Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location.

OBJECTIVE: Flail chest is most often accompanied by significant underlying pulmonary parenchymal injuries and may constitute a life-threatening thoracic injury. In this study we evaluated the treatment modalities for flail chest depending on the effect of trauma localization on mortality and morbidity. METHODS: Between 2003 and 2008, 23 patients (20 males/3 females) were treated for flail chest. Location of the trauma in the chest wall, mechanical ventilation support, prognosis and injury severity score (ISS) were recorded for all patients. Mechanical ventilation support was given in 14 patients (60.8 %), and 12 of these 14 patients required subsequent tracheostomy. Internal fixation was used in 3 patients. RESULTS: The major cause of flail chest was a car crash in 18 of 23 patients (76 %). Median ISS was 62.8 for all patients. The patients with flail chest who had bilateral costochondral separation (anterior chest location) (group I, n = 10) had a significantly higher ISS than those with single-side posterolateral flail chest (group II, n = 13; ISS: 70/55; P = 0.02). The need for mechanical ventilation support was also higher in the group with bilateral costochondral separation. Morbidity was higher in group I than in group II ( P = 0.198), and mortality was also significantly higher in group I ( P = 0.08). Patients with a cranial trauma and flail chest had a higher mortality (19 %) than patients with only flail chest (no mortality). The mean ISS was 75 for patients with cranial trauma and flail chest and 55.7 ( P = 0.001) for patients with only flail chest. Sepsis and subarachnoid bleeding were the major causes of mortality. The mean ISS was 54.5 for patients under the age of 55 (n = 14) whereas it was 69.4 in those aged 55 and over (n = 9; P = 0.034). Mortality in the older group was also higher (33 % versus 7 %; P = 0.02). CONCLUSION: Early intubation and mechanical ventilation is of paramount importance in patients with flail chest. However, prolonged mechanical ventilation is associated with a poor outcome. Tracheotomy and frequent flexible bronchoscopy are an effective pulmonary toilet. Advanced age was a major risk factor for flail chest trauma mortality, together with the severity of the injury. When cranial trauma was accompanied by flail chest, mortality and morbidity rates increased. Bilateral costochondral separation also increased the risk of morbidity and the need for mechanical ventilation in patients with flail chest.

Comparison of the effects of sevoflurane and total intravenous anaesthesia in percutaneous nephrolithotomy.

BACKGROUND AND OBJECTIVE: Although percutaneous nephrolithotomy has many advantages over open surgery, some endocrine and haemodynamic responses have been reported. However, the effects of anaesthetic agents on these responses have not previously been reported. This study compared the effects of sevoflurane and total intravenous anaesthesia using propofol and alfentanil on the haemodynamic and hormonal changes during percutaneous nephrolithotomy. METHODS: Forty-two ASA I-II patients aged between 15 and 65 yr were studied. Sevoflurane in Group S (21 patients) or TIVA in Group TIVA (21) was used for the maintenance of anaesthesia. Haemodynamic variables and serum concentrations of sodium and potassium were measured before, during and after the procedure. Arterial blood-gas status, plasma renin, aldosterone and adrenocorticotrophic hormone concentrations were measured before and during the procedure. RESULTS: Mean heart rate was lower during percutaneous nephrolithotomy in Group TIVA compared with Group S (P < 0.01). The mean systolic and diastolic arterial pressures were not different in both groups at any stage of measurement (P < 0.05). Plasma renin, aldosterone and adrenocorticotrophic hormone concentrations were increased during percutaneous nephrolithotomy in both groups, but the increase was greater in Group S (P < 0.05). CONCLUSIONS: In the sevoflurane group, the concentrations of renin, aldosterone and adrenocorticotrophic hormone were significantly higher after 15 min of irrigation compared with the total intravenous anaesthesia group. Although the clinical significance of this difference was not clear, these changes should be considered in certain patient groups.

Hormonal and hemodynamic changes during percutaneous nephrolithotomy.

The aim of this study was to investigate the hormonal and hemodynamic changes during percutaneous nephrolithotomy (PCNL) procedure. Twenty-one patients between 15-65 years of age were included in the study. Invasive blood pressure and heart rate were monitored during PCNL. Serum sodium, potassium, BUN and creatinine levels were measured before and after the operation. Sodium and potassium levels were also measured during the operation. Arterial blood gases, renin, aldosterone and adrenocorticotrophic hormone (ACTH) levels were measured before and during irrigation. The mean systolic and diastolic blood pressure levels were significantly higher (p < 0.05) during PCNL compared to post-procedure levels while heart rate remained constant. Serum sodium, potassium bicarbonate and base-excess levels were decreased during the operation compared to the baseline levels (p < 0.001). BUN and creatinine levels remained unchanged during the study (p > 0.05). In conclusion, a tendency to hyponatremia and metabolic acidosis developed in addition to significant increases in renin, aldosterone and ACTH levels during PCNL procedures. These changes may be due to the invasive nature of the intervention to the kidney and the continuous irrigation of this vital organ. This should be taken into consideration during PCNL. More detailed studies with larger groups are needed for more precise comments on this topic.