Transthoracic echocardiography is not cost-effective in critically ill surgical patients

BACKGROUND: Echocardiography has been shown to be valuable in critically ill surgical patients. Transthoracic echocardiography (TTE) often fails to provide adequate imaging in critically ill patients, necessitating subsequent transesophageal echocardiography (TEE). The objective of this study was to determine and quantify factors associated with failure of transthoracic echocardiography (TTE) in critically ill surgical patients, and to define a cost-effective strategy for echocardiography in these patients. METHODS: Demographic and clinical data were collected retrospectively and evaluated to determine which factors were associated with failure of TTE to provide adequate imaging. In addition, models were developed to estimate costs for echocardiography in critically ill surgical patients. RESULTS: TTE has a high failure rate in critically ill surgical patients. This failure rate increases significantly in patients who gain > 10% body weight from admission weight, who are supported with > or = 15 cm H(2)O positive end-expiratory pressure, and in those with chest tubes. As a result, the use of TTE in critically ill surgical patients is not cost-effective. TEE, however, is highly effective in this group of patients, and is more cost-effective than TTE in evaluating those critically ill surgical patients requiring echocardiography. CONCLUSION: The routine use of TTE to initially evaluate all critically ill surgical patients who require echocardiography should be abandoned because it is not cost-effective. TEE appears to be the most cost-effective echocardiographic modality in the surgical intensive care unit.     

OPCAB surgery is cost-effective for elderly patients

Abstract

Objective. To determine the cost-effective operative strategy for coronary artery bypass surgery in patients above 70 years. Design. Randomized, controlled trial of 900 patients above 70 years of age subjected to coronary artery bypass surgery. Patients were randomized to either on-pump or off-pump coronary artery bypass surgery. Data on direct and indirect costs were prospectively collected. Preoperatively and six months postoperatively, quality of life was assessed using EuroQol-5D questionnaires. Perioperative in-hospital costs and costs of re-intervention were included. Results. The Summary Score of EuroQol-5D increased in both groups between preoperatively and postoperatively. In the on-pump group, it increased from 0.75 (0.16) (mean (SD)) to 0.84 (0.17), while the increase in the off-pump group was from 0.75 (0.15) to 0.84 (0.18). The difference between the groups was 0.0016 QALY and not significantly different. The mean costs were 148.940 D.Kr (CI, 130.623 D.Kr–167.252 D.Kr) for an on-pump patient and 138.693 D.Kr (CI, 123.167 D.Kr–154.220 D.Kr) for an off-pump patient. The ICER base-case point estimate was 6,829,999 D.Kr/QALY. The cost-effectiveness acceptability curve showed 89% probability of off-pump being cost-effective at a threshold value of 269,400 D.Kr/QALY. Conclusions. Off-pump surgery tends to be more cost-effective than on-pump surgery. Long-term comparisons are warranted.     

Coagulation disorders in severely and critically injured patients

Forty-five patients with multiple injuries treated at an intensive care unit were studied prospectively. The patients were divided into two groups: the severely injured (no mortality) and critically injured (56% mortality). Treatment was started within two hours from the accident in all cases. The following coagulation parameters were measured for eight days: euglobulin lysis time (ELT), thromboelastography (TEG), vecalcification time (RECA), partial thromboplastin time (PTT), factor V, factor VIII, Normotest, Thrombotest, thrombin time, fibrinogen and platelets. Severe coagulation disorders were observed in one-third of the patients 12-48 hours after trauma. The abnormalities were more pronounced in patients who had sustained very severe injuries and arrived in a state of shock. The ELT was shortened 0-6 hours after the accident and accelerated coagulation was indicated simultaneously by decreased PTT, RECA, and r-values as well as by elevated Thrombotest and factor VIII values. The factor V and fibrinogen levels were initially lowered. Low platelet values at 2-4 days, prolonged thrombin and r-times, secondary decrease of fibrinogen FV, FVIII, and low Thrombotest values suggested disseminated intravascular coagulation associated with complications, such as fat embolism and "shock lung" syndromes. General bleeding tendency with high mortality was observed in 16% of the patients.     

Minicholecystectomy: a safe, cost-effective day surgery procedure

OBJECTIVE: To document effectiveness of minicholecystectomy as a safe, cost-effective day surgery procedure with rapid return to work. DESIGN: Review of medical records. SETTING: Small community hospital. PATIENTS: A total of 1207 patients who underwent minicholecystectomies from January 1, 1986, through December 31, 1997. INTERVENTION: Minicholecystectomy. MAIN OUTCOME MEASURES: Complications, length of hospital stay, cost, and time until return to work. RESULTS: Of the 1207 patients who underwent minicholecystectomy, 74% were admitted for day surgery, 88% of whom were discharged in less than 12 hours, 9.3% in 24 hours or less, and 1.7% in greater than 24 hours; 0.3% were readmitted within 2 weeks. The complication rate was 0.2%; 2 cases required laparotomy, with no common duct injuries. The cost of the procedure was S435; the average time it took working patients to return to work was 11.4 days. CONCLUSIONS: Minicholecystectomy is a safe, inexpensive day surgery method of cholecystectomy with minimal time off work after surgery.     

Nutritional therapy in critically ill and injured patients

Nutritional support of critically ill or injured patients has undergone significant advances in the last few decades. These advances are the direct result of the growing scientific progress and increased knowledge of the biology and biochemistry of key metabolic and nutrient changes induced by injury, sepsis, and other critical illnesses, both in adults and children. As this knowledge has increased, the science of nutritional support has become more disease based and disorder based. This article discusses protein and nitrogen metabolism in critically ill patients, immunomodulation, and the key nutrients involved in an immune-enhancing diet.     

Abbreviated laparotomy and planned reoperation for critically injured patients.

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.     

Bariatric surgery in patients older than 65 years is safe and effective.

BACKGROUND: To review the short-term safety and efficacy of the laparoscopic adjustable gastric band (LAGB) and laparoscopic gastric bypass (GBP) in patients older than 65 years. METHODS: A single-institution review of all bariatric procedures was performed. RESULTS: Twenty-seven patients were identified. Of the 27 patients, 13 underwent primary GBP and 14 underwent LAGB placement. The average age was 68.1 +/- 2 years (range 65-73). The average follow-up for the GBP group and LAGB group was 9.3 months (range 1-21) and 19.6 months (range 4-31), respectively. One minor (stricture) complication and zero major complications occurred in the GBP group. In the LAGB group, one minor complication (port fracture) and one major complication (total weight loss failure requiring conversion to GBP) occurred. The percentage of excess weight loss at 1 year for the GBP group was 71%. At 1 and 2 years, it was 32% and 35%, respectively, for the LAGB group. Only in the GBP group did patients have a significant decrease in medication use and in the number of comorbidities. Quality-of-life measurements improved equally after both procedures. Weight loss was no different after GBP surgery regardless of age, but older LAGB patients had a 12% decrease in the expected excess weight lost (P < 0.05). CONCLUSION: Bariatric surgery can be performed with acceptable safety, excellent weight loss, resolution of comorbidities, and significant improvement in quality of life in patients older than 65 years. The GBP seems to be as safe as, and more effective than, the LAGB in this age group.     

Elective and emergency surgery in renal transplant patients.

Additional operations were necessary in 67 (41%) of 162 renal allograft patients. General anesthesia was employed in all but 5 patients with no morbidity or mortality. All patients were immunosuppressed and no additional steroids were used before, during, or after the procedure. The source of the donor kidney made no difference in predicting if a recipient would require post-transplantation surgery or if an emergency or elective operation was required. Oerations were necessary to correct complications either directly related to the transplant procedure (71%), or medical problems of immunosuppression or uremia (21%). Nine patients (6%) required operations unrelated to transplantation. The data indicate that transplant patients frequently need additional procedures which are directly related to the transplant operation, immunosuppression, or metabolic alterations of their past uremic condition. Mortality is related to the degree of toxicity from the immunosuppressive therapy.     

Outpatient thyroid surgery is safe and desirable.

BACKGROUND: Thyroid surgery has traditionally been done on an inpatient basis. With the advent of minimal access techniques, drains are frequently not required and ambulatory thyroidectomy is possible. DESIGN: Prospective, nonrandomized analysis of consecutive series of patients. METHODS AND MATERIALS: Patients undergoing thyroid surgery between 12/1/04 and 10/31/05 were stratified based on admission status. Demographic data were collected and outcome measures were considered. RESULTS: Ninety-one patients underwent thyroid surgery. Fifty-two were done on an outpatient basis, 26 patients were observed under a 23-hour status, and 13 were admitted. There were two complications in the outpatient group and one in the inpatient group (P = 1.0). Costs were significantly lower for outpatients ($7,814) than for inpatients ($10,288; P < 0.0001). SIGNIFICANCE: In carefully selected patients who prefer convalescence at home, outpatient thyroidectomy can be performed safely and cost-effectively, particularly when prophylactic calcium supplementation is utilized after total thyroidectomy to prevent transient postoperative hypocalcemia.     

Acute acalculous cholecystitis in critically injured patients. Preoperative diagnostic imaging.

The potential lethality and predisposing factors of acute acalculous cholecystitis (AAC) are well established; however, preoperative diagnosis remains a challenge. This update of a previous report of 30 cases of AAC at a Level I trauma center describes 14 multiply injured patients who developed AAC and underwent cholecystectomy. All 14 patients had acutely inflamed gallbladders; 6 (42.8%) had areas of necrosis or gangrene. The mortality rate was 7% (1 patient). While the percentage of patients receiving prolonged intensive care (100%), narcotic analgesics (100%), and TPN (93%) correlates with the experience cited previously, the percentage undergoing preoperative diagnostic imaging is unusually high, reflecting a heightened suspicion for AAC. Computed tomographic or sonographic evidence of gallbladder wall thickness greater than or equal to 4 mm, pericholecystic fluid or subserosal edema without ascites, intramural gas, or a sloughed mucosal membrane was considered diagnostic criteria for AAC. We conclude that preoperative computed tomogram or ultrasound imaging leads to earlier recognition of this life-threatening problem.     

Tight glycemic control in critically injured trauma patients

OBJECTIVES: Evaluate the impact of a tight glucose control (TGC) protocol during the first week of admission in critically injured trauma patients. METHODS: A prospective quasi-experimental interrupted time-series design was used to evaluate the impact of TGC [24-month preintervention phase (no TGC) vs. 24-month postintervention phase]. Patients were stratified by serum glucose level on day 1 to 7 (low, 0-150 mg/dL; medium-high, 151-219 mg/dL; and high, >/=220 mg/dL), age, gender, and injury severity. Patients were further stratified by pattern of glucose control (all low, all medium high, all high, improving, worsening, highly variable). Outcome was measured by ventilator days, infection, hospital (HLOS) and ICU (ILOS) length of stay, and mortality. RESULTS: One thousand twenty-one patients were evaluated in the preintervention phase as compared with 1108 patients in the postintervention phase. There was no significant difference in mechanism of injury (83% vs. 84% blunt), gender (74% vs. 73% male), age (44 vs. 43 years), and Injury Severity Score (ISS) (26 vs. 25). The TGC group was more likely to be in the all low and improving pattern of glucose control (P<0.001). The incidence of infection significantly decreased (over the first 2 weeks) from 29% to 21% in the TGC group (P<0.001). Ventilator days (OR=3.9, 1.8, 8.1), ILOS (OR=4.3, 2.1, 7.5), and HLOS (OR=5.5, 2.2, 11) and mortality (OR=1.4, 1.1, 10) were significantly higher in the non-TGC group when controlled for age, ISS, obesity, and diabetes (P<0.01). CONCLUSION: The positive outcomes associated with the implementation of a TGC protocol necessitates further evaluation in a randomized prospective trial.     

Surgery in the resuscitation of critically injured patients

Immediate surgery is essential to resuscitate and save 5% to 10% of those suffering life-threatening trauma. Recently, emergency room surgery has been proposed as the procedure to follow in stabilizing such patients. Over a 3-year period, 41 moribund patients were treated by the trauma service at the Health Sciences Centre in Winnipeg. All were managed in the main operating theatre following a "crash protocol" for immediate surgery. Twenty-three patients arrived in cardiac arrest or with an unrecordable blood pressure; of these, 4 (17%) survived. Eighteen patients had a blood pressure of 70 mm Hg systolic or less and failed to respond to massive O positive blood transfusion; of these, 14 (77%) survived. The mix of mode of injury and injury severity scoring is important to compare results from within and between centres. The author's experience indicates that the use of a high-priority crash protocol for managing moribund patients with life-threatening traumatic injury in the main operating room provides a standard of care equal to or better than that reported for emergency room surgery.     

Nutrition therapy for critically ill and injured patients

Background

Nutrition support has undergone significant advances in recent decades, revolutionizing the care of critically ill and injured patients. However, providing adequate and optimal nutrition therapy for such patients is very challenging: it requires careful attention and an understanding of the biology of the individual patient’s disease or injury process, including insight into the consequent changes in nutrients needed.

Objective

The objective of this article is to review the current principles and practices of providing nutrition therapy for critically ill and injured patients.

Methods

Review of the literature and evidence-based guidelines.

Results

The evidence demonstrates the need to understand the biology of nutrition therapy for critically ill and injured patients, tailored to their individual disease or injury, age, and comorbidities.

Conclusion

Nutrition therapy for critically ill and injured patients has become an important part of their overall care. No longer should we consider nutrition for critically ill and injured patients just as “support” but, rather, as “therapy”, because it is, indeed, a key therapeutic modality.