Biomedical subjects

F E Pritchard

Publications and source records attributed to F E Pritchard.

At least 19 recordsLinked to original sources

PubMed1998

Utility of Gram's stain and efficacy of quantitative cultures for posttraumatic pneumonia: a prospective study.

OBJECTIVE: This prospective trial examined the efficacy of using bronchoalveolar lavage (BAL) for the diagnosis of pneumonia (PN) and the utility of Gram's stain (GS) for dictating empiric therapy. SUMMARY BACKGROUND DATA: Posttraumatic nosocomial PN remains a significant cause of morbidity and mortality. However, its diagnosis is elusive, especially in multiply injured patients. The systemic inflammatory response syndrome of fever, leukocytosis, and a hyperdynamic state is common in trauma patients, especially patients with pulmonary contusion. Bronchoscopy with BAL with quantitative cultures of the lavage effluent may distinguish between PN and systemic inflammatory response syndrome, and GS of the lavage effluent may guide empiric therapy before quantitative culture results. METHODS: Mechanically ventilated trauma patients with a clinical diagnosis of PN (fever, leukocytosis, purulent sputum, and new or changing infiltrate on chest radiograph) underwent bronchoscopy with BAL. Effluent was sent for GS and quantitative cultures. The diagnostic threshold for PN was > or =10(5) colony-forming units (CFU)/mL, and antibiotics were continued. Antibiotics were stopped for < 10(5) CFU/mL and the diagnosis of systemic inflammatory response syndrome was made. Causative organisms for PN were compared to GS. RESULTS: Over a 2-year period, 232 patients underwent 443 bronchoscopies with BAL (71% men, 29% women; mean age, 41). The mean injury severity score was 30. Sixty percent of the patients had pulmonary contusion, and 59% were cigarette smokers. The overall incidence of PN was 39% and was no different regardless of the number of BALs a patient had. The false-negative rate of BAL was 7%. GS identified gram-positive organisms in 80% of patients with gram-positive PN and 40% of patients with gram-negative PN. GS identified gram-negative organisms in 52% of patients with gram-positive PN and 77% with gram-negative PN. The duration of the intensive care unit stay relative to the timing of BAL was beneficial for guiding empiric therapy. BAL in week 1 primarily identified Haemophilus influenzae and gram-positive organisms; Acinetobacter sp. and Pseudomonas sp. were more common after week 1. CONCLUSIONS: Bronchoscopy with BAL is an effective method to diagnose PN and avoids prolonged, unnecessary antibiotic therapy. Empiric therapy should be adjusted to the duration of the intensive care unit stay because the causative bacteria flora changes over time. GS of BAL effluent correlates poorly with quantitative cultures and is not reliable for dictating empiric therapy.

Adult↗

PubMed1998

Improved success in nonoperative management of blunt splenic injuries: embolization of splenic artery pseudoaneurysms.

OBJECTIVES: By using abdominal computed tomographic scans in the evaluation of blunt splenic trauma, we previously identified the presence of vascular blush as a predictor of failure, with a failure of nonoperative management of 13% in that series. This finding led to an alteration in our management scheme, which now includes the aggressive identification and embolization of splenic artery pseudoaneurysms. METHODS: The medical records of 524 consecutive patients with blunt splenic injury managed over a 4.5-year period were reviewed for the following information: age, Injury Severity Score (ISS), American Association for the Surgery of Trauma splenic injury grade (SIG), method and outcome of management. RESULTS: Of the patients, 66% were male with a mean age of 32 +/- 16, and mean ISS of 25 +/- 13. A total of 180 patients (34%) were managed with urgent operation on admission (81% splenectomy (SIG 4.0), 19% splenorrhaphy (SIG 2.6)). The remaining 344 patients (66%) were hemodynamically stable and underwent computed tomographic scan and planned nonoperative management. Of these patients, 322 patients (94%) were successfully managed nonoperatively (61% of total splenic injuries). In 26 patients (8%), a contrast blush identified on computed tomographic scan was confirmed as a parenchymal pseudoaneurysm on arteriography. Twenty patients (SIG, 2.8) were successfully embolized. In six patients, technical failure precluded embolization; all required splenectomy (SIG, 4.0). A total of 22 patients (6%) failed nonoperative management, including the six with unsuccessful embolization attempts. Sixteen patients (SIG, 3.0) who had no evidence of pseudoaneurysm were explored for a falling hematocrit, hemodynamic instability, or a worsening follow-up computed tomography: 13 patients had splenectomy, and three patients had splenorrhaphy. CONCLUSIONS: Aggressive surveillance for and embolization of posttraumatic splenic artery pseudoaneurysms improved the rate of successful nonoperative management of blunt splenic trauma to 61%, with a nonoperative failure rate of only 6%. In comparison with our previous work, this reduction in failure of nonoperative management is a significant improvement (p < 0.03).

Adolescent↗

PubMed1997

Popliteal artery trauma. Systemic anticoagulation and intraoperative thrombolysis improves limb salvage.

OBJECTIVE: This study was conducted to evaluate those factors associated with popliteal artery injury that influence amputation, with emphasis placed on those that the surgeon can control. SUMMARY BACKGROUND DATA: Generally accepted factors impacting amputation after popliteal artery injury include blunt trauma, prolonged ischemic times, musculoskeletal injuries, and venous disruption. Amputation ultimately results from microvascular thrombosis and subsequent tissue necrosis, predisposed by the paucity of collaterals around the knee. METHODS: Patients with popliteal artery injuries over the 10-year period ending November 1995 were identified from the trauma registry. Preoperative (demographics, mechanism and severity of injury, vascular examination, ischemic times) and operative (methods of arterial repair, venous repair-ligation, anticoagulation-thrombolytic therapy, fasciotomy) variables were studied. Severity of extremity injury was quantitated by the Mangled Extremity Severity Score (MESS). Amputations were classified as primary (no attempt at vascular repair) or secondary (after vascular repair). After univariate analysis, logistic regression analysis was performed to identify the independent risk factors for limb loss. RESULTS: One hundred two patients were identified; 88 (86%) were males and 14 (14%) were females. Forty injuries resulted from blunt and 62 from penetrating trauma. There were 25 amputations (25%; 11 primary and 14 secondary). Patients with totally ischemic extremities (no palpable or Doppler pulse) more likely were to be amputated (31% vs. 13%; p < 0.04). All requiring primary amputations had severe soft tissue injury and three had posterior tibial nerve transection; the average MESS was 7.6. Logistic regression analysis identified independent factors associated with secondary amputation: blunt injury (p = 0.06), vein injury (p = 0.06), MESS (p = 0.0001), heparin-urokinase therapy (p = 0.05). There were no complications with either heparin or urokinase. CONCLUSIONS: Minimizing ischemia is an important factor in maximizing limb salvage. Severity of limb injury, as measured by the MESS, is highly predictive of amputation. Intraoperative use of systemic heparin or local urokinase or both was the only directly controllable factor associated with limb salvage. The authors recommend the use of these agents to maximize limb salvage in association with repair of popliteal artery injuries.

Adolescent↗

PubMed1997

Pancreatic trauma: a simplified management guideline.

INTRODUCTION: Recent literature supports a conservative trend in the management of pancreatic injuries. Contrary to this trend, some recommend defining ductal integrity by pancreatography, implying that the results alter management. This study examines our recent 5-year experience with a simplified approach to all pancreatic injuries. METHODS: Retrospective analysis of patients sustaining pancreatic injuries was performed. RESULTS: One hundred thirty-four patients were identified. Overall mortality was 13%, and pancreatic-related mortality was 2%. Analyses were based on 124 pancreatic injuries among patients who survived >12 hours. Thirty-seven proximal injuries were treated with drainage alone, with a pancreatic morbidity of 11%. Eighty-seven distal pancreatic injuries occurred, 54 with indeterminate ductal status. Twenty-four had high probability for duct injury and were treated by distal resection; 30 with a low probability of ductal injury were drained. Pancreatic morbidity was not different between these groups. CONCLUSIONS: Pancreatic injuries including those with indeterminate ductal status can be successfully managed with low morbidity and mortality using this simplified management protocol.

Adult↗

PubMed1996

Blunt carotid injury. Importance of early diagnosis and anticoagulant therapy.

OBJECTIVE: The incidence, associated injury pattern, diagnostic factors, risk for adverse outcome, and efficacy of anticoagulant therapy in the setting of blunt and carotid injury (BCI) were evaluated. SUMMARY BACKGROUND DATA: Blunt carotid injury is considered uncommon. The authors believe that it is underdiagnosed. Outcome is thought to be compromised by diagnostic delay. If delay in diagnosis is important, it is implied that therapy is effective. Although anticoagulation is the most frequently used therapy, efficacy has not been proven. METHODS: Patients with BCI were identified from the registry of a level I trauma center during an 11-year period (ending September 1995). Neurologic examinations and outcomes, brain computed tomography (CT) results, angiographic findings, risk factors, and heparin therapy were evaluated. RESULTS: Sixty-seven patients with 87 BCIs were treated. Thirty-four percent were diagnosed by incompatible neurologic and CT findings, 43% by new onset of neurologic deficits, and 23% by physical examination (neck injury, Horner's syndrome). There were 54 intimal dissections, 11 pseudoaneurysms, 17 thromboses, 4 carotid cavernous fistulas, and 1 transected internal carotid artery. Thirty-nine patients had follow-up angiograms. Mortality rate was 31%. Of 46 survivors, 63% had good neurologic outcomes, 17% moderate, and 20% bad. Logistic regression analysis demonstrated heparin therapy to be associated independently with survival (p < 0.02) and improvement in neurologic outcome (p < 0.01). CONCLUSIONS: Blunt carotid injury is more common than appreciated, seen in 0.67% of patients admitted after motor vehicle accidents. Therapy with heparin is highly efficacious, significantly reducing neurologic morbidity and mortality. Heparin therapy, when instituted before onset of symptoms, ameliorates neurologic deterioration. Liberal screening, leading to earlier diagnosis, would improve outcome.

Adolescent↗

PubMed1996

A randomized trial of isonitrogenous enteral diets after severe trauma. An immune-enhancing diet reduces septic complications.

OBJECTIVE: The authors randomized patients to an enteral diet containing glutamine, arginine, omega-3 fatty acids, and nucleotides or to an isonitrogenous, isocaloric diet to investigate the effect of septic outcome. A third group of patients, without enteral access but eligible by severity of injury, served as unfed controls and were studied prospectively to determine the risk of infection. SUMMARY BACKGROUND DATA: Laboratory and clinical studies suggest that diets containing specialty nutrients, such as arginine, glutamine, nucleotides, and omega-3 fatty acids, reduce septic complications. Unfortunately, most clinical trials have not compared these diets versus isonitrogenous, isocaloric controls. This prospective, blinded study randomized 35 severely injured patients with an Abdominal Trauma Index > or = 25 or a Injury Severity Score > or = 21 who had early enteral access to an immune-enhancing diet ([IED] Immun-Aid, McGaw, Inc., Irvine, CA; n = 17) or an isonitrogenous, isocaloric diet (Promote [Ross Laboratories, Columbus, OH] and Casec [Mead-Johnson Nutritionals, Evansville, IN]; n = 18) diet. Patients without early enteral access but eligible by severity of injury served as contemporaneous controls (n = 19). Patients were evaluated for septic complications, antibiotic usage, hospital and intensive care unit (ICU) stay, and hospital costs. RESULTS: Two patients died in the treatment group and were dropped from the study. Significantly fewer major infectious complications (6%) developed in patients randomized to the IED than patients in the isonitrogenous group (41%, p = 0.02) or the control group (58%, p = 0.002). Hospital stay, therapeutic antibiotics, and the development of intra-abdominal abscess was significantly lower in patients receiving the IED than the other two groups. This improved clinical outcome was reflected in reduced hospital costs. CONCLUSIONS: An IED significantly reduces major infectious complications in severely injured patients compared with those receiving isonitrogenous diet or no early enteral nutrition. An IED is the preferred diet for early enteral feeding after severe blunt and penetrating trauma in patients at risk of subsequent septic complications. Unfed patients have the highest complication rate.

Adult↗

PubMed1996

A prospective analysis of transesophageal echocardiography in the diagnosis of traumatic disruption of the aorta.

OBJECTIVE: Recently, transesophageal echocardiography (TEE) has been proposed as the standard for the diagnosis of traumatic disruption of the aorta (TDA), replacing aortography. The purpose of this study was to evaluate the accuracy and practicality of TEE in the diagnosis of TDA. DESIGN: Prospective clinical trial. MATERIALS AND METHODS: Patients with blunt trauma admitted with a suspected diagnosis of TDA were evaluated with TEE and aortography. MEASUREMENTS AND MAIN RESULTS: Thirty-four patients were evaluated with TEE and aortography. TEE was unsuccessful in five patients (15%). Of the remaining 29 patients, TEE results were true-positive in four and true-negative in 20. TEE results were false-positive in two patients, and three injuries were missed (two were proximal to the left subclavian artery, and one was a localized aortic disruption). Sensitivity and specificity of TEE were 57% and 91%, respectively, compared with aortography, for which sensitivity was 89% and specificity was 100%. CONCLUSION: Although the use of TEE in the diagnosis of TDA has several advantages, it is not more accurate than aortography. TEE should not replace aortography as the standard for the diagnosis of TDA.

Adult↗

PubMed1996

Prophylactic Greenfield filters: acute complications and long-term follow-up.

The efficacy of prophylactic vena caval filters (VCF) in reducing morbidity and mortality from pulmonary embolism (PE) in high-risk trauma patients has been shown, but minimal follow-up data is currently available. VCFs were prophylactically placed in 110 patients between August 1991 and June 1995. There was an early VCF complication rate of 7%. Twenty-two patients died; the remaining 88 patients formed the basis for the follow-up study. Forty-five patients were located and interviewed by phone, and 30 of these patients (34%) returned for evaluation. The mean follow-up time was 18 months (range, 4-42 months). There was no incidence of caval thrombosis on follow-up. Eleven patients had physical findings, and duplex evidence consistent with postphlebitic syndrome. An additional three patients had evidence of old deep venous thrombosis (DVT) by duplex, but no significant symptomatology. VCF are effective in preventing PE related deaths and have few major complications. The long-term morbidity associated with posttraumatic venous thrombosis is significant. This morbidity is related not to PE or VCF, but to the underlying DVT. Improved strategies against DVT are necessary.

Adult↗

PubMed1995

Gastric and extragastric actions of the histamine antagonist ranitidine during posttraumatic sepsis.

BACKGROUND: Histamine H2 antagonists (e.g., ranitidine) are generally thought to specifically reduce gastric acid secretion and are commonly used for stress ulcer prophylaxis in critically ill patients because of their efficacy and safety profile. A few reports suggest that ranitidine might also bind to extragastric sites and/or act as an immunomodulator. The potential effects on posttraumatic sepsis are unknown. METHODS: Mongrel pigs (n = 24) were anesthetized with fentanyl, injured by a 10 kg steel bar dropped from a height of 1 m onto the fleshy portion of the posterior thigh, and then 35% of their blood volume was drained through the arterial catheter. All the shed blood plus two times the hemorrhage volume as lactated Ringer's solution was infused after a 1-hour shock period. Either vehicle or ranitidine (1.5 mg/kg) was intravenously administered at the time of resuscitation and every 12 hours thereafter in a blinded fashion. After 72 hours a septic challenge was administered (15 micrograms/kg Escherichia coli lipopolysaccharide [LPS] x 30 min). Serial gastroscopy, gastric pH, hemodynamics, leukocyte counts, cortisol, and tumor necrosis factor were recorded for 180 minutes after LPS. RESULTS: Immediately before LPS all hemodynamic variables were identical between treatments, but gastric pH was slightly higher and stress gastritis was marginally lower with ranitidine. LPS caused profound leukopenia and a hyperdynamic circulatory response (i.e., tachycardia, increased cardiac output, and decreased peripheral vascular resistance at relatively constant blood pressure); these changes were not altered by ranitidine. Gastric pH remained elevated after LPS with ranitidine, but LPS-induced gastritis was not modified. Ranitidine delayed the LPS-induced ventilation-perfusion imbalance and attenuated the peak increase in the proinflammatory cytokine, tumor necrosis factor, without altering its antiinflammatory opponent, cortisol. Similar changes were observed in four additional animals treated with cimetidine. The proportion of circulating neutrophils and lymphocytes was slightly altered 180 minutes after LPS, but there was no obvious effect on T lymphocytes in vivo, and no effect on the LPS-induced increase in neutrophil CD18 expression in vitro was seen. CONCLUSIONS: (1) Ranitidine increased gastric pH, which blunted the stress gastritis caused by trauma but not that caused by LPS; (2) ranitidine delayed the early LPS-evoked pulmonary changes and reduced the tumor necrosis factor spike, which is consistent with a favorable immunomodulatory action that has been reported in patients who are critically ill or are undergoing an elective abdominal surgical procedure; (3) the mechanism is probably related to H2 receptor antagonism rather than to a nonspecific side effect of ranitidine, which suggests that histamine may have a previously unrecognized role in posttraumatic septic responses; and (4) the site of action is probably not in the heart or peripheral resistance vessels, but salutary effects on circulating lymphocytes or neutrophils cannot be excluded.

Acidosis↗

PubMed1995

Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial.

BACKGROUND: A number of retrospective studies recently have been published concerning nonoperative management of minor liver injuries, with cumulative success rates greater than 95%. However, no prospective analysis that involves a large number of higher grade injuries has been reported. The current study was conducted to evaluate the safety of nonoperative management of blunt hepatic trauma in hemodynamically stable patients regardless of injury severity. METHODS: Over a 22-month period, patients with blunt hepatic injury were evaluated prospectively. Unstable patients underwent laparotomies, and stable patients had abdominal computed tomography (CT) scans. Those with nonhepatic operative indications underwent exploration, and the remainder were managed nonoperatively in the trauma intensive care unit. This group was compared with a hemodynamically matched operated cohort of blunt hepatic trauma patients (control subjects) who had been prospectively analyzed. RESULTS: One hundred thirty-six patients had blunt hepatic trauma. Twenty-four (18%) underwent emergent exploration. Of the remaining 112 patients, 12 (11%) failed observation and underwent celiotomy--5 were liver-related failures (5%) and 7 were nonliver related (6%). Liver related failure rates for CT grades I through V were 20%, 3%, 3%, 0%, and 12%, respectively, and rates according to hemoperitoneum were 2% for minimal, 6% for moderate, and 7% for large. The remaining 100 patients were successfully treated without operation--30% had minor injuries (grades I-II) and 70% had major (grades III-V) injuries. There were no differences in admission characteristics between nonoperative success or failures, except admission systolic blood pressure (127 vs. 104; p < 0.04). Comparing the nonoperative group to the control group, there were no differences in admission hemodynamics or hospital length of stay, but nonoperative patients had significantly fewer blood transfusions (1.9 vs. 4.0 units; p < 0.02) and fewer abdominal complications (3% vs. 11%; p < 0.04). CONCLUSIONS: Nonoperative management is safe for hemodynamically stable patients with blunt hepatic injury, regardless of injury severity. There are fewer abdominal complications and less transfusions when compared with a matched cohort of operated patients. Based on admission characteristics or CT scan, it is not possible to predict failures; therefore, intensive care unit monitoring is necessary.

Adult↗

PubMed1995

Prognostic factors after acute subdural hematoma.

Factors that have been shown to affect outcome after acute subdural hematoma (ASDH) include age, Injury Severity Score (ISS), intracranial pressure (ICP), direct admission to a trauma center, presence of subarachnoid hemorrhage, score on the Glasgow Coma Scale (GCS), and timing of operation. However, these data come from selected patient populations (e.g., operated, comatose, or minimally symptomatic patients, etc.). In an effort to evaluate factors that predict outcome for the entire spectrum of ASDH patients, we evaluated 211 patients with ASDH and GCS scores of 3 to 15. One hundred twenty-eight patients (61%) were managed nonoperatively (Nonop), whereas 83 (39%) were managed with craniotomy [operatively (Op)]. Op patients had more severe brain injuries, as evidenced by their lower GCS scores (Op 7.8 vs. Nonop 10.7, p = 0.0001), higher incidence of large ASDH with midline shift (Op 61% large ASDH, 83% midline shift vs. Nonop 16% large ASDH, 30% midline shift, p = 0.001 for each comparison), and higher incidence of basilar cistern effacement (Op 61% vs. Nonop 21%, p = 0.001). Thirty-five percent of the Op patients had their hematoma evacuated within 4 hours (early), whereas 65% did not (delayed). Early Op patients had a significantly lower incidence of functional survival (early = 24% vs. delayed = 51%, p = 0.02). The early patients seem to have had more significant head injuries, as evidenced by their lower GCS scores (early = 7.0 vs. delayed = 8.4), higher incidence of associated intracranial injuries (early = 1.14 vs. delayed = 0.85), and higher incidence of cistern effacement (early = 76% vs. delayed = 53%, p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed1995

Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management.

Nonoperative management of blunt splenic trauma is widely accepted; however, reported failure rates have ranged as high as 40%. There are few factors available to identify failures reliably. To characterize failures of nonoperative management better, we retrospectively reviewed 309 blunt splenic injuries treated at our level I trauma center over a 5-year period. Eighty-nine patients were initially managed nonoperatively (29%), and 12 patients failed this approach (13%). Upon review of the initial computed tomography scans, a hyperdense collection of contrast media in the splenic parenchyma, or "contrast blush," was noted in 8 of 12 (67%) patients who failed and in 5 of 77 (6%) of those who were successfully managed nonoperatively (p < 0.0001). These data suggest that the presence of a contrast blush is an important consideration when deciding the method for management of the splenic injury. If these results are confirmed in a prospective fashion, the failure rate of nonoperative management of blunt splenic trauma could be reduced by identification of the contrast blush.

Adolescent↗

PubMed1995

Using bronchoalveolar lavage to distinguish nosocomial pneumonia from systemic inflammatory response syndrome: a prospective analysis.

OBJECTIVE: Ventilator-associated pneumonia (PN) is difficult to distinguish from trauma-induced systemic inflammatory response syndrome (SIRS), especially in patients with multiple injuries. Previous work using bronchoscopy and quantitative cultures demonstrated significant bacterial growth in about one-third of patients with clinical evidence of PN. In this prospective study, antibiotic therapy for PN was based solely on quantitative bronchoalveolar lavage (BAL) cultures. METHODS: Mechanically ventilated trauma patients underwent bronchoscopy with BAL when they developed clinical evidence of PN: fever (temperature > 100.5 degrees F), white blood cells > 10,000 or > 10% immature forms, purulent sputum, and new or changing infiltrate on chest roentgenogram. Patients with other infections or those receiving antibiotics for any other reason were excluded. Empiric antibiotic therapy for PN was started at the time of BAL. If the quantitative cultures revealed > or = 10(5) colony-forming units (CFU)/mL, that patient was defined as having PN and was treated. If the cultures revealed < 10(5) CFU/mL, that patient was defined as having SIRS, and empiric therapy was stopped. RESULTS: Forty-three patients (88% blunt, 12% penetrating) underwent bronchoscopy with BAL 55 times. Mean age was 40 and Injury Severity Score was 25. Twenty patients had > or = 10(5) CFU/mL (47%) and 23 had < 10(5) CFU/mL (53%). There were no differences in age, Injury Severity Score, temperature, white blood cell count, or ventilator days before BAL between groups. Sixty-five percent of those with SIRS improved after empiric therapy was stopped (average 3.3 days), and 35% underwent repeat BAL. Three patients with the initial diagnosis of SIRS developed PN (13% of SIRS). Mortality for PN was 15%, compared with 17% for SIRS; no deaths were related to antibiotic therapy. CONCLUSIONS: SIRS, which can mimic PN, is common in trauma patients. These entities can be distinguished by bronchoscopy with BAL. Basing antibiotic therapy solely on quantitative BAL cultures is efficacious in trauma patients.

Adolescent↗

PubMed1994

Is resection with primary anastomosis following destructive colon wounds always safe?

Resection with primary anastomosis was associated with a 14% anastomotic leak rate in this review of 60 patients with destructive colon wounds. The presence of an underlying medical illness or massive blood transfusion was associated with anastomotic complications. In the high-risk subset of patients who had one or both of these risk factors, the anastomotic leak rate was 42%. The incidence of anastomotic leak in previously healthy patients without massive transfusion was 3%. Ileocolostomies were no safer than colocolostomies. We conclude that resection with anastomosis should not be performed on all patients with destructive colon injuries, as the risk of anastomotic leak is prohibitive in those with either massive blood loss or underlying medical illness. We continue to perform primary anastomosis in healthy patients without excessive blood loss.

Adolescent↗

PubMed1994

Planned ventral hernia. Staged management for acute abdominal wall defects.

OBJECTIVE: Analysis of a staged management scheme for initial and definitive management of acute abdominal wall defects is provided. METHODS: A four-staged scheme for managing acute abdominal wall defects consists of the following stages: stage I--prosthetic insertion; stage II--2 to 3 weeks after prosthetic insertion and wound granulation, the prosthesis is removed; stage III--2 to 3 days later, planned ventral hernia (split thickness skin graft [STSG] or full-thickness skin and subcutaneous fat); stage IV--6 to 12 months later, definitive reconstruction. Cases were evaluated retrospectively for benefits and risks of the techniques employed. RESULTS: Eighty-eight cases (39 visceral edema, 27 abdominal sepsis, 22 abdominal wall resection) were managed during 8.5 years. Prostheses included polypropylene mesh in 45 cases, polyglactin 910 mesh in 27, polytetrafluorethylene in 10, and plastic in 6. Twenty-four patients died from their initial disease. The fistula rates associated with prosthetic management was 9%; no wound-related mortality occurred. Most wounds had split thickness skin graft applied after prosthetic removal. Definitive reconstruction was undertaken in 21 patients in the authors' institution (prosthetic mesh in 12 and modified components separation in 9). Recurrent hernias developed in 33% of mesh reconstructions and 11% of the components separation technique. CONCLUSIONS: The authors concluded that 1) this staged approach was associated with low morbidity and no technique-related mortality; 2) prostheses placed for edema were removed with fascial approximation accomplished in half of those cases; 3) absorbable mesh provided the advantages of reasonable durability, ease of removal, and relatively low cost--it has become the prosthesis of choice; and 4) the modified components separation technique of reconstruction provided good results in patients with moderate sized defects.

Abdominal Muscles↗

PubMed1994

Analysis of charges associated with diagnosis of nosocomial pneumonia: can routine bronchoscopy be justified?

Many ventilated trauma patients thought to have nosocomial pneumonia have pulmonary contusion or systemic inflammatory response syndrome with tracheobronchial colonization. Fiberoptic bronchoscopy with quantitative culture techniques of protected specimen brush (PSB; threshold 10(3) cfu/mL) or bronchoalveolar lavage (BAL; threshold 10(5) cfu/mL) can potentially eliminate the false positive cultures of the upper airway seen with routine sputum aspirates (RS). However, bronchoscopy is expensive, and routine use may not be cost effective. This prospective study evaluated the patient charges associated with bronchoscopy and quantitative cultures compared with RS for the diagnosis of nosocomial pneumonia. Specimens were obtained by RS, PSB, and BAL from the lower airway in 107 trauma patients (136 sets of triplicate cultures). All patients had clinical evidence suggestive of pneumonia (fever, leukocytosis, purulent sputum, abnormal roentgenographic findings). Typical oral flora were considered contaminants; no gram-negative specimens were excluded. Mean age was 40 years and mean ISS was 29. Seventy-eight percent had blunt injuries, 22% penetrating, and 42% had chest injuries. The incidence of nosocomial pneumonia according to each method was: RS-73%; PSB-34%; BAL-25%. Considering all charges involved (bronchoscopy, equipment, microbiologic analysis, and antibiotics), and based on a 14-day course of ceftazidime and vancomycin, the charges for PSB were 58% of RS, and charges for BAL were 43% of RS. We conclude that the charges associated with bronchoscopy are high, but can be offset by antibiotic savings. Side effects of unnecessary antibiotic therapy would be avoided. Further study is needed to determine the efficacy of PSB or BAL in trauma patients.

Adult↗

PubMed1994

Acute subdural hematoma: nonsurgical management of selected patients.

There is a current trend toward nonsurgical therapy for small, minimally symptomatic acute subdural hematomas (ASDH), but data supporting such a scheme have been lacking. We evaluated 83 patients with minimally symptomatic ASDH (Glasgow Coma Scale scores of 11-15) and found 58 managed nonsurgically (70%) and 25 managed with craniotomy (30%). Patients managed without surgery had a lower incidence of focal neurologic deficits (12% vs. 40%; p < .01), open cisterns (90% vs. 28%; p < .001), and small (< or = 1 cm) ASDHs (92% vs. 62%; p < .001). Ninety-three percent of patients managed nonsurgically had functional recovery compared with 84% of patients with craniotomy. Age and injury Severity Score were significantly associated with patient outcome. Timing of surgery had no association with outcome. Six percent of patients managed nonsurgically developed chronic SDH requiring craniotomy. We conclude that unless the hematoma is causing clinical evidence of intracranial hypertension or significant neurologic dysfunction, there appears to be no advantage in evacuating the clot. Selected patients with ASDH and GCS scores of 11-15 can safely be managed without craniotomy.

Acute Disease↗

PubMed1994

Splanchnic and systemic hemodynamic responses to portal vein endotoxin after resuscitation from hemorrhagic shock.

BACKGROUND: Hemorrhagic shock and sepsis are usually studied separately or in rodents. This study combined the two insults in a large animal model. METHODS: Anesthetized pigs were bled, held in shock for 1 hour, and then resuscitated with fluid. After 3 days, Escherichia coli endotoxin LPS was infused into the portal vein (150 micrograms/kg x 30 min) to mimic the effect of enteric substances breaching the mucosal barrier. Systemic and splanchnic hemodynamics, circulating leukocytes, and plasma levels of tumor necrosis factor (TNF) were measured in five groups: 40% hemorrhage plus fluid only resuscitation, 40% hemorrhage plus fluid-blood resuscitation, 50% hemorrhage plus fluid-blood resuscitation, sham, or sham plus 5 micrograms/kg LPS priming dose instead of hemorrhage. RESULTS: On day 4 before infusion of LPS, there were no differences between groups in hemodynamics or O2 utilization, but systemic O2 delivery and O2 consumption were each reduced in the hemorrhaged groups because of the hemodilution associated with resuscitation. For 3 hours after infusion of LPS, all animals received aggressive fluid and respiratory support, but arterial blood pressure decreased, and systemic O2 utilization, splanchnic O2 utilization, and arterial lactate level increased; there were no differences between groups. In the 50% group compared with sham, LPS-evoked decreases in cardiac index and stroke index were eliminated, and LPS-evoked tachycardia, pulmonary and systemic vasoconstriction, and increases in hepatic and portal vein lactate levels were blunted. Despite similar leukocyte counts before infusion of LPS and similar leukopenia after LPS infusion, plasma LPS level was higher in the 50% group compared with sham. Furthermore, LPS evoked increases in portal and hepatic vein plasma TNF in the shams, but those changes were reduced in the 50% group. CONCLUSIONS: Most responses to LPS were similar after hemorrhagic shock or a sham operation, which is inconsistent with the concept of "priming." LPS-evoked increases in plasma TNF were blunted after shock, probably because of trauma-induced immune dysfunction. A combined shock plus septic challenge in a large animal model may be valuable for investigating the pathogenic mechanism in human beings.

Analysis of Variance↗