Letters to the Editor
Department and discharged 30 days after the trauma. Necrotizing fasciitis after rectal perforation due to trauma is not widely reported in the literature.[3] Most cases described are secondary to perianal diseases, such as complicated abscesses, complex fistulas, and fissures. Other causes include genitourinary infections as those postoperative of the urogenital area. The diagnosis is imminent clinically, which can be supported by imaging, where CT scan shows subcutaneous emphysema as hypodense areas, subcutaneous collections, and also provides excellent information of the locoregional extension of the disease. The most frequently isolated bacteria is Gram negative E. coli, among aerobes, and Bacteroides, among anaerobes. The treatment should be introduced early and be based on empirical antibiotic therapy, together with aggressive removal of necrotic tissue, and even the use of other therapies such as hyperbaric oxygen.[4] Colostomy should be considered in those cases where the origin is colo‑proctological; in those patients with extensive lesions to prevent contamination of infected lesions or of drainage incisions made. In doubtful cases it will be preferred to be performed the procedure as both the absence and the delay in its implementation are factors shown to increase mortality.[5]
Juan Ramón Hernández -Hernández
Departments of Surgery and 1Intensive Care Unit, Insular Universitary Hospital of Gran Canaria, Las Palmas of Gran Canaria, Spain Address for correspondence: Dr. Luciano Santana-Cabrera, South Maritime Avenue n/n. Las Palmas of Gran Canaria, Canary Islands, Spain. E-mail: [email protected]
REFERENCES 1. 2.
3. 4. 5.
Fu WP, Quah HM, Eu KW. Traumatic rectal perforation presenting as necrotising fasciitis of the lower limb. Singapore Med J 2009;50:e270‑3. Koukouras D, Kallidonis P, Panagopoulos C, Al‑Aown A, Athanasopoulos A, Rigopoulos C, et al. Fournier’s gangrene, a urologic and surgical emergency: Presentation of a multi‑institutional experience with 45 cases. Urol Int 2011;86:167‑72. Basoglu M, Ozbey I, Atamanalp SS, Yildirgan MI, Aydinli B, Polat O, et al. Management of Fournier’s gangrene: Review of 45 cases. Surg Today 2007;37:558‑63. Ooi A, Chong SJ. Use of adjunctive treatments in improving patient outcome in Fournier’s gangrene. Singapore Med J 2011;52:e194‑7. Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E. Necessity of preventive colostomy for Fournier’s gangrene of the anorectal region. Ulus Travma Acil Cerrahi Derg 2009;15:342‑6.
Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124174
Julián Favre-Rizzo, Luciano Santana-Cabrera1, Eudaldo López-Tomasetti Fernández, Cristina Rodríguez Escot1,
Outcome for tracheostomized patients who requiring prolonged stay in intensive care unit Sir, The association between tracheostomy and outcomes reported in the studies of tracheostomized patients remains unclear.[1,2] There is no proven benefit of the procedure itself or related care and it might be that, after several days of mechanical ventilation (MV), intensive care unit (ICU) physicians adequately select candidates for tracheostomy, based on the highest probability of MV weaning failure associated with a reasonable probability of ICU survival.[3] The objectives of this study was to evaluate the effect of tracheostomy on ICU and in‑hospital mortality for patients requiring prolonged (>14 days) stay in ICU. We retrospectively reviewed data collected prospectively on patients admitted to the ICU from January 2004 286
to December 2010, with prolonged stay (>14 days). We analyzed outcomes of tracheostomized and non‑tracheostomized patients using univariable and multivariable logistic‑regression analyses. Of the 707 patients requiring prolonged ICU stay, 448 were tracheostomized. The results of the predictive model of survival in ICU show the performing a tracheostomy define survival (odds ratio 2.445, 95% confidence interval 1.520‑3.918, P = 0.000). However, these patients will have a better outcome at discharge from the hospital when a tracheotomy was not performed (odds ratio 0.331, 95% confidence interval 0.139‑0.768, P = 0.011). Kaplan–Meier estimates of the cumulative probability of survival as a function of the number of days after ICU admission differed significantly between the two groups, with better outcome for tracheostomized patients [Figure 1].
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
Letters to the Editor
long‑term MV patients will remain speculative until the large‑scale and adequately powered randomized, controlled trials. L Santana‑Cabrera, C Díaz Mendoza, M Sánchez‑Palacios, JD Martin‑Santana1, JR Hernández Hernández1 1
Intensive Care Unit, Universitary Hospital Insular in Gran Canaria, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain Address for correspondence: Dr. L. Santana‑Cabrera, Avenida Marítima Del Sur s/n, Las Palmas de Gran Canaria, Canary Islands 35016, Spain. E‑mail: [email protected]
REFERENCES Figure 1: Kaplan–Meier survival curves depending on the application or not of tracheostomy
We might have missed, in the present study, factors associated with the decision to perform a tracheostomy that might alter ICU and hospital outcomes as prolonged MV duration because of weaning failure, need for reintubation, nosocomial pneumonia, or aspiration.[4,5] Anyway, our results may not be applicable to patients receiving MV in other centers with different case‑mixes and different MV weaning strategies. Furthermore, we did not record decisions to withhold or withdraw life‑sustaining treatments either in our unit or after discharge from it. Such decisions might have affected the results. These data might be the focus of future studies.
1. 2. 3. 4. 5.
Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long‑term mechanical ventilation? Crit Care Med 2007;35:802‑7. Frutos‑Vivar F, Esteban A, Apezteguía C, Anzueto A, Nightingale P, González M, et al. Outcome of mechanically ventilated patients who require a tracheostomy. Crit Care Med 2005;33:290‑8. Freeman BD, Borecki IB, Coopersmith CM, Buchman TG. Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. Crit Care Med 2005;33:2513‑20. Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta‑analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005;330:1243. Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med 1999;27:1714‑20. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124176
In conclusion, tracheostomy performed in our ICU for long‑term stay patients was associated with lower ICU mortality, but higher in‑hospital rates. Whether the tracheostomy really affects the outcomes of these
Patient care delays due to scene safety Sir, Recently, responding to a 911 call of ‘gunshots fired’, two law‑enforcement officers arrived within a minute and found an unresponsive victim but were unable to allow Emergency Medical Services (EMS) on the scene as a crowd of approximately 30 bystanders became increasingly hostile, both threatening and physically assaulting the officers. Within seven minutes, approximately 20 officers had arrived and the crowd was dispersed. Once the scene was secured, paramedics found a 31‑year‑old male with three gunshot wounds to his chest. The patient maintained palpable pulses until just prior to arrival in the hospital. In the emergency department, the
patient remained pulseless and unresponsive. Bilateral thoracotomies were performed and the patient was found to have penetration of the superior vena cava without injury to the heart. Open cardiopulmonary resuscitation (CPR) with intracardiac epinephrine was performed and massive blood and plasma transfusions were administrated, but the patient could not be resuscitated. It is well established that the response time of EMS has a significant effect on morbidity and mortality for patients with severe medical or traumatic conditions. Although EMS delays in patient care have many different causes, no studies examine delays from safety risks for EMS personnel.
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
287
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Department and discharged 30 days after the trauma. Necrotizing fasciitis after rectal perforation due to trauma is not widely reported in the literature.[3] Most cases described are secondary to perianal diseases, such as complicated abscesses, complex fistulas, and fissures. Other causes include genitourinary infections as those postoperative of the urogenital area. The diagnosis is imminent clinically, which can be supported by imaging, where CT scan shows subcutaneous emphysema as hypodense areas, subcutaneous collections, and also provides excellent information of the locoregional extension of the disease. The most frequently isolated bacteria is Gram negative E. coli, among aerobes, and Bacteroides, among anaerobes. The treatment should be introduced early and be based on empirical antibiotic therapy, together with aggressive removal of necrotic tissue, and even the use of other therapies such as hyperbaric oxygen.[4] Colostomy should be considered in those cases where the origin is colo‑proctological; in those patients with extensive lesions to prevent contamination of infected lesions or of drainage incisions made. In doubtful cases it will be preferred to be performed the procedure as both the absence and the delay in its implementation are factors shown to increase mortality.[5]
Juan Ramón Hernández -Hernández
Departments of Surgery and 1Intensive Care Unit, Insular Universitary Hospital of Gran Canaria, Las Palmas of Gran Canaria, Spain Address for correspondence: Dr. Luciano Santana-Cabrera, South Maritime Avenue n/n. Las Palmas of Gran Canaria, Canary Islands, Spain. E-mail: [email protected]
REFERENCES 1. 2.
3. 4. 5.
Fu WP, Quah HM, Eu KW. Traumatic rectal perforation presenting as necrotising fasciitis of the lower limb. Singapore Med J 2009;50:e270‑3. Koukouras D, Kallidonis P, Panagopoulos C, Al‑Aown A, Athanasopoulos A, Rigopoulos C, et al. Fournier’s gangrene, a urologic and surgical emergency: Presentation of a multi‑institutional experience with 45 cases. Urol Int 2011;86:167‑72. Basoglu M, Ozbey I, Atamanalp SS, Yildirgan MI, Aydinli B, Polat O, et al. Management of Fournier’s gangrene: Review of 45 cases. Surg Today 2007;37:558‑63. Ooi A, Chong SJ. Use of adjunctive treatments in improving patient outcome in Fournier’s gangrene. Singapore Med J 2011;52:e194‑7. Akcan A, Sözüer E, Akyildiz H, Yilmaz N, Küçük C, Ok E. Necessity of preventive colostomy for Fournier’s gangrene of the anorectal region. Ulus Travma Acil Cerrahi Derg 2009;15:342‑6.
Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124174
Julián Favre-Rizzo, Luciano Santana-Cabrera1, Eudaldo López-Tomasetti Fernández, Cristina Rodríguez Escot1,
Outcome for tracheostomized patients who requiring prolonged stay in intensive care unit Sir, The association between tracheostomy and outcomes reported in the studies of tracheostomized patients remains unclear.[1,2] There is no proven benefit of the procedure itself or related care and it might be that, after several days of mechanical ventilation (MV), intensive care unit (ICU) physicians adequately select candidates for tracheostomy, based on the highest probability of MV weaning failure associated with a reasonable probability of ICU survival.[3] The objectives of this study was to evaluate the effect of tracheostomy on ICU and in‑hospital mortality for patients requiring prolonged (>14 days) stay in ICU. We retrospectively reviewed data collected prospectively on patients admitted to the ICU from January 2004 286
to December 2010, with prolonged stay (>14 days). We analyzed outcomes of tracheostomized and non‑tracheostomized patients using univariable and multivariable logistic‑regression analyses. Of the 707 patients requiring prolonged ICU stay, 448 were tracheostomized. The results of the predictive model of survival in ICU show the performing a tracheostomy define survival (odds ratio 2.445, 95% confidence interval 1.520‑3.918, P = 0.000). However, these patients will have a better outcome at discharge from the hospital when a tracheotomy was not performed (odds ratio 0.331, 95% confidence interval 0.139‑0.768, P = 0.011). Kaplan–Meier estimates of the cumulative probability of survival as a function of the number of days after ICU admission differed significantly between the two groups, with better outcome for tracheostomized patients [Figure 1].
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
Letters to the Editor
long‑term MV patients will remain speculative until the large‑scale and adequately powered randomized, controlled trials. L Santana‑Cabrera, C Díaz Mendoza, M Sánchez‑Palacios, JD Martin‑Santana1, JR Hernández Hernández1 1
Intensive Care Unit, Universitary Hospital Insular in Gran Canaria, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain Address for correspondence: Dr. L. Santana‑Cabrera, Avenida Marítima Del Sur s/n, Las Palmas de Gran Canaria, Canary Islands 35016, Spain. E‑mail: [email protected]
REFERENCES Figure 1: Kaplan–Meier survival curves depending on the application or not of tracheostomy
We might have missed, in the present study, factors associated with the decision to perform a tracheostomy that might alter ICU and hospital outcomes as prolonged MV duration because of weaning failure, need for reintubation, nosocomial pneumonia, or aspiration.[4,5] Anyway, our results may not be applicable to patients receiving MV in other centers with different case‑mixes and different MV weaning strategies. Furthermore, we did not record decisions to withhold or withdraw life‑sustaining treatments either in our unit or after discharge from it. Such decisions might have affected the results. These data might be the focus of future studies.
1. 2. 3. 4. 5.
Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long‑term mechanical ventilation? Crit Care Med 2007;35:802‑7. Frutos‑Vivar F, Esteban A, Apezteguía C, Anzueto A, Nightingale P, González M, et al. Outcome of mechanically ventilated patients who require a tracheostomy. Crit Care Med 2005;33:290‑8. Freeman BD, Borecki IB, Coopersmith CM, Buchman TG. Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. Crit Care Med 2005;33:2513‑20. Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta‑analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005;330:1243. Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med 1999;27:1714‑20. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124176
In conclusion, tracheostomy performed in our ICU for long‑term stay patients was associated with lower ICU mortality, but higher in‑hospital rates. Whether the tracheostomy really affects the outcomes of these
Patient care delays due to scene safety Sir, Recently, responding to a 911 call of ‘gunshots fired’, two law‑enforcement officers arrived within a minute and found an unresponsive victim but were unable to allow Emergency Medical Services (EMS) on the scene as a crowd of approximately 30 bystanders became increasingly hostile, both threatening and physically assaulting the officers. Within seven minutes, approximately 20 officers had arrived and the crowd was dispersed. Once the scene was secured, paramedics found a 31‑year‑old male with three gunshot wounds to his chest. The patient maintained palpable pulses until just prior to arrival in the hospital. In the emergency department, the
patient remained pulseless and unresponsive. Bilateral thoracotomies were performed and the patient was found to have penetration of the superior vena cava without injury to the heart. Open cardiopulmonary resuscitation (CPR) with intracardiac epinephrine was performed and massive blood and plasma transfusions were administrated, but the patient could not be resuscitated. It is well established that the response time of EMS has a significant effect on morbidity and mortality for patients with severe medical or traumatic conditions. Although EMS delays in patient care have many different causes, no studies examine delays from safety risks for EMS personnel.
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
287
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
