Bayshore Community Hospital

BackgroundDistinguishing surgical intensive care unit (ICU) patients with ongoing bleeding who require hemorrhage control interventions (HCI) can be challenging. Guidelines recommend risk-stratification with clinical variables and prediction tools, however supporting evidence remains mixed.MethodsThis retrospective study evaluated adult patients admitted to the surgical ICU with concern for ongoing hemorrhage under our institution's "Hemorrhage Watch" (HW) protocol and aimed to derive a clinical prediction model identifying those needing HCI with serial vital signs (VS) and serum biomarkers. The HW protocol included ICU admission followed by a 3-h observation period with VS monitoring every 15 min and hourly biomarkers. The primary outcome was the need for HCI (operative and endovascular interventions) within nine hours of ICU arrival. Secondary outcomes included in-hospital mortality, blood transfusions, and ICU and hospital length-of-stay. A clinical prediction model was developed by utilizing the variables most associated with HCI in a best subsets regression, which was subsequently internally validated using a Bootstrap algorithm.Results305 patients were identified for inclusion and 18 (5.9%) required HCI (3 operative, 15 endovascular). The median age was 70 years (IQR 54, 83), 60% had traumatic injuries, and 73% were enrolled from the emergency department. Blood product transfusion and mortality were similar between the HCI and no-HCI groups. Our analysis demonstrated that a model based on the minimum hemoglobin (9.9 vs 8.1 g/dL), minimum diastolic (57 vs 53 mm Hg) and systolic blood pressures (105 vs 90 mm Hg), and minimum respiratory rate (15 vs 18) could predict HCI with an area under the Receiver Operating Characteristics curve (AUROC) of 0.87, outperforming the Shock Index (SI) (AUROC = 0.64).ConclusionsIn this study of surgical ICU patients with concern for ongoing bleeding, a prediction model using serial VS and biomarkers outperformed the SI and may help identify those requiring HCI.

Background: The Impella ventricular assist device is often used in patients (pts) with complex coronary artery disease undergoing high-risk percutaneous coronary interventions (PCI). Limited data exits on the risks and benefits of these devices in elderly pts. Aim: To compare major bleeding and major adverse cardiac and cerebrovascular events (MACCE) in pts undergoing Impella-assisted PCI, categorized by age groups. Methods: Data was collected for quality control on pts undergoing Impella-assisted PCI. Pts were divided by age into three groups: ≤69, 70-79 and ≥80 years. Bleeding was classified by Bleeding Academic Research Consortium (BARC). MACCE was the composite of major bleeding (BARC ≥3), death and post-PCI myocardial infarction and stroke. Results: From 2010 to 2018, 252 pts had Impella-assisted PCI (Table). Pts ≤69 were often male, presented with STEMI or NSTEMI (61%) and had lower left ventricular ejection fraction (LVEF) complicated by cardiogenic shock (CS). Bleeding complications, mortality and MACCE were similar among the groups. Covariate adjustment showed pts 70-79 were not at a higher risk of MACCE compared to ≤69 pts, whereas pts ≥80 had 2.7-fold odds of MACCE compared to pts ≤69 (Figure). Conclusion: In Impella-assisted PCI pts: 1) indications for Impella varies across different ages; 2) younger pts (≤69) were healthier but in the midst of an acute coronary syndrome with severely reduced LVEF and CS; 3) BARC ≥3, mortality and MACCE were similar among the three groups; 4) by multivariable analysis, older age, female sex, STEMI and pre-PCI CS were independent predictors of MACCE; and 5) the odds of MACCE increased by almost 3-fold in pts ≥80 when compared to younger pts.

BackgroundAutomatic noninvasive oscillometric blood pressure (NIBP) devices measure mean arterial pressure (MAP); systolic and diastolic blood pressure (SBP, DBP) are algorithmically derived from MAP. The most invalid NIBP measure is SBP, yet stroke practitioners use it to manage blood pressure (BP) in accordance with thrombolysis guidelines. We determined agreement between SBP, DBP, and MAP measured manually and by NIBP in patients treated with alteplase.MethodsA multisite prospective observational study of NIBP and manual BP agreement was conducted in patients treated with alteplase immediately after bolus and infusion initiation using methods established in guidelines for the assessment of device agreement. Dual auscultatory stethoscopes were used by 2 investigators to ensure agreement with each manual BP variable and MAP was calculated using the standard formula for manual BP measures. Data were analyzed using Bland–Altman analyses and Lin concordance correlation coefficient.ResultsA total of 7 hospitals participated, collecting 5 sets of manual/NIBP BPs in 95 patients treated with alteplase (475 paired measures). Range in limits of agreement were SBP: −28.91 to 21.41 mmHg with Lin's concordance correlation coefficient 0.8; DBP: −21.0 to 19.0 mmHg with Lin's concordance correlation coefficient 0.69; and MAP: −27.5 to 16.5 mmHg with Lin's concordance correlation coefficient 0.7. There was no difference in device agreement by BP device manufacturer brand. Differences in SBP, DBP, and MAP between NIBP and manual sphygmomanometry failed to reach guideline recommendations requiring 80% of measures to fall within a 5 mmHg difference and 95% of measures to fall within a 10 mmHg difference.ConclusionNIBP devices produce significantly different BP measures then manual sphygmomanometry auscultated BP. Because NIBP devices rely on the MAP and do not directly measure SBP and DBP, definition of what constitutes safe MAP boundaries in patients treated with alteplase should be determined when automatic BP measurement is used in clinical practice.

INTRODUCTION: Oral chemotherapy with Vismodegib for locally advanced Basal Cell Carcinoma (BCC) is widely used by dermatologists. In several isolated case reports, rare hepatotoxicity has been reported, but no consumer safety notifications have been issued by the manufacturer or the FDA to date. CASE DESCRIPTION/METHODS: A 62-year-old Caucasian female presented to emergency room with profound jaundice of her skin and scleral icterus that began two weeks after completion of Vismodegib oral chemotherapy for BCC of the left lateral forehead (Figure 1). Her past medical history was only significant for hypertension and pyrosis. The patient reports that she did not take any prescription or over-the-counter medications, herbal supplements, and had no history of alcohol use. Admission labs revealed AST of 37, ALT of 287, alkaline phosphatase of 522, total bilirubin 11.2, direct bilirubin 6.9, and indirect bilirubin of 4.3. A prompt liver biopsy revealed findings consistent with drug-related injury, including bile ductular reaction associated with portal inflammation consisting of lymphocytes, eosinophils, and neutrophils (Figure 2). She was stabilized and discharged with a plan for weekly outpatient monitoring. However, she presented two weeks later with complaints of right upper quadrant pain and melanotic stools for two days. Admission labs revealed a hemoglobin of 8.4, decreased from 12.0 on previous discharge. She was transfused appropriately and an upper endoscopy (EGD) revealed bleeding from the papillary orifice, indicative of hemobilia (Figure 3), warranting selective angiography and coil embolization for successful hemostasis. Jaundice resolved fully in four weeks and hemoglobin and liver function tests (LFTs) normalized in two months at follow-up. DISCUSSION: As noted in our case, gastroenterologists are bound to see an array of iatrogenic life-threatening complications from outpatient oral therapy for cosmetic lesions. Our case involved not only the hepatotoxic effects from Vismodegib, but a rare iatrogenic complication from the biopsy with bleeding requiring further interventions. Fatalities have been reported with this drug. Therefore, heightened awareness in medical community and mandated patient safety notifications by the manufacturer and the FDA are necessary to improve outcomes.

Background: Roux-en-Y gastric bypass offers excellent long-term results in obese patients. However, it is associated with gastrointestinal complications, which have various morbidity and mortality risks. Bezoars are one of the unusual underlying causes of gastric outlet obstruction after bypass surgery. Among them, phytobezoars are the most common form.1 They can also occur after laparoscopic Rouxen-Y bypass surgery.2 Case report: A 56-year-old morbidly obese female presented to the emergency with aphagia, poor oral tolerance and postprandial vomiting. She underwent gastric bypass surgery in 2004 and lost 100 lbs. She regained some weight over the years and in view of dilated gastric pouch, a lap band was placed in 2009. Later on, she complained of epigastric pain with inability to eat or drink for which the lap band was removed in Jan 2016. However, she did not get any relief which led to the current admission. An Upper GI series showed non-passage of contrast beyond the gastric pouch, (Fig 1) with debris at GJ anastomotic site. EGD showed a narrow gastric outlet with an impacted 2.5 cm phytobezoar, (Fig 2). It was successfully removed with roth basket along with dilation of the stenosed GJ anastomotic site, (Fig 3). A follow up UGI series showed full relief of obstruction. The patient was subsequently discharged with resolution of her symptoms.Figure 1Figure 2Figure 3Conclusion: Bezoar formation is a rare late complication of gastric bypass surgery although Bezoarinduced gastric outlet obstruction is uncommon. While these lesions are often treatable, there is a risk of postoperative obstruction with perforation and death.3 In our case, the patient continued to have obstructive symptoms despite lap band removal, which was presumed to be the cause of her symptoms. The etiology turned out to be a phytobezoar having ball valve effect, intermittently plugging the narrowed gastric outlet, which was removed. The purpose of this report is to increase awareness of this problem when bariatric patients present with obstructive symptoms to facilitate early recognition and prompt intervention to minimize the morbidity.