Damage Control Surgery—The Intensivist's RoleSagraves, Scott G.; Toschlog, Eric A.; Rotondo, Michael F.
doi: 10.1177/0885066605282790pmid: 16698739
“Damage control” surgery has evolved during the past 20 years from an accepted surgical technique in the traumatized, moribund patient to an expanded role in critically ill, nontraumatized patients. Physicians caring for these patients in extremis have begun to recognize a pattern of severe physiologic derangement that prompts an abbreviated laparotomy after hemorrhage and contamination control. Emphasis then shifts from the operating theater to the intensive care unit, where the patient's physiologic deficits are corrected. Once these derangements have been resolved, the patient is taken back to the operating room for definitive, reconstructive surgical care. The purpose of this article is to review the concept of “damage control” in reference to the patient whose pathophysiologic depletion prompts the need for it. Resuscitation in the intensive care unit will be summarized, pitfalls will be identified, and treatment plans will be delineated. Complications such as abdominal compartment syndrome and difficult abdominal wall closures will also be discussed.
Diagnosis of Ventilator-Associated Pneumonia: Focus on Nonbronchoscopic Techniques (Nonbronchoscopic Bronchoalveolar Lavage, Including Mini-BAL, Blinded Protected Specimen Brush, and Blinded Bronchial Sampling) and Endotracheal AspiratesFujitani, Shigeki; Yu, Victor L.
doi: 10.1177/0885066605283094pmid: 16698740
The ideal diagnostic approach for ventilator-associated pneumonia currently is based on invasive procedures to obtain respiratory tract cultures. Given the lack of consensus and relatively poor acceptance of full bronchoscopic bronchoalveolar lavage (BAL) and protected specimen brush (PSB), less invasive procedures have been developed. We review the nonbronchoscopic procedures (nonbronchoscopic bronchoalveolar lavage, including mini-BAL, blinded protected specimen, and blinded bronchial sampling) and endotracheal aspiration. We provide a critique of the methods used, the types of catheters inserted, and the sample collection methods. Most studies were flawed in that antibiotic use before initiation of the procedure was not controlled. The variability of both the methods and the criteria for the gold standard in the numerous investigations show that these procedures are neither standardized nor proven to be accurate and often did not improve management. Pending future studies, use of endotracheal aspirates without the use of quantitation seems to be a reasonable approach for clinicians who are not committed to an invasive procedure.
Perioperative Effects and Safety of Nesiritide Following Cardiac Surgery in ChildrenSimsic, Janet M.; Scheurer, Mark; Tobias, Joseph D.; Berkenbosch, John; Schechter, William; Madera, Freddie; Weinstein, Samuel; Michler, Robert E.
doi: 10.1177/0885066605282532pmid: 16698741
Nesiritide (Natrecor, Scios Inc), human B-type natriuretic peptide, has hemodynamic effects that may be beneficial in pediatric patients after cardiac surgery. Experience with nesiritide and pediatrics is limited. The purpose of this study was to evaluate perioperative effects and safety of nesiritide in pediatric cardiothoracic surgery. Seventeen patients with congenital heart disease undergoing cardiac surgery were given a loading dose (1 µg/kg) while on cardiopulmonary bypass (constant flow) followed by continuous infusion for 24 hours (0.01 µg/kg/min × 6 hours, then 0.02 µg/kg/min × 18 hours). A 7% decrease in mean blood pressure was seen following nesiritide loading dose on cardiopulmonary bypass. No patient required intervention for hypotension while receiving nesiritide load or infusion. Nesiritide load during surgery and continuous infusion after cardiac surgery in pediatric patients resulted in no significant hemodynamic compromise.
Mechanical Complications of Central Venous CathetersEisen, Lewis A.; Narasimhan, Mangala; Berger, Jeffrey S.; Mayo, Paul H.; Rosen, Mark J.; Schneider, Roslyn F.
doi: 10.1177/0885066605280884pmid: 16698743
We analyzed 385 consecutive central venous catheter (CVC) attempts over a 6-month period. All critically ill patients 18 years of age or older requiring a CVC were included. The rate of mechanical complications not including failure to place was 14%. Complications included failure to place the CVC (n = 86), arterial puncture (n = 18), improper position (n = 14), pneumothorax (n = 5 in 258 subclavian and internal jugular attempts), hematoma (n = 3), hemothorax (n = 1), and asystolic cardiac arrest of unknown etiology (n = 1). Male patients had a significantly higher complication rate than female patients (37% vs 27%, P = .04). The subclavian approach had a higher complication rate than the internal jugular or the femoral approach (39% vs 33% vs. 24%, P = .02). The complication rate increased with the number of percutaneous punctures, with a rate of 54% when more than 2 punctures were required.
Acute Pulmonary Edema Due to Rosiglitazone Use in a Patient With Diabetes MellitusÇekmen, Nedim; Cesur, Mustafa; Çetinbaş, Riza; Bedel, Paşa; Erdemli, Özcan
doi: 10.1177/0885066605283385pmid: 16698744
Rosiglitazone is a peroxisome proliferator active receptor. γ agonist, which increases insulin sensitivity in adipose tissue, muscle, and liver. Rosiglitazone is a member of the thiazolidinedione group, and because of its significantly positive effect on glycemic control, it is especially preferred in type 2 diabetic patients with a high cardiovascular disease risk. This drug, because of its decreasing effect on insulin resistance, is used alone or combined with type 2 diabetic drugs. A 73-year-old female patient was admitted to the emergency department with dyspnea, pink frothing phlegm, cyanosis, and tiredness. She was lethargic, uncooperative, and had no orientation. In arterial blood gases, hypoxemia and hypercapnia were found. She was taken to the general intensive care unit, and oxygen was applied via mask. The patient had a history of 10 years of diabetes mellitus, hypertension, and atherosclerotic cardiac disease, and she was using rosiglitazone for the past 6 weeks. Her chest x-ray was taken, and acute pulmonary edema was diagnosed. In her last echocardiography, which was performed 1 year before, no signs indicating cardiac failure and pleural effusion could be found. Therefore, it was concluded that pulmonary edema occurred as a complication of rosiglitazone use. After stabilizing the patient's vital signs, blood glucose levels, and lactate levels, medical treatment of diabetes mellitus was rearranged, and she was discharged on the seventh day after her admittance. In a patient with diabetes mellitus who has been admitted to the intensive care unit because of acute pulmonary edema, for differential diagnosis, use of rosiglitazone should be kept in mind during the determination of treatment. Therefore, the authors aim to discuss the effect of rosiglitazone on creating acute pulmonary edema with a case report presentation.