Staged surgical repair of pulmonary atresia, ventricular septal defect, and hypoplastic, confluent pulmonary arteries.

In patients with pulmonary atresia and ventricular septal defect, hypoplasia of the central pulmonary arteries prevents single-stage complete repair. Over an interval of 8 1/2 years, 105 patients underwent establishment of continuity between the right ventricle and a hypoplastic central pulmonary arterial confluence (first stage). There were 12 hospital deaths (11%) and 11 late deaths before second-stage (complete) repair. Twenty-five patients await late evaluation. The remaining 57 individuals have had follow-up cardiac catheterization a mean of 33 months postoperatively. In 31 of these, final repair was deferred because of insufficient pulmonary arterial enlargement (14), restricted peripheral arborization (nine), or both (eight). The final 26 patients were accepted for second-stage repair, which has been performed in 24. Complete repair included ventricular septal defect closure (24), right ventricular outflow tract reconstruction (18), relief of central pulmonary arterial stenosis (14), and ligation of systemic-pulmonary collateral arteries (10). The mean postrepair peak systolic right ventricular-left ventricular pressure ratio was 0.67 (range 0.32 to 1.0). One of these patients (4%) died in the hospital and there was one late death (4%) from sepsis after tricuspid valve replacement. Three patients were lost to follow-up; the remaining 19 patients are in functional Class I or II. A two-stage surgical approach is highly successful in those patients whose pulmonary arteries are too hypoplastic to allow a single-stage repair.

Critical factors in determining mortality from abdominal aortic trauma.

Aortic injuries remain highly lethal. Major factors contributing to death in these patients appear to be free peritoneal hemorrhage and associated abdominal vascular trauma. These conditions often manifest as profound shock upon hospital presentation and portend a grim prognosis. Potential means to improve survival include: 1, vigorous resuscitation and prompt operative intervention in patients with penetrating abdominal trauma presenting in a state of shock; 2, careful search and control of associated vascular injuries prior to definitive aortic repair, and 3, constant vigilance to coagulation function, core temperature and acid-base status.

Reconstitution of intestinal continuity after resection for neonatal necrotizing enterocolitis.

Thirty-five infants were treated surgically for neonatal necrotizing enterocolitis during the past eight years. Twenty-five of these, managed by resection and exteriorization, later underwent reconstitution of the intestinal tract. Eleven infants (69 per cent) with ileostomy and three (100 per cent) with jejunostomy exhibited stenosis or severe dehydration, electrolyte loss and acidosis requiring closure to achieve positive caloric balance. Fewer serious postoperative complications were observed after reanastomosis by Roux-en-Y enteroenterostomy and single limb ileostomy (Bishop Koop) versus end to end anastomosis. Operative mortality for small intestinal stoma closure was 10 per cent. Complications from colostomy formation occurred in 67 per cent. However, fluid and electrolyte loss was not observed and adequate weight gain was achieved in four of six patients allowing for elective closure by end to end anastomosis. Operative mortality for colostomy closure was nil.

Risk of splenic salvage after trauma. Analysis of 200 adults.

This review was undertaken to analyze critically the complications resulting from operative splenic salvage. Over a 6 year period, 200 adults who sustained splenic trauma underwent laparotomy. The mechanism of injury was blunt in 138 patients (69 percent), a stab wound in 32 patients (16 percent), and a gunshot wound in 30 patients (15 percent). Splenorrhaphy was accomplished in 85 patients (42 percent). Methods of repair included cautery and hemostatic agents in 24 patients (28 percent), debridement and suturing in 42 patients (50 percent), and partial resection in 19 patients (22 percent). Six patients died, four from head trauma and two from multiple organ failure. Postoperative complications occurred in 14 patients. Four were intraabdominal. Three patients required reoperation for splenic hemorrhage; one (2 percent) after suture repair and two (11 percent) after partial resection. A left subphrenic abscess developed in another patient. Splenic reimplantation was performed in 43 patients (22 percent). Five deaths occurred. One was due to head trauma, three to multiple organ failure, and one to overwhelming pneumococcal infection. Eleven postoperative complications occurred, but none was related to splenic autotransplantation. Despite the enthusiasm for splenic salvage, the number of patients suitable for splenorrhaphy plateaued at 56 percent. Complications of splenorrhaphy are infrequent, and the risk increases with more complex salvage attempts. We believe that splenic reimplantation remains a safe procedure.

Outcome of resuscitative thoracotomy and descending aortic occlusion performed in the operating room.

Objectives of temporary descending thoracic aortic cross-clamping for exsanguinating abdominal hemorrhage are to redistribute intravascular volume to the myocardium and brain, and to limit further blood loss. This report describes our experience with left thoracotomy and descending aortic occlusion (T/AO) performed in the operating room (OR) for massive hemoperitoneum. During a 5-year period, 39 (5%) of 791 patients undergoing laparotomy for acute injury required T/AO in the OR. According to protocol, T/AO was undertaken before celiotomy if systolic blood pressure (SBP) remained less than 80 mm Hg despite full resuscitation (23 patients), and after celiotomy if SBP fell to less than 60 mm Hg with upper abdominal hemorrhage (16 patients). Mechanism of injury was gunshot wound in 21, stab injury in eight, and blunt trauma in ten. Twelve patients (31%) survived to leave the hospital. Seven of these individuals sustained hepatosplenic injuries, three had major vascular trauma, and the remaining two had combined injuries. Average SBP increased from 51 to 126 mm Hg following T/AO in the preceliotomy group, and from 48 to 131 mm Hg in post-celiotomy patients. The aorta was cross-clamped an average of 43 minutes in the preceliotomy patients, and 19 minutes in the post-celiotomy group. Six survivors (50%) developed major abdominal complications (rebleeding, fistulae, abscess, and pancreatitis). Only two patients, however, had pulmonary problems associated with T/AO; and both were minor (atelectasis and recurrent pneumothorax). In our experience, T/AO in the OR is successful in salvaging nearly one third of patients with life-threatening abdominal hemorrhage. The procedure can be performed rapidly, safely, and with minimal late sequelae.

Rapid volume replacement for hypovolemic shock: a comparison of techniques and equipment.

The achievement of a very rapid fluid infusion rate may be critical in the resuscitation of the patient in hypovolemic shock. We studied flow rates of crystalloid and whole blood through various intravenous catheters and tubing systems. The 10-gauge Angiocath and the 8 Fr pulmonary artery introducer catheter provide flow rates equivalent to intravenous tubing (3.2 mm I.D.) inserted directly into the vein. Substantially higher flow rates can be achieved with the use of large-bore intravenous tubing (5.0 mm I.D.) connected to these catheters in place of standard intravenous tubing, allowing the infusion of 1,200-1,400 cc/minute of crystalloid and whole blood into the patient in hypovolemic shock through one intravenous catheter. Clinical trials with larger bore intravenous tubing are probably indicated.

Rationale for selective application of Emergency Department thoracotomy in trauma.

The indiscriminate application of thoracotomy in the resuscitation of trauma has recently been challenged. Since 1 May 1974 400 consecutive trauma patients have undergone resuscitative thoracotomy in our Emergency Departments (ED). The mechanism of injury was blunt in 195 (49%) patients, gunshot wound in 147 (37%), and stab wound in 58 (14%) Upon arrival in the ED, 352 (88%) patients had no obtainable blood pressure (BP), 334 (84%), fixed pupils, and 315 (798%) failed to exhibit agonal respirations or other waning signs of life. One hundred six (27%) patients reached the operating room and 28 (7%) survived to be admitted to the intensive care unit. Sixteen were eventually discharged from the hospital, but four of these survivors had sustained irreversible cerebral damage. Overall, 12 of 400 (3%) patients survived ED thoracotomy with intact neurologic function. Four factors appeared predictive of poor prognosis. There were no survivors with intact neurologic function among: 150 patients sustaining blunt trauma and arriving in the ED without signs of life (BP, pupil reactivity, respiratory effort); or 87 patients with penetrating torso injuries who had no signs of life at the scene. Following thoracotomy, in the absence of cardiac tamponade, there were no intact survivors of 124 patients without cardiac activity or of aortic occlusion. We believe the above factors should militate against initiating resuscitative thoracotomy in the ED or in deciding to continue heroic measures following thoracotomy.

Inferior vena cava injuries--a continuing challenge.

The mortality from abdominal vena cava trauma remains in excess of 33% despite advances in prehospital and intraoperative care. During the 7-year period ending December 1981, 58 patients with vena cava injuries were treated at our institution. Thirty-nine (67%) were due to gunshot wounds, nine to stab injuries, and ten to blunt trauma. Overall mortality was 38%. Predictors of poor survival were: 1) presence of shock upon hospital arrival; 2) multiple abdominal vascular injuries; and 3) injuries in the retrohepatic segment. Only two (17%) of 12 patients survived retrohepatic wounds despite various shunting techniques. Of the remaining 12 deaths, 11 (92%) had associated major vascular trauma that included four portal system, three aortic, and three iliac artery injuries. This contrasts to a 96% survival rate for the 28 patients without associated abdominal vascular injuries. Our experience underscores the importance of rapid resuscitation, early operation, and searching for associated vascular injuries before a time-consuming repair of the vena cava is undertaken. Improving the survival of patients with blunt retrohepatic cava and hepatic vein trauma remains a dilemma.

Placement of 10-gauge catheter by cutdown for rapid fluid replacement.

The establishment of immediate venous access and rapid fluid administration remains of paramount importance in the treatment of hypovolemic shock. We describe a technique for placement of a recently available 10-gauge catheter via venous cutdown. This technique is simpler and quicker than placing intravenous tubing directly into the vein, and we show that flow rates through the catheter with both saline and blood are equivalent to rates obtained through intravenous extension tubing. In addition, our studies show that the use of wide-bore intravenous tubing (urology irrigating tubing) instead of standard intravenous tubing allows for much higher infusion rates through the 10-gauge catheter. With the wide-bore tubing and pressure infusion, it is possible to administer 1,200 cc of blood per minute through this catheter.

Alternatives to splenectomy in adults after trauma. Repair, partial resection, and reimplantation of splenic tissue.

Splenectomy results in a lifelong risk of overwhelming infection in the adult as well as the child. This has prompted our current enthusiasm for splenic salvage in trauma patients. A number of alternatives to total splenectomy exist; however, the complications that result from splenic salvage must not exceed the risk incurred by loss of this organ. Splenorraphy can be performed safely in the majority of patients despite associated intraabdominal injuries. When splenectomy is necessary, reimplantation of splenic tissue is feasible. The efficacy of this technique is preventing postsplenectomy sepsis remains to be established.

Major abdominal vascular trauma--a unified approach.

Advances in prehospital emergency care have increased the numbers of patients arriving at the hospital with immediate life-threatening trauma. This is a review of our recent 6-year experience with 161 major abdominal vascular injuries in 123 patients. The distribution by injury site and respective mortality were: 18, aortic (56%); 39, aortic branch (37%); 51, inferior vena cava (39%); 30, inferior vena cava branch (45%); and 23, portal venous system (39%). The overall death rate was 37%. Forty-six patients presented with unobtainable blood pressure and 19 (41%) survived. Left thoracotomy and temporary aortic occlusion were required in the resuscitation of 45 patients; when applied in the emergency department the salvage rate was 7%, and in the operating room, 35%. Forty-four patients had more than one major vascular injury and 17 (39% recovered, compared to a survival rate of 76% with single vascular trauma. Others have emphasized that most deaths from major abdominal vascular injury are a result of hemorrhage. In our study although 89% of mortality was due to bleeding, half occurred after control of the major bleeding sites. These findings suggest that coagulopathy, hypothermia, and acidosis are complicating factors which demand as much attention by the surgeon as the initial resuscitation and operative control classically emphasized.

Vascular trauma in the groin: contrast between iliac and femoral injuries.

Vascular injuries to the groin are common and often life-threatening. Injuries above the inguinal ligament, to the iliac system, are associated with a 37 percent mortality. Associated intraabdominal injuries are common. These patients must be identified promptly, given broad-spectrum antibiotics and taken immediately to the operating room for exploration through a midline incision. Injuries below the inguinal ligament are usually to the femoral vessels and are rarely fatal. These patients may be evaluated more extensively before leg exploration. Associated intraabdominal injuries are unusual, but disability from femoral fractures and nerve injuries are common.

Complications of tube thoracostomy for acute trauma.

Closed tube thoracostomy is a common and very useful procedure in therapy of acute thoracic injury. However, it is not without risk. With aggressive use of this procedure in the emergency department, the incidence of technical complications was 1 percent. Our review suggests that complications can be further diminished by the routine use of large thoracostomy tubes that are placed well up on the chest after confirmation of an open pleural space, by avoiding the use of a trocar for tube placement, and by the use of a high volume, low pressure suction system. Empyema was the most common complication associated with tube thoracostomy after trauma. It occurred in 2.4 percent of the patients. Its exact causes is not known, and the role of prophylactic antibiotics needs to be established.

Temporary cardiac pacing in traumatic arrest victims.

Temporary ventricular pacing was successfully employed in two patients suffering refractory bradycardia following traumatic cardiac arrest. The hemodynamic response to pacing was dramatic and both patients eventually recovered fully from an apparent moribund state. Cardiac pacing may be an effective adjuvant in the early resuscitation of the massively injured patient.