Infection Control Strategy for Severe Sepsis and septic shock in critically ill surgical patients

Severe sepsis is the main cause of death in critically ill surgical patients. The mainstay of management of severe sepsis and septic shock includes eradication of infection with appropriate antibiotics and source control, and aggressive supportive care, such as fluid resuscitation, vasoactive agents or mechanical ventilation. This early goal-directed therapy is widely used. Crucial components of infection control strategy for septic shock patients are early recognition, appropriate use of antibiotics, and early effective drainage or surgical control of origins of infection. We briefly summarize the points of infection control strategy for septic shock patients.ope

Patterns and Biologic Features of p53 Mutation Types in Korean Breast Cancer Patients

Purpose : The p53 gene is one of the most frequently mutated genes in breast cancer. We investigated the patterns and biologic features of p53 gene mutation and evaluated their clinical significance in Korean breast cancer patients. Methods : Patients who underwent p53 gene sequencing were included. Mutational analysis of exon 5 to exon 9 of the p53 gene was carried out using polymerase chain reaction-denaturing high performance liquid chromatography and direct sequencing. Results : A total of 497 patients were eligible for the present study and p53 gene mutations were detected in 71 cases (14.3%). Mutation of p53 was significantly associated with histologic grading (p<0.001), estrogen receptor and progesterone receptor status (p<0.001), HER2 status (p<0.001), Ki-67 (p=0.028), and tumor size (p=0.004). The most frequent location of p53 mutations was exon 7 and missense mutation was the most common type of mutation. Compared with patients without mutation, there was a statistically significant difference in relapse-free survival of patients with p53 gene mutation and missense mutation (p=0.020, p=0.006, respectively). Only p53 missense mutation was an independent prognostic factor for relapse-free survival in multivariate analysis, with an adjusted hazard ratio of 2.29 (95% confidence interval, 1.08-4.89, p=0.031). Conclusion : Mutation of the p53 gene was associated with more aggressive clinicopathologic characteristics and p53 missense mutation was an independent negative prognostic factor in Korean breast cancer patients.ope

Patterns of In-hospital Mortality and Causes of Death in Blunt Poly-trauma Patients

Purpose: This study evaluates patterns of in-hospital mortality and causes of death in blunt poly-trauma patients.Methods: Data of blunt poly-trauma patients admitted between 2011 and 2013 were retrospectively collected and analyzed. Poly-trauma was defined as an Injury Severity Score (ISS) was greater than 15. The following variables were extracted and analyzed: age, sex, ISS, Revised Trauma Score (RTS), injury mechanism, cause of death, and patterns in-hospital mortality rate. Results: Two hundred and ten patients with blunt poly-trauma were admitted. Injuries occurred predominately in the age group of 45∼64 years. Injuries occurred predominantly in males (70%). Traffic accidents (67.6%) and falls (30.5%) were the main causes of trauma. Forty-six patients (21.9%) died in the study sample. Six patients (13%) died within one hour, 23 (23.9%) between one and four hours after arrival to emergency room, six (6.5%) died during the first two weeks of hospitalization, and six (6.5%) died in the fourth week of hospitalization. The median ISS of those who died was 39.5 (20.5∼70.5) and median RTS was 4.01 (1.85∼6.15). The major cause of early death was exsanguination (39.1%), followed by central nervous system injury (34.8%). Sepsis or multi-organ failure (26.1%) were the predominant causes of late death. Conclusion: The in-hospital mortality rate is similar to other studies. However, cause of death and injury mechanisms of blunt poly-trauma death are somewhat different from other countries. Recognition of these injury and mortality patterns will help improve the trauma system.ope

Cerebral air embolism following the removal of a central venous catheter in the absence of intracardiac right-to-left shunting: a case report

Air embolism following central venous catheter (CVC) removal is a relatively uncommon complication. Despite its rare occurrence, an air embolism can lead to serious outcomes. One of the most fatal complications is cerebral air embolism. We report a case of cerebral air embolism that occurred after the removal of a CVC in a patient with an underlying idiopathic pulmonary fibrosis, subcutaneous emphysema, pneumomediastinum, and a possible intrapulmonary shunt. Although the patient had a brief period of recovery, his condition deteriorated again, and retention of carbon dioxide was sustained due to aggravation of pneumonia. Despite full coverage of antibiotics and maximum care with the ventilator, the patient died about 5 weeks after the removal of the CVC. We suggest that strict compliance to protocols is required even while removing the catheter. Furthermore, additional caution to avoid air embolism is demanded in high-risk patients, such as in this case.ope

Is Single Administration of Prophylactic Antibiotics Enough after Laparoscopic Appendectomy for Uncomplicated Appendicitis?

Purpose: Research comparing the effectiveness of different doses of antibiotics prior to surgery for preventing infection is sparse. This study examines whether a single dose of preoperative antibiotics suffices to treat uncomplicated appendicitis via laparoscopic appendectomy. Methods: This study retrospectively reviewed the medical records of 149 patients who underwent laparoscopic appendectomy from July 2013 to December 2014 in a single institution. The participants were divided into two groups; group A (n=99) was given a single dose of prophylactic antibiotics before surgery, and group B (n=50) was given both preoperative and postoperative antibiotics. Clinical factors and surgical outcomes were compared between two groups. Results: The mean length of hospital stay for group A (2.5 days) was shorter than for group B (3.2 days) (p<0.001). Average operation time was 58.7 minutes for group A, longer than for group B (52.2 minutes, p=0.027). There was no difference in pathologic results and postoperative complications, such as surgical site infection (SSI) between the two groups. In groups A and B, 4.0% of patients had superficial SSIs. One patient (2.0%) in group B had deep/organ SSI. Conclusion: A single dose of prophylactic antibiotics administration to patients undergoing laparoscopic appendectomy is acceptable as a treatment in uncomplicated appendicitis.ope

Effects of early enteral nutrition on patients after emergency gastrointestinal surgery: a propensity score matching analysis

Early postoperative enteral feeding has been demonstrated to improve the outcome of patients who underwent surgery for gastrointestinal (GI) malignancies, trauma, perforation, and/or obstruction. Thus, this study was conducted to assess the efficacy of early postoperative enteral nutrition (EN) after emergency surgery in patients with GI perforation or strangulation. The medical records of 484 patients, admitted between January 2007 and December 2012, were reviewed retrospectively. Patients were divided into 2 groups: the early EN (EEN, N=77) group and the late EN (LEN, N=407) group. The morbidity, mortality, length of hospital, and intensive care unit (ICU) stays were compared between the 2 groups. Propensity score matching was performed in order to adjust for any baseline differences. Patients receiving EEN had reduced in-hospital mortality rates (EEN 4.5% vs LEN 19.4%; P=0.008), pulmonary complications (EEN 4.5% vs LEN 19.4%; P=0.008), lengths of hospital stay (median: 14.0, interquartile range: 8.0-24.0 vs median: 17.0, interquartile range: 11.0-26.0, P=0.048), and more 28-day ICU-free days (median: 27.0, interquartile range: 25.0-27.0 vs median: 25.0, interquartile range: 22.0-27.0, P=0.042) than those receiving LEN in an analysis using propensity score matching. The significant difference in survival between the 2 groups was also shown in the Kaplan-Meier survival curve (P=0.042). In a further analysis using the Cox proportional hazard ratio after matching on the propensity score, EEN was associated with reduced in-hospital mortality (hazard ratio, 0.03; 95% confidence interval, 0.01-0.49; P=0.015). EEN is associated with beneficial effects, such as reduced in-hospital mortality rates, pulmonary complications, lengths of hospital stay, and more 28-day ICU-free days, after emergency GI surgery.ope

The Influence of How the Trauma Care System Is Applied at the Trauma Center: The Initial Experience at Single Trauma Center

Purpose: To evaluate the influence of how the trauma care system is applied on the management of trauma patients. Methods: We divided the patients into a pre-trauma system group and a post-trauma system group according to the time when we began to apply the trauma care system in our institution. We compared the general characteristics, injury severity score, initial response time to the trauma patients, number of preventable deaths, and clinical outcomes between the two groups. Results: The numbers of patients in the pre-trauma system group and the post-trauma system group were 188 and 257, respectively. No differences in the patient’s median ages, trauma scores (ISS, RTS, TRISS) and proportions of severe trauma patients (ISS>15) were observed between the two groups. The number and the proportion of patients who were admitted to our hospital were increased in the post-trauma system group. The time interval from trauma CP activation to emergency surgery or angio-embolization, and the patient’s time spent in emergency room were shortened in the posttrauma system group. However, the lengths of the ICU stay and the hospital stay, and the number of in-hospital mortalities were not improved in the post-trauma system group. In severe trauma patients (ISS>15), there were no differences between the two groups in the number and the proportion of admitted patients, and the time interval from trauma CP activation to performing a diagnostic and therapeutic procedure was not shortened in the post-trauma system group. Conclusion: Application of the trauma care system has shortened the time between the initial response and patient management. However, this improvement was not enough to result in better clinical outcomes. More trauma physicians, multidisciplinary cooperation, and a well-organized trauma management process will be needed if the maximum efficacy of the trauma system is to be achieved.ope

Relation between Blood Alcohol Concentration and Clinical Parameters in Trauma Patients

Purpose: The aim of this study was to evaluate the effects of blood alcohol concentration (BAC) on the clinical parameters in trauma patients. Methods: From January 2011 to March 2013, the records of a total of 102 trauma patients with BAC data were analyzed retrospectively. The revised trauma score (RTS), injury severity score (ISS), presence of shock, use of mechanical ventilation and blood transfusion, length of hospital stay, and mortality were collected. Patients were divided into four groups in accordance with the level of BAC: group A (250 mg/dL). Patients were also divided into two groups depending on the presence of the shock, and gender, ISS, BAC, and presence of active bleeding were compared between these two groups. Results: No statistically significant differences in the ISS, RTS, presence of active bleeding, use of mechanical ventilation, and mortality were noted between groups A to D. However, the presence of shock was significantly higher in group D. After patients with severe chest injuries had been excluded, mechanical ventilation was found to have been applied more frequently in the higher BAC groups (C and D). A logistic regression analysis of these factors showed that extremely high BAC (>250 mg/dL) was an independent indicator of shock. Conclusion: High BAC is a predicator of shock and the need for mechanical ventilation in patients with trauma, regardless of injury severity. Alcohol intoxication leads to an overestimate of the clinical condition and aggressive management for trauma patients. Thus, a guideline for the diagnosis and treatment of patients intoxicated with alcohol is necessary.ope