Penetrating injuries of the neck: selective management evolving.

Since 1990, a selective management algorithm has been used in our Trauma Center to treat 91 patients with penetrating neck injuries. Group A (n = 37) sustained zone I, zone III, or multiple-zone injuries; Group B (n = 54) sustained zone II injuries [most (55, 66.4%) from gunshot or shotgun wounds]. Nineteen Group A and 21 Group B patients required mandatory neck exploration. Vascular or aerodigestive tract injuries were found and adequately repaired in 15 Group A and 11 Group B patients. The superficial wounds of three Group A and seven Group B patients were closed, and the patients were observed for 24 hours. The remaining 15 Group A and 24 Group B patients underwent routine angiogram, arbitrary barium swallow, and, if necessary, esophagoscopy. Two of these Group B patients required surgery for common carotid artery injuries. One patient died 4 months later because of missed vertebral artery pseudoaneurysm. Overall mortality and complication rates were 6 and 1 per cent. Unnecessary exploration was avoided in 52 per cent of cases regardless of the location of the wound. Mortality and morbidity rates were acceptable. Patients with penetrating neck injuries could be safely managed selectively regardless of the injury zone.

Percutaneous dilational tracheostomy: report of 356 cases.

OBJECTIVE: To evaluate the procedure time, complications, and percutaneous dilational tracheostomy (PDT) charges. DESIGN: Operative data were prospectively collected for 356 PDTs including the initial series of 141 PDTs reported in 1994. Short- and long-term complications were retrospectively identified by review of medical records and patient telephone interviews. MATERIALS AND METHODS: PDT was performed using the "Ciaglia" method of serial dilation over a Seldinger guidewire. Discharged patients (n = 258) were followed for a mean (+/-SD) of 10 +/- 7 months. MEASUREMENTS AND MAIN RESULTS: The mean procedure time was 15 +/- 8 minutes; operative mortality rate, 0.3% (1/356); overall complication rate, 19% (69/356); long-term symptomatic tracheal stenosis rate, 3.7% (8/214). The mean total patient charge for bedside PDT was $1,370; for open tracheostomy in the operating room, $2,675. CONCLUSIONS: Surgeons can rapidly perform PDT at the bedside with a lower risk of complications than open tracheostomy and at a significantly reduced patient charge.

Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma.

A recent retrospective analysis of femur fractures concluded that early surgical fixation in patients who have sustained blunt thoracic trauma (AIS score for Thorax > or = 2) was a risk factor for postoperative pulmonary failure. We conducted a review of all femur fractures admitted to a level I trauma center from November, 1988 to May, 1993. Inclusion criteria were ISS > or = 18, mid-shaft femur fractures treated with reamed intramedullary fixation, and no mortalities secondary to head trauma or hemorrhagic shock. One hundred thirty-eight patients met these criteria. Four patient groups were created: N1--no thoracic trauma (AIS score for thorax < 2), and early surgical fixation (< 24 hours after injury, n = 49); N2--no thoracic trauma and delayed fixation (> or = 24 hours, n = 8); T1--thoracic trauma (AIS score for Thorax > or = 2) and early fixation (n = 56); T2--thoracic trauma and delayed fixation (n = 25). There were no significant differences in age, Injury Severity Score, or Glasgow Coma Scale score between the four groups. Mortality rate, length of stay (LOS), LOS in the TICU, and duration of mechanical ventilation tended to be greater in patients with delayed fracture fixation, however, this was not statistically significant. The N2 patients had a pneumonia rate of 38% compared with 10% in group N1 (p = 0.07). The T2 patients had a pneumonia rate of 48% compared with 14% in group T1 (p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Delayed elevation of ED1-cellular fibronectin in plasma following postsurgical bacteremia.

Fibronectin (Fn) exists in both a soluble form in plasma and lymph as well as an insoluble form in the extracellular matrix. Matrix-localized cellular fibronectin (cFn) contains extra domains (ED1 and/or ED2) not found in plasma Fn (pFn). Very little (< 1-2%) ED1-containing cFn exists in normal blood, and its rapid release into plasma and/or lymph is believed to reflect acute vascular injury. We used a polyclonal antibody to sheep pFn and a monoclonal antibody to ED1 domain of cFn to measure both pFn and ED1-cFn in relationship to lung lymph flow (QL), lung lymph-to-plasma (L/P) total protein concentration ratio, and lung protein clearance (LPC). Unanesthetized sheep (n = 7) were injected intravenously with Pseudomonas aeruginosa (5 x 10(8)) at both 2 and 7 days following surgical preparation of a lung lymph fistula. After both bacterial challenges, we observed an early increase in QL and a small decline in the L/P ratio (0-2 h), reflecting increased fluid filtration in the presence of an intact vascular barrier. This was followed by a further increase (P < 0.05) in QL; an elevation in the L/P ratio; and a marked (P < 0.05) increase in LPC over 3-6 h, indicative of an increase in lung endothelial protein permeability. Before the first bacterial infusion, ED1-cFn in plasma was 9.97 micrograms/ml or approximately 2% of the total Fn antigen in plasma; whereas ED1-cFn in lung lymph was 6-8% of total lymph Fn.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunofluorescent analysis of plasma fibronectin incorporation into the lung during acute inflammatory vascular injury.

Incorporation of plasma fibronectin into tissues is believed to influence endothelial cell-cell interaction, as well as endothelial cell adhesion to matrix. We used immunofluorescent microscopy coupled with tissue extraction of noncovalently incorporated fibronectin to delineate the time course for matrix incorporation of soluble plasma-derived fibronectin into the lung of sheep during postoperative bacteremia. Adult sheep were surgically prepared with both lung and peripheral lymph fistulas. Sheep were anesthetized 2 days following surgery and injected intravenously with a sublethal dose of live Pseudomonas aeruginosa, which consisted of 5 x 10(8) live organisms suspended in 0.9% saline. Bacterial infusion elicited a 300% increase in lung transvascular protein clearance but no increase in peripheral transvascular protein clearance. Purified dimeric human plasma fibronectin (hFn), used as an "immunologic marker," was then infused intravenously (100 mg/sheep) into two additional groups of sheep (nonbacteremic control group and bacteremic experimental group) and allowed to mix with the plasma pool of endogenous soluble sheep fibronectin (sFn). Incorporation of the plasma-derived hFn into the lung matrix and its distribution in relation to endogenous sheep fibronectin in the matrix was assessed by dual-label immunofluorescence using antibodies specific to either sFn or hFn. Human fibronectin from the vascular compartment codistributed with endogenous sheep fibronectin in the lung matrix. Moreover, its deposition into the lung was markedly increased in postoperative bacteremic sheep compared with nonbacteremic control sheep. Increased hFn deposition in the lung with bacteremia was clearly apparent within 2 h. The hFn deposited in the lung was nonextractable using a heparin-urea tissue extraction buffer, suggesting its rapid covalent cross-linking and incorporation into the lung matrix. Microscopic analysis of serial lung biopsies revealed focal areas of inflammation with an intense mononuclear infiltrate into the lungs by 2 h in the bacteremic sheep. Interstitial edema and vascular endothelial injury were observed by 4 h, with alveolar edema apparent over 6 to 8 h. Thus, postoperative bacteremia results in a rapid incorporation of plasma fibronectin into the lung matrix. This may be a physiologic mechanisms to stabilize the integrity of the lung vascular barrier.

Incorporation of circulating fibronectin into various tissues during sepsis: colocalization with endogenous tissue fibronectin.

We studied the plasma clearance and tissue incorporation of intravenously infused purified human plasma fibronectin into various tissues during a period of acute lung vascular injury induced by lethal postoperative bacteremia in sheep. Lung, liver, spleen, and heart tissue were examined for both endogenous sheep tissue fibronectin as well as the experimentally infused human fibronectin using dual-label immunofluorescence. Awake sheep (n = 4) received a postoperative iv infusion of 5 x 10(9) live Pseudomonas over a 60-min infusion interval. Bacterial challenge was started 2 hr after starting the iv fibronectin infusion of purified human plasma fibronectin (100 mg iv bolus; 4 hr iv at 100 mg/hr). Human fibronectin displayed a biphasic rate of clearance from the plasma with entrance into lymph. Human fibronectin readily incorporated in all tissues studied, including the lung which was the focus of vascular injury. Analysis of tissue sections by dual-label immunofluorescence indicated that the exogenous human fibronectin colocalized with the endogenous sheep fibronectin. Thus, the plasma fibronectin concentration may influence the lung vascular barrier due to its incorporation into the tissue pool of fibronectin. Moreover, the plasma may serve as a reservoir for soluble fibronectin which can enter and colocalize with the insoluble tissue pool of fibronectin in various tissues.

Kinetics of plasma fibronectin: increased lung tissue incorporation after postoperative bacteremia.

Fibronectin is an adhesive glycoprotein that may influence the permeability of the vascular barrier. We compared the plasma disappearance of purified human fibronectin (hFn) and its incorporation into lung tissue in control nonbacteremic and bacteremic sheep after surgery to determine the influence of postoperative bacteremia on the plasma clearance and lung deposition of hFn. Lymph fistulas were surgically prepared 48 h before either saline or bacterial challenge to allow for collection of timed samples of plasma, lung lymph, and peripheral lymph. On the day of the study, the sheep were anesthetized and given either 5 X 10(8) Pseudomonas aeruginosa in saline or saline alone. In parallel, they were infused intravenously with 100 mg of hFn, and the hFn concentration in plasma, lymph, and tissue extracts was subsequently determined by enzyme-linked immunosorbent assay over an 8-h experimental interval. Localization of endogenous sheep fibronectin (sFn) and the injected hFn in serial lung tissue samples was determined by dual-label immunofluorescence. In nonbacteremic control sheep, plasma hFn levels declined with an initial rapid slope (t1/2 = 0.53 +/- 0.19 min), followed by a second, gradual slope (t1/2 = 21.7 +/- 2.5 h), whereas the concentration of hFn in lung lymph and peripheral lymph rose exponentially with time. In bacteremic sheep, the early plasma disappearance of hFn was similar, but the second phase of plasma clearance was faster (t1/2 = 7.4 +/- 0.3 h). Lung tissue from control and bacteremic sheep contained the same level of extractable hFn. However, tissue extraction followed by immunofluorescence microscopy indicated that lung tissue from bacteremic sheep contained more nonextractable hFn than lung tissue from nonbacteremic sheep. Thus postoperative bacteremia that elicits acute lung vascular injury will increase the plasma disappearance of hFn and its incorporation into the lung tissue.

Plasma fibronectin levels during cardiopulmonary bypass.

Plasma fibronectin, also called cold-insoluble globulin, is a cryoprecipitable glycoprotein with both opsonic and adhesive activities. It binds to collagen, actin, and heparin and can form soluble as well as cryoprecipitable complexes in the cold. Fibronectin augments particulate phagocytosis by the reticuloendothelial system and can influence lung vascular permeability. Plasma fibronectin deficiency is temporally associated with respiratory failure in septic surgical, trauma, and burn patients. We measured plasma fibronectin and albumin levels in nine adults undergoing elective cardiopulmonary bypass to determine whether dilution alone could account for the changes in plasma fibronectin. Plasma fibronectin concentration decreased 17% with the surgical trauma of opening of the chest and placement of the vascular cannulas. On heparinization and initiation of cardiopulmonary bypass, plasma fibronectin fell an additional 48% (P less than 0.001), whereas albumin concentration (corrected for albumin in the pump prime) fell only 25% (P less than 0.001), emphasizing that dilution was not the only mechanism contributing to the decline in plasma fibronectin. Fibronectin levels began to increase after discontinuation of cardiopulmonary bypass and in association with diuresis, but unexpectedly they remained subnormal until 4 days postoperation. Thus the decline in fibronectin concentration with cardiopulmonary bypass may be due to dilution as well as opsonic consumption and possible complexing with heparin in the cold.

Pulmonary and peripheral lymph protein clearance during bacteremia after surgery.

An increase in pulmonary transvascular protein clearance is seen in sheep following postoperative bacteremia. We evaluated whether this increased protein clearance is specific for the lung by comparing in sheep the effect of postoperative bacteremia on both pulmonary and prefemoral lymph protein clearance. Fibronectin, implicated as a factor influencing vascular permeability, was also measured. After intravenous infusion of a sublethal dose of 5 x 10(8) live Pseudomonas aeruginosa (n = 10), pulmonary lymph flow (QL) increased 146% (P less than 0.01), and the lung lymph-to-plasma (L/P) total protein concentration ratio increased 21% (P less than 0.05). This resulted in a 208% elevation (P less than 0.01) in lung protein clearance (LPC = QL x L/P). In contrast, peripheral lymph flow and peripheral protein clearance were not altered. After intravenous infusion of a lethal dose of 5 x 10(9) live Pseudomonas (n = 7), QL rose 243-348% (P less than 0.025), whereas the lung L/P remained at base line, resulting in a 240-358% increase in LPC (P less than 0.025). Again, peripheral lymph flow and protein clearance did not increase. Plasma fibronectin declined slightly after low-dose bacterial challenge but decreased (P less than 0.001) 40% by 4-5 h after high-dose bacterial challenge. After both low- and high-dose bacterial challenge, fibronectin in pulmonary lymph increased (P less than 0.05) relative to total protein. In contrast, no change in peripheral lymph fibronectin was seen. Thus, while postoperative bacteremia increased lung protein clearance, it did not increase peripheral protein clearance, suggesting specificity with regard to the microvascular response to bacteremia.

Plasma fibronectin therapy and lung protein clearance with bacteremia after surgery.

Plasma fibronectin modulates macrophage phagocytic function and can also incorporate into the insoluble tissue pool of fibronectin where it influences endothelial cell adhesion and tissue integrity. We studied the effect of postoperative bacteremia on lung protein clearance in relation to plasma fibronectin levels using the unanesthetized sheep lung lymph fistula model and the effect of infusion of purified human plasma fibronectin on lung protein clearance. Sheep received live Pseudomonas aeruginosa (5 X 10(8) iv) at a time of normal plasma fibronectin (590 +/- 37 micrograms/ml) or 5 days later at a time corresponding to elevation of plasma fibronectin (921 +/- 114 micrograms/ml). After the first bacterial challenge, there was a 22% decrease (P less than 0.05) in plasma fibronectin. Lung lymph flow (QL) initially increased 308% (P less than 0.05) by 2 h (0 h = 4.7 +/- 1.1 ml/h; 2 h = 14.4 +/- 3.5 ml/h), and the total protein lymph-to-plasma concentration ratio (L/P) declined. This was followed by a sustained second phase response over 3-12 h which was characterized by a 202-393% elevation in QL (P less than 0.05), an increase in the L/P ratio, and a 240-480% (P less than 0.05) increase in lung transvascular protein clearance (TVPC = QL X L/P). Sheep with elevated fibronectin levels also manifested the early (2 h) elevation in QL (P less than 0.05) coupled with a decline in L/P ratio after the second bacterial challenge, but the second-phase increase in TVPC was markedly attenuated. Intravenous infusion of 500 mg of human plasma fibronectin into normal sheep to elevate the fibronectin level comparable to that in the hyperfibronectinemic sheep also attenuated (P less than 0.05) the second-phase (3-12 h) increase in lung protein clearance with sepsis. Thus elevation of plasma fibronectin during postoperative Gram-negative bacteremia may protect the lung vascular barrier. This response may be mediated by either fibronectin's opsonic support of phagocytic function or its influence on lung endothelial cell adhesion.

Duchenne dystrophy: abnormal generation of tension and Ca++ regulation in single skinned fibers.

Skinned, single-fiber preparations from the quadriceps or gastrocneumius muscles of four ambulatory male children with Duchenne dystrophy were tested for theri ability to generate tension and to regulate CA++. To determine the intrinsic strength (P0) of the contractile material, the maximum Ca++ -activated tensions were normalized to the fiber diameters. Sixty-four percent of the Duchenne fibers had P0 values below 1.0 kg per square centimeter--the lowest value observed in control muscle--and the average P0 values of fibers from each Duchenne biopsy were significantly (p less than 0.01) below the average P0 values for control muscle fibers and for muscle fibers obtained from one obligatory carrier of the Duchenne gene. The low tensions in the Duchenne muscle fibers could not be ascribed to altered Ca++ regulation or to substrate sensitivity of the contractile proteins in the fibers, since these were normal. However, ultrastructural abnormalities of the myofilaments, which might reduce the ability of the contractile system to develop tension, were observed. Furthermore, Ca++ regulation by the sarcoplasmic reticulum (SR) was impaired in most of those muscle fibers, from both carriers and Duchenne patients, that did develop normal tension. These results suggest that in Duchenne muscle a functional disorder in the SR may precede loss of the ability of the contractile proteins to generate tension. However, since muscle fibers from Duchenne-gene carriers developed significantly greater tensions than fibers from Duchenne-patients, while yet having similar defects in Ca++ regulation, the SR disorder may not be exclusively responsible for abnormal contractile protein function.