sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY March 2014 | Archived Issues

Mark Your Calendar


Surgery Grand Rounds

Click the "read more" to see information about upcoming Surgery Grand Rounds.

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Grand Rounds

Click here to view a schedule of all upcoming grand rounds.


Educational Schedule

Click the PDF link below to see the Department of Surgery's educational schedule for March.

Educational Schedule - March 2014 (PDF)


Surgery Scheduling

Click the "read more" for hours and contact information for surgery scheduling.

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Make Sure Reports Reflect True APLs

By Harry C. Sax, MD, MHCM

We are required to report episodes of accidental puncture or laceration (APL) that occur during procedures. The spirit of the regulation is to capture true deviations, such as blindly inserting a laparoscopic trocar into the aorta. But the determination of what is a true APL is open to interpretation.

» Read more

Cedars-Sinai Breaks U.S. Record for Heart Transplants

The Cedars-Sinai Heart Institute set a new standard for U.S. heart transplantation in 2013 by completing 117 adult heart transplants and two adult heart-lung transplants, for a total of 119 adult heart transplants.

» Read more

Outcomes Research in the Surgical Intensive Care Unit

By Eric J. Ley, MD

Outcomes research seeks to evaluate the benefit of particular healthcare practices and interventions. We conduct critical care outcomes research at Cedars-Sinai to determine which interventions are most effective.

» Read more

Circle of Friends Honorees for February

The Circle of Friends program honored 90 people in February. Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai.

» Read more

FDA Warns About Doribax; Victrelis Label Changed

Pharmacy Focus

The U.S. Food and Drug Administration has concluded that Doribax (doripenem), an antibacterial drug used to treat patients who develop pneumonia while on ventilators, carries an increased risk of death and lower clinical cure rates compared to use of imipenem and cilastatin for injection. Also, changes have been made to the label of the hepatitis C drug Victrelis.

» Read more

Make Sure Reports Reflect True APLs

By Harry C. Sax, MD, MHCM
Professor and Executive Vice Chair, Department of Surgery
Physician Liaison, Cedars-Sinai Medicine Clinical Transformation Initiative

We are required to report episodes of accidental puncture or laceration (APL) that occur during procedures. The spirit of the regulation is to capture true deviations, such as blindly inserting a laparoscopic trocar into the aorta.

But the determination of what is a true APL is open to interpretation. In addition, APL is part of an individual physician's performance metrics and is currently publicly reported by the institution.

For many years, Cedars-Sinai performed poorly in this realm, due to our tendency not to document the extensive nature or severity of the disease process. For example, a loop of ileum, completely adherent to the uterus from endometriosis, would be entered while attempting to free it. The gynecologists would dictate that the bowel was inadvertently entered, and we would report this as an APL.

With education of our Ob-Gyn colleagues to document that this was unavoidable and intentional as part of the procedure, the rate has dropped dramatically and more clearly reflects true APLs. As surgeons, we can be more accurate in our dictations. If there are extensive severe adhesions, document that. Think about these two statements, both regarding the same operation:

  • "The colonic disease process involved the ureter, which required segmental resection and primary anastomosis over a double J stent."
  • "In mobilizing the diseased colon, the ureter also was divided, which we fixed."

The second would be coded as an APL, the first would not.

As you dictate your operative reports, think about how to make it clear to the reader (and coder) what you were dealing with. And our reporting will more accurately reflect the high quality of our care.

Cedars-Sinai Breaks U.S. Record for Heart Transplants

The Cedars-Sinai Heart Institute set a new standard for U.S. heart transplantation in 2013 by completing 117 adult heart transplants and two adult heart-lung transplants, for a total of 119 adult heart transplants. The previous mark, set in 2005, was 98 adult heart transplants performed in one year.

This accomplishment underscores the work of the past four years, during each of which the Cedars-Sinai Heart Institute and Comprehensive Transplant Center performed more adult heart transplants than any other U.S. medical center, according to statistics compiled by the United Network for Organ Sharing, the nonprofit organization that manages the nation's transplant system and collects data on every transplant performed in the U.S.

Cedars-Sinai's leadership in heart transplantation extends to a mechanical pumping device called the SynCardia Total Artificial Heart. Total Artificial Hearts are implanted in heart failure patients who otherwise might not live long enough to receive a heart transplant. In 2013, Cedars-Sinai surgeons implanted 23 Total Artificial Hearts, according to SynCardia, the company that invented and manufactures the device. The manufacturer said Cedars-Sinai set a yearly record for the number of Total Artificial Heart devices implanted by a single medical center.

"Although we have made great strides toward preventing premature death from heart attacks, more patients are developing chronic heart failure, with breathlessness and inability to exercise," said Eduardo Marbán, MD, PhD, director of the Cedars-Sinai Heart Institute. "Quality of life is poor, and mortality is higher than with many malignancies. At Cedars-Sinai, we use machines to tide over the sickest patients until they can get a new heart. Because we treat more of these patients than any other center in the United States, we can tailor the approach to each individual's needs, resulting in superior outcomes."

Since the Heart Transplant Program was established in 1988, 975 patients have undergone heart transplantation at Cedars-Sinai.

"This is a golden age in organ transplantation, with more options like new anti-rejection drugs and medical devices than ever before," said Andrew S. Klein, MD, MBA, director of the Cedars-Sinai Comprehensive Transplant Center and the Esther and Mark Schulman Chair of Surgery and Transplant Medicine. "But we need to be mindful that at this moment, more than 120,000 people are on the waiting list for an organ transplant. The best way to help those patients and their families is to encourage more people to sign up to become organ donors."

Jon Kobashigawa, MD, director of the Heart Transplant Program and the DSL/Thomas D. Gordon Chair in Heart Transplantation Medicine, said, "In just a year, we dramatically increased the number of heart transplants, going from 95 heart transplants in 2012 to 119. Yet, even with that significant jump, we have maintained excellent one-year survival rates of approximately 90 percent."

Outcomes Research in the Surgical Intensive Care Unit

By Eric J. Ley, MD
Director, Surgical Intensive Care Units
Director, Surgical Critical Care Residency Program

Outcomes research seeks to evaluate the benefit of particular healthcare practices and interventions. We conduct critical care outcomes research at Cedars-Sinai to determine which interventions are most effective.

Our findings may challenge clinicians, researchers and health systems leaders to assess the impact of specific healthcare services. By deconstructing care provided for critically ill patients and then linking specific interventions to their outcomes, we develop better ways to improve the quality of care we provide.

For clinicians and patients, outcomes research offers evidence about benefits, risks and results of treatments. Here are examples of outcomes research from the Surgical Intensive Care Unit:

  • Do you find your patients in the SICU receive less intravenous maintenance fluid? Post-operative fluid therapy has been a mainstay for care of the critically ill surgical patient. We reviewed a cohort of critically ill acute care surgery patients and determined achieving a negative fluid status early during the SICU admission was associated with a nearly 40 percent reduction in the risk for post-operative complications. So we minimize the maintenance fluids whenever possible.
  • Does it seem like we check the vancomycin trough levels more frequently? We found in our critically ill trauma population that 34.6 percent of patients had a vancomycin trough level that was too high, and this was an independent predictor for acute kidney injury and mortality, so we instituted a protocol to minimize supratherapeutic trough levels. We judiciously dose vancomycin and send many more vancomycin trough levels.
  • Do you question the need to screen patients for methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE)? In a review of our SICU population, 5 percent screened positive for MRSA and 9 percent screened positive for VRE. Colonization allows us to better titrate antibiotics. We found a negative screen results in a high specificity and negative predictive value for the development of MRSA or VRE hospital-acquired infection. This means that empiric treatment for MRSA or VRE infection may be unnecessary when the associated screen is negative.
  • Are we treating fewer patients for suspected heparin-induced thrombocytopenia (HIT)? We determined the false positive rate for HIT using our previous criteria was 81 percent. We established that a PF4 equal to or greater than 2.0 OD is the point at which the rate of true positives for HIT equals the rate of false positives. So we may delay treatment for lower PF4 levels. This outcomes research has decreased our use of argatroban in case of false positive HIT.

Through the collaboration of many teams of clinicians and researchers, we can achieve the highest quality of care in the surgical critical care unit. Please chat with a surgical intensivist if you are interested in our latest outcomes research.

Circle of Friends Honorees for February

The Circle of Friends program honored 90 people in February.

Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai. When a gift is made, the person being honored receives a custom lapel pin and a letter of acknowledgement.

Click here for more information about the program and for a list of past honorees.

  • Keith L. Agre, MD
  • Julianne Ahdout, MD
  • Mohammed A. Alam
  • JonnaT. Alaman
  • Farin Amersi, MD
  • Kapil K. Anand, MD
  • Gail Anderson
  • Jay Q. Aquino
  • Eli Baron, MD
  • Paula A. Barondess
  • Leon I. Bender, MD
  • Keith L. Black, MD
  • Glenn D. Braunstein, MD
  • Barry J. Brock, MD
  • Enriqueta S. Bulatao
  • Brendan J. Carroll, MD
  • Mark Chmielewski, RN
  • Alice P. Chung, MD
  • Geemee Chung, MD
  • Stephen T. Copen, MD
  • Stephen R. Corday, MD
  • Coby B. Cowan, COTA
  • Evangeline H. Cruz, RN
  • Dudley S. Danoff, MD
  • Suzette A. Daye, RN
  • Evamarie J. Dubois Bittleston, RN
  • Mary Annalee C. Famas, BSN, RN
  • David E. Fermelia, MD
  • Ronald S. Fishbach, MD
  • Stuart Friedman, MD
  • Gerhard J. Fuchs, MD
  • Angel M. Fuentes
  • Elayne K. Garber, MD
  • Armando E. Giuliano, MD
  • Richard E. Gould, MD
  • Paul B. Hackmeyer, MD
  • Jennifer Hajj, RN
  • Andrew E. Hendifar, MD
  • Gail K. Higa, RN, OCN
  • Griselda Islas, RN
  • Laith H. Jamil, MD
  • Elaine S. Kamil, MD
  • Saibal Kar, MD
  • Maria Teresa Kariger, RN, BSN
  • Ali Khoynezhad, MD, PhD
  • Charles F. Kivowitz, MD
  • Debra L. Kleinzweig, RN
  • Thomas J. Kremen, MD
  • Babak Larian, MD
  • Susan W. Lee, DO
  • Madeline S. Lerman, RN, BSN
  • Andrew J. Li, MD
  • Rajendra Makkar, MD
  • William J. Mandel, MD
  • Behnam David Massaband, DPM
  • Philomena McAndrew, MD
  • Robert J. McKenna Jr., MD
  • Gil Y. Melmed, MD, MS
  • Shlomo Melmed, MD
  • Stewart Middler, MD, PhD
  • Amin Joseph Mirhadi, MD
  • Avinash Mondkar, MD
  • Jaime D. Moriguchi, MD
  • Liana Moskal, RN
  • Dan I. Naim, MD
  • Ronald B. Natale, MD
  • Anthony Nesburn, MD
  • Naneth New, LVN
  • Eve Makoff Newhart, MD
  • Nicholas N. Nissen, MD
  • Shi-Hui Pan, PharmD
  • Brian Perri, DO
  • Surasak Phuphanich, MD
  • Steven Piantadosi, MD, PhD
  • Edwin M. Posadas, MD
  • Jeremy D. Rudnick, MD
  • Howard M. Sandler, MD, MS
  • Wouter I. Schievink, MD
  • Randolph Sherman, MD
  • Nancy L. Sicotte, MD
  • Shirley Sinclair
  • Richard Sokolov, MD
  • Paul Y. Song, MD
  • Alfredo Trento, MD
  • Minerva Tumaru-Fong, RN
  • Christine S. Walsh, MD
  • Deane L. Wolcott, MD
  • Edward M. Wolin, MD
  • John S. Yu, MD
  • Phillip C. Zakowski, MD

FDA Warns About Doribax; Victrelis Label Changed

Pharmacy Focus

The U.S. Food and Drug Administration has concluded that Doribax® (doripenem), an antibacterial drug used to treat patients who develop pneumonia while on ventilators, carries an increased risk of death and lower clinical cure rates compared to use of imipenem and cilastatin for injection (the combination is marketed in the U.S. under the name Primaxin®). Also, changes have been made to the label of Victrelis®.

Based on an FDA analysis of data from a three-year clinical trial that was prematurely stopped in 2011 due to these safety concerns, the agency approved changes to the Doribax drug label that describe these risks. The revised label includes a new warning about this unapproved use. Doribax is not approved to treat any type of pneumonia.

According to the FDA, healthcare professionals should consider whether the benefits of Doribax treatment are likely to exceed its potential risks in patients who develop pneumonia while on ventilators. Doribax is still considered safe and effective for its FDA-approved indications — treatment of adults with complicated intra-abdominal infections and complicated urinary tract infections, including kidney infections (pyelonephritis).

Click here to learn more.

Changes Made to Victrelis Label

The FDA said the label of the hepatitis C drug Victrelis has been updated to include information about serious cases of pancytopenia that have been reported in patients receiving Victrelis in combination with peginterferon alfa and ribavirin. Complete blood counts (with white blood cell differential counts) should be obtained at pretreatment and at treatment weeks two, four, eight and 12, the FDA said. Blood counts should be monitored closely at other times, as clinically appropriate.

The label also was updated to include the risk of agranulocytosis, thrombocytopenia, pneumonia and sepsis.

Separately, the FDA approved an update to the Victrelis label to include a new virologic futility rule: If a patient has HCV-RNA results greater than or equal to 1,000 IU/mL at treatment week eight, then discontinue the three-medicine regimen.

Discontinuation of therapy is recommended in all patients with any of the following:

  • HCV-RNA levels of at least 1,000 IU per mL at treatment week eight
  • HCV-RNA levels of at least 100 IU per mL at treatment week 12
  • Confirmed detectable HCV-RNA levels at treatment week 24

The complete revised label can be viewed here.