Intraabdominal sepsis after hepatic trauma.

In a review of 58 patients who survived liver trauma seen at Boston City Hospital, 10 patients had 13 intraabdominal abscesses and 1 died from overwhelming sepsis. Multivariate analysis of risk factors revealed that the number of units of perioperative, postoperative, and total blood transfused were each highly significant (p less than 0.0001). Mode of injury, hepatic resection, gastrointestinal tract perforation, and the number of associated injuries were not significant risk factors when transfusion requirements were accounted for. Fever and leukocytosis were unreliable predictors of abscess formation. The available literature suggests a strong relationship between intraperitoneal bleeding and septic complications.

Residents' experience in the surgery of trauma.

Performance of surgery for trauma is an important part of residency training, yet what constitutes an adequate exposure to trauma surgery is ill defined. A retrospective review of records at a metropolitan receiving hospital was carried out for the academic year 1981-1982. Of the 50,902 patients treated in the Emergency Room more than one third were seen by a surgical resident. During this period 1,651 patients were admitted to General Surgery with traumatic injuries; 193 (12%) required intensive care. Two hundred twenty-seven major operations were performed by the General Surgical Service. For each patient operated on, 56 were seen in the Emergency Room and six required admission for nonoperative care of their injuries. Furthermore, less than 50% of patients admitted to the I.C.U. required surgery. An adequate education in trauma must be based on a large experience in the nonoperative resuscitation, diagnosis, and treatment of trauma victims. Nevertheless, the number of cases performed as operating surgeon provides a useful means of evaluation experience in trauma. Thirty cases are suggested as an appropriate level of exposure to the surgery of trauma, yet only one third of applicants to the American Board of Surgery attained this level.

Less-invasive cardiac output monitoring by earpiece densitometry.

Cardiac output was measured by thermodilution and ear densitometry in surgical ICU patients who had pulmonary arterial catheters. Overall comparison based on 56 sets of triplicate measurements revealed a correlation coefficient (r) of 0.76 between the two techniques. Although ear densitometry was more accurate with injection via the antecubital vein (r = 0.88) vs. more distal injection (r = 0.67), these data suggest that this technique lacks the accuracy for clinical application.

Pericardial complications in hepatic trauma.

During a 5-year period, 35 of 70 patients with liver trauma required entry of the thoracic cavity, with nine deaths. Pericardial complications developed in four of the nine survivors who had both thoracic and abdominal incisions. Two patients resolved their problems (postpericardiotomy syndrome, late pericarditis) with medical therapy. One patient required emergency thoracotomy for pericardial tamponade, and one patient developed constrictive pericarditis that required pericardiectomy. Available data support closure of the pericardium after pericardiotomy. Thoracic extension of abdominal incisions is often necessary. Pericardial complications may occur with hepatic trauma in the early or late postoperative periods and are potentially fatal.

Severe combined respiratory and myocardial failure treated with high-frequency ventilation.

High levels of positive end-expiratory pressure (PEEP) impair cardiac output. The subsequent lowering of mixed venous oxygenation, when coupled with a significant intrapulmonary shunt, may dramatically depress PaO2. We present a patient whose severe myocardial and respiratory insufficiency was unmanageable on conventional ventilation with high levels of PEEP and maximal inotropic support. High-frequency ventilation superimposed on conventional ventilation lowered peak airway pressure and dramatically improved both cardiac and pulmonary function.

Effect of high-frequency ventilation versus conventional mechanical ventilation on ICP in head-injured dogs.

Changes in intrathoracic pressure may influence intracranial pressure (ICP), presumably by affecting venous return. High-frequency ventilation (HFV) has been associated with lower intrapleural and airway pressures and has the potential to lower ICP. To evaluate the effects of HFV compared to conventional ventilation on ICP, normocarbia was maintained in nine dogs while alternating between conventional ventilation and HFV at 200 breaths/min. The mean ICP was raised from 6.3 +/- 6.1 to 24.7 +/- 1.04 mm Hg by inflation of Fogarty balloons implanted in the epidural space. The ICP peaks associated with positive inflation pressures were eliminated with HFV, but mean ICP was not significantly different between the two ventilatory modes (23.4 +/- 9.7 mm Hg for the conventional system versus 26.0 +/- 10.0 mm Hg for HFV). Four dogs exhibited neurogenic pulmonary edema: they developed elevated pulmonary artery and intrathoracic pressures and required increased inspiratory flow with HFV to maintain normocarbia. The authors conclude that, in this head-injury model, there did not seem to be an advantage of HFV over conventional ventilation.

Non-spore-forming clostridial bacteremia.

The significance of the non-spore-forming clostridium as a blood-borne pathogen has been underemphasized. Over a 7-year period, these bacteria were cultured 40 times in 30 patients. Overall mortality rate for non-spore-forming clostridial bacteremia was 39%. Patients with polymicrobial infections had a 58% mortality rate, while those with only clostridium in their blood had a mortality of 23%. Mortality increased as the number of positive cultures. Patients who were clinically septic at the time of their cultures fared poorly. Advanced age and underlying malignant disease were associated with increased mortality. Patients who have positive blood cultures for non-spore-forming clostridium are at a significant risk and should be treated aggressively.

Superficial lymph node infarction.

Superficial lymph node necrosis is an unusual pathologic diagnosis encountered in clinical practice. When seen it is usually indicative of involvement of the affected lymph nodes with either metastatic cancer or lymphoma. Occasionally it has been associated with hypersensitivity phenomena with arteriolar involvement. The underlying etiology in all of these instances is extensive occlusion of the rich vascular supply to the node. Rarely cases are seen where no clear-cut etiology can be found. Ten such cases have been reported in the medical literature including the case published in this report. Its occurrence, however, may be more common than previously recognized. Preoperatively it is usually not possible to distinguish this entity from the other diagnoses for which it is generally mistaken. These other diagnoses most commonly include femoral hernia and mass in the axillary tail of the breast. The patient reported here is unusual in regard to the size of the lesion encountered. In other published reports very few lymph nodes were involved. In this case extensive involvement of a large mass of nodes was noted. Once the diagnosis is made limited work-up as well as further close observation is important since it may herald the occurrence of a lymphoproliferative disorder.

Rectal trauma. A retrospective analysis and guidelines for therapy.

Twenty patients seen at Boston City Hospital required general or spinal anesthesia for rectal injuries, and 17 required laparotomy. Findings on sigmoidoscopy were falsely negative in 4 of 13 patients examined. Diagnosis was delayed in two patients. Associated injuries occurred in 55 percent, with the lower genitourinary tract being the area most frequently injured. Complications occurred in eight patients (40 percent). Abscess formation and bacteremia were the most common, but iatrogenic complications occurred in four patients. Pulmonary embolism occurred in two patients and was suspected in a third patient. Routine treatment included diverting colostomy with distal irrigation and adequate drainage. Repair of the injury was performed when possible. Two of the 20 patients (10 percent) died, one after a prolonged septic course and one from recurrent pulmonary embolism. Rectal trauma continues to be a challenging injury.