Showing papers by "Lena M. Napolitano published in 2010"
TL;DR: Once definitive control of hemorrhage has been established, a restrictive approach to blood transfusion should be implemented to minimize further complications.
280 citations
TL;DR: The autopsy findings in patients with fatal novel H1N1 influenza resemble other influenza virus infections with the exception of prominent thrombosis and hemophagocytosis, which should be investigated in severely ill patients with H 1N1 infection.
Abstract: A novel H1N1 influenza A virus emerged in April 2009, and rapidly reached pandemic proportions. We report a retrospective observational case study of pathologic findings in 8 patients with fatal novel H1N1 infection at the University of Michigan Health Systems (Ann Arbor) compared with 8 age-, sex-, body mass index-, and treatment-matched control subjects. Diffuse alveolar damage (DAD) in acute and organizing phases affected all patients with influenza and was accompanied by acute bronchopneumonia in 6 patients. Organizing DAD with established fibrosis was present in 1 patient with preexisting granulomatous lung disease. Only 50% of control subjects had DAD. Peripheral pulmonary vascular thrombosis occurred in 5 of 8 patients with influenza and 3 of 8 control subjects. Cytophagocytosis was seen in all influenza-related cases. The autopsy findings in our patients with novel H1N1 influenza resemble other influenza virus infections with the exception of prominent thrombosis and hemophagocytosis. The possibility of hemophagocytic syndrome should be investigated in severely ill patients with H1N1 infection.
131 citations
TL;DR: This review focuses on nonventilatory strategies in the advanced treatment of severe respiratory failure and refractory hypoxemia such as that seen in patients with severe acute respiratory distress syndrome attributable to 2009 H1N1 influenza.
Abstract: Severe respiratory failure (including acute lung injury and acute respiratory distress syndrome) caused by 2009 H1N1 influenza infection has been reported worldwide. Refractory hypoxemia is a common finding in these patients and can be challenging to manage. This review focuses on nonventilatory str
52 citations
TL;DR: National data regarding these important issues that face us in surgical critical care, trauma and acute care surgery are compiled, and potential solutions for these issues are discussed.
Abstract: Critical care workforce analyses estimate a 35% shortage of intensivists by 2020 as a result of the aging population and the growing demand for greater utilization of intensivists. Surgical critical care in the U.S. is particularly challenged by a significant shortfall of surgical intensivists, with only 2586 surgeons currently certified in surgical critical care by the American Board of Surgery, and even fewer surgeons (1204) recertified in surgical critical care as of 2009. Surgical critical care fellows (160 in 2009) represent only 7.6% of all critical care trainees (2109 in 2009), with the largest number of critical care fellowship positions in internal medicine (1472, 69.8%). Traditional trauma fellowships have now transitioned into Surgical Critical Care or Acute Care Surgery (trauma, surgical critical care, emergency surgery) fellowships. Since adult critical care services are a large, expensive part of U.S. healthcare and workforce shortages continue to impact our healthcare system, recommendations for regionalization of critical care services in the U.S. is considered. The Critical Care Committee of the AAST has compiled national data regarding these important issues that face us in surgical critical care, trauma and acute care surgery, and discuss potential solutions for these issues.
51 citations
TL;DR: The use of severity scoring and risk stratification factors, including time of onset, severity of disease, scoring systems, underlying disease and comorbidities, and effects of prior antibiotic therapy (including impact on treatment effect) in clinical trials of HAP and/or VAP are reviewed.
Abstract: Clinical studies of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) enroll patients with a very wide spectrum of disease, in part, related to the patient and/or host, the causative pathogen, and the severity of the pulmonary disease, severity of illness, and other comorbidities. Studies have identified the presence of some baseline variables (eg, Acute Physiologic Assessment and Chronic Health Evaluation II score
48 citations
TL;DR: Central line-associated bloodstream infections have been reduced in number but not eliminated in intensive care units with use of central line bundles, but many bloodstream infections that met the definition of CLABSI had sources other than central lines or represented contaminated blood samples.
Abstract: Central line-associated bloodstream infections (CLABSIs) have been reduced in number but not eliminated in our intensive care units with use of central line bundles. We performed an analysis of remaining CLABSIs. Many bloodstream infections that met the definition of CLABSI had sources other than central lines or represented contaminated blood samples.
36 citations
TL;DR: Hepcidin levels rise to extremely high but variable levels after trauma and are positively correlated with injury severity measured by ISS and duration of anemia and negatively correlated with hypoxia.
Abstract: Background: Anemia is almost universal in trauma patients admitted to the intensive care unit (ICU). Hepcidin is a liver-derived peptide that is a negative regulator of iron stores. Hepcidin synthesis is suppressed by erythropoiesis and iron deficiency and upregulated by iron overload and inflammation. Hepcidin has been shown to have an important role in the anemia of chronic inflammatory diseases but has not been previously studied in the setting of trauma. We sought to define the link between traumatic injury, hepcidin, and inflammation. Methods: One hundred fifty trauma patients admitted to the ICU were prospectively enrolled in the study. Urine was collected at regular time points for hepcidin measurement. Serum for iron studies and measurement of those cytokines associated with acute inflammation was also collected. Results: The study population comprised 73% men. Mean age was 46 years, with a median Injury Severity Score (ISS) of 27. The mean lactate level was 2.9 mmol/L, and mean hemoglobin was 12.4 g/dL. More than 50% of patients were anemic on ICU admission, and nearly all were anemic by postinjury day 10. Urinary hepcidin levels were among the highest reported to date and had a rightward skew. Iron studies confirmed functional iron deficiency. Log hepcidin values were positively correlated with ISS and negatively correlated with admission Pao 2 /FO 2 . Every increase in ISS by 10 was associated with a 40% increase in hepcidin. Initial hepcidin levels were positively correlated with duration of anemia. Conclusions: Hepcidin levels rise to extremely high but variable levels after trauma and are positively correlated with injury severity measured by ISS and duration of anemia and negatively correlated with hypoxia. Hepcidin is likely a key factor in the impaired erythropoiesis seen in critically injured trauma patients.
33 citations
TL;DR: Reporting CR-BSI thus is a more accurate measure of complications of central venous catheter use, and this rate may be more sensitive to catheter-specific interventions designed to reduce rates of BSI in the ICU.
Abstract: Background: Catheter-associated blood stream infections (CA-BSI) and catheter-related blood stream infections (CR-BSIs) differ in the degree of proof required to show that the catheter is the cause of the infection. The U.S. Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infections Surveillance [NNIS] group) collects data regarding CA-BSI nationally. We hypothesized that there would be a significant difference in the rates reported according to the definition. Methods: Prospective surveillance of CA-BSI (defined as bacteremia with no extravascular source identified) is performed in all intensive care units (ICUs) at our institution and reported as the rate per 1,000 catheter-days. In January 2006, we initiated cultures of all catheter tips to evaluate for CR-BSI (defined as a catheter tip culture with >15 colony-forming units of the same microorganism(s) found in the blood culture) in the surgical, trauma-burn, and medic...
28 citations
TL;DR: The Surgical Infection Society has been formed and is holding its first meeting here today, with the topic of surgical infections chosen to provide a current perspective and to contemplate what the future holds and the role the SIS may play.
Abstract: I am honored and humbled to stand before you today, as I follow in the footsteps of the distinguished prior Surgical Infection Society (SIS) Presidents, Doctors Stephen F. Lowry, John C. Marshall, Timothy R. Billiar, Edwin A. Deitch, and Philip S. Barie, who have served in the last five years. As I contemplated the choice of topic for my Presidential Address, I reviewed the addresses of each of these individuals (Fig. 1). I also reviewed the history of the SIS and its first President, Doctor William A. Altemeier, a true pioneer in surgical infectious diseases. The topic of Doctor Altemeier’s presidential address was ‘‘Sepsis in Surgery,’’ and the paper was read at the first annual meeting of the Society in Chicago on April 25, 1981. In this address, he stated: ‘‘Infection has always been a prominent feature of human life, and sepsis in modern surgery continues to be a significant health problem throughout the world. For this reason, the Surgical Infection Society has been formed and is holding its first meeting here today’’ [1]. I hope you will indulge me today, as I have chosen to return to the topic of surgical infections to provide a current perspective and to contemplate what the future holds and the role the SIS may play. I review three categories of surgical infections: (1) surgical site and skin infections; (2) complicated intra-abdominal infections, and (3) nosocomial and other healthcare-associated infections, including ventilator-associated pneumonia (VAP) and catheter-related blood stream infections (CR-BSI). Lastly, I touch on the topic of acute care surgery and discuss the role the SIS may play in the development of this emerging field.
19 citations
Journal Article•
TL;DR: A comprehensive knowledge of the pathophysiology, diagnostic features, causative microbial pathogens, and treatment strategies (including surgical debridement and antimicrobial therapy) is required for successful management of NSTIs.
Abstract: Necrotizing soft tissue infections (NSTIs) are aggressive severe soft tissue infection that cause rapid and widespread infection and necrosis of the skin and soft tissues and are highly lethal. NSTIs include necrotizing cellulitis, adipositis, fasciitis and myositis/myonecrosis and have significant potential for extensive soft tissue and limb loss. Early diagnosis and treatment of NSTIs remains the cornerstone of therapy. Timely aggressive surgical debridement and early appropriate antibiotic treatment are required for a successful outcome and clinical cure. Mortality rate has decreased from 25-50% in past years, to 10-16% in recent years with aggressive surgical and medical management. Additional innovative strategies for the treatment of NSTIs, including intravenous immuno-globulin G (IVIG), hyperbaric oxygen, and vacuum-assisted closure, do not yet have definitive evidence of efficacy, but may be considered in patients at high risk of death. A comprehensive knowledge of the pathophysiology, diagnostic features, causative microbial pathogens, and treatment strategies (including surgical debridement and antimicrobial therapy) is required for successful management of NSTIs.
17 citations
TL;DR: This case report describes a 45-year-old woman with paraneoplastic pemphigus who was admitted and treated in a burn intensive care unit and had progression of desquamation when potentially offending medications were discontinued.
Abstract: Paraneoplastic pemphigus is a rare cause of acute diffuse blistering in the adult patient. It commonly presents with subepidermal blistering, epidermal necrosis, and symptoms of mucosal irritation, such as conjunctivitis and vaginal ulceration. Because of its rarity, it is frequently misdiagnosed as Stevens-Johnson syndrome or toxic epidermal necrolysis. In this study, the authors will describe clinical and histologic manifestations of paraneoplastic pemphigus. This case report describes a 45-year-old woman with paraneoplastic pemphigus who was admitted and treated in a burn intensive care unit. Although initially diagnosed with Stevens-Johnson syndrome, the patient had progression of desquamation when potentially offending medications were discontinued. Diffuse adenopathy was noted on examination, and biopsy confirmed a low-grade lymphoma. Paraneoplastic pemphigus is a rare but important cause of acute diffuse blistering in adults. This disorder should be considered in the differential diagnosis of patients with diffuse blistering.
TL;DR: APACHE III is an accurate predictor of survival to hospital discharge in both open elective TAAA and AAA repairs and an excellent discriminator of hospital mortality.
TL;DR: Moxifloxacin provides clinicians with a convenient monotherapy option for the treatment of mild-to-moderate cIAIs, and demonstrates a broad spectrum of antimicrobial activity, good tissue penetration into the gastrointestinal tract, and a good tolerability profile.
Abstract: Background: Community-acquired complicated intraabdominal infections (cIAIs) present problems for clinicians and have substantial impact on hospital resources. Because of the polymicrobial nature of these infections, successful management of cIAIs depends on timely and appropriate use of antisepsis and antiinfective strategies. Methods: The literature pertinent to this article was reviewed. Results: The Surgical Infection Society and the Infectious Disease Society of America guidelines recommend a variety of single and combined antimicrobial therapies, including fluoroquinolone therapy, for prophylactic and definitive treatment of cIAIs with different severities. Moxifloxacin, a fluoroquinolone, demonstrates a broad spectrum of antimicrobial (including anaerobic) activity, good tissue penetration into the gastrointestinal tract, and a good tolerability profile. Clinical data also have demonstrated that moxifloxacin is effective as monotherapy for patients with cIAIs. This review identifies the cl...
TL;DR: Le score APACHE III est un indicateur fiable de survie hospitaliere dans the chirurgie des ATA et des AAA, bien plus important chez les survivants que chez the non-survivants.
Abstract: Objectif Aucune etude a notre connaissance n’a etudie la pertinence du score Acute Physiology and Chronic Health Evaluation (APACHE III) afin de predire la mortalite des patients operes d’une chirurgie ouverte d’un anevrysme de l’aorte thoraco-abdominale (ATA) ou abdominale (AAA). Les auteurs ont recherche a evaluer les scores APACHE III dans la prediction de la mortalite post-operatoire dans le traitement electif des ATA et des AAA. Methodes Sur une periode de 9 ans (de juillet 1998 a juin 2007), les donnees prospectives (demographiques, diagnostic a l‘admission, score APACHE III, duree d’hospitalisation ou de sejour en unite de soins intensifs, mortalite hospitaliere et en unite de soins intensifs) ont ete collectees par un coordinateur designe pour APACHE III pour tous les patients admis dans une unite de soins intensifs chirurgicale (20 lits). Des analyses comparatives et d’observation ont ete effectuees. Les chirurgies en urgence pour rupture d’anevrysme ont ete exclues de l’etude. Resultats 41 patients ont ete operes d’une chirurgie ouverte pour ATA et 404 pour AAA. L’âge moyen du groupe ATA etait de 63,4 ans, ± 9,8 ans et de 70,3 ans pour le groupe AAA ± 8,3 ans. Le score APACHE III moyen etait de 54 (10-103) pour le groupe ATA et de 45 (11-103) pour le groupe AAA. Le taux de mortalite hospitaliere etait de 4,9% pour le groupe ATA ( n = 2) et de 2% pour le groupe AAA ( n = 8). Le score APACHE III moyen etait a l’admission en unite de soins intensifs bien plus important chez les survivants que chez les non-survivants (79 contre 45, p Conclusions le score APACHE III est un indicateur fiable de survie hospitaliere dans la chirurgie des ATA et des AAA.