What is postoperative systemic inflammatory response syndrome (SIRS) and what are the symptoms?

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Bottom line:  SIRS is a response by the body to some kind of infectious or noninfectious insult.  The response includes a profound systemic inflammation that can lead to septic shock and multiple organ failure.  Surgey can elicit this systemic inflammation by exposing patient to tissue damage and to possible infection.  Signs of SIRS include changes in heart rate, respiratory rate, blood pressure, temperature regulation, and immune cell activation.

Details:
Chapter 4. Fever and hypothermia.  In: Textbook of Critical Care, 6th ed., 2011.
Chapter 8. Inflammation, Infection, & Antimicrobial Therapy.  In:  Current Diagnosis & Treatment: Surgery [AccessSurgery]
These two chapters provide a brief explanation of SIRS.  Chapter 4 also includes algorithm for looking for source of infection.

Sepsis in adults.  In: DynaMed.  Summarizes diagnostic criteria and treatment options.  Patient is considered to have SIRS if he/she exhibits more than one of these criteria from the 2001 Society of Critical Care Medicine (SCCM)/The European Society of Intensive Care Medicine (ESICM)/American College of Chest Physicians (ACCP)/American Thoracic Society (ATS)/Surgical Infection Society (SIS) International Sepsis Definitions Conference:

  • Body temperature higher than 38°C or lower than 36°C
  • Heart rate higher than 90/min
  • Hyperventilation evidenced by respiratory rate higher than 20/min or PaCO2lower than 32 mmHg
  • White blood cell count higher than 12,000 cells/ μl or lower than 4,000/ μl

Intensive Care Med 2003 Apr;29(4):530

Chapter 68.  Multiple organ failure.  In:  Trauma [AccessSurgery] explains SIRS in the context of noninfectious causes.

Does trimming peripherally inserted central catheters (PICC) increase the incidence of thrombosis?

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Bottom line: There is not much published evidence addressing this question.

Summary:
Joanna Briggs: Peripherally Inserted Central Catheters: Occlusion
Reviews evidence associated with risk associated with misplacement or movement of the catheter tip and location of insertion site.  I checked the references cited, but did not find any discussion of modifying or trimming the catheter.

PubMed:
peripherally inserted catheter AND thrombosis AND (trimmed OR trimming OR modif* OR cutting)

Evidence that specifically discusses trimming includes
Parvez. Thrombosis Research (2004) 113, 175—177:  A comparison of changes in surface of catheter at site of trimming.  Authors hypothesize that roughness introduced by trimming line can contribute to thrombosis.

EMBASE:
To view search click on the EMBASE link and then copy this search statement into the search box:

‘peripherally inserted central catheter’ AND thrombosis  AND (trimming OR trimmed OR modif*)

Additional evidence that specifically discusses trimming includes:

Trimming of peripherally inserted central catheters: The end result
Pettit J.  JAVA – Journal of the Association for Vascular Access 2006 11:4 (209-214)
This paper references a study showing how trimming affects the catheter tip.  Possibly this reference is to the Parvez article from the PubMed results above.  We do not have access to this Pettit paper, but you can request through interlibrary loan link in the Find It @ Emory menu for this article

Other papers in both the PubMed and EMBASE searches seem to mention trimming or cutting the catheter, but only as part of the procedures and not as a risk factor.

SEARCH METHODS
Resources searched:
Evidence summary resources:  Joanna Briggs JBI+Connect
Large literature databases: PubMed, EMBASE

Search included combinations of these terms:
Peripherally inserted central catheter, catheter
trimming, trimmed, modif* (for modify, modified, modification, etc.)
thrombosis

What are the latest recommendations for prevention of C. difficile?

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Dynamed references Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).  Infect Control & Hosp Epidemiology. 2010; 31(5): 421-455.
Recommendations for prevention of infection during a hospital outbreak include (definitions of ratings are in Table 1, p. 434):
•    Healthcare workers and visitors must use gloves (A-I) and gowns (B-III) on entry to a room of a patient with CDI.
•    Emphasize compliance with the practice of hand hygiene (A-II).
•    In a setting in which there is an outbreak or an increased CDI rate, instruct visitors and healthcare workers to wash hands with soap (or antimicrobial soap) and water after caring for or contacting patients with CDI (B-III).
•    Accommodate patients with CDI in a private room with contact precautions (B-III).   If single rooms are not available, cohort patients, providing a dedicated commode for each patient (C-III).
•    Maintain contact precautions for the duration of diarrhea (C-III).
•    Routine identification of asymptomatic carriers (patients or healthcare workers) for infection control purposesis not recommended (A-III) and treatment of such identified patients is not effective (B-I).
•    Identification and removal of environmental sources of C. difficile, including replacement of electronic rectal thermometers with disposables, can reduce the incidence of CDI (B-II).
•    Use chlorine-containing cleaning agents or other sporicidal agents to address environmental contamination in areas associated with increased rates of CDI (B-II).
•    Routine environmental screening for C. difficile is not recommended (C-III).

Reviewed JKN 4/14

What is the prevalence of C. difficile infection in hospitals in the United States?

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DynaMed references CDC report on prevalence of C. diff. diagnoses in hospital discharges
Emerg Infect Dis. 2006 Mar;12(3):409-15.
Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003.  McDonald LC, et al.
Study of annual rate of hospital discharges with listed diagnosis of C. difficile-associated diarrhea in National Hospital Discharge Survey.  31 per 100,000 population in 1996; increasing from 2000 to 2003 reaching 61 per 100,000 population in 2003

Emerg Infect Dis. 2008 Jun;14(6):929-31.
Increase in adult Clostridium difficile-related hospitalizations and case-fatality rate, United States, 2000-2005.  Zilberberg MD, et al.
Reports incidence of C. difficile diagnosis in hospital discharge.  Table displays incidence by age group

Reviewed JKN 4/14

How does congestive heart failure affect the kidneys and lungs?

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Chapter 26. Pathophysiology of Heart Failure.  In:  Hurst’s the Heart [AccessMedicine]
Includes a section on “Integrative Pathophysiology with Other Organ Systems” that discusses how CHF affects kidneys and lungs.
Also includes useful references at the end of the chapter.

PubMed search:  “Heart Failure/physiopathology”[majr] AND (lung OR pulmonary OR kidney OR renal)         Filters selected:  English, Review articles

This is still a large set, including many review articles on very specific aspects of heart failure and other organs instead of an overview.

Applying a filter for Nursing journals retrieved the following results.  There were a couple of relevant articles on heart failure and kidneys.
http://www.ncbi.nlm.nih.gov/pubmed?otool=emorylib&term=%22Heart%20Failure%2Fphysiopathology%22%5Bmajr%5D%20AND%20(lung%20OR%20pulmonary%20OR%20kidney%20OR%20renal) AND (Review[ptyp] AND English[lang] AND jsubsetn[text])

For articles discussing effects on the lungs, try this search in PubMed:  “Heart Failure”[majr] AND (lung OR pulmonary) AND (Review[ptyp] AND English[lang] ).  Again, you can use the filtering options on the left side of the page to limit to nursing journals (using the Journal Categories filter) which may focus the search on review articles more targeted to your interests.

Reviewed JKN 4/14

What role does inflammation play in congestive heart failure?

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Chapater 26  Pathophysiology of heart failure.  In:  Hurst’s the Heart [AccessMedicine].
This section includes a section entitled, “Inflammatory Responses: The Inflammatory Hypothesis.”

“Heart Failure/physiopathology”[majr] AND inflammat*
Filters (Limits):  English, Review articles

This search includes the following references:
The role of monocytes and inflammation in the pathophysiology of heart failure.
Wrigley BJ, Lip GY, Shantsila E.
Eur J Heart Fail. 2011 Nov;13(11):1161-71. Epub 2011 Sep 27. Review.
PMID:21952932

Immune modulation in heart failure: past challenges and future hopes.
Flores-Arredondo JH, García-Rivas G, Torre-Amione G.
Curr Heart Fail Rep. 2011 Mar;8(1):28-37. Review.
PMID:21221862

Reviewed JKN 4/14

Does the use of a thoracic impedance device during resuscitation improve patient outcomes compared to resuscitations without use of such a device?

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There is some evidence that use of an impedance threshold device added to active compression-decompression device  may result in small improvement in survival but impedance device added to standard cardiopulmonary resuscitation (CPR) does not improve survival.

Aufderheide TP, et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet. 2011 Jan 22;377(9762):301-11. RESQ Trial
1,653 adult patients with out-of-hospital cardiac arrest randomized to resuscitation with compression-decompression device plus impedance threshold device compared to standard CPR. RESULTS:  Survival to discharge without neurologic impairment was similar for both groups.

Aufderheide TP, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med. 2011 Sep 1;365(9):798-806. ROC PRIMED Trial
9,220 patients with out-of-hospital cardiac arrest randomized to standard CPR with active impedance threshold device (ITD) compared to standard CPR with sham ITD. RESULTS:  Survival to hospital discharge with normal Rankin score was 6% for the sham ITD group compared to 5.8% for the active ITD group.  Rates for return of spontaneous circulation and survival to hospital admission were also similar for both groups.

Also see Cardiac Arrest (Treatment>Other Management>Prehospital care>Improving chest compressions).  In:  DynaMed

Cabrini L, et al. Impact of impedance threshold devices on cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled studies. Crit Care Med. 2008 May;36(5):1625-32.
Systematic review of older, RCTs

Reviewed JKN 4/14