Biomedical subjects

K J Brasel

Publications and source records attributed to K J Brasel.

17 recordsLinked to original sources

PubMed2001

Teaching anatomy with surgeons' tools: use of the laparoscope in clinical anatomy.

The purpose of this study was to establish the feasibility of laparoscopy in embalmed cadavers to teach abdominal gross anatomy. One cadaver was selected based on body habitus and absence of previous abdominal operations. A standard trocar was used to enter the abdomen at the umbilicus. Two trocars were placed in the left upper quadrant. Pneumoperitoneum was achieved with continuous CO(2) pressure. Liver retraction was achieved percutaneously, exposing the porta hepatis and the gallbladder. The dissection was done with four first-year medical students using standard laparoscopic equipment. Following this, the demonstration was projected over multiple monitors so that all students could participate. Laparoscopic dissection in an embalmed cadaver is feasible and an excellent educational tool for both the medical student and the dissector. The dissector has the opportunity to manipulate laparoscopic tools in a human model closely paralleling operative experience, and the students have an opportunity to learn abdominal anatomy from a clinical perspective. Laparoscopic examination and dissection of fresh cadavers has been used for training surgeons on new procedures such as colon resection, antireflux procedures, and cholecystectomy. There is no report of this same technology used in embalmed cadavers to teach basic anatomy. This approach allows first-year medical students to learn the anatomy while exposing them to the technology currently used in surgical practice, and it affords surgical residents and students additional opportunities to practice laparoscopic skills.

Abdomen↗

PubMed2001

Postoperative atrial fibrillation in noncardiothoracic surgical patients.

BACKGROUND: Atrial fibrillation is a common arrhythmia whose prevalence increases with age. It is a well-known complication of cardiothoracic surgery, but the incidence and contributing factors to the development of atrial fibrillation in noncardiothoracic surgical patients are less well known. This study was undertaken to investigate the incidence, association with known risk factors, treatment, and outcome of atrial fibrillation in postoperative noncardiac, nonthoracic surgical patients. METHODS: A 2-year retrospective review was performed of all noncardiac, nonthoracic surgical patients that developed atrial fibrillation within 30 days of operation. Incidence, risk factors, treatment and outcome related to the development of this arrhythmia were analyzed. RESULTS: Fifty-one patients developed atrial fibrillation during this study period for an incidence of 0.37%. Most had preexisting cardiac risk factors, a positive fluid balance, or had electrolyte or arterial oxygen saturation abnormalities. Two thirds were discharged home on new cardiac medications, 16% remained in atrial fibrillation, and 12% died. CONCLUSIONS: New onset atrial fibrillation in this group of noncardiothoracic surgical patients is an uncommon problem that is a morbid event associated with significant mortality.

Adult↗

PubMed2000

Evaluation of error in medicine: application of a public health model.

A case of a chest tube placed on the wrong side during a trauma resuscitation in the emergency department is presented as an example of medical injury. Two traditional models, the legal model and the managerial model, are described and their application to medical injury discussed. A new public health model is then applied to the case example as a more effective way to address medical injury. The public health model addresses the injury event rather than the error itself using Haddon's matrix as a framework. Pre-event, event, and post-event phases are examined to find the weakest link, where intervention has the highest likelihood of successfully preventing future injuries.

Accidents, Traffic↗

PubMed1999

Treatment of occult pneumothoraces from blunt trauma.

BACKGROUND: Occult pneumothoraces (OPTXs) are seen on abdominal computed tomographic (CT) scans but not on routine chest x-ray films. Optimal treatment for blunt trauma OPTXs has not been defined. We hypothesized that OPTXs could be safely observed without need for a chest tube (CT). METHODS: A prospective trial randomized blunt trauma patients with OPTXs to CT scan or observation. Patients were not excluded for positive pressure ventilation. Primary outcome measures were respiratory distress and pneumothoraces progression. RESULTS: Thirty-nine patients with 44 pneumothoraces were enrolled. Eighteen patients received a CT scan, and 21 patients were observed. Nine patients in each group received positive pressure ventilation. There was no difference in overall complication rate. No patient had respiratory distress related to the OPTX or required emergent CT scan. CONCLUSIONS: Observation of OPTX is not associated with an increased incidence of pneumothorax progression or respiratory distress. These pneumothoraces can be safely observed in patients with blunt trauma injury regardless of the need for positive pressure ventilation.

Adult↗

PubMed1999

Risk factors and patterns of injury in snowmobile crashes.

OBJECTIVE: To evaluate risk factors for snowmobile injury and patterns of injury. METHODS: We performed a retrospective analysis of patients with snowmobile injury at three trauma centers. Data were collected from trauma databases and patients charts from January 1988 through April 1996; we obtained statistics from the Minnesota Department of Natural Resources for comparison purposes. RESULTS: There were 274 patients identified. The average age was 29 years (SD 12, range 1.6-77). The male:female ratio was 6.6:1. Helmets were used in 35%, not used in 10%, and not reported in 55%. Ethanol consumption was reported in 44% of patients. The average speed of the snowmobile at the time of the accident, when reported, was 47 mph/75 kph (n = 103, range 10-100 mph/16-166 kph). Of these patients, 26% (n = 27) reported a speed in excess of the legal limit (55 mph/88 kph). Accidents were more common in the afternoon and evening hours, and most accidents were caused by the snowmobile striking terrain or man-made objects. Mortality rate was 3.6% for this patient group (10 of 274). The average injury severity score (ISS) was 15 (SD 11). The average Glasgow Coma Score (GCS) was 14. The average number of patients who went to the intensive care unit and the total lengths of stay were 2 +/- 5 and 8 +/- 9 days, respectively. Neither GCS nor ISS correlated with reported speed. The frequencies of different types of injuries are as follows: fractures of upper and lower extremities (n = 184), serious head injury (n = 92), facial fractures or soft tissue injury to head or neck (n = 88), thoracic injury (n = 80), spine injuries (n = 50), intraabdominal injuries (n = 41), and pelvic fractures (n = 31). CONCLUSIONS: Snowmobile injuries are related to ethanol use and the high speed attained by the newer generation of snowmobiles. Extremity fractures were a common component of snowmobile injury in this series, and rates of such injuries are similar to rates injuries in motorcycle accidents in states with helmet laws. Efforts at prevention of snowmobile injuries should be targeted at rider education and enforcement of alcohol restrictions.

Accidents↗

PubMed1999

Management of penetrating colon trauma: a cost-utility analysis.

BACKGROUND: Management of penetrating colon injuries in the presence of multiple associated risk factors is controversial. Issues not considered in previous management strategies are patient perception of quality of life with a colostomy and the true cost of each therapeutic option, which includes colostomy supplies and costs of colostomy takedown. To evaluate these issues, we performed a cost-utility analysis. METHODS: We constructed a decision tree with 3 options: primary repair, resection and anastomosis, and colostomy. Chance and decision nodes on each decision branch represent injury severity, complications, colostomy takedown, and death. Chance node frequencies and utility assignments were taken from published data. We obtained actual costs for all components of perioperative care. The outcomes reported are cost and quality of life. RESULTS: Colostomy has the least quality of life and the greatest cost. Primary repair and resection each dominate colostomy in the baseline analysis. No variable significantly altered these conclusions in sensitivity analyses. CONCLUSIONS: Simple suture or resection and anastomosis at the time of initial exploration is the dominant management method for penetrating colon trauma. It also demonstrates the trade-off between cost and life expectancy of the 3 management options.

Colon↗

PubMed1998

Gastric mucosal protection from enteral nutrients: role of motility.

BACKGROUND: Cold restraint stress increases the force of gastric contractions and produces gastric mucosal injury in rats. The aim of our study was to determine whether enteral glucose or hyperglycemia alone would alter the stress-induced gastric motility pattern and ameliorate the associated gastric mucosal injury. METHODS: Adult male rats underwent surgical placement of gastric catheters, jugular venous catheters, and gastric strain gauge transducers 5 days before cold restraint. Three groups of rats received different substances during the same cold restraint stress protocol. Group 1 received 0.9% NaCl, 2 mL/h infused both intravenously (i.v.) and intragastrically (i.g.); group 2 received 0.9% NaCl, 2 mL/h i.g. plus 25% glucose, 2 mL/h i.v.; and group 3 received 0.9% NaCl, 2 mL/h i.v. plus 25% glucose i.g. Following baseline gastric motility measurements, all rats were restrained for 2 hours at 20 degrees C followed by 2 hours at 4 degrees C. RESULTS: Restraint even at room temperature increased the force of gastric contractions; the cold environment gradually prolonged gastric contractions. Enteral glucose blunted the effects of stress on gastric motility, increased gastric residual volume, decreased gastric acidity, and prevented gastric mucosal injury. Parenteral glucose had little effect on any gastric parameters. CONCLUSIONS: Enteral glucose prevents the abnormal gastric motility pattern that is necessary to produce the gastric mucosal injury associated with cold restraint stress, but hyperglycemia alone has little effect on the pathophysiology of cold restraint.

Animals↗

PubMed1998

Splenic injury: trends in evaluation and management.

BACKGROUND: Changing methods of evaluating blunt abdominal trauma and expanding selection criteria for nonoperative management (NOM) of splenic injury can increase the number of patients managed nonoperatively without affecting success rates. METHODS: The charts of 164 patients with blunt splenic injuries from July 1, 1991, to June 30, 1996, were reviewed. Thirty-eight patients were excluded because of immediate laparotomy without adjunctive tests or expiration in the resuscitative period. Injuries were graded according to the Organ Injury Scale. RESULTS: Overall, successful NOM occurred in 84% of patients (73 of 87). NOM was successful in 5 of 7 patients > 55 years old and in 14 of 15 patients with Glasgow Coma Scale scores < 13. CONCLUSION: Use of computed tomography increased NOM of splenic trauma from 11 to 71% during the 5-year period for injuries of equivalent severity. Age > 55 years or abnormal neurologic status should not preclude NOM, because success was related only to injury grade.

Adolescent↗

PubMed1998

Dedicated operating room for trauma: a costly recommendation.

BACKGROUND: A dedicated operating room (OR) for urgent trauma cases is suggested by the American College of Surgeons Committee on Trauma as a necessary component of a Level I or II trauma center. We describe a cost analysis of this recommendation. METHODS: Two models for staffing urgent trauma cases were constructed. Urgent trauma cases were defined as those taken to the OR within 30 minutes of arrival. In one model the OR was available 24 hours a day with in-hospital personnel. The second model used an out-of-hospital call schedule, assuming a patient-ready OR in 30 minutes. Costs and revenue per urgent case were calculated. A break-even analysis shows the number of cases required for costs to equal revenue. RESULTS: In the 24-hour model, the cost/urgent case is $14,288; in the call-schedule model $3,243. The number of cases to break even in the 24-hour model is 1210; in the call-schedule model 375. CONCLUSIONS: A call-schedule model is the least costly way to staff an OR for urgent trauma cases.

Costs and Cost Analysis↗

PubMed1998

Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma.

OBJECTIVE: To determine the incidence and significance of free fluid on abdominal CT in blunt trauma. DESIGN: Retrospective chart review. METHODS: All blunt trauma patients with an abdominal computed tomographic scan from August of 1993 to December of 1995 were identified from the trauma registry at a Level 1 trauma center. A total of 1,159 computed tomographic scans were performed; records of 18 patients were excluded for incomplete records. Official reports of computed tomographic scans were reviewed for free fluid, solid organ injury, bladder injury, and pelvic fracture. RESULTS: Free fluid without solid organ injury was found in 3% (34 of 1141). Laparotomy was performed because of free fluid in 13 patients. There were six small bowel injuries and one diaphragm injury for a therapeutic laparotomy rate of 54%. Ten patients had trace free fluid and did not undergo laparotomy; none had a missed small bowel injury. CONCLUSIONS: The presence of more than trace amounts of free fluid without solid organ injury in patients with blunt trauma is a strong indication for exploratory laparotomy. Patients with isolated trace amounts of free fluid can be safely observed.

Abdominal Injuries↗

PubMed1997

Trends in the management of hepatic injury.

BACKGROUND: Options for management of blunt hepatic injury have broadened to include both operative management (OM) and nonoperative management (NOM). We identify trends in evaluation and management of blunt hepatic injury at a level 1 trauma center. METHODS: Charts of 106 patients with blunt hepatic injuries from July 1, 1991 to June 30, 1995 were reviewed for method of abdominal evaluation (computed tomography versus DPL), injury severity score, liver injury grade, method of management, length of stay (LOS), transfusion requirements, complications, and outcome. RESULTS: Nonoperative management steadily increased to 86%. Successful NOM occurred in 96% (48 of 50) and was not related to injury grade. Transfusion requirements were significantly greater in the group with OM versus those with NOM (11.3 versus 2.7). Patients with NOM also had significantly shorter intensive care unit stay and total LOS. CONCLUSIONS: The majority of patients with blunt liver injury can be successfully managed nonoperatively regardless of injury grade. Nonoperative management may allow decreased resource utilization because of shorter hospital stays and decreased transfusion requirements.

Adolescent↗

PubMed1997

Decision analysis: balancing quality and cost.

Healthcare reform is a topic consuming the time and energy of many healthcare professionals, administrators, and politicians. One goal of reform is to improve value--better quality health care for less cost. Unfortunately, much of the current debate proceeds without clear definitions of quality or cost. To have profitable discussion, we must have precise definitions. With these definitions in hand, the technique of decision analysis provides a unique opportunity to evaluate quality and costs of healthcare decisions simultaneously. We believe it is imperative for physicians to become familiar with this important and powerful tool.

Cost-Benefit Analysis↗

PubMed1997

Cost-effective prevention of pulmonary embolus in high-risk trauma patients.

OBJECTIVE: To define the cost-effectiveness of screening ultrasound (US) and prophylactic inferior vena cava filters (VCF), approaches aimed at reducing the incidence of pulmonary embolus (PE) in high-risk trauma patients. DESIGN: Cost-effective analysis. MATERIALS AND METHODS: We constructed a decision tree with three approaches for PE prevention: no intervention, US, and VCF. Probabilities in each subtree were taken from published data. Sensitivity analyses evaluated all assumptions, probabilities, and outcomes for effects on baseline conclusions. RESULTS: US is more cost-effective than VCF, with a cost/PE prevented of $46,300 compared with $93,700. The strategies become equally cost-effective only when VCF are placed in the radiology suite and length of stay is > or = 2 weeks. CONCLUSIONS: US is the most cost-effective approach for PE prevention in high-risk trauma patients. VCF should be reserved for patients with an anticipated length of stay > or = 2 weeks who can safely have a filter placed in the radiology suite.

Aged↗

PubMed1997

Cost-utility analysis of contaminated appendectomy wounds.

BACKGROUND: The influence of patient preference and treatment costs has not been considered in previous analyses of wound management decisions for contaminated right lower quadrant incisions. STUDY DESIGN: We performed a decision and cost-utility analysis, conducting a MEDLINE search of the postappendectomy wound infection literature to establish assumptions and assign baseline probability estimates. Institution-specific cost data were obtained, and utility assignments were made by the authors. Studies used to assign baseline probabilities fulfilled the following criteria: perforated appendix or gangrenous appendicitis, use of perioperative antibiotics active against aerobic and anaerobic bacteria, and data stratified by wound management, operative findings, and infection rate. RESULTS: We constructed a decision tree comparing three methods of wound management for contaminated right lower quadrant incisions: primary closure, delayed primary closure, and secondary closure. Utility (a quality of life measure) was assigned to ultimate health states to incorporate patient preference. We calculated the cost-utility for each method of wound management and found that primary closure was of optimum cost-utility compared with delayed primary closure and secondary closure. To gain one quality-adjusted life year treating a population of patients with contaminated incisions, primary closure saves $22,635 over delayed primary closure and another $22,340 over secondary closure. This decision, tested by two-way sensitivity analyses, was sensitive only to high primary closure infection rates. CONCLUSIONS: Challenging traditional surgical dogma, cost-utility analysis shows that primary closure is the favored method of management for contaminated right lower quadrant incisions. This analysis is specific to right lower quadrant incisions and the conclusion is valid for all estimated primary infection rates less than 0.27.

Appendectomy↗

PubMed1996

Blunt thoracic aortic trauma. A cost-utility approach for injury detection.

OBJECTIVE: To evaluate the influences of patient preference and treatment costs on the diagnostic approach to blunt aortic trauma. METHODS: Decision and cost-utility analysis. DATA SOURCES: A MEDLINE search of all literature dealing with the diagnosis and management of blunt aortic injury was used to establish assumptions and assign baseline probability estimates. Utility assignments were made from published data and our own assignments. We obtained institution-specific cost data. STUDY SELECTION: Only randomized, prospective trials that used aortography as the gold standard test were used to assign baseline accuracy of transesophageal echocardiography and dynamic chest computed tomography. Other baseline estimates were taken from class II and class III published data. DATA SYNTHESIS: A decision tree compared 4 diagnostic approaches for blunt chest trauma after an initial normal chest radiograph: observation with follow-up chest radiography, aortography, transesophageal echocardiography, and dynamic chest computed tomography. Utility (a quality-of-life measure) was assigned to ultimate health states to incorporate patient preference. Chest radiography and aortography had similar utility. Aortography gained 1 quality-adjusted life year for minimal cost. Transesophageal echocardiography and dynamic chest computed tomography lose quality-adjusted life-years at increased cost. No variable changed the relative cost-utility of the screening methods in 2-way sensitivity analyses. CONCLUSIONS: Aortography gains additional quality life at minimal cost when used as a screening method for all patients with blunt chest trauma regardless of the results of the initial chest radiograph. With a normal initial chest radiograph, transesophageal echocardiography and dynamic chest computed tomography are associated with increased cost and loss of quality-adjusted life.

Aorta, Thoracic↗

PubMed1996

Abdominal computed tomography scan as a screening tool in blunt trauma.

BACKGROUND: One of the most difficult problems in blunt trauma is evaluation for potential intraabdominal injury. Admission for serial abdominal exams remains the standard of care after intraabdominal injury has been initially excluded. We hypothesized a normal abdominal computed tomography (CT) scan in a subgroup of minimally injured patients would obviate admission for serial abdominal examinations, allowing safe discharge from the emergency department (ED). METHODS: We reviewed our blunt trauma experience with patients admitted solely for serial abdominal examinations after a normal CT. Patients were identified from the trauma registry at a Level 1 trauma center from July 1991 through June 1995. Patients with abnormal CTs, extra-abdominal injuries necessitating admission, hemodynamic abnormalities, a Glasgow Coma Scale less than 13, or injury severity scores (ISSs) greater than 15 were excluded. Records of 238 patients remained; we reviewed them to determine the presence of missed abdominal injury. RESULTS: None of the 238 patients had a missed abdominal injury. Average ISS of these patients was 3.2 (range, 0 to 10). Discharging these patients from the ED would result in a yearly cost savings of $32,874 to our medical system. CONCLUSIONS: Abdominal CT scan is a safe and cost-effective screening tool in patients with blunt trauma. A normal CT scan in minimally injured patients allows safe discharge from the ED.

Abdominal Injuries↗

PubMed1996

Predictors of outcome in blunt diaphragm rupture.

OBJECTIVE: Identify outcome predictors in blunt diaphragm rupture (BDR). DESIGN: Retrospective chart and trauma registry review. MATERIALS AND METHODS: We reviewed records of patients with BDR from January 1987 through May 1994 for outcomes of mortality, intensive care unit stay, hospital stay, and ventilator days. Predictors tested were age, sex, Injury Severity Score (ISS), diagnostic delay, rupture side, head injury, and associated injuries. Stepwise regression models were developed and tested on an additional data base of 115 BDR records from four trauma centers. RESULTS: Thirty-two patients were identified. Age was the only significant predictor for all outcomes (p < 0.05). Age, ISS, and severe head injury were mortality predictors. In the larger data base, age and ISS remained predictive of mortality, but age was not predictive of morbidity. CONCLUSIONS: Age and ISS are predictive of BDR mortality. No morbidity predictor was validated in the larger data base. These data emphasize that predictive models from a single institution should be applied cautiously.

Adolescent↗