Hydatidosis of the liver and posterior mediastinum.

INTRODUCTION: Cystic echinococcus (CE) is an endemic zoonosis secondary to infection by the larval form of the cestode Echinococcus granulosus. An intermediate host, humans enter the organism's life cycle by exposure to infected canid feces. The liver is the most common location of CE while mediastinal hydatid cysts are rarely reported. PRESENTATION OF CASE: We report a case of synchronous CE of the liver and posterior mediastinum treated sequentially using chemotherapy, percutaneous aspiration with injection of a scolicidal agent and re-aspiration (PAIR) and then staged minimally-invasive surgeries. DISCUSSION: Synchronous CE involving the liver and posterior mediastinum is rare. The treatment of hydatid liver and mediastinal disease is multimodal including chemotherapy, percutaneous and laparoscopic or open surgical interventions. One option for controlled puncture of hepatic and mediastinal CE includes PAIR followed by surgery. CONCLUSION: The sequential use of chemotherapy and PAIR followed by surgery provides another treatment strategy for management of CE. We believe this strategy may be used safely in locations without endemic CE, including most regions of the United States.

Critical care issues in managing complex open abdominal wound.

Over the past 30 years, surgical specialties have introduced and expanded the role of open abdominal management in complicated operative cases, necessitating an intensivist's understanding of the indications and unique intensive care unit (ICU) issues related to the open abdomen. When presented with the open abdomen, resuscitation to correct shock is of primary concern. This is accomplished by correction of hypothermia, acidosis, and coagulopathy in trauma and adequate resolution of intra-abdominal hypertension or source control in general surgery. These patients typically require deep sedation and often paralysis and benefit from low-volume ventilatory strategies to prevent and treat acute lung injury. Antibiotics must be tailored to the clinical situation, but in most cases, 24 hours of perioperative treatment is all that is required. In cases of gross contamination and peritonitis, a 5- to 7-day course of broad-spectrum antibiotics may be of benefit.Adequate source control has been demonstrated to have the greatest impact on outcome and when the patient's clinical milieu dictates, bedside washouts. Enteral nutrition should be instituted as early as possible after intestinal continuity has been reestablished. Additional protein is required to account for losses from the open abdomen. Reconstruction may require staging, but in general, should proceed following resolution of shock and control of sepsis. Elevated multiorgan dysfunction score, Acute Physiology And Chronic Health Evaluation II (APACHE II), and a rise in peak inspiratory pressure portend poor source control and could result in failure of fascial closure. If unable to proceed to fascial closure, then considerations should be made for planned ventral hernia and subsequent abdominal wall reconstruction.

Postoperative neuromuscular blocker use is associated with higher primary fascial closure rates after damage control laparotomy.

BACKGROUND: Failure to achieve fascial primary closure after damage control laparotomy (DCL) is associated with increased morbidity, higher healthcare expenditures, and a reduction in quality of life. The use of neuromuscular blocking agents (NMBA) to facilitate closure remains controversial and poorly studied. The purpose of this study was to determine whether exposure to NMBA is associated a higher likelihood of primary fascial closure. METHODS: All adult trauma patients admitted between January 2002 and May 2008 who (1) went directly to the operating room, (2) were managed initially by DCL, and (3) survived to undergo a second laparotomy. Study group (NMBA+): those receiving NMBA in the first 24 hours after DCL. Comparison group (NMBA-): those not receiving NMBA in the first 24 hours after DCL. Primary fascial closure defined as fascia-to-fascia approximation by hospital day 7. RESULTS: One hundred ninety-one patients met inclusion (92 in NMBA+ group, 99 in NMBA- group). Although the NMB+ patients were younger (31 years vs. 37 years, p = 0.009), there were no other differences in demographics, severity of injury, or lengths of stay between the groups. However, NMBA+ patients achieved primary closure faster (5.1 days vs. 3.5 days, p = 0.046) and were more likely to achieve closure by day 7 (93% vs. 83%, p = 0.023). After controlling for age, gender, race, mechanism, and severity of injury, logistic regression identified NMBA use as an independent predictor of achieving primary fascial closure by day 7 (OR, 3.24, CI: 1.15-9.16; p = 0.026). CONCLUSIONS: Early NMBA use is associated with faster and more frequent achievement of primary fascial closure in patients initially managed with DCL. Patients exposed to NMBA had a three times higher likelihood of achieving primary fascial closure by hospital day 7.

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control.

BACKGROUND: The open abdomen technique, after both military and civilian trauma, emergency general or vascular surgery, has been used in some form for the past 30 years. There have been several hundred citations on the indications and the management of the open abdomen. Eastern Association for the Surgery of Trauma practice management committee convened a study group to organize the world's literature for the management of the open abdomen. This effort was divided into two parts: damage control and the management of the open abdomen. Only damage control is presented in this study. Part 1 is divided into indications for the open abdomen, temporary abdominal closure, staged abdominal repair, and nutrition support of the open abdomen. METHODS: A literature review was performed for more than 30 years. Prospective and retrospective studies were included. The reviews and case reports were excluded. Of 1,200 articles, 95 were selected. Seventeen surgeons reviewed the articles with four defined criteria. The Eastern Association for the Surgery of Trauma primer was used to grade the evidence. RESULTS: There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy. CONCLUSION: The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient. For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place.

Emergency department blood transfusion predicts early massive transfusion and early blood component requirement.

BACKGROUND: The purpose of this study was to evaluate the ability of uncrossmatched transfusions in the emergency department (ED) to predict early (< 6 hr) massive transfusion (MT) of red blood cells (RBCs) and blood components. STUDY DESIGN AND METHODS: All patients admitted to a Level 1 trauma center between July 2005 and June 2007 who received any transfusions and were transported directly from the scene of injury were included. Early MT was defined as the need for 10 U or more or RBCs in the first 6 hours. Early MT plasma was defined as 6 U or more of plasma in the first 6 hours. Early MT platelets (PLTs) were defined as two or more apheresis transfusions in the first 6 hours. Univariate and multivariate analyses were performed. RESULTS: A total of 485 patients (34%) received ED transfusions (ED RBC+) and 956 (66%) did not receive ED transfusions (ED RBC-). ED RBC+ patients were younger, were more likely to be male, and arrived with more severe injuries. Multivariate regression identified ED transfusion of uncrossmatched RBC as an independent predictor of requiring early MT of RBCs (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.36-7.59; p = 0.001), plasma (OR, 2.7; 95% CI, 1.66-4.39; p < 0.001), and PLTs (OR, 1.9; 95% CI, 1.08-3.41; p = 0.025). CONCLUSION: Patients receiving uncrossmatched RBCs in the ED are more than three times more likely to receive early MT of RBCs. Additionally, patients transfused with ED RBCs are more likely to receive 6 units or more of plasma and two or more apheresis PLT transfusions. Given these findings, ED transfusion of uncrossmatched RBCs should be considered a potential trigger for activation of an institution's MT protocol.

Exsanguination protocol improves survival after major hepatic trauma.

BACKGROUND: Hepatic injury remains an important cause of exsanguination after major trauma. Recent studies have noted a dramatic reduction in mortality amongst severely injured patients when trauma exsanguinations protocols (TEP) are employed. We hypothesised that utilisation of our institution's TEP at the initiation of hospital resuscitation would improve survival in patients with significant hepatic trauma. PATIENTS AND METHODS: All patients who (1) sustained intra-abdominal haemorrhage with Grades III-V hepatic injury and (2) underwent immediate operative intervention between February 2004 and January 2008 were included in the study. TEP was instituted in February 2006, and all subsequent patients who met inclusion criteria and were treated with TEP constituted the study group. Patients who met inclusion criteria, were treated before introduction of TEP, and received at least 10 units packed red blood cells in the first 24h constituted pre-TEP comparison group. Univariate and multivariate analyses evaluated the effects of TEP on the study population. RESULTS: Seventy-five patients were included in the study: 39 in the pre-TEP cohort (31% 30-day survival) and 36 in the TEP cohort (53% 30-day survival). There were no differences in demographics, extent of hepatic injury, or operative approach between the patient groups (all p > or = 0.27). Injury Severity Scores were significantly higher in the TEP group (41+/-18 vs. 28+/-15, p<0.01). TEP patients received more plasma and platelets during operative intervention and significantly less crystalloid (all p<0.01). Occurrence of cardiac dysfunction and abdominal compartment syndrome was significantly lower in TEP patients who survived 24-h post-injury (both p < or = 0.04). After adjusting for the significant negative effects of Grade V injury and involvement of major hepatic vasculature (both p < or = 0.02), TEP significantly improved 30-day survival: OR=0.22, 95% CI: 0.06-0.81, p=0.02. CONCLUSIONS: TEP allows for an effective use of plasma and platelets during intra-operative management of severe hepatic injury. Utilisation of TEP is associated with significant reductions of cardiac dysfunction and development of abdominal compartment syndrome, as well as, significant improvement in 30-day survival.

Hyperkalemia following massive transfusion in trauma.

BACKGROUND: Large-volume blood transfusions have been implicated in the development of hyperkalemia. The purpose of the current study was to determine whether critically injured patients receiving massive transfusions are at an increased risk of hyperkalemia. METHODS: Massive transfusion (MT) cohort, all trauma patients (02/2004-01/2008) taken directly to the OR and receiving >or=10 units of RBC in first 24h. Comparison cohort (No-RBC), all patients (02/2004-01/2008) transported directly to the OR who received no blood products in the first 24h. Hyperkalemia defined as K+ > 5.5 mEq/L. RESULTS: There were 266 MT patients, 237 No-RBC patients. MT patients were more likely to have hyperkalemia in the immediate postoperative setting (1.8% versus 4.6%, P = 0.049). However, linear regression did not identify intraoperative blood transfusions as a predictor of postoperative K+ values (P = 0.417). Logistic regression identified only preop K+ (OR 1.79, P = 0.021) and postop pH (OR 0.009, P = 0.001), but not MT, as independent risk factors for postop hyperkalemia. CONCLUSIONS: Despite concerns of hyperkalemia following MT, we found less than a 5% incidence of postop K+ (>5.5 mEq/L). After adjusting for the significant effects of preop K+ and postop pH, MT patients were at no higher risk of hyperkalemia than those who received no blood products.

Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)?

BACKGROUND: Massive transfusion (MT) occurs in about 3% of civilian and 8% of military trauma patients. Although many centers have implemented MT protocols, most do not have a standardized initiation policy. The purpose of this study was to validate previously described MT scoring systems and compare these to a simplified nonlaboratory dependent scoring system (Assessment of Blood Consumption [ABC] score). METHODS: Retrospective cohort of all level I adult trauma patients transported directly from the scene (July 2005 to June 2006). Trauma-Associated Severe Hemorrhage (TASH) and McLaughlin scores calculated according to published methods. ABC score was assigned based on four nonweighted parameters: penetrating mechanism, positive focused assessment sonography for trauma, arrival systolic blood pressure of 90 mm Hg or less, and arrival heart rate > or = 120 bpm. Area under the receiver operating characteristic curve (AUROC) used to compare scoring systems. RESULTS: Five hundred ninety-six patients were available for analysis; and the overall MT rate of 12.4%. Patients receiving MT had higher TASH (median, 6 vs. 13; p < 0.001), McLaughlin (median, 2.4 vs. 3.4; p < 0.001) and ABC (median, 1 vs. 2; p < 0.001) scores. TASH (AUROC = 0.842), McLaughlin (AUROC = 0.846), and ABC (AUROC = 0.842) scores were all good predictors of MT, and the difference between the scores was not statistically significant. ABC score of 2 or greater was 75% sensitive and 86% specific for predicting MT (correctly classified 85%). CONCLUSIONS: The ABC score, which uses nonlaboratory, nonweighted parameters, is a simple and accurate in identifying patients who will require MT as compared with those previously published scores.