Intra-abdominal hypertension and abdominal compartment syndrome in burn patients.

BACKGROUND: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are known to occur in patients after major abdominal surgery. The incidence of IAH and ACS in the burn population is not known. METHODS: We prospectively recorded the intra-abdominal pressures of major burn patients admitted to our burn center from February 1999 to September 1999. A bladder pressure greater than 25 mm Hg was diagnosed as IAH. ACS was diagnosed when pulmonary compliance decreased in association with persistent IAH and was treated with abdominal decompression. RESULTS: Ten patients were placed on the protocol; of these, seven developed IAH. Five responded to conservative treatment. Two patients with 80% body surface area burns developed ACS and required decompression. CONCLUSIONS: IAH occurs commonly in major burn patients, and ACS is seen regularly in patients with more than 70% body surface area burns. We recommend bladder pressure measurements after infusion of more than 0.25 L/kg during the acute resuscitation phase and for peak inspiratory pressures greater than 40 cm H2O. Whereas ACS warrants surgical decompression of the abdominal cavity, IAH usually responds to conservative therapy.

Abdominal compartment syndrome in patients with burns.

Abdominal compartment syndrome (ACS) is a well-recognized perioperative complication that occurs in patients who undergo intra-abdominal operations and who require extensive fluid resuscitation. The classic presentation of this syndrome includes high peak airway pressures; oliguria, despite adequate filling pressures; and intra-abdominal pressures of more than 25 mm Hg. A decompressive laparotomy performed at the bedside can alleviate ACS. If left untreated, sustained intra-abdominal hypertension is often fatal. In the literature, ACS has been described in pediatric patients with burns but not in adult patients with burns. This article describes 3 adults who sustained burns of more than 70% of their body surface areas, who required more than 20 L of crystalloid resuscitation, and who developed ACS during their resuscitation after the burn injury. The mortality rate among these patients was 100%, which confirms the grave consequences of this syndrome. In our institution, intra-abdominal pressure is now routinely measured as part of the burn resuscitation process in an attempt to diagnose and treat this syndrome earlier and more efficaciously. It is recommended that the possibility of ACS be considered when diagnosing any patient with burns who develops high airway pressures, oliguria, or both.

Fibrin glue terminates massive bleeding after complex hepatic injury.

OBJECTIVE: We determined the ability of a packaged fibrin glue (FG) product to terminate severe bleeding in a new porcine model of complex hepatic injury. METHODS: Femoral arterial and venous catheters were placed in pentobarbital-anesthetized swine (n=7 per group, 16-18 kg). Pigs received an external blast to the right upper abdomen at 0 minutes, followed by uncontrolled hemorrhage at 0 to 30 minutes, with anticoagulation (heparin, 200 U/kg) at 10 minutes. Pigs were resuscitated with lactated Ringer's solution (20 mL/kg) beginning at 15 minutes and then underwent laparotomy to control bleeding at 30 minutes. Lactated Ringer's solution was infused to keep mean arterial pressure greater than 70 mm Hg until 120 minutes, when repeat laparotomy was performed. Control animals (group 1) underwent routine surgical procedures to terminate bleeding followed by packing if hepatic bleeding continued. The FG animals (group II) underwent routine surgical procedures plus application of FG. Avoidance of packing, estimated blood loss (EBL) during and after laparotomy, and fluid resuscitation volume were the primary end points studied. RESULTS: In both groups, mean arterial pressure varied significantly from baseline to 120 minutes (group I: 100+/-3 to 52+/-11 mm Hg; group II: 99+/-4 to 66+/-3 mm Hg). Temperature decreased at the end of each experiment (group I: 37+/-1 to 33+/-1 degrees C; group II: 37+/-1 to 34+/-1 degrees C). There were no group differences in EBL before laparotomy (0-30 minutes), but from initial laparotomy to repeat laparotomy (30-120 min), EBL (group I: 875+/-265 mL; group II: 300+/-59 mL) and total fluid resuscitation (group I: 2.9+/-0.4 L; group II: 1.9+/-0.3 L) were statistically significantly less in FG pigs. Of greatest importance, six of seven control pigs required packing, but none of the FG animals were packed and none bled at repeat laparotomy. CONCLUSION: FG stopped bleeding and eliminated the need for packing in a model of severe liver injury. Further work in the clinical arena is warranted to determine the potential benefits of FG in arresting hemorrhage in hypotensive, hypothermic, coagulopathic trauma patients with complex visceral injuries.

Addressing the myths of cervical spine injury management.

Every year in the United States about 5,000 people sustain a cervical spinal cord injury. Vastly greater numbers present to hospitals after motor vehicle crashes and falls with potential cervical spine injuries (CSI) for evaluation. This group of patients requires very careful management while undergoing evaluation for potential CSI to minimize the potential for spinal cord injury. It is, therefore, incumbent on everyone caring for these patients to distinguish between fact and fiction in regard to CSI management. This article addresses the following areas of controversy: CSI is a rare injury; patients with cranial and facial injuries are at increased risk for CSI; everyone with a significant mechanism of injury needs radiological clearance of their cervical spine; a normal cross-table lateral view radiograph excludes significant CSI; oral intubation of patients with CSI is not safe; a semi-rigid collar prevents movement of the cervical spine; and the evaluation of the cervical spine needs to begin in the resuscitation room in every patient.

Benchmarking for best practice in critical care medicine: can it realistically be done?

An individual program's viewpoint on the overall benchmarking process for critical care medicine and how this process can provide a conceptual understanding of how benchmarking can be beneficial.

Polytetrafluoroethylene interposition grafts for carotid reconstruction.

Polytetrafluoroethylene interposition grafts were used for carotid reconstruction in 26 operations performed in 23 patients during a 7-year period. There were 10 men and 13 women with a mean age of 66 years. The indication for interposition graft placement was recurrent stenosis with inability to perform endarterectomy in nine operations, a severe kink or technical problem during endarterectomy in nine, aneurysmal changes of the artery in six, and thrombosis of the endarterectomy site segment with stroke in two. There were no perioperative deaths and no further perioperative neurologic complications. Follow-up with performance of yearly duplex scans was obtained in all patients, and the mean duration of follow-up was 36 months. One patient (4%) died of end-stage pulmonary disease during the study interval. Occlusion of the polytetrafluoroethylene graft occurred at 12 months in one patient (4%). Hemodynamically significant restenosis developed in two patients (8%), and two patients (8%) had mild restenosis. Evidence of a second restenosis developed in three of the nine patients who underwent polytetrafluoroethylene interposition graft placement for carotid restenosis. On the basis of our study results, we conclude that polytetrafluoroethylene can be used effectively for carotid reconstruction when an interposition graft is required. However, recurrent stenosis occurs. Patients who undergo polytetrafluoroethylene interposition graft placement for carotid restenosis appear to be at high risk for a second restenosis.