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Biomedical subjects

J S Bender

Publications and source records attributed to J S Bender.

At least 55 records · Page 3Linked to original sources
PubMed1992

The effects of hypothermia and injury severity on blood loss during trauma laparotomy.

To assess the relationships between core temperature (T) and other factors relating to operating room (OR) blood loss and mortality following abdominal injury, the records of 122 patients undergoing laparotomy for trauma at Detroit Receiving Hospital over a 1-year period (1989) were reviewed. Most injuries were penetrating (86%) and the mortality rate was 8.2%. Overall, 57 of 122 (47%) had hypothermia (T < or = 35 degrees C) upon arrival in the OR. There was a significant correlation between admission blood pressure and lowest intraoperative temperature (r = 0.60; p < 0.001). Multiple regression analysis revealed that the patient's lowest temperature (p < 0.001) and Trauma Score (TS); p < 0.0015), but not Abdominal Injury Severity Score (AISS) (p = 0.25) correlated with OR blood loss. The 28 patients with high TS (15 or 16) and AISS > or = 9 had significantly less blood loss when the OR temperature was maintained above 35 degrees C versus 33 degrees-35 degrees C (540 +/- 580 mL vs. 1820 +/- 1160 mL; p < 0.003). This suggests that hypothermia may exacerbate OR blood loss independent of degree of physiologic or anatomic injury. Thus hypothermia is common in patients undergoing a laparotomy for trauma. Trauma scores and the presence of shock preoperatively correlate with the development of intraoperative hypothermia. Hypothermic patients with similar injury severity have greater blood loss. Prevention and rapid correction of hypothermia during resuscitation and surgery appear to be extremely important in reducing blood loss in this patient population.

Abdominal Injuries↗
PubMed1991

Blood transfusion and oxygen consumption in surgical sepsis.

OBJECTIVE: To evaluate the use of serum lactic acid values to predict flow-dependent increases in oxygen consumption (VO2) in response to increasing oxygen delivery (DO2) after blood transfusion in surgical sepsis. DESIGN: Prospective study. SETTING: Tertiary care, trauma center. PATIENTS: Twenty-one patients, postsurgical or posttrauma, judged septic by defined criteria. INTERVENTIONS: Serum lactic acid concentrations, DO2, and VO2 were measured before and after transfusion therapy. MEASUREMENTS AND MAIN RESULTS: Overall, the DO2 increased from 532 +/- 146 to 634 +/- 225 (SD) mL/min.m2 (p less than .001), and the VO2 increased from 145 +/- 39 to 160 +/- 56 mL/min.m2 (p = .02). These changes occurred with an Hgb increase from 9.3 +/- 1.1 to 10.7 +/- 1.5 g/dL (p less than .001). The patients were grouped by their pretransfusion serum lactic acid values. In those patients with normal (less than 1.6 mmol/dL) serum lactic acid (n = 10), DO2 increased from 560 +/- 113 to 676 +/- 178 mL/min.m2 (p less than .02), and VO2 increased from 150 +/- 25 to 183 +/- 46 mL/min.m2 (p less than .02). However, in the increased serum lactic acid group (n = 17), VO2 was not significantly changed after transfusion (143 +/- 46 to 146 +/- 58 mL/min.m2) despite increased DO2 (515 +/- 163 to 609 +/- 251 mL/min.m2, p less than .01). CONCLUSIONS: Blood transfusion can be used to augment DO2 and VO2 in septic surgical patients. Increased serum lactic acid values do not predict patients who will respond. The absence of lactic acidosis should not be used in this patient population to justify withholding blood transfusions to improve flow-dependent VO2. Patients who have increased lactate concentrations may have a peripheral oxygen utilization defect that prevents improvement in VO2 with increasing DO2.

Acidosis, Lactic↗
PubMed1991

Percutaneous innominate vein catheterisation: a new technique for venous access in the critically ill.

Venous access in the critically ill can be a major problem despite the wide variety of methods now available. A new technique is described involving percutaneous catheterisation of the innominate vein via a right second intercostal space approach. It has been successful in five patients over a four-year period. While there have been no major complications, it is advocated for use only when access is necessary for life-saving administration of fluids or drugs. Venous access can be obtained in the majority of patients by a variety of safe and accepted measures such as peripheral venepuncture, central vein catheterisation by the subclavian or internal jugular vein, or by a cutdown. There remains, however, a small subgroup of patients with venous thrombosis from a previous catheter insertion or intravenous drug abuse for whom a number of ingenious methods have been devised. These include cutdowns on the intercostal vein; the middle thyroid vein in infants; and on the inferior epigastric vein, the azygos vein, the iliac vein, and even the inferior vena cava in adults. Access for patients suffering from haemorrhagic shock can be facilitated by multiple catheters in one or more subclavian veins. Even more rarely, these methods may be unsuccessful or contraindicated because of vein thrombosis, infection overlying the insertion site, or patient instability. A new method has been developed allowing percutaneous catheterisation of the innominate vein.

Adult↗
PubMed1991

Complications after percutaneous endoscopic gastrostomy removal.

We report two cases of complications after percutaneous endoscopic gastrostomy (PEG) removal. The first was persistence of a gastrocutaneous fistula that required operative closure. The second patient developed pneumoperitoneum after an attack of vomiting 3 weeks after PEG removal. Laparotomy showed separation of the stomach from the posterior abdominal wall, with peritonitis. These cases highlight the need for careful monitoring of patients even after tube removal.

Adult↗
PubMed1991

Massive hemorrhage associated with pancreatic pseudocyst: successful treatment by pancreaticoduodenectomy.

Major hemorrhage arising from a pseudocyst in the head of the pancreas is a rare and difficult clinical problem. Successful management of this condition by pancreaticoduodenectomy is presented. Arteriographic embolization of the bleeding inferior pancreaticoduodenal artery was not technically possible. Review of the literature suggests pancreaticoduodenectomy constitutes the best definitive management of this problem when embolization is not possible.

Adult↗
PubMed1991

Antrectomy with gastrojejunostomy for unresectable pancreatic cancer-causing duodenal obstruction.

The traditional approach to gastric outlet obstruction caused by unresectable pancreatic cancer is gastrojejunostomy performed during or after biliary bypass surgery. Previous work showed that gastrojejunostomy failed in 95% of patients with preoperative outlet obstruction, which was evidenced by nausea and vomiting. This study defines a better bypass procedure, namely, antrectomy with gastrojejunostomy, which was performed in 19 such patients. The cancer was primary pancreatic in 17 patients and metastatic to the pancreas in two patients with a renal and urinary bladder primary. All patients had duodenal extension with impaired alimentation. Fourteen patients underwent simultaneous biliary bypass surgery and antrectomy with gastrojejunostomy; the antrectomy with gastrojejunostomy procedure was performed in five patients 3 weeks to 6 months after biliary bypass surgery when duodenal obstruction supervened. Visible cancer extended to the duodenal stump in five patients, including two patients whose partial closure was buttressed with omentum. All 19 patients tolerated regular diet at the time of discharge 1 to 4 weeks after the antrectomy with gastrojejunostomy procedure. All patients, who died at 4 to 21 months after surgery tolerated solid food until immediately before death. All nine surviving patients have taken solid foods 9 to 29 months since the antrectomy with gastrojejunostomy procedure. We conclude that the antrectomy with gastrojejunostomy procedure, whether performed simultaneously with or subsequently to biliary bypass surgery, is the best palliative procedure for duodenal obstruction in patients with unresectable pancreatic cancer.

Aged↗
PubMed1991

Morbidity and mortality following total abdominal colectomy for massive lower gastrointestinal bleeding.

During the period of 1980 to 1986, 49 total abdominal colectomies were performed at the authors' institution for lower gastrointestinal bleeding. The overall mortality was 13 of 49 (27%). In the elective/urgent group, mortality was one of 14 (7%); in the emergency with ileostomy group it was two of two (100%); and in the emergency with anastomosis group it was ten of 33 (30%). Morbidity and mortality in this latter group were affected by age [mortality three of 15 (21%) for age less than 70 vs seven of 18 (37%) for age greater than or equal to 70] and the number of units of blood needed preoperatively and intraoperatively. There was no effect on outcome from type of anastomosis (stapled vs hand-sewn), choice of antibiotics, degree of underlying illness, or day of operation following admission. Thirteen patients had less than 10 units of blood transfused; one (7%) died and there was one complication. Conversely, 20 patients had ten or more blood transfusions and nine (45%) died (P = 0.05 vs former group). This latter group also had 16 major complications, including five anastomotic leaks, three intra-abdominal abscesses, and three myocardial infarctions. Total abdominal colectomy when done as an emergency for colonic hemorrhage is associated with excessive morbidity and mortality rates. An important factor contributing to morbidity and mortality that may be controllable is the amount of blood loss. Should total abdominal colectomy be the surgeon's operation of choice, it should be performed prior to 10 units of blood being needed. If this limit is passed, strong consideration should be given to performance of an ileostomy.

Age Factors↗
PubMed1990

The management of flail chest injury: factors affecting outcome.

The records of 57 patients presenting with flail chest injury from 1981 through 1987 were reviewed to determine factors affecting morbidity and mortality. Fifteen patients (26%) had 8+ rib fractures with a unilateral flail and seven (12%) had multiple rib fractures with a bilateral flail. Thirty-two (56%) had moderate-severe pulmonary contusions and 44 (77%) required chest tubes for hemo-pneumothorax. Ventilatory assistance was used in 36 (63%). The major factors determining the need for ventilatory assistance were: an ISS greater than or equal to 23, blood transfusions in the first 24 hours, moderate-severe associated injuries (fractures, head injuries or truncal organs requiring operation), and shock on admission (p less than 0.001). An adverse outcome occurred in 15 (28%); nine required ventilatory assistance greater than or equal to 14 days and six died of sepsis with pneumonia. The main factors associated with an adverse outcome were: an ISS greater than or equal to 31 (p less than 0.001), moderate-severe associated injuries (p less than 0.001), and blood transfusions (p less than 0.005). Although the primary determinants of an adverse outcome were the associated injuries and blood loss, a bilateral flail (p less than 0.01) and age greater than or equal to 50 years (p less than 0.02) were contributing factors.

Adolescent↗
PubMed1990

The management of large soft-tissue defects following close-range shotgun injury.

Large soft-tissue defects following close-range shotgun blasts remain a major technical challenge to trauma surgeons. During the period 1980 through 1988, 43 patients who survived greater than 48 hours following this injury were managed in our center. The locations of their soft-tissue defects were: extremity, 22; abdomen/chest, 18; and head/neck, three. All patients underwent immediate surgical exploration and wide debridement of all devitalized tissue along with repair of associated injuries. Management included mandatory frequent dressing changes, debridement, irrigation in the operating room, and the perioperative administration of broad-spectrum antibiotics. Four patients whose abdominal wall defects could not be initially closed had temporary placement of rayon cloth to prevent evisceration. Overall, four patients underwent delayed primary closure, eight were covered with split-thickness skin grafts, nine had closure with myocutaneous flaps, and 19 closed by secondary intent. Two patients, who were transferred to us following initial management, developed wound sepsis due to inadequate debridement and both eventually required amputation as did one patient who developed early myonecrosis following lengthy arterial repair. Frequent operative dressing changes, adequate debridement, and irrigation minimize sepsis following close-range shotgun blasts and should be the treatment of choice for this devastating injury. Techniques of wound closure need to be individualized to the particular situation.

Abdominal Injuries↗
PubMed1990

Management of close-range shotgun injuries to the chest by diaphragmatic transposition: case reports.

A method of reconstructing the chest wall following close-range shotgun injuries is described. This technique requires detaching the diaphragm peripherally and suturing it above the chest wall defect, resulting in an intact chest cavity and an abdominal wall defect. This latter problem can then be addressed by a variety of standard methods. Two patients are presented with excellent long-term results of diaphragmatic transposition, which should be in the armamentarium of all surgeons who deal with trunk trauma.

Adult↗
PubMed1990

Management of rectal injuries. Dogma versus practice.

The current treatment of civilian rectal injuries stems from military practice. Five principles have evolved: 1) complete fecal diversion, 2) debridement and closure, 3) rectal stump irrigation, 4) presacral drainage, and 5) broad spectrum antibiotics. To assess our practice results, the records of 52 consecutive patients with rectal injury seen at Detroit Receiving Hospital from 1980-88 were reviewed. Etiologies were gunshot (40), shotgun (9), anal assault (2), and stab (1). There were no blunt injuries and no deaths. Treatment consisted of celiotomy (52), diverting colostomy (51), presacral drains (35), rectal stump irrigation (26), and primary closure (1). Broad spectrum antibiotics were administered in all patients. Despite lack of universal application of the "standard" principles, only five patients had postoperative complications and none were related to the rectal injury. Our results demonstrate that a single approach may not be justified, as excellent outcome was achieved with low morbidity and no mortality despite selective management. The universal application of colostomy, repair, irrigation, drainage, and antibiotics cannot be supported.

Adolescent↗
PubMed1989

Approach to the acute abdomen.

As our population ages, more patients will be presenting with acute abdominal problems which require attention. Unlike younger patients, the aged present later in the course of their disease and also often have concomitant underlying diseases. The diagnosis of an acute abdomen is further complicated by the relative lack of physical findings which is due to the elderly's lack of pain perception. The surgical problems in the elderly also tend to be more rapidly life-threatening than in younger patients. This further emphasizes the need for rapid diagnosis should an elderly patient present with abdominal pain. Methods to decrease the mortality from acute surgical problems are limited, but are potentially very effective. The first is to arrange for elective correction of the problem should it be known, and the second is to refer the patients promptly for operative consideration before sepsis becomes firmly established. Exact diagnosis before referral, while intellectually satisfying, is often contributory to a poor outcome in these patients.

Abdomen, Acute↗
PubMed1989

Intra-abdominal sepsis following liver trauma.

Of 330 consecutive patients with liver trauma having a celiotomy over a 5-year period, 295 (89%) survived more than 72 hours. Of these 295, 35 (12%) developed sepsis, and 11 (31%) of these septic patients died. The sources of the sepsis in 30 of these patients included: abdominal abscesses--23, pneumonia or empyema--seven, acalculous cholecystitis--two, gangrene of right colon--two, and thigh abscess--one. In five other patients, the source of the sepsis was not found, even at autopsy. The mortality rate in the 30 patients with one or more identifiable foci of infection was 23%. In contrast, when the source of the sepsis could not be found, the mortality rate was 80% (4/5) (p less than 0.05). Factors associated with an increased incidence of abdominal abscess included: splenectomy, 75% (3/4); liver packs, 63% (5/8); 20+ units of blood, 57% (8/14); Class IV-V liver injury, 35% (8/23); 10-19 units of blood, 25% (7/28); colon injury, 19% (7/36); and open (Penrose) drainage of the abdomen, 11% (23/213). None of 82 patients without drains developed an intra-abdominal abscess. Thus early control of an identifiable source of infection provides the best results with sepsis following liver trauma. The most effective method for preventing intra-abdominal abscesses appears to be avoidance of drains in mild (Class I-II) liver injuries. The use of a closed system in the most severe injuries is still controversial and needs to be addressed in a prospective trial.

Abdomen↗
PubMed1989

Small bowel obstruction in the elderly.

The records of 56 consecutive patients, age 70 years or older, who were operated on for mechanical small bowel obstruction were reviewed to determine the effect of early operation versus delayed operation. Delayed operation was defined as a laparotomy performed more than 48 hours after admission. Excluding the 13 patients with hernias, there were no significant differences between the early operation and delayed operation groups in regard to age, cause of small bowel obstruction, duration of prehospitalization symptoms, degree of underlying disease, or physical findings on presentation--with the exception of a significantly higher number of patients in the early operation group who had abdominal tenderness. There were no differences between mortality and small bowel infarction rates in the two groups. There was an increase in the complication rate (60 vs 24%, P less than .05) and the mean length of stay (29.6 vs 20.0 days, P less than 0.05) in the delayed operation group. This increased mean length of stay was directly related to the higher number of complications caused by delay in operation. Advanced age in a patient with complete small bowel obstruction should not stay the surgeon's hand because delay only leads to a prohibitive increase in complications and length of hospitalization.

Aged↗
PubMedDate not supplied

Diagnostic laparoscopy in critically ill intensive-care-unit patients.

The diagnosis of intraabdominal sepsis in critically ill intensive-care-unit patients remains a challenge. Diagnostic laparoscopy has been performed in seven such patients following admission for coronary artery bypass surgery, gram-negative sepsis, major burns, pneumonia, myocardial infarction, and post-pneumonectomy. Laparoscopy revealed acalculous cholecystitis in two patients (one removed laparoscopically), gangrenous colon in two, cirrhosis with liver infarction in one, and, in two patients, no pathology. Although five patients died postoperatively, none was related to the laparoscopy. There were no intraoperative complications and no known pathology was missed. Because of its ease and accuracy, diagnostic laparoscopy should be considered in all critically ill patients suspected of harboring intraabdominal pathology. Further studies are needed to fully establish its efficacy and safety.

Abdominal Pain↗