Journal of the American College of Surgeons
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Randomized Controlled Trial
Closed loop control of inspired oxygen concentration in trauma patients.
Transport of mechanically ventilated patients in a combat zone presents challenges, including conservation of resources. In the battlefield setting, provision of oxygen supplies remains an important issue. Autonomous control of oxygen concentration can allow a reduction in oxygen usage and reduced mission weight. ⋯ Closed loop control of FIO(2) offers the opportunity for maximizing oxygen resources, reducing mission weight, and providing targeted normoxemia without increasing risk of hypoxemia in ventilated trauma patients.
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Randomized Controlled Trial
Less is more: improved outcomes in surgical patients with conservative fluid administration and central venous catheter monitoring.
The ARDS Clinical Trials Network Fluid and Catheter Treatment Trial (FACTT) addressed fluid management and central monitoring of patients with acute respiratory distress syndrome/acute lung injury (ARDS/ALI). Because surgical patients may have been fundamentally different from the overall FACTT cohort, we set out to separately analyze the surgery patients in the trial. ⋯ The risk of death did not vary with fluid management or catheter. A conservative fluid-administration strategy and central venous catheter monitoring resulted in more ventilator-free and ICU-free days in surgical patients with acute lung injury, and conservative fluid administration did not result in more renal failure.
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Emergency department (ED) crowding and delays in care represent a national problem; no large study has examined the impact of such delays in surgical patients. We sought to determine the impact of delayed transfer from the ED on outcomes in trauma/emergency general surgical patients in a center that has developed a policy to triage more critically ill/severely injured patients to earlier ICU admission. ⋯ Experienced clinicians can effectively triage more critically injured patients to earlier ICU admission and alter associations between ED length of stay and mortality. Hospitals with a large trauma/emergency general surgery caseload resulting in delays in ED throughput should institute policies and procedures for triage of more severely injured patients for early ICU admission and develop a monitoring system to ensure that delays do not adversely affect patient outcomes.
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Comparative Study
Longterm outcomes for whole and segmental liver grafts in adult and pediatric liver transplant recipients: a 10-year comparative analysis of 2,988 cases.
Data on longterm outcomes after liver transplantation with partial grafts are limited. We compared 10-year outcomes for liver transplant patients who received whole grafts (WLT), split grafts from deceased donors (SLT), and partial grafts from living donors (LDLT). ⋯ Longterm graft survival rates in both adults and children for segmental grafts from deceased and living donors are comparable with those in whole organ liver transplantation. In adults, patient survival was lower for split compared with whole grafts when used in retransplantations and in critically ill recipients. Split graft-to-recipient matching is crucial for optimal organ allocation and best use of a scarce and precious resource.
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The Institute of Medicine has urged the adoption of electronic prescribing systems in all health-care organizations by 2010. Accordingly, computerized physician order entry (CPOE) warrants detailed evaluation. Mixed results have been reported about the benefit of this system. No review of its application in surgical patients has been reported to date. We present the implementation of CPOE in the management of surgical patients within an academic multispecialty practice. ⋯ Present CPOE technology can allow major efficiency gains, but refinements will be required for improvements in patient safety.