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.

Successful Endovascular Management of Post-Traumatic Phlegmasia Cerulea Dolens from Rupture of the External Iliac Vein

We report a rare case of a 47-year-old male with posttraumatic phlegmasia cerulea dolens caused by a ruptured right external iliac vein and treated with an endovascular venous stent graft. The patient was the victim of motor vehicle accident, and suffered direct injuries to the head and abdomen. The patient had a cyanotic and swollen right lower leg. Abdominal and lower extremity computed tomography angiography revealed a large retroperitoneal hematoma caused by a ruptured right external iliac vein, and grade I liver injury. The right external iliac vein rupture was successfully treated with a venous stent graft, followed by inferior vena cava filtering, because a venous thrombus was identified below the stent graft. He initially was hemodynamically unstable but recovered following treatment. The patient was comatose when presenting at the emergency department. He was discharged, fully recovered, on hospital day 18.

A Retrospective Clinical Study: Complications of Totally Implanted Central Venous Access Ports

BACKGROUND: When managing patients who require repeated venous access, gaining a viable intravenous route has been problematic. To improve the situation, various studies on techniques for venous access have been conducted. The aim of this study is to evaluate the clinical results of complications following totally implanted central venous access port (TICVAP) insertion. METHODS: A retrospective analysis was conducted on 163 patients, from December 2008 to March 2013. The occurrence of complications was studied in three separate periods of catheter use: the intraoperative period, postoperative period, and period during the treatment. RESULTS: A total of 165 cases of TICVAP insertions involving 156 patients were included in the final analysis. There were 35 complications (21%) overall. Among these, 31 cases of complications (19%) occurred during the treatment period and the other 4 cases were intraoperative and postoperative complications (2%). There were no statistically significant differences in age and gender of the patients between the two groups to be risk factors (p=0.147, p=0.08). Past history of chemotherapy, initial laboratory findings, and the locations of TICVAP insertion also showed no statistical significance as risk factors (p>0.05). CONCLUSION: Because the majority of complications occurred after port placement and during treatment, meticulous care and management and appropriate education are necessary when using TICVAPs.

Vacuum-Assisted Closure Therapy as an Alternative Treatment of Subcutaneous Emphysema

Vacuum-assisted closure therapy is an alternative method for a massive subcutaneous emphysema treatment. It is easily applicable and shows rapid effectiveness in massive subcutaneous emphysema, intractable with chest tube drainage.

A Rare Case of Bilateral Pulmonary Sequestration Managed with Embolization and Surgical Resection in a Patient

In this article, we report a rare case of a 22-year-old male with bilateral pulmonary sequestration, treated with embolization and surgical resection. The initial plan involved staged bilateral lobectomy for both lungs and prophylactic embolization of feeding vessels for preventing unexpected hemorrhage during operation. Symptomatic right lower lobe was resected with video-assisted thoracic surgery after embolization, and the patient refused surgery of left lower lobe upon symptomatic relief. The two-year follow-up examination revealed that the patient was healthy and had no relevant discomfort.

Surgical Treatment of Thoracic Menigocele Associated with Neurofibromatosis and Kyphoscoliosis

A 46-year-old man presented with a lateral thoracic meningocele associated with cutaneous neurofibromatosis type I and kyphoscoliosis of the thoracic spine upon medical examination. In the majority of such cases, these meningoceles remain asymptomatic, but surgery is indicated when giant or symptomatic cysts are present. The large thoracic meningocele was successfully extirpated through the transthoracic approach in combination with lumbar puncture and cerebrospinal drainage for decompression of the cyst.

Thoracic Epidural Anesthesia and Analgesia (TEA) in Patients with Rib Fractures

BACKGROUND: We analyzed the results of surgical reduction and fixation of ribs under thoracic epidural anesthesia and analgesia (TEA) in patients who had no more than 3 consecutive rib fractures with severe displacement to examine the clinical usefulness of this method. MATERIALS AND METHODS: From May 2008 to March 2010, 35 patients underwent surgical reduction and fixation of ribs under TEA. We reviewed the indications for this technique, number of fixed ribs, combined surgical procedures for thoracic trauma, intraoperative cardiopulmonary events, postoperative complications, reestablishment of enteral nutrition, and ambulation. RESULTS: The indications of TEA were malunion or nonunion of fractured ribs in 29 (82.9%; first operation) and incompletely ribs under previous general anesthesia in 6 (17.1%; second operation). The average number of fixed ribs per patient was 1.7 (range: 1~3). As a combined operation for thoracic trauma, 17 patients (48.6%) underwent removal of intrathoracic hematomas, and we performed repair of lung parenchyma (2), wedge resection of lung (1) for accompanying lung injury and pericardiostomy (1) for delayed hemopericardium. No patient had any intraoperative cardiopulmonary event nor did any need to switch to general anesthesia. We experienced 3 postoperative complications (8.6%): 2 extrapleural hematomas that spontaneously resolved without treatment and 1 wound infection treated with secondary closure of the wound. All patients reestablished oral feeding immediately after awakening and resumed walking ambulation the day after operation. CONCLUSION: Thoracic epidural anesthesia and analgesia (TEA) may positively affect cardiopulmonary function in the perioperative period. Moreover, this technique leads to an earlier return of gastrointestinal function and early ambulation without severe postoperative complications, resulting in a shortened hospital stay and lowered costs.