A prospective study of erectile dysfunction in men after pelvic surgical procedures and its association with non-modifiable risk factors.

OBJECTIVE: A pelvic surgery can cause erectile dysfunction. The purpose of this study was to evaluate erectile function at various times after pelvic surgery in male patients; to search the non-modifiable risk factors associated with the presence and intensity of sexuality in these patients. This prospective study used the erectile dysfunction IIEF scale. RESULTS: The study population comprised of 106 male patients who had undergone minor pelvic surgery at least 9 months before and during the 2010-2016 period in the 4th Surgical Clinic. A control group of healthy males (N = 106) who underwent no pelvic surgery matched for age was also used for reference values. The main age of the participants was 66.16 ± 13.07 years old. A history of colectomy was present in 36.8%, 18.9% had undergone sigmoidectomy, and 33% inguinal hernia repair. The percentage of severe erectile function increased from 38.7% before surgery to 48.1% (25% increase) after surgery, at the end of the follow-up period (p < 0.05). In the multivariate analysis model, age emerged as an independent predictor of erectile function (p < 0.001). Age was the most important determinant of the IIEF score, which was aggravated by 25% from the first to the last assessment of patients.

Operating on penetrating trauma to the mediastinal vessels.

BACKGROUND AND AIMS: Patients with penetrating trauma of the major vessels of the chest are infrequently encountered. This is due to the fact that the majority of these patients die on scene, as well as due to the overall dramatic decline in the incidence of penetrating trauma in the Western world. A certain proportion of survivors are physiologically stable and can be transferred to adequate care. Patients who are physiologically unstable must be dealt with by the surgeons available without delay. Rapid diagnosis and operation can salvage patients who would otherwise be lost, and all general surgeons should be capable of recognizing these injuries and intervening if a trauma and/or cardiothoracic surgeon is not immediately available. MATERIAL AND METHODS: Technical description of practical emergency surgery approaches to patients bleeding to death from penetrating mediastinal vessel injuries. RESULTS: The scope of this review familiarizes the "uninitiated" surgeon with the operative management of this rare and lethal type of injuries. Technical aspects are described, and pitfalls as well as tips and tricks of the trade are discussed. CONCLUSIONS: Patients with penetrating injuries to the mediastinal vessels can be saved by swift and knowing operative management of this rare and lethal type of injuries, even if a trauma and/or cardiothoracic surgeon is not immediately available.

The role of thyroid hormone administration in potential organ donors.

HYPOTHESIS: Levothyroxine sodium therapy should be used in brain-dead potential organ donors to reverse hemodynamic instability and to prevent cardiovascular collapse, leading to more available organs for transplantation. DESIGN: Prospective, before and after clinical study. SETTING: A surgical intensive care unit of an academic county hospital. PATIENTS: During a 12-month period (September 1, 1999, through August 31, 2000), we evaluated 19 hemodynamically unstable patients with traumatic and nontraumatic intracranial lesions, who were candidates for organ donation following brain death declaration. INTERVENTIONS: All patients were resuscitated aggressively for organ preservation by fluids, inotropic agents, and vasopressors. If, despite all measures, the patients remained hemodynamically unstable, a bolus of 1 ampule of 50% dextrose, 2 g of methylprednisolone sodium succinate, 20 U of insulin, and 20 microg of levothyroxine sodium was administered, followed by a continuous levothyroxine sodium infusion at 10 microg/h. RESULTS: There was a significant reduction in the total vasopressor requirement after levothyroxine therapy (mean +/- SD, 11.1 +/- 0.9 microg/kg per minute vs 6.4 +/- 1.4 microg/kg per minute, P =.02). Ten patients (53%) had complete discontinuation of vasopressors. There were no failures to reach organ donation due to cardiopulmonary arrest. CONCLUSIONS: Levothyroxine therapy plays an important role in the management of hemodynamically unstable potential organ donors by decreasing vasopressor requirements and preventing cardiovascular collapse. This may result in an increase in the quantity and quality of organs available for transplantation.

Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?

OBJECTIVE: To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds. SUMMARY BACKGROUND DATA: Selective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds. METHODS: The authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed. RESULTS: Initially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study. CONCLUSION: Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.

Penetrating trauma in patients older than 55 years: a case-control study.

BACKGROUND: Multiple studies have compared young and elderly blunt trauma patients, and concluded that, because elderly patients have outcomes similar to young patients, aggressive resuscitation should be offered regardless of age. Similar data on penetrating trauma patients are limited. STUDY DESIGN: In a retrospective review, 79 patients with penetrating injuries and age > or =55 were blindly matched for Injury Severity Score (ISS) and Abbreviated Injury Scores (AIS) with 79 penetrating trauma patients aged 15-35 years, who were admitted to the hospital over the same 4 year period (June 1994-June 1998). Mortality rates and length of stay in the intensive care unit (ICU) and the hospital were compared between the two groups. RESULTS: The average ISS for all patients was 12 (range 1-75) and identical for both groups. Both groups had similar injuries and were evaluated by an equal number and type of diagnostic studies. The mean ISS was not different between severely injured older and younger patients who required ICU admission or died. Among 32 nonsurvivors (18 older and 14 younger), older patients were more likely than younger patients to present with normal vital signs, although the comparison did not reach statistical significance (50% vs. 13%, P=0.25). There was a clinically significant trend for longer ICU (15+/-30 vs. 3+/-2 days, P=0.096) and hospital stay (10+/-18 vs. 6+/-8 days, P=0.08) among older patients, but mortality rates were similar (23% in older vs. 18% in younger, P=NS). Furthermore, these outcome parameters showed no difference when both groups were classified according to severity of injury or physiologic response. CONCLUSIONS: Following penetrating trauma, older patients arriving alive and admitted to the hospital are as likely to survive as younger patients who have injuries of similar severity, but at the expense of longer ICU and hospital stays.

Spiral computed tomography for the diagnosis of pulmonary embolism in critically ill surgical patients: a comparison with pulmonary angiography.

HYPOTHESIS: Spiral computed tomographic pulmonary angiography (CTPA) is sensitive and specific in diagnosing pulmonary embolism (PE) in critically ill surgical patients. DESIGN: Prospective study comparing CTPA with the criterion standard, pulmonary angiography (PA). SETTING: Surgical intensive care unit of an academic hospital. PATIENTS: Twenty-two critically ill surgical patients with clinical suspicion of PE. The CTPAs and PAs were independently read by 4 radiologists (2 for each test) blinded to each other's interpretation. Clinical suspicion was classified as high, intermediate, or low according to predetermined criteria. All but 2 patients had marked pulmonary parenchymal disease at the time of the event that triggered evaluation for PE. INTERVENTIONS: Computed tomographic pulmonary angiography and PA in 22 patients, venous duplex scan in 19. RESULTS: Eleven patients (50%) had evidence of PE on PA, 5 in central and 6 in peripheral pulmonary arteries. The sensitivity and specificity of CTPA was, respectively, 45% and 82% for all PEs, 60% and 100% for central PEs, and 33% and 82% for peripheral PEs. Duplex scanning was 40% sensitive and 100% specific in diagnosing PE. The independent reviewers disagreed only in 14% of CTPA and 14% of PA interpretations. There were no differences in risk factors or clinical characteristics between patients with and without PE. The level of clinical suspicion was identical in the 2 groups. CONCLUSIONS: Pulmonary angiography remains the gold standard for the diagnosis of PE in critically ill surgical patients. Computed tomographic pulmonary angiography needs further evaluation in this population.

Clinically significant blunt cardiac trauma: role of serum troponin levels combined with electrocardiographic findings.

BACKGROUND: The true importance of blunt cardiac trauma (BCT) is related to the cardiac complications arising from it. Diagnostic tests that can predict accurately if such complications will develop or not may allow early and aggressive monitoring or early discharge. We investigated the role of two simple and convenient tests, serum cardiac troponin I (cTnI) and electrocardiogram (ECG), when used to identify patients at risk of cardiac complications after BCT. METHODS: Over a 10-month period, 115 patients with evidence of significant blunt thoracic trauma were prospectively followed to identify the presence of clinically significant BCT (Sig-BCT), defined as cardiogenic shock, arrhythmias requiring treatment, or structural cardiac abnormalities directly related to the cardiac trauma. An ECG was obtained at admission and at 8 hours. Cardiac troponin I was measured at admission, at 4 hours, and at 8 hours. Transthoracic echocardiography was performed when clinically indicated. The sensitivity, specificity, and positive and negative predictive values of ECG and cTnI to identify Sig-BCT were calculated. Clinical risk factors for Sig-BCT were examined by univariate and multivariate analysis. RESULTS: Nineteen patients (16.5%) were diagnosed with Sig-BCT and, in 18 of them, symptoms presented within 24 hours of admission. Abnormal electrocardiographic findings were detected in 58 patients (50%) and elevated cTnI levels in 27 (23.5%). Electrocardiography and cTnI had positive predictive values of 28% and 48% and negative predictive values of 95% and 93%, respectively. However, when both tests were abnormal (positive) or normal (negative), the positive and negative predictive values increased to 62% and 100%, respectively. Other independent risk factors for Sig-BCT were head injury, spinal injury, history of preexisting cardiac disease, and a chest Abbreviated Injury Score greater than 2. CONCLUSION: The combination of ECG and cTnI identifies reliably the presence or absence of Sig-BCT. Patients with an abnormal ECG and cTnI need close monitoring for at least 24 hours. Patients with a normal admission ECG and cTnI can be safely discharged in the absence of other injuries.

"Insignificant" mechanism of injury: not to be taken lightly.

BACKGROUND: Trauma resources should be spent rationally. The mechanism of trauma is used extensively to triage patients to appropriate levels of care. We examine the hypothesis that patients with "insignificant" mechanism of trauma may have major injuries that require expert trauma care. STUDY DESIGN: Over 9 months at a high-volume Level I trauma center, a prospective study was done on patients who sustained ground-level falls (GLF), low-level falls (LLF) from less than 10 feet, or were found down (FD) with no external evidence of significant trauma, and required evaluation by the trauma team. Of 301 patients included, 110 (37%) had GLF, 95 (31%) LLF, and 96 (32%) FD. Our main outcomes measure was significant injuries, defined as visceral or intracranial injuries, long-bone, pelvic, facial, or spinal fractures. RESULTS: One hundred ten patients (37%) had significant injuries, 20 (7%) were admitted to the ICU, 14 (5%) required an operation, and 4 (1%) died. The most common injuries were intracranial and skeletal. Almost all patients were evaluated by CT (95%), but only one-quarter had abnormal findings on it. LLF, age more than 55 years, and the absence of severe intoxication (blood alcohol level of less than 200 mg/dL) were independent risk factors for significant injuries. A statistical prediction model showed that, when all risk factors are present, the probability of significant injuries is 73%; when all risk factors are absent, there is still a 16% chance for significant injuries. Patients with significant injuries had more operations, longer hospital stays, and higher hospitalization costs compared with patients without significant injuries. CONCLUSIONS: Low-energy trauma may produce significant injuries, predominantly intracranial and skeletal. Trauma care providers should be cautious about dismissing such patients based on the trivial mechanism of injury. Patients with LLF who are older than 55 years and not severely intoxicated have a high likelihood for significant injuries. Resources should be spent rationally for patients who do not have these characteristics, because the probability of significant injuries among them is low, but not zero.

Aerodigestive injuries of the neck.

Cervical aerodigestive trauma is rare and most centers have a limited experience with its management. The purpose of this review was to study the epidemiology, diagnosis, and problems related to the early evaluation and management of these injuries. This was a retrospective study based on trauma registry and on chart, operative, radiological, and endoscopic reports. There were 1560 admissions with blunt or penetrating trauma to the neck. The overall incidence of aerodigestive trauma was 4.9 per cent (10.2% for gunshot wounds, 4.6% for stab wounds, and 1.2% for blunt trauma). All patients with aerodigestive trauma had suspicious signs or symptoms on admission. The most common life-threatening problem in the emergency room and directly related to the aerodigestive trauma was airway compromise. Twenty-nine per cent of patients with laryngotracheal trauma required an emergency room airway establishment because of threatened airway loss. Although rapid sequence induction was successful in the majority of cases, in 11.9 per cent there was loss of airway and a cricothyroidotomy was necessary. Overall, 9 per cent of cases with aerodigestive injuries were successfully treated nonoperatively. Thirty-six per cent of patients with laryngotracheal trauma and surgical repair were successfully treated without a protective tracheostomy. There was no mortality due to the aerodigestive injuries. Cervical aerodigestive trauma is rare. In conclusion, all patients with significant aerodigestive injuries requiring treatment had suspicious signs and symptoms. Airway compromise was a common problem in the emergency room. Loss of airway after rapid sequence induction is a potentially lethal complication and the trauma team should be ready for a surgical airway. Repair of laryngotracheal injuries without a protective tracheostomy is safe in selected cases.

Prophylactic antibiotics after severe trauma: more is not better.

After severe trauma, physicians frequently use multiple antibiotics for prolonged periods of time to prevent sepsis, based on intuition rather than scientific evidence. Over a 1-year period (January-December 1999) we included prospectively 112 critically injured patients who required an operation and/or chest tube insertion and stayed for more than 2 days in the intensive care unit (ICU). Of these patients, 46 received a single prophylactic antibiotic for 24 hours (group SING+SHORT), and 66 received one or more prophylactic antibiotics for more than 24 hours (group MULT+LONG), based on physician discretion. Twenty-seven outcome parameters were collected to compare the effect of the different prophylactic antibiotic regimens. The two groups were similar in regard to overall injury severity, age, gender, mechanism of injury, and physiologic condition on admission. However, more SING+SHORT patients had an abdominal operation (83% versus 62%, P = 0.02), and more MULT+LONG patients had an orthopedic operation (35% versus 15%, P = 0.03). There was no difference in sepsis (41% versus 42%, P = 1.0), organ failures (37% versus 50%, P = 0.18), mortality (7% versus 12%, P = 0.52), ICU stay (14 +/- 2.5 versus 16 +/- 2 days, P = 0.57), hospital stay (26 +/- 3 versus 28 +/- 2 days, P = 0.53), or any other outcome parameter. Independent risk factors for sepsis were blunt mechanism of trauma, Injury Severity Score > or = 25, and more than two units of blood transfused over the first 24 hours, but not the amount of prophylactic antibiotics given. In conclusion, we found that 24-hour prophylaxis with a single broad-antibiotic is as effective as prophylaxis for longer periods of time with multiple spectrum antibiotics for critically injured patients at high risk for sepsis.

Timing, safety, and efficacy of thoracoscopic evacuation of undrained post-traumatic hemothorax.

Residual post-traumatic hemothorax (RPTH) occurs in 3 to 8 per cent of patients with tube thoracostomy and may cause serious infectious complications. Surgical evacuation is recommended, and thoracoscopic evacuation (THEVA) tends to replace open thoracotomy for this purpose. The objective of this study is to evaluate the optimal timing, safety, and efficacy of THEVA. Over 5 years patients with tube thoracostomy for trauma who had unresolved opacities on plain chest radiograph were evaluated by CT. If the residual fluid volume was estimated to be more than 500 mL3 on CT the patients were offered THEVA. Unstable patients were excluded. A score ranging from one (easy) to three (difficult) was used to grade the difficulty of the operation according to the attending surgeon's perception. Of 1728 chest trauma patients 143 (8%) were evaluated by CT for persistent opacity on plain film, 31 (1.8%) were found to have RPTH, and 24 (1.4%) were eventually taken for THEVA at 3.5+/-2 days after admission. Low oxygen saturation (less than 94%) was found in 58 per cent of patients before THEVA but in only 25 per cent after THEVA (P = 0.02). The majority of chest tubes (75%) were removed within 4 days of the operation. Two patients required conversion to thoracotomy. THEVA done within 3 days of admission was associated with a lower operative difficulty score, shorter hospital stay, and a trend toward shorter intraoperative time compared with THEVA done after 3 days of admission. All patients had effective resolution of their radiographic opacities after THEVA. Three patients developed a complication (urinary tract infection, pneumonia, and persistent air leak). We conclude that patients with significant RPTH and without major physiologic compromise are appropriate candidates for THEVA. The procedure is safe, evacuates PRTH effectively, and improves the respiratory function of affected patients. Ideally it should be performed within 3 days of admission.

Around-the-clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients.

Financial constraints due to increasing operating cost and decreased reimbursement do not allow many hospitals to maintain coverage by attending radiologists around the clock (CARAC). Preliminary film readings by radiology trainees may be inaccurate. In trauma, decisions are made fast and are often based on these preliminary readings. To examine whether there are significant discrepancies between preliminary readings (PRs) and final readings (FRs) of CT scans of trauma patients we prospectively recorded PRs (done immediately by radiology residents) and FRs (done the following working day by radiology attendings) over a period of 6 months for trauma CT scans done between 5 PM and 7 AM on weekdays or weekends. A discrepancy was classified as significant if a change in management was instituted after FR. In 42 of 383 (11%) trauma patients there was a discrepancy between PR and FR. Patients with discrepancies had a higher Injury Severity Score, higher incidence of penetrating trauma, longer hospital stay, higher hospital charges, and higher mortality than patients without any discrepancy. Most of the discrepancies were found on abdominal CT scans. The lower the level of radiology resident doing the PR the higher the likelihood of a discrepancy. In 20 patients (5%) a significant discrepancy was found. We conclude that the absence of CARAC results in inaccurate FRs risking optimal trauma patient care. The institutional savings realized by avoiding CARAC may be offset by the cost of additional care provided to patients who have delayed diagnosis and treatment due to the lack of it.

Fetal death after trauma in pregnancy.

Trauma in pregnancy places the mother and fetus at risk. The objective of this study is to identify risk factors independently associated with acute termination of pregnancy and/or fetal mortality after trauma. The medical and trauma registry records of 80 injured pregnant patients were reviewed. Data were collected and then analyzed by univariate and multivariate analysis. Three patients died (3.7%), 23 had the pregnancy acutely terminated (30%), and 14 suffered fetal death (17.5%). The only independent risk factors for fetal mortality were an Injury Severity Score (ISS) > or =9 and a nonviable pregnancy (<23 weeks). The combination of both risk factors increased the likelihood of fetal mortality by fivefold over that of patients without either risk factor. Maternal hemodynamic parameters did not predict fetal loss. Two patients lost their fetuses despite insignificant trauma (ISS = 1) and normal hemodynamic parameters, whereas eight delivered normal babies despite major trauma (ISS > or = 16). Hemodynamic stability on admission does not predict fetal mortality. Although the presence of moderate to severe injuries (ISS > or = 9) increases the likelihood of fetal mortality, this complication may occur even with insignificant trauma. Close maternal and fetal monitoring is justified, regardless of maternal hemodynamic presentation or severity of injury.

Endpoints of resuscitation of critically injured patients: normal or supranormal? A prospective randomized trial.

OBJECTIVE: To evaluate the effect of early optimization in the survival of severely injured patients. SUMMARY BACKGROUND DATA: It is unclear whether supranormal ("optimal") hemodynamic values should serve as endpoints of resuscitation or simply as markers of the physiologic reserve of critically injured patients. The failure of optimization to produce improved survival in some randomized controlled trials may be associated with delays in starting the attempt to reach optimal goals. There are limited controlled data on trauma patients. METHODS: Seventy-five consecutive severely injured patients with shock resulting from bleeding and without major intracranial or spinal cord trauma were randomized to resuscitation, starting immediately after admission, to either normal values of systolic blood pressure, urine output, base deficit, hemoglobin, and cardiac index (control group, 35 patients) or optimal values (cardiac index >4.5 L/min/m2, ratio of transcutaneous oxygen tension to fractional inspired oxygen >200, oxygen delivery index >600 mL/min/m2, and oxygen consumption index >170 mL/min/m2; optimal group, 40 patients). Initial cardiac output monitoring was done noninvasively by bioimpedance and, subsequently, invasively by thermodilution. Crystalloids, colloids, blood, inotropes, and vasopressors were used by predetermined algorithms. RESULTS: Optimal values were reached intentionally by 70% of the optimal patients and spontaneously by 40% of the control patients. There was no difference in rates of death (15% optimal vs. 11% control), organ failure, sepsis, or the length of intensive care unit or hospital stay between the two groups. Patients from both groups who achieved optimal values had better outcomes than patients who did not. The death rate was 0% among patients who achieved optimal values compared with 30% among patients who did not. Age younger than 40 years was the only independent predictive factor of the ability to reach optimal values. CONCLUSIONS: Severely injured patients who can achieve optimal hemodynamic values are more likely to survive than those who cannot, regardless of the resuscitation technique. In this study, attempts at early optimization did not improve the outcome of the examined subgroup of severely injured patients.