David J. Steiger, M.D.

A case of acute exacerbation of IPF following orthopedic surgery
Basavaraj A.; Steiger D.; Callahan C.; Rom W.; Dweck E.
2011 ;140(4):?-?, Chest
INTRODUCTION: Acute exacerbation of IPF is increasingly being recognized as a common clinical event in the IPF population. The exact etiology remains unknown. Previous reports have shown an association between lung surgery, bronchoalveolar lavage, and surgical lung biopsies as a potential trigger for exacerbations of IPF. To our knowledge, there are no known cases in the literature reporting an exacerbation of IPF following a non-thoracic surgical procedure. We report a case of acute exacerbation of IPF following orthopedic surgery. CASE PRESENTATION: 78 year old male with a history of COPD (thirty pack year smoking history) and severe osteoarthritis was admitted to the NYU Hospital for Joint Diseases to undergo evaluation for total hip arthroplasty. Pre-operative evaluation was significant for a restrictive pattern with low DLCO on pulmonary function testing, as well increased interstitial markings on chest x-ray concerning for a fibrotic process. The patient reported no pulmonary symptoms, and underwent successful total hip arthroplasty without complication. On Post op day #6, the patient developed dyspnea on exertion and at rest, requiring increasing amounts of oxygen supplementation. A Chest CT was negative for pulmonary embolism, however did show bronchiectasis and evidence of fibrosis. An echocardiogram did not show evidence of heart failure. The patient was started on broad spectrum antibiotics with Vancomycin, Zosyn and Azithromycin. He also was started on high dose IV steroids (Solumedrol 60mg IV every 6 hours) for a potential COPD exacerbation. Sputum culture was positive only for Candida glabrata, and the patient completed a course of Anidulafungin. However, the patient's respiratory status continued to deteriorate, eventually requiring noninvasive positive pressure ventilation. High dose steroids were continued, as well as therapeutic anticoagulation. A repeat CT chest showed increased groundglass opacities, worsening bronchiectasis and fibrosis diffusely in a UIP pattern. A repeat echocardiogram showed new evidence for pulmonary hypertension, however otherwise normal. A trial of diuretics was initiated without a response. The patient eventually required intubation and tracheostomy, and later passed away. An autopsy revealed evidence for diffuse alveolar damage on a background of honeycombing and bronchiectasis. DISCUSSION: The etiology and pathogenesis of IPF exacerbations remains unknown. One hypothesis involves the loss of alveolar cell integrity following injury, leading to extrusion of fibrin into the alveolar spaces and remodeling. Fibrocytes can be recruited in response to chemokines generated by infection and injury and may potentiate fibrogenesis, leading to diffuse alveolar damage. This process may be triggered by pulmonary procedures, as previously reported. However, a similar inflammatory response may occur after a non-thoracic procedure, leading to the fibrogenic process. The above patient suffered an unexplained worsening fibrotic process, as evidenced by imaging, respiratory failure, and autopsy findings. Alternative causes, such as left heart failure and pulmonary embolism, were excluded. Potential infections were treated with antibiotics. Commonly proposed diagnostic criteria for IPF exacerbation were met. This is the first case to our knowledge of a non-pulmonary procedure triggering the disease process. Cases such as this are likely more common than realized and remain underreported. Clinicians should be aware of the potential for exacerbation of IPF following non-thoracic surgical procedures. CONCLUSIONS: Acute exacerbation of IPF is increasingly being recognized as a common clinical event and may occur after non-thoracic procedures, such as orthopedic surgery
— id: 149979, year: 2011, vol: 140, page: ?, stat: Journal Article,

Effects of perioperative blood product use on surgical site infection following thoracic and lumbar spinal surgery
Schwarzkopf, Ran; Chung, Christine; Park, Justin J; Walsh, Michael; Spivak, Jeffrey M; Steiger, David
2010 Feb 1;35(3):340-346, Spine
STUDY DESIGN: Retrospective case-control review. OBJECTIVE: This retrospective study explored the hypothesis that the perioperative administration of blood products is an identifiable risk factor of increased surgical site infections (SSIs) after thoracic and lumbar spine surgical procedures. SUMMARY OF BACKGROUND DATA: Surgical site infections are a significant cause of postoperative morbidity and mortality. According to the Center for Disease Control's National Nosocomial Infections Surveillance system, which monitors the rate of hospital-acquired infections in the United States, SSIs represent the third most commonly reported type of nosocomial infection, accounting for 14% to 16% of all nosocomial infections. The incidence of SSIs after spinal surgery is influenced by both preoperative and intraoperative risk factors. The relationship between blood products and SSIs has been a matter of debate for more than 2 decades. Several studies have supported the association between the use of blood products and the development of postoperative surgical site infections. METHODS: A retrospective case-control study was performed. We reviewed the charts of all patients who had undergone thoracic and/or lumbar spinal surgery at the NYU Hospital for Joint Diseases between 2002 and 2007. All patients who had developed surgical site infections following spine surgery in this 5-year period were identified. RESULTS: Data for 61 cases and 71 controls were included in this study. The analysis of the preoperative risk factors was performed for the entire population of patients. Body mass index and blood transfusions were found to be statistically significant risk factors for increased surgical site infections for this population. CONCLUSION: Our findings support current theories that blood transfusions may have modulatory effects on the immune system of the recipients. Our specific study in spine patients may contribute to the expanding literature on allogeneic blood transfusions and the risk of nosocomial infections and encourage surgeons to favor a more restrictive policy with regard to transfusions
— id: 106498, year: 2010, vol: 35, page: 340, stat: Journal Article,

G2 inferior vena cava filter: retrievability and safety
Charles, Hearns W; Black, Michelle; Kovacs, Sandor; Gohari, Arash; Arampulikan, Joseph; McCann, Jeffrey W; Clark, Timothy W I; Bashar, Mona; Steiger, David
2009 Aug;20(8):1046-1051, Journal of vascular & interventional radiology
PURPOSE: To assess the retrievability of the G2 inferior vena cava (IVC) filter and factors influencing the safety and technical success of retrieval. MATERIALS AND METHODS: From October 2006 through June 2008, G2 IVC filters were placed in 140 consecutive patients who needed prophylaxis against pulmonary embolism (PE). General indications for filter placement included history of thromboembolic disease (n = 98) and high risk for PE (n = 42); specific indications included contraindication to anticoagulation (n = 120), prophylaxis in addition to anticoagulation (n = 16), and failure of anticoagulation (n = 4). Filter dwell time, technical success of filter retrieval, and complications related to placement or retrieval were retrospectively evaluated in patients who underwent filter removal. RESULTS: Twenty-seven attempts at G2 filter removal were made in 26 patients (12 men; age range, 24-88 years; mean age, 55.4 y) after a mean period of 122 days (range, 11-260 d). Data were collected retrospectively with institutional review board approval. Filter removal was successful in all 27 attempts (100%). Tilting of the filter (> or =15 degrees ) occurred in five cases (18.5%), with probable filter incorporation into the right lateral wall of the IVC in one. Other complications of retrieval such as filter thrombosis, significant filter migration, filter fracture, and caval occlusion were not observed. CONCLUSIONS: G2 IVC filter retrieval has a high technical success rate and a low complication rate. Technical success appears to be unaffected by the dwell time within the reported range
— id: 101318, year: 2009, vol: 20, page: 1046, stat: Journal Article,

Utility of retrievable inferior vena cava filters for primary prophylaxis of pulmonary embolism in high-risk preoperative orthopedic patients
Dweck, E; Bashar, M; Hansen, D; Clark, TW; Rom, WN; Steiger, D
2007 OCT ;132(4):627S-627S, Chest
— id: 87207, year: 2007, vol: 132, page: 627S, stat: Journal Article,

A case of a 52 year old female with scleroderma, pulmonary fibrosis and recurrent acute respiratory distress
Kline, MY; Steiger, D
2004 OCT ;126(4):995S-995S, Chest
— id: 49317, year: 2004, vol: 126, page: 995S, stat: Journal Article,

Duplex ultrasonography in patients suspected of postoperative pulmonary embolism following total joint arthroplasty
Della Valle, Craig J; Steiger, David J; DiCesare, Paul E
2003 Aug;32(8):386-388, American journal of orthopedics (Belle Mead, NJ)
Duplex ultrasonography of the deep venous system of the lower extremities is often utilized in the diagnostic evaluation of total hip and knee arthroplasty patients suspected of pulmonary embolism in an attempt to identify the embolic source. A retrospective review of 135 patients who were clinically suspected of pulmonary embolism after 71 total knee arthroplasties and 64 total hip arthroplasties was performed. Of the 35 patients diagnosed with pulmonary embolism, 2 (5.7%) had deep venous thrombosis identified by duplex ultrasonography. The routine use of this imaging modality is not an effective strategy for identifying clinically significant deep venous thrombosis that leads to pulmonary embolism. A negative duplex ultrasound result should not preclude an extensive evaluation for pulmonary thrombosis in symptomatic patients
— id: 94864, year: 2003, vol: 32, page: 386, stat: Journal Article,

Sleep apnea syndrome in patients undergoing total joint arthroplasty
Parikh, Shital N; Stuchin, Steven A; Maca, Cielo; Fallar, Eileen; Steiger, David
2002 Aug;17(5):635-642, Journal of arthroplasty
Sleep apnea syndrome (SAS) is a condition of repeated episodes of apnea and hypopnea during sleep. It can cause life-threatening morbidities, including cardiac arrhythmia and ischemia, hypertension, and respiratory arrest, and even death. In a retrospective study at our institution of patients who underwent hip or knee total joint arthroplasty (TJA) with a diagnosis of SAS, we hypothesized that avoiding factors that exacerbate SAS in the perioperative period would minimize adverse outcomes. There were 19 patients with a preoperative diagnosis of moderate or severe SAS; 15 patients received continuous positive airway pressure or bilevel positive airway pressure noninvasive ventilation, 1 patient experienced respiratory arrest secondary to intraoperative propafol, and 2 patients developed postoperative respiratory depression. Avoidance of opioids and sedative drugs, awareness of the possibility of acute airway obstruction, and close monitoring during and after surgery are vital in patients with SAS
— id: 73520, year: 2002, vol: 17, page: 635, stat: Journal Article,

Anticoagulant treatment of thromboembolism with intravenous heparin therapy in the early postoperative period following total joint arthroplasty
Della Valle CJ; Jazrawi LM; Idjadi J; Hiebert RN; Stuchin SA; Steiger DJ; Di Cesare PE
2000 Feb;82(2):207-212, Journal of bone & joint surgery (American volume)
BACKGROUND: Treatment of thromboembolism with intravenous heparin therapy in the early postoperative period after total joint arthroplasty has been associated with a high rate of complications. The purpose of the present study was to compare the rate of bleeding complications in a group of patients who required intravenous heparin therapy for the treatment of thromboembolism after total hip or knee arthroplasty with the rate in a control group of patients who received only prophylactic anticoagulation. METHODS: The postoperative courses of forty-four consecutive patients who were managed with intravenous administration of heparin and oral administration of warfarin for the treatment of a thromboembolic event following unilateral total hip or knee arthroplasty were compared with those of a control group of 376 consecutive patients who had these same procedures but did not have a thromboembolic complication. The patients in the control group were managed with prophylactic anticoagulation with use of enoxaparin. Sixty-eight percent (thirty) of the forty-four patients in the heparin group received the initial dose of heparin on or before the fourth postoperative day, and 82 percent (thirty-six) received an initial bolus of 5000 units of heparin at the initiation of therapy. RESULTS: The rate of bleeding complications was 9 percent (four of forty-four) in the heparin group, compared with 6 percent (twenty-three of 376) in the control group (p = 0.44). The mean transfusion requirement in the heparin group (1.8 units of packed red blood cells) was significantly greater than that in the control group (0.8 unit) (p < 0.0001). Three of the four patients who had a bleeding complication while receiving heparin and warfarin had coagulation parameters that were substantially higher than recommended levels. The mean duration of hospitalization in the heparin group (fifteen days) was significantly longer than that in the control group (seven days) (p < 0.0001). CONCLUSIONS: The results of the present study suggest that the use of intravenous heparin therapy for the treatment of thromboembolism in the early postoperative period after total joint arthroplasty is associated with a rate of bleeding complications that is similar to that associated with the use of prophylactic anticoagulation with use of enoxaparin alone. One should expect an increased transfusion requirement and a longer duration of hospitalization for patients who require intravenous heparin therapy for the treatment of a thromboembolic event
— id: 32648, year: 2000, vol: 82, page: 207, stat: Journal Article,

Paradoxical cerebral embolism complicating a major orthopaedic operation. A report of two cases
Della Valle CJ; Jazrawi LM; Di Cesare PE; Steiger DJ
1999 Jan;81(1):108-110, Journal of bone & joint surgery (American volume)
— id: 7320, year: 1999, vol: 81, page: 108, stat: Journal Article,

Efficacy and complications of inferior vena cava filter placement in orthopedic patients with pulmonary embolism or deep vein thrombosis
Sauthoff, H; Addrizzo-Harris, DJ; DellaValle, C; Schlossberg, P; Rosen, R; Gold, J; Fallar, E; Rom, WN; Steiger, D
1999 MAR ;159(3):A360-A360, American journal of respiratory & critical care medicine
— id: 53879, year: 1999, vol: 159, page: A360, stat: Journal Article,

Thromboembolism after hip and knee arthroplasty: diagnosis and treatment
Della Valle CJ; Steiger DJ; Di Cesare PE
1998 Nov-Dec;6(6):327-336, Journal of the American Academy of Orthopaedic Surgeons
Postoperative thromboembolism is a potentially lethal complication. Its diagnosis may be difficult, as the classic clinical signs and symptoms are often absent, making a high index of suspicion imperative for diagnosis. Anticoagulant therapy is effective in reducing morbidity and mortality due to thromboembolism, but is associated with a substantial rate of bleeding complications in the immediate postoperative period. Inferior vena cava filters constitute an alternative to anticoagulant therapy, but are also associated with a substantial complication rate. The appropriate use of diagnostic tests combined with clinical suspicion can guide the orthopaedic surgeon in deciding which patients require treatment for thromboembolism
— id: 57027, year: 1998, vol: 6, page: 327, stat: Journal Article,