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Stanley A Nasraway

Publications and source records attributed to Stanley A Nasraway.

17 recordsLinked to original sources
PubMed2006

Morbid obesity is an independent determinant of death among surgical critically ill patients.

OBJECTIVE: To determine whether extreme obesity (morbid obesity; body mass index > or =40 kg/m(2)) is an independent risk factor for death among critically ill patients; this objective is most salient in the subset of patients who sustain a prolonged intensive care unit stay during which the burdens of care imposed by obesity and its consequences would become most apparent. DESIGN: Cohort analysis of data from the Project Impact database used to catalog admissions and outcomes to a surgical intensive care unit, with predetermined end point analyses of outcomes. SETTING: Surgical intensive care unit serving Tufts-New England Medical Center, a tertiary care and university medical center in Boston. PATIENTS: All critically ill surgical patients admitted to the Tufts-New England Medical Center surgical intensive care unit from January 1998 to March 2001. INTERVENTIONS: Intensive care unit and hospital mortality and lengths of stay were compared with body mass index subclassified into five groups: underweight, normal weight, overweight, obese, and extremely obese. Data were examined for all admissions during the study period and for a predetermined subgroup with a prolonged intensive care unit stay (> or =4 days). MEASUREMENTS AND MAIN RESULTS: The prevalence of obesity in the surgical intensive care unit was 26.7%; extreme obesity was observed in 6.8%. In the full cohort of patients (n = 1373), median length of stay was short (2 days) and there were no differences in mortality in patients among any of the body mass index classes. In the subgroup of prolonged stay patients (n = 406), intensive care unit and hospital mortality rates were significantly increased in extremely obese patients compared with all other patients (intensive care unit, 33.3% vs. 12.3%, p = .009; hospital, 33.3% vs. 16%, p = .045). Multivariate analysis showed that extreme obesity was an independent predictor of death in surgical critically ill patients with prolonged intensive care unit stay after controlling for age, gender, and severity of illness. The odds of death increased 7.4 times in patients with morbid obesity. CONCLUSIONS: Morbid obesity (body mass index > or =40 kg/m(2)) is an independent risk factor for death in surgical patients with catastrophic illness requiring prolonged intensive care. The prevalence of obesity is growing, both in the intensive care unit and in the general population. The increased risk of complications and death in this population mandates that we adapt customized processes of care to specifically address this unique and very challenging subset of patients.

Critical Care↗
PubMed2006

Heparin-induced thrombocytopenia in the critical care setting: diagnosis and management.

BACKGROUND: Thrombocytopenia is a common occurrence in critical illness, reported in up to 41% of patients. Systematic evaluation of thrombocytopenia in critical care is essential to accurate identification and management of the cause. Although sepsis and hemodilution are more common etiologies of thrombocytopenia in critical illness, heparin-induced thrombocytopenia (HIT) is one potential etiology that warrants consideration. OBJECTIVE: This review will summarize the pathogenesis and clinical consequences of HIT, describe the diagnostic process, and review currently available treatment options. DATA SOURCE: MEDLINE/PubMed search of all relevant primary and review articles. DATA SYNTHESIS AND CONCLUSIONS: HIT is a clinicopathologic syndrome characterized by thrombocytopenia (>/=50% from baseline) that typically occurs between days 5 and 14 after initiation of heparin. This temporal profile suggests a possible diagnosis of HIT, which can be supported (or refuted) with a strong positive (or negative) laboratory test for HIT antibodies. When considering the diagnosis of HIT, critical care professionals should monitor platelet counts in patients who are at risk for HIT and carefully evaluate for, a) temporal features of the thrombocytopenia in relation to heparin exposure; b) severity of thrombocytopenia; c) clinical evidence for thrombosis; and d) alternative etiologies of thrombocytopenia. Due to its prothrombotic nature, early recognition of HIT and prompt substitution of heparin with a direct thrombin inhibitor (e.g., argatroban or lepirudin) or the heparinoid danaparoid (where available) reduces the risk of thromboembolic events, some of which may be life-threatening.

Anticoagulants↗
PubMed2005

The impact of gown-use requirement on hand hygiene compliance.

BACKGROUND: Hand hygiene compliance remains low, despite its effectiveness in preventing infections. Gowns are routinely used to reduce dissemination of organisms within hospitals. Use of gowns is time consuming and costly, and their effectiveness, compared with that of hand hygiene alone, is debated. Among the arguments supporting a gown-use requirement is the potential to boost awareness of infection control, leading to improved hand hygiene compliance. METHODS: Hand hygiene compliance was recorded in a 14-month crossover trial comparing compliance at 2 intensive care units during periods with and without a gown-use requirement. RESULTS: During 170 h of observation, 1619 hand hygiene opportunities were recorded. Compliance was 10% before care was given and 36% after care was given. Compliance with glove and gown use was 62% and 63%, respectively. After-care hand hygiene compliance for nurses, physicians, and therapists was 40%, 38%, and 22%, respectively. Compliance after patient contact, body fluid contact, and other in-room activity was 42%, 48%, and 22%, respectively. For periods with and without a gown-use requirement, overall after-care compliance (37% vs. 34%) and rates by personnel and activity type were similar. In the subgroup of patients on contact precautions, hand hygiene compliance during the period with a gown-use requirement versus the period without a gown-use requirement was 11% versus 10% (P=.85) before care was given and 45% versus 39% (P=.09) after care was given. In this subgroup, after adjustment for type of in-room activity, medical personnel, intensive care unit, and observer, the predicted after-care hand hygiene compliance during periods with and without a gown-use requirement was 48% versus 41% (P=.02). CONCLUSIONS: The hypothesis that a gown-use requirement might improve hand hygiene compliance in the intensive care unit could not be confirmed. In the subgroup of patients on contact precautions, improvement in hand hygiene compliance associated with the gown-use requirement was small and did not affect precare rates.

Guideline Adherence↗
PubMed2005

Roundtable debate: Controversies in the management of the septic patient--desperately seeking consensus.

Despite continuous advances in technologic and pharmacologic management, the mortality rate from septic shock remains high. Care of patients with sepsis includes measures to support the circulatory system and treat the underlying infection. There is a substantial body of knowledge indicating that fluid resuscitation, vasopressors, and antibiotics accomplish these goals. Recent clinical trials have provided new information on the addition of individual adjuvant therapies. Consensus on how current therapies should be prescribed is lacking. We present the reasoning and preferences of a group of intensivists who met to discuss the management of an actual case. The focus is on management, with emphasis on the criteria by which treatment decisions are made. It is clear from the discussion that there are areas where there is agreement and areas where opinions diverge. This presentation is intended to show how experienced intensivists apply clinical science to their practice of critical care medicine.

Anti-Bacterial Agents↗
PubMed2004

Rapidly advancing necrotizing fasciitis caused by Photobacterium (Vibrio) damsela: a hyperaggressive variant.

OBJECTIVE: To describe the first case of Vibrio damsela necrotizing fasciitis in New England, emphasizing the importance of very early operative intervention to achieve source control in this extremely aggressive infection. DESIGN: Case report. SETTING: Surgical intensive care unit at Tufts-New England Medical Center in Boston, MA. PATIENT: A 69-yr-old retired fisherman with rapidly progressive necrotizing fasciitis from Photobacterium (Vibrio) damsela infection and ensuing multiple-system organ failure. INTERVENTIONS: Surgical debridement, ventilator support, vasopressors, continuous veno-venous hemofiltration, and blood product transfusions. MEASUREMENTS AND MAIN RESULTS: Death. CONCLUSIONS: A high index of suspicion is necessary for the diagnosis of this specific pathogen and concordant infection. The willingness to surgically debride and amputate without hesitation at a very early point may be the only intervention capable of saving the lives of patients affected by Photobacterium (Vibrio) damsela.

Aged↗
PubMed2003

Linezolid does not increase the risk of thrombocytopenia in patients with nosocomial pneumonia: comparative analysis of linezolid and vancomycin use.

Reports from uncontrolled studies suggest that linezolid is associated with rates of thrombocytopenia higher than those reported in clinical studies. We assessed the risk of thrombocytopenia in 686 patients with nosocomial pneumonia who received linezolid or vancomycin for > or =5 days in 2 randomized, double-blind studies and for whom follow-up platelet counts had been measured. New-onset thrombocytopenia (platelet count of <150x10(9) platelets/L) occurred in 19 (6.4%) of 295 linezolid recipients and 22 (7.7%) of 285 vancomycin recipients with baseline platelet counts of > or =150x10(9) platelets/L; severe thrombocytopenia (platelet count of <50x10(9) platelets/L) occurred in only 1 patient in each group. Platelet counts decreased to less than the baseline level in 4 (6.6%) of 61 linezolid recipients and 5 (11.1%) of 45 vancomycin recipients who had baseline counts of <150x10(9) platelets/L. No patient had a decrease to <20x10(9) platelets/L. There were no statistically significant differences between groups in these or any other platelet assessments. Clinically significant thrombocytopenia was uncommon in our analysis, and linezolid was not associated with a greater risk of thrombocytopenia in seriously ill patients than was vancomycin.

Acetamides↗
PubMed2003

The problems and challenges of immunotherapy in sepsis.

Despite decades of research, the morbidity and mortality of sepsis and septic shock remain very high. To further compound the problem, results from all investigative trials (with one exception) have shown that tested immunotherapies aimed at modulating the excessive expression of key cytokines, such as the interleukins and tumor necrosis factor, have been either equivalent or inferior to placebo. While controversy prevails in terms of continuing such investigative trials, study designs can be held accountable for inherent flaws. Testing for the wrong hypothesis, errant study design, using the wrong agent, focusing on an inappropriate target group, excessive expectations, and uncontrolled variables have potentially obscured the real efficacy such agents might have to offer. By standardizing protocols and reducing uncontrolled variables, research can be more precisely targeted so as to unmask the real benefits to the patient.

Animals↗
PubMed2002

Multidisciplinary care of the obese patient with chronic critical illness after surgery.

The surgical patient with prolonged critical illness usually has a higher severity of illness on ICU admission, and is destined for greater morbidity, debilitation, and poorer hospital and long-term survival. Care of those with obesity is particularly difficult. Only with meticulous attention to detail and refined, dedicated, multidisciplinary processes of care, preferably assisted by protocolization, can these patients sustain any hope of recovery to acceptable functionality.

Blood Pressure Determination↗
PubMed2002

Clinical utility of blood cultures drawn from central venous or arterial catheters in critically ill surgical patients.

OBJECTIVE: To determine the sensitivity, specificity, and predictive values of cultures done with blood drawn through a central venous or arterial catheter compared with peripheral venipuncture. DESIGN: Retrospective cohort study of critically ill surgical patients in whom samples for paired cultures were drawn through a central venous or arterial catheter and peripheral venipuncture. SETTING: Tertiary-care, university-affiliated medical center. PATIENTS: Two hundred seventy-one patients hospitalized on a surgical and a cardiothoracic intensive care unit between November 1994 and August 1997. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Blinded assessments of culture results done by two physicians were used as the gold standard. Sensitivity, specificity, and positive and negative predictive values were compared for culture of blood from catheters and culture of blood from peripheral venipuncture. Of 499 observations, 426 were catheter-negative/venipuncture-negative, 19 were catheter-positive/venipuncture-positive, 18 were catheter-negative/venipuncture-positive, and 36 were catheter-positive/venipuncture-negative pairs. For catheter draws compared with peripheral venipuncture, sensitivity was 78% (confidence interval [CI], 65% to 90%) and 65% (CI, 50% to 79%) (p = .2), specificity was 95% (CI, 94% to 97%) and 98% (CI, 97% to 99%) (p = .002), positive predictive value was 63% (CI, 51% to 76%) and 78% (CI, 64% to 91%) (p = .1) and negative predictive value was 98% (CI, 96% to 99%) and 97% (CI, 95% to 98%) (p = .3). When central venous specimens as differentiated from arterial catheter specimens were compared with peripheral venipuncture, the difference between positive predictive values reached statistical significance (61% and 82%; p = .04). CONCLUSIONS: In critically ill surgical patients, cultures of blood drawn through a catheter are less specific than those obtained from a peripheral venipuncture. Both types of cultures have an excellent negative predictive value. Positive predictive value of cultures of blood drawn through a catheter is low and, when obtained from a central line, statistically less than from a peripheral venipuncture. Additional cultures seem to be necessary for the proper interpretation of a positive culture drawn through a catheter in critical care patients.

Aged↗
PubMed2002

Candidemia as a cause of septic shock and multiple organ failure in nonimmunocompromised patients.

OBJECTIVE: To describe outcomes of septic shock and multiple organ failure arising from candidemia. DESIGN: Secondary cohort analysis of data from the placebo arm of the North American Septic Shock Trial (NORASEPT II), the largest prospective, randomized, double-blind, controlled multiple center study of septic shock conducted to date, with predetermined end point analysis of outcomes. SETTING: Adult intensive care units in 105 hospitals in the United States and Canada. SUBJECTS: A cohort of ten purely candidemic patients in septic shock were compared with a cohort of 376 purely bacteremic patients in septic shock. Patients were not immunocompromised, because patients on corticosteroids, with neutropenia, or posttransplantation were excluded from enrollment in NORASEPT II. MEASUREMENTS AND MAIN RESULTS: Demographic variables, baseline characteristics, 28-day mortality rates, and multiple organ failure were compared for the two cohorts. Candidemic patients were more likely to have a history of underlying renal failure at baseline and to require dialysis at onset of septic shock. Both causes of septic shock are associated with an extremely high severity of illness (Acute Physiology and Chronic Health Evaluation II: candidemic septic shock, 32 +/- 10; bacteremic septic shock, 30 +/- 8; p =.44). More than 70% of patients with candidemia and septic shock were in multiple organ failure at days 3, 7, and 14; patients with candidemic septic shock sustained persistent multiple organ failure and showed delayed recovery from multiple organ failure compared with patients with bacteremic septic shock. Mortality rate at 28 days was 60% in candidemic septic shock and 46% in bacteremic septic shock (p =.38). CONCLUSIONS: Candidemia with septic shock is infrequent in nonimmunocompromised patients but has a very high mortality rate, a high likelihood of associated multiple organ failure, and possibly a delayed recovery from multiple organ failure. Patients with candidemic septic shock are more likely to have underlying renal failure at baseline.

APACHE↗
PubMedDate not supplied

Hyperglycemia during critical illness.

BACKGROUND: We sought to review the literature describing the benefits of tight glycemic control in critically ill patients, comparing outcome differences in subgroup populations. METHODS: We searched PubMed for relevant literature on the topic of hyperglycemia and its management in the intensive care unit. RESULTS: Overwhelming evidence in both surgical and medical patients conclusively demonstrates that hyperglycemia is a marker of severity of illness and is also an independent determinant of bad outcome, largely from infectious complications. Randomized trial evidence, in conjunction with historically controlled trials, supports the use of intensive insulin therapy and euglycemic control in critically ill patients, with nondiabetics possibly benefiting even more than diabetic patients. Euglycemia is best achieved, and hypoglycemia attenuated, through use of a protocolized approach. Further elaboration as to what threshold range defines euglycemia in patient subpopulations is needed and what pitfalls must be avoided in this practice. Development of continuous blood glucose monitoring has started and will someday be incorporated into routine practice in the same way that continuous electrocardiographic monitoring and pulse oximetry are standards of care in the intensive care unit. CONCLUSIONS: Hyperglycemia is a predictor of death and complications in critically ill patients. Early aggregated study results show that control of hyperglycemia improves outcomes. Well-designed studies involving thousands of patients have started to better elucidate the concomitant promoters of hyperglycemia and to better quantify the benefits from tight glycemic control.

Biomarkers↗
PubMedDate not supplied

Hyperglycemia in the critically ill.

Hyperglycemia is frequently seen in acutely ill patients and has historically been viewed as a normal response to stress. Treatment is often not initiated unless blood glucose exceeds 200 to 250 mg/dL. Recent evidence suggests that hyperglycemia is associated with worse outcomes within the population of medical and surgical intensive care units. Hyperglycemia in this population of patients develops from increased gluconeogenesis and insulin resistance. Although the specific mechanisms by which hyperglycemia contributes to poor outcomes are as yet unknown, disruption of normal mitochondrial respiration, direct glucose toxicity, accumulation of asymmetric dimethylarginine, and impairment of immune cell function are among the possibilities implicated. Studies demonstrate that intensive insulin therapy to achieve euglycemia reduces mortality and morbidity in critically ill patients. In addition to recognizing and treating hyperglycemia, it is as important to identify other frequently overlooked factors that contribute to hyperglycemia, such as medications, intravenous fluids, and enteral and parenteral nutrition.

Blood Glucose↗