David A. Spain, MD

Abstract

Traditionally, trauma resuscitation protocols have advocated sequential administration of therapeutic components, beginning with crystalloid solutions infused to replace lost intravascular volume. However, rapid restoration of the components of blood is essential for ensuring adequate tissue perfusion and for preventing acidosis, coagulopathy, and hypothermia, referred to as the 'lethal triad' in trauma settings. The review summarizes practical approaches for transfusion support of patients with massive hemorrhage.Massive transfusion protocols for blood transfusion support are reviewed, including practical considerations from our own. We maintain an inventory of thawed, previously frozen plasma (four units each of blood group O and A), which can be issued immediately for patients in whom the blood type is known. As frozen plasma requires 45?min to thaw, liquid AB plasma (26 day outdate) functions as an excellent alternative, particularly for patients with unknown or blood group B or AB types.Close monitoring of bleeding and coagulation in trauma patients allows goal-directed transfusions to optimize patients' coagulation, reduce exposure to blood products, and to improve patient outcomes. Future studies are needed to understand and demonstrate improved patient outcomes.

View details for DOI 10.1097/ACO.0b013e32835d6f8f

View details for Web of Science ID 000316310800018

View details for PubMedID 23446185

Abstract

Ruptured abdominal aortic aneurysm (rAAA) is a critically time-sensitive condition with outcomes dependent on rapid diagnosis and definitive treatment. Emergency department (ED) death reflects the hemodynamic stability of the patient upon arrival and the ability to mobilize resources before hemodynamic stability is lost. The goals of this study were to determine the incidence and predictors of ED death for patients presenting to EDs with rAAAs.Data for patients presenting with International Classification of Disease, 9th Revision, Clinical Modification codes for rAAA from 2006 to 2008 were extracted from discharge data using the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. The NEDS is the largest stratified weighted sample of US hospital-based ED visits with links to inpatient files. We compared those transferred to those admitted and treated. Sample weights were applied to produce nationally representative estimates. Patient and hospital factors associated with transfer were identified using multivariate logistic regression. These factors were then analyzed for a relationship with ED deaths.A total of 18,363 patients were evaluated for rAAAs. Of these, 7% (1201) died in the ED, 6% (1160) were admitted and died without a procedure, 42% (7731) were admitted and died after repair, and 41% (7479) were admitted, treated, and survived. Transfers accounted for 4% (793) of all ED visits for rAAAs. ED death was more likely for patients seen in nonmetropolitan hospitals (12.7%) vs metropolitan nonteaching (7.0%) or metropolitan teaching hospitals (4.5%; P < .0001). Compared with other regions, the West had a higher ED mortality rate (9.6% vs 5.1%-6.9%; P = .0038). On multivariate analysis, ED death was associated with hospital groups exhibiting both high and low transfer rates.ED death remains a significant cause for mortality for rAAAs and varies by hospital type, rural/urban location, and geographic region. Both delays in ED arrival and delays in providing definitive care may contribute to increased ED death rates, suggesting that improved regional systems of care may improve survival after rAAA.

View details for DOI 10.1016/j.jvs.2012.02.025

View details for Web of Science ID 000308085500010

View details for PubMedID 22560234

Abstract

Reconstruction of abdominal wall defects is a challenging problem. Often, the surgeon is presented with a patient having multiple comorbidities, who has already endured numerous unsuccessful operations, leaving skin and fascia that are attenuated and unreliable. Our study investigated preoperative, intraoperative, and postoperative factors and techniques during abdominal wall reconstruction to determine which variables were associated with poor outcomes.Data were collected on all patients who underwent ventral abdominal hernia repair by 3 senior-level surgeons at our institution during an 8-year period. In all cases, placement of either a synthetic or a biologic mesh was used to provide additional reinforcement of the repair.A total of 106 patients were included. Seventy-nine patients (75%) had preoperative comorbid conditions. Sixty-seven patients developed a postoperative complication (63%). Skin necrosis was the most common complication (n = 21, 19.8%). Other complications included seroma (n = 19, 17.9%), cellulitis (n = 19, 17.9%), abscess (n = 14 13.2%), pulmonary embolus/deep vein thrombosis (n = 3, 2.8%), small bowel obstruction (n = 2, 1.9%), and fistula (n = 8, 7.5%). Factors that significantly contributed to postoperative complications (P < 0.05) included obesity, diabetes, hypertension, fistula at the time of the operation, a history of >2 prior hernia repairs, a history of >3 prior abdominal operations, hospital stay for >14 days, defect size > 300 square cm, and the use of human-derived mesh allograft. Factors that significantly increased the likelihood of a hernia recurrence (P < 0.05) included a history of >2 prior hernia repairs, the use of human-derived allograft, using an overlay-only mesh placement, and the presence of a postoperative complication, particularly infection. Hernia recurrences were significantly reduced (P < 0.05) by using a "sandwich" repair with both a mesh overlay and underlay and by using component separation.A history of multiple abdominal operations is a major predictor of complications and recurrences. If needed, component separation should be used to achieve primary tension-free closure, which helps to reduce the likelihood of hernia recurrences. Our data suggest that mesh reinforcement used concomitantly in a "sandwich" repair with component separation release may lead to reduced recurrence rates and may provide the optimal repair in complex hernia defects.

View details for DOI 10.1097/SAP.0b013e31823b68b1

View details for Web of Science ID 000301800600013

View details for PubMedID 22421484

Abstract

The repair of large ventral hernias is a challenging problem. This study investigated the use of decellularized, chemically cross-linked porcine dermal xenograft in conjunction with component separation (a.k.a. the "Pork Sandwich" Herniorraphy) in the repair of abdominal wall defects.We prospectively collected data over a 3-year period. Primary or near-total primary fascial closure was our goal in operative repair. A cross-linked porcine dermal xenograft mesh underlay and overlay were used to provide maximal reinforcement of the repair. Outcomes were compared with a case-controlled cohort of 84 patients who underwent ventral hernia repairs with alternative methods at our institution.Nineteen patients were included. Mean age was 55 years old, and mean body mass index (BMI) was 30 kg/m(2). Mean defect size was 321 cm(2). Post-operative complications were observed in ten out of 19 patients. Complications included seroma (n = 2), wound infection (n = 2), abscess (n = 1), skin necrosis (n = 6), and fistula formation (n = 3). Seven patients required re-operation. Statistically significant factors (p < 0.05) that contributed to increased post-operative complications or re-operation rates included smoking, presence of pre-operative enterocutaneous fistulae, extended post-operative hospital stay (>2 weeks), and a defect size greater than 300 cm(2). There were no hernia recurrences in our "Pork Sandwich" group, which contrasted favorably to the retrospective case-control group in which the hernia recurrence rate was 19% (p = 0.038).For the repair of abdominal hernias, primary closure, with component separation as needed, with an underlay and overlay of cross-liked porcine xenograft should be considered to minimize risk of recurrent herniation. Additional long-term prospective comparative studies are needed for further validation of the optimal method and material for repair.

View details for DOI 10.1016/j.bjps.2011.09.044

View details for Web of Science ID 000300524800016

View details for PubMedID 22000333

View details for Web of Science ID 000300524500022

View details for PubMedID 22351918

Abstract

since California lacks a statewide trauma system, there are no uniform interfacility pediatric trauma transfer guidelines across local emergency medical services (EMS) agencies in California. This may result in delays in obtaining optimal care for injured children.this study sought to understand patterns of pediatric trauma patient transfers to the study trauma center as a first step in assessing the quality and efficiency of pediatric transfer within the current trauma system model. Outcome measures included clinical and demographic characteristics, distances traveled, and centers bypassed. The hypothesis was that transferred patients would be more severely injured than directly admitted patients, primary catchment transfers would be few, and out-of-catchment transfers would come from hospitals in close geographic proximity to the study center.this was a retrospective observational analysis of trauma patients ? 18 years of age in the institutional trauma database (2000-2007). All patients with a trauma International Classification of Diseases, 9th revision (ICD-9) code and trauma mechanism who were identified as a trauma patient by EMS or emergency physicians were recorded in the trauma database, including those patients who were discharged home. Trauma patients brought directly to the emergency department (ED) and patients transferred from other facilities to the center were compared. A geographic information system (GIS) was used to calculate the straight-line distances from the referring hospitals to the study center and to all closer centers potentially capable of accepting interfacility pediatric trauma transfers.of 2,798 total subjects, 16.2% were transferred from other facilities within California; 69.8% of transfers were from the catchment area, with 23.0% transferred from facilities ? 10 miles from the center. This transfer pattern was positively associated with private insurance (risk ratio [RR] = 2.05; p < 0.001) and negatively associated with age 15-18 years (RR = 0.23; p = 0.01) and Injury Severity Score (ISS)?> 18 (RR = 0.26; p < 0.01). The out-of-catchment transfers accounted for 30.2% of the patients, and 75.9% of these noncatchment transfers were in closer proximity to another facility potentially capable of accepting pediatric interfacility transfers. The overall median straight-line distance from noncatchment referring hospitals to the study center was 61.2 miles (IQR = 19.0-136.4), compared to 33.6 miles (IQR = 13.9-61.5) to the closest center. Transfer patients were more severely injured than directly admitted patients (p < 0.001). Out-of-catchment transfers were older than catchment patients (p < 0.001); ISS > 18 (RR = 2.06; p < 0.001) and age 15-18 (RR = 1.28; p < 0.001) were predictive of out-of-catchment patients bypassing other pediatric-capable centers. Finally, 23.7% of pediatric trauma transfer requests to the study institution were denied due to lack of bed capacity.from the perspective an adult Level I trauma center with a certified pediatric intensive care unit (PICU), delays in definitive pediatric trauma care appear to be present secondary to initial transport to nontrauma community hospitals within close proximity of a trauma hospital, long transfer distances to accepting facilities, and lack of capacity at the study center. Given the absence of uniform trauma triage and transfer guidelines across state EMS systems, there appears to be a role for quality monitoring and improvement of the current interfacility pediatric trauma transfer system, including defined triage, transfer, and data collection protocols.

View details for DOI 10.1111/j.1553-2712.2010.00926.x

View details for Web of Science ID 000284848100018

View details for PubMedID 21122022

Abstract

Traumatic blunt aortic injury has traditionally been viewed as a surgical emergency, whereas nonoperative therapy has been reserved for nonsurgical candidates. This study reviews our experience with deliberate, nonoperative management for blunt thoracic aortic injury.A retrospective chart review with selective longitudinal follow-up was conducted for patients with blunt aortic injury. Surveillance imaging with computed tomography angiography was performed. Nonoperative patients were then reviewed and analyzed for survival, evolution of aortic injury, and treatment failures.During the study period, 53 patients with an average age of 45 years (range, 18-80 years) were identified, with 28% presenting to the Stanford University School of Medicine emergency department and 72% transferred from outside hospitals. Of the 53 patients, 29 underwent planned, nonoperative management. Of the 29 nonoperative patients, in-hospital survival was 93% with no aortic deaths in the remaining patients. Survival was 97% at a median of 1.8 years (range, 0.9-7.2 years). One patient failed nonoperative management and underwent open repair. Serial imaging was performed in all patients (average = 107 days; median, 31 days), with 21 patients having stable aortic injuries without progression and 5 patients having resolved aortic injuries.This experience suggests that deliberate, nonoperative management of carefully selected patients with traumatic blunt aortic injury may be a reasonable alternative in the polytrauma patient; however, serial imaging and long-term follow-up are necessary.

View details for DOI 10.1016/j.jtcvs.2010.02.056

View details for Web of Science ID 000281116000016

View details for PubMedID 20579668

Abstract

In the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers to accept hand trauma transfers for higher level of care if capacity exists. However, patient transfer for non-medical reasons, such as ability to pay, is still perceived as a common practice. We hypothesized that EMTALA would cause selective transfer of hand patients who were underinsured or uninsured, thus, effectively burdening a Level I trauma center. A dedicated transfer center documented the demographics and outcomes of all calls for hand trauma transfers from December 2003 to September 2005. This data registry was reviewed for age, gender, race, insurance status, and length of hospital stay. This data was compared with direct admissions to the emergency room for hand emergencies during that same time period. During the 2-year time period, a total of 151 calls for EMTALA transfer were received for hand emergencies. Our institution accepted 92 of these patients for transfer. Reasons for not accepting transfer included lack of bed availability and unavailability of the on-call surgeon due to other emergency operative cases. Compared with hand emergency patients brought directly to our emergency department during the same time period, transferred patients were younger and had a shorter length of stay. Interestingly, they were very similar in terms of sex, race, and insurance status. These data suggest that the primary motivations for EMTALA hand trauma transfers are truly complexity of patient care and specialist availability. Given the often urgent nature of hand trauma surgery and the limited resources available, expansion and development of hand and microsurgery regional centers will be vital to adequately meet demand without overburdening existing centers.

View details for DOI 10.1007/s11552-009-9214-7

View details for PubMedID 19603237

Abstract

Experimentation involving human subjects requires careful attention to the protection of their rights. Beginning with the Belmont Report in 1979, the United States has developed various sets of rules and regulations that identify the requirements for performing human subject research. In addition, these standards attempt to define the fundamental difference between what constitutes research versus clinical treatment versus innovation. We explore the intersection between two areas of independent bioethics, surgical innovation and emergency research; the point we refer to as emergency innovation.A systematic literature review in each of the fields of emergency research and surgical innovation was completed. The ethical principles involved in each field were identified. In addition, a recent case of surgical innovation within the context of emergency treatment is evaluated for the ethics invoked.One of the great challenges in emergency innovation is that the main protection offered in innovation (heightened informed consent) is not possible in the emergency context where in fact informed consent is waived. Interestingly, the rest of the protections outlined for each field are not mutually exclusive. They can and should be utilized in any project that takes place at this intersection. However, as there are no strict regulations in place for the collision of these two fields, the possibility of having the majority of the involved ethical principles misinterpreted or ignored is very real.For emergency innovation, where it is unclear what ethical principles and regulatory powers apply, it is imperative to be unambiguous about the purpose of the investigation, to adhere to all applicable ethical principles, and to have utmost consideration for protection of the research subject. To determine intent, the goals of the study must be outlined precisely - and if those include the prospect of publication, institutional review board (IRB) approval should be involved early. If, however, the innovation is subtle and the goal geared toward improved patient care, a small feasibility trial would be an appropriate first step before transitioning to a formal larger study approved by an IRB. In either case, the degree of the change in practice must be carefully evaluated and the vulnerability of the research subjects respected. With careful attention paid to all applicable ethical principles at the emergency innovation intersection, medical progress can continue at minimized risk to the human subject participants.

View details for DOI 10.1097/TA.0b013e3181bba255

View details for Web of Science ID 000272658100060

View details for PubMedID 20009701

Abstract

Exsanguinating hemorrhage necessitating massive blood product transfusion is associated with high mortality rates. Recent data suggest that altering the fresh frozen plasma to packed red blood cell ratio (FFP:PRBC) results in significant mortality reductions. Our purpose was to evaluate mortality and blood product use in the context of a newly initiated massive transfusion protocol (MTP).In July 2005, our American College of Surgeons-verified Level I trauma center implemented an MTP supporting a 1:1.5 FFP:PRBC ratio, improved communications, and enhanced systems flow to optimize rapid blood product availability. During the 4 years surrounding protocol implementation, we reviewed data on trauma patients directly admitted through the emergency department and requiring 10 or more units PRBCs during the first 24 hours.For the 2 years before and subsequent to MTP initiation, there were 4,223 and 4,414 trauma activations, of which 40 and 37 patients, respectively, met study criteria. The FFP:PRBC ratios were identical, at 1:1.8 and 1:1.8 (p = 0.97). Despite no change in FFP:PRBC ratio, mortality decreased from 45% to 19% (p = 0.02). Other significant findings included decreased mean time to first product: cross-matched RBCs (115 to 71 minutes; p = 0.02), FFP (254 to 169 minutes; p = 0.04), and platelets (418 to 241 minutes; p = 0.01).MTP implementation is associated with mortality reductions that have been ascribed principally to increased plasma use and decreased FFP:PRBC ratios. Our study found a significant reduction in mortality despite unchanged FFP:PRBC ratios and equivalent overall mean numbers of transfusions. Our data underscore the importance of expeditious product availability and emphasize that massive transfusion is a complex process in which product ratio and time to transfusion represent only the beginning of understanding.

View details for DOI 10.1016/j.jamcollsurg.2009.04.016

View details for Web of Science ID 000268747300006

View details for PubMedID 19632596

Abstract

After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances.The Trauma Registry was used to derive data for all trauma patients evaluated in the emergency department from 2001 to 2007. Clinical data analyzed included number of admissions, interfacility transfers, injury severity scores (ISS), length of stay, and mortality for 2001 to 2007. Financial performance was assessed for fiscal years 2001 to 2007. Data were divided into patients discharged from the emergency department and those admitted to the hospital.Admissions increased 30%, representing a 7.6% annual increase (p = 0.004), mostly due to a nearly fivefold increase in interfacility transfers. Severe trauma patients (ISS >24) increased 106% and mortality rate for ISS >24 decreased by 47% to almost half the average of the National Trauma Database. There was a 78% increase in revenue and a sustained increase in hospital profitability.A major hospital commitment to Committee on Trauma verification had several salient outcomes; increased admissions, interfacility transfers, and acuity. Despite more seriously injured patients, there has been a major, sustained reduction in mortality and a trend toward decreased intensive care unit length of stay. This resulted in a substantial increase in contribution to margin (CTM), net profit, and revenues. With a high level of commitment and favorable payer mix, trauma center verification improves outcomes for both patients and the hospital.

View details for DOI 10.1097/TA.0b013e3181a51b2f

View details for Web of Science ID 000267953100035

View details for PubMedID 19590334

Abstract

To correlate deficient pituitary function with life satisfaction and functional performance in subjects with a recent history of traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH).Cross-sectional study.Eighteen subjects with TBI and 16 subjects with SAH underwent pituitary hormonal and functional assessments 5-12 months following the event. Adrenal reserve was assessed with a 1 mcg cosyntropin stimulation test and growth hormone deficiency (GHD) was diagnosed by insufficient GH response to GHRH-Arginine stimulation. Assessments of life satisfaction and performance-function included the Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART) and the Mayo Portland Adaptability Inventory-4 (MPAI-4).Hypopituitarism was present in 20 (58.8%) subjects, including 50% with adrenal insufficiency. Hypothyroidism correlated with worse performance on SWLS and CHART measures. GHD was associated with poorer performance on CHART and MPAI-4 scale.In this series of subjects with history of TBI and SAH, hypothyroidism and GHD were associated with diminished life satisfaction and performance-function on multiple assessments. Further studies are necessary to determine the appropriate testing of adrenal reserve in this population and to determine the benefit of pituitary hormone replacement therapy on function following brain injury.

View details for DOI 10.1080/02699050902970778

View details for Web of Science ID 000267370600008

Abstract

Triage of the trauma patient in the field is a complex and challenging issue, especially deciding when to use aeromedical transport. The American College of Surgeons Committee on Trauma recently defined an acceptable under-triage rate [seriously injured patient not taken to a trauma center (TC)] as 5%, whereas over-triage rates may be as high as 25% to 50%. Effective utilization of prehospital helicopter transport requires both accurate assessment of patients and effective communication. The rural county adjacent to our developed trauma system uses standardized triage criteria to identify patients for direct transport to our TCs. We hypothesized these criteria accurately identify major trauma victims (MTV) and further that communication could be simplified to expedite transport.Prehospital personnel use a MAP (mechanism, anatomy, and physiology) scoring system to triage trauma patients. Patients with > or = 2 "hits" are defined as MTV. In 2004, the triage policy was changed so that MTV would be transported directly to a TC without base hospital consultation (previously required). The Emergency Medical Services (EMS) Medical Director reviewed cases transported to the TC to determine the appropriateness of triage decisions (over- and under-triage using the American College of Surgeons Committee on Trauma definitions). Data were compared before and after this policy change.For 2004 to 2006, we evaluated 676 air transports to TC and compared them to 468 in the prior 56 months. The overall transport rate increased slightly 7% to 10%. During the study period the over-triage rate was 31% compared with 21%, before the policy change. The MAP triage tool yielded a 93.8% sensitivity and a 99.5% specificity. Therefore, it determined the need for air-medical transport out of a rural environment into an established trauma system with > 90% accuracy.Prehospital personnel can accurately use a trauma triage tool to identify MTV. Eliminating base station contact, a potential for introducing communication error, did increase over-triage but still well within accepted limits. The system change also resulted in the transport of a greater proportion of minor trauma patients who later proved to have major injuries.

View details for DOI 10.1097/TA.0b013e31818bbfc2

View details for Web of Science ID 000261706000010

View details for PubMedID 19077609

Abstract

Strict glucose control with insulin is associated with decreased mortality in a mixed patient population in the intensive care unit. Controversy exists regarding the relative benefits of glucose control versus a direct advantageous effect of exogenous insulin. As a combined medical/surgical population differs significantly from the critically injured patient primed for secondary insult, our purpose was to determine the influence of insulin on activated macrophages. Our hypothesis was that insulin would directly abrogate the inflammatory cascade.Differentiated human monocytic THP-1 cells were stimulated with endotoxin (lipopolysaccharide [LPS], 100 ng/mL) for 6 hours. Cells were treated +/-10(-7) M insulin for 1 hour and 24 hours. Total RNA was isolated and gene expression for TNF-alpha and IL-6 performed using Q-RT-PCR. Supernatants were assayed for TNF-alpha and IL-6 protein by ELISA.At 1 hour, compared with macrophages treated with LPS alone, macrophages treated with insulin produced significantly more TNF-alpha protein (11.4 +/- 5.9 pg/mL vs. 32.5 +/- 3.1 pg/mL; p < 0.03). At 24 hours compared with macrophages treated with LPS alone, macrophages treated with insulin produced significantly more TNF-alpha protein (83 +/- 2.02 pg/mL vs. 114 +/- 6.54 pg/mL; p < 0.01). However, gene expression of TNF-alpha and IL-6 was not different in LPS stimulated macrophages with and without insulin treatment at both 1 hour and 24 hours.Contrary to our hypothesis, insulin does not have direct anti-inflammatory properties in this experimental model. In fact, insulin increases proinflammatory cytokine protein levels from activated macrophages.

View details for DOI 10.1097/TA.0b013e3181801cc0

View details for Web of Science ID 000258461600026

View details for PubMedID 18695473

Abstract

Traditionally, conventional arteriography is the diagnostic modality of choice to evaluate for arterial injury. Recent technological advances have resulted in multidetector, fine resolution computed tomographic angiography (CTA). This study examines CTA for evaluation of extremity vascular trauma compared with conventional arteriography. Our hypothesis is that CTA provides accurate and timely diagnosis of peripheral vascular injuries and challenges the gold standard of arteriogram. Traumatic extremity injuries over a 5-year period were identified using a Level I trauma center registry and radiology database. Information collected included patient demographics, mechanism, imaging modality, vascular injuries, management, and follow-up. Two thousand two hundred and fifty-one patients were identified with extremity trauma. Twenty-four patients were taken directly to the operating room for evaluation and management of vascular injuries. Fifty-two underwent vascular imaging. Fourteen patients had conventional arteriograms with 13 abnormal studies: 7 were managed operatively, 2 embolized, and 4 observed. Thirty-eight patients underwent CTA with 17 abnormal scans: 9 were managed operatively, 3 embolized, and 5 observed. There were no false negatives or missed injuries. CTA provides accurate peripheral vascular imaging while additionally offering advantages of noninvasiveness and immediate availability. Secondary to these advantages, CTA has supplanted arteriography for initial radiographic evaluation of peripheral vascular injuries at our Level I trauma center. This study supports CTA as an effective alternative to conventional arteriography in assessing extremity vascular trauma.

View details for Web of Science ID 000253009300002

View details for PubMedID 18306857

Abstract

During the past 40 years, management of solid organ injury in pediatric trauma patients has shifted to highly successful nonoperative management. Our purpose was to characterize children requiring operative intervention. We hypothesized that older children would be more likely to require operative intervention. In particular, we wanted to examine potential outcome disparities between children who were operated upon immediately and those in whom attempted nonoperative management failed. Additionally, we asked whether attempted nonoperative management, when failed, put children at higher risk for mortality or morbidities such as increased blood product transfusions or lengths of stays.Retrospective cohorts from seven Level I pediatric trauma centers were identified. Blunt splenic, hepatic, renal, or pancreatic injuries were documented in 2,944 children <1 to 19 years of age from January 1993 to December 2002. Data collected included demographics, hemodynamics, blood transfusions, Glasgow Coma Scale score, Injury Severity Score, hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality. Analysis involved 140 (4.8%) of 2,944 patients requiring operation. Two cohorts were characterized: (1) immediate operation (IO), defined as laparotomy 3 hours after arrival (n = 59; 42%).Comparing the two cohorts, no age differences were found. Compared with F-NOM, IO had significantly worse hemodynamics, Injury Severity Score, and Glasgow Coma Scale score and was associated with liver injuries. Pancreatic injuries were significantly associated with F-NOM. While controlling for injury severity to compare IO versus F-NOM, linear regression revealed equivalent blood transfusions, ICU LOS, hospital LOS, and mortality rates.IO and F-NOM are rare events and independent of age. When operated upon for appropriate physiology, the timing of operation in pediatric solid organ injury is irrelevant and not detrimental with respect to blood transfusion, mortality, ICU and hospital LOS, and resource utilization.

View details for DOI 10.1097/TA.0b013e318142d2c2

View details for Web of Science ID 000249503300023

View details for PubMedID 18073608

View details for DOI 10.1097/01.ta.0000210439.64958.df

View details for Web of Science ID 000248062600047

View details for PubMedID 17622901

Abstract

More than one third of adults over the age of 65 suffer a fall each year, facing morbidity and mortality. Modifiable risk factors for falls have been identified, but specific recruitment strategies for prevention programs have not been evaluated. The purpose of this observational study was to evaluate recruitment strategies for a fall prevention program.Participants were recruited during an 11-month period at a Level I trauma center. Participants were eligible if >65 years old, living independently, and had a fall. Recruitment modalities included (1) emergency medical services, (2) emergency department (ED), (3) primary care providers, and (4) media exposure leading to self-referral. Data were collected on baseline rate of fall victims seen in the ED, demographics, medical history, and source of referral.There were 91 individuals referred, with 61 (67%) enrolled. Enrollment rates were higher among patients referred by self or primary care providers than among those referred by emergency medical services or the ED. There were no significant differences in demographics or medical history among the eligible but not referred ED population, the referred population, and the enrolled population. Reasons for not enrolling included inappropriate referral (33%), no response (17%), other illness (13%), and patients thinking that they do not need the services (37%).These recruitment strategies were successful in enrolling a representative population of patients at risk for recurrent falls, but could be improved to capture more potential participants. Source of referral has a significant effect on rate of enrollment. We outline challenges and solutions to recruitment.

View details for DOI 10.1097/TA.0b013e318068428a

View details for Web of Science ID 000248062600025

View details for PubMedID 17622882

Abstract

The Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers (TC) to accept all transfers for a higher level of care if capacity exists. We hypothesized that EMTALA would burden a Level I TC by a selective referral of a poor payer mix of primarily nonoperative patients.All transfer calls (December 2003 and September 2005) to our Level I TC are handled by a dedicated transfer center. Calls were reviewed for age, surgical service requested, and outcome of request. The trauma registry was queried to compare Injury Severity Scale (ISS) score, hospital stay (LOS), operations, mortality, and payer status for transfer and primary catchment patients.In all, 821 calls were received; 77 calls were cancelled by the referring hospital and 52 were for consultation only. Of the 692 transfer requests, 534 (77%) were accepted, 134 (19%) were denied for no capacity, and only 24 (4%) were declined by TC as not clinically indicated. Transferred patients were younger (32.0 +/- 1.49 versus 38.9 +/- 0.51, p < 0.05), had similar ISS scores (13.6 +/- 0.62 versus 13.7 +/- 0.26) and LOS (7.0 +/- 0.70 versus 7.4 +/- 0.25), but were somewhat more likely to require an operation than direct admissions (58% versus 51%, p < 0.05). Although trauma (24%) and neurosurgery (24%) were the most commonly requested services, followed by orthopedics (20%), orthopedics accounted for 60% of operations on transferred patients compared with 10% to 13% for trauma and neurosurgery (mostly spine). There was no difference in the payer status of transfer and direct admit patients.Contrary to our assumptions, EMTALA patients had an identical payer mix and similar operative need compared with our primary catchment patients. They do represent a large additional patient load (20% of admissions) and differentially impact specialists, mostly operative for orthopedics and complex nonoperative care for trauma and neurosurgery. These data suggest that the primary motivations for transfer are specialist availability and complexity of care rather than financial concerns. As TCs provide backup specialty call coverage for a wide geographic area, this further supports the need for trauma systems development.

View details for DOI 10.1097/TA.0b013e31802d9716

View details for Web of Science ID 000243490100012

View details for PubMedID 17215734

View details for PubMedID 16998146

Abstract

Traumatic thoracic aortic injury (TAI) is traditionally treated with immediate surgery. Previously published studies have established the safety and efficacy of treating TAI with endovascular stents. Our hypothesis was that stents are supplanting operative repair as the primary therapy for TAI.Retrospective cohort.University level I trauma center.Blunt trauma patients admitted to a level I trauma center diagnosed with TAI between September 1997 and November 2003 were identified from an institutional trauma registry (N = 25). Data were abstracted from medical records and analyzed. Three groups were defined: surgical repair (cardiopulmonary bypass or clamp and sew) (n = 10); medical management (n = 8); and endovascular stent (n = 7).Prior to 2002, 9 (75%) of 12 patients were treated by surgical repair, 2 (17%) by medical management, and 1 (8%) by endovascular stent. Since 2002, 1 patient (8%) was treated by surgical repair, 6 (46%) by medical management, and 6 (46%) by endovascular stent. Injury Severity Scores were comparable between the surgical cohort (mean +/- SEM score, 34.9 +/- 3.4), stent placement (35.1 +/- 3.7), and medical management (29.9 +/- 2.8) (P = .48). Overall survival was 80% with no differences in morbidity or mortality. The stented group had shorter hospital lengths of stay compared with surgical management (28 vs 46 days) (P<.05). The 1 operative case since 2002 was a combined arch/innominate injury that anatomically precluded stent placement.Initial reports suggested thoracic aortic stents as an alternative for injured patients with prohibitive operative risks. Our data suggest stent placement is quickly evolving into the primary therapy for TAI across all Injury Severity Score profiles.

View details for Web of Science ID 000235217400016

View details for PubMedID 16490896

View details for Web of Science ID 000235066300046

View details for PubMedID 16456457

Abstract

Despite significant risk for venous thromboembolism, severely injured trauma patients often are not candidates for prophylaxis or treatment with anticoagulation. Long-term inferior vena cava (IVC) filters are associated with increased risk of postphlebitic syndrome. Retrievable IVC filters potentially offer a better solution, but only if the filter is removed; our hypothesis is that the most of them are not.This retrospective study queried a level I trauma registry for IVC filter insertion from September 1997 through June 2004.One IVC filter was placed before the availability of retrievable filters in 2001. Since 2001, 27 filters have been placed, indicating a change in practice patterns. Filters were placed for prophylaxis (n = 11) or for therapy in patients with pulmonary embolism or deep vein thrombosis (n = 17). Of 23 temporary filters, only 8 (35%) were removed.Surgeons must critically evaluate indications for IVC filter insertion, develop standard criteria for placement, and implement protocols to ensure timely removal of temporary IVC filters.

View details for DOI 10.1016/j.amjsurg.2005.08.009

View details for Web of Science ID 000233759800007

View details for PubMedID 16307934

View details for DOI 10.1097/01.ta.0000196439.77828.9d

View details for Web of Science ID 000234514000043

View details for PubMedID 16385305

Abstract

Trauma surgery as a specialty in the United States is at a crossroads. Currently, less than 100 residents per year pursue additional specialty training in trauma and surgical critical care. Many forces have converged to place serious challenges and obstacles to the training of future trauma surgeons. In order for the field to flourish, the training of future trauma surgeons must be modified to compensate for these changes.Recent medical literature regarding the training of trauma surgeons and report of the Future of Trauma Surgery/Trauma Specialization Committee of the American Association for the Surgery of Trauma.The new post-graduate trauma training fellowship of the future should be built on a foundation of general surgery. The goal of this program will be to train a surgeon with broad expertise in trauma, critical care, and emergency general surgery. This new emphasis on non-trauma emergency surgery required an image change and thus a new name; Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery.

View details for DOI 10.1016/j.amjsurg.2005.05.014

View details for Web of Science ID 000230637600013

View details for PubMedID 16023433

Abstract

Our goal was to identify factors that can be targeted during medical education to encourage a career in surgery.We conducted a cross-sectional survey of first and fourth year classes in a Liaison Committee on Medical Education-accredited medical school. Students scored 19 items about perceptions of surgery using a Likert-type scale. Students also indicated their gender and ranked their top three career choices.There were 121 of 210 (58%) first year and 110 of 212 (52%) fourth year students who completed the survey. First year students expressed a positive correlation between surgery and career opportunities, intellectual challenge, performing technical procedures, and obtaining a residency position, although length of training, work hours, and lifestyle during and after training were negatively correlated with choosing surgery. Fourth year student responses correlated positively with career and academic opportunities, intellectual challenge, technical skills, role models, prestige, and financial rewards. Factors that correlated negatively were length of training, residency lifestyle, hours, call schedule, and female gender of the student respondent. Forty-four percent of first year male students expressed an interest in surgery versus 27% of fourth year male students (p < 0.04). Eighteen percent of first year female students expressed an interest in surgery versus 5% of fourth year female students (p < 0.006).Lifestyle issues remain at the forefront of student concerns. Intellectual challenge, career opportunities, and technical skills are consistently recognized as strengths of surgery. Additionally, fourth year students identify role models, prestige, and financial rewards as positive attributes. Emphasizing positive aspects may facilitate attracting quality students to future careers in surgery.

View details for DOI 10.1016/j.jamcollsurg.2005.02.033

View details for Web of Science ID 000229663800021

View details for PubMedID 15922210

Abstract

Elevated residual volumes (RV), considered a marker for the risk of aspiration, are used to regulate the delivery of enteral tube feeding. We designed this prospective study to validate such use.Critically ill patients undergoing mechanical ventilation in the medical, coronary, or surgical intensive care units in a university-based tertiary care hospital, placed on intragastric enteral tube feeding through nasogastric or percutaneous endoscopic gastrostomy tubes, were included in this study. Patients were fed Probalance (Nestle USA) to provide 25 kcal/kg per day (to which 10 yellow microscopic beads and 4.5 mL of blue food coloring per 1,500 mL was added). Patients were randomized to one of two groups based on management of RV: cessation of enteral tube feeding for RV >400 mL in study patients or for RV >200 mL in controls. Acute Physiology and Chronic Health Evaluation (APACHE) III, bowel function score, and aspiration risk score were determined. Bedside evaluations were done every 4 hrs for 3 days to measure RV, to detect blue food coloring, to check patient position, and to collect secretions from the trachea and oropharynx. Aspiration/regurgitation events were defined by the detection of yellow color in tracheal/oropharyngeal samples by fluorometry. Analysis was done by analysis of variance, Spearman's correlation, Student's t-test, Tukey's method, and Cochran-Armitage test.Forty patients (mean age, 44.6 yrs; range, 18-88 yrs; 70% male; mean APACHE III score, 40.9 [range, 12-85]) were evaluated (21 on nasogastric, 19 on percutaneous endoscopic gastrostomy feeds) and entered into the study. Based on 1,118 samples (531 oral, 587 tracheal), the mean frequency of regurgitation per patient was 31.3% (range, 0% to 94%), with a mean RV for all regurgitation events of 35.1 mL (range, 0-700 mL). The mean frequency of aspiration per patient was 22.1% (range, 0% to 94%), with a mean RV for all aspiration events of 30.6 mL (range, 0-700 mL). The median RV for both regurgitation and aspiration events was 5 mL. Over a wide range of RV, increasing from 0 mL to >400 mL, the frequency of regurgitation and aspiration did not change appreciably. Aspiration risk and bowel function scores did not correlate with the incidence of aspiration or regurgitation. Blue food coloring was detected on only three of the 1,118 (0.27%) samples. RV was < or =50 mL on 84.1% and >400 mL on 1.4% of bedside evaluations. Sensitivities for detecting aspiration per designated RV were as follows: 400 mL = 1.5%; 300 mL = 2.3%; 200 mL = 3.0%; and 150 mL = 4.5%. Low RV did not assure the absence of events, because the frequency of aspiration was 23.0% when RV was <150 mL. Raising the designated RV for cessation of enteral tube feeding from 200 mL to 400 mL did not increase the risk, because the frequency of aspiration was no different between controls (21.6%) and study patients (22.6%). The frequency of regurgitation was significantly less for patients with percutaneous endoscopic gastrostomy tubes compared with those with nasogastric tubes (20.3% vs. 40.7%, respectively; p = .046). There was no correlation between the incidence of pneumonia and the frequency of regurgitation or aspiration.Blue food coloring should not be used as a clinical monitor. Converting nasogastric tubes to percutaneous endoscopic gastrostomy tubes may be a successful strategy to reduce the risk of aspiration. No appropriate designated RV level to identify aspiration could be derived as a result of poor sensitivity over a wide range of RV. Study results do not support the conventional use of RV as a marker for the risk of aspiration.

View details for DOI 10.1097/01.CCM.0000153413.46627.3A

View details for Web of Science ID 000227077500006

View details for PubMedID 15699835

Abstract

Serum elevations of interleukin-6 (IL-6) correlate with multiple organ dysfunction syndrome and mortality in critically injured trauma patients. Data from rodent models of controlled hemorrhage suggest that recombinant IL-6 (rIL-6) infusion protects tissue at risk for ischemia-reperfusion injury. Exogenous rIL-6 administered during shock appears to abrogate inflammation, providing a protective rather than a deleterious influence. In an examination of this paradox, the current study aimed to determine whether rIL-6 decreases inflammation in a clinically relevant large animal model of uncontrolled hemorrhagic shock, (UHS), and to investigate the mechanism of protection.Swine were randomized to four groups (8 animals in each): (1) sacrifice, (2) sham (splenectomy followed by hemodilution and cooling to 33 degrees C), (3) rIL-6 infusion (sham plus UHS using grade 5 liver injury with packing and resuscitation plus blinded infusion of rIL-6 [10 mcg/kg]), and (4) placebo (UHS plus blinded vehicle). After 4 hours, blood was sampled, estimated blood loss determined, animals sacrificed, and lung harvested for RNA isolation. Quantitative reverse transcriptase-polymerase chain reaction was used to assess granulocyte colony-stimulating factor (G-CSF), IL-6, and tumor necrosis factor-alpha (TNFalpha) messenger ribonucleic acid (mRNA) levels. Serum levels of IL-6 and TNFalpha were measured by enzyme-linked immunoassay (ELISA).As compared with placebo, IL-6 infusion in UHS did not increase estimated blood loss or white blood cell counts, nor decrease hematocrit or platelet levels. As compared with the sham condition, lung G-CSF mRNA production in UHS plus placebo increased eightfold (*p < 0.05). In contrast, rIL-6 infusion plus UHS blunted G-CSF mRNA levels, which were not significantly higher than sham levels (p = 0.1). Infusion of rIL-6 did not significantly affect endogenous production of either lung IL-6 or mRNA. As determined by ELISA, rIL-6 infusion did not increase final serum levels of IL-6 or TNFalpha over those of sham and placebo conditions.Exogenous rIL-6 blunts lung mRNA levels of the proinflammatory cytokine G-CSF. The administration of rIL-6 does not increase the local expression of IL-6 nor TNFalpha mRNA in the lung. Additionally, rIL-6 infusion does not appear to cause systemic toxicity.

View details for DOI 10.1097/01.TA.0000141970.68269.AC

View details for Web of Science ID 000225660600008

View details for PubMedID 15580019

View details for DOI 10.1053/j.jvca.2004.05.007

View details for Web of Science ID 000224223500017

View details for PubMedID 15365933

View details for DOI 10.1016/j.jamcollsung.2004.02.023

View details for Web of Science ID 000222317100021

View details for PubMedID 15217641

Abstract

Resuscitation from hemorrhagic shock is associated with impairment of the endothelium-dependent dilation response, whereas the dilation response induced by the endothelium-independent pathway, which is mediated by nitroprusside, a nitric oxide (NO) donor and a direct activator of guanylate cyclase, remains unaltered. Whether the impairment of the endothelium-dependent dilation response is caused by a specific receptor alteration or generally a defect in signal transduction pathway remains undetermined. Anesthetized rats were monitored for hemodynamics, and the terminal ileum was prepared for intravital videomicroscopy. Hemorrhage was 50% of mean arterial pressure for 60 min followed by resuscitation with the shed blood returned plus 2 volumes of normal saline. Intestinal microvascular reactivity to the endothelium-dependent receptor-dependent agonists acetylcholine or substance P (10(-8) or 10(-6) M), as well as the endothelium-dependent receptor-independent calcium ionophore, was determined at baseline and at 2 h postresuscitation from hemorrhagic shock. Measured vascular diameters for premucosal A3 arterioles (pA3 and dA3) were normalized and expressed as percentage of the maximal dilation capacity, as obtained from the response to the endothelium-independent NO donor sodium nitroprusside (10(-4) M). At 2 h postresuscitation, there was a marked constriction of pA3 (-70.1 +/- 20) and dA3 (-61.5 +/- 11.6) from maximal dilation capacity. Baseline premucosal arteriolar response to substance P (10(-8) M) was 30.68 +/- 4.19% and 34.66 +/- 5.82% for pA3 and dA3 arterioles, respectively. This was significantly reduced to 20.97 +/- 2.41% and 17.94 +/- 3.60% at 2 h postresuscitation. However, no significant difference between baseline and postresuscitation arteriolar responses was observed at the higher dose of substance P (10(-6) M). Postresuscitation premucosal arteriolar response to the endothelium-dependent receptor-independent calcium ionophore (10(-9) to 10(-5) M) is characterized by a marked decrease in sensitivity and an enhanced threshold for calcium ionophore-mediated dilation. The logEC50 was -7.62 +/- 0.39 and -7.75 +/- 0.32 for the pA3 and dA3 at baseline, respectively. This was significantly (P < 0.01) reduced to -5.15 +/- 0.14 and -4.39 +/- 0.71 at 2 h postresuscitation. These data suggest that impairment of the endothelium-dependent dilation response after resuscitation from hemorrhagic shock is not mediated by specific receptor alteration. Cellular mechanisms that participate in or are part of oxygen free radical formation after resuscitation from hemorrhagic shock such as Ca2+ and leukocytes, appear to have a pivotal role in the mechanism of cellular dysfunction.

View details for Web of Science ID 000188392300014

View details for PubMedID 14752293

Abstract

Intra-abdominal infection is common and frequently seen by the surgeon. Mortality is related to disease acuity and organ failure. This report, based on medical literature and personal experience, is a brief review of this subject, highlighting important historical milestones and recent advances in surgical and antibiotic therapy. Peritonitis remains a clinical challenge. Aggressive resuscitation, diagnostic imaging, and surgical treatment are the mainstays of appropriate therapy. Percutaneous drainage of intra-abdominal collections has increased over time and is particularly helpful in certain postoperative patients. Adjunctive antibiotic therapy against gram-negative aerobes and anaerobes should be limited to a 7- to 10-day course, except in selected patients, such as those with inadequate source controls.

View details for PubMedID 14684221

View details for DOI 10.1067/msy.2003.157

View details for Web of Science ID 000184456700010

View details for PubMedID 12874580

Abstract

To study the effects of peritoneal resuscitation from hemorrhagic shock.Methods for conventional resuscitation (CR) from hemorrhagic shock (HS) often fail to restore adequate intestinal blood flow, and intestinal ischemia has been implicated in the activation of the inflammatory response. There is clinical evidence that intestinal hypoperfusion is a major factor in progressive organ failure following HS. This study presents a novel technique of peritoneal resuscitation (PR) that improves visceral perfusion.Male Sprague-Dawley rats were bled to 50% of baseline mean arterial pressure (MAP) and resuscitated with shed blood plus 2 equal volumes of saline (CR). Groups were 1) sham, 2) HS + CR, and 3) HS + CR + PR with a hyperosmolar dextrose-based solution (Delflex 2.5%). Groups 1 and 2 had normal saline PR. In vivo videomicroscopy and Doppler velocimetry were used to assess terminal ileal microvascular blood flow. Endothelial cell function was assessed by the endothelium-dependent vasodilator acetylcholine.Despite restored heart rate and MAP to baseline values, CR animals developed a progressive intestinal vasoconstriction and tissue hypoperfusion compared to baseline flow. PR induced an immediate and sustained vasodilation compared to baseline and a marked increase in average intestinal blood flow during the entire 2-hour post-resuscitation period. Endothelial-dependent dilator function was preserved with PR.Despite the restoration of MAP with blood and saline infusions, progressive vasoconstriction and compromised intestinal blood flow occurs following HS/CR. Hyperosmolar PR during CR maintains intestinal blood flow and endothelial function. This is thought to be a direct effect of hyperosmolar solutions on the visceral microvessels. The addition of PR to a CR protocol prevents the splanchnic ischemia that initiates systemic inflammation.

View details for Web of Science ID 000185834700023

View details for PubMedID 12724637

Abstract

Enteral feeding improves outcome following surgery. Benefits depend on timing, route (enteral vs parenteral), and nutrient composition (standard vs immune-enhancing diets; IED). IED augments intestinal immunity and stimulates gut blood flow during absorption in a nutrient-specific manner. We hypothesize that a mechanism for the gut protective effect of IED is augmentation of blood flow to the gut-associated lymphoid tissue (GALT) in the terminal ileum.Male Sprague-Dawley rats (200-230 g) were fed for 5 days either an IED (Impact, Novartis) or an isocaloric, isonitrogenous control diet (CD, Boost, Mead-Johnson) matched to the daily caloric intake (rat chow). Rats were then anesthetized and cannulated for microsphere determination of whole organ blood flow. Blood glucose levels and blood flow to abdominal organs were determined at baseline and 30, 60, 90, and 120 min after gastric gavage (2 ml) with IED or CD. Intestinal tissues were harvested for cytokine levels (ELISA: IL-4, IL-10, IFN-gamma, and IgA).Chronic IED increased baseline blood flow in the distal third of the small intestine compared to chow-fed and CD. Baseline blood flow was comparable between IED and CD in all other organs. CD and IED produced different blood flow patterns after gavage. CD increased blood flow compared to baseline and IED in antrum, duodenum, and jejunum. Ileal blood flow remained elevated in IED rats for 2 h, perhaps suggesting maximal blood flow. IED increased blood glucose compared to CD. Chronic IED increased IL-4 and decreased IL-10 in the terminal ileum.Chronic IED exposure increases and sustains ileal blood flow compared to CD with altered proinflammatory cytokine expression. Our data suggest that a mechanism for the IED effect involves the selective perfusion of the terminal ileum and contiguous GALT during IED nutrient absorption.

View details for DOI 10.1006/jsre.2002.6621

View details for Web of Science ID 000183356600007

View details for PubMedID 12788666

Abstract

The use of steady state as the endpoint for performance of indirect calorimetry (IC) is controversial. We designed this prospective study to evaluate the necessity and significance of achieving steady state.Patients with respiratory failure placed on mechanical ventilation in a short- or long-term acute care unit at any 1 of 3 university-based urban hospitals were eligible for the study. The 24-hour total energy expenditure (TEE) was determined by a Nellcor Puritan Bennett 7250 continuous IC monitor. Measured gas exchange parameters were obtained and averaged every 1 minute for the initial hour and then every 15 minutes for the next 23 hours. Over the initial hour, resting energy expenditure (REE) was averaged for intervals over the first 20, 30, 40, and 60 minutes, and for various definitions of steady state where oxygen consumption (VO2) and carbon dioxide production (VCO2) changed by <10%, 15%, and 20%. Coefficient of variation (CV) was calculated for VO2 over the first 30 minutes of study.Twenty-two patients (mean age, 52.8 years, 59% male, mean Acute Physiology and Chronic Health Evaluation (APACHE III) score 42.0) were entered in the study. The best correlation between short-term "snapshot" REE and the 24-hour TEE was achieved by the steady-state period defined by the most stringent criteria (change in VO2 and VCO2 by <10%). The average REE for all steady-state and interval periods correlated significantly to TEE with no significant difference in the absolute values for REE and TEE. Adding 10% for an activity factor to the average REE for each steady-state and interval period again correlated to TEE in a similar fashion with the same R value, but the absolute values for REE + 10% for all steady-state and interval periods were significantly different than the corresponding TEE. In those patients with less variation (CV for VO2 < or = 9.0), the REE obtained for the steady-state period defined by the most stringent criteria still had the best correlation, but similar correlation could be obtained by interval testing of > or = 30-minute duration. In those patients with greater variation (CV for VO2 >9.0), interval testing of at least 60 minutes or more was required to attain levels of correlation similar to that achieved by the steady-state period defined by the most stringent criteria.These data support the use of steady state, best defined as an interval of 5 consecutive minutes whereby VO2 and VCO2 change by <10%. The mean REE from this period correlates best to the 24-hour TEE regardless of CV. IC testing can be completed after achievement of steady state. Activity factors of 10% to 15% should not be added to the steady-state REE, because this practice significantly decreases the accuracy. In patients who fail to achieve steady state, the CV helps to determine the appropriate duration of IC testing. In those patients with a low CV (< or = 9.0), 30-minute test duration is adequate. In patients with CV >9.0, test duration of at least 60 minutes may be required. These latter patients should be considered for 24-hour IC testing.

View details for Web of Science ID 000180422100003

View details for PubMedID 12549593

Abstract

Endothelial cell dysfunction occurs during hemorrhagic shock (HS) and persists despite adequate resuscitation (RES) that restores and maintains hemodynamics. We hypothesize that RES from HS with crystalloid solutions alone aggravate the endothelial cell dysfunction. To test this hypothesis, anesthetized nonheparinized rats were monitored for hemodynamics, and the terminal ileum was studied with intravital video microscopy. HS was 50% of mean arterial pressure (MAP) for 60 min. Four hemorrhaged groups (10 animals in each group) were randomized for RES: group I with shed blood returned + equal volume of normal saline (NS); group II with shed blood returned + 2x NS; group III with 2x NS only; and group IV with 4x NS only. Two hours post-RES, endothelial cell function was assessed with the endothelial-dependent agonist acetylcholine (ACh, 10(-9)-10(-4) M). Maximum arteriolar diameter was elicited by the endothelial-independent agonist sodium nitroprusside (NTP, 10(-4) M). HS caused a selective vasoconstriction associated with low blood flow in inflow A1 arterioles in all hemorrhaged groups. Post-RES vasoconstriction developed in A1 and premucosal arterioles (pA3 and dA3) In all hemorrhaged groups regardless of the RES regimen. However, A1 vasoconstriction and flow were significantly worst in the animals RES with NS alone (-43% and -75%, respectively) compared with those resuscitated with blood and NS (-27% and -57%). Impaired dilation response to ACh was noted in all hemorrhaged animals. However, a significant shift to the right of the dose-response curve (decreased sensitivity) was observed in the animals resuscitated with NS alone irrespective of the RES volume. These animals required at least two orders of magnitude greater ACh concentration to produce a 20% dilation response. For all vessel types, Group II had the best preservation of endothelial cell function. In conclusion, HS causes a selective vasoconstriction of A1 arterioles, which was not observed in A3 vessels. RES from HS results in progressive vasoconstriction in all intestinal arterioles irrespective of the RES regimen. Crystalloid RES after HS does not restore hemodynamics to baseline and is associated with a marked endothelial cell dysfunction. Blood-containing RES regimens preserve and maintain hemodynamics and are associated with the least microvascular dysfunction. Therefore, regimens for RES from HS must contain blood. Endothelial cell dysfunction is not the sole etiologic factor of post-RES microvascular impairment.

View details for DOI 10.1097/01.shk.00000436119685.33

View details for Web of Science ID 000179382500014

View details for PubMedID 12462567

Abstract

After assessing the critically ill patient for risk of aspiration, the clinician still must decide if the patient is ready to be fed. The goal is to identify critically ill patients who are likely to tolerate enteral nutrition and attempt to minimize complications.A synthesis of the both clinical and animal studies to identify factors related to patient readiness for enteral nutrition.The key issue to be resolved is adequacy of resuscitation and restoration of mesenteric perfusion. Currently, there is no reliable clinical tool to measure gut perfusion. The best indicators currently are stabilization of vital signs, decreasing fluid and blood requirements, normalization of the base deficit, and lactate and removal of inotropic or vasopressor support.Most critically ill patients should be ready for enteral nutrition within 24 to 48 hours of intensive care unit admission. Critically ill patients who need catecholamine support, heavy sedation, or therapeutic neuromuscular blockade should probably not receive enteral nutrition until they have been stabilized.

View details for PubMedID 12405625

Abstract

The development of delirium tremens (DT) is associated with significant morbidity and mortality. This study identifies characteristics in trauma patients that are predictive of DT.Data from 1,856 trauma patients who either developed DT (n = 105) or had a positive blood alcohol concentration but did not develop DT (n = 1,751) were collected from the trauma registry of a Level I trauma center. Odds ratios were used to measure the association between predictors and DT as an outcome and between DT and length of stay as an outcome.Of seven significant (p < 0.05) predictors of DT, four were retained after stepwise logistic regression: age >40, white race, burn as a mechanism of injury and, as a negative predictor, motor vehicle collision as a mechanism of injury. The DT group stayed an average of 6.5 and 5.2 days longer in the hospital and the intensive care unit, respectively, than those in the control group.It is possible to determine which intoxicated trauma patients are at increased risk for DT using the above predictors. Patients who develop DT have worse outcomes than those who do not. Whether routine DT prophylaxis would improve outcomes among those at increased risk for DT is unknown, but deserves further study.

View details for DOI 10.1097/01.TA.0000030628.71406.31

View details for Web of Science ID 000179403900016

View details for PubMedID 12435941

Abstract

Current evaluation of patients with negative findings on a focused abdominal sonography for trauma scan and an isolated increase of admission hepatic enzymes includes abdominal computed tomography (CT). Many of these patients do not have clinically important hepatic injuries. The purpose of this study was to establish the admission aspartate aminotransferase (AST) level below which patients do not need an abdominal CT for injury evaluation and treatment.Patients who were hemodynamically stable, had a focused abdominal sonography for trauma scan with negative findings, and an AST level greater than 200 IU/L were identified over a 1-year period. Medical records were reviewed for demographics, injuries sustained, mechanism, evaluation, interventions, and complications.A total of 67 patients, mostly with blunt trauma, were identified; 42 (63%) had an AST level < 360 IU/L, and 25 (37%) had an AST level > 360 IU/L. Patients with an AST level > 360 IU/L had a 88% chance of having any hepatic injury and a 44% chance of having an injury of grade III or greater (P =.0001). Patients with an AST level of < 360 IU/L only had a 14% chance of having a liver injury and no chance of having an injury of grade III or greater (P =.036).Clinically important hepatic injuries are not missed if an abdominal CT is only performed for patients with a focused abdominal sonography for trauma scan with negative findings and an AST level of > 360 IU/L. Eliminating unnecessary CT allows for more cost-effective use of resources.

View details for DOI 10.1067/msy.2002.127556

View details for Web of Science ID 000179023200024

View details for PubMedID 12407348

Abstract

Conventional peritoneal dialysis solutions are vasoactive. This vasoactivity is attributed to hyperosmolality and lactate buffer system. This study was conducted to determine if the vasodilator property of commercial peritoneal dialysis solutions is a global phenomenon across microvascular levels, or if this vasodilation property is localized to certain vessel types in the small intestine.Experimental study in a standard laboratory facility.Hemodynamics of anesthetized rats were monitored while the terminal ileum was prepared for in vivo intravital microscopy. Vascular reactivity of inflow arterioles (A1), branching (A2), and arcade, as well as pre-mucosal (A3) arterioles was assessed after suffusion of the terminal ileum with a non-vasoactive solution or a commercial 4.25% glucose-based solution (Delflex; Fresenius USA, Ogden, Utah, USA). Vascular reactivity of three different level venules was also assessed. Maximum dilation response was obtained from sequential applications of the endothelial-dependent dilator, acetylcholine (10(-5) mol/L), and the endothelial-independent nitric oxide donor, sodium nitroprusside (NTP; 10(-4) mol/L).Delflex induced an instant and sustained vasodilation that averaged 28.2% +/- 2.4% of baseline diameter in five different-level arterioles, ranging in size between 7 mu and 100 mu. No significant vascular reactivity was observed in three different-level venules. Delflex increased intestinal A1 blood flow from baseline 568 +/- 31 nL/ second to 1,049 +/- 46 nL/sec (F= 24.7, p< 0.001). Similarly, intestinal venous outflow increased to 435 +/- 17 nL/sec from a baseline outflow of 253 +/- 59 nL/sec (F= 4.7, p < 0.05). Adjustment of the initial pH of Delflex from 5.5 to 7.4 resulted in similar microvascular responses before pH adjustment.Ex vivo exposure of intestinal arterioles to conventional peritoneal dialysis solutions produces a sustained and generalized vasodilation. This vasoactivity is independent of arteriolar level and the pH of the solution. Dialysis solution-mediated vasodilation is associated with doubling of A1 intestinal arteriolar blood flow. Addition of NTP at an apparent clinical dose does not appear to produce any further significant arteriolar dilation than that induced by dialysis solution alone. Experimental data that estimate the exchange vessel surface area per unit volume of tissue will be required to make a correlation with permeability in order to extrapolate our findings to clinical in vivo conditions.

View details for Web of Science ID 000179256400010

View details for PubMedID 12455570

Abstract

Clinical studies show that immune-enhancing enteral diets (IED; with L-arginine, fish oil, and RNA fragments) decrease the rate of sepsis and shorten the length of hospital stay after the start of enteral feeding. These beneficial effects are dependent on the route of administration (enteral vs parenteral) and on the nutrient composition (IED vs standard diets). Gut exposure to an IED seems to preserve and/or augment intestinal mucosal immunity. However, nutrient absorption stimulates gut blood flow in a nutrient-specific manner (i.e., postprandial hyperemia). We hypothesized that an IED would initiate a different pattern of whole organ blood flow compared to a standard diet. This suggests that a mechanism for the protective effect of IED might be the preferential augmentation of gut blood flow to gut-associated lymphoid tissue (GALT) or mucosa-associated lymphoid tissue (MALT).Male Sprague-Dawley rats (200-225 g) were anesthetized and cannulated for colorimetric microsphere determination of blood flow distribution (with the phantom organ technique). Animals received gastric gavage (2 ml) of an IED (Impact; Novartis) or an isocaloric, isonitrogenous control diet (Boost; Mead-Johnson). Blood flow to the antrum, duodenum, jejunum, ileum, colon, liver, kidneys, and spleen was determined at baseline and 30, 60, 90, and 120 min after gavage.Baseline blood flows to the left and right kidneys were within 10%, indicating the technical integrity of the microsphere technique and assay. Control diet augmented blood flow compared to IED in the antrum, duodenum, jejunum, and spleen. Conversely, IED gavage stimulated a delayed and sustained hyperemic response in the ileum. IED also increased hepatic blood flow early (30 min). IED increased blood glucose levels compared to control diet at 30, 60, and 90 min, suggesting enhanced nutrient absorption.These data show that blood flow distribution depends on nutrient composition and that IED preferentially augments blood flow to the ileum. Since the terminal jejunum and ileum contain much of the GALT, our data suggest that a mechanism for enterally stimulated mucosal immunity involves selective perfusion of the terminal ileum during IED nutrient absorption.

View details for DOI 10.1006/jsre.2002.6424

View details for Web of Science ID 000177260600005

View details for PubMedID 12127804

Abstract

Focused abdominal sonography for trauma (FAST) is an unreliable method for assessing intra-abdominal injury in patients with seat belt marks.Retrospective review of trauma patients with intestinal injury and seat belt marks during a 3-year period. Records were reviewed for patient demographics, FAST results, computed tomographic (CT) scan results, and operative findings. The CT scan results were considered positive if bowel wall thickening, extraluminal air, or free fluid without solid organ injury were present.University hospital designated as a level I trauma center.Twenty-three patients who required operation for intestinal or mesenteric injury and who had an abdominal seat belt mark.Sensitivity of FAST in these patients.All patients were evaluated using both FAST and CT scan of the abdomen and pelvis. Eighteen patients (78%) had either negative or equivocal FAST results when significant intestinal injury was present. All 23 patients had CT scan findings suggestive of bowel or mesenteric injury. Moderate-to-large free intraperitoneal fluid without solid organ injury was the most common finding (n = 21, 91%). Operative findings included small-bowel perforation (n = 18, 78%), colonic perforation (n = 7, 30%), bowel deserosalization (n = 8, 35%), and isolated mesenteric injury (n = 5, 22%). Sixteen patients (70%) had multiple intra-abdominal injuries. All patients were taken directly from the emergency department to the operating room. Seventeen percent of operative explorations (4/23) were nontherapeutic (no repairs required).This study confirms that FAST cannot reliably exclude intestinal injury in patients with seat belt marks.

View details for Web of Science ID 000176045500024

View details for PubMedID 12049544

Abstract

Facial fractures (FF) have been suggested to protect the brain from severe injury. However, others have stated that facial fractures are a marker for increased risk of brain injury. The aim of this study is to evaluate the association between facial fractures, brain injury, and functional outcome. A retrospective review of our prospective trauma database was performed for blunt trauma patients during a 7-year period (January 1993 through December 1999) at the University of Louisville Hospital. We identified 7324 blunt trauma patients at a Level 1 trauma center. Severity of head injury in patients with and without FF was compared. The severity of brain injury was evaluated by admission Glasgow Coma Score (GCS) as well as specific head, neck, cervical spine, and face Acute Injury Score (AIS). Length of intensive care unit (ICU) stay, hospital stay, and Functional Independence Measures (FIM) score were also identified. A total of 1068 (14.6%) patients were diagnosed with FF; of these 848 (79.4%) patients suffered some form of brain injury by CT abnormality, clinical examination, or both. A total of 2192 patients were treated for head injury without FF; 220 patients were treated for FF without head injury. FF with traumatic brain injury (TBI) were found to occur significantly greater than FFs without TBI (P < 0.001). The mean GCS on admission for FF with head injury was 12, which was similar to that of patients with head injury alone with a GCS of 10 but was significantly less than that of patients with FF alone with a GCS of 15 (P < 0.05). Injury Severity Score for patients with FF and head injury was significantly worse compared with patients with head injury alone and those with FF alone (P < 0.0001). Mean ICU stay and hospital stay were similar for all three groups (ranges 3-6 and 6-12 days); and were not significant (P < 0.06). FIM score was significantly lower for patients with FF and head injury compared with FF alone (P = 0.0003) and similar to that of patients with head injury. FF were found to have a significantly greater incidence of TBI. FF with TBI had a similar severity of head injury when compared with patients with head injury alone by demonstrating similar GCS, AIS of the head and neck, and early functional recovery. This analysis does not support the hypothesis that the face provides a protective effect for the brain and therefore leading to a more favorable short-term outcome. Thus patients with facial fractures should be treated with the same caution as patients with significant blunt head trauma.

View details for Web of Science ID 000175432000017

View details for PubMedID 12017150

View details for Web of Science ID 000175650500004

View details for PubMedID 12006415

Abstract

Hospital admission for an alcohol-related traumatic injury may offer a "teachable moment" to address a patient's alcohol problem. Although trauma teams provide a number of other health-related services, there may be characteristics of alcohol-positive victims that act as barriers toward providing alcohol counseling. The purpose of this study was to compare the characteristics and hospital outcomes of trauma patients who tested positive for alcohol at the time of hospital admission with those who did not. This information is useful for planning interventions and referrals for treatment.The study was a retrospective comparison of alcohol-positive and alcohol-negative patients who were admitted for at least 48 hours to a Level-I trauma center. Data from 1,049 trauma victims (736 male, 742 alcohol-negative) were abstracted from clinical records.Several characteristics were found to be associated with alcohol-related injuries: being male, aged 40 years or less, having a toxicology screen positive for illicit drugs, lacking health insurance, being indigent and sustaining an injury related to violence. Alcohol-positive patients were also found to spend fewer days in a critical care unit, to be less likely to die and to be less likely to be transferred to another hospital than alcohol-negative patients, despite having similar injury severity.Patient characteristics suggest that there are obstacles to providing interventions and referrals by healthcare professionals for victims of alcohol-related injuries. Less expensive options that consider the demographic features of this patient population need to be developed as an alternative to expensive, professional interventions.

View details for Web of Science ID 000176296200015

View details for PubMedID 12086139

Abstract

Early diagnosis, expeditious vascular repair, and aggressive management of complications have resulted in an amputation rate of less than 9%. Repair rather than ligation of an associated femoral vein injury is commonly practiced by experienced trauma surgeons. In most circumstances, a reversed autogenous saphenous vein graft from the contralateral extremity is the conduit of choice; however, if a saphenous vein cannot be used because of size discrepancies, multiple associated trauma, or extensive contamination, polytetrafluoroethylene can be used with good results. If vein ligation is performed, early fasciotomy is indicated for close and meticulous monitoring of the compartmental pressures. Clearly, the most crucial components for a successful outcome are a thorough evaluation, early operation, and a flawless vascular repair.

View details for Web of Science ID 000174276100006

View details for PubMedID 11905951

Abstract

Although the use of stapling devices in elective colon surgery has been shown to be as safe as handsewn techniques, there have been concerns about their safety in emergency trauma surgery. The purpose of this study was to compare stapled with handsewn colonic anastomosis following penetrating trauma.This was a prospective multicenter study and included patients who underwent colon resection and anastomosis following penetrating trauma. Multivariate logistic regression analysis was used to identify independent risk factors for abdominal complications and compare outcomes between stapled and handsewn repairs.Two hundred seven patients underwent colon resection and primary anastomosis. In 128 patients (61.8%) the anastomosis was performed with handsewing and in the remaining 79 (38.2%) with stapling devices. There were no colon-related deaths and the overall incidence of colon-related abdominal complications was 22.7% (26.6% in the stapled group and 20.3% in the handsewn group, p = 0.30). The incidence of anastomotic leak was 6.3% in the stapled group and 7.8% in the handsewn group (p = 0.69). Multivariate analysis adjusting for blood transfusions, fecal contamination, and type of antibiotic prophylaxis showed that the adjusted odds ratio (OR) of complications in the stapled group was 0.83 (95% CI, 0.38-1.74, p = 0.63). In a second multivariate analysis adjusting for blood transfusions, hypotension, fecal contamination, Penetrating Abdominal Trauma Index, and preoperative delays the adjusted OR in the stapled group was 0.99 (95% CI, 0.46-2.11, p = 0.99).The results of this study suggest that the method of anastomosis following colon resection for penetrating trauma does not affect the incidence of abdominal complications and the choice should be surgeon's preference.

View details for Web of Science ID 000173449700022

View details for PubMedID 11791061

Abstract

Clinical pathways (CPs) have been shown to be beneficial in optimizing patient care and resource use.A multidisciplinary CP for the treatment of severe traumatic brain injury (Glasgow Coma Scale score of 3-7) was developed. Data from these patients (group I) were collected prospectively and compared with a retrospective database (group II).There were a total of 119 patients managed in conjunction with the CP and 43 patients in the control group. No statistical differences were found between the groups in age, Glasgow Coma Scale score at 24 hours, or Injury Severity Scores. There was a significant decrease in the length of hospital stay, intensive care unit stay, and length of ventilator support in the study group (group I: 22.5, 16.8, and 11.5 days, respectively; group II: 31.0, 21.2, and 14.4 days, respectively; p < 0.03).The use of this CP helped to standardize and improve patient care with fewer complications and a potential cost savings of approximately $14,000 per patient.

View details for Web of Science ID 000170462400024

View details for PubMedID 11493802

Abstract

The factors contributing to a higher mortality rate in elderly thermal injury victims are not well delineated. The purpose of this study is to determine the impact of the initial injury, medical comorbidities, and burn size on patient outcome and to determine a level of injury in this population when comfort care is an appropriate first choice. Individual medical records of patients over 65 years of age admitted to our burn center over a 10-year interval were reviewed for patient demographics, mechanism of injury, total body surface area (TBSA) burned, medical comorbidities, use of Swan-Ganz catheters, evidence of inhalation injury, level of support, and patient outcome. The mechanisms of thermal injury were flame (68%), scald (21%) and electrical or chemical contact (11%). Twenty-six preventable bathing, cooking, and smoking-related injuries were seen (33%). The average TBSA was 25 per cent. Average length of stay varied depending on outcome. The overall mortality rate for this group was 45 per cent. Patients older than 80 years with 40 per cent or greater TBSA burned had a 100 per cent mortality rate despite aggressive treatment. Burn wound size correlated better with probability of poor outcome than age. Thermal injuries in the elderly are becoming more important with the aging of our population. Underlying medical problems--specifically chronic obstructive pulmonary disease--do play a role in increased patient morbidity and mortality. This study shows that age greater than 80 years in combination with burns greater than 40 per cent TBSA are uniformly fatal despite aggressive therapy. We believe that delaying the start of comfort-only measures in this situation only prolongs the pain and suffering for the patient, the family, and the physician.

View details for Web of Science ID 000169609500025

View details for PubMedID 11450794

Abstract

Clinical pathways have been proven to be valuable tools in improving outcomes in patients with neurological diagnoses. However, their use with trauma populations has been limited. The unpredictable nature of trauma makes it difficult to develop a day-by-day plan of care that would be applicable to all patients with the same trauma diagnosis. Nevertheless, a severe traumatic brain injury (TBI) clinical pathway was developed and implemented at a Level 1 Trauma Center with significant reductions in length of stay and number of ventilator days. With the publication of the Guidelines for the Management of Severe Head Injury, this pathway was refashioned into a severe TBI phased-outcome pathway. Rather than a day-by-day plan of care, this clinical pathway consists of four phases of care: (a) admission to the intensive care unit, (b) acute critical care, (c) mobility and weaning, and (d) pre-rehabilitation. After 12 months, the improvements accomplished by the original pathway have been maintained or exceeded.

View details for PubMedID 11326621

Abstract

The frequency of women who have sustained severe injuries has increased over the past 30 years. The purpose of this study was to evaluate whether severely injured women have a survival advantage over men. To address this issue, we undertook a multicenter evaluation of the effects of gender dimorphism on survival in trauma patients.Patient information was collected from the databases of three level I trauma centers. We included all consecutive patients who were admitted to these centers over a 4-year period. We evaluated the effects of age, gender, mechanism of injury, pattern of injury, Abbreviated Injury Score (AIS), and Injury Severity Score (ISS) on survival.A total of 20,261 patients were admitted to the three trauma centers. Women who were younger than 50 years of age (mortality rate 5%) experienced a survival advantage over men (mortality rate 7%) of equal age (odds ratio 1.27, P <0.002). This advantage was most notably found in the more severely injured (ISS >25) group (mortality rate 28% in women versus 33% in men). This difference was not attributable to mechanism of injury, severity of injury, or pattern of injury.Severely injured women younger than 50 years of age have a survival advantage when compared with men of equal age and injury severity. Young men have a 27% greater chance of dying than women after trauma. We conclude that gender dimorphism affects the survival of patients after trauma.

View details for Web of Science ID 000169437800003

View details for PubMedID 11438262

View details for Web of Science ID 000168243200036

View details for PubMedID 11303177

Abstract

Nonoperative management is now regarded as the best alternative for the treatment of patients with complex blunt liver injuries. However, some patients still require surgical treatment for complications that were formerly managed with laparotomy and a combination of image-guided studies.We reviewed the medical records of 15 patients who had complex blunt liver injuries that were managed nonoperatively and in which biliary peritonitis developed.Delayed laparoscopy was performed 2-9 days after admission in patients with extensive liver injuries. All 15 patients had developed local signs of peritonitis or a systemic inflammatory response. Laparoscopy was indicated to drain a large retained hemoperitoneum (eight patients), bile peritonitis (four patients), or an infected perihepatic collection (three patients). Laparoscopy was successful in all patients, and there was no need for further interventions.The data indicate that as more patients with complex liver injuries are treated nonoperatively and the criteria for nonoperative management continue to expand, more patients will need some type of interventional procedure to treat complications that historically were managed by laparotomy. At this point, laparoscopy is an excellent alternative that should become part of the armamentarium of the trauma surgeons who treat these patients.

View details for Web of Science ID 000167977000018

View details for PubMedID 11344437

Abstract

Our aim was to evaluate the impact of cell-saver volume and free hemoglobin load on renal dysfunction. Intraoperative blood salvage was conducted in standard fashion, and in each case a sample of the blood was removed for testing. Outcome data on individual patients were collected during a 6-year period (1992-1998). The total amount of free hemoglobin each patient received was calculated. Renal dysfunction was defined as a rise in creatinine level of 1.0 mg/dL above baseline. There were a total of 125 patients who received salvaged blood. The free hemoglobin concentration ranged from 19 to 304 mg/dL (mean, 87.5 mg/dL). Patients were stratified into groups on the basis of the total free hemoglobin received, and the Kruskal-Wallis test demonstrated a difference between groups in the prevalence of renal dysfunction (P < 0.001). A total of 15 patients (12%) had significant postoperative renal dysfunction. There was an association between the amount of free hemoglobin load and subsequent renal dysfunction. This may warrant further study toward establishing policies and limits regarding maximal free hemoglobin blood.

View details for Web of Science ID 000166594000012

View details for PubMedID 11206896

View details for Web of Science ID 000087080200042

View details for PubMedID 10823548

Abstract

Multiple factors contribute to the development of posttraumatic empyema. These factors include the conditions under which the tube is inserted (emergent or urgent), the mechanism of injury, retained hemothorax, and ventilator care. The incidence of empyema in placebo groups ranges between 0 and 18%. The administration of antibiotics for longer than 24 hours did not seem to significantly reduce this risk compared with a shorter duration, although the numbers in each series were small. Most reports found a significant reduction in pneumonitis when patients received prolonged prophylactic antibiotics. This use of antibiotics might possibly be better described as presumptive therapy rather than prophylactic.

View details for Web of Science ID 000086499900038

View details for PubMedID 10780613

Abstract

Respiratory failure is a common complication among patients sustaining major blunt trauma. This is usually due to the underlying pulmonary injury, pneumonia, or adult respiratory distress syndrome. However, we have frequently found these patients to actually have a pleural process as the cause of their respiratory failure. Our objective was to assess the frequency of empyema and restrictive pleural processes after blunt trauma and their contribution to respiratory failure. We retrospectively reviewed all blunt trauma patients over a 5-year period who required a thoracotomy and decortication for empyema. Twenty-eight patients with blunt trauma required a thoracotomy and decortication for empyema. The most common finding was infected, loculated hemothorax/effusion in 23 patients, whereas 5 had an associated pneumonia. Chest radiographs were nondiscriminating, whereas CT scans in 25 patients showed previously unrecognized fluid collections, air-fluid levels, or gas bubbles. Neither thoracentesis nor placement of additional chest tubes was helpful. Positive cultures were uncommon. Ventilator dependence was present preoperatively in 13 patients who were on the ventilator an average of 13 days preoperatively and only 5.8 days postoperatively. Several patients believed to have adult respiratory distress syndrome were weaned within 72 hours of operation. All patients were ultimately cured. Empyema is an under-recognized complication of blunt trauma and may contribute to respiratory failure and ventilator dependence. Although difficult to diagnose, empyema should be considered in blunt trauma patients with respiratory failure and an abnormal chest radiograph. CT aids in the diagnosis, and the results of surgical treatment are excellent.

View details for Web of Science ID 000085223300022

View details for PubMedID 10695756

View details for PubMedID 10802263

View details for PubMedID 10802258

View details for PubMedID 10802252

View details for PubMedID 10802260

Abstract

To evaluate those factors that impact on the delivery of enteral tube feeding.Prospective study.Medical intensive care units (ICU) and coronary care units at two university-based hospitals.Forty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male) who were to receive nothing by mouth and were placed on enteral tube feeding.Rate of enteral tube feeding ordered, actual volume delivered, patient position, residual volume, flush volume, presence of blue food coloring in oropharynx, and stool frequency were recorded every 4 hrs. Duration and reason for cessation of enteral tube feeding were documented.Physicians ordered a daily mean volume of enteral tube feeding that was 65.6% of goal requirements, but an average of only 78.1% of the volume ordered was actually infused. Thus, patients received a mean volume of enteral tube feeding for all 339 days of infusion that was 51.6% of goal (range, 15.1% to 87.1%). Only 14% of patients reached > or = 90% of goal feeding (for a single day) within 72 hrs of the start of enteral tube feeding infusion. Of 24 patients weighed before and after, 54% were noted to lose weight on enteral tube feeding. Declining albumin levels through the enteral tube feeding period correlated significantly with decreasing percent of goal calories infused (p = .042; r2 = .13). Diarrhea occurred in 23 patients (52.3%) for a mean 38.2% of enteral tube feeding days. In >1490 bedside evaluations, patients were observed to be in the supine position only 0.45%, residual volume of >200 mL was found 2.8%, and blue food coloring was found in the oropharynx 5.1% of the time. Despite this, cessation of enteral tube feeding occurred in 83.7% of patients for a mean 19.6% of the potential infusion time. Sixty-six percent of the enteral tube feeding cessations was judged to be attributable to avoidable causes.The current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support. Barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings.

View details for Web of Science ID 000081906300003

View details for PubMedID 10446815

Abstract

Postprandial intestinal hyperemia is a complex vascular response during nutrient absorption. Many mediators have been studied including enteric reflexes, GI hormones, and absorption-stimulated metabolic mediators such as pH and adenosine. We have shown that nitric oxide (NO) mediates premucosal arteriolar dilation during glucose absorption and that glucose-induced portal vein NO metabolite production requires adenosine A2b receptor activation. We hypothesize that Na+-linked absorption of l-glutamine or l-glycine might also stimulate NO release in the enteroportal circulation via adenosine A2b receptors.Male Sprague-Dawley rats (190-220 g) were anesthetized with urethane/alpha-chloralose and cannulated for hemodynamic monitoring and blood sampling. A right paramedian abdominal incision was made for access to both the stomach (gavage) and the portal vein (blood sampling). Animals received intragastric nutrient gavage (saline, d-glucose, l-glutamine, racemic glycine, or oleic acid) with and without adenosine A2b receptor blockade. NO metabolites (NOx) were measured by a fluorescent modified-Greiss assay at baseline and 30 min after nutrient gavage.Glucose and glutamine gavage increased portal NOx levels compared to baseline, while glycine and oleic acid gavage did not. Adenosine A2b antagonism returned NOx levels to baseline in both glucose and glutamine gavage animals, but did not alter portal NOx levels in glycine- or oleic acid-treated animals.These data suggest that nutrient-induced adenosine is involved in a signaling process from the intestinal epithelium to nitric oxide-producing cells elsewhere in the vasculature. Adenosine A2b receptors are required for NO production during Na+-linked glucose or glutamine absorption.

View details for Web of Science ID 000080571200011

View details for PubMedID 10334890

Abstract

Allowing a patient's nutritional state to deteriorate through the perioperative period adversely affects measureable outcome related to nosocomial infection, multiple organ dysfunction, wound healing, and functional recovery. Careful preoperative nutritional assessment should include a determination of the level of stress, an evaluation of the status of the GI tract, and the development of specific plans for securing enteral access. Patients already demonstrating compromise of nutritional status (defined by > 10% weight loss and serum albumin level < 2.5 g/dL) should be considered for a minimum of 7 to 10 days of nutritional repletion prior to surgery. Widespread use of total parenteral nutrition in unselected patients is unwarranted, may actually worsen outcome, and should be reserved for preoperative nutritional support only in severely malnourished patients in whom the GI tract is unavailable. Compared with the parenteral route, use of perioperative enteral feeding has been shown to provide more consistent and beneficial results, and can be expected to promote specific advantages in long-term morbidity and mortality.

View details for Web of Science ID 000080356600008

View details for PubMedID 10331336

Abstract

The "two-hit" theory of multiple organ dysfunction (MOD) proposes that an initial insult, such as hemorrhage (HEM), primes the host for an abnormal response to a second stress such as infection. The immunologic/inflammatory component of this theory has been well examined; however, the effects on vascular responsiveness are poorly understood. We hypothesized that HEM primes the vasculature for an altered response to a second pathophysiologic stress.Male Sprague-Dawley rats underwent a fixed-volume HEM with resuscitation (H/R) or sham procedure (Sham). At 48 h, animals were given iv E. coli or saline and followed for 1 h. Thoracic aortic rings were then placed in organ baths containing Krebs buffer aerated with 95% O2, 5% CO2. Cumulative dose-response curves to phenylephrine (PHE) and acetylcholine (ACH) were obtained. Maximum force of contraction (Fmax) was measured and pD2 values (receptor sensitivity) were derived.H/R alone resulted in heightened constrictor tone and blunted dilator tone. E. coli reduced Fmax in response to PHE by 50% in Sham vs 76% in H/R. Receptor sensitivity (pD2) to PHE was reduced to a greater degree in H/R (3-fold vs 2-fold). These animals also had a more pronounced enhancement of ACH receptor sensitivity (7-fold vs 2-fold).Hemorrhage primes the vasculature for an altered response to a subsequent stress. When infection is added as a "second hit," responsiveness to adrenergic agents is diminished and dilator tone is increased. These data may explain the cardiovascular derangements seen clinically in patients who develop MODS after major hemorrhage followed sequentially by infection.

View details for Web of Science ID 000078358200013

View details for PubMedID 9889059

Abstract

Following resuscitation (RES) from hemorrhagic shock (HEM), intestinal microvessels develop progressive vasoconstriction that impairs mucosal blood flow, despite central hemodynamic RES. These events might have clinical consequences secondary to occult intestinal ischemia. We hypothesized that the microvascular impairments were due to progressive endothelial cell dysfunction and an associated reduction in the dilator, nitric oxide (NO), following HEM/RES. Male Sprague-Dawley rats, were monitored for central hemodynamics and the terminal ileum was studied with in vivo videomicroscopy. HEM was 50% of baseline mean arterial pressure (MAP) for 60 min, and RES was with shed blood + 1 volume of normal saline (NS). Following HEM/RES, acetylcholine (10)(-7), 10(-5) M) was topically applied and ileal inflow (A1) and premucosal arteriolar diameters were measured to assess endothelial-cell function at 60 and 120 min post-RES. Normalization of MAP, cardiac output, and heart rate demonstrated adequate systemic resuscitation. Post-RES vasoconstriction developed in A1 (-25%) and premucosal (-28%) arterioles with an associated reduction in A1 flow (-47%). However, there was a selective impairment of endothelial-dependent dilation that was manifested only in the smaller premucosal arterioles and not in the inflow, A1 arterioles. This suggests that multiple mechanisms are involved in the development of the post-RES vasoconstriction. The premucosal response was likely mediated by endothelial cell dysfunction, while the A1 response was probably the result of enhanced vasoconstrictor forces. This early microvascular dysfunction might contribute to the late sequelae of intestinal ischemia and might alter microvascular responses to subsequent systemic insults.

View details for Web of Science ID 000077413700007

View details for PubMedID 9872681

Abstract

Small intestine microvascular vasoconstriction and hypoperfusion develop after resuscitation (RES) from hemorrhage (HEM), despite restoration of central hemodynamics. The responsible mechanisms are unclear. We hypothesized that the microvascular impairment following HEM/RES was due to decreased intestinal microvascular nitric oxide (NO) production.Male Sprague-Dawley rats (195-230 g) were utilized and three experimental groups were studied: (1) SHAM (cannulated but no HEM), (2) HEM only, and (3) HEM/RES. HEM was to 50% of baseline mean arterial pressure for 60 min, and RES was with shed blood and an equivalent volume of saline. Ex vivo isolated intestinal perfusion and a fluorometric modification of the Greiss reaction were used to quantify production of NO metabolites (NOx). Perfusate von Willebrand factor (vWF) was used as an indirect marker of endothelial cell activation or injury. To assess the degree of NO scavenging by oxygen-derived free radicals, immunohistochemistry was used to detect nitrotyrosine formation in the intestine.Intestinal NOx decreased following HEM/RES (SHAM 1.35 +/- 0.2 mM vs HEM/RES 0.60 +/- 0.1 mM, P < 0.05), but not with HEM alone (1.09 +/- 0.3 mM). There were no differences in serum NOx levels between the three groups. Release of vWF was increased during the HEM period (SHAM 0.18 +/- 0.1 g/dl vs HEM 1.66 +/- 0.6 g/dl, P < 0.05). There was no detectable nitrotyrosine formation in any group.Intestinal NO metabolites decrease following HEM/RES. Elevated vWF levels during HEM and the lack of detectable nitrotyrosine suggest that this is due to decreased endothelial cell production of NO. HEM/RES-induced endothelial cell dysfunction may contribute to persistent small intestine post-RES hypoperfusion and vasoconstriction.

View details for Web of Science ID 000076737300016

View details for PubMedID 9790822

Abstract

Complement, a nonspecific immune response, is activated during hemorrhage/resuscitation (HEM/RES) and is involved in cellular damage. We hypothesized that activated complement injures endothelial cells (ETCs) and is responsible for intestinal microvascular hypoperfusion after HEM/RES.Four groups of rats were studied by in vivo videomicroscopy of the intestine: SHAM, HEM/RES, HEM/RES + sCR1 (complement inhibitor, 15 mg/kg intravenously given before resuscitation), and SHAM + sCR1. Hemorrhage was to 50% of mean arterial pressure for 60 minutes followed by resuscitation with shed blood plus an equal volume of saline. ETC function was assessed by response to acetylcholine.Resuscitation restored central hemodynamics to baseline after hemorrhage. After resuscitation, inflow A1 and premucosal A3 arterioles progressively constricted (-24% and -29% change from baseline, respectively), mucosal blood flow was reduced, and ETC function was impaired. Complement inhibition prevented postresuscitation vasoconstriction and gut ischemia. This protective effect appeared to involve preservation of ETC function in the A3 vessels (SHAM 76% of maximal dilation, HEM/RES 61%, HEM/RES + sCR1 74%, P < .05).Complement inhibition preserved ETC function after HEM/RES and maintained gut perfusion. Inhibition of complement activation before resuscitation may be a useful adjunct in patients experiencing major hemorrhage and might prevent the sequelae of gut ischemia.

View details for Web of Science ID 000076320400026

View details for PubMedID 9781002

Abstract

The usefulness of clinical pathways for the complex trauma patient is unclear. We analyzed the effect of a clinical pathway for severe traumatic brain injury (TBI) on resource utilization.A clinical pathway for severe TBI (Glasgow Coma Scale (GCS) score < or = 8 at 24 hours) was developed by a multidisciplinary team and used for all patients with severe TBI. Data were gathered prospectively for 15 months and compared with data from historical controls from the previous year. Patients who survived < 48 hours were excluded.The clinical pathway was used for 84 patients with severe TBI and compared with 49 historical controls. No differences in Injury Severity Scores (27 vs. 27) or GCS scores at 24 hours (6.2 vs. 6.5) existed between control or pathway patients. There was an overall increase in the mortality rate of pathway patients (from 12.2 to 21.4%), but this was entirely attributable to withdrawal of care that was initiated by family members in patients with an average age of 71 years, an average GCS score of 4.7, and an average Injury Severity Score of 29. Among survivors, pathway patients had a significant decrease in ventilator days (11.5 +/- 0.9 vs. 14.6 +/- 1.2; p < 0.05), intensive care unit days (16.7 +/- 1.0 vs. 21.2 +/- 1.4; p < 0.05), and hospital days (23.4 +/- 1.2 vs. 31.0 +/- 3.0; p < 0.05). There were no differences in the incidence of complications or functional outcomes.The use of a clinical pathway for severe TBI resulted in a significant reduction in resource utilization. This study suggests that clinical pathways may be a useful component of patient care after blunt trauma.

View details for Web of Science ID 000074883200025

View details for PubMedID 9680020

Abstract

Patients with severe pancreatitis, characterized by multiple organ failure and pancreatic necrosis on CT scan (identified by an Acute Physiology and Chronic Health Evaluation II score of > or = 10 with > or = 3 Ranson criteria), most likely require aggressive nutritional support. Use of the enteral route of feeding may help contain the hypermetabolic stress response, reduce morphologic change and atrophy of the gut, and theoretically decrease late complications of nosocomial infection and organ failure. Evidence that decreasing degrees of stimulation of the pancreas occur as the site of feeding descends in the gastrointestinal tract and evidence from perspective, randomized trials suggest that jejunal feeding appears at least as safe and well tolerated as total parenteral nutrition in acute pancreatitis.

View details for Web of Science ID 000074367400009

View details for PubMedID 9650025

Abstract

The objective was to determine intestinal microvascular endothelial cell control after sequential hemorrhage and bacteremia.Sepsis that follows severe hemorrhagic shock often results in multiple system organ failure (MSOF) and death. The sequential nature of this clinical scenario has led to the idea of a "two-hit" theory for the development of MSOF, the hallmark of which is peripheral vasodilation and acidosis. Acute bacteremia alone results in persistent intestinal vasoconstriction and mucosal hypoperfusion. Little experimental data exist to support the pathogenesis of vascular dysregulation during sequential physiologic insults. We postulate that hemorrhagic shock followed by bacteremia results in altered microvascular endothelial cell control of dilation and blood flow.Rats underwent volume hemorrhage and resuscitation. A sham group underwent the vascular cannulation without hemorrhage and resuscitation, and controls had no surgical manipulation. After 24 and 72 hours, the small intestine microcirculation was visualized by in vivo videomicroscopy. Mean arterial pressure, heart rate, arteriolar diameters, and A1 flow by Doppler velocimetry were measured. Endothelial-dependent dilator function was determined by the topical application of acetylcholine (ACh). After 1 hour of Escherichia coil bacteremia, ACh dose responses were again measured. Topical nitroprusside was then applied to assess direct smooth muscle dilation (endothelial-independent dilator function) in all groups. Vascular reactivity to ACh was compared among the groups.Acute bacteremia, with or without prior hemorrhage, caused significant large-caliber A1 arteriolar constriction with a concomitant decrease in blood flow. This constriction was blunted at 24 hours after hemorrhage but was restored to control values by 72 hours. There was a reversal of the response to bacteremia in the premucosal A3 vessels, with a marked dilation both at 24 and 72 hours. The sequence of hemorrhage and E. coli resulted in a progressive enhanced reactivity to the endothelial-dependent stimulus of ACh in the A3 vessels at 24 and 72 hours. Reactivity to endothelial-independent smooth muscle relaxation and subsequent vessel dilation was similar for all groups.These data indicate that there is altered endothelial control of the intestinal microvasculature after hemorrhage in favor of enhanced dilator mechanisms in premucosal vessels with enhanced constrictor forces in inflow vessels. This enhanced dilator sensitivity is most evident in small premucosal vessels. This experimental finding supports the premise that an initial pathophysiologic stress alters the subsequent microvascular blood flow responses to systemic inflammation. These changes in the intestinal microcirculation are in concert with the "two-hit" theory for MSOF.

View details for Web of Science ID 000074163300015

View details for PubMedID 9637548

Abstract

Multiple-trauma patients are at increased risk for deep venous thrombosis (DVT) but are also at increased risk of bleeding, and the use of heparin may be contraindicated. Sequential pneumatic compression devices (SCDs) are an alternative for DVT prophylaxis. However, lower extremity fracture or soft tissue injury may preclude their use. In these circumstances, foot pumps (FPs) are often substituted, yet little clinical data exist to support their use. We identified 184 consecutive high-risk trauma patients who received DVT prophylaxis with compression devices. We reviewed demographic data, mechanism of injury, Injury Severity Score, injury pattern, and method of prophylaxis. Generally, SCDs were preferred, but FPs were substituted in patients with lower extremity injuries. Occurrences of DVT or pulmonary embolism were also noted. Patients surviving less than 48 hours were excluded. SCDs were used in 118 patients (64%) and FPs in 66 patients (34%). There were no differences in age, Injury Severity Score, or presence of shock on admission. As expected, FP patients were more likely to have lower extremity fractures (65 vs 26%; P < 0.05) and were also more likely to have associated pelvic fracture (59 vs 25%; P < 0.05) and chest injury (61 vs 26%, P < 0.05). There was no difference in the incidence of head injury, although SCD patients had more severe head injuries (Glasgow Coma Score, 7.9 vs 10.5; P < 0.05). The overall incidence of DVT was 5.4 per cent (10 of 184), with no differences between the two groups (SCD 7% vs FP 3%). Three patients had a pulmonary embolism (FP, two; SCD, one), none of which were fatal. Compression devices provide adequate DVT prophylaxis with a low failure rate (3-8%) and no device-related complications. FPs appear to be a reasonable alternative in the high-risk trauma patient when lower extremity fractures precludes use of SCD.

View details for Web of Science ID 000073855100006

View details for PubMedID 9619172

Abstract

Persistent posttraumatic pneumothorax (PPP) is an uncommon complication of traumatic injuries of the chest, usually managed with suction drainage and involving prolonged hospital stays. This study was conducted to assess the advantages of using video-assisted thoracoscopic surgery (VATS) in the management of patients with PPP.Eleven patients with PPP underwent VATS for diagnosis and for definitive treatment.Before VATS was done, all patients had undergone multiple attempts to resolve the PPP; the hospital stay before VATS was 10 days (range, 4-14 days). In 10 patients, the cause of the PPP was identified and a segmental stapled resection was performed, with complete success in resolving the air leak and obtaining pleural synthesis. In another patient, the source of the air leak was not identified and a thoracoscopically assisted chemical pleurodesis was performed, with immediate cessation of the air leak. All chest tubes were removed within 48 hours of the procedure; 9 patients were discharged within 72 hours of VATS. Preoperative computed tomography of the chest was useful in 2 patients, but bronchoscopy did not disclose any major airway injury.Videothoracoscopy is an accurate, safe, and reliable alternative to an open thoracotomy in the management of patients with PPP. In the patients in whom the procedure was completed, excellent results were obtained and the hospital stay was reduced. We believe that VATS should be used earlier and more frequently after failure of conservative management in such patients.

View details for Web of Science ID 000073986300004

View details for PubMedID 9632149

Abstract

The high mortality and morbidity rates after iliac vessel injuries remain a challenging problem for trauma surgeons. Several controversial issues surround the management of iliac vessel injuries, including the value of abbreviated laparotomy, the role of extra-anatomic bypass reconstruction (EABR), the use of vascular prostheses in the presence of contamination, and the need and timing for fasciotomy.Retrospective review of the records of patients who sustained an injury to the iliac vessel between 1987 and 1996.A total of 64 patients were treated, including 23 with isolated iliac vein injuries, 17 with arterial injuries, and 24 with combined arteriovenous injuries. Vascular prostheses were placed in 17 patients with arterial injuries, including 12 with associated intestinal wounds. Graft infection did not occur. Of the 24 patients with combined injuries, 11 underwent abbreviated laparotomy and 1 died. Five deaths, however, occurred in 13 patients in whom no attempts were made for damage control laparotomy. Significant differences between survivors and nonsurvivors included final arterial pH, final prothrombin time, length of hypotension, and number of transfusions. Arterial ligation with EABR was performed in five patients and failed in two. Deep venous thrombosis and pulmonary embolism occurred in four patients, in three of them after venous injuries were ligated. The overall mortality rate was 23%.Our findings show that (1) abbreviated laparotomy reduces mortality in iliac injuries; (2) EABR should be performed early after stabilization to prevent limb ischemia; (3) the use of vascular prostheses with associated intestinal injuries did not appear to increase the incidence of graft infection; and (4) after vein ligation, early fasciotomy and prophylaxis against extremity swelling, deep venous thrombosis, and pulmonary embolism should be considered.

View details for Web of Science ID 000074164600020

View details for PubMedID 9637158

Abstract

To examine the relationship between annual trauma volume per surgeon and years of attending experience with outcome in a Level I trauma center with a large panel of trauma attending surgeons.The outcomes of trauma patients were examined in 1995 and 1996 in relationship to surgeon annual trauma volume and years of experience. Outcome variables studied included overall mortality, mortality stratified by Trauma and Injury Severity Score, mortality in patients with an Injury Severity Score greater than 15, and preventable or possibly preventable deaths. Morbidity outcomes examined were overall complication rate and length of stay per attending surgeon. Additionally, five difficult problems were evaluated for critical management decisions by the attending surgeons, and these outcomes were correlated to annual volume and experience.There was no difference in outcome in either morbidity or mortality that correlated with annual volume of patients treated or years of experience. Critical management errors occurred sporadically and were not related to volume or experience.Outcome after trauma seemed to be related to severity of injury rather than annual volume of cases per surgeon. Although our results may not be applicable to other institutions, they should urge caution in adopting and promulgating volume requirements for individual attending surgeons in trauma centers.

View details for Web of Science ID 000072317300005

View details for PubMedID 9498496

Abstract

Intestinal mucosal hypoperfusion and loss of barrier function during sepsis may contribute to maintaining the septic state. Free radicals are produced during sepsis and antioxidants improve survival from experimental sepsis. It is unclear whether endothelial cell injury from free radicals results in altered microvascular reactivity. Lazaroids are antioxidants which scavenge radicals and block lipid radical chain reactions. The authors sought to determine whether lazaroids altered the intestinal microvascular responses to sepsis.In vivo video microscopy was used to study the ileal microcirculation of the rat. A1 (inflow) arteriolar diameter and flow, A3 (premucosal) arteriolar diameters, and cardiac output were measured. Lazaroid or vehicle was infused before a bolus injection of live Escherichia coli or saline.Lazaroid alone had no effect on the intestinal vessels or haemodynamics. E. coli caused vasoconstriction (A1, -21 per cent, A3, -19 per cent of baseline) and hypoperfusion (-36 per cent) despite increased cardiac output (+31 per cent). Lazaroid significantly attenuated both constriction (A1, -11 per cent; A3, 10 to -1 per cent) and hypoperfusion (-15 per cent), but did not increase cardiac output (30 per cent).E. coli bacteraemia led to intestinal vasoconstriction and hypoperfusion. Lazaroid reduced this effect without altering central haemodynamic responses, suggesting that free radicals have a deleterious effect on the intestinal microcirculation during bacteraemia.

View details for Web of Science ID 000071214800018

View details for PubMedID 9448623

Abstract

The hemodynamic effects of sepsis have been attributed in part to increased nitric oxide (NO) production and activation of guanylate cyclase, resulting in increased cGMP and relaxation of vascular smooth muscle. Heme oxygenase-1 (HO-1), a heat shock protein, has been shown to increase intracellular cGMP levels by formation of carbon monoxide (CO). We hypothesized that HO may be an important mediator of the hepatic response to infection. Male Swiss Webster mice underwent standard cecal ligation and puncture (CLP, 18 gauge 2X) or sham operation, and received either normal saline (NS) or Zn protoporphyrin IX (ZN PP IX), a competitive HO inhibitor (n = 6-8/group). Hepatic tissue samples were collected at 3, 6, 12, and 24 hr from separate mice. Serum was collected at 3 and 24 hr. A semiquantitative reverse transcriptase polymerase chain reaction method was used to measure HO-1 mRNA levels. Hepatic cGMP levels were measured by ELISA. Groups were repeated (n = 10/group) to assess mortality. Serum was collected at 3 and 24 hr to measure serum aspartate aminotransferase (AST) levels. HO-1 mRNA expression increased significantly by 3 hr after CLP and with HO inhibition alone (P < 0.05 vs sham + NS). HO-1 mRNA remained elevated through 24 hr. CLP animals with HO inhibition showed a significant reduction of hepatic cGMP following CLP compared with CLP + saline at 24 hr (P < 0.05). Mortality was significantly increased in the CLP + ZN PP group at 24 hr (P < 0.05 CLP NS vs CLP ZN PP). CLP caused a marked increase in AST activity, which was increased further with HO inhibition. HO-1 mRNA expression was induced by CLP. AST levels following CLP were markedly increased with HO inhibition. HO-1 function appeared to contribute to elevation of hepatic cGMP during peritonitis and may be an important hepatic adaptive response to infection.

View details for Web of Science ID A1997XR04000002

View details for PubMedID 9271271

View details for Web of Science ID A1997XN91700036

View details for PubMedID 9253923

Abstract

To study the hypothesis that fluid resuscitation alters cytokine gene expression after experimental murine peritonitis.Mice underwent cecal ligation and puncture (CLP) to induce peritonitis and were randomized to receive variable amounts of normal saline (0, 0.25, 1.0 ml. subcutaneously) and serum (0 or 0.1 mL) after operation. Hepatic and small intestinal (ileal) tissue were harvested at 3 or 6 hours after CLP, and total tissue RNA was extracted. Reverse transcriptase polymerase chain reaction was used to provide relative quantitation of tumor necrosis factor-alpha and interleukin (IL)-1 beta messenger RNA (mRNA) compared with beta-actin.CLP without resuscitation resulted in significant increases in hepatic tumor necrosis factor-alpha mRNA (1190% at 6 hours compared with normal animals), and IL-1 beta mRNA (1475%), and intestinal IL-1 beta mRNA (1243%). Volume administration attenuated cytokine expression at both 3 and 6 hours, and saline seemed to have more potent effects than serum. The volume of resuscitation correlated with survival at 18 hours. Survival in the saline (1 mL) + serum group was 90% at 18 hours compared with 20 to 40% in the groups with little or no resuscitation. Overall, there were no survivors at 30 hours.Fluid resuscitation (amount, composition, timing) should be an important consideration in the utilization of experimental infection models. Furthermore, optimization of the patient's intravascular volume status during sepsis may have important effects on immune responses, in addition to improving hemodynamic variables.

View details for Web of Science ID A1996VL84800005

View details for PubMedID 8858019

Abstract

Complex thoracic injuries are a leading cause of death in trauma patients. Four difficult problems of diagnosis and treatment are discussed, including (1) air leak not associated with pneumothorax, (2) management of major thoracic esophageal injuries, (3) penetrating trauma, and (4) retained hemothorax and empyema.

View details for Web of Science ID A1996VC95500007

View details for PubMedID 8782470

Abstract

Bacteremia leads to rapid intrarenal vasoconstriction, mediated by endogenous vasoconstrictors such as TXA2 and endothelin. These changes occur before the onset of neutrophil adherence, platelet aggregation, or increases in proinflammatory cytokines. Pentoxifylline (PTX) increases red cell deformability, reduces neutrophil adhesion, abrogates rises in TNFalpha, and lessens the deleterious effects of other cytokines during prolonged sepsis. PTX also improves renal function in models of established sepsis, but the specific mechanisms of this effect are unclear. Because PTX is a relatively selective visceral vasodilator we sought to determine whether PTX improves renal microvascular hypoperfusion during bacteremia and whether the mechanism involves altered vascular reactivity. Rat hydronephrotic kidneys were studied by videomicroscopy. Interlobular (ILA) arteriolar diameter and flow, afferent (AFF) and efferent (EFF) arteriolar diameters, and cardiac output (CO) were measured at 15-min intervals for 120 min. PTX was infused alone or prior to a bolus injection of live Escherichia coli. The responses were compared to controls infused with equivalent volumes of normal saline alone. PTX led to improved renal blood flow and to pre- and postglomerular vasodilatation. This improvement remained significant compared to bacteremic animals throughout the period of observation. We conclude that PTX improves renal blood flow during bacteremia due to pre- and postglomerular vasodilation. These responses may be a consequence of increased intracellular cAMP and release of vasodilator prostanoids.

View details for PubMedID 8661165

Abstract

Endothelins (ET) have been demonstrated to mediate intestinal microvascular constriction during acute Escherichia coli bacteremia, however, their role during chronic infection is unknown. The purpose of this study was to determine whether ET-1 is synthesized in the small intestine in a more chronic peritonitis model. ET-1 mRNA levels of the terminal ileum in mice following cecal ligation and puncture (CLP) were compared to sham-operated animals and normal unoperated animals. ET gene expression was analyzed using differential reverse transcriptase chain reaction (RT-PCR) with co-amplification of beta-actin as an internal standard. To assess ET peptide expression, serum and intestinal tissue levels were measured using a specific enzyme immunoassay (ELISA). The pattern of ET-1 gene expression post-CLP with a single puncture of the cecum with a 23 ga. needle demonstrated a 3.6-fold increase at 8 h, and a return to sham levels by 24 h (374 +/- 64% at 8 h, p < .05, 128 +/- 13%). An increase of mRNA levels at 24 h post-CLP was observed with a double puncture with an 18 ga. needle (230 +/- 36%, p < .05) accompanied by an increase in serum ET levels (270 +/- 31%, p < .05) and higher tissue ET levels. These data indicate a time-dependent response of ET-1 gene expression in the terminal ileum post-CLP which is related to severity of infection.

View details for Web of Science ID A1995TJ33800004

View details for PubMedID 8608397

Abstract

Early enteral nutrition is reported to improve outcome of patients with severe closed head injuries (CHI). The efficacy and safety of nasoenteric tube (NET) feeds, however, has been questioned; the risk of aspiration is the major concern. Our purpose was to determine the rate of transpyloric migration, the efficacy of adjunctive measures to promote passage, and the effect on pulmonary complications. Seventy-four consecutive patients with moderate to severe CHI received enteral nutrition. Glasgow Coma Scale (GSC) score was 5.2 on admission and 6.9 at 48 hours. NETs were placed an average of 5.6 days after admission; an average of three abdominal films per patient were used to assess tube position. No patients had endoscopic NET placement during this period. Ten patients required fluoroscopic placement after failure to pass spontaneously by 5 days. Overall, transpyloric passage was achieved in 32 patients (43%), whereas 42 (57%) remained intragastric. There were no differences between the postpyloric and intragastric groups in days to full feeding (5 vs. 7 days), ventilator days (11.9 vs. 12.5), intensive care unit length of stay (15.5 vs. 15.1), or incidence of pneumonia (81 vs. 69%) or aspiration (6 vs 7%). Sixty-two patients (83%) were transferred to extended care facilities and 50 (68%) were still receiving NET feedings. Spontaneous transpyloric passage of NET occurred in less than one-half of patients with severe CHI. The routine use of adjunctive measures to promote transpyloric passage was not particularly successful, had no obvious benefit, and therefore may not be necessary.

View details for Web of Science ID A1995TL90500015

View details for PubMedID 7500401

Abstract

Resuscitation (RES) after hemorrhage (HEM) results in persistent arteriolar constriction and hypoperfusion of the small intestine (SI) despite restoration of mean arterial pressure (MAP) and cardiac output (CO) to normal values. We postulated that increased adrenergic activity contributes to this vasoconstriction and impairment of flow. A loop of SI from decerebrate rats was exteriorized and suffused with Krebs' solution (37 degrees C, pH 7.4). In initial experiments, the effectiveness of alpha-adrenergic receptor antagonism by phentolamine (PHEN) was assessed. Subsequent groups received either topical PHEN (10(-6) M, n = 6) or saline (n = 6) in the suffusion and were then bled to 50% baseline (BL) MAP for 60 min and resuscitated to BL with shed blood/lactated Ringer's. Intravital microscopy and optical Doppler velocimetry were used to measure large (A1) and small, premucosal (A3) arteriolar diameters and RBC velocity; microvascular blood flow was calculated. MAP and transpulmonary CO were measured. During HEM, control animals developed A1 constriction and hypoperfusion with A3 arteriolar dilation. PHEN treatment prevented A1 constriction and enhanced A3 dilation but did not improve flow. Immediately after RES in controls, microvascular diameters and A1 flow returned to BL; however, over the 2-hr post-RES period there was progressive A1 and A3 vasoconstriction and hypoperfusion despite maintenance of BL MAP and CO. After RES in PHEN-treated animals, A1 flow returned to BL, but progressive hypoperfusion was only partially prevented. alpha-Adrenergic-mediated vasoconstriction contributes to intestinal hypoperfusion after HEM, but other mechanisms are also involved in microvascular responses during RES.(ABSTRACT TRUNCATED AT 250 WORDS)

View details for Web of Science ID A1995RN70200010

View details for PubMedID 7637345

Abstract

Nephrotoxicity caused by cyclosporin A (CSA) is the result of vasoconstriction of the renal microcirculation. The endothelium-derived relaxing factor nitric oxide (NO) regulates microvascular blood flow in various tissues, and mediates the microcirculatory response during hypertension and sepsis. This study investigated the role of NO in CSA-induced renal vasoconstriction. Hydronephrotic kidneys in rats were suspended in an environmentally controlled tissue bath, and interlobular, afferent and efferent arteriolar diameters and blood flow were measured by in vivo videomicroscopy. CSA was administered alone, with the nitric oxide synthase (NOS) inhibitor N omega-nitro-L-arginine methyl ester (L-NAME) or with exogenous NOS substrate L-arginine. CSA significantly constricted the whole of the renal microvasculature whereas L-NAME alone preferentially constricted the preglomerular vessels. L-Arginine reversed the vasoconstriction induced by CSA whereas L-NAME had no further effect. Preglomerular basal vascular tone is dependent on continuous production of NO and alterations in the L-arginine-NO pathway contribute to CSA-induced renal vasoconstriction.

View details for Web of Science ID A1995QH07300016

View details for PubMedID 7749687

View details for PubMedID 7852823

Abstract

To determine whether arachidonic acid metabolites are mediators of regional blood flow changes during sepsis, we examined the effects of cyclooxygenase blockade on intestinal microvascular diameters and blood flow during acute bacteremia, induced in the rat by the intravenous injection of 10(9) live Escherichia coli. Mean arterial pressure, cardiac output, intestinal microvascular diameters, and blood flow were measured in the presence or absence of a topically applied selective cyclooxygenase inhibitor (mefenamate). Bacteremia caused a diffuse constriction of both arterioles and venules and a concomitant 50% decrease in blood flow. Treatment with mefenamate did not affect baseline intestinal microvascular tone or bacteremia-induced arteriolar constriction and hypoperfusion, but did reverse an intense venular constriction. Our results suggest that the small intestinal microcirculation has a differential response to cyclooxygenase products of arachidonic acid metabolism during acute bacteremia. They appear not to be mediators of the intestinal arteriolar constriction and hypoperfusion observed during acute E. coli bacteremia, but profoundly influence the mesenteric venular constriction. These observations support the concept that microvascular control mechanisms are different not only between but within organ specific vascular beds.

View details for Web of Science ID A1994PY83400004

View details for PubMedID 7743370

Abstract

Antibiotic usage was assessed in a prospective, randomized trial of recombinant interferon-gamma (rIFN-gamma) versus placebo for 212 severely injured trauma patients in four university hospitals. All patients were observed until death or discharge from the hospital. We found the number of antibiotics used and their associated costs staggering and difficult to justify, although serious antibiotic-related complications were infrequent. Regular antibiotic administration following severe trauma should be re-evaluated since clinical evidence supports the use of shorter courses for these patients, with presumed similar outcomes and much-reduced expenses.

View details for Web of Science ID A1994PF50700017

View details for PubMedID 8080071

Abstract

Nitric oxide (NO) is an important mediator of the hemodynamic effects of sepsis; however, its microcirculatory effects are unknown. To determine the role of NO in the small intestinal (SI) microcirculation, an intact SI loop was exteriorized from decerebrate rats into a controlled Krebs' bath. Bacteremic rats received 10(9) Escherichia coli intravenously. Videomicroscopy was used to measure arteriolar diameters (A1, A3) and optical Doppler velocimetry to quantitate flow. In controls, topical NO synthase (NO-S) substrate L-arginine (L-ARG; 10(-4) M) did not affect diameters or flow. Inhibition of NO-S by N omega-nitro-L-arginine methyl ester (L-NAME; 10(-4) M) caused constriction (A1 = -18%; A3 = -24% from baseline diameter) and reduced A1 flow by 62%. These alterations were similar to bacteremic controls (A1 = -20%; A3 = -18%; A1 flow = -42%), despite the increased cardiac output (+21%). L-NAME treatment of bacteremic rats resulted in further constriction (A1 = -31%; A3 = -32%) and decreased A1 flow (-75%). Topical L-ARG (10(-4) M) ameliorated constriction (A1 = -6%; A3 = +7%) and improved blood flow (-5%) during bacteremia. We conclude that: 1) NO is important for basal SI microvascular tone; 2) bacteremia causes SI arteriolar constriction and hypoperfusion; 3) NO-S inhibition during sepsis may exacerbate SI vasoconstriction and hypoperfusion.

View details for Web of Science ID A1994PC45300009

View details for PubMedID 7537619

Abstract

Nitric oxide (NO) is an important hemodynamic mediator of sepsis; however, its visceral microcirculatory effects are largely unknown. To determine the role of systemic nitric oxide synthase (NO-S) inhibition on the microcirculation of the small intestine (SI), an intact loop of SI was exteriorized from decerebrate rats into a controlled tissue bath. Videomicroscopy was used to measure arteriolar diameters (A1, A3) and optical Doppler velocimetry was used to quantitate flow. In nonbacteremic controls inhibition of NO-S by N omega-nitro-L-arginine methyl ester (L-NAME; 1 mg/kg IV) caused vasoconstriction (A1 = -7%; A3 = -24% baseline values) and reduced A1 flow by 26%. Bacteremic controls received 10(9) Escherichia coli IV, which resulted in arteriolar constriction and hypoperfusion (A1 = -16%; A3 = -21%; A1 flow = -44%), despite increased cardiac output (+33%). Treatment of bacteremic rats with L-NAME corrected the increased cardiac output (-3%), but exacerbated vasoconstriction (A1 = -24%; A3 = -27%) and did not improve A1 flow (-49%). These data indicate that (1) NO mediates basal microvascular tone of the SI; (2) hyperdynamic bacteremia causes arteriolar constriction and hypoperfusion of the SI; and (3) although systemic NO-S inhibition normalizes cardiac output and increases blood pressure, it aggravates vasoconstriction in the SI and does not improve hypoperfusion.

View details for Web of Science ID A1994NN28300022

View details for PubMedID 7514673

Abstract

The records of 26 patients who underwent cholecystostomy procedures for presumed acute cholecystitis during a 6-year period were reviewed. Nine patients had operative tube cholecystostomy (OC), and 17 patients had radiologic percutaneous cholecystostomy (PC). A correct diagnosis of acute cholecystitis was made in 22 of 26 patients (84%), including 14 of 17 PC patients and 8 of 9 in the OC group. The rate of resolution of cholecystitis was the same in each group (75% OC versus 78% PC). APACHE II scores prior to treatment were significantly higher in OC patients (20.9 OC versus 12.4 PC, p < 0.01). There were 5 deaths, including 3 in the OC groups and 2 in the PC group. Nonfatal complications were more frequent in the PC group. Two of the 14 correctly diagnosed PC patients (14%) subsequently required emergency cholecystectomy for persistent biliary sepsis, and 6 patients (43%) required at least 1 tube exchange for occlusion or dislodgement. Overall, only 5 of the 14 patients (36%) in the PC group were successfully treated without complications compared with 5 of 8 patients (63%) in the OC group. Despite its theoretical advantages, PC was no more effective than OC in the treatment of acute cholecystitis. These data suggest that OC remains a viable treatment option in critically ill patients with acute cholecystitis.

View details for Web of Science ID A1993LN14800006

View details for PubMedID 8328626

Abstract

Bilateral shattered kidneys secondary to blunt abdominal trauma has not, to our knowledge, been reported. In the case reported herein, severe pulmonary, myocardial, and orthopedic injuries necessitated nonoperative management of this peculiar injury. The patient recovered without sequelae related to the renal injury.

View details for Web of Science ID A1993LL20800017

View details for PubMedID 8516997

Abstract

The intestinal sling procedure has been used successfully without the observance of pelvic infections. This procedure involves the implantation of polyglycolic acid (PGA) mesh to hold the bowel out of the pelvis to prevent radiation enteritis. We previously showed that PGA mesh has no intrinsic bactericidal activity. Since phagocytic leukocytes produce reactive oxygen intermediates during respiratory burst that are associated with oxygen-dependent bactericidal activity, we examined peritoneal cell types and their respiratory burst activity isolated from patients with biopsy-confirmed rectal carcinoma who underwent the intestinal sling procedure (N = 12) compared with patients who did not (N = 13). There was no significant difference in the cell types within the peritoneal cavity over the 7-day postoperative period examined. However, there was a significant increase in the ability of leukocytes isolated from mesh patients to produce hydrogen peroxide in the absence of an exogenous stimulus (P less than 0.05), as measured by flow cytometric quantitation of oxidation of the hydroperoxide-sensitive dye, 2',7'-dichlorofluorescin diacetate (DCFH-DA). Despite the higher endogenous DCFH oxidation by leukocytes from mesh patients, the cells retained the ability to oxidize DCFH following treatment with a membrane-active stimulant for respiratory burst activity, 12-O-tetradecanoyl-phorbol-13-acetate. These observations suggest that PGA mesh used for the intestinal sling procedure stimulates the respiratory burst activity of peritoneal leukocytes during the postoperative period in which bacterial proliferation and colonization occur. The stimulation of reactive oxygen intermediates involved in oxygen-dependent bactericidal activity by PGA mesh may be one of the mechanisms underlying the lack of infections observed with the use of PGA mesh in contaminated settings.

View details for Web of Science ID A1991GA50100006

View details for PubMedID 1649736

Abstract

Portable resuscitation-area cervical-spine radiographs (PCS) frequently constitute a routine part of the emergency evaluation of patients suffering from blunt trauma. Their adequacy and cost were evaluated by reviewing the records of 92 consecutive trauma patients. Forty-seven of 74 patients (63.5%) had adequate PCS in that all seven cervical vertebrae were visualized. In 27 patients (36.5), all seven cervical vertebrae were not adequately visualized. Inadequate studies were most likely to occur in patients with abnormal vital signs on admission (56%) (P less than .01) and in those subsequently requiring general anesthesia (34.5%). Fifteen patients were intubated without difficulty by maintaining neck immobilization because of uncertainty regarding cervical-spine injuries. The annual cost of inadequate cervical-spine studies was estimated to be $31,000.00. Although the four cervical-spine injuries were diagnosed by the portable technique, routine PCS were frequently inadequate in visualizing all seven cervical vertebrae. Major decisions concerning intubation and surgery frequently had to be made before adequate radiographic evaluation could be completed. It is suggested that time and money are lost by routinely doing a single lateral portable cervical radiograph. It is more appropriate to obtain complete radiographic studies after life-threatening injuries are addressed while patients are treated using the standard techniques of neck immobilization.

View details for Web of Science ID A1990CR17400009

View details for PubMedID 2106809

Abstract

The Whipple procedure traditionally is associated with an operative mortality of 20 to 25 percent. As a result, percutaneous and endoscopic techniques have been advocated to alleviate symptoms in patients with periampullary carcinoma. Now, dramatic reductions in operative mortality rates have been reported. Since radical pancreaticoduodenectomy is the only treatment for cure, a re-evaluation of the role of this procedure is warranted.

View details for PubMedID 2300278