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R R Ivatury

Publications and source records attributed to R R Ivatury.

At least 19 recordsLinked to original sources
PubMed2005

In the wake of Hurricane Isabel: a prospective study of postevent trauma and injury control strategies.

Preventing hurricane-related injuries (HRI) has historically centered on the pre-event and event phases of the disaster. To date, no study has focused on injuries occurring during the postevent phase. We examined HRI that occurred after Hurricane Isabel struck a U.S. urban city. HRI presenting 1 week prior to the hurricane were collected from emergency department electronic records. HRI that presented to our level 1 trauma center were prospectively collected for 1 week after the hurricane. Nine hundred seventy-eight patients with possible HRI were identified. Fifty-one patients with trauma directly attributed to the hurricane were used for analysis. The number of HRI occurring before, during, and after the hurricane were 7 (14%), 3 (6%), and 41 (80%), respectively. The majority of HRI (37%) occurred on posthurricane day 1. Head, chest, upper and lower extremities accounted for 9 (18%), 8 (16%), 13 (26%), and 14 (28%) of HRI. More than one third of HRI patients were admitted to the hospital, and 12 (24%) underwent an operation. The average hospital length of stay was 4.7 days. Of our trauma alerts, 75 per cent had an Injury Severity Score (ISS) >8, and 20 per cent had an ISS >15. Tree-related injuries (TRI) accounted for 59 per cent of HRI. Males, ages 50-60, had the highest incidence of injury (63%). Significant injuries occur in the wake of a hurricane. Optimization of disaster preparation must include prevention strategies targeted to the postevent recovery phase of disasters.

Adolescent↗
PubMed2002

Factors associated with mortality in patients with penetrating abdominal vascular trauma.

OBJECTIVE: Prehospital transport, resuscitation, and operative intervention are all critical to the care of the penetrating trauma victim. We determined which factors most affected mortality in patients with penetrating abdominal vascular injuries. METHODS: Consecutive patients with penetrating abdominal vascular injuries from an urban Level I trauma center from January 1993 to December 1998 were identified from the trauma registry and their charts reviewed. All patients who died prior to operative intervention were excluded. Data collected included mortality, age, scene time (ST), EMS transport time (TT), time in the emergency department (ED), initial systolic blood pressure in the ED (BP), operating time, intraoperative estimated blood loss (EBL), and worst base deficit in the first 24 h (BD). These variables were compared between nonsurvivors and survivors by univariate ANOVA. Multivariate ANOVA (MANOVA) determined independent effects on mortality. RESULTS: Forty-six penetrating abdominal vascular injuries were identified in 31 patients, 11 of whom died (38.7%). Examining prehospital parameters, mean ST averaged 16.5 +/- 3.6 min, while TT was 31.8 +/- 7.1 min. For ED parameters, initial BP was 94.8 +/- 6.4 mm Hg and initial heart rate was 109 +/- 7 beats per minute. Mean operative EBL for all patients was 3518 +/- 433 ml. The mean BD for all patients was -12.9 +/- 1.8. Significant differences were noted in the univariate analysis between survivors and nonsurvivors for BD (P < 0.0001), BP (P = 0.0062) and EBL (P = 0.0002). MANOVA revealed that only base deficit (P < 0.0001) had an independent effect on mortality. CONCLUSIONS: In patients with penetrating abdominal vascular injuries who survive their ED stay, adverse physiologic parameters reflecting the adequacy of resuscitation are more predictive of mortality than identifiable prehospital parameters.

Abdomen↗
PubMed2001

Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study.

BACKGROUND: The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. METHODS: This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. RESULTS: Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. CONCLUSION: The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Adult↗
PubMed2001

Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial.

BACKGROUND: Construction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries. METHODS: Using a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed. RESULTS: A total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08-infinity, p = 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96-7.57, p = 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89-4.86, p = 0.076). CONCLUSION: Anastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.

Adolescent↗
PubMed2001

Should trauma surgeons render definitive vascular repair in peripheral vascular injuries?

Our hypothesis is that in an established Level I trauma center general trauma surgeons should repair peripheral vascular injuries even in stable patients when there is time for a vascular consult. We reviewed all penetrating peripheral vascular injuries in stable patients operated on by nine experienced general trauma surgeons (1993-1996). Outcome measures were amputation, nerve damage, and vascular complications. There were 43 patients with 44 peripheral vascular injuries identified. Sixty per cent were from stab wounds. There were 27 arterial injuries (carotid four, subclavian one, vertebral two, axillary three, brachial eight, ulnar one, radial two, femoral five, and anterior tibial one). There were three venous injuries (one each subclavian, axillary, and popliteal). There were 14 combined injuries (vertebral two, femoral nine, and popliteal three). There were no mortalities. Morbidity was limited to patients with lower extremity injuries. In the nine patients with combined femoral vessel injury there were three complications (nerve damage, thrombosed arterial repair, and thrombosed venous repair). In the four patients with popliteal venous injuries there were two complications, both venous thrombosis. Our early arterial patency rate was 97.6 per cent. These data support the hypothesis that general surgeons with trauma experience can provide effective treatment of peripheral vascular injuries. The significance of these findings in improving the image of trauma surgery as a career is discussed.

Adolescent↗
PubMed2000

Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: preliminary findings.

BACKGROUND: The purpose of this study was to determine the utility of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of pancreatic duct trauma and pancreas-specific complications. METHODS: Ten hemodynamically stable patients with clinically suspected pancreatic injury related to blunt abdominal trauma (n = 8), penetrating trauma (n = 1), or iatrogenic trauma (n = 1) underwent MRCP. Two abdominal radiologists conducted a review of the MRCPs to assess for the presence or absence of pancreatic duct trauma and pancreas-specific complications such as pseudocysts. The MRCP findings were correlated with endoscopic retrograde cholangiopancreatograms (n = 2), surgical findings (n = 1), computed tomographic scans (n = 10), and with clinical, biochemical or imaging follow-up (n = 10). RESULTS: Diagnostic quality MRCPs were obtained in each of the 10 patients. A mean imaging time of 5 minutes was required to perform the MRCPs. Pancreatic duct injuries were detected in four patients; pseudocysts were detected in three of these four patients. The pancreatic duct injuries in three patients were acute or subacute. In one of the three patients, disruption of a side branch of the pancreatic duct diagnosed with MRCP was not detected with endoscopic retrograde cholangiopancreatography but was confirmed surgically. In the fourth patient, the pancreatic duct injury was chronic; MRCP revealed a posttraumatic stricture in this patient who had sustained blunt abdominal trauma 17 years previously. In the remaining six patients, pancreatic duct trauma was excluded with MRCP. The information derived from the MRCPs was used to guide clinical decision-making in all 10 patients. CONCLUSIONS: MRCP enables noninvasive detection and exclusion of pancreatic duct trauma and pancreas-specific complications and provides information that may be used to guide management decisions.

Adolescent↗
PubMed2000

Intestinal perforation secondary to Salmonella typhi: case report and review of the literature.

The case of a young woman presenting with fever, abdominal distention, and diarrhea is presented. While hospitalized, she developed peritonitis, and a laparotomy was performed emergently. Intraoperative and pathologic examinations are highly suggestive of Salmonella typhi as an etiology for her symptoms and eventual perforation. Salmonella enteritis can be a difficult diagnosis to make, but in most cases it is a self-limited disease process. In a minority of cases, multidrug antibiotic therapy may be required secondary to an increasing prevalence of resistant strains. Patients who perforate require prompt operation to limit morbidity and mortality. Outcome is significantly improved in those patients by directed resection of the affected segment of bowel and by aggressive perioperative care.

Adult↗
PubMed1999

Laparoscopy in the new century.

Minimally invasive surgery already has established itself as a useful tool in the management of trauma. The future holds exciting possibilities for this field, borne and fostered by innovative developments in imaging, computer technology, and artificial intelligence. The next millennium may witness the disappearance of trauma surgery as it is known today.

Artificial Intelligence↗
PubMed1999

The surgical intensive care unit as a cost-efficient substitute for an operating room at a Level I trauma center.

Critically ill patients in the surgical intensive care unit (SICU) continue to require operative procedures. Traditionally, this has meant the transport of these critically ill patients out of the safe, monitored confines of the SICU to the operating room (OR). This can be hazardous to the patient, as well as expensive. Performing the procedures in the OR can avoid both the dangers of transport and the expense of the OR. Herein is a descriptive study of 80 procedures performed on 36 patients in the SICU. We believe that these data show that the SICU can be a cost-effective alternative to the OR in a trauma center in critically ill patients. Significant cost savings may be realized without increasing the iatrogenic or infectious complications.

Cost-Benefit Analysis↗
PubMed1999

Antioxidant therapy in the prevention of organ dysfunction syndrome and infectious complications after trauma: early results of a prospective randomized study.

Reactive oxygen species have been implicated in the etiology of multiorgan dysfunction syndrome and infectious complications in trauma patients by either direct cellular toxicity and/or the activation of intracellular signaling pathways. Studies have shown that the antioxidant defenses of the body are decreased in trauma patients; these include glutathione, for which N-acetylcysteine is a precursor, and selenium, which is a cofactor for glutathione. Eighteen trauma patients were prospectively randomized to a control or antioxidant group where they received N-acetylcysteine, selenium, and vitamins C and E for 7 days. As compared with the controls, the antioxidant group showed fewer infectious complications (8 versus 18) and fewer organs dysfunctioning (0 versus 9). There were no deaths in either group. We conclude that these preliminary data may support a role for the use of this antioxidant mixture to decrease the incidence of multiorgan dysfunction syndrome and infectious complications in the severely injured patient. This remains to be confirmed in larger trials.

Acetylcysteine↗
PubMed1999

Preferred route of tracheostomy--percutaneous versus open at the bedside: a randomized, prospective study in the surgical intensive care unit.

Percutaneous tracheostomy has been touted as the preferred route of tracheostomy. However, to date, no prospective randomized study comparing bedside percutaneous (BP) to bedside open (BO) tracheostomy has been performed. Surgical intensive care unit (sICU) patients were randomized to receive either a BP or a BO tracheostomy. Patients were monitored for complications. Procedure time was documented. A group of medical ICU patients had open tracheostomies in the operating room (OR) and served as contemporaneous controls. Over 11 months, there were 24 surgical ICU patients randomized to receive either BP tracheostomy or BO tracheostomy, 12 in each group. Forty-six medical ICU patients received standard open tracheostomy in the OR. The number of ventilator days before placing the tracheostomy was similar between the BP and BO groups, 9.8 and 12.4, respectively. The clinical indications for tracheostomy were similar between the two groups. The procedure time for the BP group was 14.5 minutes, whereas 25.2 minutes for the BO group. There were no postprocedure complications in the BP and BO groups. There was a trend toward more complications in the BP group, including the loss of the airway, leading to death. The procedure time and complications were similar between the BO and OR groups. These data do not support that BP tracheostomy is the preferred route of tracheostomy when compared with BO tracheostomy. These data support that experienced surgical intensivists can perform BO tracheostomies with lower risk and cost, when compared with BP tracheostomy.

Adult↗
PubMed1998

A critical reappraisal of indications for fasciotomy after extremity vascular trauma.

OBJECTIVE: To critically reevaluate the indications for fasciotomy in vascular trauma of the extremities. DESIGN: Case-control study. SETTING: Level I trauma center. MATERIALS AND METHODS: One hundred sixty-three vascular injuries to the extremeties were analyzed. Fasciotomy as an adjunct to vascular repair was performed in 45 limbs (28%), based either on the nature of injury or measured compartment pressure of greater than 35 mm Hg. MAIN OUTCOME MEASURES: Need for fasciotomy or limb amputation. RESULTS: Fasciotomy was performed for 29.5% of isolated arterial injuries, 15.2% of isolated venous injuries, and 31.6% of combined arterial and venous injuries, and was not related to venous repair or ligation. Seven delayed fasciotomies were performed either for vascular repair failure (5 patients) or compartment syndrome (2 patients). The highest incidence was for popliteal vessel injury (arterial 57%, combined 61%). Of the 33 lower-extremity fasciotomies, 58% were for popliteal vessel injury. In 51 combined injuries of the lower extremity, only 7 (19%) of 38 patients with injury above the knee required fasciotomy, as compared with 8 (62%) of 13 with injury to the popliteal vessels (P<.001), with or without venous repair. There were 3 amputations, all resulting from vascular repair failure. CONCLUSIONS: The presence of a combined vascular injury or the need for venous ligation does not necessitate routine fasciotomy. The need for fasciotomy may be maximal for injuries to popliteal vessels.

Adolescent↗