Hospital risk factors for bovine pericardial bioprosthesis valve implantation

BACKGROUND

Identification of preoperative heart valve surgery risk factors aim to improve surgical outcomes with the possibility to offset conditions related to increased morbidity and mortality.

OBJECTIVE

Intent of this study is to identify hospital risk factors in patients undergoing bovine pericardial bioprosthesis implantation.

METHODS

Retrospective study including 703 consecutive patients who underwent implantation of at least one St. Jude Medical-Biocor bovine pericardial bioprosthesis between September 1991 and December 2005 at the Rio Grande do Sul Cardiology Institute; 392 were aortic, 250 were mitral and 61 were mitroaortic. Characteristics analyzed were gender, age, body mass index, NYHA (New York Heart Association) functional class, ejection fraction, valve lesions, systemic hypertension, diabetes mellitus, kidney function, arrhythmias, prior heart surgery, coronary artery bypass graft, tricuspid valve surgery and elective, urgent or emergency surgery. Main outcome was in-hospital mortality. Relationship between risk factors and in-hospital mortality was analyzed using logistic regression.

RESULTS

Were 101 (14.3%) in-hospital deaths. Characteristics with significant relationship to increased mortality were female gender (p<0.001), age over 70 years (p=0.004), atrial fibrillation (p=0.006), diabetes mellitus (p=0.043), creatinine > 2.4 mg/dl (p=0.004), functional class IV (p<0.001), mitral valve lesion (p<0.001), previous heart surgery (p=0.005), tricuspid valve surgery (p<0.001) and emergency surgery (p<0.001).

CONCLUSION

Mortality rate observed is accepted by literature and is justifiable due to the high prevalence of risk factors, showing an increased significance level for female gender, age above 70, functional class IV, tricuspid valve repairs and emergency surgery. Offsetting these factors could contribute to reduced in-hospital mortality for valve surgery.

The preparedness of emergency medical services against occupationally acquired communicable diseases in the prehospital environment in South Africa

BACKGROUND

Emergency medical care is performed in an uncontrolled environment and involves invasive procedures and life support measures. The performance of these duties places emergency care practitioners (ECPs) at risk of occupationally acquired injuries and communicable diseases. Although legislative guidelines exist for the protection of healthcare workers, little is known about the protective measures available for and utilised by ECPs in the pre-hospital environment in South Africa.

OBJECTIVES

To review the availability and implementation of emergency medical services (EMS)-specific infection control policies and standard operating procedures in the pre-hospital environment.

METHODS

Interviews with key informants were used to collect data concerning policies on communicable diseases and infection control in the EMS, the operational aspects of these policies, and educational programmes on communicable diseases and infection control for ECPs.

RESULTS

There is no national policy on communicable diseases and infection control in EMS. Only KwaZulu-Natal, Eastern Cape and Gauteng have EMS-specific standard operating procedures for communicable diseases and infection control. Formal education and in-service training is limited.

CONCLUSIONS

A national communicable disease and infection control policy specific to the EMS needs to be developed together with an accredited training module on communicable diseases and infection control for EMS in the pre-hospital environment.

Aggressive management of surgical emergencies

Increasing evidence suggests that two factors significantly influence outcome in a surgical emergency - premorbid health and the degree of inflammation during the first 24 h following trauma. Repeat observations suggest that the depth of post-trauma immunoparalysis reflects the height of early inflammatory response. Administration to surgical emergencies, as was routine in the past, of larger amounts of fluid and electrolytes, fat, sugar and nutrients seems counterproductive as it increases immune dysfunction, impairs resistance to disease and, in fact, increases morbidity. Instead, strong efforts should be made to limit the obvious superinflammation, which occurs during the first 24 h after trauma and, thereby, reduce the subsequent immunoparalysis. Several approaches show efficacy in limiting early superinflammation such as strict control of blood glucose, avoidance of stored blood when possible, supply of antioxidants, live lactic acid bacteria and plant fibres. This review focuses mainly on use of live lactic acid bacteria and plant fibres, often called synbiotics. Encouraging experience is reported from clinical trials in liver transplantation, severe pancreatitis and extensive trauma. Immediate control of inflammation by enteral nutrition and supply of antioxidants, lactic acid bacteria and fibres is facilitated by feeding tubes, introduced as early as possible on arrival at the hospital.

Urgent airway intervention: does outcome change with personnel performing the procedure?

BACKGROUND

Recent studies indicate that prehospital endotracheal intubation (PHEI) is associated with increased septic morbidity. Because the decision to intubate in the field is considered a life-sustaining mandate we analyzed our experience to validate these reports and to compare field intubation to that done in more controlled circumstances on patient arrival at the trauma center.

METHODS

The registry of our Level l trauma center was queried from January 2002 through December 2003 for patients who required emergent EI and had a hospital stay > 2 days. Patients were stratified by site of EI into PHEI and trauma center intubation (TCEI). Demographic data (age, gender, Glasgow Comma Scale, Injury Severity Score) as well as outcome measures (incidence of pneumonia [PNA], Intensive Care Unit length of stay [ICU LOS], hospital length of stay [hospital LOS], and mortality) were compared between groups. Results were subjected to chi2 or unpaired t test, accepting p < 0.05 as significant.

RESULTS

The 628 patients requiring EI consisted of 27l in PHEI and 357 in TCEL. When comparing these groups, PHEI were more severely injured (lower Glasgow Comma Scale score and higher Injury Severity Score), but had no other differences in demographics or in measured outcome variables. Within these groups, patients who developed PNA were comparable. They demonstrated similar time of onset of PNA after injury and had similar incidence of resistant organisms (46%).

CONCLUSIONS

These data demonstrate no increased risk of PNA for urgent prehospital intubation. Moreover, the onset of PNA and the similar bacteriology is reflective of injury severity and not of additional infectious risk posed by these prehospital lifesaving maneuvers.

Favorable outcome following emergency second trimester cerclage

BACKGROUND

To evaluate the outcome of midtrimester emergency cerclage with or without bulging of membranes.

METHODS

A retrospective cohort study of 99 women who underwent emergency second trimester cerclage (16-27 gestational weeks). In 75 women the cervix was dilated and effaced but without bulging of membranes (group 1), and in 24 women the dilation and effacement of the cervix were accompanied by bulging of membranes into the vagina in an hourglass formation (group 2). McDonald technique was applied in all patients.

RESULTS

Prolongation of pregnancy was significantly longer in group 1 compared to group 2 (14.3+/-6.5 vs 9.3+/-4.8 weeks, p=0.007). The mean gestational age at delivery was significantly higher in group 1 compared to group 2 (34.6+/-4.6 vs 29.5+/-3.2 weeks, p=0.001). The incidence of chorioamnionitis was higher in group 2 compared to group 1 but statistically insignificant (25% vs 15%, p=0.2). The overall neonatal survival was 83% (82 out of 99 neonates), without statistical difference between the two groups (86% in group 1 and 71% in group 2, p=0.2).

CONCLUSIONS

Favorable neonatal outcome may be accomplished in patients with cervical incompetence in the second trimester of pregnancy following cervical emergency suturing even performed when the membranes are bulging through the cervix into the vagina.

Paradoxical reaction to epinephrine induced by beta-blockers in an anaphylactic shock induced by penicillin

Increased risk of severe and resistant anaphylactic shock is a rare and not widely known adverse effect of beta-blocker treatment. It is illustrated in a case of refractory anaphylactic shock occurring in a 47-year-old woman who received beta-blockers. Actually, beta-blockers increase the release of anaphylactic mediators, decrease the cardiovascular compensatory changes to the anaphylactic shock and promote paradoxical reflex vagotonic effects when using epinephrine.

Is emergency endovascular aneurysm repair associated with higher secondary intervention risk at mid-term follow-up?

OBJECTIVE

The study assessed mid-term outcome of emergency endovascular repair for acute infrarenal abdominal aortic aneurysms, with special attention to secondary interventions.

METHODS

Between May 1998 and August 2005, 56 patients underwent emergent endovascular repair for a ruptured abdominal aortic aneurysm (n = 34) or an acute nonruptured abdominal aortic aneurysm (n = 22). During the same period, 322 consecutive patients underwent elective endovascular aneurysm repair and were used as control group. Five types of stent grafts were used: Vanguard, Talent, Excluder, Zenith, and Quantum. Follow-up included abdominal radiograph, duplex ultrasound scanning, and computed tomographic angiography. Outcome measures included all-cause and aneurysm-related mortality, complications, and secondary interventions.

RESULTS

Mortality at 30 days was 18%, 5%, and 1% in the ruptured, acute nonruptured, and elective aneurysm groups, respectively. Overall mean follow-up was 38 +/- 26 months. In the ruptured aneurysm group, survival was 67.8% +/- 8.6% at 1 year and 62.1% +/- 9.5% at 2 and 3 years. Seven secondary interventions (4 early and 3 late) were required in five patients (15%), with a cumulative risk of 9.2% +/- 5.1% at 1 year and 16.2% +/- 8.2% at 2 and 3 years. In the acute nonruptured aneurysm group, survival was 90.9% +/- 6.1% at 1 year, 84.8% +/- 8.2% at 2 years, and 76.4% +/- 10.9% at 3 years. Four secondary interventions (1 early and 3 late) were required in four patients (18%), with a cumulative risk of 9.6% +/- 6.5% at 1 and 2 years and 20.9% +/- 12.0% at 3 years. In the elective aneurysm (control) group, survival was 95.2% +/- 1.2% at 1 year, 89.9% +/- 1.8% at 2 years, and 86.2% +/- 2.1% at 3 years. A total of 51 secondary interventions (4 early, 47 late) were required in 38 patients (12%), with a cumulative risk of 4.2% +/- 1.1% at 1 year, 7.6% +/- 1.6% at 2 years, and 12.9% +/- 2.2% at 3 years.

CONCLUSIONS

To our surprise, emergency endovascular aneurysm repair did not present with higher secondary intervention rate at mid-term follow-up.

Safety of bowel resection for colorectal surgical emergency in the elderly

OBJECTIVE

Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study.

PATIENTS AND METHODS

In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma.

RESULTS

The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction.

CONCLUSION

Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.

Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies

PURPOSE

There is no consensus about the risk factors for anastomotic failure after elective or emergency colorectal surgery. The purpose of this study was to analyze the factors that may contribute in anastomotic dehiscence.

METHODS

A total of 208 patients who underwent left colonic resection and primary anastomosis for distal colonic emergencies were studied. Preoperative and operative variables analyzed for each patient were gender, age, American Society of Anesthesiologists score, comorbidities, indication for surgery, etiology of the disease, presence and grade of peritonitis, preoperative creatinine, hematocrit, hemoglobin, and leukocyte count, need for preoperative and operative transfusion. The end point was the clinical evident incidence of anastomotic leak. Bivariate comparisons of those patients with or without anastomotic leak were unpaired, and all tests of significance were two-tailed. A multivariate analysis, in which presentation of anastomotic leak was the dependent outcome variable, was performed by forward stepwise logistic regression model.

RESULTS

One hundred five patients (50.4 percent) had one or more complications. Anastomotic leak was diagnosed in 12 patients (5.7 percent). Seventeen patients (8.2 percent) needed a reoperation for complication. The overall mortality was 6.2 percent (13 patients). Obesity was significant as a predictor of anastomotic leak.

CONCLUSIONS

Obesity is a factor predicting anastomotic leak risk after resection and primary anastomosis for left-sided colonic emergencies.

[Complications in the treatment of cholangiolithiasis. Personal experience]

Bile ducts lithiasis is a very common disease all over the world. In Italy prevalence is about 5 millions cases: 11% of the population. Choledocholithiasis concurrent with gallbladder stones frequency is estimated from 4 to 20%. Incidence is even higher in the elderly and in patients affected by chronic liver disease. The treatment of bile ducts lithiasis is still debated; several surgical strategies may be performed: (1) fully laparoscopic procedure; (2) endo-laparoscopic sequential treatment; (3) sequential inverse treatment (endoscopy following video laparoscopic cholecystectomy); (4) combined endo-laparoscopic treatment simultaneously performed; (5) 'open" treatment. The authors refer their experience concerning a series of 172 patients who underwent endo-laparoscopic sequential treatment to amend bile duct and gallbladder lithiasis. Complications are pointed out, pending to demonstrate safeness and effectiveness of this strategy.

Deadly drug interactions in emergency medicine

Many life-threatening drug interactions are predictable, avoidable events. Emergency medicine physicians have a responsibility to recognize and prevent drug interactions. Keeping current on the many pharmaceutical therapies,their pharmacology, and potential drug interactions currently represents one of the biggest challenges for emergency medicine practitioners. Using current drug interaction resources and knowing the limited number of medications that are responsible for the most serious drug interactions can ease this seemingly overwhelming burden greatly. Clinicians need to be particularly vigilant when prescribing drugs for patients who are taking medications with potential for drug interactions leading to serious consequences.

Neurosurgery in the law court

AIM

The evident rise in the number of neurosurgical malpractice and the apparent lack of adequate training in neurosurgery patient management are discussed. However, alongside neurosurgeons, neurosurgical malpractice claims involve also physicians from primary to specialist care, particularly those attending neurosurgical patients in emergency rooms. Some pathologies and disputed treatments are described.

METHODS

The case series includes 138 medical malpractice lawsuits examined over a 10-year period (1992-2002). The pathologies for which disputed treatment led to malpractice lawsuit as well as their frequency are presented.

RESULTS

Of the total 138 lawsuits examined, 38 did not involve professional health care workers, whereas the remaining 100 cases involved: neurosurgeons (48 cases); other specialist or primary physicians (51 cases); nursing staff (1 case). These malpractice lawsuits and the relevant pathologies are examined in detail.

CONCLUSION

On the basis of personal experience, some considerations and recommendations are suggested for the clinical practice.

Rapid sequence intubation of trauma patients in Scotland

BACKGROUND

Endotracheal intubation remains the gold standard for trauma airway management. Rapid sequence intubation (RSI) has traditionally been performed by anesthesiologists but increasingly, emergency physicians are also undertaking RSI. We aimed to compare success and complication rates for trauma intubations for the two specialties.

METHODS

Two year, prospective multi-center descriptive study of trauma RSI in seven Scottish urban emergency departments.

RESULTS

439 trauma patients were identified, including 233 RSIs. Patients intubated by emergency physicians had a higher median ISS (p < 0.001) and lower median RTS (p < 0.001) compared with anesthesiologists. For RSI, anesthesiologists had more grade I & II views at laryngoscopy (p = 0.051) and more successful first attempt intubations (p = 0.034) but there was no difference in the number of patients suffering complications (emergency physicians 10.0%, anesthesiologists 10.6%).

CONCLUSION

There is no significant difference in complication rates for trauma RSI between emergency physicians and anesthesiologists in Scottish urban centers. A collaborative approach to the critical trauma airway is vital. Emergency physicians should consult with senior anesthesiologists before RSI when intubation is predicted to be difficult.

Blind Nasotracheal Intubation for Patients With Penetrating Neck Trauma

BACKGROUND

Early airway management is advocated for patients with penetrating neck trauma who have any signs of airway compromise. This study examined the clinical course of patients with penetrating neck trauma who received prehospital blind nasotracheal intubation, including successful intubation rates, and outcomes.

METHODS

A retrospective review of patients admitted to the emergency department for penetrating neck trauma was conducted from January 1, 1993 to July 1, 2001 at the Denver Health Medical Center. Patients were identified from the trauma registry, and data were collected using standardized inclusion and exclusion criteria.

RESULTS

The study identified 240 patients with penetrating neck trauma. Overall mortality was 8.3%. Among the 240 patients, 89 (37%) required airway management, and 40 (17%) underwent prehospital management with blind nasotracheal intubation. The success rate for prehospital intubation using the blind nasotracheal method was 90%. The mean number of attempts was 1.16 (range, 1-4), and the mortality in this group was 5%.

CONCLUSION

The patients managed with blind nasotracheal intubation did not experience complications related to the choice of airway management. Despite prior warnings in the literature, the results of this study suggest that blind nasotracheal intubation may well be a valuable tool for the management of patients with penetrating neck trauma.

Cyclooxygenase-2 inhibitors: Do they have a role in emergency department prescribing?

Cyclooxygenase-2 selective inhibitors (COXIB or CSI) have been released with a fanfare as efficacious and safer alternatives to traditional non-steroidal anti-inflammatory drugs. They purport to offer equivalent degrees of analgesia and an improved safety profile. COXIB currently available in Australasia are celecoxib (Celebrex), rofecoxib (Vioxx) and etoricoxib (Arcoxia). This review discusses the pharmacology of these agents and reviews recent literature regarding their effectiveness and safety. It endeavours to answer the question 'Should we be using COXIB in emergency departments in Australasia'?

Anaphylactoid reactions to intravenous N-acetylcysteine: a prospective case controlled study

INTRODUCTION

Since its introduction in 1977, intravenous N-acetylcysteine has become the treatment of choice for paracetamol overdose. The aim of our study was to investigate the existence of predictive factors in the likelihood of developing anaphylactoid reactions to N-acetylcysteine.

METHODS

Prospective case-controlled study of all patients who presented to our emergency department (ED) between January 1997 and June 1999, and who were treated with intravenous N-acetylcysteine on the short stay observation ward.

RESULTS

Sixty-four patients received N-acetylcysteine infusions; thirty-one (48.4%) developed an anaphylactoid reaction. Nineteen patients who reacted were commenced on N-acetylcysteine prior to receipt of paracetamol concentrations and fifteen (48.4%) were categorised as high-risk. Seventy-one percent of reactions occurred within the first 15 min. Thirteen patients who developed a reaction, had levels which fell below the treatment lines. The levels of a further nine reactors lay above the high-risk but below the normal-risk lines. Only five patients who reacted had levels above the normal-risk line. Two of the patients who reacted to intravenous N-acetylcysteine presented at a later date with a further paracetamol overdose. Both required treatment with intravenous N-acetylcysteine, the first bag being infused over one hour. Neither developed a reaction.

CONCLUSION

We report a substantially higher incidence of anaphylactoid reactions to intravenous N-acetylcysteine than has previously been documented. It appears that these reactions are more likely to occur in high-risk patients, when plasma paracetamol concentrations were found to be below the treatment lines and in late presenters. Perhaps, giving the loading dose of N-acetylcysteine over 60 min could reduce the incidence of adverse reactions.