Shunt Malfunction Without Device Occlusion: A Case Report / 대한신경손상학회지

Shunt malfunction is the most common cause of ventriculoperitoneal shunt failure. In literature, occlusion of the tube with brain parenchyma, choroid plexus, blood, and proteinaceous debris has been suggested as a mechanism of obstruction. We herein report a case of shunt malfunction without any identifiable occlusion. Our case findings suggest that unapparent abdominal pathology, including inflammation and fibrosis, should be considered when treating shunt failures.

Emergency Department Laparotomy Can Be a Resuscitative Option for Patient with Cardiac Arrest and Impending Arrest due to Intra-Abdominal Hemorrhage

Purpose@#Managing patients with hemorrhagic shock is mainly dependent on stopping the bleeding as fast as possible. Emergency Department laparotomy (EDL) is considered one of the approaches to control intra-abdominal bleeding rapidly. This study aims to evaluate the outcomes of EDL in a regional trauma center of Pusan National University Hospital in a 4-year period. @*Methods@#The medical records and data of patients who underwent EDL from January 2016 to December 2019 were analyzed. Patients who underwent preperitoneal pelvic packing only or did not receive surgery immediately after EDL were excluded. @*Results@#Twenty-four patients who underwent EDL were included in the study. 18 patients had sustained blunt trauma, and 6 suffered from penetrating injuries. Small bowel mesentery and liver injuries were the most frequent. Increase of median systolic blood pressure (SBP) after EDL was 55.5 mmHg. Four (16.7%) out of the 24 survived; one of the four survivors received cardiopulmonary resuscitation (CPR). In the nonsurvivor group, Injury Severity Score was significantly higher (p = 0.013), initial pH was lower (p = 0.035) and the amount of packed red blood cells transfusion after EDL was significantly higher (p = 0.013) than those in the survivor group. @*Conclusion@#The mortality rate was very high in trauma patients who were required EDL. Although EDL was not proved to be an effective procedure for resuscitation in trauma patients, it could be considered as one of the treatment options for trauma patients in extremis. Further studies are required to examine the effects of EDL.

Emergency Department Laparotomy Can Be a Resuscitative Option for Patient with Cardiac Arrest and Impending Arrest due to Intra-Abdominal Hemorrhage

Purpose@#Managing patients with hemorrhagic shock is mainly dependent on stopping the bleeding as fast as possible. Emergency Department laparotomy (EDL) is considered one of the approaches to control intra-abdominal bleeding rapidly. This study aims to evaluate the outcomes of EDL in a regional trauma center of Pusan National University Hospital in a 4-year period. @*Methods@#The medical records and data of patients who underwent EDL from January 2016 to December 2019 were analyzed. Patients who underwent preperitoneal pelvic packing only or did not receive surgery immediately after EDL were excluded. @*Results@#Twenty-four patients who underwent EDL were included in the study. 18 patients had sustained blunt trauma, and 6 suffered from penetrating injuries. Small bowel mesentery and liver injuries were the most frequent. Increase of median systolic blood pressure (SBP) after EDL was 55.5 mmHg. Four (16.7%) out of the 24 survived; one of the four survivors received cardiopulmonary resuscitation (CPR). In the nonsurvivor group, Injury Severity Score was significantly higher (p = 0.013), initial pH was lower (p = 0.035) and the amount of packed red blood cells transfusion after EDL was significantly higher (p = 0.013) than those in the survivor group. @*Conclusion@#The mortality rate was very high in trauma patients who were required EDL. Although EDL was not proved to be an effective procedure for resuscitation in trauma patients, it could be considered as one of the treatment options for trauma patients in extremis. Further studies are required to examine the effects of EDL.

A Peripherally Inserted Central Catheter is a Safe and Reliable Alternative to Short-Term Central Venous Catheter for the Treatment of Trauma Patients

PURPOSE@#To determine whether a peripherally inserted central catheter (PICC) meets the goals of a low infection rate and long-term use in trauma patients.@*METHODS@#From January 2016 to June 2018, the medical records of patients who underwent central venous catheterization at a level I trauma center were retrospectively reviewed. Data collected included age, sex, injury severity score, site of catheterization, place of catheterization (intensive care unit [ICU], emergency department, or general ward), type of catheter, length of hospital stay during catheterization, types of cultured bacteria, time to development of central line-associated bloodstream infection (CLABSI), and complications.@*RESULTS@#During the study period, 333 central vein catheters (CVC) were inserted with a total of 2,626 catheter-days and 97 PICCs were placed with a total of 2,227 catheter- days. The CLABSI rate was significantly lower in the PICC group when the analysis was limited to patients for whom the catheter was changed for the first time in the ICU after CVC insertion in the ER with similar indication and catheter insertion times (18.6 vs. 10.3/1,000 catheter-days, respectively, p<0.05). The median duration of catheter use was significantly longer in the PICC group than in the CVC group (16 vs. 6 days, respectively, p<0.05).@*CONCLUSIONS@#The study results showed that the duration of catheter use was longer and the infection rate were lower in the PICC group than in the CVC group, suggesting that PICC is a safe and reliable alternative to conventional CVC.

Clinical Effects of Intra-Abdominal Pressure in Critically Ill Trauma Patients

PURPOSE@#There is increasing interest in intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) in critically ill patients. This study investigated the effects and outcomes of elevated IAP in a trauma intensive care unit (ICU) population.@*METHODS@#Eleven consecutive critically ill patients admitted to the trauma ICU at Pusan National University Hospital Regional Trauma Center were included in this study. IAP was measured every 8–12 hours (intermittently) for 72 hours. IAP was registered as mean and maximal values per day throughout the study period. IAH was defined as IAP ≥12 mmHg. Abdominal compartment syndrome was defined as IAP ≥20 mmHg plus ≥1 new organ failure. The main outcome measure was in-hospital mortality.@*RESULTS@#According to maximal and mean IAP values, 10 (90.9%) of the patients developed IAH during the study period. The Sequential Organ Failure Assessment (SOFA) score was significantly higher in patients with IAP ≥20 mmHg than in those with IAP <20 mmHg (16 vs. 5, p=0.049). The hospital mortality rate was 27.3%. Patients with a maximum IAP ≥20 mmHg exhibited significantly higher hospital mortality rates (p=0.006). Non-survivors had higher maximum and mean IAP values.@*CONCLUSIONS@#Our results suggest that an elevated IAP may be associated with a poor prognosis in critically ill trauma patients.

Infected Groin (Graft/Patch): Managed with Sartorious Muscle Flap

PURPOSE: The purpose of this study was to review the natural history, clinical outcome and safety in patients undergoing sartorius muscle flap (SMF) for groin infection, including lymphocele. MATERIALS AND METHODS: We retrospectively reviewed the records of patients who underwent SMF in a single center between 2000 and 2009. RESULTS: Thirty patients (17 male, 13 female) underwent SMF for groin infection, which included infections of 22 artificial femoral bypass grafts (including 2 cryoveins) and 5 common femoral patch grafts, and 3 lymphocele infections (2 cardiac catheterizations and 1 penile cancer lymph node dissection). Wound isolates were most commonly Gram-positive organisms (n=22) with Gram-negative isolates and mixed infections accounting for 4 and 3 cases, respectively. In 9 patients there was no growth of organisms. Adjunctive wound vacuum-asssisted wound closure therapy was performed in 18 patients. Follow-up duration ranged from 8 days to 56 months (mean 14.1 months) after SMF. Reoperation was performed in 3 patients due to wound bleeding (n=1) and reinfection (n=1). One patient underwent graft excision with external bypass operation. There was 1 mortality case due to sepsis during the study period. CONCLUSION: We found that muscle flap surgery provides successful single-intervention therapy for groin infections including lymphocele. Graft ligation or aggressive excision with bypass surgery should be reserved for patients requiring rapid control of sepsis for lifesaving.

Factors influencing on difficulty with laparoscopic total extraperitoneal repair according to learning period

PURPOSE: Laparoscopic total extraperitoneal (TEP) repair of inguinal hernia is technically challenging enough to build high barrier to entry. The purpose of this study was to identify clinical factors influencing technical difficulty with laparoscopic TEP according to learning period. METHODS: We conducted a retrospective study of 112 adult patients who underwent laparoscopic TEP for unilateral inguinal hernia from January 2009 to September 2013. A technically difficult case was defined as the 70th percentiles or more in the distribution curve of operative time, major complication, or open conversion. RESULTS: The rate of body mass index (BMI) above 25 kg/m2 was significantly higher in the difficult group than the nondifficult group in the learning period of laparoscopic TEP (57.9% vs. 26.8%, respectively, P = 0.020). However, in the experience period, it revealed no statistical difference with technical difficulty (31.3% vs. 33.3%, respectively, P = 0.882). In multivariate analysis, BMI (> or =25 kg/m2) was identified as a significant independent factor for technical difficulty with laparoscopic TEP in the learning period (odds ratio, 4.572; P = 0.015). CONCLUSION: Patient's BMI (> or =25 kg/m2) can create technical difficulty with laparoscopic TEP only in the learning period, but not in the experience period. Therefore BMI could be applied as one of the guidelines for patient selection, especially for surgeons in the learning curve of laparoscopic TEP.