Renal dysfunction in trauma: even a little costs a lot.

BACKGROUND: Acute renal failure (ARF) is a devastating complication in critically ill patients. There is a paucity of data that describes the impact of ARF on the outcome of trauma patients admitted to the intensive care unit. METHODS: We studied trauma patients admitted to the surgical intensive care unit to determine the effect of increases in serum creatinine on the number of ventilator days, length of stay, mortality, and cost. We used the administrative database of the hospital and the trauma registry. Renal failure (RF) was defined as one or more of the following: creatinine >1.5 mg/dL, increase in creatinine of >50%, or increase of creatinine by 0.5 mg/dL. RESULTS: We obtained data on 1,033 patients. Two hundred and forty-six (23.8%) patients met at least one criterion for RF. Only 25 of these patients had one or more episodes of renal replacement therapy. The RF group had mortality of 24.4% compared with 2.3% in the no renal failure group (p < 0.0001). For each 1 mg/dL increase from the initial creatinine, length of stay increased by 2.21 days, ventilator days increased by 1.09 days, and the mortality risk increased by 1.83 times (CI, 1.47-2.29; p < 0.0001). For any diagnosis of renal dysfunction, the average cost increase was $3,088.00 and increased mortality risk was 7.19 times (CI, 4.11-12.58). CONCLUSION: Vigilance in preventing creatinine increases and ameliorating or removing potential causes should occur as soon as creatinine begins to rise to avoid worsening renal function, to reduce cost, and to improve patient outcome.

Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly.

BACKGROUND: America's aging population has led to an increase in the number of elderly patients necessitating emergency general surgery. Previous studies have demonstrated that increased frailty is a predictor of outcomes in medicine and surgical patients. We hypothesized that use of a modification of the Canadian Study of Health and Aging Frailty Index would be a predictor of morbidity and mortality in patients older than 60 years undergoing emergency general surgery. METHODS: Data were obtained from the National Surgical Quality Improvement Program Participant Use Files database in compliance with the National Surgical Quality Improvement Program Data Use Agreement. We selected all emergency cases in patients older than 60 years performed by general surgeons from 2005 to 2009. The effect of increasing frailty on multiple outcomes including wound infection, wound occurrence, any infection, any occurrence, and mortality was then evaluated. RESULTS: Total sample size was 35,334 patients. As the modified frailty index increased, associated increases occurred in wound infection, wound occurrence, any infection, any occurrence, and mortality. Logistic regression of multiple variables demonstrated that the frailty index was associated with increased mortality with an odds ratio of 11.70 (p < 0.001). CONCLUSION: Frailty index is an important predictive variable in emergency general surgery patients older than 60 years. The modified frailty index can be used to evaluate risk of both morbidity and mortality in these patients. Frailty index will be a valuable preoperative risk assessment tool for the acute care surgeon. LEVEL OF EVIDENCE: Prognostic study, level II.

Developing an experimental model for surgical drainage investigations: an initial report.

BACKGROUND: We sought to pilot and initiate validation of a surgical drainage model. METHODS: We designed a laboratory model to compare Jackson-Pratt surgical drains using 3 soups to emulate body fluids of serous, purulent, and necrotic debris. Each drain was trialed with each of the 3 fluids. Time and completeness of drainage were recorded. A survey of surgical residents and faculty was performed for convenience sampling. RESULTS: Under serous conditions, the round Jackson-Pratt drained the cavity quicker, but left a larger residual volume of fluid. Under purulent conditions, the round Jackson-Pratt was slower and drained less fluid. With debris fluid, the round Jackson-Pratt was quicker with less residual fluid whereas the flat type clogged each time. Survey results showed adequate concordance with surgeons in agreement on soup choice. CONCLUSIONS: The Jackson-Pratt drains perform differently depending on the drainage situation. The surgical community requires improved drain data to drive practice patterns.