Coagulopathy and intraoperative blood salvage (IBS).

The use of potentially contaminated shed blood and the contribution of autotransfused blood to coagulopathy are controversial issues associated with intraoperative blood salvage (IBS) in trauma patients. Intraoperative blood salvage was used in 154 trauma patients and resulted in reinfusion of 7.97 units per patient. Moderate to severe abnormalities of the prothrombin time (PT) and partial thromboplastin time (PTT) occurred in 39 patients (31%). Prolongation of the PT and PTT occurred with increasing transfusion. Coagulopathy was seen in patients receiving greater than 15 IBS units and in patients receiving greater than 50 combined units of blood. Of the 66 patients with bowel injury, 58 patients received shed blood. Patients with bowel injury showed no increase in infection but did develop prolongation of PT and PTT at lower levels of IBS transfusion. Based on the results of this study, patients receiving greater than 15 units of IBS transfusion require careful monitoring and factor replacement, and IBS transfusion should be limited to less than 10 units in patients with bowel injury.

Meperidine serum concentrations and analgesic response in postsurgical patients.

We examined the relationship between serum concentrations of meperidine hydrochloride and analgesic response in postsurgical patients allowed to use patient-controlled analgesia (PCA) and compared these findings with those of patients receiving conventional intramuscular (IM) dosing. Six patients who had undergone abdominal surgery were randomly assigned to receive postoperative analgesia with either PCA or IM therapy. A sequence of five-point pain and sedation scores and serum meperidine concentrations were obtained in all patients the day after surgery. Minimum effective concentration (MEC) was defined as that concentration of meperidine at which patients felt pain relief as indicated by a decrease in pain rankings. The mean MEC for patients using PCA, 296 +/- 112 ng/mL, was significantly lower than the mean MEC in patients receiving IM dosing (551 +/- 164 ng/mL, p less than 0.05). The mean maximum change in meperidine concentrations in the PCA group, 177 +/- 88 ng/mL, was significantly lower than that of the IM group (484 +/- 125 ng/mL, p less than 0.05). Mean maximum changes in pain and sedation scores for patients in the PCA group were not significantly different from those of the IM group. During this investigation patients using PCA experienced smaller swings in meperidine concentrations than did patients receiving IM injections. MEC analysis suggests that PCA patients may experience pain relief at lower meperidine concentrations than those needed by IM patients.

Management of general surgical emergencies in pregnancy.

The management of 25 pregnant patients (gestational age 4-40 weeks) treated at Henry Ford Hospital from 1980-86 was reviewed. Eleven women were treated for a variety of nontraumatic general surgical emergencies including cholecystitis, appendicitis, pancreatitis, and gastrointestinal obstruction. Fourteen women were treated after sustaining traumatic injuries. Ten patients were managed without operation and 15 required surgical intervention as part of their treatment. Diagnostic studies that proved helpful included diagnostic peritoneal lavage, ultrasonography, intravenous pyelography, and roentgenograms of the chest and abdomen. There were no maternal deaths, but two fetal deaths occurred as a result of traumatic injuries. Five women and one neonate developed major complications requiring prolonged hospitalization. Early aggressive resuscitation and thorough diagnostic evaluation are required to achieve a favorable outcome in the management of the pregnant patient who presents with an emergent general surgical problem.

Organ and tissue procurement in the acute care setting: principles and practice--Part 2.

In this two-part series on organ and tissue procurement in the acute care setting, the procurement problem, cost-benefit analysis, organizational development and framework, approach to surviving relatives, public attitudes, and brain death certification were discussed in part 1 (January 1990). Part 2 examines evaluation, selection, maintenance, and management of the organ-tissue donor. It concludes with a discussion of disease transmission, controversial issues, and financial considerations relevant to the procurement process in the acute care setting.

Organ and tissue procurement in the acute care setting: principles and practice--Part 1.

The specialty of organ transplantation has grown tremendously during the past decade. With the advent of cyclosporine, artificial organs, and organ-assist devices, the possibility of suitable patients with end-stage organ disease becoming successful transplant recipients has increased dramatically. Consequently, the need for donor organs has risen. The greatest source of potential organ-tissue donors exists in the acute care setting (ie, emergency departments and intensive care units). To meet the need for this increasing demand, emergency physicians must become familiar with the techniques of procurement. Part 1 defines the problem of procurement and presents financial, historic, organizational, legal, and psychosocial aspects of organ-tissue procurement. A synopsis of brain death concludes the discussion. Part 2 (February 1990) presents aspects of the evaluation, selection, maintenance, and management of the organ-tissue donor. Disease transmission and controversial issues in organ-tissue procurement also are discussed.

Patient-controlled analgesia: a review of effectiveness of therapy and an evaluation of currently available devices.

Patient-controlled analgesia (PCA) is a major advance in the management of pain in postoperative and cancer patients. The success of PCA has resulted in a proliferation of marketed devices to administer small bolus doses of parenteral pain-control drugs at fixed intervals controlled by the patient with the push of a button. Because patients demonstrate marked individual variation in pain medication requirements, PCA devices should be able to accommodate rapidly changing requirements for drugs with a minimum amount of effort on behalf of health care personnel. Crude electronic devices were developed in the late 1960s and the early 1970s and usually consisted of a syringe pump connected to some sort of timing device. Most modern PCA devices marketed in the past five years are much more sophisticated devices that are microprocessor based and some newer devices even generate hard copy for a permanent record of drug administration. Although many such devices are available (including a totally disposable PCA device), few have undergone extensive clinical evaluation. A review of the literature shows many devices are available for use without a single publication to document the safety and utility of the device in the routine patient care situation. Use of the PCA method of pain control will grow, and all hospital-based health care personnel should become familiar with their use and limitations.

Comparative accuracy of diagnostic peritoneal lavage, liver-spleen scintigraphy, and visceral angiography in blunt abdominal trauma.

Diagnostic peritoneal lavage (DPL), liver-spleen scintigraphy (LSS), and visceral angiography (VA) have been cited as useful in the evaluation of patients sustaining blunt abdominal trauma to determine the existence of injuries requiring operative intervention. We have reviewed the clinical courses of 44 patients who sustained blunt abdominal trauma and had various combinations of DPL, LSS, and VA employed in their diagnostic evaluation. The predictive value and efficiency of these tests have been compared in this group of patients. DPL is sensitive and specific for the presence of intraperitoneal blood. LSS is sensitive and specific for parenchymal irregularity in the liver and spleen. VA is sensitive and specific for vascular abnormality, severe hemorrhage, and arteriovenous shunting. None of these tests are completely sensitive and specific for the spectrum of surgically significant injuries produced by blunt abdominal trauma. In this group of patients who had multiple studies because of diagnostic uncertainty, DPL had the highest predictive value and the highest efficiency. LSS results did not by themselves dictate a change in management for any patient. In some patients VA was helpful in determining operative or nonoperative management.

Pancreatic transection. A concept of evolving injury.

We describe the difficulties in diagnosing a pancreatic injury in two patients with multiple injuries who did not have an obvious need for a celiotomy. Multiple diagnostic tests were employed, but in each patient, there was a delay in the diagnosis of the injury. A pancreatic injury may evolve over time so that repetitive clinical diagnostic studies may be required to evaluate the condition of these patients.

The role of contrast radiography in presumed bowel obstruction.

A retrospective review of 229 patients with a final diagnosis of small-bowel obstruction was undertaken to evaluate the role of contrast radiography in the management of their conditions. In 84 patients (37%) the clinical findings and plain abdominal roentgenograms were sufficient for diagnosis and subsequent management. Of the remaining 145 patients with equivocal findings, 27% had an upper gastrointestinal series, 29% a barium enema, and 44% had both. Useful information (complete obstruction, unobstructed passage of contrast, or diagnosis other than adhesional obstruction) was obtained from 86% of the radiographic studies. Three patients had negative contrast studies yet eventually underwent adhesiolysis (enterolysis) and were classified as false-negative. Two patients had evidence of high-grade obstruction yet had nonoperative resolution and were classified as false-positive. The mortality in the contrast group (7%) was not statistically different than that in the no-contrast group (7%). Contrast radiography is a safe and effective means of increasing diagnostic accuracy in patients with presumed small-bowel obstruction.

Urban trauma: a chronic recurrent disease.

Urban trauma, often presumed to be an acute episodic event, may actually be a chronic recurrent disease related to the lifestyle, environment, and other factors of its victims. To test this idea an attempt was made to obtain 5-year followup for 501 consecutive survivors of violent trauma seen at one hospital, 1980-1981. Followup information for these patients was obtained from medical records at four local Level I trauma centers, death certificates, Medical Examiner's records, and police crime computer files. Of the 501 patients, 263 had medical followup including 148 patients with one trauma and 115 patients with recurrent trauma. Of these 263 patients, 200 (76%) were unemployed and 164 (62%) abused alcohol or drugs. From 1982-1987 142 out of 263 patients were involved in 133 crimes and 52 died. These data suggest that urban trauma is a chronic disease with a recurrent rate of 44% and a 5-year mortality rate of 20%.

Catheter aspiration for simple pneumothorax. Experience with 114 patients.

Between 1983 and 1987, 114 adult patients with 131 pneumothoraces were treated utilizing catheter aspiration for simple pneumothorax as an alternative to tube thoracostomy. The causes of simple pneumothorax were as follows: 79 needle-induced, 36 spontaneous, and 16 traumatic. Thirty-eight of the pneumothoraces were small (less than 20% of volume), 55 were moderate (20% to 40% of volume), 36 were large (greater than 40% of volume), and 2 were of unknown size. Overall, catheter aspiration for simple pneumothorax was successful in 90 patients (69%). The success rate was 75% with needle-induced, 53% with spontaneous, and 75% with traumatic pneumothoraces. Small pneumothoraces were successfully managed with catheter aspiration for simple pneumothorax in 87% of patients, moderate-sized in 60%, and large in 61%. There were three complications (2.3%), including one hemothorax and two retained sheared catheter tips. The average cost per patient was +868 for catheter aspiration, and $6402 for a tube thoracostomy. These data support catheter aspiration as a safe, cost-effective, and successful technique for managing simple pneumothorax.

Antibiotics for penetrating abdominal trauma: a prospective comparative trial of single agent cephalosporin therapy versus combination therapy.

In this prospective, comparative study, 129 patients who sustained penetrating abdominal trauma were randomized to receive preoperatively, and for 3-5 days postoperatively, one of three antibiotic regimens: Group I--cefotaxime (CTX) (2 Gm Q8H), Group II--cefoxitin (2 Gm Q6H), or Group III--clindamycin (900 mg Q8H) and gentamicin (3-5 mg/kg/day in divided doses Q8H). The three groups were similar in terms of the following: age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions, or positive intraoperative cultures. Septic complications occurred as follows: Group I--6.9%, Group II--2.3%, and Group III--6.9%. The three regimens ranked as follows in terms of therapy costs: CTX less than cefoxitin less than clindamycin and gentamicin. It is concluded that single agent therapy with a cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, lower toxicity, and lower costs.

Nitrogen balance in adult hospitalized patients with the use of a pediatric amino acid model.

Normalization of plasma amino acid patterns and that relationship to improved nitrogen balance was studied using a pediatric-specific amino acid solution in 21 adults requiring total parenteral nutrition therapy. There was a significantly positive correlation between improved nitrogen balance and the amino acids cystine, tyrosine, total cysteine/cystine, and ornithine. When additional cysteine was added to the solution of 11 subjects, taurine also correlated with nitrogen balance. Despite higher amounts of histidine in solution, plasma amino acid levels were not normalized. These amino acids, heretofore considered nonessential, may be required in specific molar ratios in stress. The use of a 30% branched-chain pediatric-balanced amino acid solution resulted in near normalization of plasma amino acid levels and group mean positive nitrogen balance.

Sequential treatment of a simple pneumothorax.

In a prospective investigation of isolated simple pneumothorax, the treatment of 35 patients with a total of 37 pneumothoraces was studied. A standardized sequential treatment approach was followed for evacuation of the pneumothorax and maintenance of lung reexpansion. The protocol involved catheter placement using a Seldinger technique, aspirations, and documentation of reexpansion by chest radiography and observation. Reaccumulation of air was treated with Heimlich valve attachment to the catheter at intrapleural pressure and further observation. Continued air leak following Heimlich valve attachment was treated with chest catheter suction using a Pleurovac at -20 cm H2O pressure. Chest tube thoracostomy was performed for continued failure of reexpansion. In 22 of the 37 pneumothoraces (59%) simple catheter aspiration maintained lung reexpansion without complications. In the remaining 15 pneumothoraces (41%), seven (47%) responded to Heimlich valve attachment, and three (20%) maintained expansion with chest catheter suction. Chest tube thoracotomy was required to maintain expansion in 33% (five) of those who failed catheter suction (14% of all pneumothoraces studied). Patients treated successfully with simple catheter aspiration were sent home. Patients requiring a Heimlich valve, chest catheter suction, or chest tube thoracostomy were hospitalized. Use of these catheter techniques resulted in lower cost and was associated with shorter hospitalizations than in chest tube thoracostomy. Our study suggests that sequential treatment of simple pneumothorax should be considered as a cost-effective and therapeutically successful alternative to immediate chest thoracostomy in selected cases.

Preventative antibiotics for penetrating abdominal trauma--single agent or combination therapy?

In this open, prospective, comparative study, 75 patients who sustained penetrating abdominal trauma were randomised to receive 1 of 3 antibiotic regimens preoperatively and for 3 to 5 days postoperatively. Group I received cefotaxime 2g 8-hourly, group II received cefoxitin 2g 6-hourly and group III received clindamycin (900 mg 8-hourly) and gentamicin 3 to 5 mg/kg/day in divided doses 8-hourly. The 3 groups were not statistically different in terms of age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions or positive intra-operative cultures. Septic complications occurred in 8% of patients in group I, in 4% of group II patients and in 8% of group III patients. Cefotaxime was the least costly regimen, followed by cefoxitin, then clindamycin and gentamicin. It may be concluded that single agent therapy with a broad spectrum cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, less toxicity and lower costs.

The relationship of scoring systems and mortality in the surgical intensive care unit.

To determine the relationship between severity of illness and mortality, therapeutic intervention score (TISS) and acute physiology score (APS) were determined on admission to the Surgical Intensive Care Unit (SICU). Patients were divided into survivors and nonsurvivors and differences were compared by chi-square analysis. The 1524 patients admitted to the SICU during a 12-month period had a mean TISS of 3.03 and a mean APS of 13. The average length of stay (LOS) was 3.75 days. Of the 1524 patients, 97 (6.4%) died. The number of nonsurvivors increased with higher TISS and APS scores (P less than 0.001). There were no deaths in the TISS Category 1 patients or in the APS 0-5 group. Mortality rates dramatically increased with APS greater than 20 (P less than 0.001). There were 1286 patients with APS less than 20, and 24 (2%) of these patients died, whereas 73 (31%) of 238 patients with APS greater than 20 died. Nonsurvivors had a mean TISS of 3.6, mean APS of 27, and LOS of 4.88 days, all of which totals were higher than the survivors' totals. In this study population, risk of death was one in three if the APS was greater than 20. These data indicate that TISS and APS scores are effective means of assessing mortality risk in SICU patients.

Minimum urine collection periods for accurate determination of creatinine clearance in critically ill patients.

The accuracy of creatinine clearance (CLcr) determinations obtained from urine collections of less than 24 hours duration and the cyclical variation in creatinine excretion were studied in 10 critically ill patients with trauma or postoperative complications. Data from patients who received drugs or had diseases known to influence creatinine production or interfere with assay methods were excluded. Twelve consecutive two-hour urine collections and midpoint blood samples were obtained for each patient. Urine and serum samples were assayed for creatinine content by kinetic and enzymatic methods, respectively. The mean 24-hour CLcr was 110.6 +/- 47.0 mL/min. Clearance values determined from 8- and 12-hour collections were within 20% of the 24-hour CLcr value, and values determined from 14- to 22-hour collections were not significantly different from the 24-hour CLcr value. Mean differences between each 2-hour interval and the 24-hour interval were not significant for the 12 collection intervals. In critically ill trauma or postsurgical patients, the 24-hour CLcr can be estimated from an 8-hour urine collection if a deviation of up to 20% from the 24-hour value is clinically acceptable. No significant cyclical variation in creatinine excretion over 24 hours was found.