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James K Lukan

Publications and source records attributed to James K Lukan.

11 recordsLinked to original sources
PubMed2005

Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients.

BACKGROUND AND AIMS: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

APACHE↗
PubMed2005

Toxicology screening results: injury associations among hospitalized trauma patients.

BACKGROUND: Substance abuse is associated with injuries, but these associations have not been well characterized by type of substance and injury type. METHODS: A cross-sectional study of patients selected for toxicology screening compared those with positive and those with negative test results for drugs and alcohol. RESULTS: Patients with positive alcohol toxicology results were more likely to have violence-related and penetrating injuries than patients with negative results. However, after adjustment for positive cocaine toxicology results, the association between alcohol and penetrating injury was no longer significant. Positive test results for any drug were not associated with any specific injury type, but cocaine was independently associated with violence-related injury. The associations of alcohol and cocaine with violence-related injury appear to be additive. In contrast, opiates were independently associated with nonviolent injuries and burns. CONCLUSIONS: Alcohol and cocaine use is independently associated with violence-related injuries, whereas opiate use is independently associated with nonviolent injuries and burns.

Adolescent↗
PubMed2004

Admission characteristics of trauma patients in whom delirium develops.

BACKGROUND: The purpose of this study was to describe the admission characteristics of trauma victims that are predictive of the development of delirium during hospitalization. METHODS: In this case-control study, data (demographics, injury type, medical histories, admission laboratory values, medications, and outcomes) were obtained from the records of 120 patients in whom delirium developed and 145 in whom it did not after admission for traumatic injury. Odds ratios were employed to identify significant predictors used in a stepwise logistic regression analysis. RESULTS: Admission characteristics, retained after stepwise logistic regression, that were independently predictive of delirium were age more than 45 years, positive admission blood alcohol, and an elevated mean corpuscular volume. Those in whom delirium developed had longer hospital and intensive care unit lengths of stay than in whom it did not. CONCLUSIONS: Older patients and alcoholics are at increased risk for delirum. Therapies directed at prevention have the potential to improve care and decrease lengths of stay.

Age Distribution↗
PubMed2004

Laryngotracheal injuries: does injury mechanism matter?

Laryngotracheal injuries are potentially lethal injuries whose diagnosis can be difficult. The purpose of this study was to delineate the effect of injury mechanism on the types of injury sustained and patient outcome. Patient records during a 7-year period were reviewed for injury mechanism, patient demographics, clinical presentation, patient evaluation, injury location, associated injuries, operative interventions, and outcome. Fifteen patients with laryngotracheal injuries were studied. Blunt injuries were more common (60%). Patient demographics, mortality, average length of stay, and Injury Severity Score were similar for both groups. Prevalent physical findings on examination included subcutaneous air (53%), hoarseness (47%), stridor (20%), and neck tenderness (27%). Diagnosis was confirmed by CT scan of the neck (66% blunt, 33% penetrating) or bronchoscopy (44% blunt, 66% penetrating). Injury location, patient disposition, and associated injures were the same for both groups. The most frequent operative intervention performed for both groups consisted of a primary airway repair via a collar incision within 8 hours of injury. Only patients with a laryngeal injury required concomitant tracheostomy regardless of mechanism. Blunt and penetrating neck injuries resulted in similar types of tracheal and laryngeal injuries. Anatomic location of the injury determined the need for tracheostomy. Regardless of mechanism, the overall outcome for patients with laryngotracheal injuries is good when injuries are recognized and treated expeditiously. A high level of suspicion must be maintained when evaluating all potential laryngotracheal injury patients irrespective of the mechanism of injury.

Adult↗
PubMed2002

Abdominal seat belt marks in the era of focused abdominal sonography for trauma.

HYPOTHESIS: Focused abdominal sonography for trauma (FAST) is an unreliable method for assessing intra-abdominal injury in patients with seat belt marks. DESIGN: 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. SETTING: University hospital designated as a level I trauma center. PATIENTS: Twenty-three patients who required operation for intestinal or mesenteric injury and who had an abdominal seat belt mark. MAIN OUTCOME MEASURE: Sensitivity of FAST in these patients. RESULTS: 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). CONCLUSION: This study confirms that FAST cannot reliably exclude intestinal injury in patients with seat belt marks.

Abdomen↗
PubMed2002

Examination of the role of abdominal computed tomography in the evaluation of victims of trauma with increased aspartate aminotransferase in the era of focused abdominal sonography for trauma.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Abdominal Injuries↗
PubMed2002

Enteral access for nutritional support: rationale for utilization.

Acquisition of enteral access and provision of a sufficient volume of enteral nutrients early in the hospital course of a critically ill patient afford an opportunity to improve the outcome of that patient through the progression of his or her disease process. Failure to use the enteral route of feeding not only squanders this opportunity, but may, in addition, promote a pro-inflammatory state, which exacerbates disease severity and worsens morbidity. Enteral feeding provides a conduit for the delivery of immune stimulants and serves as effective prophylaxis against stress-induced gastropathy and gastrointestinal hemorrhage. Tube placement beyond the stomach into the small bowel in hypermetabolic, severely ill patients prone to ileus and disordered gut motility aids delivery of enteral nutrients while reducing risk of aspiration. Endoscopic skills and expertise in gastrointestinal physiology are vital to the success of a nutrition support service and the provision of enteral tube feeding.

Burns↗
PubMed2002

Reevaluation of diagnostic procedures for transmediastinal gunshot wounds.

BACKGROUND: Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies. METHODS: Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures. RESULTS: Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation. CONCLUSION: Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.

Adolescent↗
PubMed2002

Risk factors for delirium tremens in trauma patients.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Adult↗
PubMedDate not supplied

Nonoperative management of lower extremity claudication caused by a Baker's cyst: case report and review of the literature.

A Baker's or popliteal cyst is a synovial cyst in the popliteal fossa arising from the knee joint. The majority of patients develop a popliteal mass that is asymptomatic, but in a small percentage of patients, complications and symptoms occur; these may not only encompass the popliteal veins and arteries but may also include cyst leakage, infection, hemorrhage, and compartment syndrome. Severe lower limb ischemia caused by a Baker's cyst is extremely rare, having been reported only six times since 1960; all patients were treated with surgical intervention. We report the case of a 29-year-old male presenting with right calf claudication caused by a Baker's cyst. The patient was managed nonoperatively with nonsteroidal anti-inflammatory agents, proper exercises, and close observation. His claudication improved progressively and had completely disappeared at 12 months of follow-up. A repeat duplex arterial study showed that increased blood flow to the right foot and the right ankle/brachial index improved to 0.97 from 0.67. Repeat ultrasonography demonstrated that the size of the cyst decreased from 4.5 x 1.5 cm to 2.8 x 0.9 cm. The patient had been followed for 20 months and remained asymptomatic in the last 8 months. We will continue to follow the patient to evaluate the long-term outcome. In summary, our own data and literature review suggest that the limb ischemia caused by Baker's cyst may be a transient condition and can be managed nonoperatively in selected patients.

Adult↗