Foot pump prophylaxis for deep venous thrombosis: the rate of effective usage in trauma patients.

Trauma patients are at risk for deep venous thrombosis (DVT) but often cannot receive systemic anticoagulation therapy. The major reason for failure of mechanical methods of DVT prophylaxis is ineffective usage. It has been postulated that foot pumps may have a better compliance rate than do other devices. One thousand observations were performed on trauma patients in both the intensive care unit (ICU) and on the surgical ward. Foot pumps were applied properly and functioning correctly 59% of the time. Patients in the ICU had significantly better compliance than did patients on the surgical ward. These rates are not better than published rates for other devices for DVT prophylaxis.

The effects of femoral intramedullary reaming on pulmonary function in a sheep lung model.

Two methods of intramedullary fixation of fractures of the middle of the femoral shaft were evaluated in a sheep model to determine the effect of femoral reaming on pulmonary function. The effect of a modified reamer was also studied. A second experiment with the same model was performed to evaluate the relationship between embolization and pulmonary dysfunction. This experiment involved two groups of sheep--those with normal lungs and those with contused lungs--divided into subgroups--those that had nailing with reaming and those that had nailing without reaming. Intracardiac ultrasound was used to measure the magnitude and duration of transvenous particulate embolization during the operations. Both experiments involved hemodynamic monitoring during and after the nailing. The pulmonary tissue was examined histologically after the animals were killed. The hemodynamic monitoring revealed only a transient increase in pulmonary vascular resistance in the animals that had femoral nailing with reaming in both experiments. The modified reamer had no effect on the pulmonary response. Histological analysis of pulmonary tissue demonstrated a significant increase in the number of fat emboli in both the animals that had nailing with reaming and the animals that had nailing without reaming compared with the control animals. Intravascular ultrasound revealed that the operative maneuver associated with the greatest number of emboli was opening of the intramedullary canal with the awl. The first two passes of the reamer produced more emboli and embolism of longer duration than did the later passes. Pulmonary confusion did not increase the risk of pulmonary dysfunction due to intramedullary nailing in this model.

A prospective study of simplified omeprazole suspension for the prophylaxis of stress-related mucosal damage.

OBJECTIVES: To determine the efficacy, safety, and cost of simplified omeprazole suspension in mechanically ventilated critically ill patients who have at least one additional risk factor for stress-related mucosal damage. DESIGN: Prospective, open-label study. SETTING: Surgical intensive care and burn unit at a university tertiary care center. PATIENTS: Seventy-five adult, mechanically ventilated patients with at least one additional risk factor for stress-related mucosal damage. INTERVENTIONS: Patients received 20 mL of simplified omeprazole suspension (containing 40 mg of omeprazole) initially, followed by a second 20-mL dose 6 to 8 hrs later, then 10 mL (20 mg) daily. Simplified omeprazole suspension was administered through a nasogastric tube, followed by 5 to 10 mL of tap water. The nasogastric tube was clamped for 1 to 2 hrs after each administration. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was clinically significant gastrointestinal bleeding determined by endoscopic evaluation, nasogastric aspirate examination, or heme-positive coffee ground material that did not clear with lavage, which was associated with at least a 5% decrease in hematocrit. Secondary efficacy measures were gastric pH measured 4 hrs after omeprazole was first administered, mean gastric pH after omeprazole was started, and the lowest gastric pH during omeprazole therapy. Safety-related outcomes included the occurrence rate of adverse events and pneumonia. No patient experienced clinically significant upper gastrointestinal bleeding after receiving omeprazole suspension. The 4-hr postomeprazole mean gastric pH was 7.1, the mean gastric pH after starting omeprazole was 6.8, and the mean lowest pH after starting omeprazole was 5.6. The occurrence rate of pneumonia was 12%. No patient in this high-risk population experienced an adverse event or a drug interaction that was attributable to omeprazole. CONCLUSIONS: Simplified omeprazole suspension prevented clinically significant upper gastrointestinal bleeding and maintained gastric pH of > 5.5 in mechanically ventilated critical care patients without producing toxicity.

Abdominal vascular injuries.

Injuries to major abdominal arteries and veins frequently are associated with exsanguinating hemorrhage and visceral ischemia. Expeditious management is the key to survival and good outcome. Knowledge of anatomic relationships between viscera and vessels forms the basis for directed dissection, optimal exposure, and lasting repair of vessels. Although penetrating mechanism of injury remains the most common cause of these injuries, trauma surgeons must be familiar with patterns of blunt trauma-mediated injury to avoid the devastating consequences of delayed management.