Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma.

OBJECTIVE: To compare the effectiveness of calf-thigh sequential pneumatic compression devices with the effectiveness of plantar venous intermittent pneumatic compression devices in prevention of venous thrombosis after major trauma. SUBJECTS AND METHODS: We evaluated 181 consecutive patients after major trauma without lower extremity injuries that precluded the use of pneumatic compression devices. We randomly assigned 149 patients to either calf-thigh sequential pneumatic compression or plantar venous pneumatic compression. After blinding the observers to the method of prophylaxis against deep-vein thrombosis, we performed bilateral compression ultrasonography on or before day 8 after randomization. RESULTS: Among 149 randomized patients, 62 who received calf-thigh sequential pneumatic compression and 62 who received plantar venous intermittent pneumatic compression devices completed the trial. Thirteen patients randomized to plantar venous intermittent pneumatic compression (21.0%) and 4 patients randomized to calf-thigh sequential pneumatic compression (6.5%) had deep-vein thrombosis (p = 0.009). Seven of 13 patients with deep-vein thrombosis after prophylaxis with plantar venous intermittent pneumatic compression had bilateral deep-vein thromboses, whereas all 4 patients with deep-vein thrombosis after prophylaxis with calf-thigh sequential pneumatic compression had unilateral deep-vein thrombosis. CONCLUSION: Calf-thigh sequential pneumatic compression prevents deep-vein thrombosis more effectively than plantar venous intermittent pneumatic compression after major trauma without lower extremity injuries.

Peripherally inserted central venous catheters. Low-risk alternatives for ongoing venous access.

We prospectively evaluated the use of peripherally inserted central venous catheters to provide ongoing venous access in general medical and surgical patients in a Department of Veterans Affairs medical center. Between 1985 and 1988 trained nurses successfully inserted 393 catheters in 460 suitable patients (an 85.4% success rate). Correct catheter tip placement in the superior vena cava was documented in 359 of the 393 (91.3%) catheter insertions, but an additional 30 catheters were in a position deemed adequate for the intended use. The mean duration of catheter use was 27.6 +/- 5.2 (1 standard deviation) days (median 20 days, range 1 to 370 days). A total of 65 patients left the hospital with catheters in place, with the mean length of catheter use at home being 36.2 +/- 6.0 days (range 2 to 266). In all, 79% of the catheters were in use until the successful completion of therapy or patient death; catheter-related complications led to premature catheter removal in the remaining 21%. Catheter-related complications included bland phlebitis (8.2%), occlusion (8.2%), local infection (3.6%), bacteremia or fungemia (2.1%), mechanical failure or rupture (2.6%), venous thrombosis (0.7%), and other (3.3%). One patient required vein excision for the management of suppurative phlebitis, but no deaths were attributed to catheter use. This study illustrates the use and safety of peripherally inserted central venous catheters to provide reliable vascular access over prolonged periods in an elderly veteran population. At our facility, percutaneous central venous catheters and surgically implanted (Hickman or Broviac) catheters are now reserved for use in patients in whom peripherally inserted catheters cannot be placed.

Advanced carotid disease in patients requiring aortic reconstruction.

Perioperative stroke is a devastating complication of abdominal aortic operations. Patients requiring aortic reconstruction with advanced carotid occlusive disease pose a particularly challenging management problem regarding timing of operations. All patients (n = 121) undergoing both carotid artery endarterectomy (CEA) and abdominal aortic reconstruction (AAR) within 1 year of each other between 1979 and 1989 were reviewed. The sequence of operation was analyzed to determine its effect on early and late outcome. CEA was the first operation in 99 patients (group I); AAR was performed first in 22 patients (group II). Age, gender, number, types of risk factors, and associated medical problems were similar in both groups. Indications for CEA were: transient ischemic attacks (TIAs), recent ipsilateral stroke, or high-grade asymptomatic carotid artery stenosis exceeding 80%. Indications for aortic operation included: abdominal aortic aneurysm, aortoiliac occlusive disease, and combined aortic and renovascular disease. There were five perioperative strokes, two in group I (2%) and three in group II (14%) (p < 0.04). All strokes occurred after AAR. There were five perioperative deaths (4%), four in group I (4%) and one in group II (5%). Overall survival was significantly greater in group I compared to group II (p < 0.04); 5-year survival was 77% and 51%, respectively. Multivariate analysis demonstrated age, hypertension, and diabetes to adversely affect survival; CEA as the first procedure, however, had a protective effect. Importantly, eight strokes occurred in group I in late follow-up, but only one was ipsilateral to the CEA. We conclude that CEA in selected patients who require AAR is safe, and, when performed prior to abdominal aortic repair, reduces perioperative stroke and may improve long-term survival.

Splenic artery dissection: a case report and review of the literature.

Spontaneous arterial dissection may occur in a dramatic fashion and is often fatal if treatment is not instituted promptly. Diagnosis may be particularly difficult when cases of arterial dissection appear in unusual locations. We report a rare case of atraumatic dissection of the splenic artery that occurred in a 66-year-old male patient, who was admitted with acute severe epigastric and substernal pain, which worsened on inspiration. On admission, his physical examination was unremarkable, and he was hemodynamically stable. After excluding cardiopulmonary catastrophes and aortic dissection as a cause, a left retroperitoneal mass was found on arteriography to be a contained rupture of a splenic artery dissection. The patient underwent urgent resection of the splenic artery with preservation of the spleen. Splenic artery dissection is a rare condition. Only 11 cases have been previously published in the literature, and all of these cases were diagnosed after death. Successful management depends on consideration of the diagnosis, especially when other more common disease processes have been excluded.

Hemobilia--evolution of current diagnosis and treatment.

"Hemobilia," upper gastrointestinal tract bleeding that originates from within the biliary tract, has become widely recognized due to an increased clinical awareness of the disorder and to improvements in diagnostic techniques. In addition, the growing use of percutaneous liver puncture for the diagnosis of and therapy for hepatobiliary diseases and the increased incidence of both blunt and penetrating hepatic trauma have contributed to a rising incidence of hemobilia. We review the history, pathophysiology, and current approaches to the diagnosis and treatment of this disease.

Initial evaluation of absorbable polydioxanone suture for peripheral vascular surgery.

The long-term integrity of an autogenous vascular anastomosis is primarily dependent on the strength of tissue healing; therefore permanent mechanical support of an autogenous anastomosis with sutures is unnecessary. In this study we evaluated monofilament absorbable polydioxanone as an alternative to polypropylene for suturing autogenous vascular tissue during adult peripheral vascular operations. We used polydioxanone suture for 21 vascular procedures in 20 patients. We evaluated suture handling characteristics during operation and then followed patients with clinical assessments and serial duplex scans to monitor for pseudoaneurysms, anastomotic narrowing, and vessel patency. Indications for surgery included limb salvage (67%), dialysis access (23%), traumatic arteriovenous fistula and claudication (5% each). The operative procedures included infrainguinal bypass (57%), arteriovenous fistula formation (24%), thromboembolectomy (14%), and arteriovenous fistula repair (5%). Polydioxanone sutures were placed in 39 separate test sites (35 arterial, 4 venous). No deaths occurred during operation. Polydioxanone suture was found to have handling characteristics similar to polypropylene. During mean patient follow-up of 7.2 +/- 0.6 months, we found no cases of anastomotic narrowing or pseudoaneurysms. Actuarial test site patency at 1, 3, and 6 months was 97%, 97%, and 86%, respectively. Polydioxanone suture has handling properties that are acceptable for use in vascular applications, and it provides adequate mechanical support for sutured vessels to heal. A randomized trial comparing polydioxanone with polypropylene suture will be necessary to determine whether the lack of permanent foreign material in vascular anastomoses can improve long-term patency.

A comparison of absorbable suture and argon laser welding for lateral repair of arteries.

Conventional vascular anastomoses between autogenous vessels are performed with nonabsorbable sutures. Recently, use of absorbable sutures and laser-assisted vascular anastomoses has been advocated because of their improved healing characteristics. This study compared arterial repairs with the argon laser, absorbable suture, and nonabsorbable suture for technical characteristics including additional suture and overall success rates, burst strength, and cost. Absorbable and nonabsorbable suture closures were comparable with respect to technique, but laser-assisted vascular anastomosis was technically more demanding and required almost twice as much time for completion. The argon laser successfully closed only 58.6% of the arteriotomies, and 90% of the closures required additional sutures for complete hemostasis. All sutured arteriotomies were successfully completed by use of either absorbable or nonabsorbable suture. Burst strength was similar for all groups, but was uniformly greater than 300 mm Hg for sutured repairs, whereas two of five laser-assisted closures burst below 300 mm Hg. Finally, costs for purchasing ($35,000) and operating ($300/hr.) an argon laser make laser-assisted vascular anastomosis much more expensive than sutured repair. These data suggest argon laser-assisted vascular anastomoses are more technically demanding, less successful, and more expensive than conventional sutured anastomoses when evaluated in large caliber arteries in a canine model. Absorbable suture, however, is comparable to conventional nonabsorbable sutured arterial repairs in expense, handling characteristics, and success rates with the added advantage of eliminating permanent foreign body in the arterial wall when it is absorbed.

Differences in mortality from thermal injury between pediatric and adult patients.

Children differ from adults in their responses to thermal injury, as reflected by higher reported mortality rates for equivalent major injuries. The age at which children's survival rates equal those of young adults has not been well defined, and some investigators have recently claimed that pediatric and adult burn mortality do not differ. We evaluated age-related mortality among 1,443 consecutive patients without inhalation injury treated from 1978 to 1988, inclusively. The sample consisted of 595 children aged 12 years or less, 243 children aged 13 to 20 years, and 605 young adults aged 21 to 40 years who served as a comparison group of patients with the best predicted survival. We separately examined mortality in patients with burns exceeding 30% total body surface area. There were no significant differences in mortality between age groups for the study sample as a whole, but among patients with large burns, children aged 0 to 48 months had higher mortality than comparably injured adults (31% v 12%, P less than .05 by analysis of covariance). Improvements in survival were also demonstrated between the first and second halves of the study period for children aged 25 months to 8 years. These data indicate that children 48 months of age and younger do not tolerate large thermal injuries as well as adults. Improvements in pediatric burn survival are being achieved in most age groups.

The declining incidence of fatal sepsis following thermal injury.

Successful management of burned patients requires effective prevention and management of infectious complications. This study reviews the incidence of fatal sepsis in our burn center and attempts to analyze factors which may predict septic mortality. From January 1, 1978, through May 31, 1988, 1,913 patients were admitted, with a mean age of 24.8 +/- 0.5 years, a mean burn size of 17.7 +/- 0.4% total body surface area (%TBSA), and a mean 10.1 +/- 0.5% TBSA full-thickness injury. Nine per cent of patients sustained concurrent inhalation injuries. Overall mortality was 7.4%, and 1.6% of patients died from sepsis. Regression analysis showed that overall burn size, presence of inhalation injury, and the extent of full-thickness burn injury were significant independent predictors of death from sepsis, in decreasing order of relative importance. During the period 1983-1988, the incidence of septic mortality was 0.7%, which was significantly lower than the earlier half (1978-1982) of the study period (p less than 0.01). These data indicate that fatal infections are becoming increasingly uncommon after thermal injury. The reasons for this decline are probably multiple, and they include the widespread practice of early excision, and improvements in fluid resuscitation and the general medical care of burned patients.

Major abdominal complications following cardiac transplantation. Utah Transplantation Affiliated Hospitals Cardiac Transplant Program.

Serious complications involving the alimentary tract are commonly reported following cardiac transplantation, and may be associated with significant morbidity and mortality. The aim of this report was to review the incidence, severity, and outcome of abdominal complications in our heart transplant population in whom we used corticosteroid-sparing protocols for immunosuppression. From March 1985 through September 1988, 178 patients underwent 185 cardiac transplants. Twenty-six cardiac transplant recipients (15%) sustained 33 major abdominal complications, including gastrointestinal bleeding (n = 8), pancreatitis (n = 8), bowel perforation (n = 6), cholecystitis (n = 4), and miscellaneous other problems (n = 7). Operative therapy was required in 61% of cases. No deaths were caused by the gastrointestinal complications of their operative management. Corticosteroid-sparing immunosuppression may be responsible for the low incidence of abdominal morbidity, and early, aggressive surgical intervention may reduce subsequent mortality.

Atraumatic hemobilia arising from a cirrhotic liver.

Biliary hemorrhage may occur in a variety of clinical settings, but spontaneous hemobilia has not been reported from a cirrhotic liver. We describe a case of major hepatic hemobilia in a patient with cirrhosis and no history of trauma. A 50-year-old woman had abdominal pain, melena, and profound anemia. An extensive workup did not show the site of bleeding but did show a mass in the gallbladder. Cholecystectomy was performed, and at operation the patient was found to have cirrhosis and portal hypertension. The gallbladder "mass" was simply an organized clot, and hemorrhage recurred postoperatively. On reoperation, bleeding from the ampulla of Vater was observed, confirming the diagnosis of hemobilia. She was treated with angiographic interruption of hepatic arterial flow, at which time bleeding ceased. Her total transfusion requirements included 46 units of blood. Through 16 months of follow-up the patient has had no recurrent bleeding and no evidence of encephalopathy. This case demonstrates that spontaneous hemobilia may indeed arise from a cirrhotic liver. Proximal interruption of arterial flow is usually not recommended for hemobilia, especially in the presence of portal hypertension and cirrhosis, but may be life-saving in selected patients.

Effect of exchange transfusion on cell-mediated immune function following thermal injury.

We assessed the effect of syngeneic and allogeneic exchange transfusion (XTF) on cell-mediated immunity in a murine burn model. Mice were given a 30% TBSA scald injury and lymphocyte function was monitored with the popliteal lymph node assay for host-versus-graft (HVG) or graft-versus-host (GVH) response. Nonexchanged burned animals exhibited suppression of GVH response on postburn days (PBD) 3 and 8 and suppression of HVG response on PBD 3, 8, 11, and 14. Syngeneic XTF stimulated GVH response on PBD 3, and significantly improved both GVH and HVG response to alloantigens on postburn days 3 and 8 compared to the response of burned controls. Allogeneic XTF significantly improved GVH response on PBD 3 and 8, but did not improve HVG response. Restoration of lymphocyte function in all experimental groups occurred between PBD 14 and 18 and coincided with wound healing.

Increased survival after major thermal injury. A nine year review.

This study has reviewed the results of burn care in a burn center between 1978 and 1986. The total population included 1,458 patients. Mean burn size was 19 percent total body surface area, mean patient age was 24.4 years, and overall survival rate was 92 percent. We separately analyzed patients with burns of 30 percent total body surface area or greater during both halves of the study with respect to survival and length of hospital stay. Before 1982, patient survival was 59 percent and mean length of hospital stay was 28.1 days. Since that, the survival rate increased to 77 percent and mean length of hospital stay increased to 35.2 days. The early burn mortality rate remained nearly constant during the period of study (17 percent during the first half of the study and 16 percent during the second half), but the late mortality rate decreased significantly during the second half of the study (24 percent versus 8 percent, p less than 0.01). These data demonstrate increased survival rates after major thermal injury due to improvements in prevention and treatment of sepsis and other late complications of thermal injury.

In vivo monitoring of postburn immune response.

Following a severe thermal injury (30% TBSA), 50% of the burned mice died within 48 hours. The immune response of the survivors was evaluated in vivo using the popliteal lymph node assay (PLNA) for host versus graft (HVG) or graft versus host (GVH) response. Suppression of GVH reactivity was observed using isolated splenocytes from burned mice harvested on postburn days 3, 8, and 11. Lymphocyte response evaluated in the burn environment using the HVG assay was profoundly deficient on postburn days 3 and 11. Recovery of immune function as determined by measurements of both responses occurred by postburn days 14-21, and coincided with wound healing. The PLNA proved to be a sensitive measure of immune function, and allowed for the evaluation of isolated cell populations, as well as measurement of lymphocyte function in the burn environment in the presence of circulating suppressor factors.

Fluid resuscitation in thermally injured children.

The fluid resuscitation requirements and mortality from thermal injury were reviewed in 177 children admitted to the Intermountain Burn Center over a 7 year period. Mean burn size was 27 percent of the total body surface area, whereas the mean full-thickness burn size was 13 percent of total body surface area. Twelve percent of children had associated inhalation injuries. The mean amount of fluid received during burn shock resuscitation was 5.8 +/- 0.25 ml/kg per percentage of total body surface area burned and the mean amount of sodium, 1.06 +/- 0.04 mEq/kg per percentage of total body surface area burned. There was no morbidity due to fluid overload. The presence of inhalation injury did not increase fluid or sodium requirements, but did increase mortality (29 percent versus 7 percent, p less than 0.05). The resuscitative mortality rate for all pediatric patients was 7 percent, the in-hospital mortality rate was 15 percent, and the 50 percent mortality burn correlate for these patients was 64 percent of the total body surface area. Data on children with burns were compared with an unselected, concurrent group of adult burn patients using an analysis of covariance. Fluid and sodium requirements were significantly higher for children, but there was no difference in the length of resuscitation or mortality rate. We conclude that children require much more fluid for resuscitation from burn shock than adults with similar burns. Appropriately aggressive fluid therapy for acute thermal injury in children is essential to achieve an acceptable survival rate in these patients.

Full-thickness skin grafting for contact burns of the palm in children.

The authors report their experience in the treatment of deep contact burns of the palm with 12 children injured from 1980 to 1986. As an alternative to the use of split-thickness skin grafts for resurfacing, since 1983 they have used full-thickness skin grafts harvested from the groin. To date, no child has required secondary revision of a full-thickness skin graft nor is it anticipated. There has been no donor-site morbidity thus far. Current protocol for treatment of these injuries depends upon an aggressive program of physical therapy, which includes nocturnal "sandwich" splinting and the close participation of the family. Prevention of these injuries will depend upon improved design of safety features for household appliances and consumer education at the time of purchase.