Palliative Care Training During Surgical Critical Care Fellowship: A Preliminary Needs Assessment at a Major Academic Center

Surgical palliative care (PC) facilitates communication between surgeons and patients/family about prognosis, symptom control, and therapeutic goals. Surgical critical care (SCC) fellows are at the forefront of the intensive care team; thus, we aim to assess previous and ongoing experiences in delivering PC by surveying fellows at a large academic center. Seventeen surveys were completed in which 59% of fellows reported no previous PC education. Six fellows (35%) reported participating in goals of care/end-of-life (GOC/EOL) discussions "a few times a year" during residency, while 41% responded the same for transitioning patients to comfort-focused care (CFC). When asked if respondents felt comfortable facilitating GOC/EOL discussions prior to fellowship, 7 (41%) answered "disagree" or "strongly disagree." Most fellows reported that more training in navigating GOC/EOL discussions (88%) and transitioning patients to CFC (76%) is needed. This assessment demonstrates variability in fellows' prior PC exposure and a strong desire for more structured training.

Is There a Community Microbial Community? A Comparison of Pathogens Between Two Hospital Surgical Intensive Care Units in a Single City

Background: Nosocomial and health-care-associated infections drive increased healthcare costs and negatively affect patient outcomes. The human microbiome has been heavily explored in recent years with incomplete data regarding hospital-specific and community-specific microbial communities. Although bacterial species differ between intensive care units in the same hospital, it is unclear if they differ between similar units in similar hospitals in the same community. Our hypothesis is that pathogens in surgical intensive care units (SICUs) are distinct between hospitals, even in the same community. Methods: From 2017 to 2021, data were collected prospectively from the SICUs of two 400-bed hospitals located three miles apart in the same city (Hospital A and Hospital B). Infections defined using U.S. Centers for Disease Control and Prevention (CDC) criteria were recorded for trauma and general surgery patients, as well as patient demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and causative organism. Results: Overall, Escherichia coli was the most commonly isolated pathogen in Hospital A, whereas Staphylococcus aureus was most commonly isolated at Hospital B. Enterococci were more common in Hospital A, and Haemophilus influenzae and Enterobacter spp. were more common in Hospital B. After stratification between trauma and non-trauma patients, however, these differences disappeared, with the exception of more overall gram-positive organisms and fewer gram-negative organisms among Hospital A trauma patients compared to Hospital B. There were no differences in rates of isolation of either fungi or resistant bacteria between hospitals. Conclusions: At a species level, admission diagnosis appears to be a greater determinant of pathogen isolation than hospital when comparing similar intensive care units (ICUs) in the same geographic area, but a larger body of data is needed to flesh out a distinct microbial map of the organisms occupying a certain geographic region. Further areas for investigation include comparison between hospital units, specific anatomic sites, and ICU versus floor patients.

Content and Accessibility of Surgical Critical Care Fellowship Websites in the United States

BACKGROUND

Resident physicians are using the Internet to gather information about graduate medical education programs. The content of fellowship websites has been demonstrated to influence applicants' decisions. The purpose of this study was to evaluate the content of the surgical critical care fellowship (SCCF) program websites.

METHODS

A list of Eastern Association for the Surgery of Trauma (EAST) and American Association for the Surgery of Trauma (AAST) SCCF programs was obtained, and compared to the Accreditation Council for Graduate Medical Education (ACGME) list of accredited programs. The accessibility of each website was assessed through Google®. Content areas were assessed for each SCCF website.

RESULTS

At the time of this study, 76 SCCF were listed on the EAST website and an additional 14 were supplied by the AAST database. 125 programs were listed in the ACGME database. Of the 76 SCCF listed by EAST, 44 (58%), 32 (42%), and 7 (9%) of SCCF programs had an EAST listing that was 3, 5, or 10 years or more out of date, respectively. Of the 90 SCCF programs listed on EAST or AAST sites, 36 programs (40%) had an inaccurate PD named on their listing. One hundred and nineteen of the 125 (95%) SCCF programs had websites accessible through Google®. Only 25 (20%) programs had a website containing a program description, faculty list, curriculum, and current/past fellows list.

CONCLUSIONS

Many SCCF websites lacked information regarding program specifics. Valuable information for potential applicants was inadequate across SCCF websites.

Incidence and Outcomes of Undiagnosed and Untreated Diabetes Mellitus in Trauma Patients

Diabetes is a major determinate for mortality in trauma patients. Many diabetics are undiagnosed or poorly controlled. Trauma patients disproportionately come from lower socioeconomic status, making missed diagnoses more likely. We aimed to quantify the incidence of undiagnosed or poorly controlled diabetics assessed at a Level 1 Trauma Center. We did a retrospective chart review of admitted trauma patients over a one-month period. Past Medical History, home medication lists, and Hemoglobin A1c on admission were recorded for each patient. We determined that 30 of 173 trauma patients qualifying for the study were diabetic. Furthermore, 30% of these diabetics were undiagnosed or had poorly controlled diabetes. Undiagnosed pre-diabetics made up 20% of the entire study group. Our data show that 26% of trauma patients would benefit from an intervention for improved glucose control. Trauma centers should consider creating routine clinical practice guidelines to identify at-risk patients and provide intervention for long-term management.

Palliative Care in the Trauma and Surgical Critical Care Settings: A Narrative Review

BACKGROUND

We aimed to conduct a narrative review of available literature to understand the use of palliative care in the trauma and surgical critical care setting.

METHODS

PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the use of palliative care in the trauma and surgical critical care setting. The search included all studies published through January 9th, 2022. The risk of bias of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Outcomes were summarized in tables and synthesized qualitatively.

RESULTS

A total of 22 studies were included in this review. Key elements of successful palliative care include communication, shared decision-making, family involvement, pain control, establishing a patient's prognosis, and end-of-life management. Approaches to implementation based upon these key elements include best-case/worst-case scenarios, consultation trigger systems, and integrated institutional palliative care programs. Palliative care may reduce hospital length of stay, improve symptom management, and increase patient satisfaction, but the impact on mortality is unclear.

CONCLUSION

The core elements of palliative care have been identified and palliative care has been shown to improve outcomes in trauma and surgical critical care. However, the approaches for implementation still require development. The underutilization of palliative care for trauma patients reveals the need for refining criteria for use of palliative care and improvement in the education of surgical critical care teams to provide primary palliative care services.

Maintaining Zone 1 Occlusion is a Dynamic Process: The Effects of Proximal Pressure and Blood Transfusion During REBOA

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides hemodynamic support to patients with non-compressible truncal hemorrhage. As cardiac output increases due to aortic occlusion (AO), aortic diameter will increase as a function of compliance, potentially causing unintended flow around the balloon.

MATERIALS AND METHODS

Swine (N = 10) were instrumented to collect proximal mean arterial blood pressure (pMAP), distal MAP (dMAP), balloon pressure (bP), balloon volume (bV), and distal aortic flow (Qaorta). A 7-Fr automated REBOA catheter was positioned in Zone 1. At T0, animals underwent 30% total blood volume hemorrhage over 30 min followed by balloon inflation to complete AO. Automated balloon inflation occurred from T30-T60 when Qaorta was detected. Period of interest was T55-T60, while the balloon actively worked to maintain AO during transfusion of shed blood.

RESULTS

Median weight of the cohort was 73.75 [IQR:71.58-74.45] kg. During T40-T55 and T55-T60, median pMAP was 88.95 [IQR:76.80-109.92] and 108.13 [IQR:99.13-119.51] mmHg, P = 0.07. Median Qaorta during T40-T55, and T55-T60 was 0.81 [IQR:0.41-0.96], and 1.53 [IQR:1.07-1.96] mL/kg/min, P = 0.06. Median number of balloon inflations during T40-T55 was 0.00 [IQR:0.00-0.75] and increased during active transfusion to 10.00 [IQR:5.25-14.00], P = 0.001.

DISCUSSION

In clinical practice, following initial establishment of AO, progressive balloon inflations are required to maintain AO in response to intrinsic and transfusion-mediated increases in cardiac output, blood pressure, and aortic diameter.

Coronavirus-Associated Coagulopathy After Trauma

Coronavirus disease 2019 (COVID-19) is linked with a hypercoagulable state called COVID-19-associated coagulopathy (CAC). Due to elevated levels of factor VIII and fibrinogen as well as inflammation-linked hyperviscosity of blood, the risk for venous thromboembolism is increased in patients who have CAC. We report the case of a patient with recent COVID-19 infection and no other past medical history who presented after a motorcycle collision with left middle and distal femur fractures, who underwent retrograde intramedullary nailing, and then developed immediate massive bilateral pulmonary emboli. The patient was treated with tissue plasminogen activator administration via bilateral pulmonary artery thrombolysis catheters without improvement, and was then placed on venoarterial extracorporeal membrane oxygenation for subsequent cardiogenic shock. During a 58-day hospital stay, the patient recovered and was discharged with a good long-term prognosis. In this report, we discuss CAC, the role of surgical critical care in the management of the disease, and issues specific to this patient's disease process and treatment.

Early feeding after percutaneous endoscopic gastrostomy tube placement in trauma and surgical intensive care patients: A retrospective cohort study

BACKGROUND

Critically ill patients experience frequent interruptions in enteral nutrition(EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy tube(PEG) placement, post-procedure fasting time varies from 1-24hrs, depending on the surgeon's preference. There is no evidence to support prolonged fasting after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with reduced fasting time after PEG.

METHODS

150 adult ventilated trauma and surgical ICU patients at a level I trauma center underwent PEG placement March 2015-May 2018 by one of 6 surgical intensivists. Retrospective review revealed variable post-PEG fasting practices among them: 1 started EN at 1hr, 2 at 4hrs, 2 at 6hrs, and 1 at 24hrs. Time to initiation of EN and complication rates were assessed. Patients were divided into early feeding(<4hrs) and prolonged fasting(≥4hrs) groups.

RESULTS

Median post-procedure fasting time was 5.5hrs. Complications included bleeding(2), infection(1), tube leak(1), feeding intolerance(1) and aspiration(0). The overall complication rate was 3.3%, with feeding intolerance rate 0.7% and aspiration rate 0%. There was no difference in complication rate for early feeding(3.1%) as compared to delayed feeding(3.4%) (OR 0.92, 95%CI 0.10-8.52, p = 0.7).

CONCLUSION

Complication rates following PEG placement in ventilated trauma and surgical ICU patients are low and do not change with early feeding <4hr compared to prolonged fasting ≥4hr. Early feeding after PEG is probably safe. With this data, a randomized controlled trial is underway that will provide evidence to support a more consistent practice, thus mitigating a source of EN interruption in a population vulnerable to malnutrition. This article is protected by copyright. All rights reserved.

The Impact of Hospital/University Affiliation on Research Productivity Among US-Based Authors in the Fields of Trauma, Surgical Critical Care, Acute Care, and Emergency General Surgery

BACKGROUND

Research productivity is critical to academic surgery and essential for advancing surgical knowledge and evidence-based practice. We aim to determine if surgeon affiliation with top US universities/hospitals (TOPS) is associated with increased research productivity measured by numbers of peer-reviewed publications in PubMed (PMIDs).

METHODS

A bibliometric analysis was performed for PMIDs. Affiliated authors who published in trauma surgery (TS), surgical critical care (SCC), acute care surgery (ACS), and emergency general surgery (EGS) were evaluated for publications between 2015 and 2019, and lifetime productivity. Our analysis included 3443 authors from 443 different institutions. Our main outcome was PMIDs of first author (FA) and senior author (SA) in each field (2015-2019) and total lifetime publications.

RESULTS

Significant differences exist between PMIDs from TOPS vs non-TOPS in FA-TS (1.34 vs 1.23, P = .001), SA-TS (1.71 vs 1.46, P < .001), total SA-PMIDs (44.10 vs 26.61, P < .001), and SA-lifetime PMIDs (90.55 vs 59.03, P < .001). There were no significant differences in PMIDs for FA or SA-SCC, FA or SA-ACS, FA or SA-EGS, FA-total PMIDs 2015-2019, or FA-lifetime PMIDs (P > .05 for all).

CONCLUSION

There were significantly higher TS PMIDs among FAs and SAs affiliated with top US institutions in 2015-2019, along with higher total PMIDs (2015-2019) and lifetime PMIDs. These findings are of significance to future graduate medical applicants and academic surgeons who need to make decisions about training and future career opportunities.

Trends in Surgical Critical Care Training Among General Surgery Residents: Pursuing an Ideal Curriculum

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) provides no specific guidelines for surgical critical care (SCC) training during general surgery residency. Growing emphasis is placed on this experience with increasing case requirements and dedicated SCC content on board certification exams.

METHODS

A digital survey was distributed to ACGME-accredited general surgery residencies via email. Respondents reported number and setting of critical care months during residency and rated comfort level within 5 critical care principles and overall satisfaction with their SCC experience. Study cohorts were formed to compare experiences and competencies between respondents based on setting, months, postgraduate year (PGY) level, and formal surgical intensive care unit (SICU) experience. Differences between cohorts were compared using the Mantel-Haenszel test (P < .05).

RESULTS

Seventy-three residents responded with 45% training at academic centers versus 46% in community hospitals. Approximately 50% completed a formal SICU rotation, while 9% reported no dedicated critical care rotation during residency. Overall, 78% felt satisfied with their SCC experience. Residents training at academic centers were more satisfied overall and felt more comfortable with ventilator management. Those who completed 5 or more months of critical care training reported greater confidence with intravenous sedation and ventilator management, while residents having a formal SICU rotation felt more confident with vasopressor and ventilator management.

DISCUSSION

Variability remains within SCC training among general surgery residents with perceived benefits seen in training at academic centers and completing a formal SICU rotation. Although limited, these findings offer a foundation for developing an effective SCC curriculum.

Trauma ICU Prevalence Project: the diversity of surgical critical care

Background

Surgical critical care is crucial to the care of trauma and surgical patients. This study was designed to provide a contemporary assessment of patient types, injuries, and conditions in intensive care units (ICU) caring for trauma patients.

Methods

This was a multicenter prevalence study of the American Association for the Surgery of Trauma; data were collected on all patients present in participating centers’ trauma ICU (TICU) on November 2, 2017 and April 10, 2018.

Results

Forty-nine centers submitted data on 1416 patients. Median age was 58 years (IQR 41–70). Patient types included trauma (n=665, 46.9%), non-trauma surgical (n=536, 37.8%), medical (n=204, 14.4% overall), or unspecified (n=11). Surgical intensivists managed 73.1% of patients. Of ICU-specific diagnoses, 57% were pulmonary related. Multiple high-intensity diagnoses were represented (septic shock, 10.2%; multiple organ failure, 5.58%; adult respiratory distress syndrome, 4.38%). Hemorrhagic shock was seen in 11.6% of trauma patients and 6.55% of all patients. The most common traumatic injuries were rib fractures (41.6%), brain (38.8%), hemothorax/pneumothorax (30.8%), and facial fractures (23.7%). Forty-four percent were on mechanical ventilation, and 17.6% had a tracheostomy. One-third (33%) had an infection, and over half (54.3%) were on antibiotics. Operations were performed in 70.2%, with 23.7% having abdominal surgery. At 30 days, 5.4% were still in the ICU. Median ICU length of stay was 9 days (IQR 4–20). 30-day mortality was 11.2%.

Conclusions

Patient acuity in TICUs in the USA is very high, as is the breadth of pathology and the interventions provided. Non-trauma patients constitute a significant proportion of TICU care. Further assessment of the global predictors of outcome is needed to inform the education, research, clinical practice, and staffing of surgical critical care providers.

Level of evidence

IV, prospective observational study.

Optimizing critical care of the trauma patient at the intermediate care unit: a cost-efficient approach

Background

The aim of this study was to describe the case load, safety, and cost savings of critical care of the trauma patient provided at the surgical intermediate care unit (IMCU).

Methods

This cohort study included all trauma admissions between January 1, 2011 and January 7, 2015 at the general intensive care unit (ICU), stand-alone neuro(surgical) IMCU, and stand-alone (trauma) surgical IMCU. Trauma mechanism, Abbreviated Injury Scale score and Injury Severity Score (ISS), vital signs, laboratory parameters, admission duration, intubation duration, ICU transfer, and in-hospital mortality were prospectively collected. Hypothetical cost savings were calculated using the fixed cost price per IMCU (US$1500) and ICU (US$2500) admission day.

Results

A total of 1320 admissions were included, 675 (51.1%) at the IMCU and 645 (48.9%) at the ICU. Patients admitted at the IMCU had a median ISS of 17 (11, 22). Their median duration of admission was 32.8 hours (18.8, 62.5). At the IMCU, one patient died due to aneurogenic shock. A subsequent ICU transfer was required in 38 (5.6%) IMCU admissions. Of these transfers, four patients died due to neurological deterioration. At the ICU, the median ISS was 22 (14, 30). Nearly all (n=620, 96.3%) ICU trauma patients required mechanical ventilation. Expected total cost savings due to the presence of the IMCU were US$1 772 785.

Discussion

A substantial amount of trauma patients in need of critical care can safely be admitted at the IMCU, without the need for further mechanical ventilation. Thereby, the IMCU could fulfill an essential cost-saving role in the management of severely injured trauma patients.

Level of evidence

Level IV.

Joint management format at the mixed-surgical intermediate care unit: an interrupted time series analysis

Background

The management format of the mixed-surgical intermediate care unit (IMCU) affects its performance. A format of combined supervision of surgeons with additional critical care certifications and admitting specialists, named the “joint format”, may herein be a promising new model of specialized critical care. This study aims to assess the performance of the joint management format.

Methods

This observational cohort study compared three IMCU management formats at the stand-alone, mixed-surgical IMCU of a tertiary referral hospital using interrupted time series analyses. All admissions from 2001 until 2015 were included. Predetermined criteria for performance (utilization, efficiency, and safety) were applied to three different management format periods: open (2001–2006), closed (2006–2011), and joint (2011–2015) formats.

Results

A total of 8894 admissions were analyzed. In terms of case load (utilization), there was an overall increase in the number of surgical patients (0.25%/year) (p<0.001), age (0.38/year) (p<0.001), and readmissions from the ward (0.16%/year) (p<0.001) and from the intensive care unit (ICU) (0.17%/year) (p=0.014). In terms of efficiency, the admission duration decreased (1.58 hours/year) (p<0.001). Transfer to the ICU within 24  hours, readmission within 24  hours from the ward, and unplanned mortality (eg, safety) did not change over time.

Discussion

At a time of increasingly complex case load, the joint format at the mixed-surgical IMCU is an efficient and safe management format in which the admitting specialist continues to provide specialized care. Specialty-specific supervision at IMCUs is a safe option which should be considered in healthcare policy decisions.

Level of evidence

Level IV.

Prospective Trial of House Staff Time to Response and Intervention in a Surgical Intensive Care Unit: Pager vs. Smartphone

OBJECTIVE

The objective of the study was to characterize house staff time to response and intervention when notified of a patient care issue by pager vs. smartphone. We hypothesized that smartphones would reduce house staff time to response and intervention.

DESIGN

Prospective study of all electronic communications was conducted between nurses and house staff between September 2015 and October 2015. The 4-week study period was randomly divided into two 2-week study periods where all electronic communications between intensive care unit nurses and intensive care unit house staff were exclusively by smartphone or by pager, respectively. Time of communication initiation, time of house staff response, and time from response to clinical intervention for each communication were recorded. Outcomes are time from nurse contact to house staff response and intervention.

SETTING

Single-center surgical intensive care unit of Cedars-Sinai Medical Center in Los Angeles, California, an academic tertiary care and level I trauma center.

PARTICIPANTS

All electronic communications occurring between nurses and house staff in the study unit during the study period were considered. During the study period, 205 nurse-house staff electronic communications occurred, 100 in the phone group and 105 in the pager group.

RESULTS

House staff response to communication time was significantly shorter in the phone group (0.5 [interquartile range = 1.7] vs. 2 [3]min, p < 0.001). Time to house staff intervention after response was also significantly more rapid in the phone group (0.8 [1.7] vs. 1 [2]min, p = 0.003).

CONCLUSIONS

Dedicated clinical smartphones significantly decrease time to house staff response after electronic nursing communications compared with pagers.

Are Predictive Energy Expenditure Equations in Ventilated Surgery Patients Accurate?

BACKGROUND:

While indirect calorimetry (IC) is the gold standard used to calculate specific calorie needs in the critically ill, predictive equations are frequently utilized at many institutions for various reasons. Prior studies suggest these equations frequently misjudge actual resting energy expenditure (REE) in medical and mixed intensive care unit (ICU) patients; however, their utility for surgical ICU (SICU) patients has not been fully evaluated. Therefore, the objective of this study was to compare the REE measured by IC with REE calculated using specific calorie goals or predictive equations for nutritional support in ventilated adult SICU patients.

MATERIALS AND METHODS:

A retrospective review of prospectively collected data was performed on all adults (n = 419, 18-91 years) mechanically ventilated for >24 hours, with an Fio₂ ≤ 60%, who met IC screening criteria. Caloric needs were estimated using Harris-Benedict equations (HBEs), and 20, 25, and 30 kcal/kg/d with actual (ABW), adjusted (ADJ), and ideal body (IBW) weights. The REE was measured using IC.

RESULTS:

The estimated REE was considered accurate when within ±10% of the measured REE by IC. The HBE, 20, 25, and 30 kcal/kg/d estimates of REE were found to be inaccurate regardless of age, gender, or weight. The HBE and 20 kcal/kg/d underestimated REE, while 25 and 30 kcal/kg/d overestimated REE. Of the methods studied, those found to most often accurately estimate REE were the HBE using ABW, which was accurate 35% of the time, and 25 kcal/kg/d ADJ, which was accurate 34% of the time. This difference was not statistically significant.

CONCLUSION:

Using HBE, 20, 25, or 30 kcal/kg/d to estimate daily caloric requirements in critically ill surgical patients is inaccurate compared to REE measured by IC. In SICU patients with nutrition requirements essential to recovery, IC measurement should be performed to guide clinicians in determining goal caloric requirements.

The pulmonary artery catheter in 2008 - A (finally) maturing modality?

The first description of the flow-directed pulmonary artery catheter (PAC) was published in the 1970s by Jeremy Swan and William Ganz. Ever since its clinical debut, many controversies surrounded the use of the PAC. Regardless of these controversies, the most fundamental issues surrounding this hemodynamic monitoring device remain unresolved, including the exact indications, contraindications, identification of patients who potentially benefit from this technology, and the way we interpret and use PAC-derived parameters. Despite recent intensification of attacks against the use of the PAC by its opponents, it seems overly harsh to discount a technology that might be beneficial in appropriately selected clinical situations, especially when considering the fact that our true knowledge of this technology is somewhat limited. In fact, the PAC may still play an important role considering the resurgence of the concepts of euvolemic resuscitation and hemodynamic sufficiency.

Republished with Permission from: Stawicki SP, Prosciak MP. The pulmonary artery catheter in 2008 – a (finally) maturing modality? OPUS 12 Scientist 2008;2(4):5-9.

A Statewide Analysis of the Incidence and Outcomes of Acute Mesenteric Ischemia in Maryland from 2009 to 2013

Introduction

Acute mesenteric ischemia is a surgical emergency that entails complex, multi-modal management, but its epidemiology and outcomes remain poorly defined. The aim of this study was to perform a population analysis of the contemporary incidence and outcomes of mesenteric ischemia.

Methods

This was a retrospective analysis of acute mesenteric ischemia in the state of Maryland during 2009–2013 using a comprehensive statewide hospital admission database. Demographics, illness severity, comorbidities, and outcomes were studied. The primary outcome was inpatient mortality. Survivors and non-survivors were compared using univariate analyses, and multivariable logistic regression analysis was performed to evaluate risk factors for mortality.

Results

During the 5-year study period, there were 3,157,499 adult hospital admissions in Maryland. A total of 2,255 patients (0.07%) had acute mesenteric ischemia, yielding an annual admission rate of 10/100,000. Increasing age, hypercoagulability, cardiac dysrhythmia, renal insufficiency, increasing illness severity, and tertiary hospital admission were associated with development of mesenteric ischemia. Inpatient mortality was high (24%). After multivariate analysis, independent risk factors for death were age >65 years, critical illness severity, mechanical ventilation, tertiary hospital admission, hypercoagulability, renal insufficiency, and dysrhythmia.

Conclusion

Acute mesenteric ischemia occurs in approximately 1/1,000 admissions in Maryland. Patients with mesenteric ischemia have significant illness severity, substantial rates of organ dysfunction, and high mortality. Patients with chronic comorbidities and acute organ dysfunction are at increased risk of death, and recognition of these risk factors may enable prevention or earlier control of mesenteric ischemia in high-risk patients.

Ethical Issues in Surgical Critical Care: The Complexity of Interpersonal Relationships in the Surgical Intensive Care Unit

A major challenge in the era of shared medical decision making is the navigation of complex relationships between the physicians, patients, and surrogates who guide treatment plans for critically ill patients. This review of ethical issues in adult surgical critical care explores factors influencing interactions among the characters most prominently involved in health care decisions in the surgical intensive care unit: the patient, the surrogate, the surgeon, and the intensivist. Ethical tensions in the surgeon-patient relationship in the elective setting may arise from the preoperative surgical covenant and the development of surgical complications. Unlike that of the surgeon, the intensivist's relationship with the individual patient must be balanced with the need to serve other acutely ill patients. Due to their unique perspectives, surgeons and intensivists may disagree about decisions to pursue life-sustaining therapies for critically ill postoperative patients. Finally, although surrogates are asked to make decisions for patients on the basis of the substituted judgment or best interest standards, these models may underestimate the nuances of postoperative surrogate decision making. Strategies to minimize conflicts regarding treatment decisions are centered on early, honest, and consistent communication between all parties.

Acute Kidney Injury in Critically Ill Vascular Surgery Patients is Common and Associated with Increased Mortality

INTRODUCTION

Vascular surgery patients have multiple risk factors for renal dysfunction, but acute kidney injury (AKI) is poorly studied in this group. The purpose of this study was to define the incidence, risk factors, and outcomes of AKI in high-risk vascular patients.

METHODS

Critically ill vascular surgery patients admitted during January-December 2012 were retrospectively analyzed with 1-year follow-up. The endpoint was AKI by established RIFLE creatinine criteria. The primary analysis was between patients with or without AKI, with secondary analysis of post-operative AKI. Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge renal function.

RESULTS

One-hundred and thirty six vascular surgery patients were included, representing 27% of all vascular surgery admissions during the study period. Sixty-five (48%) developed AKI. Independent global risk factors for AKI were diabetes, increasing critical illness severity, and sepsis. While intraoperative blood loss and hypotension were associated with subsequent renal dysfunction, post-operative AKI rates were similar for patients undergoing aortic, carotid, endovascular, or peripheral vascular procedures. All RIFLE grades of AKI were associated with worse outcomes. Overall, patients with AKI had significantly increased short- and long-term mortality, longer inpatient lengths of stay, and worse discharge renal function.

CONCLUSION

AKI is common among critically ill vascular surgery patients. Importantly, the type of surgical procedure appears to be less important than intra- and perioperative management in determining renal dysfunction. Regardless of its severity, AKI is a clinically significant complication that is associated with substantially worse patient outcomes.

The Complex Surgical Abdomen: What the Nonsurgeon Intensivist Needs to Know

Intensivists are often called upon to help care for patients who develop severe sepsis syndrome and septic shock where the primary source is an enterocutaneous fistula (ECF). The purpose of this article is to describe to the nonsurgeon intensivist how these complex surgical situations arise in the first place and provide the reader with a detailed understanding of the potentially devastating complications of ECF. In addition, we will describe a structured algorithm regarding the management of this often highly challenging surgical situation.