Common Iatrogenic Complication Research Articles

Contrast-induced nephropathy: Pathophysiology, risk factors, and prevention.

Contrast-induced acute kidney injury is a common iatrogenic complication associated with increased health resource utilization and adverse outcomes, including short- and long-term mortality and accelerated progression of preexisting renal insufficiency. The incidence of contrast-induced nephropathy (CIN) has been reported to range from 0% to 24%. This wide range reported by the studies is due to differences in definition, background risk factors, type and dose of contrast medium used, and the frequency of other coexisting potential causes of acute renal failure. CIN is usually transient, with serum creatinine levels peaking at 2-3 days after administration of contrast medium and returning to baseline within 7-10 days after administration. Multiple studies have been conducted using variety of therapeutic interventions in an attempt to prevent CIN. Of these, careful selection of patients, using newer radiocontrast agents, maintenance of hydration status, and avoiding nephrotoxic agents pre- and post-procedure are the most effective interventions to protect against CIN. This review focuses on the basic concepts of CIN and summarizes our recent understanding of its pathophysiology. In addition, this article provides practical recommendations with respect to CIN prevention and management.

New Persistent Opioid Use Among Patients With Cancer After Curative-Intent Surgery.

Purpose The current epidemic of prescription opioid misuse has increased scrutiny of postoperative opioid prescribing. Some 6% to 8% of opioid-naïve patients undergoing noncancer procedures develop new persistent opioid use; however, it is unknown if a similar risk applies to patients with cancer. We sought to define the risk of new persistent opioid use after curative-intent surgery, identify risk factors, and describe changes in daily opioid dose over time after surgery. Methods Using a national data set of insurance claims, we identified patients with cancer undergoing curative-intent surgery from 2010 to 2014. We included melanoma, breast, colorectal, lung, esophageal, and hepato-pancreato-biliary/gastric cancer. Primary outcomes were new persistent opioid use (opioid-naïve patients who continued filling opioid prescriptions 90 to 180 days after surgery) and daily opioid dose (evaluated monthly during the year after surgery). Logistic regression was used to identify risk factors for new persistent opioid use. Results A total of 68,463 eligible patients underwent curative-intent surgery and filled opioid prescriptions. Among opioid-naïve patients, the risk of new persistent opioid use was 10.4% (95% CI, 10.1% to 10.7%). One year after surgery, these patients continued filling prescriptions with daily doses similar to chronic opioid users ( P = .05), equivalent to six tablets per day of 5-mg hydrocodone. Those receiving adjuvant chemotherapy had modestly higher doses ( P = .002), but patients with no chemotherapy still had doses equivalent to five tablets per day of 5-mg hydrocodone. Across different procedures, the covariate-adjusted risk of new persistent opioid use in patients receiving adjuvant chemotherapy was 15% to 21%, compared with 7% to 11% for those with no chemotherapy. Conclusion New persistent opioid use is a common iatrogenic complication in patients with cancer undergoing curative-intent surgery. This problem requires changes to prescribing guidelines and patient counseling during the surveillance and survivorship phases of care.

Comparative Ultrasound Review of Free Intra-Peritoneal Fluid (Ascites)

The aim of this study is to review clinical case ascites and the use of ultrasound for the detection/classification of free intra-peritoneal fluid. Current therapeutic modality is in support of ultrasound guided paracentesis/thoracocentesis as a multidisciplinary procedure for ascitic reduction. Post-surgical free intra-peritoneal fluid is a common iatrogenic complication. We present ascitic cases of diseased conditions, questionable origins (in females) following hernia reduction and laparoscopic procedures to evaluate ascitic etiology through ultrasound. Average attenuation and quadrant sum of largest fluid pocket ultrasound (frozen) images were measured. 12 patients with free intra-peritoneal fluid had identifiable anatomical organs: liver, kidneys, urinary bladder and bowel loops. The size of maximal pocket of ascitic fluid in ill-patients was 1210/300 mm2, while fluid in subjects with non-traumatic injury was clear (free of striations) and appeared less dense.

AKIGUARD (Acute Kidney Injury GUARding Device) trial: in-hospital and one-year outcomes.

Contrast-induced acute kidney injury (CIAKI) in patients with chronic kidney disease undergoing coronary angiography or percutaneous coronary intervention is a common iatrogenic complication associated with increased morbidity and mortality. This study compares sodium bicarbonate/isotonic saline/N-acetylcysteine/vitamin C prophylaxis (BS-NAC) against high-volume forced diuresis with matched hydration in CIAKI prevention. One-hundred and thirty-three consecutive patients undergoing coronary angiography or percutaneous coronary intervention with estimated glomerular filtration rate less than 60 mL/min/1.73m were randomized to the study group receiving matched hydration (MHG) or to the control group receiving BS-NAC. MHG received in vein (i.v.) 250 mL isotonic saline bolus, followed by a 0.5 mg/kg furosemide i.v. bolus to forced diuresis. A dedicated device automatically matched the isotonic saline i.v. infusion rate to the urinary output for 1 h before, during and 4 h after the procedure. MHG had the lowest incidence of CIAKI (7 vs. 25%, P = 0.01), major adverse cardiac and cerebrovascular events at 1 year (7 vs. 32%, P < 0.01) and readmissions to cardiology/nephrology departments (8 vs. 25%, P = 0.03; hospitalization days 1.0 ± 3.8 vs. 4.9 ± 12.5, P = 0.01). Three months after the procedure the decrease in the estimated glomerular filtration rate was 0.02% for MHG versus 15% for the control group. Matched hydration was more effective than BS-NAC in CIAKI prevention. One-year follow-up showed that matched hydration was associated also with limited chronic kidney disease progression, major adverse cardiac and cerebrovascular events and hospitalizations.

Adjacent-Level Hypermobility and Instrumented-Level Fatigue Loosening With Titanium and PEEK Rods for a Pedicle Screw System: An In Vitro Study.

Adjacent-level disease is a common iatrogenic complication seen among patients undergoing spinal fusion for low back pain. This is attributed to the postsurgical differences in stiffness between the spinal levels, which result in abnormal forces, stress shielding, and hypermobility at the adjacent levels. In addition, as most patients undergoing these surgeries are osteoporotic, screw loosening at the index level is a complication that commonly accompanies adjacent-level disease. Recent studies indicate that a rod with lower rigidity than that of titanium may help to overcome these detrimental effects at the adjacent level. The present study was conducted in vitro using 12 L1-S1 specimens divided into groups of six, with each group instrumented with either titanium rods or PEEK (polyetheretherketone) rods. The test protocol included subjecting intact specimens to pure moments of 10 Nm in extension and flexion using an FS20 Biomechanical Spine Test System (Applied Test Systems) followed by hybrid moments on the instrumented specimens to achieve the same L1-S1 motion as that of the intact specimens. During the protocol's later phase, the L4-L5 units from each specimen were segmented for cyclic loading followed by postfatigue kinematic analysis to highlight the differences in motion pre- and postfatigue. The objectives included the in vitro comparison of (1) the adjacent-level motion before and after instrumentation with PEEK and titanium rods and (2) the pre- and postfatigue motion at the instrumented level with PEEK and titanium rods. The results showed that the adjacent levels above the instrumentation caused increased flexion and extension with both PEEK and titanium rods. The postfatigue kinematic data showed that the motion at the instrumented level (L4-L5) increased significantly in both flexion and extension compared to prefatigue motion in titanium groups. However, there was no significant difference in motion between the pre- and postfatigue data in the PEEK group.

Clinical pattern and effect of Co-Morbidities in the etiopathogenesis of incisional hernias

Background: Incisional hernia is a common iatrogenic complication of abdominal surgery and is a cause of unwanted morbidity. The study was reported for the first time from Republic of Mauritius. Aims & Objectives: The objective of the study was to analyze the clinical pattern and effect of comorbidities on the clinical course of incisional hernias and repair. Methods: The study is a cross sectional study conducted at a tertiary care hospital for over 22 months. 38 patients with incisional hernia were studied with special emphasis laid on the predisposing factors and co-morbidities at the time of hernia repair. Results: In this study the incidence of incisional hernia was prevalent in females and occurrence was 3 times more than males. All hernias in females were the result of a gynaecological operation. 68% (26 out of 38 patients studied) of hernias were reported within 2 years of gynaecological operation. Majority of patients presented with swelling and pain related to scar. Twenty two out of thirty eight were operated and hernia repaired. Obesity was found to be the most important factor when the effects of co-morbidities were studied. Fifteen out of thirty eight (39.47%) patients came under the category of morbidly obese. Conclusion: In patients with recurrent hernia control of obesity and other comorbidities before the attempt to repair hernia can be decisive.

Indwell times, complications and costs of open vs closed safety peripheral intravenous catheters: a randomized study

Catheter-related infections (CRIs) caused by peripheral intravenous catheters (PIVCs) are an increasingly common iatrogenic complication. To prevent this, recommended timelines for routine replacement of PIVCs have increased from 48 h to 72 h and subsequently to 96 h, despite a lack of supporting scientific evidence. To compare closed-system (COS) PIVCs with open-system (MOS) PIVCs. This prospective, randomized controlled trial compared the indwell time of COS PIVCs without complications with that of MOS PIVCs, removed only by clinical indication. In total, 1199 PIVCs (642 inpatients) were randomized and 283 PIVCs were cultured. Sixteen catheters (11 patients) were lost to the study after randomization. In total, 104,469 catheter-hours (54,173 h in 584 COS and 50,296 h in 599 MOS) were recorded. The median dwell time was 137.1h for COS PIVCs and 96 h for MOS PIVCs (P = 0.001). Among PIVCs in place for ≥ 24 h, the median dwell time was 144.5h for COS PIVCs [95% confidence interval (CI) 123.4-165.6] and 99 h for MOS PIVCs (95% CI 87.2-110.8). Use of COS PIVCs reduced phlebitis rates by 29% (31 vs 45 cases/1000 catheter-days; P = 0.004). The probability that a MOS PIVC would last for 96 h was 79.9%, and the probability that a COS PIVC would last for 144 h was 80.4%. There were no significant differences in rates of bacterial colonization per 1000 catheter-days (51.1 COS vs 54.1 MOS) or CRI (5.76 COS vs 6.65 MOS). Nevertheless, there was a 20% relative risk reduction in CRI. Use of COS PIVCs reduced episodes of phlebitis and risk of infection at a cost of only € 0.09/day. When PIVCs are replaced based on clinical indication, COS PIVCs last for up to 144 h and MOS PIVCs last for up to 96 h without increased risk and with significant cost savings (€ 786,257/year/1000 beds).

Inhibition of MK2 shows promise for preventing postoperative ileus in mice

BackgroundPostoperative ileus (POI) is a common iatrogenic complication caused by physical disturbances to the bowel during abdominal surgery. Inflammation contributes to the development of POI and leads to impaired intestinal motility. Mitogen-activated protein kinase-activated protein kinase 2 (MK2) plays an essential role in inflammation and is an established drug target for many inflammatory diseases. We evaluated the role of MK2 in POI and investigated whether MK2 inhibition will alleviate POI. Materials and methodsOne group of mice were sham operated as controls. In another two groups, POI was induced by intestinal manipulation, and in one of the groups, MK2 inhibitor was administered 1 h before intestinal manipulation. The bowel tissues were collected and analyzed using real-time reverse-transcriptase polymerase chain reaction, immunoblot, whole-mount histochemistry, immunofluorescence in muscularis, and functional analyses. ResultsBowel manipulation resulted in an upregulation of MK2 activation. Preoperative treatment with an MK2 inhibitor reduced the proinflammatory gene expression induced by intestinal manipulation, such as macrophage inflammatory protein-1α, tumor necrosis factor-α, interleukin-6, interleukin-1β, intercellular adhesion molecule-1, and monocyte chemotactic protein-1. MK2 inhibitor administration significantly reduced the number of myeloperoxidase-positive polymorphonuclear neutrophils, mast cells, and monocyte-derived macrophages that infiltrated the muscularis and prevented the surgically induced reduction in bowel smooth muscle contractility and gastrointestinal transit ability. ConclusionsMK2 mediated the cellular inflammatory responses within the intestinal muscularis in a mouse model of POI. Inhibition of MK2 activity reduced recruitment of immune cells to the intestinal muscularis, preventing loss of intestine smooth muscle contractility. These findings suggest MK2 inhibition is a promising potential target for preventing POI.

Variations in the Locations of the Recurrent Laryngeal Nerve in Relation to the Ligament of Berry

Injury to the recurrent laryngeal nerve (RLN) is one of the most common iatrogenic complications of thyroid surgery. The anatomical course of the nerve also increases its susceptibility to injury and many variations have been documented in the literature. The topographical relationship of the RLN to the ligament of Berry has been extensively studied over the past decades. The consensus in the literature is divided with several authors reporting the nerve to be embedded within the ligament and others reporting a constant finding of the nerve being posterolateral to the ligament. A new operative concept has been recently introduced as a possible resolution for the conflicting reports among authors. Further investigations are needed, however, to assess its reliability and overall effects on clinical outcomes.

A Retrospective Review of Iatrogenic Skin and Soft Tissue Injuries

BackgroundEven though the quality of medical and surgical care has improved remarkably over time, iatrogenic injuries that require surgical treatment including injuries caused by cast and elastic bandage pressure, extravasation, and dopamine-induced ischemia still frequently occur. The goal of this study was to estimate the incidence and analyze the distribution of iatrogenic injuries referred to our department.MethodsA retrospective clinical review was performed from April 2006 to November 2010. In total, 196 patients (116 females and 80 males) were referred to the plastic surgery department for the treatment of iatrogenic injuries. We analyzed the types and anatomic locations of iatrogenic complications, along with therapeutic results.ResultsAn extravasation injury (65 cases, 37.4%) was the most common iatrogenic complication in our study sample, followed by splint-induced skin ulceration, dopamine-induced necrosis, prefabricated pneumatic walking brace-related wounds and elastic bandage-induced wounds. Among these, prefabricated pneumatic walking brace-related complication incidence increased the most during the 5-year study period.ConclusionsThe awareness of the very common iatrogenic complications and its causes may allow physicians to reduce their occurrence and allow for earlier detection and referral to a plastic surgeon. We believe this is the first study to analyze iatrogenic complications referred to a plastic surgery department in a hospital unit.

Common iatrogenic pleural complications

All invasive pleural procedures have the potential to cause harm. Complications from pleural procedures include empyema, intercostal artery laceration, hemothorax, and pneumothorax as well as other organ puncture. Many of these complications will be life threatening and will increase morbidity and hospital length of stay. An understanding of iatrogenic pleural disease helps clinicians to appreciate how these risks can be minimized and complications managed promptly and effectively. This review systematically evaluates the current evidence and guidelines regarding iatrogenic pleural complications and their management. Whilst impossible to eliminate procedural risk entirely, complications will be reduced to a minimum by ensuring adequate medical training, use of pleural ultrasound, and adherence to guidelines and standard operating procedures (SOPs).

Neurological and systemic complications of tuberculous meningitis and its treatment at Auckland City Hospital, New Zealand

Mortality and serious long-term sequelae still occur in about 50% of patients with tuberculous meningitis. The frequency and the clinical features of neurological and systemic complications were determined in a retrospective review of 104 patients with tuberculous meningitis. Complications occurred in 81 patients (78%). The most common complications were: hyponatraemia 49%, hydrocephalus 42%, stroke 33%, cranial nerve palsies 29%, epileptic seizures 28%, diabetes insipidus 6%, tuberculoma 3%, myeloradiculopathy 3% and hypothalamic syndrome 3%. The most common iatrogenic complication was hepatotoxicity related to anti-tuberculosis treatment in seven patients. Twenty-three patients (22%) died. At last follow-up one patient (1%) remained in a persistent vegetative state, 14 patients (13%) had severe disability and 12 patients (12%) were moderately disabled. The most common complications in the 81 long-term survivors were cognitive impairment (12%) and epilepsy (11%). Neurological and systemic complications of tuberculous meningitis were common and were important causes of mortality and long-term morbidity.

IMMEDIATE-TYPE ALLERGY TO DRUGS AND RELATED COMPOUNDS: EVALUATION AND MANAGEMENT

Adverse drug reactions (ADR) constitute a major health issue in outpatient and inpatient clinical settings. An allergic drug reaction is an immunologically mediated adverse drug reaction that exhibits specificity and recurrence on re-exposure to the offending and/or cross-reactive compound(s). Diagnosis of drug allergy is difficult, as a broad spectrum of different drugs can elicit various immune-mediated diseases with distinct (sometimes unclear) pathomechanism, the exact structure (epitope) that causes the reaction is frequently unknown, the presence of an in vitro or in vivo test results might not be predictive of a clinical situation, and the gold standard or reference test for diagnosis, the drug challenge, is a complicated and sometimes dangerous endeavour. Nevertheless, during the past few years serious attempts have been made to standardise and validate in vitro and in vivo techniques for the diagnosis of drug allergy. New techniques, e.g. flow-assisted analysis of in vitro basophil activation, are replacing older ones like histamine release for immediate-type hypersensitivity reactions. However, additional comprehensive studies are required to further validate the technique and allow its entrance in mainstream diagnostic use, particularly for non-IgE-mediated hypersensitivity. This review attempts to summarize the major causes of immediate hypersensitivity reactions to drugs and related compounds. Special attention is paid to the diagnostic and therapeutic management of this common iatrogenic complication.

Percutaneous Induced Thrombosis of Iatrogenic Femoral Pseudoaneurysms following Catheterization

Femoral pseudoaneurysms are one of the common iatrogenic complications following catheterization procedures done via the femoral approach. Their treatment has evolved over the last decade from operative repair to ultrasound-guided compression (USGC) and more recently to thrombin injection of the pseudoaneurysm. We report our experience with that technique and compare the results of thromboobliteration to those of the compression method. All consecutive iatrogenic femoral pseudoaneurysms diagnosed in the vascular laboratory of two large community hospitals were referred for the study. Under ultrasound guidance, percutaneous thromboobliteration (PTO) of the pseudoaneurysms was done by injecting thrombin solution (500-unit increments) into the pseudoaneurysm. Time to thrombosis, dose of thrombin, patient's discomfort, and ease of procedure were recorded and analyzed. Comparison with results of USGC reported in the literature was made. Percutaneous thromboobliteration may be a simple and very effective treatment of femoral pseudoaneurysms. The high success rate, ease of procedure, and cost benefit over USGC are noteworthy. A larger trial is currently under way. If results are duplicated, PTO will emerge as the preferred treatment for iatrogenic femoral pseudoaneurysms.

Treatment of Upper-Extremity Phlegmasia Cerulea Dolens with Intra-arterial Thrombolysis

Upper-extremity deep vein thrombosis is a common iatrogenic complication in patients who have had central venous catheters, and is usually associated with mild symptoms. This report is of a 57-year-old craftsman who developed phlegmasia cerulea dolens of his left upper extremity 16 hours after removal of an ipsilateral subclavian vein catheter. The extremity was tensely edematous, hand was mottled, and tips of the digits were cyanotic. Arterial Doppler signals were normal. Fourteen hours of extremity elevation and heparin anticoagulation resulted in no clinical improvement. Duplex ultrasonography and venography showed diffuse thrombosis of the veins of the arm and forearm, but patent axillary and subclavian veins. Due to the severity of the edema and evidence of vascular compromise, an infusion catheter, introduced through the right common femoral artery, was positioned in the left brachial artery and an intra-arterial urokinase infusion of the left upper extremity initiated. Within 12 hours, the patient's left upper extremity improved notably. Ninety-three hours later, the urokinase infusion was stopped and the left upper extremity appeared normal. Follow-up duplex ultrasonography documented no residual thrombus in the deep veins of the left arm and forearm. Six months later, the patient has no residual disability, extremity edema, or limitations in function. An extensive review of the English literature identified no previous reports of intraarterial thrombolysis for upper-extremity phlegmasia cerulea dolens. This case is discussed and pertinent literature reviewed.

Outcome in critical care patients: a multivariate study.

To identify patient variables that were significantly associated with outcome in the ICU. Retrospective chart study of ICU patients. Letterman Army Medical Center, Presidio of San Francisco. A total of 110 consecutive patients who remained in the ICU for greater than 72 hrs. Univariate analysis of 26 input variables, representing physiologic status and chronic health assessment at the time of ICU admission of the patients, and adverse events that occurred during their ICU stay. The dependent variable assessed was the outcome of patients after ICU intervention. A bad outcome included patient mortality or discharge from the ICU in worse condition or in a chronic vegetative condition. Five selected input variables were used in a multivariate logistic regression analysis to identify independent predictors of a successful outcome. Univariate statistical techniques comparing the values of 26 input variables of patients who improved during their ICU stay (46 patients) with those values of patients who did not improve (52 deaths and 12 unimproved patients) indicated that the following nine variables were significantly different in these two groups: a) age (p = .04), b) acute physiologic score (p = .047), c) Acute Physiology and Chronic Health Evaluation (APACHE II) score (p = .040), d) the number of repeat ICU admissions during a given hospitalization (p = .019), e) development of respiratory complications while in the ICU (p = .033), f) sepsis developing while in the ICU (p = .0001), g) renal failure developing while in the ICU (p less than .0001), h) disseminated intravascular coagulation while in the ICU (p = .0028), and i) the occurrence of any iatrogenic complication while in the ICU (p less than .0001). Five of these nine variables were used in a stepwise logistic regression analysis to develop a model to predict ICU outcome. This model showed the following three variables to be significantly associated with unfavorable ICU outcome: a) occurrence of any iatrogenic event while in the ICU (p less than .001), b) development of renal failure in the ICU (p = .001), and c) occurrence of sepsis while in the ICU (p = .042). A common iatrogenic complication associated with unfavorable ICU outcome was related to drug therapy (frequently aminoglycoside toxicity). Twenty-one iatrogenic drug complications occurred in 64 patients who did not improve in the ICU, whereas only three iatrogenic drug complications occurred in 46 patients who improved (p less than .001). For patients who remain in the ICU for greater than 72 hrs, events occurring after ICU admission are negatively associated with ICU outcome, more so than ICU admission status as reflected by such indices as APACHE II scores. Iatrogenic complications, often due to inappropriate drug therapy, have a significant association with adverse outcome by multivariate analysis. We suggest that iatrogenic complications influence ICU outcome, and that they are potentially preventable. By lessening their frequency, ICU outcome may be improved.

The outcome of community acquired pneumonia treatedon the intensive care unit

Eighteen patients with community acquired pneumonia required intensive care for severe or progressive hypoxaemia, rising arterial carbon dioxide tension or respiratory arrest, and 17 received intermittent positive pressure ventilation. Thirteen survived to leave hospital and 12 are long term survivors. Ventilation was started within 4 days of admission in all cases and was continued for up to 34 days; six patients required ventilation for over 3 weeks. The most common medical complication was renal failure. The most common iatrogenic complication was pneumothorax. We believe that all the hypoxic patients would have died from their hypoxia had it not been corrected. We estimated that up to 5% of patients admitted with community acquired pneumonia need intensive care. This study demonstrates the effectiveness of such care, which is multidisciplinary, demanding, and may need to be prolonged.