Gerard Fulda - Academia.edu (original) (raw)

Papers by Gerard Fulda

Critical Care Medicine, 2012

Critical Care Medicine, 2014

Critical Care Medicine, 2013

The Joint Commission Journal on Quality and Patient Safety, 2008

Background: In 2004, Christiana Care Health System (Christiana Care), a 1,100-bed tertiary care f... more Background: In 2004, Christiana Care Health System (Christiana Care), a 1,100-bed tertiary care facility, used the Surviving Sepsis Campaign guidelines as the foundation for an independent initiative to reduce the mortality rate by at least 25%. Methods: In 2004, an interdisciplinary sepsis team developed a process for rapidly recognizing at-risk patients; evaluating a patient's clinical status; and providing appropriate, timely therapy in three major areas of sepsis care; recognition of the sepsis patient, resuscitation priorities, and intensive care management. The Sepsis Alert program, which did not require additional staffing, was developed and implemented in 10 months. The Sepsis Alert packet included a care management guideline, a treatment algorithm, an emergency department treatment order set, and multiple adjuncts to streamline patient identification and management. Results: Introduction of sepsis resuscitation and critical care management standards led to a 49.4% decrease in mortality rates (p < .0001), a 34.0% decrease in average length of hospital stay (p < .0002), and a 188.2% increase in the proportion of patients discharged to home (p < .0001) when the historic control group is compared with the postimplementation group from January 2005 through December 2007. Discussion: An integrated leadership team, using existing resources, transformed frontline clinical practice by providers from multiple disciplines to reduce mortality in the population of patients with sepsis.

Surgery Today, 2011

This report presents the case of the emergency repair of a radiation-induced aortoesophageal fist... more This report presents the case of the emergency repair of a radiation-induced aortoesophageal fistula (AEF) with an endograft. The patient presented with multiple episodes of upper gastrointestinal bleeding. The fistula was discovered and treated in the operating room. The placement of a temporary aortic endograft was successful. The patient unfortunately exsanguinated while awaiting definitive aortic and esophageal repair. The potential occurrence of AEF should be considered in any patient presenting with massive hematemesis without a clear source of the bleeding. Although the patient succumbed to the fistula, this case illustrates the cryptic nature of an AEF and the difficult issues that are inherent in its treatment.

Journal of the American College of Surgeons, 2009

BACKGROUND: Human polymerized hemoglobin (PolyHeme, Northfield Laboratories) is a universally com... more BACKGROUND: Human polymerized hemoglobin (PolyHeme, Northfield Laboratories) is a universally compatible oxygen carrier developed to treat life-threatening anemia. This multicenter phase III trial was the first US study to assess survival of patients resuscitated with a hemoglobin-based oxygen carrier starting at the scene of injury. STUDY DESIGN: Injured patients with a systolic blood pressure Յ 90 mmHg were randomized to receive field resuscitation with PolyHeme or crystalloid. Study patients continued to receive up to 6 U of PolyHeme during the first 12 hours postinjury before receiving blood. Control patients received blood on arrival in the trauma center.This trial was conducted as a dual superiority/noninferiority primary end point. RESULTS: Seven hundred fourteen patients were enrolled at 29 urban Level I trauma centers (79% men; mean age 37.1 years). Injury mechanism was blunt trauma in 48%, and median transport time was 26 minutes. There was no significant difference between day 30 mortality in the asrandomized (13.4% PolyHeme versus 9.6% control) or per-protocol (11.1% PolyHeme versus 9.3% control) cohorts. Allogeneic blood use was lower in the PolyHeme group (68% versus 50% in the first 12 hours). The incidence of multiple organ failure was similar (7.4% PolyHeme versus 5.5% control). Adverse events (93% versus 88%; p ϭ 0.04) and serious adverse events (40% versus 35%; p ϭ 0.12), as anticipated, were frequent in the PolyHeme and control groups, respectively. Although myocardial infarction was reported by the investigators more frequently in the PolyHeme group (3% PolyHeme versus 1% control), a blinded committee of experts reviewed records of all enrolled patients and found no discernable difference between groups. CONCLUSIONS: Patients resuscitated with PolyHeme, without stored blood for up to 6 U in 12 hours postinjury, had outcomes comparable with those for the standard of care. Although there were more adverse events in the PolyHeme group, the benefit-to-risk ratio of PolyHeme is favorable when blood is needed but not available.

Critical Care Medicine, 2010

he determination of human death continues to provoke public fascination and medical scrutiny. In ... more he determination of human death continues to provoke public fascination and medical scrutiny. In its 1981 report Defining Death, the U.S. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research provided the most frequently cited comprehensive analysis (1). Defining Death had three principal goals: 1) to provide a conceptual basis for the new medical practice of death determination using neurological tests; 2) to explain the relationship between determining death on neurological and circulatory-respiratory grounds; and 3) to enhance the uniformity among jurisdictions by proposing and justifying a *See also p. 1011.

Critical Care Clinics, 2003

Intensivists frequently collaborate with plastic and reconstructive surgeons in treating patients... more Intensivists frequently collaborate with plastic and reconstructive surgeons in treating patients with major wounds, following significant reconstructive procedures, and following free-tissue transfers. Pressure ulcers are a significant source of morbidity and mortality in the intensive care unit; prevention, early recognition, and multidisciplinary treatment are critical components for successful management. Necrotizing fasciitis is an aggressive, soft-tissue infection that requires rapid diagnosis, early surgical intervention frequent operative debridements, and soft-tissue reconstruction Catastrophic abdominal injuries and infections can be treated with an open abdominal approach and require the expertise of a plastic surgeon to reconstruct the abdominal wall. The success of free-tissue transfers and complex reconstructive procedures requires a thorough understanding of the factors that improve flap survival.

Annals of Emergency Medicine, 2014

One barrier for implementing programs of uncontrolled organ donation after the circulatory determ... more One barrier for implementing programs of uncontrolled organ donation after the circulatory determination of death is the lack of consensus on the precise moment of death. Our panel was convened to study this question after we performed a similar analysis on the moment of death in controlled organ donation after the circulatory determination of death. We concluded that death could be determined by showing the permanent or irreversible cessation of circulation and respiration. Circulatory irreversibility may be presumed when optimal cardiopulmonary resuscitation efforts have failed to restore circulation and at least a 7-minute period has elapsed thereafter during which autoresuscitation to restored circulation could occur. We advise against the use of postmortem organ support technologies that reestablish circulation of warm oxygenated blood because of their risk of retroactively invalidating the required conditions on which death was declared.

Critical Care Medicine, 2006

Delaware medical journal, 2011

OBJECTIVE Postpartum hemorrhage is a leading cause of maternal mortality. Massive transfusion in ... more OBJECTIVE Postpartum hemorrhage is a leading cause of maternal mortality. Massive transfusion in obstetric patients is rare. Recombinant Factor VIIa (rFVIIa) use in trauma patients with massive transfusion is efficacious. Our goal was to evaluate the safety and efficacy of rFVIIa use in obstetric patients with massive postpartum hemorrhage (MPH). METHODS Patients records with MPH from 2003 to 2006 were reviewed. Data collected were demographics, APACHE II scores, International Normalized Ratio (INR), fibrinogen level, blood product administration, rates of pulmonary embolism (PE), deep vein thrombosis (DVT), myocardial infarction (MI), hysterectomy, and mortality. Continuous variables within groups were analyzed with paired t-test, and independent t-test between groups. Categorical variables were compared via chi2 or Fishers Exact test and significance was denoted by a p < or = 0.05. RESULTS Twenty-seven patients with MPH were investigated, eight received rFVIIa (study group) and...

OBJECTIVE This study examined outcomes in elderly TBI patients who underwent a cranial operation.... more OBJECTIVE This study examined outcomes in elderly TBI patients who underwent a cranial operation. METHODS We identified TBI patients > or = 65 who underwent a cranial operation from January 1, 2004 to December 31, 2008. Data collected included: age, admission GCS, mechanism of injury, ISS, Head AIS, type of operation, hemorrhage acuity, time to operation, pre-hospital warfarin or clopidogrel, and in-hospital death. Survivors were contacted by phone to determine an Extended Glasgow Outcome Score (GOSE). A favorable outcome was defined as having a GOSE of > or = 5 at follow-up, an unfavorable outcome was defined as: in-hospital death, death within one year of injury, and a GOSE < 5 at follow-up. Chi-square and student's t-test were used. RESULTS One hundred sixty-four elderly TBI patients underwent cranial surgery. Mean age was 79.2 +/- 7.6 years. Most patients: had a ground level fall (86.0%), suffered a subdural hematoma (95.1%), and underwent craniotomy (89.0%). Twenty...

Critical Care

Background Urine output is widely used as one of the criteria for the diagnosis and staging of ac... more Background Urine output is widely used as one of the criteria for the diagnosis and staging of acute renal failure, but few studies have specifically assessed the role of oliguria as a marker of acute renal failure or outcomes in general intensive care unit (ICU) patients. Using a large multinational database, we therefore evaluated the occurrence of oliguria (defined as a urine output 16 years) patients in the ICON audit who had a urine output measurement on the day of admission were included. To investigate the association between oliguria and mortality, we used a multilevel analysis. Results Of the 8292 patients included, 2050 (24.7%) were oliguric during the first 24 h of admission. Patients with oliguria on admission who had at least one additional 24-h urine output recorded during their ICU stay (n = 1349) were divided into three groups: transient—oliguria resolved within 48 h after the admission day (n = 390 [28.9%]), prolonged—oliguria resolved > 48 h after the admission...

Open Forum Infectious Diseases

Society of Nuclear Medicine Annual Meeting Abstracts, May 1, 2014

The Journal of Trauma Injury Infection and Critical Care, 2009

BMJ Quality & Safety, 2013

no points for improvement concerning the tools. Patients commented on the website, and changes we... more no points for improvement concerning the tools. Patients commented on the website, and changes were made accordingly. Discussion We developed a tailor-made strategy for PPH guideline implementation. The next step in the implementation process is to evaluate the feasibility of the strategy, including an effect, process and cost evaluation.

The Journal of Trauma: Injury, Infection, and Critical Care, 1997