Forehead expansion and total nasal reconstruction.

Forehead flaps are the method of choice for total nasal reconstruction. However, if adequate skin is unavailable, tissue expansion of this donor site for subtotal nasal reconstruction seems logical, as has been described elsewhere. The literature, however, appears devoid of reports of using this technique when all the nasal structures are absent. We report on 3 patients for whom expanded forehead flaps provided poor long-term results because of late shrinkage.

The inferior trapezius musculocutaneous flap in head and neck reconstruction.

The trapezius musculocutaneous flap based on the descending branch of the transverse cervical vessels has been used to reconstruct a variety of large and complex defects in the head and neck region. Forty-three flaps were performed in 41 patients over a period of 26 months. Excellent reconstruction was achieved in 37 patients. Six total and nine partial flap failures were noted. There were 8 deaths during this time, 2 attributable directly to flap failure. Patient positioning during surgery and the tedious dissection are disadvantageous. The advantages of this flap are its thinness, long reach, and a posterior donor defect. These attributes are ideally suited for certain complex reconstructive endeavors in the head and neck.

Psychiatric training for primary care residents: proposed standards.

Most of the nation's psychiatric care is provided by primary care physicians, and this trend is expected to continue. Primary care physicians see themselves as poorly trained in psychiatry, and evidence supports a high incidence of missed diagnosis and inadequate or inappropriate treatment. In addition, poor training may underlie the indifference to psychiatric problems often demonstrated by primary physicians. The Ohio Psychiatric Association Foundation has designated an annual award to be given to the primary care program which provides the best psychiatric training in the state, and the psychiatric training directors met to develop criteria for selecting the recipients. The resulting standards emphasize the importance of training which is relevant to a medical care setting, provided by psychiatrists, and supportive of the integration of psychiatric methods into medical care.

Clinical applications of the extended deep inferior epigastric flap.

The extended deep inferior epigastric flap, described by Taylor et al. in 1983, consists of the lower portion of the rectus abdominis muscle and a superolateral fasciocutaneous extension based on the periumbilical perforators. We have used this flap four times to close large defects of the abdomen, groin, and thigh and twice as a free flap to close wounds of the head and leg. There were no ischemic complications, and there was uncomplicated wound healing in the recipient and in the donor wounds. We recommend this highly versatile and reliable flap as one to be considered early in planning the closure of large wounds.

Indocyanine green. Its use as an early indicator of hepatic dysfunction following injury in man.

To evaluate hepatic function, the kinetics of indocyanine green clearance were studied in seven injured patients with hepatic venous catheters. Indocyanine green clearance after a bolus injection of 20 mg was relatively monoexponential on the first day after injury. Following this, a second slower compartment of indocyanine green clearance was uniformly evident, becoming most prominent around the fourth day after injury. Indocyanine green clearance again became more uniform as recovery continued. Fractional indocyanine green extraction ten minutes after injection decreased from 0.9 on the first day after injury to 0.2 three days later, and then returned to 0.7 on the seventh day after injury. These decreases in indocyanine green clearance preceded an increase in total serum bilirubin concentration to a mean value of 1.9 mg/dL. Indocyanine green clearance was thus found to be an early and sensitive indicator of impaired hepatic function.

Hepatic perfusion and splanchnic oxygen consumption in patients postinjury.

Hepatic dysfunction following injury is felt to be due to hepatic ischemia. To test this hypothesis we measured hepatic blood flow (HBF) and splanchnic oxygen delivery and consumption in nine multiply injured patients. HBF, measured by indocyanine green clearance, was 0.4 +/- 0.1 L/min/m2 12 hours after injury. It steadily increased to 1.3 +/- 0.1 L/min/m2 by 1 week after injury. Changes in cardiac output were similar and were due largely to changes in HBF. Hepatic hypoperfusion was correlated with subsequent increases in serum bilirubin. High oxygen consumption was associated with high HBF and oxygen delivery, and splanchnic oxygen consumption became a large fraction (range, 21-67%) of total body oxygen consumption. Although splanchnic oxygen delivery was diminished with low HBF, splanchnic oxygen consumption remained normal (37 +/- 2 ml/min/m2) due to increased oxygen extraction. We conclude that hepatic blood flow is markedly reduced after injury. Reduced HBF is correlated with liver dysfunction although normal splanchnic oxygen consumption is maintained.

Delayed pulmonary dysfunction in head-injured patients.

Intracranial pressure (ICP), cardiopulmonary function, and the degree of neurological dysfunction were measured in 13 patients with serious head injury to determine the relationship of these indices to the development of delayed pulmonary dysfunction. All patients had serious isolated head injury with Glasgow Coma Scale scores of 7 or less 6 hours after injury and elevated ICP at the time of admission to the protocol. Three patients developed arterial pO2 of less than or equal to 80 torr despite the initiation of elevated inspired oxygen fraction (FIO2 greater than or equal to 0.5) and positive end expiratory pressure (greater than or equal to 5 cm H2O. One of these three patients had a decline in neurological function, quantified by the Albany Head-Injury Watch Sheet, associated with hypoxemia. The only patients who developed intrapulmonary shunt fractions of more than 15% were five patients who had increased pulmonary vascular resistance (PVR) and elevated or increasing cardiac index, suggesting persistent perfusion to areas of the lung which normally are hypoperfused due to hypoxic pulmonary vasoconstriction. This mismatching of the distribution of ventilation and perfusion was confirmed using the multiple inert gas elimination technique in two patients with an increased shunt fraction. Unperfused gas exchange units were also found to be present, as confirmed by an abnormal multiple inert gas elimination techniques, high PVR and dead space/tidal volume ratio (VD/VT), and low extravascular lung water. Abnormalities of ICP and cerebral perfusion pressure could not be correlated with changes in any of the cardiopulmonary functions studied.

Failure of red blood cell transfusion to increase oxygen transport or mixed venous PO2 in injured patients.

Post-trauma patients have an oxygen consumption which is proportional to oxygen delivery, suggesting that tissue oxygen consumption is limited by diffusion. Transfusion of packed red blood cells (RBC), which increases the oxygen-carrying capacity of blood, would be expected to increase mixed venous PO2, thereby improving tissue oxygenation. However, the low P50 of stored blood may increase the affinity of hemoglobin for oxygen and reduce oxygen consumption. To evaluate the net effect of these mechanisms, we studied hemodynamic and oxygen transport parameters before and after RBC transfusion in eight critically ill patients. Mixed venous O2 content was measured directly by fuel cell O2 analyzer, and standard P50 was calculated. Following transfusion of one unit of packed RBC which increased mean hemoglobin from 9.2 +/- 0.3 gm/dl to 10.1 +/- 0.3 gm/dl (p less than 0.01), there were no changes in oxygen delivery (490 +/- 80 ml/min/m2), oxygen consumption (210 +/- 30 ml/min/m2), or mixed venous PO/ (37 +/- 2 Torr). Cardiac index (4.1 +/- 0.71 L/min) decreased by 0.4 L/min/m2 (p less than 0.05). Standard P50 decreased by 4.2 +/- 2.4 Torr following transfusion of two units of RBC (p less than 0.05). Red blood cell transfusion thus failed to increase oxygen consumption in these patients, despite an increase in oxygen content. Thus, RBC transfusion may not improve tissue oxygenation.

Nitroprusside and nitroglycerine in patients with posttraumatic pulmonary failure.

Pulmonary artery pressure is frequently elevated in patients with post-traumatic pulmonary dysfunction. To ascertain whether or not this increase is reversible and what effects such reversal would have on gas exchange, the vasodilators nitroprusside and nitroglycerine were administered to 11 such patients. Pulmonary hemodynamics an gas exchange were observed. Mean pulmonary artery pressure and pulmonary vascular resistance decreased and pulmonary shunt increased. Cardiac output did not change. These results imply that much of the increase in pulmonary artery pressure is due to a reversible restriction of blood flow past unventilated alveoli. Hypoxic vasoconstriction is postulated to be a major cause of the increase in pulmonary artery pressure.

A system to measure functional residual capacity in critically ill patients.

The use of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV) in spontaneously breathing, intubated patients has prompted the development of new procedures for measuring functional residual capacity (FRC). The authors have developed a system for measuring FRC by the multiple breath nitrogen washout technique, which is suitable for use on intubated patients breathing with CPAP, IMV, or intermittent positive pressure ventilation (CONTROL) and on nonintubated patients. This system uses a pair of synchronized volume ventilators to permit a step change in inspired N2 fraction while providing therapeutic ventilatory support. A rapid-response nitrogen analyzer and a modified bellows spirometer are used for continuous measurement of airway nitrogen concentration and expired gas flow rate. FRC is calculated on-line by a digital computer. The system accuracy was tested on a mechanical lung simulator in the CPAP and CONTROL modes. The measured volume was found to agree within 58 +/- 52 ml of the actual volume in the CONTROL mode and within 104 +/- 22 ml in the CPAP mode. The system was also tested for repeatability by making duplicate FRC determinations in patients with respiratory insufficiency. In the 18 patients studied, the correlation coefficient of these duplicate measurements was r = 0.987 and the mean difference between measurements was 49 +/- 24 ml. This noninvasive system also provides data used to calculate anatomical deadspace by Fowler's method (VSDS) and uniformity of ventilation (V/V) for multicompartment lung models.