The American surgeon
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The American surgeon · May 2014
Checklist-styled daily sign-out rounds improve hospital throughput in a major trauma center.
The checklist concept has received much attention as a result of its ability to improve patient care by minimizing complications. We hypothesized daily sign-out rounds using a checklist, by improving team communication and consistency of clinical care, could lead to expedited throughput for patients at a major trauma center. A retrospective study examined patients admitted to a mature trauma center. ⋯ A simple, organ system-based checklist can be successfully adopted for daily sign-out round on a busy, multiprovider trauma service. We were able to expedite trauma patient throughput in both ICU and overall hospital stays with a trend toward decreasing mortality. This improved throughput may potentially translate into a cost saving for the hospital.
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Most evidence suggests early vasopressor use is associated with death after trauma, but no previous study has focused on patients requiring emergency operative intervention (OR). We test the hypothesis that vasopressors are harmful in this population. Records from 746 patients requiring OR from July 2009 to March 2013 were retrospectively reviewed and stratified based on vasopressor use (epinephrine [EPI], phenylephrine, ephedrine, norepinephrine, dobutamine, vasopressin) or no vasopressor use. ⋯ We conclude that vasopressor use is relatively common in the most severely injured patients requiring OR and is associated with mortality. EPI is most often used for cardiac arrest, whereas other vasopressors are used for their vasoconstrictive properties. This suggests that, except for EPI, vasopressors during OR are not independently associated with mortality.
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The American surgeon · May 2014
Outcomes of emergent inguinal hernia repair in veteran octogenarians.
Outcomes from emergent inguinal hernia (IH) repair in veteran octogenarians are not well described. We reviewed outcomes for this cohort from 2005 to 2012 at the VA North Texas Health Care System. There were 15 emergent (Group I) and 86 elective (Group II) operations performed in octogenarians. ⋯ Despite the high rate of comorbid conditions in our group, the risk associated with elective repair of IH was not prohibitive. In contrast, we observed that 15 per cent of patients presented with an incarcerated hernia during the study period and the mortality rate was 13 per cent in this cohort. Factors that might predict incarceration in veteran octogenarians need to be further investigated.
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The American surgeon · May 2014
Pediatric appendectomy: optimal surgical timing and risk assessment.
Appendicitis is one of the most common pediatric surgical problems. In the older surgical paradigm, appendectomy was considered to be an emergent procedure; however, with changes to resident work hours and other economic factors, the operation has evolved into an urgent and deliberately planned intervention. This paradigm shift in care has not necessarily seen universal buy-in by all stakeholders. ⋯ Perforated appendicitis carries a higher risk of development of IAA that is not reduced by an emergent operative or delayed nonoperative management strategy. The timing of appendectomy appears to be an extremely important factor in reducing the incidence of IAA after all presentations of appendectomy. The role of resuscitation and antibiotics in limiting the effects of the inflammatory cascade and development of laboratory markers that accurately measure the latter need to be the focus of further research in this field.
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The American surgeon · Apr 2014
Prothrombin complex concentrate accelerates international normalized ratio reversal and diminishes the extension of intracranial hemorrhage in geriatric trauma patients.
Warfarin therapy increases the incidence intracranial hemorrhage (ICH), especially in the geriatric population. Timely reversal of international normalized ratio (INR) is integral in the management of these patients for whom fresh frozen plasma (FFP) with vitamin K is the standard of treatment. We hypothesized that implementing a protocol that used prothrombin complex concentrate (PCC) would reverse INR values more swiftly and decrease the amount of FFP administered. ⋯ Rapid reversal of coagulopathy in geriatric patients on warfarin is vital to limit the extent of ICH. PCC allows a much more rapid reversal than standard treatment with only FFP and vitamin K. Adopting such a protocol is associated not only with a more rapid reversal and less FFP use, but also less patients went on to extend their head bleeds.