The morbidity of trauma nephrectomy.

Mortality has been shown to be high in patients after trauma nephrectomy (TN). However, there are little data regarding morbidity in survivors. The objective of this study was to determine the morbidity rates associated with TN with attention directed to renal failure (RF) and formation of intra-abdominal abscess (IAA). Patients who underwent TN over a 9-year period (1996 to 2004) were identified from the trauma registry. Records were reviewed for all complications after TN in patients surviving at least 48 hours. Eighty-nine patients were identified with TN; 61 per cent resulted after penetrating trauma. Overall mortality was 34 per cent. Seventy-one patients survived greater than 48 hours; 51 (72%) experienced at least one morbidity. There was no difference in morbidity rates between patients undergoing blunt trauma and those undergoing penetrating trama. Patients with morbidities were significantly older, more severely injured, and had higher mortality rates and longer hospital courses. Infectious complications were seen in 52 per cent, respiratory in 48 per cent, gastrointestinal in 30 per cent, coagulopathy in 25 per cent, and RF and IAA were each seen in 14 per cent of patients. Patients undergoing TN are severely injured with significant morbidity. The results from this study allow us to establish benchmarks to assess complication rates for patients who undergo TN, which can provide prognostic information and goals to improve patient outcomes.

Antibiotic-coated ePTFE decreases graft colonization and neointimal hyperplasia.

BACKGROUND: Synthetic vascular conduits used in traumatic or infected fields have a high failure rate leading to catastrophic consequences including amputation and death. Although efforts to coat vascular grafts with antibiotics have had varying results, we developed a novel coating technique for expanded-polytetrafluoroethylene (ePTFE), which has proven to be effective in vitro. Thus, we hypothesized that the coated grafts would resist infection and have decreased neointimal hyperplasia when used in vivo in a large animal model. METHODS: Minocycline and rifampin suspended in a mixture of methacrylates were coated onto a 3cm segment of 6mm ePTFE (Bard, Tempe, AZ). An antibiotic-coated (ABX), adhesive-coated (AC), or control (C) ePTFE graft was then placed as an end-to-side graft into the left iliac artery of a male mongrel pig. Sterile saline or innoculum containing 3x10(8)Staphylococcus aureus (SA) or Staphylococcus epidermidis (SE) was then placed directly on the graft and the reflected peritoneum re-approximated to confine the bacteria. After 6 wk, the graft was harvested, cultured, and morphometric analyses of neointimal hyperplasia were performed. RESULTS: Twenty-seven pigs had grafts placed (9 ABX, 9 AC, 9 C) and harvested. Of the nine grafts exposed to SA, the uncoated and adhesive-coated grafts averaged greater than 50,000 colonies of SA while the antibiotic-coated grafts averaged less than 50 colonies. Although not statistically significant, neointimal hyperplasia was decreased by 15% to 20% when using an ABX graft in an infected field. CONCLUSIONS: The coated grafts appeared to decrease NIH formation although not significantly in this small pilot study. The methacrylate antibiotic-coated ePTFE graft did provide resistance to infection when used in infected fields.

Prosthetic vascular conduit in contaminated fields: a new technology to decrease ePTFE infections.

Vascular reconstruction using prosthetic materials in contaminated fields can lead to infection, graft loss, and subsequent amputation. We hypothesized that minocycline and rifampin bound to an ePTFE graft using a unique methacrylate technology would provide for resistance from infection and controlled antibiotic elution. Kirby Bauer susceptibility testing was performed on plates overlaid with Staph aureus (SA) and Staph epidermidis (SE) using 6 mm diameter discs of uncoated graft or antibiotic coated graft (ABX). Zones of inhibition (ZIH) were determined after 24 hours. ABX grafts were then placed in a continuous water bath and a recirculating, pulsatile flow device. Susceptibility testing and high performance liquid chromatography with mass spectroscopy was performed to determine graft performance and antibiotic elution rate. ABX grafts had an average ZIH of 35 mm for SA and 44 mm for SE (each P < 0.0001). After the 1 week water bath, the ZIH of the ABX grafts was 23 mm on both the SA and SE plates. The high performance liquid chromatography with mass spectroscopy revealed that after 24 hours, 50 per cent of the antibiotics remained on the graft, and there was a sustained elution for 7 days. Minocycline and rifampin can be bound to ePTFE vascular grafts using a unique methacrylate method. In vitro, the grafts provide a slow elution of antibiotics that provide resistance from infection by SA and SE for up to 2 weeks after graft insertion.

Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial.

BACKGROUND: Although benzodiazepines are the recommended first-line therapy for the prevention of alcohol withdrawal syndrome (AWS), the administration of intravenous ethanol as an alternative prophylactic agent persists in many surgical ICUs. Advocates of this therapy argue that ethanol provides effective prophylaxis against AWS without the excessive sedation observed with benzodiazepine therapy. No study to date, however, has compared the two therapies with regard to their sedative effects. The purpose of this study was to prospectively evaluate the efficacy of intravenous ethanol compared with benzodiazepines for the prevention of AWS with particular emphasis on the sedative effects of each therapy. METHODS: During a 15-month period, trauma patients admitted to the ICU with a history of chronic daily alcohol consumption greater than or equal to five beverage equivalents per day were prospectively randomized to one of two 4-day prophylactic regimens: intravenous ethanol infusion (EtOH) versus scheduled-dose diazepam (BENZO). Patients were evaluated with the Riker sedation-agitation scale, a 7-point instrument for the subjective assessment of both sedation (1 = unarousable) and agitation (7 = dangerous agitation). According to protocol, regimens were titrated to achieve and maintain a Riker score of 4 (calm and cooperative). Deviation from a score of 4 during the course of treatment was compared between groups. RESULTS: Fifty patients met study criteria and were randomized after obtainment of informed consent (EtOH, n = 26; BENZO, n = 24). Overall, the EtOH group had a significantly greater proportion of patients who deviated from a score of 4 during the course of treatment (p = 0.020). In both groups, the majority of deviation from a score of 4 reflected periods of under-sedation rather than over-sedation. One patient in the EtOH group failed treatment, requiring diazepam and haloperidol for control of AWS symptoms as per protocol, whereas no patient in the BENZO group failed treatment (p = NS). CONCLUSION: Concerning the prophylaxis of AWS, intravenous ethanol offers no advantage over diazepam with respect to efficacy or adverse sedative effects. The purported benefit of intravenous ethanol as a prophylactic agent against AWS was not evident.

The utility of serial computed tomography imaging of blunt splenic injury: still worth a second look?

BACKGROUND: Serial computed tomography (CT) imaging of blunt splenic injury (BSI) can identify the latent formation of splenic artery pseudoaneurysms (PSAs), contributing to improved success in splenic salvage. The practice of serial CT imaging, however, has not been embraced. The purpose of this study was to reevaluate the clinical practice of serial CT imaging within the context of an institutional protocol for the nonoperative management (NOM) of BSI. METHOD: Consecutive patients with BSI selected for NOM were identified from our trauma registry. Patients were managed according to protocol, whereby hemodynamically stable patients with PSA on initial or follow-up CT imaging were referred for angiography. Follow-up CT was performed 24 to 48 hours after the initial CT. Data were abstracted from hospital, clinic, and radiology records, and included age, Injury Severity Score, splenic injury grade (SIG), and CT findings. The incidence and timing of PSA identification with respect to subsequent management and outcome were reviewed. RESULTS: Of 426 BSI admissions during a 2.5-year period, 341 (80%) were selected for NOM. Mean follow-up was 39 days, with 76% followed for >or=7 days. Serial CT imaging resulted in the angiographic detection of 14 (4%) early PSAs and 11 (3%) latent PSAs. PSAs were associated with increasing SIG (p<0.001); however, 24% of PSAs were observed in SIG 1 and 2. Embolization was successful in 13 of 14 (93%) patients with early PSAs and 10 of 11 (91%) with latent PSAs. The splenic salvage rate for all patients selected for NOM during the study period was 329 of 341 (97%). CONCLUSIONS: Adherence to a NOM protocol guided by serial CT imaging has resulted in one of the highest splenic salvage rates reported to date. Identification and embolization of latent PSA likely contributes to NOM success, given the unfavorable natural history of these lesions. Although PSA formation is correlated with increasing SIG, PSAs are not exclusive to higher-grade injury, warranting serial CT surveillance regardless of SIG.

Antithrombotic therapy and endovascular stents are effective treatment for blunt carotid injuries: results from longterm followup.

BACKGROUND: Significant confusion exists about management of blunt carotid injuries (BCI). Currently, three common treatments are being used without significant longterm followup data to demonstrate efficacy. Although heparin has been shown to reduce in-hospital stroke rates, antiplatelet therapy (aspirin and clopidogrel) has emerged as an alternate therapy without proved efficacy; carotid stenting has also been implemented for pseudoaneurysms (13% BCI), but its utility has recently been challenged. This is the first study to assess longterm efficacy of various therapeutic approaches. STUDY DESIGN: Consecutive patients treated and followed at a single regional trauma center over 10 years (1996 to 2005) were reviewed. Outcomes evaluated included cerebral infarction, functional status, and angiographic evolution. RESULTS: One hundred ten patients (11/year) were diagnosed with 133 injuries (23 bilateral). Overall mortality was 26%, with 6% directly attributable to BCI. Angiographic followup was available on 67 injuries (in 50 patients) at a mean of 6 months (range 0.25 to 67 months); 75% remained the same or improved. Clinical followup was available in 55 of 81 patients (68%) who survived to discharge (mean, 34.4 months [range 1 to 109 months]). Of surviving patients receiving antithrombotic therapy, 44% were treated with antiplatelet therapy, 49% with anticoagulation, and 7% with both. No patients experienced cerebral infarction after discharge, and there was no difference in functional outcomes based on the therapy received. Twenty-two endovascular stents were placed (18 for pseudoaneurysms, 4 for extensive dissection). Mean followup on these patients was 29.7 months (range 3 to 94 months). No patients receiving stents experienced periprocedural complications, and one patient with an associated brain injury had a cerebral infarction. CONCLUSIONS: Longterm followup of BCI demonstrates that antithrombotic therapy prevents cerebral infarction; antiplatelet therapy and anticoagulation are equally effective; and carotid stents appear to be safe and effective for lesions that develop pseudoaneurysms or extensive dissections.

Aerosolized ceftazidime prophylaxis against ventilator-associated pneumonia in high-risk trauma patients: results of a double-blind randomized study.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a frequent complication during recovery of severely traumatized patients. The primary objective of this study was to determine if prophylactic administration of aerosolized ceftazidime reduced the incidence of VAP in high-risk injured patients without altering the incidence of other infectious complications. PATIENTS AND METHODS: This was a single-institution double-blind, randomized trial that compared a seven-day course of aerosolized ceftazidime with placebo. Intubated high-risk patients admitted to the trauma intensive care unit at a large regional trauma center between February 2003 and September 2005 were eligible for enrollment. The main outcome evaluated was the incidence of VAP at two weeks and 30 days. The incidences of multi-drug-resistant infections and other infectious complications were secondary outcomes. RESULTS: A total of 105 patients were randomized, resulting in 52 patients in the placebo arm and 53 patients in the ceftazidime arm. There was no statistical difference between the groups with regard to demographic data, injury severity, calculated risk of VAP, or the number of doses received. In the intention-to-treat analysis, the incidence of VAP at two weeks was 24/52 (46%) in the placebo group and 21/53 (40%) in the ceftazidime group. The number of patients with VAP at 30 days was 26/52 (50%) in the placebo group and 26/53 (49%) in the ceftazidime group. There was no statistical difference in the development of multi-drug-resistant VAP or other infectious complications in the two groups. CONCLUSION: The use of aerosolized ceftazidime did not reduce the rate of VAP in high-risk patients admitted after traumatic injury, but neither did it increase the incidence of other infectious complications. Routine use of prophylactic aerosolized ceftazidime to prevent VAP in trauma patients cannot be recommended.

"Awake" laparoscopy for the evaluation of equivocal penetrating abdominal wounds.

BACKGROUND: Diagnostic laparoscopy is useful for the assessment of equivocal penetrating abdominal wounds, and has become the modality of choice for the evaluation of such wounds at our institution. We hypothesised that, in appropriate patients, diagnostic "awake" laparoscopy (AL) could be performed under local anaesthesia in the emergency department (ED), allowing for expedited discharge and potential cost savings. METHODS: Selected haemodynamically stable patients with penetrating abdominal injury underwent AL. Suitability for AL was at the discretion of the attending surgeon. Identification of peritoneal penetration by AL led to exploratory laparotomy in the operating room. Patients with no evidence of peritoneal penetration were discharged from the ED (ALneg). These patients were matched to a cohort of 24 patients who underwent diagnostic laparoscopy in the OR which was negative for peritoneal penetration (DLneg). Length of stay and hospital charges were compared. RESULTS: Over a 30-month period, 15 patients underwent AL without complication. No peritoneal penetration was found in 11 patients. The remaining four patients underwent exploratory laparotomy, of which two were positive for intra-abdominal injury. Mean time to discharge was 7h in the ALneg group versus 18 h in the DLneg group (p=0.0003). Cost savings on hospital charges averaged 2227 US dollars per patient in the ALneg group compared with the DLneg group. CONCLUSIONS: AL may be safely performed in the ED, allowing for expedited patient discharge. Cost savings are achieved by the avoidance of charges inherent to diagnostic laparoscopy performed in the operating room.

The effect of bacterial contamination on neointimal hyperplasia in vascular grafts.

Neointimal hyperplasia (NH) is the most significant contributing factor to long-term vascular graft failure. Inflammation is known to be important in its development; however, the role of bacterial infection is unclear. We examined the effect of contamination with common organisms on the development of NH in expanded polytetrafluoroethylene grafts. Thirty adult pigs were randomized into one of four groups: no infection, contamination with Staphylococcus aureus, mucin-producing Staphylococcus epidermidis, or Pseudomonas aeruginosa. An expanded polytetrafluoroethylene graft (6 mm x 3 cm) was placed as a common iliac artery interposition graft and was inoculated with 1-2 x 10(8) of the selected organism before closure. Grafts were explanted 6 weeks postoperatively. Microbiologic, histological, and morphometric evaluations were performed. All grafts were patent at the time of euthanasia. The mean areas of NH were 5.45 mm(2) in sterile grafts, 8.36 mm(2) in S. aureus, 7.63 mm(2) in S. epidermidis, and 11.52 mm(2) in P. aeruginosa grafts. Comparison of means via analysis of variance showed that P. aeruginosa grafts had significantly higher formation of NH than sterile grafts (P = 0.025). NH production in infected grafts appears to be organism specific and is significantly higher with P. aeruginosa than common Gram-positive organisms. Increased NH from subclinical infection may be a significant factor contributing to late graft failures.