Showing papers by "Lena M. Napolitano published in 2004"

Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update.

Abstract: bated, and the task force chairman modified the document until <10% of the experts disagreed with the recommendations. Conclusions: An organized approach to the hemodynamic support of sepsis was formulated. The fundamental principle is that clinicians using hemodynamic therapies should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis by monitoring a combination of variables of global and regional perfusion. Using this approach, specific recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult patients were promulgated. (Crit Care Med 2004; 32:1928 ‐1948)

Epidemiology of sepsis in patients with traumatic injury.

Abstract: Objective:To characterize the epidemiology of sepsis in trauma.Design:Analysis of a prospectively collected administrative database (Pennsylvania trauma registry).Setting:All trauma centers in the state of Pennsylvania (n = 28)Patients:All patients (n = 30,303) with blunt or penetrating injury admit

Allogenic blood transfusion in the first 24 hours after trauma is associated with increased systemic inflammatory response syndrome (SIRS) and death

Abstract: Background: Previous studies have documented that blood transfusion incites a substantial inflammatory response with the systemic release of cytokines. Furthermore, blood transfusion is a significant independent predictor of multiple organ failure in trauma. The objective of this study was to assess the risk of systemic inflammatory response syndrome (SIRS) and intensive care unit (ICU) admission, length of stay (LOS), and mortality in trauma patients who require blood transfusion. Methods: Prospective data were collected on 9,539 trauma patients admitted to the R. Adams Cowley Shock Trauma Center over a 30-month period from January, 1997 to July, 1999. Complete SIRS data were available on 7,602 patients. Patients were stratified by age, gender, race, Glasgow coma scale (GCS), and injury severity score (ISS). A systemic inflammatory response to a wide variety of severe clinical insults (SIRS) was defined as a SIRS score of ≥2, as calculated on admission. Blood transfusion was assessed as an independent pr...

Male gender is associated with increased risk for postinjury pneumonia.

Abstract: Nosocomial pneumonia in trauma patients is a significant source of resource utilization and mortality. We have previously described increased rates of pneumonia in male trauma patients in a single institution study. In that study, female trauma patients had a lower incidence of postinjury pneumonia but a higher relative risk for mortality when they did develop pneumonia. We sought to investigate the hypothesis that male trauma patients have an increased incidence of postinjury pneumonia in a separate population-based dataset. Prospective data were collected on 30,288 trauma patients (26,231 blunt injuries, 4057 penetrating injuries) admitted to all trauma centers (n = 26) in Pennsylvania over 24 months (January 1996 to December 1997). Gender differences in pneumonia were determined for the entire dataset. A second analysis examined all blunt injury patients and excluded all patients with a hospital length of stay less than 24 h, eliminating patients who expired early after admission. In trauma patients with minor injury (ISS 15), male trauma patients had a significantly increased incidence of postinjury pneumonia (ISS 15-30, male 8.85%, female 6.45%; ISS > 30, male 24.35%, female 17.30%). Logistic regression analysis of blunt trauma patients revealed that gender, ISS, injury type, admission Revised Trauma Score (RTS), admission respiratory rate, history of cardiac disease, and history of cancer were all independent predictors of pneumonia. Trauma patients with nosocomial pneumonia had a significantly higher mortality rate (P < 0.001) than patients without pneumonia. There was no gender-specific difference in mortality among pneumonia patients. Male gender is significantly associated with an increased incidence of postinjury pneumonia. In contrast to our initial study, there was no gender difference in postinjury pneumonia mortality rates identified in this population-based study.

Guidelines for critical care medicine training and continuing medical education

Abstract: ObjectiveCritical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical

Methicillin-resistant Staphylococcus aureus infections in vascular surgery: increasing prevalence.

Abstract: Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent organism that causes substantial infection-related morbidity and mortality in hospitalized patients. For example, MRSA i...

Scope of the problem: epidemiology of anemia and use of blood transfusions in critical care.

Abstract: Anemia is a common problem in critically ill patients. It is caused, in part, by blood loss related to phlebotomy for diagnostic testing, occult gastrointestinal bleeding, renal replacement therapies, surgical intervention, and traumatic injuries. Reduced red cell life span and nutritional deficiencies (iron, folate, vitamin B12) may be other contributing factors. In addition, critically ill patients have impaired erythropoiesis because of blunted endogenous erythropoietin production and the direct inhibitory effects of inflammatory cytokines on red blood cell production by the bone marrow. Blood transfusions are commonly utilized for treatment of anemia in critical care, resulting in high use of blood transfusions in the intensive care unit (ICU). The percentage of patients transfused in the ICU is inversely related to admission hemoglobin and directly related to age and severity of illness. Patients with an increased length of stay in the ICU are also at increased risk for receiving blood transfusions. Studies are needed to improve our understanding of the pathophysiology of ICU-acquired anemia, to determine the efficacy of blood transfusions in critical care, and to investigate alternatives to blood transfusion for the treatment of anemia in the ICU.

A consensus statement on empiric therapy for suspected gram-positive infections in surgical patients

Abstract: Background Multidrug resistance among gram-positive pathogens in tertiary and other care centers is common. A systematic decision pathway to help select empiric antibiotic therapy for suspected gram-positive postsurgical infections is presented. Data sources A Medline search with regard to empiric antibiotic therapy was performed and assessed by the 15-member expert panel. Two separate panel meetings were convened and followed by a writing, editorial, and review process. Conclusions The main goal of empiric treatment in postsurgical patients with suspected gram-positive infections is to improve clinical status. Empiric therapy should be initiated at the earliest sign of infection in all critically ill patients. The choice of therapy should flow from β-lactams to vancomycin to parenteral linezolid or quinupristin-dalfopristin. In patients likely to be discharged, oral linezolid is an option. Antibiotic resistance is an important issue, and in developing treatment algorithms for reduction of resistance, the utility of these new antibiotics may be extended and reduce morbidity and mortality.

Current status of blood component therapy in surgical critical care.

Abstract: PURPOSE OF REVIEW The use of blood component therapy, with transfusion of red cells, plasma, and platelets, is common in critical care. New evidence has emerged documenting the risks associated and lack of efficacy or improvement in clinical outcome with blood transfusion for the treatment of anemia in critically ill patients who are hemodynamically stable. RECENT FINDINGS The safety of a restrictive transfusion strategy (transfuse only if hemoglobin < 7 g/dL) was reported in 1999. Despite compelling evidence from this prospective randomized clinical trial, clinicians have not substantially changed practice regarding blood transfusion in critical care. The recently published CRIT trial reported that the mean pre-transfusion hemoglobin was 8.6 g/dL in this large multicenter trial that examined transfusion practices in critical care in the US. Furthermore, only 19% of hospitals had an institutional blood transfusion protocol. The Surviving Sepsis Campaign guidelines have also recommended blood transfusion only when hemoglobin falls to 7.0 g/dL, following resolution of tissue hypoperfusion and in the absence of significant coronary artery disease or acute hemorrhage. We have an increased understanding of the pathophysiology of the anemia associated with critical care, related to the inflammatory response, downregulation of erythropoietin, and lack of iron availability due to macrophage sequestration. Clinical trials are underway to confirm the efficacy of recombinant erythropoietin in the treatment of critically ill patients with anemia. SUMMARY Current data regarding blood transfusion thresholds and risks of blood transfusion have not as yet significantly altered practice patterns. Efforts to reduce blood transfusion rates in critically ill patients are required. These strategies will require education, unit and institutional protocols, and reduction of phlebotomy for diagnostic laboratory testing in the intensive care unit. Further investigations regarding anemia in critical care and new treatment and prevention strategies are required.

Efficacy of blood transfusion in the critically ill: Does age of blood make a difference?

Abstract: Anemia is prevalent in critically ill patients, and recent studies well document that this results in large numbers of red blood cell (RBC) transfusions being given to treat the anemia in these critically ill patients (1, 2). By intensive care unit day 3, 95% of critically ill patients are anemic, and 40% to 50% of these patients received, on average, almost five units of RBCs during their intensive care unit stay (3). Blood loss, inappropriately low endogenous erythropoietin production, reduced red cell lifespan, reduced iron availability, and inhibition of erythropoiesis by cytokines and the inflammatory response all contribute to the anemia of critical illness (4) Despite the frequency of RBC transfusion in the critically ill, the optimal treatment of anemia in euvolemic critically ill patients remains controversial. During the last decade, the routine use of RBC transfusion for the treatment of anemia in critically ill patients has been scrutinized (3– 8). Little data exist supporting the efficacy of RBC transfusion, and recent data suggest that a more liberal transfusion practice may, in fact, result in worse clinical outcomes in some critically ill patients (3, 5– 8). It is not clear whether the adverse effects of RBC transfusion are a result of factors related to the RBC transfusion itself or a higher hemoglobin level. However, studies by Marik and Sibbald (9) and Fitzgerald et al. (10) have raised the question that transfusion of “older” ( 14 days) stored RBCs may be associated with adverse clinical effects. This is an important clinical question because the average age of RBCs transfused in the critically ill is 21 days, with almost 40% being 28 days old (3). If old cells are indeed a problem and should not be used, this would have a major impact on an already stressed blood supply system. In this issue of Critical Care Medicine, Walsh and colleagues (11) report the results of a prospective, randomized, double-blind pilot study aimed at investigating the effects of transfusion of two units of “fresh” ( 5 days) or “stored” ( 20 days) prestorage leukodepleted and plasma-depleted red blood cells in ventilated euvolemic critically ill patients (n 22) with anemia (hemoglobin concentration 9 g/dL). They determined that at 5 hrs, neither “fresh” nor “stored” RBC transfusions were associated with an improvement in tissue oxygenation as measured by automated gas tonometry. Furthermore, no adverse effect of “stored” red blood cell transfusion was identified in this study using the study outcome measures of pHi, Pg-PaCO2 gap, lactate, and base deficit. This is an important study that further extends our knowledge regarding the lack of efficacy of RBC transfusion for the treatment of anemia in critically ill patients. There are, however, some significant limitations to this single-center trial that should be noted. The authors stated that they enrolled euvolemic patients, but did not specify how they determined that the study patients were euvolemic. In fact, they defined a pHi of 7.35 as abnormal, and both study cohorts had abnormal pHi and high arterial lactate concentrations at baseline. Furthermore, the decision for RBC transfusion was at the treating physician’s discretion rather than any objective criteria. The study group was not homogeneous and included both surgical and medical patients and those with and without infection at time of study entry. There was also no evidence that these patients were, in fact, “delivery dependent.” The sample size was small, and there was considerable variability in intensive care unit length of stay at study entry, ranging from 2 to 22 days. The outcome measures in this study included regional and global indices of tissue oxygenation. Regional tissue oxygenation was measured by gastric tonometry indices of gastric mucosal oxygenation before, during, and after RBC transfusion. Global indices of tissue oxygenation were measured by serial lactate and base deficit. The variables were measured at 5 hrs, however it is unclear whether results would have been similar several hours later after the complete recovery of 2, 3 diphosphoglyceric acid. This study also did not assess other important more long-term outcome variables in critically ill patients, such as nosocomial infection and multiple organ failure (measured only at baseline in this study). Other studies have documented that RBC transfusion is an independent risk factor for nosocomial infection and multiple organ failure (11–18), although the use of leukodepleted RBC in this study may mitigate this risk (19). In stored blood preparations, it has been documented that free hemoglobin and polymorphonuclear leukocyte elastase concentrations increase significantly with storage time, with resultant increased hemolysis of RBCs (20). A recent hypothesis has emerged regarding the adverse effects of transfusion of stored blood. Cell-free ferrous hemoglobin in the plasma, after transfusion of stored blood, rapidly destroys nitric oxide by oxidation to methemoglobin and nitrate. Nitric oxide reacts at least 1,000 times more rapidly with free hemoglobin than with erythrocytes. Limited nitric oxide bioavailability promotes regional and systemic vasoconstriction and subsequent organ dysfunction (21, 22). In their current study, Walsh and colleagues (11) did not evaluate for these potential adverse effects associated with the transfusion of stored blood. Although prestorage leukoreduced blood was utilized in this study, it should be recognized that this only reduces the number of donor leukocytes infused from approximately 10 to 10 white blood cells per unit of blood (23). *See also p. 364. Copyright © 2004 by Lippincott Williams & Wilkins

Necrotizing soft tissue infection from decubitus ulcer after spinal cord injury.

Abstract: STUDY DESIGN: A case of necrotizing soft tissue infection in a patient with spinal cord injury with extension of infection into the spinal canal and spinal cord is presented. OBJECTIVE: To review the history, risk factors, pathophysiology, diagnosis, treatment, and morbidity and mortality regarding necrotizing soft tissue infection as they relate to spinal cord injury. SUMMARY OF BACKGROUND DATA: Necrotizing soft tissue infection related to decubitus ulcers is rare. To our knowledge, this is the first report of this disease related to a sacral decubitus ulcer with extension of the necrotizing infection into the spinal canal. METHODS: The clinical, radiographic, and pathologic features associated with necrotizing soft tissue infection are presented. The patient presented with a late-stage necrotizing soft tissue infection requiring extensive de-bridement of necrotic tissue, which the patient underwent on admission. RESULTS: The patent died of refractory septic shock and multiple-organ failure after surgery. CONCLUSION: Necrotizing soft tissue infections from decubitus ulcers are rare and unpredictable, and ultimately have a progressively aggressive course. The case reported herein is the first report of necrotizing soft tissue infection from a decubitus ulcer in a patient with spinal cord injury with extension into the spinal canal and spinal cord.

Pyogenic liver abscess complicating biliary stricture due to chronic pancreatitis.

Abstract: Background: Chronic pancreatitis uncommonly causes common bile duct stricture, and common bile duct stricture rarely leads to pyogenic liver abscess. Methods: We describe a 51-year-old man who deve...