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Philip S Barie

Publications and source records attributed to Philip S Barie.

At least 19 recordsLinked to original sources
PubMed2006

Factors influencing DNR decision-making in a surgical ICU.

BACKGROUND: End-of-life decisions in the surgical ICU can be complicated by the unique characteristics of perioperative illness and the focus on life-extending interventions. We sought to determine whether illness severity correlated with the presence of DNR order in critically ill surgical patients. STUDY DESIGN: All surgical ICU patients who were given a DNR order from May 1, 1991 to May 31, 1998 were identified. Demographic data for all patients were collected prospectively. Patients who died without a DNR order were compared with patients with DNR orders. Variables in the analysis included date of DNR order, age, ICU, and hospital lengths of stay, APACHE II and III scores and maximum multiple organ dysfunction scores, past medical history, and mortality. ANOVA, multivariate ANOVA, and chi-square statistical tests were used to analyze the data, with p </= 0.05 used to reject the null hypothesis. RESULTS: Mortality for DNR patients was 84.7%. Multiple organ dysfunction syndrome was ubiquitous in this group of patients. There were no differences between DNR and no-DNR groups on the basis of age or APACHE III score or multiple organ dysfunction score. ICU lengths of stay were substantially higher in the patients made DNR, 1.8 +/- 0.1 versus 1.0 +/- 0.1, p = 0.0001, and 16.9 +/- 0.2 versus 12.1 +/- 1.2, p = 0.011, respectively. Multivariate ANOVA revealed that only past medical history predicted a DNR order. CONCLUSIONS: Although acuity of illness and organ dysfunction consistently predicted mortality in critically ill patient populations, only elements of the past medical history were positively associated with a DNR order in critically ill surgical patients. Additional prospective studies need to be performed to determine the relative influences of physiologic, demographic, and sociologic factors on the creation of DNR orders in critically ill surgical patients.

Aged↗
PubMed2006

International integrated database for the evaluation of severe sepsis and drotrecogin alfa (activated) therapy: analysis of efficacy and safety data in a large surgical cohort.

BACKGROUND: The International Integrated Database for the Evaluation of Severe Sepsis and Drotrecogin alfa (activated) Therapy includes an extensive cohort of surgical patients (1659/4459; 37%). This database broadens the experience reported on a comparatively small set of surgical patients from the pivotal Protein C Worldwide Evaluation in Severe Sepsis trial to examine issues of safety and efficacy in a much larger cohort. METHODS: We conducted a retrospective analysis of prospectively defined outcomes from 5 integrated clinical studies of severe sepsis. Multivariable analyses incorporated propensity scores, treatment, and significant baseline risk factors as independent variables in logistic regression models for 2 outcomes: serious adverse events that were observed during infusion and 28-day, all-cause mortality rates. Adjusted odds ratios were calculated for clinically important strata. Multiple subcategories of serious bleeding-event rates are presented. RESULTS: Although surgical patients who were treated with drotrecogin alfa [activated] (DrotAA) experienced a greater proportion of serious bleeding events during the infusion period, most of the patients were treated without fatal consequence. A 10.7% absolute all cause mortality risk reduction (adjusted odds ratio, 0.66; 95% CI, 0.45-0.97) was observed for DrotAA-treated, high-risk (Acute Physiology and Chronic Health Evaluation II, >or=25) surgical patients. We could not demonstrate a survival benefit in DrotAA-treated, low-risk (Acute Physiology and Chronic Health Evaluation II, <25) surgical patients. When surgical patients were stratified by number of organ dysfunctions, absolute risk reductions were observed in both categories: multiorgan (4.3%) and single (4.5%). CONCLUSION: International Integrated Database for the Evaluation of Severe Sepsis and Drotrecogin alfa (activated) Therapy analyses affirmed the favorable benefit/risk profile of DrotAA for surgical patients. The serious adverse event rate that was experienced by surgical patients during the study drug infusion period was 7.5% in the DrotAA-treated group versus 6.3% in the placebo-treated group (odds ratio, 1.41; 95% CI, 0.89-2.25). The clinical benefit of DrotAA therapy paralleled baseline risk of death and substantiated findings from the Protein C Worldwide Evaluation in Severe Sepsis study. Future analyses are needed to evaluate the special relationships among sepsis severity, bleeding management, and the postoperative timing of DrotAA administration.

Adult↗
PubMed2006

Efficacy and safety of drotrecogin alfa (activated) for the therapy of surgical patients with severe sepsis.

BACKGROUND: The efficacy of therapy with drotrecogin alfa (activated) (DrotAA) (recombinant human activated protein C) for surgical patients with severe sepsis has been questioned, and there is concern that patients who have undergone surgery recently may be at increased risk of bleeding complications from the drug. This review was performed to analyze recent data and clinical trends in the management of surgical patients with severe sepsis with respect to the efficacy and safety of therapy with DrotAA. METHODS: Review and synthesis of the pertinent English-language literature. RESULTS: Source control is the mainstay of therapy for surgical infections, including intraabdominal infections, whereas antibiotics, fluid resuscitation, and support of visceral organ function are necessary adjuncts. Therapy with DrotAA can be given to surgical patients, albeit with some delay (most protocols specify a 12-h wait after major surgery to mitigate the perceived increased risk of bleeding), but efficacy as well as safety have been questioned. In the pivotal PROWESS clinical trial, DrotAA therapy did not appear to be efficacious for surgical sepsis, but rigorous scrutiny of surgical indications and adequacy of source control by blinded reappraisal of the PROWESS database suggested that DrotAA therapy may be effective for surgical patients at high risk of death (Acute Physiology and Chronic Health Evaluation [APACHE] II score>or=25 points). Several comparable studies have now been aggregated in the INDEPTH database, which shows a significant reduction in mortality (OR 0.66; 95% CI 0.45-0.97) for therapy with DrotAA of surgical patients with severe sepsis and a high risk of death. The risk of bleeding is higher in surgical patients compared with DrotAA-treated non-surgical patients, but there is a substantial improvement in survival with DrotAA treatment. In contrast, surgical patients at a lower risk of death do not benefit from therapy with DrotAA but are placed at risk for bleeding. CONCLUSION: Accumulating experience indicates that surgical patients with severe sepsis and a high risk of death (APACHE II>or=25 points) have a significantly lower mortality rate if treated with DrotAA. The increased risk of bleeding associated with therapy is acceptable given the clear improvement in survival. Surgical patients with sepsis who are at lower risk of death do not appear to benefit from therapy with DrotAA, which should be withheld in most circumstances because of the increased risk of bleeding.

APACHE↗
PubMed2006

Critical care of the bariatric patient.

OBJECTIVE: To synthesize the current literature on care of obese, critically ill, and bariatric surgical patients. DATA SOURCE: A MEDLINE/PubMed search from 1966 to August 2005 was conducted using the search terms obesity, bariatric surgery, and critical illness, and a search of the Cochrane Library was also conducted. DATA EXTRACTION AND SYNTHESIS: An increase in both the prevalence of obesity and the number of bariatric procedures performed has resulted in an increased number of obese and, specifically, bariatric surgical patients who require intensive care unit care. Obesity is a chronic inflammatory state with resultant effects on immune, metabolic, respiratory, cardiovascular, gastrointestinal, hematologic, and renal function. Principles of care of the critically ill obese patient are reviewed and then applied to critically ill bariatric surgical patients. Pharmacotherapy, vascular access, and the presentation and management of both pressure-induced rhabdomyolysis and anastomotic failure after bariatric surgery are also reviewed. CONCLUSIONS: Obesity causes a range of pathologic effects on all major organ systems. Knowledge of these effects and issues specific to the intensive care unit care of bariatric patients can help to predict and manage complications in this population.

Bariatric Surgery↗
PubMed2006

Diagnosis and management of iron-related anemias in critical illness.

OBJECTIVE: To review of the prevalence, pathogenesis, diagnosis, and management of iron (Fe)-related anemias in critical illness. DATA SOURCE: A MEDLINE/PubMed search from 1966 to October 2005 was conducted. References from relevant articles were manually cross-referenced with additional original articles, review articles, correspondence, and chapters from selected textbooks. DATA EXTRACTION AND SYNTHESIS: Both Fe metabolism and erythropoiesis are affected by the inflammatory response that accompanies critical illness. As a result, many critically ill patients develop the anemia of inflammation, which may be compounded by an underlying Fe deficiency. Most commonly available markers of total body Fe detect Fe deficiency unreliably in the setting of inflammation. Among these tests, the serum transferrin receptor assay is relatively accurate in reflecting total body Fe, regardless of inflammation. Treatment options for Fe-related anemias in critical illness include Fe replacement and recombinant human erythropoietin therapy. The decision to implement these therapies is complex and centers on a critical evaluation of ability to affect anemia, morbidity, and mortality in critical illness and on the potential risks of therapy. CONCLUSIONS: Fe deficiency anemia and the anemia of inflammation may co-exist in critical illness. Diagnosis of and differentiation between these two anemias involves careful interpretation of multiple markers of total body Fe stores. The utility of treatment with both Fe and recombinant human erythropoietin for these disorders during critical illness requires further investigation.

Anemia, Iron-Deficiency↗
PubMed2006

Structure of surgical critical care and trauma fellowships.

INTRODUCTION: Surgical critical care (SCC) and trauma fellowships have developed in a variety of formats. Although SCC fellowships must meet specific requirements for accreditation by the Accreditation Council for Graduate Medical Education, trauma fellowships do not. As the American Board of Surgery is considering combining SCC, trauma, and emergency surgery into "acute care surgery" fellowship training, a better understanding of current program structures is needed. METHODS: The Education Committee of the Surgery Section of the Society of Critical Care Medicine sent surveys by e-mail to all SCC program directors. The survey included questions regarding the content of the fellowship, specifically, subspecialty rotations, trauma content, and operative experience. If they offered a trauma fellowship, the survey queried its structure also. RESULTS: A total of 39 of 82 surveys were returned. About one third of the programs have only SCC fellowships, one third combine SCC/trauma in 1-yr programs, and the remainder combine SCC/trauma in 2 yrs. Of the programs, 79% provided operative experience: 15% on a separate rotation and 39% on call during intensive care unit coverage. About half of the operative experiences were related to trauma and one quarter to emergency general surgery. The great majority of rotations were in general surgical or trauma intensive care units. CONCLUSION: SCC programs already include meaningful trauma and emergency general surgery operative experience. Surgical subspecialty intensive care unit and operative rotations may contribute to optimal training of the "acute care surgeon."

Critical Care↗
PubMed2006

Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery.

BACKGROUND: Emergency surgery patients are older, often critically ill, and at high risk of morbidity and mortality. We studied factors associated with issuance of a do-not-resuscitate (DNR) order and impact on morbidity and mortality in emergency surgery patients. METHODS: Prospective study of all patients since January 1, 2000 who underwent emergency surgery before admission to the intensive care unit. Data collected were: age, sex, admission diagnosis (case-mix), raw- (AIII) and age-adjusted (aAIII) APACHE III scores, issuance of a DNR order, and morbidity and mortality. Primary outcomes were DNR status and morbidity and mortality. Groups were stratified by age (patients >75 years versus younger) and sex. Statistics were calculated by chi(2) test, analysis of variance, and logistic regression. RESULTS: In all, 723 emergency surgery patients (gastrointestinal: 35%; traumatic: 20%; neurologic: 17%) met study criteria and had morbidity and mortality of 17.8% (AIII-predicted: 31%). Ninety-two patients (12%) were made DNR, of whom 82.6% died. Women received DNR status more often (16.4% versus 9.5%, p < 0.01) but morbidity and mortality was the same for women and men (18.2% versus 17.5%, p = 0.85). By logistic regression, sex most predicted new DNR status (odds ratio [OR] 2.512, p = 0.005) compared with Multiple Organ Dysfunction score (OR 1.410, p < 0.0001), Age (OR 1.054, p < 0.0001) and aAIII (OR 0.995, 0.355), with goodness of fit of 3.876 (p = 0.868) and Nagelkerke R(2) of 0.511. Percent correct was 88.9, implying good discrimination. CONCLUSIONS: Female sex and, to a lesser extent, age were associated with issuance of DNR in series of patients who received emergency surgery. The association of DNR with female sex is an unexpected finding and may indicate clinician bias and necessitate the performance of further analysis.

Age Factors↗
PubMed2006

An update on the surgeons scope and depth of practice to all hazards emergency response.

This article outlines the position of The Eastern Association of the Surgery of Trauma (EAST) in defining the role of surgeons, and specifically trauma/critical care surgeons, in the development of public health initiatives that are designed to react to and deal effectively with acts of terrorism. All aspects of the surgeon's role in response to mass casualty incidents are considered, from prehospital response teams to the postevent debriefing. The role of the surgeon in response to mass casualty incidents (MCIs) is substantial in response to threats and injury from natural, unintentional, and intentional disasters. The surgeon must take an active role in pre-event community preparation in training, planning, and executing the response to MCI. The marriage of initiatives among Departments of Public Health, the Department of Homeland Security, and existing trauma systems will provide a template for successful responses to terrorist acts.

Disaster Planning↗
PubMed2005

Surgical site infections.

This article examines the epidemiology and risk factors for the development of surgical site infections (SSIs), the importance of appropriate administration of prophylactic antibiotics, nonpharmacologic strategies, and the role of new "active" devices in reducing SSIs. A review of the pertinent English-language literature shows that many factors contribute to the risk of a patient developing an SSI. These include the patient's health status, preparation of the patient before surgery, and the use of appropriate antibiotic prophylaxis. Careful preparation of the patient and care after surgery is especially important. The use of new "active" antibacterial devices may reduce risk further. Surgeons can minimize the risk to the patient of the development of SSI through strict adherence to established surgical guidelines for perioperative care.

Anti-Bacterial Agents↗
PubMed2005

Temporary insanity?

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Biomedical Research↗
PubMed2005

Antibiotic prophylaxis in surgery--2005 and beyond.

TARGET AUDIENCE: Surgeons, pharmacists, and other physicians who prescribe prophylactic antibiotics. LEARNING OBJECTIVES: After reading this article, the reader should be able to: Outline the attributes of antibiotics that are suitable for prophylaxis; review the activity and safety profiles of commonly-prescribed prophylactic antibiotics; and discuss the importance of proper administration as well as proper choice of an agent to minimize the risk of infection. CME ACCREDITATION: The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide Continuing Medical Education (CME) for physicians. NFID takes responsibility for the content, quality, and scientific integrity of this CME activity. NFID designates this CME activity for a maximum of one (1.0) category 1 credit toward the AMA Physician's Recognition Award. Physicians should only claim those hours of credit that he/she actually spent in the educational activity. SUPPORT: This CME ctivity has been made possible by an unrestricted educational grant from Cubist Pharmcaeuticals, Inc. DISCLOSURE: Dr. Barie serves as a consultant for Cubist Pharmaceuticals, Inc. Dr. Nichols serves on the surgery advisory board for Cubist Pharmaceuticals, Inc. Dr. Condon has no financial relationship to disclose. CME INSTRUCTIONS: To receive CME credits after reading the entire publication, please go to the following website to complete the self-assessment examination and evaluation. Requests for credit must be received no later than six months following the publication date.

Anti-Bacterial Agents↗