Admission base deficit predicts transfusion requirements and risk of complications.

BACKGROUND: Trauma center resource management could be facilitated by a readily available indicator of resource consumption. This marker should identify patients more likely to require transfusion and intensive care services and to develop complications. Base deficit (BD) has been shown to be a valuable indicator of shock, abdominal injury, fluid requirements, efficacy of resuscitation, and to be predictive of mortality after trauma. This study was performed to determine whether BD could be used to identify which patients were likely to require blood transfusion in the first 24 hours of hospitalization, and to develop shock-related complications and increased intensive care unit (ICU) and hospital stays. METHODS: A retrospective review of 2,954 patients admitted to the Valley Medical Center Level I trauma service from July 1990 through August 1995 was done using the trauma registry and blood bank data bases. Medical record review was done to supplement missing data. RESULTS: Transfusion requirements increased as the BD category became more severe (p < 0.001). Transfusions were required within 24 hours of admission in 72% of patients with a BD < or = -6 versus 18% of patients with a BD > -6 (p < 0.001, chi 2). Both ICU and hospital length of stay increased with worsening BD (p < 0.015 and p < 0.05, respectively). The frequency of adult respiratory distress syndrome (ARDS) (p < 0.01), renal failure (p = 0.015), coagulopathy (p < 0.001), and multiorgan system failure (MOF) (p = 0.002) all increased with increasingly severe BD. Discriminate analysis using Injury Severity Score (ISS) and BD category demonstrated predictive accuracy of 81%, 77%, and 77% for coagulopathy, ARDS, and MOF, respectively. Mortality also increased with worsening BD. When stratified by BD category, there was no difference between observed and predicted survival. CONCLUSIONS: Admission BD identifies patients likely to require early transfusion and increased ICU and hospital stays, and be at increased risk for shock-related complications. Patients with BD < or = -6 should undergo type and cross-match rather than type and screen. The use of ISS and BD category probability curves may identify candidates for early invasive monitoring.

Evaluating the cost-effectiveness of treatment with third-generation cephalosporins.

Spreadsheet computer software was used to compare the estimated global treatment costs of the third-generation cephalosporins, cefotaxime and ceftriaxone, in the management of pneumonia using treatment schedules taken from current studies. Included in the analysis were not only acquisition costs, but also costs that contribute to total expenses for a course of treatment, such as those of (a) preparation and administration (disposable supplies, nursing, and pharmacy time), (b) projected laboratory costs to monitor for hypoprothrombinemia, and (c) complication costs (diarrhea, superinfection, pseudocholelithiasis, and so on). The cost analysis was performed using United States trial-derived factors. Where published cost factors were not available, reasonable estimates were sought. Our analysis indicates that cefotaxime therapy may be less costly than ceftriaxone therapy in the dosage schedules used in these clinical studies and routine clinical practice.

Bleeding Meckel's diverticulum in an adult.

The 99mtechnetium pertechnetate nuclear red blood cell scan proved to be a valuable diagnostic tool in localizing the site of bleeding, from a Meckel's diverticulum, in a 41-year-old man. When peptic ulcer or colorectal disease has been excluded by panendoscopy, bleeding Meckel's diverticulum remains a diagnostic consideration, even in adults. We provide a 20-year list of bleeding Meckel's diverticula reported in adults, along with a brief discussion.

Computer modelling antibiotic therapy costs. Impact of therapeutic range.

Computer modelling techniques were used to examine the economic consequences of intravenous chemotherapy of serious infection. Acquisition cost of the drug was found to be a poor predictor of global cost, since inclusion of the preparation and administration costs and projected laboratory and drug complication costs narrow, or even reverse, apparent cost differentials between drugs. Thus, the cost per day for acquisition/total treatment (in US dollars) are: penicillin $5/$30, gentamicin $1/$46, amikacin $26/$63, clindamycin $38/$57, metronidazole $12/$20 and cefotaxime $47/$60. 'Triple therapy' involving gentamicin ($0.40/dose) resulted in higher hospital costs than the equivalent regimen involving cefotaxime ($16/dose). Even when the purchase price is high, humanitarian considerations advocate the use of safe, predictable, efficacious drugs. Fortunately, the present analysis suggests that such drugs frequently result in the lowest total treatment cost. Current cost containment efforts that are based on acquisition costs only are flawed and may result in both suboptimal care and higher actual costs.

Cost-effective aminoglycoside therapy in surgical patients.

There is a risk that the current pressures for hospital cost containment may result in inappropriately restrictive administrative measures. A failure to take into account all factors in estimating the cost of antibiotic therapy yields a greatly distorted view of the importance of acquisition costs. Higher-priced drugs may actually be more cost-effective if they have greater efficacy, wider therapeutic range, and/or are less costly to prepare and administer. Simple microcomputer modeling techniques may be easily employed to examine the economic consequences of therapeutic decisions.

Procidentia in identical twins. Report of cases and analysis of treatment options.

Within a six-week interval, adult identical twin brothers presented with third-degree complete rectal prolapse. Since no other predisposing factors were evident, contribution of an inherited predisposition is implied. Evaluation of alternatives supports use of presacral rectal mobilization with subtotal anterior resection and reanastamosis of sigmoid colon and rectum as the curative procedure.

Effect of duodenal cooling on small intestinal pacing.

The aim of this study was to determine whether mid-duodenal cooling would decrease the frequency of the pacesetter potentials in the distal duodenum and so facilitate pacing of the distal duodenum by electrical stimuli. Stepwise cooling of the mid duodenum of four awake dogs from 38 degrees to 4 degrees C decreased markedly the frequency of the distal duodenal pacesetter potentials (mean +/- SEM, 19.7 +/- 0.6 versus 13.6 +/- 0.4 cycles/min, P less than 0.05). Moreover, during cooling, electrical pacing near the ligament of Treitz increased the frequency of the pacesetter potentials in the distal duodenum and reversed their direction of travel from caudad to orad. The maximum driven frequency was progressively slowed as the mid duodenum was cooled from 38 degrees to 4 degrees C (20.9 +/- 0.5 versus 18.0 +/- 0.7 cycles/min, P less than 0.05). Because the unpaced frequency declined more rapidly than the maximum driven frequency as the mid duodenum was cooled, the spread between them, or the "pacing range," enlarged with decreasing temperature. We concluded that duodenal cooling decreased the frequency of the distal duodenal pacesetter potentials and expanded the range over which the pacesetter potentials could be paced.

Electrical pacing for short bowel syndrome.

In five dogs, the abroad two-thirds of the small intestine were removed, and a jejunocolostomy was performed to create the short bowel syndrome. Electrodes were affixed to the remaining proximal part of the small intestine for recording and to the distal part of the small intestine for stimulating. A comparison was made between 15 day periods in which feedings were followed by either four hours of retrograde electrical pacing or no pacing. Daily weight loss was less during the periods of pacing in each dog than during the periods of no pacing. Retrograde electrical pacing of the small intestine decreased weight loss in dogs with the short bowel syndrome.

Electrical control of canine jejunal propulsion.

We wondered whether the direction of propagation of intestinal pacesetter potentials determines the direction of movement of intestinal content. In six dogs, electrodes for pacing were implanted near each end of an 80-cm isolated jejunal loop, and a cannula was positioned at the middle of the loop for intraluminal insertion of solids and/or liquids. After recovery and during fasting, 50 nylon spheres (2 mm diam) always emptied from the distal stoma regardless of the direction of pacing. In contrast, 150 mM NaCl, given alone at 2.8 ml/min or with spheres, emptied from the distal stoma during forward pacing and from the proximal stoma during backward pacing. Spheres given with the liquid emptied from the distal stoma during forward pacing, but during backward pacing, the site of emptying varied among dogs. Neither pacing nor spheres altered jejunal interdigestive myoelectric cycles, but the perfusate abolished the cycles and resulted in a noncyclic pattern of jejunal action potentials. We concluded that the direction of pacesetter potential propagation determined the direction of liquid transit. Direction of solid transit depended, in part, on other mechanisms.

Role of gastroenterostomy in patients with unresectable carcinoma of the pancreas.

A group of 107 patients with unresectable carcinoma of the pancreas who underwent simultaneous biliary bypass and gastroenterostomy were compared with a group of 107 matched patients who underwent biliary bypass only. Hospital mortality was identical. A longer hospital stay was evident after concomitant gastroenterostomy and was related to problems with delayed gastric emptying. However, the patients with this complication had preoperative signs or symptoms suggestive of partial or impending duodenal obstruction. Notably, eight of 53 patients with adequate follow-up data after biliary bypass alone required gastroenterostomy within nine months because of duodenal obstruction. Results of our experience suggest that patients with a favorable prognosis who undergo palliative biliary bypass for carcinoma of the pancreas should also undergo a gastroenterostomy.

Enhancing absorption in the canine short bowel syndrome by intesitnal pacing.

Our goal was to determine whether intestinal absorption could be enhanced by pacing the small bowel backward in dogs with the short bowel syndrome. In five dogs the aborad one third of the small bowel and the entire colon were removed, and an ileorectostomy was established. The small bowel and the entire colon were removed, and an ileorectostomy was established. The duodenum was transected and reanastomosed 10 cm from the pylorus to facilitate pacing, and cannulas were inserted in the intestine at 15, 110, and 115 cm for perfusion, sample collection, and balloon occlusion, respectively. Recording and stimulating electrodes were affixed to the bowel between perfusion and collection cannulas. In four or more trials in each dog, an isotonic perfusate of glucose (138 mM), NaCl (76 mM), and 3H-polyethylene glycol was introduced via the proximal cannula at 2.9 ml/min and effluent collected from the distal cannula for 3 hours. During hour 2, electrical stimuli were applied to the distal end of the perfused segment to drive the pacesetter potentials, hence contractions, of the perfused segment backward. Pacing decreased markedly the output of water, glucose, sodium, and potassium and increased the concentration of polyethylene glycol in the effluent. We concluded that retrograde electrical pacing increased small intestinal absorption of water, glucose, and sodium and decreased output of potassium in dogs with short bowel syndrome.

Independence of canine gastric and duodenal pacesetter potentials shown by electric pacing.

Our objective was to determine if the canine gastric pacesetter potential spreads across the pylorus to influence the duodenal pacesetter potential, and vice versa. Electric pacing of the gastric corpus increased the frequency of the gastric pacesetter potential and slowed the velocity of its aborad propagation, but gastric pacing did not change the frequency of the duodenal pacesetter potential or alter the velocity or aborad direction of its propagation. Electric pacing of the distal duodenum increased the frequency of the proximal duodenal pacesetter potential, reversed its direction of propagation from aborad to orad, and slowed its velocity of propagation. However, duodenal pacing did not alter the frequency, velocity, or direction of propagation of the gastric pacesetter potential. Our conclusion is that the gastric pacesetter potential and the duodenal pacesetter potential are each independent of the frequency, velocity, and direction of propagation of the other.