Management of wounds and wound infections in the intensive care unit.

Many factors combine to make management of wounds and wound infections in patients in intensive care units (ICUs) a complex task. An understanding of the anatomy, pathophysiology, and bacteriology provides a framework to approach these patients. The patient's underlying disease influences the care of the wound. Wound factors such as necrotic tissue, bacterial load, or presence of fistulae or a foreign body have important impact on the patient's care. With assessment and knowledge of normal healing, timely intervention in the ICU can identify patients whose wounds are not healing properly and allow for corrective interventions to help the patient return to normal function.

No difference in catheter sepsis between standard and antiseptic central venous catheters. A prospective randomized trial.

OBJECTIVE: To determine the efficacy of antiseptic compared with standard triple lumen central venous catheters (CVCs) in reducing the incidence of catheter sepsis and catheter site infection in patients with CVCs for total parenteral nutrition. DESIGN: A prospective, randomized, controlled trial. SETTING: Truman Medical Center, the public teaching hospital for University of Missouri, Kansas City, School of Medicine. PATIENTS: Seventy-two inpatients on the Metabolic Support Service received a CVC for the infusion of total parenteral nutrition. Diagnoses included pancreatic disease, cancer, bowel obstruction, and intestinal surgery, among others. Patients who had a higher risk for contamination during insertion, such as those with a catheter placed through an introducer, inserted in the emergency department, or changed over a guidewire were excluded from the study. INTERVENTION: The control group received a standard CVC without antiseptics. The treatment group received a CVC with a coating of silver sulfadiazine and chlorhexidine gluconate. Each CVC was inspected for infection or malfunction by the Metabolic Support Service 5 times per week. A transparent occlusive dressing was changed every 7 days or more often if there were signs of infection or nonocclusion. When the CVC was removed, the catheter tip, the blood, and the insertion site were cultured. MAIN OUTCOME MEASURES: Although 88 catheters were inserted, only 72 catheters were evaluable. There were 40 patients in the standard group and 32 in the antiseptic group. There were no statistically significant differences between the 2 groups for diagnosis, sex, age, length of stay, days with a CVC, or catheter location. The catheter sepsis rate in the standard group was 8% and in the antiseptic group it was 6%. There were no statistically significant differences between the 2 groups in frequency of site infections or catheter sepsis. CONCLUSIONS: In this study, there were no statistically significant differences in the incidence of catheter-related sepsis or catheter site infections between the standard and antiseptic groups. Future prospective, randomized controlled trials with a larger number of antiseptic catheters are encouraged to confirm or refute these results.

Salmonella mediastinal abscess.

Salmonella is a rare cause of a mediastinal infection. This report describes the 14-year natural history of a mediastinal mass with eventual abscess formation. Computed tomography provided excellent visualization, and surgical drainage afforded prompt diagnosis and treatment.

Embryologic and anatomic basis of inguinal herniorrhaphy.

The embryology and surgical anatomy of the inguinal area is presented with emphasis on embryologic and anatomic entities related to surgery. We have presented the factors, such as patent processus vaginalis and defective posterior wall of the inguinal canal, that may be responsible for the genesis of congenital inguinofemoral herniation. These, together with impaired collagen synthesis and trauma, are responsible for the formation of the acquired inguinofemoral hernia. Still, we do not have all the answers for an ideal repair. Despite the latest successes in repair, we, to paraphrase Ritsos, are awaiting the triumphant return of Theseus.

Theophylline disposition following parenteral feeding of malnourished patients.

OBJECTIVE: To investigate the effect of parenteral nutrition on theophylline disposition in malnourished patients. DESIGN: Before-after trial. SETTING: Tertiary care center. PATIENTS: Ten patients with historic, anthropometric, and laboratory evidence of malnutrition. INTERVENTIONS: Patients received two 5-mg/kg intravenous infusions of theophylline separated by at least 48 hours of glucose-based parenteral nutrition providing the entire estimated nutritional requirements. MAIN OUTCOME MEASURES: Following each theophylline administration, serum theophylline samples were collected over a 24-hour period for delineation of maximum plasma concentrations, volume of distribution, elimination rate constant, clearance, and area under the curve. RESULTS: Peak plasma theophylline concentrations were significantly lower prior to feeding (5.3 mumol/L, 95 percent confidence interval [CI] 0.78-10.0 mumol/L, p = 0.028). Volume of distribution decreased after parenteral feeding (0.08 L/kg, 95 percent CI 0.006-0.15 L/kg, p = 0.037). The elimination rate of theophylline increased after parenteral feeding reflected by an increase in the elimination rate constant (0.06 h-1, 95 percent CI 0.01-0.10 h-1, p = 0.023). CONCLUSIONS: This study suggests that parenteral nutrition using a glucose-based solution acutely influences theophylline disposition in malnourished patients.

Oral ranitidine as prophylaxis for gastric stress ulcers in intensive care unit patients: serum concentrations and cost comparisons.

OBJECTIVES: a) To determine whether enteral ranitidine in intensive care unit (ICU) patients would produce serum levels that would reduce stimulated gastric acid by > or = 50%, and b) to evaluate the differences in cost between enteral and parenteral administration of ranitidine. DESIGN: Prospective, nonrandomized clinical trial. SETTING: A surgical ICU in a public primary teaching hospital for a medical school. PATIENTS: Postoperative or posttraumatic surgical patients who met one or more main criteria for stress. INTERVENTIONS: Two groups of patients were given ranitidine through a nasogastric tube. Group 1 (n = 10) received 150 mg every 12 hrs, and group 2 (n = 8) received 300 mg every 12 hrs. MEASUREMENTS AND MAIN RESULTS: Serum samples for measurement of ranitidine concentrations were collected at 2, 6, and 12 hrs after the fifth dose of oral ranitidine. Patients were monitored for upper gastrointestinal bleeding. All patients had therapeutic serum ranitidine concentrations at 2 and 6 hrs, while 88% of patients had therapeutic levels at 12 hrs. CONCLUSIONS: a) Enteral administration of ranitidine every 12 hrs leads to effective absorption of the drug from the upper gastrointestinal tract of ICU patients. b) Serum concentrations of ranitidine for both 150-mg and 300-mg enteral doses remained within, or exceeded, the therapeutic range in > 90% of ICU patients with clinically important criteria of stress.

Necrotizing fasciitis secondary to discoid lupus erythematosus.

Necrotizing fasciitis (NF) is an uncommon, but devastating, disease with a significant morbidity and mortality, unchanged in the last several decades. This case report is the first successful management of a patient with NF secondary to discoid lupus erythematosus. A review of the literature describes current concepts of etiology, pathophysiology, diagnosis, and treatment of NF. This case report represents a growing class of patients at increased risk of NF due to iatrogenic immune compromise.

Insulin-like growth factor-binding protein-3 proteolysis is induced after elective surgery.

The insulin-like growth factors (IGFs) are bound to several binding proteins (IGFBPs) that appear to regulate IGF transport, receptor binding, and action. The concentrations of these peptides are altered by catabolic conditions. To determine if IGF-I and IGFBP levels change after surgery, sera were obtained from 16 patients before and after cholecystectomy. Immunoreactive IGF-I measured in plasma samples from which IGFBPs had been extracted did not change postoperatively. In contrast, IGF-I determined in unextracted samples increased roughly 3-fold postoperatively, presumably due to changes in IGFBPs. Two days postoperatively, IGFBP-3 levels, determined by ligand blot, averaged 36% of preoperative values, whereas levels of IGFBP-2 and a 24,000 mol wt IGFBP did not change significantly. Similarly, by immunoblot, intact IGFBP-3 was decreased 84.2 +/- 20.2%, and a 31,000 mol wt IGFBP-3 fragment increased 57.5 +/- 47.4% postoperatively. Coincubation of postoperative, but not preoperative, sera with control sera resulted in a significant decrease in IGFBP-3 and production of proteolytic fragments. IGFBP-3 proteolytic activity in postoperative sera was markedly inhibited by antipain, Na-p-tosyl-L-lysine chloromethyl ketone, phenylmethylsulfonylfluoride, aprotinin, o-phenanthroline, and EDTA, but not by leupeptin or N-tosyl-L-phenylalanine chloromethyl ketone. This pattern of inhibition is consistent with a metal-dependent trypsin-like serine protease. We speculate that proteolysis of IGFBP-3 may alter tissue uptake of IGF-I and thereby help to counteract the catabolic state caused by surgery.

Enteral feeding in the hypoalbuminemic patient.

Previous studies have correlated intolerance of isotonic, intact protein enteral solutions with hypoalbuminemia. The purpose of this retrospective study was to determine whether the level of serum albumin (SA) influenced tolerance of such an enteral nutrient solution (ENS). All patients who received Entrition during 1987 for a minimum of 48 hr were studied for the first 10 days of enteral feeding. Documentation included SA, medications, stool frequency, gastric residuals (GR), and daily caloric intake. ENS intolerance was defined as greater than 3 stools/day for greater than 48 hr or GR greater than twice the hourly infusion rate for greater than 48 hr. Patients were categorized into two groups: those with SA greater than or equal to 2.5 g/dl (group I) and those with SA less than 2.5 g/dl (group II). Of 88 patients studied, 48 (86%) in group I and 28 (88%) in group II tolerated the ENS. Eight (14%) in group I and 4 (12%) in group II experienced ENS intolerance. There was no statistically significant difference in the frequency of ENS intolerance between these two groups (p less than 0.05). Also, 97% of all those with a SA less than 2.5 g/dl were fed 80% or more of their estimated caloric requirements. We concluded that ENS tolerance was not affected by the SA level and patients with hypoalbuminemia (SA less than 2.5 g/dl) could be fed enterally.

The significance of gallbladder trauma.

This study reviewed patients with gallbladder trauma over a 14-year period treated at Truman Medical Center to determine the complications, associated injuries, and mortality rate. Fourteen patients had gallbladder trauma, 12 penetrating and two blunt. All patients underwent cholecystectomy and 10 had 3 or more associated injuries that required operative care. There were no biliary duct injuries or postoperative biliary complications. Seven patients had postoperative wound, pulmonary, or abdominal infections. There was one mortality due to delayed splenic hematoma, myocardial infarction, and cardiac dysrhythmia. Gallbladder trauma was always associated with significant multi-organ injuries that required early operative intervention.

Surgical anatomy of the inguinal area.

The anatomy of the inguinal region is enigmatic and confusing. Among the many structures involved in hernial repair are the iliopubic tract, the transversus abdominis aponeurosis and the transversalis fascia, the transversalis crura and sling, and the inguinal canal. There is still much disagreement among surgeons and anatomists about the existence, structure, and function of these anatomic entities.

The duodenum. Part 4: Surgery.

This is the last part of our efforts to present, if possible, the duodenum in toto as an anatomical and surgical entity. For all practical purposes, Part 4 is a short presentation of the anatomy involved in mobilization and exposure of the duodenum from a surgical standpoint with specific applications. A table with most of the anatomical complications of duodenal surgery is also included.

The duodenum. Part 3: Pathology.

Duodenal pathology includes various developmental malformations and acquired lesions. This report provides brief descriptions of various congenital anomalies of the duodenum, including stenosis and atresia, annular pancreas and ectopic duodenal pancreatic tissue, megaduodenum, duodenal diverticula, preduodenal portal vein, and paraduodenal fossae. Acquired lesions, such as duodenal ulcer, tumors, vascular compression, and duodenal trauma are also described.

The duodenum. Surgical anatomy.

The second part of this monograph on the duodenum describes the muscular and mucosal changes observed at the gastroduodenal junction. The structure of the duodenal wall and details of the intramural portion of the common bile and pancreatic ducts are described, together with the surgical anatomy of the four parts of the duodenum. The arterial supply, the venous and lymphatic drainage, and the innervations are described from the surgeon's point of view.

The duodenum. Part 1: History, embryogenesis, and histologic and physiologic features.

Long before the Christian era, the duodenum was named and its function in controlling gastric emptying was conjectured. It received almost no further attention until the Eighteenth century when its relation to the bile and pancreatic ducts became know. The embryogenesis of the duodenum and the histological features of the organ are described as well as the gross movements that explain the mature relations of the duodenum to the surrounding structures. The "sphincters" of the duodenum are mentioned and evaluated.

The role of the nutritional support team in preventing and identifying complications of parenteral and enteral nutrition.

As the technology of parenteral and enteral nutrition advances, a multidisciplinary nutritional support team (NST) can be used to assure quality care. NST functions include developing and using standard protocols and solutions, monitoring patients, and preventing complications. Interventions by NSTs can save money for the hospital as well. Examples from Truman Medical Center (Kansas City, Missouri) illustrate how the NST can perform these functions.

Sepsis from triple- vs single-lumen catheters during total parenteral nutrition in surgical or critically ill patients.

We prospectively studied the infection rates for 59 triple-lumen (TLC) and 68 single-lumen (SLC) subclavian catheters during the administration of total parenteral nutrition (TPN) to surgical or critically ill patients. A standard protocol was used for catheter insertion and maintenance. The infection control committee determined independently whether patients had catheter-related sepsis, an infected insertion site only, or no catheter infection. The TLCs had an increased incidence of catheter sepsis (19%) compared with the SLCs (3%). Low rates (5% for TLCs and 3% for SLCs) of infected catheter sites only indicated that the catheter care was comparable for both groups. The patients in the two groups were similar but not identical; those with TLCs appeared to be sicker and, therefore, at greater risk to develop catheter sepsis than patients with SLC. However, since TLCs were involved in six times more catheter sepsis than were SLCs, limiting the use of a subclavian catheter to giving TPN only and strict adherence to a TPN protocol are necessary to minimize the risk of catheter sepsis.