Journal of the American College of Surgeons
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Reduction in integer heart rate variability (HRVi), one potential measurement of complex biologic systems, is common in ICU patients and is strongly associated with hospital mortality. Adrenal insufficiency (AI) and reduced HRVi are associated with autonomic dysfunction. Failure of the autonomic nervous system can be associated with loss of biologic complexity. We hypothesize decreased HRVi is associated with AI, and HRVi improves after treatment of AI, suggesting "recomplexification" (resumption of normal stress response to injury). ⋯ Reduced heart-rate variability, a potential measurement of complex biologic systems, is associated with cosyntropin-confirmed AI; improved in patients responding to steroid therapy; and is a noninvasive, real-time biomarker suggesting AI.
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Multicenter Study
Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy.
To establish a reliable definition of postoperative hepatic insufficiency (PHI) in noncirrhotic patients undergoing major hepatectomy. No standard definition of PHI has been established, but one is essential for meaningful comparison of outcomes data across studies. ⋯ PHI defined as (Peak)Bil > 7.0 mg/dL accurately predicts liver-related death and worse outcomes after major hepatectomy. Standardized reporting of complications, PHI, and 90-day mortality is essential to accurately determine the risk of major hepatectomy and to compare outcomes data.
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Sepsis from bloodstream infection (BSI) is an important cause of morbidity and mortality among surgical patients. Our hypothesis was that fever and leukocytosis during BSI would be associated with gram-negative pathogens and worse outcomes among hospitalized surgical patients. ⋯ Among surgical patients with sepsis, fever during BSI was not associated with a gram-negative cause and correlated with survival, although increasing WBC had little effect. Mortality after BSI appears associated more with an initially blunted physiologic response than with a robust, proinflammatory response. In addition, a threshold for blood culture other than temperature > or = 38.5 degrees C should be considered.
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Intensive insulin therapy to maintain serum glucose levels between 80 and 110 mg/dL has previously been shown to reduce mortality in the critically ill; recent data, however, have called this benefit into question. In addition, maintaining uniform, tight glucose control is challenging and resource demanding. We hypothesized that, by use of a protocol, tight glucose control could be achieved in the surgical trauma intensive care unit (STICU), and that improved glucose control would be beneficial. ⋯ Improvements in glucose control in the ICU can be achieved by using a protocol for intensive insulin therapy. In our ICU, this was temporally associated with a significant reduction in mortality.
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Fate of the remnant pancreas after resection of noninvasive intraductal papillary mucinous neoplasm.
The risk of local recurrence in the pancreatic remnant after resection of noninvasive intraductal papillary mucinous neoplasm (IPMN) is not well defined. ⋯ Patients who have undergone resection for noninvasive IPMN require indefinite surveillance because local recurrences may be identified several years from the initial operation and be resected while still noninvasive. Although the risk of local recurrence appears to increase in the setting of positive margins, the majority of patients with positive margins have not developed local recurrence. Negative margins should be the goal of the operation when achievable with partial pancreatectomy, but the risk of local recurrence is not high enough to mandate total pancreatectomy for microscopic positive margins.