Speciality
Spotlight

 




 

Critical Medicine – Emergency Medicine

 

 




  • VM
    Ranieri, PM Suter, C Tortorella, et al (Universita di Bari, Italy; Universite de Geneva, Switzerland; Univ of Toronto, Canada)


    Effect of Mechanical Ventilation on Inflammatory Mediators in Pateints with Acute Respiratory Distress Syndrome : A Randomized Controller Trial


    JAMA 282: 54-61, 1999

          


    Mechanical ventilation can escalate or cause an inflammatory response and acute lung injury. The influence of mechanical ventilation on the lung and systemic cytokine levels was assessed in patients with acute respiratory distress syndrome in a randomized controlled trial.

         


    This study offers stimulating data in patients with ARDS, showing elevation of multiple cytokines in BAL fluid and plasma in patients treated with conventional ventilator settings, and a decrease in these mediators over a period of time in patients treated with a protection ventilation strategy. Patients in the protective protocol were treated with lower end-expiratory pressures, tidal volumes and fraction of inspired oxygen. The mechanisms by which ventilator-induced injury might be mediated remain uncertain, and clinical trials of lung protective strategies have yielded variable results. However, in this study, Ranieri and colleagues offer striking evidence for the link between mechanical ventilation and acute inflammatory lung injury, and the potential for benefit by limiting lung distention.

         

  • Goldhaber
    SZ [Harvard Med school]

    Pulmonary Embolism

    N. Engl J Med 339 : 93-104, 1998

       

    The best approach to diagnosis of pulmonary embolism
    is a careful history and physical examination with
    selective testing as indicated.

       

    Dyspnea
    is the major symptom.

       

    Tachypnea
    is the major sign.

       

    A
    massive embolism is suspected in patients with
    Dyspnea, Syncope or cyanosis whereas with pleuritic
    pain, cough or hemoptysis are more likely to have a
    small embolism near the pleura.

       

    To
    rule out acute pulmonary embolism perfusion lung
    scanning is still the most important test.

      

    Main
    stage of treatment is heparin.

      

    Unless
    contraindicated, patient should receive intensive
    heparin anticoagulation – usually 5000 to 10000
    units bolus followed by continuous infusion at a
    rate of 18 units per kg per hour; which should be
    given during the diagnostic working. This usually
    produces a therapeutic partial thromboplastin time
    of 60 to 80 seconds. Patients with venous thrombosis
    associated with metastatic cancer may receive short
    or long term heparin therapy to prevent recurrent
    thrombosis.

      

    Once a patient has reached a therapeutic partial
    thromboplastin time – it is usually safe to start
    warfarin therapy, although at least 5 days of
    continuous intravenous heparin is 
    recommended to achieve true anticoagulation.
    Anticoagulation should continue preferably for 6
    months and not 6 weeks to prevent recurrences.

       

    Current
    understanding of the importance of the right
    ventricular dysfunction enables more accurate
    prognosis in  patients
    with pulmonary embolism. Finally, the take home
    message is that surgeons should have a low threshold  
    to evaluate seemingly minor post operative
    complications viz, fever, tachycardia because many
    of these patients have small pulmonary embolism that
    are effectively treated by aggressive
    anticoagulation.

       

  • Heyland
    DK, for the Canadian Critical Care Trials Group
    [Queen’s Univ, Kingston, Ont, Canada; et al]

    The Clinical Utility of Invasive Diagnostic
    Techniques in the Setting of Ventilator – Associated
    Pneumonia


    Chest
    115: 1076-1084, 1999

       

    Ventricular-associated
    pneumonia [VAP] is often diagnosed on clinical
    grounds alone and contributes to the morbidity,
    mortality and costs of caring for critically ill
    patients. Overdiagnosis may be disastrous with the
    use of needless antibiotics and the delay in
    recognition of the ‘true’ diagnosis.

       

    The
    utility of invasive investigations like bronchoscopy,
    with protected brush catheter [PBC] bronchoalveolar
    lavage [BAL] was evaluated in 92 patients receiving
    ventilatory support with
    a clinical suspicion of VAP.

       

    The
    results showed that VAP was often overdiagnosed
    after BAL or PBC after these procedures. Patients
    received fewer antibiotics. Both groups had similar
    duration of mechanical ventilation and ICU stay.
    Those who underwent PBC/BAL had a lower mortality.

      

    Invasive
    diagnostic testing may boost physicians confidence
    in the diagnosis and management of VAP.

        

  • Kristen
    Moller and Peter Skinhoj (Dept of Infectious
    Diseases, Denmark)

    Guidelines
    for managing acute bacterial meningitis

    BMJ,
    Vol.320, 13 May 2000, pg.1290

       

    Nearly one in four adults with acute
    bacterial meningitis will die and many survivors
    sustain neurological deficits. 
    The outcome has not changed despite potent
    antibiotics and specialised intensive care units.

     

    Standardised guidelines are issued by British
    Infection Society. Family
    doctors may give benzylpenicillin before admission
    to hospital. After
    admission to hospital, widely accepted empirical
    treatment is a third generation cephalosporine, such
    as cefotaxim or ceftriaxone, with ampicillin
    if listerial meningitis cannot be ruled out.
    In patients with obvious meningococcal
    disease, penicillin is the drug of choice.
    Pneumococci are less susceptible to
    penicillin and rifampicin is useful for truly
    penicillin resistant penumococci.
    Selection of appropriate treatment for
    patients who are hypersensitive to beta-lactams is
    difficult. Meropenem
    or broad spectrum quinolones may be considered.
    There is little evidence that they work.

      

    Supportive treatment is debated.  Corticosteroids reduce neurological deficit in children with Haemophilus
    influenzae
    or broad spectrum quinolones may be
    considered.  There
    is little evidence that they work.

      

    Corticosteroids reduce neurological deficit in children with haemophilus
    influenzae
    , but evidence in adults is lacking.
    Glycerol or mannitol if there is intracranial
    hypertension, full fluid replacement is necessary.

      

    Speedy
    diagnosis and treatment will serve patients well.

        

  • J
    Briegel, H Forst, M Haller, et al (Ludwig-Maximilians-Universitat
    Munchen, Munich)

    Stress Doses of Hydrocortisone
    Reverse Hyperdynamic Septic Shock: A Prospective,
    Randomized, Double-blind, Single-center Study.

    Crit Care Med 27:723-732, 1999.

       

    Past studies have showed that stress doses of
    hydrocortisone were ineffective in septic shock.  However, recent studies have shown that a patient in septic
    shock may have relative adrenocortical
    insufficiency.

        

    In
    septic shock, a 100mg loading dose of hydrocortisone
    was given within 30 min, and followed by an infusion
    of (0.18mg/kg/hr) hydrocortisone. 
    After reversal of shock, the dose was reduced
    to 0.08mg/kg/hr and continued for 6 days.

        

    This
    significantly reduces the duration of vasopressor
    support and may shorten the time for resolution of
    sepsis induced organ dysfunction.

        

  • MB
    Malay, Jr Ashton RC, DW Landry, et al (Allegheny Gen
    Hosp, Pittsburgh, Pa; Columbia, Univ, New York)




    Low-Dose
    Vasopressin in the Treatment of Vasodilatory Septic
    Shock

    J Trauma  47: 699-705, 1999.

       

    Refractory
    hypotension not responding to epinephrine in septic
    shock is potentially fatal. 
    It has been suggested that asopressin used
    concomitantly could give better results.

       

    The
    vasopressor was infused at a rate of 0.04U/min. 
    This permitted maintenance of arterial
    pressure thus allowing withdrawal of vasopressors.

       

  • MWA
    Angstwurm, J Schottdorf, J Schopohl, et la (Univ of
    Munich, Germany)

    Selenium
    Replacement in Patients with Severe Systemic
    Inflammatory Response Syndrome Improves Clinical
    Outcome.

    Crit Care Med 27: 1807-1813, 1999.

       

    Systemic inflammatory response syndrome (SIRS)
    causes substantial morbidity and mortality. It has
    also been recorded that selenium concentrations are
    reduced in SIRS. 
    This is a pilot study on the effects of
    selenium replacement on SIRS related morbidity and
    mortality.

       

    Selenium
    was replaced as i.v. sodium selenite in a decreasing
    dosage over a period of 10 days.

       

    Within
    30 days, patients had normal selenium and
    glutathione peroxidose levels. 
    There was significant reduction in Acute
    Physiologic and Chronic Health Evaluation III scores
    as compared to controls. 
    Only 14% (as against 43% in controls) had
    renal failure and the mortality was 34% against 54%
    in the control group.

      

  • JE
    Gadek, and the Enteral Nutrition in ARDS Study Group
    (Ohio State Univ, Columbus; et al )

    Effect
    of Enteral Feeding with Eicosapentaenoic Acid,
    g-Linolenic
    Acid, and Antioxidants in Patients with Acute
    Respiratory Distress Syndrome.

    Crit Care Med  27:
    1409-1420, 1999.

       

    Low carbohydrate, high fat nutritional support
    for ventilated patients reduces demands on the
    respiratory system and decreases the severity of the
    inflammatory injury. 
    Animal studies show that diets rich in
    eicosapentaenoic acid,
    g-linolenic
    acid and antioxidants can moderate inflammation. 
    This is a prospective double blind randomized
    controlled trial (multi-centered) to evaluate the
    effect of a diet supplemented with EPA, GLA and
    antioxidants on the clinical outcome of ARDS.

       

    The
    patients on the test diet required fewer days of
    ventilatory support in ICU or on supplemental oxygen
    and had less new organ failure. 
    The infection rates were the same but the
    test diet patients had fewer adverse events.

        

  • VM
    Ranieri, PM Suter, C Tortorella, et al (Univ of
    Toronto)


    Effect
    of Mechanical Ventilation on Inflammatory Mediators
    in Patients with Acute Respiratory Distress
    Syndrome: A Randomized Controlled Trial.

    JAMA 282:54-61, 1999

        

    Mechanical ventilation can escalate or cause an
    inflammatory response and acute lung injury. 
    The influence of mechanical ventilation on
    the lung and systemic cytokine release was assessed
    in patients with ARDS.

       

    Two
    groups were assessed (1) a control group and (2) a
    lung protective strategy group.

        

    At
    baseline physiologic characteristics and cytokine
    concentrations were similar. 
    But after 24 and 36 hours, there were
    significant between-group differences in tidal
    volume, end-inspiratory plateau pressures and PEEP.  The lung protective strategy group had significantly better
    results.  It
    could be concluded that mechanical ventilation can
    produce a cytokine response that may be diminished
    by minimising overdistension and recruitment and
    derecruitment of the lung.

       

  • PC
    Hebert, for the Canadian Critical Care Trials Group
    (Univ of Ottawa, Canada; et al)

    A Multicenter, Randomized, Controlled Clinical Trial of Transfusion
    Requirements in Critical Care,

    N Engl J Med 340: 409-417, 1999.

       

    The optimal transfusion strategy for cirtically
    ill anaemia patients has not been standardised. 
    A randomised, controlled study was undertaken
    comparing a restrictive (when Hb <7.0gms/dL) with
    a liberal approach (when Hb <10gms/dL).

      

    The study was conducted on 838 critically ill
    patients randomly assigned to one of the two groups.

       

    The overall 30 days mortality was similar. 
    Mortality rates were significantly lower in
    the restrictive group in less acutely ill patients
    but was similar in critically ill patients. 
    The mortality during hospitalization was
    significantly lower in the restrictive group.

      

  • S
    Deb, B Martin, L Sun, et al (Natl Naval Med Ctr,
    Bethesdam Md; Walter Reed Army Med Ctr, Washington,
    DC; Uniformed Services Univ of the Health
    Sciences, Bethesda, Md)

    Resuscitation With Lactated Ringer’s Solution in Rats with Hemorrhagic
    Shock Induces Immediate Apoptosis.

    J Trauma: Injury Infect Crit Care 
    46: 582-589, 1999.

         

    For patients in haemorrhagic shock, reperfusion
    injury can cause cell damage, leading to cell death
    and organ failure. 
    Apoptotic cell death is thought to play an
    important role in the pathophysiology of
    haemorrhagic shock. 
    The effects of resuscitation with lactated
    Ringer’s solution on cell apoptosis were assessed.

       

    It was seen that the use of lactated Ringer’s
    solution for resuscitation caused a significant
    increase in cell apoptosis in the small intestine
    and the liver as compared with other agents used for
    resuscitation.

       

    FA Luchette, BRH Robinson, LA Friend, et al (Univ of
    Cincinnati, Ohio)

    Adrenergic Antagonists Reduce Lactic Acidosis in Response to Hemorrhagic
    Shock

    J Trauma : Injury Infect Crit Care 
    46: 873-880, 1999.

      

    During haemorrhagic shock, lactic acidosis and
    plasma catecholamines are significantly increased. 
    The increase in circulating catecholamines
    have a greater effect on the post haemorrhagic
    lactic acidosis than do poor perfusion and tissue
    hypoxia.

       

    The use of a-blockers
    with a b-blocker
    significantly reduces plasma lactate levels, but had
    no effect on tissue perfusion. 
    In an in-vitro study propranolol eliminated
    the increased lactate production by muscle in
    response to epinephrine.

        

    The results question the use of lactate clearance as
    a resuscitation end point for patients with
    haemorrhagic shock.

       

    E Barquist, E Fein, D Shadick, et al (Univ of Miami,
    Fla)

    A Randomized Prospective Trial of Amphotericin B Lipid Emulsion Versus
    Dextrose Colloidal Solution in Critically ill
    Patients.

    J Trauma 
    47: 336-340, 1999.

       

    Amphotericin B is the drug of choice in fungal
    infections in critically ill patients. 
    However, it carries at least a 50% risk of
    nephrotoxicity, inspite of preventive measures.

       

    A trial was conducted using a combination of
    Amphotericin B with 20% intralipid solution in
    critically ill patients with positive fungal
    cultures of peritoneum, sputum or blood. 
    The dose was 1mg/kg/d as against 0.5mg/kg/d
    given to controls (with 5% dextrose).  

        

    It was found to have less nephrotoxicity than
    Amphotericin with Dextrose. 
    It can safely be given at a higher total
    cumulative dose.

       

  • RS
    Hotchkiss, PE Swanson, CM Knudson, et al (Washington
    Univ, St Louis)

    Overexpression of Bcl-2 in Transgenic Mice Decreases Apoptosis and
    Improves Survival in Sepsis.

    J Immunol 162: 4148-4156, 1999

       

    Sepsis is associated with extensive lymphocyte
    apoptosis, which may reduce  nflammation, but
    impairs host defences.

       

    The effect of Bcl-2 (a protein product) has been
    shown to prevent apoptotic cell death. 
    Its effect on lymphocyte 
    apoptosis was studied in a rat model
    comparing 2 sets. (1) transgenic mice that
    selectively overexpressed B cl-2 in T lymphocytes as
    well as in endotoxin 
    resistant species and (2) the endotoxin
    sensitive species.

       

    The Bcl-2 overexpressors showed complete protection
    against sepsis induced apoptosis. 
    The protective effect may result from the
    preservation of mitochondrial membrane potential.

       

    The aim of the study is to assess the influence of
    preoperative portal vein embolization on the
    long-term outcome of liver resection for colorectal
    metastases.  

        

    30 patients underwent PVE and 88 patients did
    not before resection of 4 or more liver segments. 
    The groups were comparable in terms of sex,
    age, number and type of metastases (synchronous vs
    metachronous) and number of courses of neoadjuvant
    chemotherapy.

        

    The main criterion for PVE was that resection was
    technically feasible but contraindicated because the
    remnant liver was too small (as estimated by CT scan
    volumetry). 
    It was done when the estimated rate of
    remnant functional liver parenchyma (ERRFLP) was 40%
    or less.

       

    PVE was feasible in all patients. 
    There were no deaths with a complication rate
    of 3%. 
    The post ERRFLP was significantly increased
    as compared to pre PVE value. 
    Liver resection was performed in 19 patients
    (63%) with a mortality of 4% and complication rate
    of 7%. 
    The survival rates after hepatectomy in both
    groups were comparable.

       

    The authors conclude that PVE allows more patients
    with unresectable liver metastases to benefit from
    surgery.

       

  • Lena
    Gamrin, Pia Essen, Eric Hultman, et al (The
    Department of Anesthesiology and Intensive Care and
    Clinical Chemistry II, Huddinge University Hospital,
    Karolinska Institute, Stockholm, Sweden; and the
    Department of S6urgery at State University of New
    York,Stony Brook, New York)

    Protein-Sparing Effect in Skeletal Muscle of Growth Hormone Treatment in
    Critically III Patients.

    Annals of Surgery, April 2000, 231(4), 577-586.

      

    This study investigates the effect of growth
    hormone (GH) treatment on skeletal muscle protein
    catabolism in patients with multiple organ failure
    in the ICU.

       

    20 critically ill ICU patients were randomized into
    2 groups – one as control and the other with GH
    (0.3U/kg/day). Percutaneous muscle biopsy was taken
    before and 5 days after treatment starting on day 3
    to 42 of the patient’s ICU stay. 
    Protein content, protein synthesis, water
    nucleic acids and free amino acids were analysed.

       

    The fractional protein synthesis rate and muscle
    free glutaminic increased in 
    the GH group. 
    Total intramuscular water did not increase
    but the intracellular water increased.

       

    It is concluded that treatment with GH in patients
    with multiple organ failure, stimulated muscle
    protein synthesis, increased muscle free glutaminic
    and increased into a cellular water.

      

  • Byers
    RJ, Eddleston JM, Pearson RC, et al [Univ of
    Manchester, Manchester Royal Infirmary, England]

    Dopexamine Reduces the Incidence of Acute
    Inflammation in the Gut Mucosa After Abdominal
    Surgery in High-risk Patients


    Crit
    Care Med 27: 1787-1793, 1999

       

    About
    20% of critically ill patients have acute
    inflammation in the stomach/duodenum. 
    Dopexamine has dopaminergic receptor agonist
    properties but no alpha or beta [1] effects. 
    It may exhibit anti-inflammatory effects.  Thus, a study was devised to examine endoscopically and
    histologically the effect of Dopexamine on gut
    mucosa. The study represented the side arm of a
    large, prospective, randomized, controlled,
    multicenter European Study
    [Effect
    of Dopexamine on Outcome after Major Abdominal
    Surgery].

      

    38 patients with at least one high risk
    criterion, who were undergoing major abdominal
    surgery of at least 1.5 hours’ duration, were
    submitted to endoscopy and biopsy of the upper
    gastrointestinal tract immediately after anesthesia. 
    After being stabilized, patients received
    placebo [Group A, n=12], 0.5 micro-g/Kg per minute
    of dopexamine [Group B, n=13], and 
    2.0 micro-g/kg  
    per minute  
    of  
    dopexamine 
    [ Group C, n=13]. At 72 hours, endoscopy and
    biopsy were repeated in 27 patients. 
    Upper gut blood flow was estimated using
    tonometry.  pH
    was calculated at baseline, after surgery, and
    2,6,12,24,30 and 36 hours after surgery.

       

    Gastric pH decreased significantly and similarly in
    all the three groups, with the greatest increase
    being recorded at the end of surgery. 
    Erythema or hemorrhagic changes were found in
    33.3% of Group A, 38.5% of Group B, and 15.4% of
    Group C. Erosive disease was seen in 25%, 7.7% and
    38.5% respectively. 
    At 72 hours, endoscopy revealed that the
    number of patients with no detectable abnormality
    had decreased to 25%, 20%, and 33.3% respectively. 
    Polymorphonuclear neutrophil proliferation
    was seen in 86%, 37.5% and 37.5% respectively. 
    There was no correlation between endoscopy
    and histologic findings.

      

    Dopexamine
    does protect against the ill effects of decreased pH
    during surgery though it does not prevent such a
    decrease.

      

  • Hebert
    PC, et al for the Canadian Critical Care Trials
    Group [Univ. of Ottawa, Ontario]

    A Multicentric, Randomized Controlled Clinical
    Trial of Transfusion Requirements in Critical Care


    N
    Engl J Med 340:409-417, 1999

      

    The
    optimal transfusion strategy for critically ill
    anemic patients has not been determined. 
    To understand the potential risks and
    benefits of transfusions in critically ill patients,
    a randomized, controlled clinical trial compared a
    restrictive versus a liberal approach to red cell
    transfusions.

       

    The
    study group consisted of 838 critically ill patients
    admitted to hospitals or ICUs in Canada, over a 4
    year period.  Consecutive
    critically ill normovolemic patients were randomly
    assigned to either a restrictive strategy
    [transfusion when hemoglobin level fell below 7.0 g/dL],
    or a liberal strategy [transfusion when hemoglobin
    level fell below 10 g/dl]. 
    The primary outcome measure was 30-day death
    from all causes. 
    Secondary outcomes included 60-day death from
    all causes.

       

    The
    overall 30-day mortality rate was not significantly
    different in the two groups. 
    Mortality rates were lower in younger, less
    acutely ill patients in the restrictive group,
    though not in patients with severe cardiac disease. 
    The mortality rate during hospitalization was
    significantly lower in the restrictive group
    compared to the liberal transfusion strategy group.

       

    Restrictive
    red cell transfusion strategy [hemoglobin levels
    below 7.0 g/dL], was as effective as, and in some
    cases superior to, the liberal transfusion strategy
    [hemoglobin levels below 10 g/dL], in critically ill
    normovolemic anemic patients, except in those with
    severe cardiac disease.

      

  • Hanson
    CW III, Deutschman CS, Anderson HL III, et al [Univ
    of Pennsylvania, Philadelphia : Univ of California,
    Irvine]

    Effects
    of an Organized Critical Care Service on Outcomes
    and Resource Utilization : A Cohort Study


    Crit Care Med 27: 270-274, 1999

       

    Practice
    patterns are under scrutiny at both institutional
    and national levels to eliminate inefficiency, lower
    costs, and improve clinical results. 
    Critical care medicine would seem to be
    particularly susceptible to the current forces of
    change.  The
    cost and effectiveness of two patterns of critical
    care practice, in an academic medical center, were
    examined to determine whether presence of an
    on-site, organized, supervised critical care service
    improves care and reduces resource utilization.

      

    Two patients cohorts admitted to a surgical
    intensive care unit [SICU] were compared. One group
    received care from an on-site critical care team,
    supervised by an intensive care specialist. 
    The other group received care from a team
    with patient care responsibilities in multiple sites
    supervised by a general surgeon. The primary outcome
    measures were duration of stay, resource
    utilization, complication rates, resultant effects
    on added investigations, consultations, and terminal
    outcomes.

      

    The results showed patients receiving care from an
    on-site critical care service had higher Acute
    Physiology and Chronic Health Evaluation II [APACHEII]
    scores, yet they spent less time in SICU, used fewer
    resources, had fewer complications, and had lower
    total hospital charges. 
    These differences were more pronounced with
    increasing severity of illness.

      

  • Pronovest
    PJ, Jenckes MW, Dorman T, et al [John Hopkins Univ,
    Baltimore, MD]

    Organizational
    Characteristics of Intensive Care Units Related to
    Outcomes of Abdominal Aortic Surgery

    JAMA 281: 1310-1317, 1999

      

    ICUs at different institutions vary widely in
    terms of morbidity and mortality rates. 
    The effects of ICU structure and care
    processes on these outcomes are not known. 
    The effects of ICU organization on the
    clinical and economic outcomes for patients
    undergoing abdominal aortic surgery were studied.

      

    Hospital
    data on 2987 patients on whom abdominal aorta
    surgery was performed, in the state of Maryland,
    over a two year period, was analyzed. 
    Data on organizational characteristics of
    ICUs were obtained from medical directors. 
    The main outcomes assessed were in-hospital
    mortality, and length of total hospital and ICU
    stay.

      

    The
    in-hospital mortality rates ranged from 0% to 66%.
    ICUs that did not have daily rounds by an ICU
    physician showed a 3-fold increase in in-hospital
    mortality after adjustment for patient demographic,
    co-morbidity, severity of illness, hospital and
    surgeon volume, and hospital characteristics. 
    Other outcomes, such as cardiac arrest, acute
    renal failure, septicemia, and reintubation, were
    also more likely at centers without daily rounds by
    an ICU physician.

          

  • Leape
    LL, Cullen DJ, Clapp MD, et al [Harvard School of
    Public Health : Massachusetts Gen. Hospital; Brigham
    and Women’s Hosp., Boston]

    Pharmacist
    Participation on Physicians Rounds and Adverse Drug
    Events in the Intensive Care Unit

    JAMA 282: 267-270, 1999

       

    Although studies show that pharmacist review of
    ICU prescription orders prevents mistakes and lowers
    drug costs by reducing drug use, there have been no
    studies on the benefits of having a pharmacist
    present in the ICU at the time drugs are prescribed. 
    The efficacy of pharmacist participation in a
    medical ICU in preventing adverse drug events [ADEs]
    was tested in a controlled clinical trial.

        

    Between
    February 1 and July 31, 1993 [Phase 1
    Preintervention] and October 1, 1994 and July 7,
    1995 [Phase 2 postintervention], the effect of
    pharmacist intervention was tested in a 17-bed ICU
    [the study unit] and compared with no pharmacist
    intervention in a 15-bed coronary care unit with
    similar occupancy rate [the control unit].

      

    ADEs
    were compared for 75 randomly selected patients in
    each of the 3 groups from amongst all patients
    admitted to the study unit in Phase 1 and 2, and all
    patients admitted to the control unit in Phase 2. An
    experienced pharmacist made daily morning rounds
    with ICU personnel in the study unit; an experienced
    pharmacist was available for consultation but did
    not make daily rounds in the control unit. 
    Outcome measures included measurements of
    ADEs, interventions the pharmacist made, and the
    acceptance of pharmacist interventions by the
    physicians and nurses.

        

    The
    overall rate of preventable ordering and ADEs/1000
    patient days decreased by 66% in the study unit from
    Phase 1 to 2, with significant savings in drugs
    costs.  The
    rate of ADEs came down significantly in the study
    group from Phase 1 to 2. In the control group the
    rate of ADEs continued to remain high.

       

    Of
    the 398 pharmacist interventions reported, 366 were
    related to ordering and 362 were accepted by the
    physicians.  Pharmacist
    – initiated clarifications or correction of
    incomplete orders, wrong dose, wrong frequency,
    inappropriate choice, or duplicate therapy accounted
    for 46% of interventions. 
    Drug interactions or adverse reactions were
    prevented in 22 cases. 

        

    The
    presence of a pharmacist at rounds in ICUs
    significantly reduces incidence of ADEs and result
    in substantial cost savings.

        

  • Darouiche
    RO for the Catheter Study Group [Baylor College of
    Medicine, Houston, et al]

    A
    Comparison of Two Antimicrobial -Impregnated Central
    Venous Catheters

    N. Engl J Med 340: 1-8, 1999

       

    Previous studies have shown that rates of
    central venous catheter colonization and catheter
    related blood stream infection can be significantly
    reduced through the use of catheters impregnated
    with minocycline and rifamycin or with chlorhexidine
    and silver sulphadiazine. 
    However, no studies have directly compared
    the benefits of the two types of catheter.
    Minocycline/rifamycin and chlorhexidine/silver
    sulphadiazine catheters were compared for their
    ability to prevent colonization and catheter-related
    blood stream infections.

       

    The
    prospective, multicenter trial included adult
    patients considered at high risk for
    catheter-related infection who were likely to
    require a central venous catheter for 3 days or
    longer.  The
    patients were randomized to receive polyurethane
    triple-lumen catheters impregnated with minocycline/rifamycin
    on the luminal and external surfaces or with
    chlorhexidine/silver sulphadiazine on the external
    surface only. Catheter tips and subcutaneous
    segments were cultured by both the roll-plate and
    sonication methods after removal, with peripheral
    blood cultures performed as indicated. 
    The analyses included a total of 738
    catheters with evaluable culture results.

       

    The
    two catheter groups were similar in their clinical
    characteristics and infection risk factors. 
    The catheter colonization rate was 8.3% with
    monocycline/rifamycin impregnated catheters vs 22.8%
    in the other group. The former were also associated
    with lower rate of blood stream infection [0.3% vs
    3.4%]. The authors emphasize that adequate aseptic
    technique must complement the use of monocycline/rifamycin
    impregnation of central venous catheters.

      
          
     


  • D.S.
    Walsh, P. Siritongtaworn, K. Pattanapanyasat. P.
    Thavichaigarn, P. Kongcharoen, N. Jiarakul, P.
    Tongtawe, K. Yongvanitchit, C. Komoltri, C.
    Dheeradhada, F.C. Pearce, W.P. Wiesmann and H.K
    Webster [**]

    [**
    Department of Immunology and Medicine, US Army
    Medical Component, Armed Forces Research Institute
    of Medical Sciences, Departments of Surgery,
    Hematology and Clinical epidemiology, Siriraj
    Hospital, Department of Surgery, Pharmongkutklao
    [Royal Thai Army] Hospital, and Department of
    Surgery, Police Hospital, Bangkok, Thailand and
    Division of Surgery, Walter Reed Army Institute of
    Research, Washington, DC, USA ]

    Lymphocyte Activation After Non-Thermal Trauma

    Br.
    J. of  Sur.,  Volume 87, Number 2, February, 2000, Pg. 223-230

       

    Service
    injury causes immunologial changes that may
    contribute to a poor outcome. Longitudinal
    characterization of lymphocyte response patterns may
    provide further insight into the basis of these
    immunological alterations.

      

    Venous
    blood obtained seven times over 2 weeks from 61
    patients with injury severity scores over 20 was
    assessed for lymphocyte and activation markers
    together 
    with serum 
    levels of interleukin [IL]2, IL-4, soluble
    IL-2 receptor [sIL-2R], soluble CD4 [sCD4], soluble
    CD8 [sCD8] and interferon g.

       

    Severe
    injury was associated with profound changes in the
    phenotypic and activation profile in the phenotypic
    and activation profile of circulating lymphocytes.
    Activation was indicated by increased number of T
    cells expressing CD25, sIL-2R and sCD4 and sCD8 were
    found in-patients with sepsis syndrome.

       

    Polytrauma
    is associated with dramatic alterations in the
    phenotypic and activation profile of circulating
    lymphocytes which are generally independent of
    clinical course. In contrast several lymphocyte
    soluble factors including sCD4 and SIL-2R,
    paralleled the clinical course. These data provide
    new insight into lymphocyte responses after injury
    and suggest the further assessment of soluble
    factors as clinical correlates. 

       

  • Helen
    F Galley , ( Academic Unit of Anaesthesia and
    Intensive Care, Department of Medicine, Aberdeen ).

    Commentary –  Renal Dose Dopamine : Will the
    message now get through ?

    Lancet, Vol.356, 23/30 December, 2000, pg. 2112

      

    Deterioration in renal function is common in
    critically ill patients under intensive care. It
    lengthens patient’s stay in the intensive – care
    unit and their risk of death. Management of such
    cases is restricted to supportive measures and
    critical care doctors are eager for any new approach
    that might prevent the onset of renal dysfunction or
    hasten its recovery.

      

    Dopamine is used in intensive – care units as an
    inotropic and vosoactive agent. At low or
    “renal” doses (0.5 to 2.0 mg/kg per min )
    its actions are mainly dopaminergic . In laboratory
    animals and healthy volunteers low doses of dopamine
    increase renal blood flow and GFR and inhibit
    proximal tubular reabsorption of sodium, which
    result in natriuresis. Such findings have not been
    clearly shown in patients in intensive care. Despite
    no evidence of benefit, low-dose dopamine has been
    widely used for preventing renal failure in the
    critically ill patients.

      

    The large study conducted by the Australian
    and  NewZealand Intensive Care Society (ANZICS),
    clinical trials group confirms the lack of renal
    protection offered by low-dose dopamine in the
    critically ill. Dopamine can also be harmful . There
    is no justification for using “renal dose”
    dopamine in the critically ill.

             

  • Auleley G-R, Ravaud P, Giraudeau B, et al (Assistance Publique-Hopitaux de Paris; Saint-Louis Hosp, Paris; Cochin Hosp, Paris; et al)

    Implementation of the Ottawa Knee Rules in France: A Multicenter Randomized Controlled Trial 

    JAMA 277: 1935-1939, 1997

            

    This is a multicenter randomized clinical controlled trial involving 5 Paris University teaching hospitals (2 for intervention and 3 as controls) to evaluate the impact of this rule during a 5 month intervention period as well as to note the effect of using posters alone to sustain the effect of the rules.

            

    Control hospitals were given data collection forms, but not preprinted rules. In the intervention group, meetings were held to explain and distribute the rules. These rules were also posted in the emergency departments and data collection forms were distributed. The outcome was measured as the number of patients referred for radiography. There were 1005 controls and 906 patients in the intervention group. 

          

    Before intervention 98.5% of controls and 98% of intervention group were referred for radiography. During intervention, 99.6% of controls and 76% of intervention group requested radiographs (reduction of 22.4% in intervention group).

           

    In the postintervention period 83.1% were referred for radiography in the intervention group against 98% in control group.

            

    Implementation of the Ottawa ankle rules resulted in a significant reduction in the number of radiographs requested.

           

  • Tuli S, Tator CH, Fehlings MG, et al (Univ of Toronto)

    Occipital Condyle Fractures

    Neurosurgery 41: 368-377, 1997

            

    Occipital condyle fractures (OCF) present a diagnostic challenge.

           

    This is a retrospective study of 93 patients (medical records and radiographs) who had sustained trauma and had undergone CT scan of the skull and cervical spine.

           

    Of 93 cases studied, 3 had OCF (2 women 64 years and a 27-year old man). 2 had vehicular accidents and one had a fall down a flight of stairs. All 3 had neck pain but no cranial nerve deficits. CT identified OCF in 2 patients only and missed the diagnosis in one (eventually diagnosed by a high resolution CT scan during retrospective study).

            

    Review of literature showed 58 living patients with OCF and 38 diagnosed at autopsy. Cranial nerve deficits were seen in 31%; delayed deficits in 38%.

           

    Cervical spine X rays revealed no fracture in 96%. A new classification of OCF is proposed on the degree of ligamentous laxity and presence of displacement observed on CT and by the determination of O-C1-C2 instability

            

  • Plewa MC, Delinger M (St Vincent Mercy Med Ctr, Toledo, Ohio; Med College of Ohio, Toledo)

    The False-positive Rate of Thoracic Outlet Syndrome Shoulder Maneuvers in Healthy Subjects 

    Acad Emerg Med 5: 337-342, 1998

           

    This study has been conducted on 53 healthy volunteers who had no symptoms of Thoracic Outlet Syndrome (TOS).

            

    Shoulder maneuvers including Adson’s test (AT), costoclavicular maneuver (CCM), elevated arm stress test (EAST), and supraclavicular pressure (SCP) were performed for diagnostic evaluation. Participants were evaluated for pulse quality and the presence of pain/paresthesias.

            

    All maneuvers resulted in change of pulse quality but most commonly with EAST. Paresthesias were also most often seen with EAST (only in the upper extremity, not radiating to neck, head or chest in any case).

            

    There was no pain with the AT and CCM maneuvers and pain was seen in only one case with SCP. Overall, pulse alteration, pain and paresthesias were present in 74%, 21% and 47%, respectively, of participants.

             

    No participants had positive findings with all maneuvers. Outcomes with reasonable false positive rates included pain with AT (7%), CCM (7%), SCP (10%), or any two shoulder (TOS) maneuvers (10%).

             

    In TOS, pulse alternations and paresthesias (after shoulder maneuvers are unreliable in general).

            

  • Pandey R, McNally E, Ali A, et al (John Radcliffe Hosp, Oxford England)

    The Role of MRI in the Diagnosis of Occult Hip Fractures

    Injury 29: 61-63, 1998

          

    Traumatic hip fractures are common particularly in the elderly. Clinical examination and initial radiography may be inconclusive. Misdiagnosis significantly alters prognosis, morbidity, management and length of hospital stay and cost of treatment.

          

    In this study, MRI was performed on 33 patients with posttraumatic painful hips and negative radiographs. Fractures were diagnosed when an area of intermediate signal intensity on the T1-weighted images, representing trabecular edema, traversed by a low signal intensity line depicted by the fracture.

          

    10 of 33 cases revealed no fracture. None of these subsequently went on to fracture – 100% true negative findings. 

           

    The MRIs revealed that 40% of patients had a fractured neck of the femur, 15% had intertrochanteric fractures, and 11% had other fractures around the hip. One patient had a tumor.

          

    MRI is recommended in all patients with traumatic significant hip pain and negative plain radiographs.

          

  • Reinus WR, Strome G, Zwemer FL Jr (Washington Univ, St. Louis) 

    Use of Lumbosacral Spine Radiographs in a Level II Emergency Department 

    AJR 170: 443-447, 1998

            

    This study determines the reasons clinicians ask for lumbosacral spine radiographs in an emergency department. The study includes 482 patients examined for low backache in a level II emergency department (ED).

             

    Physicians were asked to complete a request form before ordering a lumbosacral spine X ray.

            

    The most common indications for the X ray were low back pain (92%) and trauma (36%), in 42% patient expectation and medicolegal concern related to insurance or litigation. 88% of patients had a neurologic deficit. 4% had history of neoplasm.

             

    The most common suspected lesion was strain and fracture (56% and 20% respectively). 86% had normal findings or spondylosis. Fractures were detected in 55%, of these 10 were definitely acute fractures. 7 had osseous metastases. 37 patients with neurologic deficits had findings that did not correlate with abnormalities observed on lumbosacral spine X rays. Decompression was not needed in any of the fractures.

            

  • Weiss HB, Friedman DI, Coben JH (Univ of Pittsburgh, Pa)

    Incidence of Dog Bite Injuries Treated in Emergency Departments 

    JAMA 279: 51-53, 1998

           

    The incidence and characteristics of dog bite injuries for the United States have been calculated.

           

    This is a retrospective study. The E-code E906.0 was used to determine the incidence of dog bites treated in Emergency Departments (ED).

           

    The annualized weighted estimate of the incidence of new dog bites and related injuries in EDs of USA over the 3-year period observed was 333,687, a rate of 12.9/10,000 persons. They represented 0.4% of all ED visits during this period. 

          

    This works out as 914 new dog bite injuries requiring ED visits. The median age of the patients was 15 years. Children between 5-9 years had the highest incidence (60.7/10,000). Children more than adults were likely to have bites on the neck, face and head (73% vs 30%). The highest incidence is in the summer. More than 50% of dog bites occurred at home.

          

    94% of cases were treated in ED and sent home. The remainder required admission. There was a 4% hospitalization rate among nearly 334,000 dog bites treated on EDs in USA.

          

  • Jacobson JA, Powell A, Craig JG, et al (Henry Ford Hosp, Detroit)

    Wooden Foreign Bodies in Soft Tissue: Detection at US 

    Radiology 206: 45-48, 1998

          

    Radiolucent foreign bodies (FB) are extremely difficult to detect. It is imperative to detect and remove them, as retained FBs may lead to severe infections and may lead to malpractice lawsuits.

           

    The use of ultrasonography (US) for detection of wooden FBs implanted in cadaveric specimen has been evaluated.

           

    Using 5-mm-long incisions in the plantar soft tissues of 3 cadaver feet, wooden FBs were randomly placed. Ten FBs 5 mm x 1 mm and ten of the size of 2.5 mm x 1 mm were implanted.

           

    US was performed to detect the presence of a FB. There was a 86.7% sensitivity for detection of the 25 mm x 1 mm sized FB and 96.7% specificity. There was an overall negative predictive value of 83%. A positive predictive value of 98%, specificity of 96.7% and a sensitivity of 90%.

           

    US is an effective tool for detecting wooden FBs in soft tissue that are radiolucent.

             


 



 

 

Speciality Spotlight

 

 

  • VM Ranieri, PM Suter, C Tortorella, et al (Universita di Bari, Italy; Universite de Geneva, Switzerland; Univ of Toronto, Canada)
    Effect of Mechanical Ventilation on Inflammatory Mediators in Pateints with Acute Respiratory Distress Syndrome : A Randomized Controller Trial
    JAMA 282: 54-61, 1999
          
    Mechanical ventilation can escalate or cause an inflammatory response and acute lung injury. The influence of mechanical ventilation on the lung and systemic cytokine levels was assessed in patients with acute respiratory distress syndrome in a randomized controlled trial.
         
    This study offers stimulating data in patients with ARDS, showing elevation of multiple cytokines in BAL fluid and plasma in patients treated with conventional ventilator settings, and a decrease in these mediators over a period of time in patients treated with a protection ventilation strategy. Patients in the protective protocol were treated with lower end-expiratory pressures, tidal volumes and fraction of inspired oxygen. The mechanisms by which ventilator-induced injury might be mediated remain uncertain, and clinical trials of lung protective strategies have yielded variable results. However, in this study, Ranieri and colleagues offer striking evidence for the link between mechanical ventilation and acute inflammatory lung injury, and the potential for benefit by limiting lung distention.
         

  • Goldhaber SZ [Harvard Med school]
    Pulmonary Embolism
    N. Engl J Med 339 : 93-104, 1998
       
    The best approach to diagnosis of pulmonary embolism is a careful history and physical examination with selective testing as indicated.
       
    Dyspnea is the major symptom.
       
    Tachypnea is the major sign.
       
    A massive embolism is suspected in patients with Dyspnea, Syncope or cyanosis whereas with pleuritic pain, cough or hemoptysis are more likely to have a small embolism near the pleura.
       
    To rule out acute pulmonary embolism perfusion lung scanning is still the most important test.
      
    Main stage of treatment is heparin.
      
    Unless contraindicated, patient should receive intensive heparin anticoagulation – usually 5000 to 10000 units bolus followed by continuous infusion at a rate of 18 units per kg per hour; which should be given during the diagnostic working. This usually produces a therapeutic partial thromboplastin time of 60 to 80 seconds. Patients with venous thrombosis associated with metastatic cancer may receive short or long term heparin therapy to prevent recurrent thrombosis.
      
    Once a patient has reached a therapeutic partial thromboplastin time – it is usually safe to start warfarin therapy, although at least 5 days of continuous intravenous heparin is  recommended to achieve true anticoagulation. Anticoagulation should continue preferably for 6 months and not 6 weeks to prevent recurrences.
       
    Current understanding of the importance of the right ventricular dysfunction enables more accurate prognosis in  patients with pulmonary embolism. Finally, the take home message is that surgeons should have a low threshold   to evaluate seemingly minor post operative complications viz, fever, tachycardia because many of these patients have small pulmonary embolism that are effectively treated by aggressive anticoagulation.
       

  • Heyland DK, for the Canadian Critical Care Trials Group [Queen’s Univ, Kingston, Ont, Canada; et al]
    The Clinical Utility of Invasive Diagnostic Techniques in the Setting of Ventilator – Associated Pneumonia
    Chest 115: 1076-1084, 1999
       
    Ventricular-associated pneumonia [VAP] is often diagnosed on clinical grounds alone and contributes to the morbidity, mortality and costs of caring for critically ill patients. Overdiagnosis may be disastrous with the use of needless antibiotics and the delay in recognition of the ‘true’ diagnosis.
       
    The utility of invasive investigations like bronchoscopy, with protected brush catheter [PBC] bronchoalveolar lavage [BAL] was evaluated in 92 patients receiving ventilatory support with a clinical suspicion of VAP.
       
    The results showed that VAP was often overdiagnosed after BAL or PBC after these procedures. Patients received fewer antibiotics. Both groups had similar duration of mechanical ventilation and ICU stay. Those who underwent PBC/BAL had a lower mortality.
      
    Invasive diagnostic testing may boost physicians confidence in the diagnosis and management of VAP.
        

  • Kristen Moller and Peter Skinhoj (Dept of Infectious Diseases, Denmark)
    Guidelines for managing acute bacterial meningitis
    BMJ, Vol.320, 13 May 2000, pg.1290
       
    Nearly one in four adults with acute bacterial meningitis will die and many survivors sustain neurological deficits.  The outcome has not changed despite potent antibiotics and specialised intensive care units.
     
    Standardised guidelines are issued by British Infection Society. Family doctors may give benzylpenicillin before admission to hospital. After admission to hospital, widely accepted empirical treatment is a third generation cephalosporine, such as cefotaxim or ceftriaxone, with ampicillin if listerial meningitis cannot be ruled out. In patients with obvious meningococcal disease, penicillin is the drug of choice. Pneumococci are less susceptible to penicillin and rifampicin is useful for truly penicillin resistant penumococci. Selection of appropriate treatment for patients who are hypersensitive to beta-lactams is difficult. Meropenem or broad spectrum quinolones may be considered. There is little evidence that they work.
      
    Supportive treatment is debated.  Corticosteroids reduce neurological deficit in children with Haemophilus influenzae or broad spectrum quinolones may be considered.  There is little evidence that they work.
      
    Corticosteroids reduce neurological deficit in children with haemophilus influenzae, but evidence in adults is lacking. Glycerol or mannitol if there is intracranial hypertension, full fluid replacement is necessary.
      
    Speedy diagnosis and treatment will serve patients well.
        

  • J Briegel, H Forst, M Haller, et al (Ludwig-Maximilians-Universitat Munchen, Munich)
    Stress Doses of Hydrocortisone Reverse Hyperdynamic Septic Shock: A Prospective, Randomized, Double-blind, Single-center Study.
    Crit Care Med 27:723-732, 1999.
       
    Past studies have showed that stress doses of hydrocortisone were ineffective in septic shock.  However, recent studies have shown that a patient in septic shock may have relative adrenocortical insufficiency.
        
    In septic shock, a 100mg loading dose of hydrocortisone was given within 30 min, and followed by an infusion of (0.18mg/kg/hr) hydrocortisone.  After reversal of shock, the dose was reduced to 0.08mg/kg/hr and continued for 6 days.
        
    This significantly reduces the duration of vasopressor support and may shorten the time for resolution of sepsis induced organ dysfunction.
        

  • MB Malay, Jr Ashton RC, DW Landry, et al (Allegheny Gen Hosp, Pittsburgh, Pa; Columbia, Univ, New York)


    Low-Dose Vasopressin in the Treatment of Vasodilatory Septic Shock
    J Trauma  47: 699-705, 1999.
       
    Refractory hypotension not responding to epinephrine in septic shock is potentially fatal.  It has been suggested that asopressin used concomitantly could give better results.
       
    The vasopressor was infused at a rate of 0.04U/min.  This permitted maintenance of arterial pressure thus allowing withdrawal of vasopressors.
       

  • MWA Angstwurm, J Schottdorf, J Schopohl, et la (Univ of Munich, Germany)
    Selenium Replacement in Patients with Severe Systemic Inflammatory Response Syndrome Improves Clinical Outcome.
    Crit Care Med 27: 1807-1813, 1999.
       
    Systemic inflammatory response syndrome (SIRS) causes substantial morbidity and mortality. It has also been recorded that selenium concentrations are reduced in SIRS.  This is a pilot study on the effects of selenium replacement on SIRS related morbidity and mortality.
       
    Selenium was replaced as i.v. sodium selenite in a decreasing dosage over a period of 10 days.
       
    Within 30 days, patients had normal selenium and glutathione peroxidose levels.  There was significant reduction in Acute Physiologic and Chronic Health Evaluation III scores as compared to controls.  Only 14% (as against 43% in controls) had renal failure and the mortality was 34% against 54% in the control group.
      

  • JE Gadek, and the Enteral Nutrition in ARDS Study Group (Ohio State Univ, Columbus; et al )
    Effect of Enteral Feeding with Eicosapentaenoic Acid, g-Linolenic Acid, and Antioxidants in Patients with Acute Respiratory Distress Syndrome.
    Crit Care Med  27: 1409-1420, 1999.
       
    Low carbohydrate, high fat nutritional support for ventilated patients reduces demands on the respiratory system and decreases the severity of the inflammatory injury.  Animal studies show that diets rich in eicosapentaenoic acid,
    g-linolenic acid and antioxidants can moderate inflammation.  This is a prospective double blind randomized controlled trial (multi-centered) to evaluate the effect of a diet supplemented with EPA, GLA and antioxidants on the clinical outcome of ARDS.
       
    The patients on the test diet required fewer days of ventilatory support in ICU or on supplemental oxygen and had less new organ failure.  The infection rates were the same but the test diet patients had fewer adverse events.
        

  • VM Ranieri, PM Suter, C Tortorella, et al (Univ of Toronto)

    Effect of Mechanical Ventilation on Inflammatory Mediators in Patients with Acute Respiratory Distress Syndrome: A Randomized Controlled Trial.
    JAMA 282:54-61, 1999
        
    Mechanical ventilation can escalate or cause an inflammatory response and acute lung injury.  The influence of mechanical ventilation on the lung and systemic cytokine release was assessed in patients with ARDS.
       
    Two groups were assessed (1) a control group and (2) a lung protective strategy group.
        
    At baseline physiologic characteristics and cytokine concentrations were similar.  But after 24 and 36 hours, there were significant between-group differences in tidal volume, end-inspiratory plateau pressures and PEEP.  The lung protective strategy group had significantly better results.  It could be concluded that mechanical ventilation can produce a cytokine response that may be diminished by minimising overdistension and recruitment and derecruitment of the lung.
       

  • PC Hebert, for the Canadian Critical Care Trials Group (Univ of Ottawa, Canada; et al)
    A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care,
    N Engl J Med 340: 409-417, 1999.
       
    The optimal transfusion strategy for cirtically ill anaemia patients has not been standardised.  A randomised, controlled study was undertaken comparing a restrictive (when Hb <7.0gms/dL) with a liberal approach (when Hb <10gms/dL).
      
    The study was conducted on 838 critically ill patients randomly assigned to one of the two groups.
       
    The overall 30 days mortality was similar.  Mortality rates were significantly lower in the restrictive group in less acutely ill patients but was similar in critically ill patients.  The mortality during hospitalization was significantly lower in the restrictive group.
      

  • S Deb, B Martin, L Sun, et al (Natl Naval Med Ctr, Bethesdam Md; Walter Reed Army Med Ctr, Washington, DC; Uniformed Services Univ of the Health Sciences, Bethesda, Md)
    Resuscitation With Lactated Ringer’s Solution in Rats with Hemorrhagic Shock Induces Immediate Apoptosis.
    J Trauma: Injury Infect Crit Care  46: 582-589, 1999.
         
    For patients in haemorrhagic shock, reperfusion injury can cause cell damage, leading to cell death and organ failure.  Apoptotic cell death is thought to play an important role in the pathophysiology of haemorrhagic shock.  The effects of resuscitation with lactated Ringer’s solution on cell apoptosis were assessed.
       
    It was seen that the use of lactated Ringer’s solution for resuscitation caused a significant increase in cell apoptosis in the small intestine and the liver as compared with other agents used for resuscitation.
       
    FA Luchette, BRH Robinson, LA Friend, et al (Univ of Cincinnati, Ohio)
    Adrenergic Antagonists Reduce Lactic Acidosis in Response to Hemorrhagic Shock
    J Trauma : Injury Infect Crit Care  46: 873-880, 1999.
      
    During haemorrhagic shock, lactic acidosis and plasma catecholamines are significantly increased.  The increase in circulating catecholamines have a greater effect on the post haemorrhagic lactic acidosis than do poor perfusion and tissue hypoxia.
       
    The use of a-blockers with a b-blocker significantly reduces plasma lactate levels, but had no effect on tissue perfusion.  In an in-vitro study propranolol eliminated the increased lactate production by muscle in response to epinephrine.
        
    The results question the use of lactate clearance as a resuscitation end point for patients with haemorrhagic shock.
       
    E Barquist, E Fein, D Shadick, et al (Univ of Miami, Fla)
    A Randomized Prospective Trial of Amphotericin B Lipid Emulsion Versus Dextrose Colloidal Solution in Critically ill Patients.
    J Trauma  47: 336-340, 1999.
       
    Amphotericin B is the drug of choice in fungal infections in critically ill patients.  However, it carries at least a 50% risk of nephrotoxicity, inspite of preventive measures.
       
    A trial was conducted using a combination of Amphotericin B with 20% intralipid solution in critically ill patients with positive fungal cultures of peritoneum, sputum or blood.  The dose was 1mg/kg/d as against 0.5mg/kg/d given to controls (with 5% dextrose).  
        
    It was found to have less nephrotoxicity than Amphotericin with Dextrose.  It can safely be given at a higher total cumulative dose.
       

  • RS Hotchkiss, PE Swanson, CM Knudson, et al (Washington Univ, St Louis)
    Overexpression of Bcl-2 in Transgenic Mice Decreases Apoptosis and Improves Survival in Sepsis.
    J Immunol 162: 4148-4156, 1999
       
    Sepsis is associated with extensive lymphocyte apoptosis, which may reduce  nflammation, but impairs host defences.
       
    The effect of Bcl-2 (a protein product) has been shown to prevent apoptotic cell death.  Its effect on lymphocyte  apoptosis was studied in a rat model comparing 2 sets. (1) transgenic mice that selectively overexpressed B cl-2 in T lymphocytes as well as in endotoxin  resistant species and (2) the endotoxin sensitive species.
       
    The Bcl-2 overexpressors showed complete protection against sepsis induced apoptosis.  The protective effect may result from the preservation of mitochondrial membrane potential.
       
    The aim of the study is to assess the influence of preoperative portal vein embolization on the long-term outcome of liver resection for colorectal metastases.  
        
    30 patients underwent PVE and 88 patients did not before resection of 4 or more liver segments.  The groups were comparable in terms of sex, age, number and type of metastases (synchronous vs metachronous) and number of courses of neoadjuvant chemotherapy.
        
    The main criterion for PVE was that resection was technically feasible but contraindicated because the remnant liver was too small (as estimated by CT scan volumetry).  It was done when the estimated rate of remnant functional liver parenchyma (ERRFLP) was 40% or less.
       
    PVE was feasible in all patients.  There were no deaths with a complication rate of 3%.  The post ERRFLP was significantly increased as compared to pre PVE value.  Liver resection was performed in 19 patients (63%) with a mortality of 4% and complication rate of 7%.  The survival rates after hepatectomy in both groups were comparable.
       
    The authors conclude that PVE allows more patients with unresectable liver metastases to benefit from surgery.
       

  • Lena Gamrin, Pia Essen, Eric Hultman, et al (The Department of Anesthesiology and Intensive Care and Clinical Chemistry II, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden; and the Department of S6urgery at State University of New York,Stony Brook, New York)
    Protein-Sparing Effect in Skeletal Muscle of Growth Hormone Treatment in Critically III Patients.
    Annals of Surgery, April 2000, 231(4), 577-586.
      
    This study investigates the effect of growth hormone (GH) treatment on skeletal muscle protein catabolism in patients with multiple organ failure in the ICU.
       
    20 critically ill ICU patients were randomized into 2 groups – one as control and the other with GH (0.3U/kg/day). Percutaneous muscle biopsy was taken before and 5 days after treatment starting on day 3 to 42 of the patient’s ICU stay.  Protein content, protein synthesis, water nucleic acids and free amino acids were analysed.
       
    The fractional protein synthesis rate and muscle free glutaminic increased in  the GH group.  Total intramuscular water did not increase but the intracellular water increased.
       
    It is concluded that treatment with GH in patients with multiple organ failure, stimulated muscle protein synthesis, increased muscle free glutaminic and increased into a cellular water.
      

  • Byers RJ, Eddleston JM, Pearson RC, et al [Univ of Manchester, Manchester Royal Infirmary, England]
    Dopexamine Reduces the Incidence of Acute Inflammation in the Gut Mucosa After Abdominal Surgery in High-risk Patients
    Crit Care Med 27: 1787-1793, 1999
       
    About 20% of critically ill patients have acute inflammation in the stomach/duodenum.  Dopexamine has dopaminergic receptor agonist properties but no alpha or beta [1] effects.  It may exhibit anti-inflammatory effects.  Thus, a study was devised to examine endoscopically and histologically the effect of Dopexamine on gut mucosa. The study represented the side arm of a large, prospective, randomized, controlled, multicenter European Study [Effect of Dopexamine on Outcome after Major Abdominal Surgery].
      
    38 patients with at least one high risk criterion, who were undergoing major abdominal surgery of at least 1.5 hours’ duration, were submitted to endoscopy and biopsy of the upper gastrointestinal tract immediately after anesthesia.  After being stabilized, patients received placebo [Group A, n=12], 0.5 micro-g/Kg per minute of dopexamine [Group B, n=13], and  2.0 micro-g/kg   per minute   of   dopexamine  [ Group C, n=13]. At 72 hours, endoscopy and biopsy were repeated in 27 patients.  Upper gut blood flow was estimated using tonometry.  pH was calculated at baseline, after surgery, and 2,6,12,24,30 and 36 hours after surgery.
       
    Gastric pH decreased significantly and similarly in all the three groups, with the greatest increase being recorded at the end of surgery.  Erythema or hemorrhagic changes were found in 33.3% of Group A, 38.5% of Group B, and 15.4% of Group C. Erosive disease was seen in 25%, 7.7% and 38.5% respectively.  At 72 hours, endoscopy revealed that the number of patients with no detectable abnormality had decreased to 25%, 20%, and 33.3% respectively.  Polymorphonuclear neutrophil proliferation was seen in 86%, 37.5% and 37.5% respectively.  There was no correlation between endoscopy and histologic findings.
      
    Dopexamine does protect against the ill effects of decreased pH during surgery though it does not prevent such a decrease.
      

  • Hebert PC, et al for the Canadian Critical Care Trials Group [Univ. of Ottawa, Ontario]
    A Multicentric, Randomized Controlled Clinical Trial of Transfusion Requirements in Critical Care
    N Engl J Med 340:409-417, 1999
      
    The optimal transfusion strategy for critically ill anemic patients has not been determined.  To understand the potential risks and benefits of transfusions in critically ill patients, a randomized, controlled clinical trial compared a restrictive versus a liberal approach to red cell transfusions.
       
    The study group consisted of 838 critically ill patients admitted to hospitals or ICUs in Canada, over a 4 year period.  Consecutive critically ill normovolemic patients were randomly assigned to either a restrictive strategy [transfusion when hemoglobin level fell below 7.0 g/dL], or a liberal strategy [transfusion when hemoglobin level fell below 10 g/dl].  The primary outcome measure was 30-day death from all causes.  Secondary outcomes included 60-day death from all causes.
       
    The overall 30-day mortality rate was not significantly different in the two groups.  Mortality rates were lower in younger, less acutely ill patients in the restrictive group, though not in patients with severe cardiac disease.  The mortality rate during hospitalization was significantly lower in the restrictive group compared to the liberal transfusion strategy group.
       
    Restrictive red cell transfusion strategy [hemoglobin levels below 7.0 g/dL], was as effective as, and in some cases superior to, the liberal transfusion strategy [hemoglobin levels below 10 g/dL], in critically ill normovolemic anemic patients, except in those with severe cardiac disease.
      

  • Hanson CW III, Deutschman CS, Anderson HL III, et al [Univ of Pennsylvania, Philadelphia : Univ of California, Irvine]
    Effects of an Organized Critical Care Service on Outcomes and Resource Utilization : A Cohort Study
    Crit Care Med 27: 270-274, 1999
       
    Practice patterns are under scrutiny at both institutional and national levels to eliminate inefficiency, lower costs, and improve clinical results.  Critical care medicine would seem to be particularly susceptible to the current forces of change.  The cost and effectiveness of two patterns of critical care practice, in an academic medical center, were examined to determine whether presence of an on-site, organized, supervised critical care service improves care and reduces resource utilization.
      
    Two patients cohorts admitted to a surgical intensive care unit [SICU] were compared. One group received care from an on-site critical care team, supervised by an intensive care specialist.  The other group received care from a team with patient care responsibilities in multiple sites supervised by a general surgeon. The primary outcome measures were duration of stay, resource utilization, complication rates, resultant effects on added investigations, consultations, and terminal outcomes.
      
    The results showed patients receiving care from an on-site critical care service had higher Acute Physiology and Chronic Health Evaluation II [APACHEII] scores, yet they spent less time in SICU, used fewer resources, had fewer complications, and had lower total hospital charges.  These differences were more pronounced with increasing severity of illness.
      

  • Pronovest PJ, Jenckes MW, Dorman T, et al [John Hopkins Univ, Baltimore, MD]
    Organizational Characteristics of Intensive Care Units Related to Outcomes of Abdominal Aortic Surgery
    JAMA 281: 1310-1317, 1999
      
    ICUs at different institutions vary widely in terms of morbidity and mortality rates.  The effects of ICU structure and care processes on these outcomes are not known.  The effects of ICU organization on the clinical and economic outcomes for patients undergoing abdominal aortic surgery were studied.
      
    Hospital data on 2987 patients on whom abdominal aorta surgery was performed, in the state of Maryland, over a two year period, was analyzed.  Data on organizational characteristics of ICUs were obtained from medical directors.  The main outcomes assessed were in-hospital mortality, and length of total hospital and ICU stay.
      
    The in-hospital mortality rates ranged from 0% to 66%. ICUs that did not have daily rounds by an ICU physician showed a 3-fold increase in in-hospital mortality after adjustment for patient demographic, co-morbidity, severity of illness, hospital and surgeon volume, and hospital characteristics.  Other outcomes, such as cardiac arrest, acute renal failure, septicemia, and reintubation, were also more likely at centers without daily rounds by an ICU physician.
          

  • Leape LL, Cullen DJ, Clapp MD, et al [Harvard School of Public Health : Massachusetts Gen. Hospital; Brigham and Women’s Hosp., Boston]
    Pharmacist Participation on Physicians Rounds and Adverse Drug Events in the Intensive Care Unit
    JAMA 282: 267-270, 1999
       
    Although studies show that pharmacist review of ICU prescription orders prevents mistakes and lowers drug costs by reducing drug use, there have been no studies on the benefits of having a pharmacist present in the ICU at the time drugs are prescribed.  The efficacy of pharmacist participation in a medical ICU in preventing adverse drug events [ADEs] was tested in a controlled clinical trial.
        
    Between February 1 and July 31, 1993 [Phase 1 Preintervention] and October 1, 1994 and July 7, 1995 [Phase 2 postintervention], the effect of pharmacist intervention was tested in a 17-bed ICU [the study unit] and compared with no pharmacist intervention in a 15-bed coronary care unit with similar occupancy rate [the control unit].
      
    ADEs were compared for 75 randomly selected patients in each of the 3 groups from amongst all patients admitted to the study unit in Phase 1 and 2, and all patients admitted to the control unit in Phase 2. An experienced pharmacist made daily morning rounds with ICU personnel in the study unit; an experienced pharmacist was available for consultation but did not make daily rounds in the control unit.  Outcome measures included measurements of ADEs, interventions the pharmacist made, and the acceptance of pharmacist interventions by the physicians and nurses.
        
    The overall rate of preventable ordering and ADEs/1000 patient days decreased by 66% in the study unit from Phase 1 to 2, with significant savings in drugs costs.  The rate of ADEs came down significantly in the study group from Phase 1 to 2. In the control group the rate of ADEs continued to remain high.
       
    Of the 398 pharmacist interventions reported, 366 were related to ordering and 362 were accepted by the physicians.  Pharmacist – initiated clarifications or correction of incomplete orders, wrong dose, wrong frequency, inappropriate choice, or duplicate therapy accounted for 46% of interventions.  Drug interactions or adverse reactions were prevented in 22 cases. 
        
    The presence of a pharmacist at rounds in ICUs significantly reduces incidence of ADEs and result in substantial cost savings.
        

  • Darouiche RO for the Catheter Study Group [Baylor College of Medicine, Houston, et al]
    A Comparison of Two Antimicrobial -Impregnated Central Venous Catheters
    N. Engl J Med 340: 1-8, 1999
       
    Previous studies have shown that rates of central venous catheter colonization and catheter related blood stream infection can be significantly reduced through the use of catheters impregnated with minocycline and rifamycin or with chlorhexidine and silver sulphadiazine.  However, no studies have directly compared the benefits of the two types of catheter. Minocycline/rifamycin and chlorhexidine/silver sulphadiazine catheters were compared for their ability to prevent colonization and catheter-related blood stream infections.
       
    The prospective, multicenter trial included adult patients considered at high risk for catheter-related infection who were likely to require a central venous catheter for 3 days or longer.  The patients were randomized to receive polyurethane triple-lumen catheters impregnated with minocycline/rifamycin on the luminal and external surfaces or with chlorhexidine/silver sulphadiazine on the external surface only. Catheter tips and subcutaneous segments were cultured by both the roll-plate and sonication methods after removal, with peripheral blood cultures performed as indicated.  The analyses included a total of 738 catheters with evaluable culture results.
       
    The two catheter groups were similar in their clinical characteristics and infection risk factors.  The catheter colonization rate was 8.3% with monocycline/rifamycin impregnated catheters vs 22.8% in the other group. The former were also associated with lower rate of blood stream infection [0.3% vs 3.4%]. The authors emphasize that adequate aseptic technique must complement the use of monocycline/rifamycin impregnation of central venous catheters.
      
            

  • D.S. Walsh, P. Siritongtaworn, K. Pattanapanyasat. P. Thavichaigarn, P. Kongcharoen, N. Jiarakul, P. Tongtawe, K. Yongvanitchit, C. Komoltri, C. Dheeradhada, F.C. Pearce, W.P. Wiesmann and H.K Webster [**]
    [** Department of Immunology and Medicine, US Army Medical Component, Armed Forces Research Institute of Medical Sciences, Departments of Surgery, Hematology and Clinical epidemiology, Siriraj Hospital, Department of Surgery, Pharmongkutklao [Royal Thai Army] Hospital, and Department of Surgery, Police Hospital, Bangkok, Thailand and Division of Surgery, Walter Reed Army Institute of Research, Washington, DC, USA ]
    Lymphocyte Activation After Non-Thermal Trauma
    Br. J. of  Sur.,  Volume 87, Number 2, February, 2000, Pg. 223-230
       
    Service injury causes immunologial changes that may contribute to a poor outcome. Longitudinal characterization of lymphocyte response patterns may provide further insight into the basis of these immunological alterations.
      
    Venous blood obtained seven times over 2 weeks from 61 patients with injury severity scores over 20 was assessed for lymphocyte and activation markers together  with serum  levels of interleukin [IL]2, IL-4, soluble IL-2 receptor [sIL-2R], soluble CD4 [sCD4], soluble CD8 [sCD8] and interferon g.
       
    Severe injury was associated with profound changes in the phenotypic and activation profile in the phenotypic and activation profile of circulating lymphocytes. Activation was indicated by increased number of T cells expressing CD25, sIL-2R and sCD4 and sCD8 were found in-patients with sepsis syndrome.
       
    Polytrauma is associated with dramatic alterations in the phenotypic and activation profile of circulating lymphocytes which are generally independent of clinical course. In contrast several lymphocyte soluble factors including sCD4 and SIL-2R, paralleled the clinical course. These data provide new insight into lymphocyte responses after injury and suggest the further assessment of soluble factors as clinical correlates. 
       

  • Helen F Galley , ( Academic Unit of Anaesthesia and Intensive Care, Department of Medicine, Aberdeen ).
    Commentary –  Renal Dose Dopamine : Will the message now get through ?
    Lancet, Vol.356, 23/30 December, 2000, pg. 2112
      
    Deterioration in renal function is common in critically ill patients under intensive care. It lengthens patient’s stay in the intensive – care unit and their risk of death. Management of such cases is restricted to supportive measures and critical care doctors are eager for any new approach that might prevent the onset of renal dysfunction or hasten its recovery.
      
    Dopamine is used in intensive – care units as an inotropic and vosoactive agent. At low or “renal” doses (0.5 to 2.0 mg/kg per min ) its actions are mainly dopaminergic . In laboratory animals and healthy volunteers low doses of dopamine increase renal blood flow and GFR and inhibit proximal tubular reabsorption of sodium, which result in natriuresis. Such findings have not been clearly shown in patients in intensive care. Despite no evidence of benefit, low-dose dopamine has been widely used for preventing renal failure in the critically ill patients.
      
    The large study conducted by the Australian and  NewZealand Intensive Care Society (ANZICS), clinical trials group confirms the lack of renal protection offered by low-dose dopamine in the critically ill. Dopamine can also be harmful . There is no justification for using “renal dose” dopamine in the critically ill.
             

  • Auleley G-R, Ravaud P, Giraudeau B, et al (Assistance Publique-Hopitaux de Paris; Saint-Louis Hosp, Paris; Cochin Hosp, Paris; et al)
    Implementation of the Ottawa Knee Rules in France: A Multicenter Randomized Controlled Trial 
    JAMA 277: 1935-1939, 1997
            
    This is a multicenter randomized clinical controlled trial involving 5 Paris University teaching hospitals (2 for intervention and 3 as controls) to evaluate the impact of this rule during a 5 month intervention period as well as to note the effect of using posters alone to sustain the effect of the rules.
            
    Control hospitals were given data collection forms, but not preprinted rules. In the intervention group, meetings were held to explain and distribute the rules. These rules were also posted in the emergency departments and data collection forms were distributed. The outcome was measured as the number of patients referred for radiography. There were 1005 controls and 906 patients in the intervention group. 
          
    Before intervention 98.5% of controls and 98% of intervention group were referred for radiography. During intervention, 99.6% of controls and 76% of intervention group requested radiographs (reduction of 22.4% in intervention group).
           
    In the postintervention period 83.1% were referred for radiography in the intervention group against 98% in control group.
            
    Implementation of the Ottawa ankle rules resulted in a significant reduction in the number of radiographs requested.
           

  • Tuli S, Tator CH, Fehlings MG, et al (Univ of Toronto)
    Occipital Condyle Fractures
    Neurosurgery 41: 368-377, 1997
            
    Occipital condyle fractures (OCF) present a diagnostic challenge.
           
    This is a retrospective study of 93 patients (medical records and radiographs) who had sustained trauma and had undergone CT scan of the skull and cervical spine.
           
    Of 93 cases studied, 3 had OCF (2 women 64 years and a 27-year old man). 2 had vehicular accidents and one had a fall down a flight of stairs. All 3 had neck pain but no cranial nerve deficits. CT identified OCF in 2 patients only and missed the diagnosis in one (eventually diagnosed by a high resolution CT scan during retrospective study).
            
    Review of literature showed 58 living patients with OCF and 38 diagnosed at autopsy. Cranial nerve deficits were seen in 31%; delayed deficits in 38%.
           
    Cervical spine X rays revealed no fracture in 96%. A new classification of OCF is proposed on the degree of ligamentous laxity and presence of displacement observed on CT and by the determination of O-C1-C2 instability
            

  • Plewa MC, Delinger M (St Vincent Mercy Med Ctr, Toledo, Ohio; Med College of Ohio, Toledo)
    The False-positive Rate of Thoracic Outlet Syndrome Shoulder Maneuvers in Healthy Subjects 
    Acad Emerg Med 5: 337-342, 1998
           
    This study has been conducted on 53 healthy volunteers who had no symptoms of Thoracic Outlet Syndrome (TOS).
            
    Shoulder maneuvers including Adson’s test (AT), costoclavicular maneuver (CCM), elevated arm stress test (EAST), and supraclavicular pressure (SCP) were performed for diagnostic evaluation. Participants were evaluated for pulse quality and the presence of pain/paresthesias.
            
    All maneuvers resulted in change of pulse quality but most commonly with EAST. Paresthesias were also most often seen with EAST (only in the upper extremity, not radiating to neck, head or chest in any case).
            
    There was no pain with the AT and CCM maneuvers and pain was seen in only one case with SCP. Overall, pulse alteration, pain and paresthesias were present in 74%, 21% and 47%, respectively, of participants.
             
    No participants had positive findings with all maneuvers. Outcomes with reasonable false positive rates included pain with AT (7%), CCM (7%), SCP (10%), or any two shoulder (TOS) maneuvers (10%).
             
    In TOS, pulse alternations and paresthesias (after shoulder maneuvers are unreliable in general).
            

  • Pandey R, McNally E, Ali A, et al (John Radcliffe Hosp, Oxford England)
    The Role of MRI in the Diagnosis of Occult Hip Fractures
    Injury 29: 61-63, 1998
          
    Traumatic hip fractures are common particularly in the elderly. Clinical examination and initial radiography may be inconclusive. Misdiagnosis significantly alters prognosis, morbidity, management and length of hospital stay and cost of treatment.
          
    In this study, MRI was performed on 33 patients with posttraumatic painful hips and negative radiographs. Fractures were diagnosed when an area of intermediate signal intensity on the T1-weighted images, representing trabecular edema, traversed by a low signal intensity line depicted by the fracture.
          
    10 of 33 cases revealed no fracture. None of these subsequently went on to fracture – 100% true negative findings. 
           
    The MRIs revealed that 40% of patients had a fractured neck of the femur, 15% had intertrochanteric fractures, and 11% had other fractures around the hip. One patient had a tumor.
          
    MRI is recommended in all patients with traumatic significant hip pain and negative plain radiographs.
          

  • Reinus WR, Strome G, Zwemer FL Jr (Washington Univ, St. Louis) 
    Use of Lumbosacral Spine Radiographs in a Level II Emergency Department 
    AJR 170: 443-447, 1998
            
    This study determines the reasons clinicians ask for lumbosacral spine radiographs in an emergency department. The study includes 482 patients examined for low backache in a level II emergency department (ED).
             
    Physicians were asked to complete a request form before ordering a lumbosacral spine X ray.
            
    The most common indications for the X ray were low back pain (92%) and trauma (36%), in 42% patient expectation and medicolegal concern related to insurance or litigation. 88% of patients had a neurologic deficit. 4% had history of neoplasm.
             
    The most common suspected lesion was strain and fracture (56% and 20% respectively). 86% had normal findings or spondylosis. Fractures were detected in 55%, of these 10 were definitely acute fractures. 7 had osseous metastases. 37 patients with neurologic deficits had findings that did not correlate with abnormalities observed on lumbosacral spine X rays. Decompression was not needed in any of the fractures.
            

  • Weiss HB, Friedman DI, Coben JH (Univ of Pittsburgh, Pa)
    Incidence of Dog Bite Injuries Treated in Emergency Departments 
    JAMA 279: 51-53, 1998
           
    The incidence and characteristics of dog bite injuries for the United States have been calculated.
           
    This is a retrospective study. The E-code E906.0 was used to determine the incidence of dog bites treated in Emergency Departments (ED).
           
    The annualized weighted estimate of the incidence of new dog bites and related injuries in EDs of USA over the 3-year period observed was 333,687, a rate of 12.9/10,000 persons. They represented 0.4% of all ED visits during this period. 
          
    This works out as 914 new dog bite injuries requiring ED visits. The median age of the patients was 15 years. Children between 5-9 years had the highest incidence (60.7/10,000). Children more than adults were likely to have bites on the neck, face and head (73% vs 30%). The highest incidence is in the summer. More than 50% of dog bites occurred at home.
          
    94% of cases were treated in ED and sent home. The remainder required admission. There was a 4% hospitalization rate among nearly 334,000 dog bites treated on EDs in USA.
          

  • Jacobson JA, Powell A, Craig JG, et al (Henry Ford Hosp, Detroit)
    Wooden Foreign Bodies in Soft Tissue: Detection at US 
    Radiology 206: 45-48, 1998
          
    Radiolucent foreign bodies (FB) are extremely difficult to detect. It is imperative to detect and remove them, as retained FBs may lead to severe infections and may lead to malpractice lawsuits.
           
    The use of ultrasonography (US) for detection of wooden FBs implanted in cadaveric specimen has been evaluated.
           
    Using 5-mm-long incisions in the plantar soft tissues of 3 cadaver feet, wooden FBs were randomly placed. Ten FBs 5 mm x 1 mm and ten of the size of 2.5 mm x 1 mm were implanted.
           
    US was performed to detect the presence of a FB. There was a 86.7% sensitivity for detection of the 25 mm x 1 mm sized FB and 96.7% specificity. There was an overall negative predictive value of 83%. A positive predictive value of 98%, specificity of 96.7% and a sensitivity of 90%.
           
    US is an effective tool for detecting wooden FBs in soft tissue that are radiolucent.
             

 

 

By |2022-07-20T16:42:19+00:00July 20, 2022|Uncategorized|Comments Off on Critical Medicine – Emergency Medicine

About the Author: