Endotracheal Intubation: The Role of Sterility

Background: There is a paucity of data regarding whether sterile handling of endotracheal tubes (ETTs) impacts the incidence and prevalence of pneumonia in the emergency, urgent, or elective clinical scenarios. Intensive care units employ infection control and reduction schemes to reduce pneumonia rates. Methods: A MEDLINE search of the English-language literature for the last 30 years was performed using the keywords “endotracheal intubation,” “intubation,” “pneumonia,” “sinusitis,” “tracheobronchitis,” “nosocomial infection,” and “infection.” Data were limited to those papers addressing the role of sterile handling or passage of ETTs, infection with antibiotic-resistant micro-organisms, antibiotic prophylaxis, and the role of virulence determinants in supporting invasive infection. Also, a convenience sample of a single author's patients requiring tracheal intubation was undertaken. Data were acquired on tube handling, success of insertion, and subsequent occurrence of pneumonia. Results: Virtually no data exist on the impact of sterile ETT handling, but unsterile manipulation of the ETT prior to insertion is common (112 of 154 intubation events). Within the limited patient sample, no conclusions may be drawn regarding the impact of unsterile handling on pneumonia rates, although sinusitis after nasotracheal intubation clearly increases the incidence of pneumonia. Biofilm generation as a facilitator of bacterial colonization of artificial airway surfaces is a ubiquitous virulence determinant that is not ameliorated by antibiotic administration. Conclusions: Unsterile ETT handling and insertion techniques are not clearly associated with pneumonia induction, but physiologically sound approaches that retard biofilm production may decrease pneumonia rates.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63193/1/sur.2006.054.pd

Persistent left superior vena cava: Review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients

Persistent left superior vena cava (PLSVC) represents the most common congenital venous anomaly of the thoracic systemic venous return, occurring in 0.3% to 0.5% of individuals in the general population, and in up to 12% of individuals with other documented congential heart abnormalities. In this regard, there is very little in the literature that specifically addresses the potential importance of the incidental finding of PLSVC to surgeons, interventional radiologists, and other physicians actively involved in central venous access device placement in cancer patients. In the current review, we have attempted to comprehensively evaluate the available literature regarding PLSVC. Additionally, we have discussed the clinical implications and relevance of such congenital aberrancies, as well as of treatment-induced or disease-induced alterations in the anatomy of the thoracic central venous system, as they pertain to the general principles of successful placement of central venous access devices in cancer patients. Specifically regarding PLSVC, it is critical to recognize its presence during attempted central venous access device placement and to fully characterize the pattern of cardiac venous return (i.e., to the right atrium or to the left atrium) in any patient suspected of PLSVC prior to initiation of use of their central venous access device

Abdominal Compartment Syndrome: Risk Factors, Diagnosis, and Current Therapy

Abdominal compartment syndrome’s manifestations are difficult to definitively detect on physical examination alone. Therefore, objective criteria have been articulated that aid the bedside clinician in detecting intra-abdominal hypertension as well as the abdominal compartment syndrome to initiate prompt and potentially life-saving intervention. At-risk patient populations should be routinely monitored and tiered interventions should be undertaken as a team approach to management

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

BACKGROUND: Because of the 80-hour work week, extensive service cross-coverage creates great potential for patient care errors. These patient care emergencies are increasingly managed using a rapid response team (RRT) to reduce patient morbidity. We examine the proximate causes of a surgical RRT activation. We hypothesize that most RRTs would occur during cross-coverage hours and be preventable or potentially preventable. METHODS: All surgical RRTs more than a 15-month period were captured using a nursing database and the note from the staffing intensivist/fellow. RRTs were reviewed for appropriateness (pre-existing criteria) and proximate cause. Proximate causes were further classified as patient disease, team error, nursing error, or system error as well as preventable, potentially preventable, or nonpreventable. RESULTS: Of 98 RRT activations, complete data were available for 82 (84%); 100% met activation criteria; and 76 (93%) occurred between 2100 and 0600. Seventy-six patients were 48 hours to 72 hours postoperative; six had nonoperatively managed injuries. The most common reason for activation was impending respiratory failure and acute volume overload (n = 72; 88%). RRT therapies included diuretics (n = 72), antiarrhythmics (n = 48), oxygen (n = 82), and bronchodilators (n = 36); only 2 received blood component therapy. Seventy-eight patients (95%) were transferred to higher level of care (61, surgical intensive care unit; 17, SSDU). Only 46% of patients required intubation. Performance improvement review identified 90% of physician related RRTs as preventable/potentially preventable because of errors in judgment or omission. Four RRTs because of patient disease were unpreventable. Two potentially preventable errors were each ascribed to RN or system concerns. CONCLUSION: RRT activations principally result from team-based errors of omission, more often occur between 2100 and 0600, and are more often preventable or potentially preventable. Careful attention to fluid balance and medications for comorbid diseases would reduce RRT needs