Non-traumatic lateral abdominal wall hernia.

A rare lateral abdominal wall hernia is described in an adult patient. This was diagnosed in a patient with a prominent right lateral abdominal wall deformity. The patient had been experiencing pain that increased progressively in severity over time. A computerized tomography (CT) scan of the abdomen revealed the location of the lateral abdominal wall defect. The hernia defect was through the transversus abdominis and the internal oblique, with the inferior aspect of the 11th rib forming part of the superior border of the defect. A 4-cm bony spur from the inferior aspect of the rib formed part of the lateral margin of the defect. The hernia sac was contained within a space underneath the external oblique muscle. The association of the hernia defect with a bony spur was highly suggestive of a congenital etiology. The hernia was successfully repaired laparoscopically with Parietex mesh (Sofradim, Lyons, France), and the patient had resolution of the symptoms on discharge and follow-up visits.

Adrenal insufficiency in high-risk surgical ICU patients.

STUDY OBJECTIVES: To examine the incidence and response to treatment of adrenal insufficiency (AI) in high-risk postoperative patients. DESIGN: Prospective observational case series. SETTING: Large urban tertiary-care surgical ICU (SICU). PARTICIPANTS: Adults > 55 years of age who required vasopressor therapy after adequate volume resuscitation in the immediate postoperative period. INTERVENTIONS: Each patient underwent a cosyntropin (ACTH) stimulation test; at the discretion of the clinical team, some patients were empirically given hydrocortisone (100 mg IV q8h for three doses) before serum cortisol values became available. MEASUREMENTS: Adrenal dysfunction (AD), defined as serum cortisol < 20 microg/dL at all time points, with Delta cortisol (60 min post-ACTH minus baseline) of < or = 9 microg/dL; functional hypoadrenalism (FH), defined as serum cortisol < 30 microg/dL at all time points or Delta cortisol (60 min post-ACTH minus baseline) < or = 9 microg/dL; and AI, as the presence of either AD or FH. RESULTS: One hundred four patients were enrolled with a mean age (SD) of 65.2 +/- 16.9 years. AI (AD plus FH) was found in 34 of 104 patients (32.7%): AD was found in 9 patients (8.7%), FH in 25 patients (24%), and normal adrenal function in 70 patients (67.3%). The absolute eosinophil count was significantly higher in the combined AD and FH groups compared with the group with normal adrenal function (p < 0.05). Forty-six of 104 patients (44.2%) received hydrocortisone; 29 (63%) could be weaned from treatment with vasopressors within 24 h. This beneficial effect of hydrocortisone reached statistical significance in the FH group when compared with untreated patients (p < 0.031); a similar trend was seen in the AD group (p = 0.083). Mortality was also lower in the hydrocortisone-treated AI patients (5 of 23 [21%] vs 5 of 11 [45%] in those not receiving hydrocortisone; p < 0.01). CONCLUSION: There is a high incidence of AI among SICU patients > 55 years of age with postoperative hypotension requiring vasopressors. There is also a significant association between hydrocortisone replacement therapy, resolution of vasopressor requirements, and improved survival.

Transferring patients to a pediatric trauma center: the transferring hospital's perspective.

The rationale behind a regionalized trauma system is that patient outcomes are improved when trauma patients are rapidly transported to facilities with the level of expertise need to treat their injury. Functioning as an adult Level II trauma center, we wanted to know how the transfer process worked for pediatric patients whom we transfer to a Level I pediatric trauma center, which is part of the same multihospital system. Complete information on time of arrival, the time the transfer was accepted, and patient departure time were available for 116 patients (72% of pediatric patients transferred) for the period of January 1, 1997 through June 30, 1998. Patients were retrospectively stratified into two priority groups representing differing transport priority, based on use of a nasogastric tube, endotracheal tube or Foley catheter. Means for decision time and total time in transferring hospital were inspected. Decision time was 44 minutes (standard error 4.5 minutes) for priority patients and 92 minutes (11.5) for non-priority patients (t = 2.94, df = 114, P = 0.004). Total time for priority patients was 129 minutes (7.6) and 197 minutes (14.0) for non-priority patients (t = 3.37, df = 114, P = 0.001). Decision time was not influenced by extensive injury assessment or secondary studies. On average, pediatric patients spent nearly three hours in our facility. Our data indicate that a shorter decision time did not necessarily result in a reduction in wait time. Improving pediatric transfer times requires attention not only to injury assessment processes at the transferring facility and interhospital communications but also mobilization, hand-over, and any space or personnel constraints at the receiving pediatric facility.

Urban trauma care is threatened by inadequate reimbursement.

BACKGROUND: Hospitals struggle to support trauma care. Recent installation of cost accounting systems now provides information on actual costs for different categories of patients. This paper examines the cost of trauma care in an urban teaching hospital. METHODS: All patients entered into the hospital trauma registry for the period July 1, 1996, through June 30, 1997, were abstracted from the registry. These data were merged with a database of all admitted patients with an injury-compatible ICD-9 diagnostic code for the same time period that included cost and estimated revenue from the cost accounting system. Complete data were available for 667 patients and the remaining 96 were uninsured patients with missing cost data. RESULTS: The calculated cost of care for the 667 patients was $10,342,130; total expected revenue was $10,396,456; estimated net revenue for insured patients was $54,326. The estimated cost of care for the 96 uncompensated patients was $1,619,989. The hospital had positive net revenue for patients with length of stay of 7 days or less, but was unable to recoup costs for patients with a longer stay. Reimbursement exceeded hospital cost for blunt injuries, primarily motor vehicle crash victims, and for other injuries covered by fee-for-service insurers. Managed care plans and government-funded insurance did not reimburse sufficiently to cover hospital costs. CONCLUSIONS: These data confirm that earlier literature, based on charges and estimated costs, were correct in documenting a serious threat to the continuation of centers providing high volumes of trauma care.

Impact of a dedicated trauma service on the quality and cost of care provided to injured patients at an urban teaching hospital.

BACKGROUND: To determine the impact of a dedicated trauma service on cost and quality of care in an urban teaching hospital, a before-and-after study was designed. The key elements of the trauma service were dedicated in-house trauma attending surgeons and residents, and continuity and integration of trauma care. METHODS: Injury Severity Scores and probabilities of survival for each patient were calculated from the hospital International Classification of Diseases, Ninth Revision, codes, and individual patient costs were estimated from charges using the Medicare Cost Report. RESULTS: The trauma service resulted in a significant increase in the severity of injuries. There was a highly significant (p<0.001) increase in the mean probability of death (from 0.16 to 0.21). There was no change in actual mortality. Although the mean cost of care increased by 16.6%, there were small reductions in the cost of care of the most severely injured patients. CONCLUSION: A dedicated trauma service has a positive impact on the quality of care.

Use of absorbable mesh as an aid in abdominal wall closure in the emergent setting.

A surgeon has many options available to aid in the closure of abdominal wall defects in the elective setting. In the emergent setting, active infection or contamination increases the likelihood of infection of permanent prosthetic material and limits the surgical options. In such settings, we have used absorbable mesh (Dexon) as an adjunct to fascial closure until the acute complications resolve. To evaluate the effectiveness of this technique, we reviewed the outcome of such closures in 26 critically ill patients. Between July 1987 and June 1993, 26 patients were identified who had placement of absorbable mesh as part of an emergent laparotomy at a major urban trauma center. Through a retrospective chart review, the incidence of complications and outcome of the closure were tabulated. Seven patients were initially operated on for trauma. Two of the patients had mesh placement at their initial procedure secondary to fascial loss from trauma. The remainder of the patients hd mesh placement during a subsequent laparotomy for complications related to their initial procedure. Indications for these laparotomies included combinations of wound dehiscence, intra-abdominal abscess, anastomotic disruption, and perforation. Mesh placement in patients with intra-abdominal infection created effectively open abdominal wounds that allowed continued abdominal drainage, but required extensive wound care. Despite the absorbable nature of the mesh and often prolonged hospital stay in these ill patients, none of them required reoperation for dehiscence, recurrence of intra-abdominal abscess, or infection of the mesh.(ABSTRACT TRUNCATED AT 250 WORDS)

Increases in intra-abdominal pressure affect pulmonary compliance.

OBJECTIVES: To determine the effect of increased intra-abdominal pressure (IAP) on pulmonary compliance and to determine an effective means to measure IAP. DESIGN: A prospective study. SETTING: An urban tertiary care hospital. PATIENTS: Twenty-six adult patients undergoing laparoscopic cholecystectomy. INTERVENTIONS: Intra-operative management of laparoscopic cholecystectomy requiring endotracheal intubation with general anesthesia, nasogastric and urinary bladder catheters, and position changes. Additional interventions included use of a rectal manometer and a respiratory pressure module inserted within the ventilator circuit. MAIN OUTCOME MEASURES: Correlation of changes in IAP with changes in dynamic pulmonary compliance, measured as tidal volume/(end inspiratory pressure--end expiratory pressure) and comparison of three different measurement techniques (bladder, rectal, and gastric) with a standard technique (insufflation pressure) in three different positions (supine, Trendelenburg's, and reverse Trendelenburg's). RESULTS: Compliance was significantly related to insufflation pressure (P < .001) by analysis of variance. In the gas insufflation model, the mean increment in bladder pressure reflected most closely the IAP increment in the supine position (5.7 vs 6 mm Hg) but not in the Trendelenburg (2.1 vs 6 mm Hg) and reverse Trendelenburg positions (3.4 vs 6 mm Hg). Rectal and gastric pressures were also position dependent and technically less reliable. CONCLUSIONS: Increased IAP has a major influence on pulmonary compliance (50% decrease at 16 mm Hg). Measurements of IAP by intraorgan manometry are position dependent and may not accurately reflect the intraperitoneal pressure.

Primary common bile duct closure following exploration: an effective alternative to routine biliary drainage.

Primary closure of the common bile duct following exploration has been safely and effectively performed, as advocated by Halsted, provided no evidence of pancreatitis, cholangitis, or ampullary obstruction exists. Using this precedent, the operative management and clinical course of 29 patients undergoing common bile duct exploration (CBDE) for choledocholithiasis from 1986 to 1992 were reviewed. Ten patients had primary closure of the common bile duct (CBD) following choledochotomy and exploration, and 17 patients had t-tube placement. Two patients had CBDE through an enlarged cystic duct that was then ligated. Patients were selected for t-tube placement if they had pancreatitis, ascending cholangitis, evidence of retained stones, or ampullary obstruction. Two patients in this series died. No patient with primary closure of the CBD suffered a biliary complication including retained stones, biliary fistula, pancreatitis, or bile peritonitis. Serious systemic complications were comparable in both groups. The results of this series support the safety of primary common bile duct closure in selected cases.

Coagulation defects resulting from ambient temperature-induced hypothermia.

Ambient temperature-induced hypothermia noted in trauma patients is frequently accompanied by a bleeding diathesis despite "laboratory normal" coagulation values. To document this impression, the following experiment was conducted. Coagulation studies and platelet function studies were performed in ten minipigs during induced whole body hypothermia (40 degrees C to 34 degrees C) and rewarming. Cooling was achieved in 2 to 3 hours and rewarming took 4 to 5 hours. In addition, similar coagulation and platelet function studies were conducted on plasma samples from the same animals that were cooled and then rewarmed in a water bath. Platelet counts and function as measured by Sonoclot analysis and aggregation did not decrease significantly with hypothermia in either model. Plasma cooled in a water bath demonstrated abnormal PT and aPTT (p < 0.001). Whole body hypothermia demonstrated abnormal bleeding time and PT (p < 0.001). Ambient temperature-induced hypothermia produced significant coagulation defects in a porcine model. Some of the coagulation defects were most pronounced during rewarming.

The management of massive lower gastrointestinal bleeding.

To evaluate what has been the most effective surgical treatment for massive lower gastrointestinal bleeding, we reviewed the records of 31 patients who underwent colon resection for hemodynamic instability and/or the need for continued transfusions. These 31 patients underwent either segmental colectomy (21 patients) or subtotal colectomy (10 patients). Resections were performed for diverticular disease (19 patients), angiodysplasia (eight patients), acute ulceration (three patients), and polyps (one patient). The re-bleeding rate (mean follow-up 1 year) for subtotal colectomy was 0 per cent, segmental resection with positive angiography was 14 per cent, and segmental resection with negative angiography was 42 per cent. The complication rate including myocardial infarction, ARDS, pneumonia, and renal failure was highest (83 per cent) in those patients receiving segmental resection with a negative angiogram. The mortality rate was also highest for segmental resection patients with negative angiography (57 per cent). The results of this review suggest that segmental resection should be performed when the bleeding site is identified angiographically. Subtotal colectomy should be reserved for massive bleeding with negative angiography.

A characterization of hypothalamic-pituitary-adrenal axis function during and after human cardiac arrest.

OBJECTIVE: This study characterizes hypothalamic-pituitary-adrenal axis function during cardiopulmonary arrest and after return of spontaneous circulation. DESIGN: Prospective case series. SETTING: A large urban emergency department and intensive care unit over an 8-month period. PATIENTS: Two hundred five adult patients presenting in cardiopulmonary arrest to an urban emergency department. Three patients known to be taking corticosteroids were excluded from the study. MEASUREMENTS AND MAIN RESULTS: Cortisol concentrations were measured before and after advanced cardiac life support and for five consecutive hours after return of spontaneous circulation. Adrenocorticotropic hormone (ACTH) concentrations were measured before advanced cardiac life support and when the cosyntropin stimulation tests were performed 6 and 24 hrs after the return of spontaneous circulation. The mean initial serum cortisol concentration was 32.0 +/- 33.1 micrograms/dL (882.9 +/- 913.2 nmol/L). Fifty-three percent of patients had cortisol concentrations of < 20 micrograms/dL (< 552 nmol/L) at the end of cardiac arrest. Among 44 patients who achieved return of spontaneous circulation, 98% had initial cortisol concentrations of > 10 micrograms/dL (> 276 nmol/L) and 73% of patients had initial cortisol concentrations of > 20 micrograms/dL (> 552 nmol/L). Mean serum cortisol concentrations increased significantly (p = .0001) from 1 to 6 hrs after return of spontaneous circulation and decreased significantly (p = .03) from 6 to 24 hrs. A serum cortisol concentration of < 30 micrograms/dL (< 828 nmol/L) was associated with a 96% and 100% mortality rate at 6 and 24 hrs, respectively. Mean ACTH concentrations were increased without a significant difference between the initial and 6-hr concentrations. Mean ACTH concentrations decreased between 6 and 24 hrs (p = .06). There were no significant responses to the cosyntropin stimulation at 6 and 24 hrs. CONCLUSIONS: Cortisol concentrations after out-of-hospital cardiac arrest are lower than those concentrations reported in other stress states. There is an association between cortisol concentrations and short-term survival after cardiac arrest. Survivors have a significantly greater increase in serum cortisol concentrations than nonsurvivors during the first 24 hrs. Lower than expected cortisol concentrations for the extreme stress of cardiac arrest may have pathologic significance in the hemodynamic instability seen after return of spontaneous circulation. The etiology of the low cortisol concentrations may be primary adrenal dysfunction.

Arterial injuries of the thoracic outlet: a ten-year experience.

Arterial injuries of the thoracic outlet are complex and require a precise plan for adequate management and prompt exposure of injured vessels. Our 10-year experience with 28 such injuries is reviewed. Arteriography was performed whenever possible in stable patients (15) and aided in planning the operative approach. Unstable patients with active bleeding, pulsatile or expanding hematoma, or pulse deficit were taken to the operating room without delay. A thoracic approach was required in 15 patients, and the exposure was extrathoracic in 12 patients. Airway was secured with liberal use of emergency endotracheal intubation (16 patients). Primary repair was possible in 16 patients, with grafting performed in eight and ligation in three. One vertebral artery injury was successfully controlled with embolization. Venous injuries were repaired in six patients and ligation was necessary in eight; there was no significant morbidity. Two patients died in this series from complications of severe hemorrhage. Significant morbidity was encountered from associated neurologic injuries in 15 patients. Stroke was evident in two patients, both of whom were moribund preoperatively. Proximal subclavian artery injuries were particularly more problematic and frequently required an interim anterior thoracotomy for early control of exsanguinating hemorrhage. Our philosophy in the management of these injuries and choices of exposure are discussed in detail.

Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclusion with vagotomy.

The operative management and clinical course of 17 patients treated for severe pancreatico-duodenal injuries from 1983 to 1990 was reviewed. The etiology of these injuries was gunshot wound in 15 patients; stab wound in 1 patient; and a motor vehicle accident in 1 patient. Seven patients presented in shock with a systolic blood pressure of less than 80. At exploration, 57 associated injuries were found in the 17 patients including 16 major vascular injuries. All patients were treated with pyloric exclusion and drainage. Vagotomy was performed in eight patients. None of these 17 patients were felt to have extensive enough damage to require pancreatico-duodenectomy. Two patients died in the immediate postoperative period of severe coagulopathy and two patients died of sepsis. Seven patients had complications related to the pancreatico-duodenal injury. All seven developed pancreatic fistulas; three also had pancreatitis and two developed multiple enterocutaneous fistulas. Systemic complications included pulmonary complications in eight patients and sepsis in five patients, including two patients with abdominal abscesses. Six patients bled in the immediate postoperative period secondary to coagulopathy. Three patients had complications related to pyloric exclusion. One developed afferent loop syndrome necessitating reoperation. The other two had marginal ulcers, which either perforated or bled and required reoperation. Of interest, neither of these two patients had vagotomy initially. The results of this series confirm the effectiveness of pyloric exclusion with vagotomy for severe pancreatico-duodenal injury.

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.

Fasted state impedes recovery of porcine hepatic oxygen consumption after warm hepatic ischemia.

The most effective means to prepare the hepatic donor liver for harvest, preservation, and transplantation are not known. Studies have shown that in combination with an injury to the liver, fasting reduces hepatic function. This study randomized 20 market pigs, 20 to 45 kg, to an overnight fast (fed group) or a 42-hour fast (fasted group). Under general anesthetic perfusion of the portal vein and hepatic artery were controlled. Studies were performed at high flow (30 ml/min/kg portal flow and 10 ml/min/kg arterial flow) and after a 90-minute period of warm ischemia (no flow). Flow was restored at 25% of the original (low flow), then increased to 50% of the original (medium flow). After the ischemic insult, the fed group improved hepatic oxygen consumption at a faster rate than the fasted group (p less than 0.05 by ANOVA). In addition, significant differences were noted between the fed and fasted groups in the amount of insulin delivered by the portal venous system to the liver (p less than 0.001 by ANOVA). Hepatic oxygen consumption was related to insulin delivery (r2 = 0.46; p less than 0.001) for both groups. The data suggest that acute changes in the nutritional status of both the donor and the recipient may affect hepatic recovery from ischemia.

The physiologic basis for nutritional support in hepatic failure.

Hepatic failure is often perceived as a unidimensional progression from near normal clinical function (Child's class A) to overt clinical failure (Child's class C). As this view fails to distinguish between patients who are capable of using exogenous protein and those who cannot, it hinders the nutritional support team in determining protein supplementation. This report addresses the physiologic basis for variable findings in hepatic failure and proposes a simple definition of hepatic failure based upon ability to utilize amino acids.

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.

Amino acid abnormalities in infants with extrahepatic biliary atresia and cirrhosis.

We measured fasting plasma amino acids in 26 children aged 6 months to 5 years with extrahepatic biliary atresia and cirrhosis and compared them with fasting values in 95 normal control children aged 4 months to 12 years. We found that the cirrhotic children had elevations of total free plasma amino acids implying reduced hepatic metabolism of amino acids and that the molar ratio of the branched chain amino acids (isoleucine, leucine, and valine) to the aromatic amino acids (phenylalanine and tyrosine) was significantly depressed. Methionine was also markedly elevated, and taurine concentrations were significantly decreased. Manipulation of the amino acid distribution in dietary protein to normalize plasma amino acids prior to orthotopic hepatic transplantation may be helpful in improving amino acid utilization.