of bolus injections (0.001--4 U/kg). Blood flow increase in the pancreatico-duodenal arteries was highest of all arteries observed. This flow increase in the superior pancreatico-duodenal artery was also found in its truncal artery (gastroduodenal a.), but to a less extend: the effect was diluted by the other--less reacting--branch (right gastro-epiploic a.) of the same truncal artery. We conclude that secretin preferentially increased blood flow in the pancreatico-duodenal arteries. Since secretin effects on heart rate and arterial pressure were but small, the flow increase in the pancreatico-duodenal area were caused by a lowering of the resistance of the pancreatico-duodenal vasculature. Comparison between the flow responses, elicited by secretin (Boots) and secretin (Karolinska), is discussed.

Amoxicillin-clavulanate prophylaxis against wound infections after clean-contaminated surgery. A controlled, randomized, prospective study.

In a single-blind, prospective randomized and controlled trial, amoxicillin-clavulanate was compared with gentamicin plus clindamycin as perioperative prophylaxis for 24 hours in clean-contaminated abdominal surgery. Proven infections of the abdominal incision occurred in one of 59 evaluable patients given amoxicillin-clavulanate and one of 43 with gentamicin/clindamycin. In the latter group there was also one incisional perineal wound infection. At follow-up enquiry by telephone around postoperative day 30, four patients in the amoxicillin-clavulanate group reported minor wound discharge for which they had not sought medical attention. Intraperitoneal infection occurred in one patient of that group, and in three of the gentamicin/clindamycin group. Both regimens thus were effective and safe as prophylaxis in clean-contaminated abdominal surgery.

Open management of the abdomen and planned reoperations in severe bacterial peritonitis.

OBJECTIVE: To assess the results of open management of the abdomen and planned re-operations in severe bacterial peritonitis after perforation or anastomotic disruption of the digestive tract. DESIGN: Retrospective study. SETTING: University Hospital, The Netherlands. SUBJECTS: 67 consecutive patients. INTERVENTIONS: Open management of the abdomen and planned reoperations. MAIN OUTCOME MEASURES: Hospital morbidity and mortality, long-term follow-up. RESULTS: 38 patients developed multiple organ failure (MOF), but 29 needed only ventilatory and inotropic support. The mean number of re-operations was nine. 16 patients developed severe bleeding and 16 fistulas. In-hospital mortality was 42% (n = 28). Long-term morbidity, particularly the number of abdominal wall defects (n = 10), was considerable. CONCLUSION: Despite open management of the abdomen and planned re-operations, mortality of severe bacterial peritonitis still continues to be too high, and both short and long-term morbidity are appreciable. The value of open management of the abdomen and planned re-operations rests only on the clinical observation that other conventional surgical treatments of severe bacterial peritonitis often fail.

Hemodynamic actions of pentagastrin.

Pentagastrin (Peptavlon, ICI 50123) is known as a powerful stimulator of gastric acid secretion. Several authors have demonstrated a close relationship between gastric acid secretion and gastric blood flow. In this study the general hemodynamic properties of pentagastrin were investigated qualitatively and quantitatively. The study was performed on anesthetized mongrel dogs. Blood flow was assessed with non-cannulating electromagnetic flow probes. Pentagastrin was injected intravenously at intervals of 2 min in amounts between 1 ng and 8192 ng/kg, following a logarithmic scale. Pentagastrin dose-dependently increased splanchnic blood flow in a reversed U-shaped manner. The major vasoactivity occurred in two organ areas--the gastric area and the pancreatico-duodenal area. Pentagastrin increased blood flow in these areas to 300% and 350% of initial value, respectively, at a dose of 2-4 microgram/kg. Since heart rate, cardiac output, and arterial pressure were not influenced, pentagastrin had no general hemodynamic effect. This was confirmed by blood flow measurements in the renal a., common carotid a., and femoral a. It was therefore concluded that the splanchnic blood flow increase was due to an extreme decrease of splanchnic vascular resistance.

Prevention of colonization and infection in critically ill patients: a prospective randomized study.

In a prospective randomized study to determine whether prevention of colonization of Gram-negative bacteria results in prevention of Gram-negative bacterial infections, 96 intensive care patients were randomly allocated into a control group and a study group. The study group received oral nonabsorbable antimicrobial agents (i.e., tobramycin, amphotericin B, and polymyxin E) in addition to parenteral antibiotics. Colonization with Gram-negative microorganisms in the oropharynx, and respiratory and digestive tracts increased in the control group during their stay, while the study group did not tend to colonize with Gram-negative bacteria. In the control group, 107 nosocomial infections were diagnosed, vs. 42 nosocomial infections in the study group. Nosocomial infections caused by Gram-negative bacteria were significantly less frequent in the study group. Mortality due to an acquired infection was significantly less frequent in the study group. We conclude that colonization, infection, and subsequent mortality by nosocomial Gram-negative bacteria can be prevented by a regime of topically applied nonabsorbable antibiotics.

Predictors of recurrence of fulminant bacterial peritonitis after discontinuation of antibiotics in open management of the abdomen.

OBJECTIVE: To assess a scoring system for predicting recurrence of fulminant bacterial peritonitis after discontinuation of antimicrobial treatment in patients being treated by open management of the abdomen for persistent bacterial peritonitis after perforation of the digestive tract, anastomotic disruption, or necrotising pancreatitis. DESIGN: Retrospective study. SETTING: University Hospital, The Netherlands. SUBJECTS: 58 consecutive patients. MAIN OUTCOME MEASUREMENTS: Recurrence of fulminant bacterial peritonitis and survival. RESULTS: 13 of the 58 patients (22%) died during the initial course of antimicrobial drugs. 14 of the remaining 45 patients had a recurrence of fulminant bacterial peritonitis after discontinuation of antimicrobial drugs, 4 of whom died. Predictive criteria included raised white cell count (WCC) (p = 0.02), duration of initial antibiotic treatment (p = 0.05), and deterioration in Simplified Acute Physiology Score (p = 0.05). Using the WCC and the duration of initial antimicrobial treatment together with other variables that showed a predictive trend (body temperature, percentage band cells, underlying disease, and use of inotropic agents), in a new scoring system (0-12), fulminant bacterial peritonitis did not recur when the score was 0-3, but in 9 of 11 patients with a score of 6 or more it did (p < 0.001). CONCLUSION: Patients at increased risk of recurrence of fulminant bacterial peritonitis during open management of the abdomen can be identified at the time of discontinuation of antimicrobial treatment by a new scoring system; antimicrobial treatment should not be discontinued in patients with a score of 6 or more.