Pulmonary artery rupture associated with the Swan-Ganz catheter.

OBJECTIVES: This study was designed to determine the incidence rate, define risk factors, and suggest proper management protocols for pulmonary artery (PA) rupture associated with Swan-Ganz catheters. DESIGN: This is a retrospective chart-review study. SETTING: This study involved 32,442 inpatients requiring hemodynamic monitoring with Swan-Ganz catheters in the operating rooms and ICUs at a large, private teaching hospital over a 17-year period (1975 to 1991). RESULTS: Ten patients sustained PA rupture, yielding an observed rupture rate of 0.031% of catheter insertions. All ten patients had hemoptysis and five (50%) had pulmonary hypertension. Two patients (20%) had undergone anticoagulation at the time of rupture. Four of the six surgical patients were still in surgery at the first sign of rupture. A thoracotomy was performed in five patients. We noted a trend toward survival with thoracotomy, but it was not statistically significant. The overall mortality rate was 70%. When data from our 10 patients were combined with 65 patients from the literature, we found that thoracotomy was essential for survival in patients with hemothorax. There were no survivors among seven patients with hemothorax simply observed, compared with eight (50%) survivors in 16 patients undergoing thoracotomy (p = 0.026). Thirty-nine (75%) of 52 patients without hemothorax survived, whether or not a thoracotomy was performed. CONCLUSIONS: Our study suggested that the incidence of Swan-Ganz catheter-associated PA rupture is 0.031% and that an urgent thoracotomy should be performed if hemothorax is present at any point.

Benign obstructing papilloma of the ampulla of Vater in infancy.

Obstructive jaundice due to benign neoplasms of the extrahepatic bile ducts is rare in all age groups. A case is reported which represents the first obstructing papilloma of the ampulla of Vater found in the pediatric age group and the literature pertaining to benign obstructing neoplasms is reviewed briefly. Differential diagnosis of persistent jaundice past the immediate neonatal period is discussed and the need for operative cholangiogram and open liver biopsy in difficult cases is stressed. Obstructing papillomas and other neoplasms of the extrahepatic bile ducts should be added to the differential diagnosis of jaundice in the pediatric age group.

Reducing the frequency of errors in medicine using information technology.

BACKGROUND: Increasing data suggest that error in medicine is frequent and results in substantial harm. The recent Institute of Medicine report (LT Kohn, JM Corrigan, MS Donaldson, eds: To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999) described the magnitude of the problem, and the public interest in this issue, which was already large, has grown. GOAL: The goal of this white paper is to describe how the frequency and consequences of errors in medical care can be reduced (although in some instances they are potentiated) by the use of information technology in the provision of care, and to make general and specific recommendations regarding error reduction through the use of information technology. RESULTS: General recommendations are to implement clinical decision support judiciously; to consider consequent actions when designing systems; to test existing systems to ensure they actually catch errors that injure patients; to promote adoption of standards for data and systems; to develop systems that communicate with each other; to use systems in new ways; to measure and prevent adverse consequences; to make existing quality structures meaningful; and to improve regulation and remove disincentives for vendors to provide clinical decision support. Specific recommendations are to implement provider order entry systems, especially computerized prescribing; to implement bar-coding for medications, blood, devices, and patients; and to utilize modern electronic systems to communicate key pieces of asynchronous data such as markedly abnormal laboratory values. CONCLUSIONS: Appropriate increases in the use of information technology in health care- especially the introduction of clinical decision support and better linkages in and among systems, resulting in process simplification-could result in substantial improvement in patient safety.

Contact plate thermography: a new technique for diagnosis of breast masses.

Ninety-four consecutive patients who underwent breast biopsy were prospectively evaluated with contact plate thermography. Final diagnosis based on surgically excised tissue was used as the standard of comparison. There were 77 benign lesions and 17 malignant lesions in the study group. A diagnosis of cancer was made by contact plate thermography in 11 of the 17 patients with malignant neoplasms, with six false-negative diagnoses. Among the 77 histologically benign lesions, contact plate thermography made the correct diagnosis in 66 cases, with 11 false-positive results. Considering all 94 patients, contact plate thermography was accurate in 81.9%, with 6.4% false-negative and 11.7% false-positive diagnoses. These data compared favorably with other diagnostic data used in this study, namely physical examination and mammography. Contact plate thermography is a quick, inexpensive, and harmless diagnostic procedure. Further evaluation of it is indicated, including its possible inclusion in breast cancer screening programs.

Surgical intensive care in the nonagenarian. No basis for age discrimination.

OBJECTIVE: To investigate the effect of extreme age on outcome from surgical intensive care. DESIGN: Prospective data collection. SETTING: A 20-bed noncardiac surgical intensive care unit (SICU) that admits 2200 patients per year from a 1201-bed tertiary medical center. PATIENTS: Nonagenarians were compared with patients under 90 years of age over a 33-month period. Seven patients over age 100 years and 77 nonsurgical patients were excluded. MAIN OUTCOME MEASURES: Mortality and length of stay were determined for both the SICU and the entire hospitalization. The nonagenarian and younger groups were stratified by severity of illness using the first-day Simplified Acute Physiology Score (SAPS). RESULTS: One hundred forty nonagenarian patients (mean +/- SE age, 92.1 +/- 0.2 years) were compared with 5652 younger patients (mean age, 60.1 +/- 0.3 years). The mean SAPS of 11.1 for nonagenarian patients was significantly higher than the SAPS of 8.6 for younger patients (P < .001). Mortality in the SICU was 4.3% for nonagenarian patients vs 2.3% for younger patients (P = .13). SICU mortality rose with increasing SAPS in both groups, but there was no significant difference between nonagenarian and younger patients for any SAPS group. Hospital mortality differed significantly, with 17.1% for nonagenarian patients and 5.3% for younger patients (P < .001). Hospital and SICU length of stay did not differ significantly between the groups. CONCLUSIONS: Nonagenarians do not differ from younger SICU patients in survival from SICU care, although hospital mortality is greater in nonagenarians. Age alone should not be used to make decisions about the utility of SICU care for the elderly. Outcome correlates better with severity of illness, and the measure is valid in young and old alike.

Telesurgery. Acceptability of compressed video for remote surgical proctoring.

OBJECTIVE: To determine the clinical acceptability of various levels of video compression for remote proctoring of laparoscopic surgical procedures. DESIGN: Observational, controlled study. SETTING: Community-based teaching hospital. PARTICIPANTS: Physician and nurse observers. INTERVENTIONS: Controlled surgical video scenes were subjected to various levels of data compression for digital transmission and display and shown to participant observers. MAIN OUTCOME MEASURES: Clinical acceptability of video scenes after application of video compression. RESULTS: Clinically acceptable video compression was achieved with a 1.25-megabit/second data rate, with the use of odd-screen 43.3:1 Joint Photographic Expert Group compression and a small screen for remote viewing. CONCLUSION: With proper video compression, remote proctoring of laparoscopic procedures may be performed with standard 1.5-megabit/second telecommunication data lines and services.

Automatic extraction of intensity-intervention scores from a computerized surgical intensive care unit flowsheet.

Systems that objectively score severity of illness and intensity of patient care interventions have been used to guide the appropriate use of intensive care facilities, provide information on nurse staffing ratios, validate subjective classifications of patient illness, and normalize scientific and financial studies for severity of illness. Existing scoring systems require a well-trained observer to perform a thorough chart review to complete manual scoring forms. We have designed a new system in which computerized intensity-intervention scores are automatically extracted from electronic intensive care unit flowsheets, eliminating both manual labor and potential observer variation. In prospective studies, these computerized scores correlated well with manual TISS scores, intensive care unit mortality, intensive care unit length of stay, hospital length of stay, and a subjective classification of patients to graded levels of hospital care. Such automated scores may be used for real-time allocation of health care resources and normalization of prospective studies for severity of illness.

Local delayed cutaneous hypersensitivity reactions in breast cancer patients with and without removal of axillary lymph nodes.

Fifty-five patients were sensitized to dinitrochlorobenzene (DNCB). Two weeks later they were challenged. The minimal concentration yielding 2+ reactivity and one dilution above and below were then applied to the anterior chest wall on both the operated and nonoperated sides. Using multinomial chi-square statistical analysis, we found that the operated and nonoperated sides evidenced equal reactivity. Futhermore, the absence of axillary lymph nodes did not diminish the reactivity in the operated area. These data support the contention that maintenance of local cellular immunity, as assessed by DNCB skin test reactivity, is systemic and counters the argument that regional lymphadenectomy impairs local and/or systemic cellular immunity.

Glucose intolerance in critically ill surgical patients: relationship to total parenteral nutrition and severity of illness.

The authors evaluated the relative influence of severity of illness and total parenteral nutrition (TPN) on glucose intolerance in critically ill surgical patients. Records of TPN administration, serum glucose measurements, and the simplified acute physiology score (SAPS) were extracted from the surgical intensive care unit (SICU) and hospital clinical information systems (CIS) for all patients admitted to the SICU from October 1, 1989 through March 31, 1990. Critical hyperglycemia was defined as glucose > 400 mg/dL and critical hypoglycemia as < 40 mg/dL. During the study period, 1,129 patients received 3,054 days of care, including 88 patients who received 705 days of TPN. Of 4,985 glucose determinations performed during the study period, 48 (0.96%) were critically abnormal. Critical hyperglycemia occurred in 1.7 per cent of blood samples from TPN patients, compared to 0.7 per cent in non-TPN patients (P < 0.005). However, the mean admission and daily and maximum severity of illness scores were significantly higher in TPN patients compared to non-TPN patients (all P < 0.0005). Mean glucose levels rose with increasing SAPS in both TPN and non-TPN patients. When stratified by severity of illness, TPN patients did not have significantly higher glucose levels than non-TPN patients except for the SAPS = 15 category. The authors conclude that the glucose intolerance noted in critically ill TPN patients reflects their underlying severity of illness rather than TPN administration per se.

Automated severity scoring in level I trauma patients.

The authors evaluated the sensitivity and specificity of a computerized Simplified Acute Physiology Score (SAPS) for outcome prediction in Level I trauma patients admitted to a Surgical ICU (SICU). SAPS was compared with the combined Trauma Score (TS) and Injury Severity Score (ISS). 1434 consecutive trauma patients admitted to the SICU over a 3-year period were studied. All patients had the SAPS automatically calculated on the first SICU day. Patient data was extracted from an electronic flowsheet, and the most abnormal values for the previous 24 hours were used to calculate the SAPS. TS and ISS were calculated by a trained nurse. The relationship among the severity scores, ICU length of stay (LOS), and survival was evaluated. A logistic regression equation was calculated for SAPS alone and for TS combined with ISS. The predictive power of the severity methods was compared using Receiver Operating Characteristic (ROC) curve analysis. Scores for survivors and non-survivors were compared with Student's t-tests. 1085 patients had complete data available. There were 995 survivors and 90 non-survivors. The mean (+/- standard error of the mean) ISS was 12.7 (+/- 3.2) with 36 per cent of the patients having an ISS > or = 15. The mean SAPS was 8.1 (+/- 2.5). Survivors had a significantly lower SAPS than non-survivors, 7.0 versus 20.2 (P < 0.0005) and a shorter LOS, 2.5 versus 4.9 days (P < 0.002). ROC curve analysis revealed no statistically significant difference in the areas under the two curves, indicating that the SAPS was equivalent to TS combined with ISS in outcome prediction (P > 0.70).(ABSTRACT TRUNCATED AT 250 WORDS)

ICU care after infra-inguinal arterial surgery: an analysis of indications and outcomes.

The authors analyzed 632 consecutive, nontrauma Surgical Intensive Care Unit (SICU) admissions after infra-inguinal arterial surgery over a 3-year period (4/89-3/92) for the need for postoperative SICU care. Group I consisted of 122 patients (58 males, 64 females) with at least one absolute indication for SICU care, including mechanical ventilation, pulmonary artery, catheter monitoring, or intravenous infusion of vasoactive or antiarrythmic drugs. Group II comprised 510 patients (275 males, 235 females) without an absolute indication for SICU care. Data collected included age, first day ICU severity of illness scores (Simplified Acute Physiology Score [SAPS] and Quantitative Therapeutic Intervention Scoring System [QTISS]), preoperative length of stay (LOS), SICU LOS, hospital LOS, and mortality. Ten patients (8.2%) in Group I and ten patients (2.0%) in Group II died in the SICU (P = 0.0004). There was no significant difference in the age of Group I and Group II patients, but Group I patients had a significantly longer preoperative LOS (6.1 +/- 0.7 vs 3.2 +/- 0.3 days, P < 0.0005). In Group II patients there were significant correlations between patient age and postoperative death, as well as between preoperative LOS and SICU LOS > 1 day. Patient age > or = 80 years and preoperative LOS > 3 days are significant preoperative correlates of the need for SICU care following infra-inguinal arterial surgery in patients who do not have an absolute indication for such care.

Impact of ICU nosocomial infections on outcome from surgical care.

The authors studied the impact of intensive care unit (ICU) acquired nosocomial infections on surgical patients stratified by severity of illness before acquisition of the infection. Data were analyzed from 2,122 consecutive patients admitted to a 20 bed surgical intensive care unit (SICU) from January 1, 1988 to December 31, 1988. The simplified acute physiology score (SAPS), a measure of illness severity that correlates with mortality, was calculated for all patients on their first SICU day. Ninety-seven nosocomial infections from various sites were documented in 54 patients. Patients who acquired a nosocomial infection were significantly more ill upon admission to the SICU than patients who did not acquire such an infection (control patients). Stratified by admission severity of illness, patients acquiring one or more nosocomial infections had a significantly longer SICU stay, averaging 25.3 days compared to 2.3 days in control patients (P less than 0.001). Hospital stay was also significantly increased at 59.9 days, compared to 15.0 days in control patients (P less than 0.001). However, the overall mortality rate for patients developing nosocomial infections was significantly higher than control patients only in the middle range of admission SAPS measurements. The authors found that the monthly incidence of isolates of Xanthomatous maltophilia, a multiply-resistant nosocomial organism, reflected the overall incidence of nosocomial infections in the SICU. They observed a decline in the number of new X. maltophilia isolates and nosocomial infections concomitant with the introduction of gown and glove contact isolation procedures. The authors conclude that nosocomial infections in the SICU setting are directly related to increased patient morbidity and mortality depending, in part, on severity of illness upon admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Mature fibrous cyst formation after Marlex mesh ventral herniorrhaphy: a newly described pathologic entity.

UNLABELLED: Two patients developed seromas overlying Marlex mesh repairs of ventral hernias. After repeated unsuccessful attempts at aspiration of the fluid, each patient underwent formal exploration and excision of the cystic mass to the level of the mesh. Histology showed thick, fibrous, trabeculated cysts. Postoperatively, one patient had prolonged closed suction drainage. In the other, suction drains had scant output, but she developed a recurrence of serous fluid, which resolved with two aspirations. CONCLUSIONS: 1) Mature fibrous cyst is a rare complication of Marlex mesh herniorrhaphy; 2) Chronic seroma collections may be etiologic; 3) Surgical excision and closed suction drainage, rather than simple aspiration, are required for treatment; 4) Prolonged postoperative drainage may be needed to prevent recurrence.

Intensive care unit outcomes of surgical centenarians: the "oldest old" of the new millennium.

This study compared the severity of illness and outcomes of surgical intensive care unit (SICU) patients age 100 years or older with those of younger SICU patients. Severity of illness was measured with the Simplified Acute Physiology Score (SAPS) and the Quantified Therapeutic Intervention Scoring System (QTISS). Outcomes were evaluated with SICU length of stay (LOS), hospital LOS, SICU mortality, and hospital mortality. All patients admitted to an urban, tertiary-care SICU from August 1, 1986 to July 31, 1998 (12 years) were included. A total of 24,395 consecutive patients were evaluated of whom nine (0.037%) were age 100 or more. Complete outcome data were available for 13,773 patients who were divided into five groups on the basis of age: <70, 70 to 79, 80 to 89, 90 to 99, and 100 years and above. Nine centenarians were admitted to the SICU of whom one died in the SICU and another died in the hospital after SICU discharge (22.2% overall mortality). Centenarian patients had higher SAPS and QTISS on admission than patients in all other groups, although this difference was not significant because of the small number of centenarians. SICU and hospital LOS were not significantly longer for centenarians. Mortality in the SICU and hospital was significantly different across the age groups and rose with age. However, the modest 11.1 per cent SICU mortality rate in centenarians along with their LOS statistics indicate that these patients fare relatively well in surgical intensive care.

Outcomes from abdominal aortic aneurysm resection: does surgical intensive care unit length of stay make a difference?

Recent studies indicate that surgical intensive care unit (SICU) length of stay (LOS) may be shortened without significantly compromising patient care. We tested the validity of that claim in patients following abdominal aortic aneurysm (AAA) resection, a group that traditionally mandated SICU care, to determine whether recent changes in care have affected outcomes. Severity of illness, utilization of SICU-specific resources, lengths of stay, and outcomes were measured in 295 consecutive AAA patients admitted to the SICU postoperatively over a 6-year period (1988-1994). Patient age ranged from 32 to 97 years (mean, 73.1 +/- 0.5) with 82 per cent males and 18 per cent females. There were 266 elective AAAs and 29 ruptured AAAs. Overall mortality was 5.8 per cent, including a 3.4 per cent mortality in elective AAA patients and 27.6 per cent mortality in the ruptured group. Patients with ruptured AAAs were 4.5 years older than were elective AAA patients, had higher severity of illness scores, and had longer SICU and hospital LOS. In the elective group, SICU LOS declined from 3.3 +/- 0.4 to 1.7 +/- 0.3 days over the study period, without a concomitant change in admission severity of illness, hospital LOS, or mortality. Severity of illness at the time of transfer from the SICU to floor care rose over 21 per cent during the study period. Over a 6-year period, SICU LOS was reduced by nearly 50 per cent in patients receiving elective AAA resections without affecting outcome, as measured by hospital LOS or mortality. Decreasing the SICU LOS was effected by transferring patients to floor care with a higher severity of illness. This change saved approximately $175,000 per year in SICU costs.

Relationship of hyperglycemia and severity of illness to neurologic outcome in head injury patients.

Hyperglycemia upon hospital admission has been associated with poorer neurologic outcomes in patients with brain injury, but this relationship has not been well defined. To evaluate the relationship of hyperglycemia and severity of illness to neurologic outcome, the authors examined Surgical Intensive Care Unit (SICU) records for a 6 month period at a Level I trauma center. Of 276 trauma admissions, 97 patients had intracranial injuries. The peak glucose determination on the first day of admission was correlated with the Glasgow Coma Scale (GCS) score upon admission and discharge from the SICU and with severity of illness as measured by the Simplified Acute Physiology Score (SAPS). The mean admission GCS was 10.6 (+/- 0.49 S.E.M.), the mean glucose on the first SICU day was 146 (+/- 7.7 S.E.M.), and the mean peak glucose was 176 (+/- 8.2 S.E.M.). The peak glucose was inversely related to both GCS on admission and GCS at discharge (P < 0.001). However, stepwise multiple regression analysis revealed that the best single predictor of GCS at discharge was the GCS on admission. The next best predictor was the SAPS on the first SICU day. Peak glucose did not add to the power of admission GCS and SAPS to predict neurologic outcome. Peak glucose levels in brain-injured patients may simply reflect severity of illness and injury that is better represented by SAPS.

When is ICU care warranted after carotid endarterectomy? A three-year retrospective analysis.

The purpose was to determine the valid indications for Surgical Intensive Care Unit (SICU) admission after carotid endarterectomy (CEA). The indications for admission to the SICU after CEA were studied over a 3-year period (4/89-3/92). Absolute indications for ICU admission (AIA) included mechanical ventilation, a pulmonary artery catheter, and intravenous vasoactive or antiarrhythmic drug infusion. Patients were grouped according to presence of an AIA (Group A), absence of an AIA and a one day SICU length of stay (Group B), or absence of an AIA and a SICU length of stay > 1 day (Group C). A total of 305 patients were admitted to the SICU during the study. There were 55 patients in Group A. Of the 250 patients without an AIA, 239 were in Group B and 11 comprised Group C. Group A patients had a significantly higher severity of illness compared with Groups B and C (P < 0.05). Group B patients demonstrated no need for SICU care. Group C patients received ongoing SICU care due to postoperative neurological changes, arrhythmias, angina, incisional bleeding, vocal cord paresis, and unavailability of a ward room. None of these conditions was life-threatening, and only vocal cord paresis would have required SICU admission. Two patients in Group A died; no patients died in Group B or C. Only patients with an AIA, perioperative neurological changes, or early hemodynamic instability require SICU admission after CEA. An observation period in the recovery room allows for selection of nearly all patients who will eventually require SICU care.

Outcomes from nonemergent orthotopic liver transplantation: is postoperative care becoming routine?

The outcome of surgical intensive care unit (SICU) care after nonemergent orthotopic liver transplantation (OLTX) was evaluated in 168 consecutive patients over a 6-year period (1/90-12/95). Prospective data collected included age, first and last SICU day Simplified Acute Physiology Score and Quantitative Therapeutic Intervention System Score, SICU length of stay (LOS), and mortality. The patient population was 61 per cent male and 39 per cent female, with ages ranging from 20 to 75 years. A total of four patients died in the SICU, for a mortality of 2.4 per cent. Over the study period, SICU LOS decreased by 21 per cent, from 3.9 +/- 0.7 to 3.1 +/- 0.3 days (P < 0.05). Although no difference in admission severity of illness was observed over the study period, there was an increase in the intensity of intervention performed on admission to the SICU. Over the study period, there was no difference in severity of illness or intensity of intervention upon discharge to floor care. The decreased SICU LOS did not adversely affect patient mortality or severity of illness upon SICU discharge during the 6-year period. With intensified SICU intervention, nonemergent orthotopic liver transplantation patients can have a shorter SICU LOS without adverse effects on outcome.

Early diagnosis and treatment of sinusitis in the critically ill trauma patient.

Sinusitis is an important cause of sepsis in the critically ill patient and may be difficult to diagnose. Four patients admitted to the surgical intensive care unit with closed head trauma were found to have sinusitis as the cause of persistent bacteremia. All patients received pharmacologic doses of corticosteroids for treatment of head injury and had prolonged nasotracheal and/or nasogastric intubation. A bedside procedure was used for diagnosis and management. Under local anesthesia, a 16-gauge angiocatheter was inserted under the inferior turbinate and into the maxillary sinus. After purulent fluid was aspirated, the sinuses were irrigated with normal saline. All four patients defervesced within 24 to 48 hours of this procedure, and facial x rays demonstrated clearing of the maxillary sinus. It was concluded that: 1) Sinusitis is a complication of closed head trauma in critically ill patients and should be included in the differential diagnosis when persistent bacteremia occurs; 2) The use of corticosteroids in the treatment of head injury may increase the risk of sinus infection; 3) Facial x rays showing air-fluid levels and/or opacification are a valuable screening test for paranasal sinusitis; and 4) bedside aspiration of the maxillary sinus is an effective diagnostic and therapeutic technique for management of sinusitis in the critically ill.

Future shock: trauma in the managed care era.

This study examines the effects of managed care on the treatment of 1724 trauma patients seen over a 2-year period at an urban Level I trauma center. Fifty-one per cent of all trauma patients were insured. Managed care plans represented 42 per cent of the insurance coverage overall, increasing from 39 per cent in the first year to 45 per cent in the second. All treatment was provided by the receiving general surgery trauma team and was rendered independent of insurance status. Eighty per cent of patients completed their hospitalization at the trauma center. Clinical outcome, transfer rates, and mortality were similar regardless of insurance type. We conclude that managed care plans represent a significant and increasing portion of the insurance coverage of trauma patients, and propose that national guidelines should be developed to guarantee quality and continuity of trauma care.