The Utility of Impedance Cardiography in Hemodynamic Monitoring of Patients With Sepsis

BACKGROUND: Commonly used biochemical indicators and hemodynamic and physiologic parameters of sepsis vary with regard to their sensitivity and specificity to the diagnosis. The aim of this preliminary study was to evaluate non-invasive impedance cardiography as a monitoring tool of the hemodynamic status of patients with sepsis throughout their initial volume resuscitation to explore the possibility of identifying additional measurements to be used in the future treatment of sepsis. METHODS: Nine patients who presented to the emergency room and received a surgical consultation during a 3-month period in 2016, meeting the clinical criteria of sepsis defined by systemic inflammatory response syndrome in the 2012 Surviving Sepsis Campaign Guidelines, were included in this study. We applied cardiac impedance monitors to each patient\u27s anterior chest and neck and obtained baseline recordings. Measurements were taken at activation of the sepsis alert and 1 hour after fluid resuscitation with 2 L of intravenous crystalloid solution. RESULTS: Nine patients met the inclusion criteria. The mean age was 60±17 years and two were female; eight were febrile, five were hypotensive, four were tachycardic, seven were treated for infection, and six had positive blood cultures. Hemodynamic parameters at presentation and 1 hour after fluid resuscitation were heart rate (beats per minute) (97±13 and 93±18; p=0.23), mean arterial pressure (mm Hg) (81±13 and 85±14; p=0.55), systemic vascular resistance (dyne-s/cm DISCUSSION: Through measuring a patient\u27s systemic vascular resistance and systemic vascular resistance index (afterload), statistical significance is achieved after intervention with a 2 L crystalloid bolus. This suggests that, along with clinical presentation and biochemical markers, impedance cardiography may show utility in providing supporting hemodynamic data to trend resuscitative efforts in patients with sepsis. LEVEL OF EVIDENCE: Level IV

Trauma Care Within an Integrated Health Care System-A Paradigm Shift in the New Era of Health Care Reform

At the conclusion of this presentation the participant will be able to: 1. Understand the theory in the development of inclusive trauma systems 2. Under the military and civilian milestones creating today\u27s US trauma care delivery system 3. Understand the theory and strategy of service line organization and integration at large health systems in the era of health care reform. Presentation: 1:00:3

Postoperative day one: a high risk period for respiratory events

In 2001, the Joint Commission on Accreditation of Healthcare Organizations released Pain Management Standards that has led to an increased focus on pain control. Since then the Institute for Safe Medication Practices has noted that overaggressive pain management has led to increases in oversedation and fatal respiratory depression. One of our previous studies found that postoperative patients may be reaching dangerously high levels of sedation as a result of pain management. Our hypothesis is that postoperative patients who have a respiratory event caused by analgesic use are more likely to have that event in the first postoperative day. We performed a retrospective case-control analysis identifying 62 postoperative patients who had a respiratory event. A respiratory event was defined as respiratory depression caused by narcotic use in the postoperative period that was reversed by naloxone. Sixty-two postoperative patients with no such event were chosen randomly and frequency matched based on surgical procedure and diagnosis-related group. Risk factors for an event were identified. Of the cases, 77.4% had a respiratory event in the first 24 hours postoperatively. Significant risk factors for an event were as follows: 65 years of age or older, having chronic obstructive pulmonary disease, having 1 or more comorbidities, and being placed on hydromorphone. The first 24 hours after surgery represents a high-risk period for a respiratory event as a result of narcotic use. The realization of this risk can lead to the implementation of standards to increase patient safety in the first postoperative day

Stab wounds to the back and flank in the hemodynamically stable patient: A decision algorithm based on contrast-enhanced computed tomography with colonic opacification

The authors wanted to determine whether contrast-enhanced computed tomography (CE-CT) with colonic opacification is an accurate tool to triage hemodynamically stable victims of stab wounds to the flank and back. One hundred forty-five consecutive patients were categorized as low-risk (penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) based on CE-CT findings. There were no significant differences in admission vital signs, Glasgow Coma Scale, or complete blood counts between low- and high-risk groups. None of the 92 low-risk patients required surgery or had sequelae. Six of the 53 high-risk patients underwent surgery, 2 based on initial CE-CT, 4 due to evolving clinical signs. The CE-CT correctly predicted surgical findings in all cases. Hemodynamically stable patients with stab wounds to the back and/or flank can be successfully triaged based on CE-CT findings. Low-risk patients may be discharged immediately. High-risk patients may have a discharge decision implemented at 24 hours

The Need for Aggressive Nutritional Intervention in the Injured Patient: The Development of a Predictive Model

Early nutritional intervention has been advocated in trauma patients. We have developed a model to identify those patients who will most benefit from the invasive and costly measures that are required to provide injured patients with early enteral feedings. Four hundred forty-two patients admitted to a level I trauma center during a 2-month period were evaluated using 21 clinical variables. Time to tolerance of a regular diet was used as the dependent variable in a step-wise regression, and then the selected variables were used to build a classification and regression tree to predict tolerance of a regular diet within 5 days. Our findings demonstrate that intensive care unit disposition, Injury Severity Score, Abdominal Trauma Index, and the need for early surgical intervention are important predictors regarding the need for early nutritional intervention. When the model was applied to the study population, it had a sensitivity of 83%, a specificity of 84%, and an accuracy of 84%