Prospective outcome analysis of a protocol for the surgical and rehabilitative management of burns to the hands.

Treatment protocols for the management of burned hands are essential for integrating team efforts and achieving optimal functional results. Standard protocols are especially useful during mass casualty incidents, when the admission of multiple patients with large burns and/or associated injuries may reduce the priority usually accorded the hands. We prospectively evaluated a surgical and rehabilitative treatment protocol for burned hands during a mass casualty incident, after which 43 burn patients with 82 burned hands were admitted to one burn center. Soft-tissue management was individualized to achieve, if possible, wound closure within 14 days, and included the use of topical antimicrobials, cutaneous debridement and/or tangential excision, biologic dressings, and split-thickness autografts. Range of motion therapy was based on daily measurement of active motion of the metacarpophalangealjoints. Static splinting alternating with continuous passive motion every 4 hours was utilized for sedated patients. Continuous passive motion alternating with active ranging and night splinting was utilized for metacarpophalangeal flexion <70 degrees. Active ranging and progressive resistance was utilized for metacarpophalangeal flexion > or =70 degrees. Sixty-four hands required excision and grafting, with 89 percent having at least one autografting procedure completed by postburn day 16. Total active motion of the hands treated averaged 220.6 degrees on discharge and 229.9 degrees at 3 months after injury. Mean hand grip strength was 60.8 pounds at discharge and 66.0 pounds at 3 months after injury. Adherence to a standard hand burn protocol resulted in timely wound coverage and recovery of hand function for a large group of patients treated at a single burn facility after a mass casualty incident.

Computer-assisted evaluation of hand and arm function after thermal injury.

Comprehensive care of the burned upper extremity requires accurate and complete evaluation of function, including two-point discrimination, active and passive range of motion, and grip strength. These evaluations, when performed serially during a course of therapy, are time-consuming and manpower-intensive. We tested the utility and accuracy of a commercially available computer-assisted impairment evaluation system when used to automate and standardize measurement of upper-extremity function. The function of 80 upper extremities was evaluated with both the conventional and the computer-assisted methods. The time required to perform a complete examination with each method was recorded, and measurements of grip strength and total active motion made with both methods were compared. Complete upper-extremity evaluation required an average of 20.3 minutes with the computer-assisted method, compared to 62.9 minutes with conventional means. Measurements of extremity function with computer-assisted and conventional methods had correlation coefficients of 0.984 for grip strength and 0.996 for total active motion. The computer-assisted impairment evaluation system was found to be a useful and accurate adjunct in the acute and rehabilitative management of burned upper extremities.

Effect of chronic intrauterine stress on the disappearance of tunica vasculosa lentis of the fetal eye: a neonatal observation.

We performed ophthalmologic examinations on 180 neonates (27 to 34 weeks gestational age) shortly after birth, and disappearance of the anterior capsule of the lens vessels was used to estimate gestational age. Three groups of patients were studied: I: chronic hypertension (n = 80); II: preeclampsia (n = 60); III: normal pregnancies (n = 40). The gestational age was also determined by a reliable menstrual history or early ultrasound examination, or both, and Ballard's scoring and compared with that assessed by grading of the anterior vascular capsule of the lens. We found a significant acceleration of gestational age in vascular capsule of the lens when maternal chronic hypertension existed. This study shows that chronic intrauterine stress results in the disappearance of the tunica vasculosa lentis of the fetal eye and therefore suggesting accelerated maturation of this vascular compartment.

Peritoneovenous shunt for hydrothorax associated with ascites.

Two patients with massive hydrothorax associated with ascites resistant to intensive long-term medical management were treated by insertion of a peritoneovenous (LeVeen) shunt. In each case the effusion was resolved within one month after insertion. With one revision each, the two shunts have remained clear for nine and 18 months. The peritoneovenous shunt is an alternative to medical therapy for large effusions. Its effectiveness in resolving them supports the idea that diaphragmatic defects help cause their formation.

Serum protein response to surgery and starvation.

To investigate the effect of stress on the dynamics of serum protein response during starvation, serum albumin, prealbumin, and transferrin changes were studied in six chair-adapted macaques during two separate 7-day test periods: (1) Starvation--NPO + IV D5/W (100 cc/kg/day), and (2) Surgery/starvation--laparotomy and gastrostomy + NPO + IV D5/W (100 cc/kg/day). During the starvation period, transferrin was the only protein that decreased from baseline values and did so at day 7 of the study period. In contrast, during the period of starvation following surgery, both prealbumin and transferrin were significantly decreased at both day 4 and day 7 of the study period, whereas albumin was only decreased at day 7 of this period. These findings indicate that the addition of a surgical stress to starvation results in a depression of serum protein levels that is not only of greater magnitude, but also more rapid in onset than observed with starvation alone. In addition, the differential response of prealbumin and transferrin to starvation and stress may provide a useful indicator of the presence and/or degree of stress in certain situations. The clinical utility of this finding remains to be ascertained.

Value of routine vascular laboratory studies to identify vein graft stenosis.

Thirty-three stenotic lesions were found in 30 vein grafts (17 femoral-popliteal, 13 femoral-tibial) 3 months to 8 years postoperatively--77% appeared within 1 year of surgery. Seventeen (57%) of the patients presented with normal distal pulses, and a similar number were asymptomatic. Only eight (26%) presented with unequivocal clinical evidence of graft stenosis based on decreased pulses and return of ischemic symptoms. Forty percent were completely asymptomatic with normal distal pulses. The mean postoperative ankle systolic pressure index (ASPI) was 0.83 +%- 0.03 (SEM); it fell to 0.57 +/- 0.04 (SEM) when stenosis developed. The peripheral vascular laboratory measurements were the key factor influencing the decision for repeat arteriography in many of these patients and reinforced the need for a repeat arteriogram when the clinical diagnosis was unclear. Early diagnosis of vein graft lesions prior to graft occlusions allowed 24 of 30 of these stenotic grafts to be treated primarily by percutaneous transluminal angioplasty (PTA); 80% remained patent 24 months after PTA. Since most vein graft stenoses can be treated by such a simple, nonoperative technique (PTA), every effort should be made to diagnose and treat lesions prior to graft occlusion. Our experience indicates that frequent vascular laboratory measurements of ASPI are more sensitive then clinical examinations in detecting early vein graft stenosis.

Hyperalimentation in primates. A nutritional model.

To establish the subhuman primate as an effective laboratory animal in parenteral nutrition research, 18 male macaque monkeys were adapted to chronic chair restraint and maintained on intravenous nutrition for 1- and 2-week periods. The animals remained in the restraint chairs for 11.6 +/- (2.3) weeks and the inferior vena cava catheters remained for 53 +/- (7.8) days. Catheter and metabolic complications during intravenous nutrition infusion were few and morbidity was low. The animals maintained weight, serum albumin, and serum transferrin levels as well as a positive nitrogen balance during the study period. The macaque is a highly suitable model for nutritional studies requiring a controlled environment during long-term studies.

Host-tumor interaction and nutrient supply.

Adequate parenteral nutritional support improves nutritional status in cancer patients, but its effect on tumor growth remains controversial. Using a transplantable mammary adenocarcinoma in a rat-TPN model, the relative effect of different exogenous intravenous nutrients on tumor growth and host maintenance was studied. Relative to chow controls, starvation increased host depletion without reducing tumor growth. Adequate carbohydrate calories alone neither improved host maintenance nor stimulated tumor growth, yet adequate amino acids alone did improve host maintenance but also stimulated tumor growth. Adequate amino acids and carbohydrates given simultaneously maximized both host maintenance and tumor growth. In contrast, an isocaloric, isonitrogenous, intravenous diet providing non-nitrogenous calories as fat promoted host maintenance equivalent to carbohydrate-based TPN with no tumor stimulation. This apparent differential utilization of fat calories by normal and malignant cells may permit manipulation of the relative benefit of parenteral nutrition to host or to tumor, permitting host repletion without tumor stimulation or alternatively tumor stimulation at appropriate times to increase sensitivity to phase-specific antineoplastic therapy.

Prognostic nutritional index in gastrointestinal surgery.

Based on assessment of 161 nonemergency general surgical patients, a multiparameter index of nutritional status was defined relating the risk of postoperative complications to baseline nutritional status. When applied prospectively to 100 gastrointestinal surgical patients, this index provided an accurate, quantitative estimate of operative risk, permitting rational selection of patients to receive preoperative nutritional support.