The role of pharmacological steroid therapy in preservation of renal function in severely injured patients requiring massive transfusion.

PURPOSE: Glucocorticoids (GC) attenuate the post-insult inflammatory response and have been observed to confer end-organ protection following a variety of ischemic insults. We aim to assess this benefit on renal perfusion and function in injured patients requiring massive transfusion. METHODS: The effect of pharmacologic methylprednisolone (MP) therapy was studied in 118 patients (pts), of whom 60, by random, received 1 g MP intraoperatively and 15 mg/kg for an additional 3 days. Postoperative measurements were made of effective renal plasma flow (ERPF), glomerular filtration by inulin (CIn), creatinine clearance (CCr) and clearances of osmoles (CCosm), sodium (CNa), and free water ([Formula: see text]). Continuous variables were compared between the two groups using the student's t test. RESULTS: Enrolled pts on average received 13.5 units of PRBCs with no differences in the resuscitation regimen. There were no statistically significant differences in the postoperative renal function as measured by ERPF (p = 0.57), CIn (p = 0.84), CCr (p = 0.99), CNa (p = 0.07), COsm (p = 0.95), and [Formula: see text] (p = 0.33). The incidence of renal compromise, as determined by an inulin clearance of <25 mL/min or serum creatinine greater than 3.0 mg/dL, was also similar. Three patients in the MP treatment group had renal compromise compared to one in the control group. CONCLUSIONS: In the absence of larger studies, this study demonstrates that GC likely have no role in preserving renal function in severely injured patients.

Effect of a composite membrane of chitosan and poloxamer gel on postoperative adhesive interactions.

Excessive postoperative adhesion formation is a major result of surgery. The adhesion reduction effects of a chitosan membrane and poloxamer gel barrier were measured in a rat peritoneal model. Forty-four male Sprague-Dawley rats were divided into four groups (control, poloxamer, chitosan, and poloxamer+chitosan sandwich). Two cm2 of cecal serosa and the adjacent abdominal wall were abraded. The denuded cecum was covered with either a chitosan membrane, a poloxamer gel, chitosan in a sandwich configuration with poloxamer on both sides, or neither (control group) and apposed to the abdominal wall. Fourteen days after surgery adhesions were graded using a whole-number scoring system of zero to five. Adhesion strength was determined using a whole-number system of one to four. Adhesion area was measured on a continuous scale of adhesion severity. Adhesion grades were highest in the control group (5.00 +/- 0.00) and were significantly (P < 0.05) lower in the poloxamer group (3.50 +/- 1.35), the chitosan group (1.64 +/- 1.63), and the poloxamer+chitosan group (1.18 +/- 1.25). The two chitosan-containing groups also had significantly (P < 0.05) reduced adhesion grades in comparison with the poloxamer group. Adhesion area in both chitosan-containing groups was reduced in comparison with control and adhesion strength was reduced significantly (P < 0.05) in all groups compared with control. The poloxamer+chitosan group had significantly (P < 0.05) reduced adhesion strength versus poloxamer only. There was a significant (P < 0.05) linear correlation (r = 0.931, P < 0.001) between adhesion grade and adhesion strength. We conclude that chitosan and the combination of poloxamer+chitosan were shown to effectively reduce adhesion area, grade, and strength.

Effects of physiologic albumin and hespan levels on hepatocytes in vitro.

BACKGROUND: Although albumin and hydroxyethyl starch (HES) are routinely used in critically ill, hypoalbuminemic patients, no studies have tested the effect of supplemental albumin and HES on hepatocyte function. METHODS: In this study, the effects of these agents were evaluated by using stable, rat hepatocyte cultures in a collagen sandwich configuration. Hepatocyte synthesis of albumin, urea, and intracellular triglycerides was monitored in Dulbecco's modified Eagle medium (supplemented with fetal bovine serum, hydrocortisone, L-proline, gentamycin, and insulin) without supplemental colloid (control cultures) and with supplemental 2% bovine serum albumin (BSA), 4% BSA, 2% HES, or 4% HES. RESULTS: The albumin secretion in control cultures rose from 31.03 microg/day per 10(6) cells on day 3 to 154.17 microg/day per 10(6) cells by day 12 and remained constant. In contrast, the level of albumin synthesis in the 2% and 4% BSA groups rose from significantly higher initial values (p < 0.05) of 71.25 microg/day per 10(6) cells and 73.27 microg/day per 10(6) cells, respectively, to 127.61 microg/day per 10(6) cells and 107.95 microg/day per 10(6) cells by day 7, then declined rapidly to 58.98 microg/day per 10(6) cells and 41.28 microg/day per 10(6) cells by day 12 when cell disruption was present. HES also reduced albumin synthesis. The urea genesis in the control groups and in the treatment groups was found to be comparable throughout the study. The BSA supplemented groups accumulated large amounts of intracellular lipid droplets during the experiment. The intracellular triglycerides analysis found the 4% BSA group to be significantly (p < 0.05) higher than the 4% HES. CONCLUSION: BSA, added to a collagen sandwich hepatocyte preparation, causes reduced hepatocyte synthesis by day 8, probably a result of intracellular triglyceride accumulation, whereas HES reduces synthesis through unidentified mechanisms.

Changing times and the treatment of liver injury.

We hypothesized that the frequency, diagnosis and treatment of liver injury have changed dramatically in the past 30 years. Patients with liver injuries treated in an urban level I trauma center were analyzed for three separate time periods, namely, 1969-1970, 1981-1982, and 1997-1998. The injuries were categorized by etiology; Abbreviated Injury Score severity, and type of treatment, including observation (Ob), laparotomy without treatment of liver injury (OR No Rx), suture repair (Sut), tractotomy with intraperipheral hemostasis (Tr), dearterialization (HAL), and resection (Re) (See Table, below). There were 249 patients in 1969-1970, 70, 79 in 1981-1982, and 116 in 1997-1998. Stab wounds and gunshot wounds decreased from 235 patients in 1969-1970 to 61 patients in 1997-1998. Blunt injuries increased from 14 patients in 1969-1970 to 55 patients in 1997-1998. Major injuries (Abbreviated Injury Score 4-5) fell from 104 to 25 to 20 during the decade. Laparotomy was done in all patients in 1969-1970 and 1981-1982, whereas most blunt injuries were observed in 1997-1998; only 9 of 65 blunt injuries in 1997-1998 required hemostasis. [table in text] We conclude the following: 1) Central urban depopulation reduces experience with liver trauma, 2) abdominal CT increases the diagnosis of liver injury, and 3) observation of stable patients with blunt liver injury is now the standard.

Surgical decompression of ductal obstruction in patients with chronic pancreatitis.

BACKGROUND: Recurrent acute pancreatitis often leads to chronic obstructive ductal disease requiring operative decompression. METHODS: From 1983 through 1998, 124 patients with ductal obstruction underwent lateral pancreaticojejunostomy (78 patients), distal pancreatectomy with end-to-side pancreaticojejunostomy (27 patients), distal pancreatectomy with placement of a pancreas with a filleted duct within a jejunal limb (15 patients), or pancreaticoduodenectomy (4 patients). Preoperative symptoms included abdominal and back pain (99%), nausea with vomiting (99%), and diarrhea with weight loss (11%). Associated conditions included hypertension (20%) and diabetes mellitus (12%). Endoscopy in 106 patients demonstrated distal stricture (37%), proximal stricture (36%), pseudocyst (30%), chain of lakes (15%), calcification and debris (19%), and bile duct stricture (8%). RESULTS: Two patients died, one of an unrecognized esophageal perforation during intubation and the other of leakage of a 1-layer pancreaticojejunostomy. Thirty-six patients developed 53 complications including intra-abdominal abscess (7 patients) and bleeding requiring reoperation in 1 patient. Pain relief was complete in 61 patients, substantial in 39 patients, moderate in 11 patients, minimal in 8 patients, and nonexistent in 3 patients with multiple stones and narrow duct. Ten patients died, with 6 deaths as a result of pancreatic cancer Two other patients may have died of pancreatic cancer. CONCLUSIONS: Lateral pancreaticojejunostomy is the procedure of choice in most patients. Recurrent pancreatitis usually follows alcoholic binges. Long-term follow-up must assess for pancreatic cancer.

Inhibition of alpha-smooth muscle actin expression in an in vitro wound healing model by certain antibiotics.

OBJECTIVE: This study assesses the effects of antimicrobials on wound healing in an in vitro model of chicken flexor tendons in a collagen gel matrix. Two equidistant tendons were bathed in a culture medium for 28 days as fibroblasts (fb) grew from the tendon ends into the collagen gel and migrated toward each other until gap closure. Five groups of 10 paired tendons each included the control and the study groups, which received oxacillin (Ox), clindamycin (Cl), chloramphenicol (Chl), or tetracycline (Tet) in the culture medium to assess their effects on gap closure rate, fb migration, and myofibroblast alpha-smooth muscle (alpha-SM) actin expression. RESULTS: Gap closure, by day 27, was 98.5% in the controls compared with 97%, 92%, 89.5%, 21.75% in the Tet, Cl, Ox, and Chl groups. Chl retarded gap closure (p < 0.05). Fb migration was similar for all groups. In the control and Ox groups, myofibroblast expressed actin at day 5. By day 7, fb cells were clearly visible in the control, Ox, and Cl groups, whereas, only light actin was present in the Chl and Tet groups. Actin band densities for the Cl, Ox, Tet, and Chl groups were 78.4%, 62.5%, 61.7% and 26.1%, respectively, of the control group. CONCLUSION: These studies suggest that one reason certain antimicrobials impair wound healing, is due to myofibroblast inhibition of alpha-SM actin.

Lower esophageal sphincter dysfunction often precludes safe gastric feeding in stroke patients.

OBJECTIVES: To determine the relationship between stroke and lower esophageal dysfunction with vomiting and to identify an optimal nutrition protocol based on our findings. PATIENTS AND METHODS: The lower and upper esophageal sphincter functions were assessed in 35 patients who had an acute stroke to determine whether gastric or jejunal enteral feeding was the optimal route. Stroke was due to unilateral ischemia in 20 patients, unilateral intracerebral hemorrhage in 8 patients, and global ischemia in 7 patients. Our study consisted of 18 men and 17 women with an average age of 64 years. RESULTS: Using standard esophageal manometric definitions, the lower esophageal sphincter function was below normal in 24 patients: 3 had global anoxia, 5 had unilateral hemorrhage, and 16 had unilateral ischemia. The upper esophageal sphincter function was low in 30 patients: 6 had global anoxia, 7 had unilateral hemorrhage, and 17 had unilateral ischemia. Based on lower esophageal sphincter pressure, 7 patients underwent tube gastrostomy and 13 patients underwent tube jejunostomy placement. All tolerated enteral alimentation well. Prior to lower esophageal sphincter assessment, 4 patients had percutaneous endoscopy gastrostomy feedings that led to aspiration pneumonitis and consultation for tracheostomy; 2 terminally ill patients were referred to the ethics service, and 2 were converted to feeding via jejunostomy tube at the time of tracheostomy and did well. CONCLUSIONS: Vomiting with aspiration due to lower esophageal sphincter dysfunction is common after acute strokes. Esophageal manometry serves as a guide to find the optimal feeding route.

Autologous closure of giant abdominal wall defects.

Split-thickness skin graft coverage of exposed and granulating intestines within large abdominal wall defects provides a life-saving permanent biologic dressing. The resultant abdominal wall defect often is closed with mesh, which may infect and fistulize. This report describes bilateral advancement flaps of the external oblique and recti muscles in 11 patients treated over 3 years. The defects, which averaged 16 x 24 cm, were due to necrotizing fasciitis subsequent to trauma with bowel perforation (3 patients), multiple ventral herniorrhaphies (2 patients), perforated diverticulitis (4 patients), and perforated peptic ulcer (2 patients). Eight patients were initially treated elsewhere where closure was achieved by split-thickness skin graft in five patients or mesh in 3 patients; 3 developed enterocutaneous fistulae and were transferred for closure while receiving long-term antibiotic and total parenteral nutrition therapy. All 11 patients had successful primary closure. The 8 patients operated on electively had primary healing; 2 developed seromas. Two of the three patients operated on urgently developed superficial wound infections; both healed by second intent without compromise of the primary closure. The following conclusions can be drawn: (1) the linea alba survives despite necrotizing fasciitis, (2) a tension-free primary closure is feasible; (3) morbidity is minimal, and (4) the long-term result is excellent.

Simulation program for optimal orthopedic call: a modeling system for orthopedic surgical trauma call.

This report uses a mathematical modeling system to define optimal orthopedic coverage for trauma centers. Data from 2,325 patients treated with emergency orthopedic operations within 24 hours of admission at 78 randomly sampled and at four totally sampled verified centers were used to create a profile of (1) admission by month, day, and hour; (2) operation times; and (3) operation duration. The reason for operation included (1) open fracture or crush (809 patients); (2) irreducible dislocations (164 patients); (3) fracture with vascular injury (seven patients); (4) dislocation with vascular injury (17 patients); (5) compartment syndrome (11 patients); (6) femoral neck fracture in young patients (36 patients); (7) combination of categories 1 to 6 (70 patients); (8) fracture with multiple injuries (171 patients); and (9) urgent not emergent (1,040 patients). The program defined the frequency that an injured patient needing an orthopedic consult would wait beyond 30 minutes because the orthopedic surgeon was doing a trauma related operation at a center with one or two orthopedic surgeons on call. The probability that a patient cannot be seen promptly by one orthopedic surgeon in a center doing 25, 50, 75, 100, 200, and 300 emergency procedures per year is 0.17, 0.74, 1.6, 3.1, 12.5, and 28 patients per year. When two are on call, 1.3 patients, yearly, will wait more than 30 minutes in a center doing 300 emergency procedures. Thus, mandatory orthopedic backup call for a trauma center performing fewer than 100 emergent trauma procedures within 24 hours is unwarranted.

The role of rectosigmoid neocolporrhaphy.

BACKGROUND: Vaginoplasty for congenital vaginal atresia, a component of the Mayer-Rokitansky-Kuster syndrome, or for gender confirmation, may be achieved by several techniques. This report focuses on the efficacy of rectosigmoid neocolporrhaphy (RSNC) performed either primarily or secondarily after failure of another procedure. METHODS: Sixty patients underwent isoperistaltic RSNC, three primarily and 57 secondarily. The indication was vaginal atresia in 1 patient and gender dysphoria in 59 patients. RESULTS: All 60 patients survived and have a functional neovagina. One major complication, an anastomotic leak with colovaginal fistula, was treated by a temporary colostomy and later reconstruction through a combined anterior and posterior approach. Late complications were reversible stomal stenosis (six patients), reversible conduit narrowing (five patients), transient rhabdomyoblastosis (one patient), and temporary mucosal bleeding from hyperplasia (three patients). Thirty patients have regular intercourse, 12 patients have occasional intercourse, and the others feel "whole," with their intact desired sexual anatomy awaiting a suitable partner. CONCLUSIONS: The number of patients seeking vaginoplasty is increasing. Primary or secondary RSNC is a safe and effective method.

Neurosurgical trauma call: use of a mathematical simulation program to define manpower needs.

Resource criteria for trauma centers (TC) mandate a first plus backup neurosurgeon (NS) coverage, an unnecessary expense for TC treating few neurosurgery patients. This report uses a mathematical modeling system to define optimal NS trauma coverage. Random data from 749 patients treated with emergency neurosurgery operations (OR) within 24 hours of admission at 97 TC were used to create a 1-year profile of admission by month, day, and hour, operation times, and operation duration. These data were entered into a simulation program to define the frequency that a patient needing a NS consult would wait beyond 30 minutes because the NS was in the operating room at a trauma center with one, two, or three neurosurgeons on-call. One thousand iterations were done for each sample size of 25 to 300 patients in 25-patient increments. The probability that a patient could not be seen promptly by one NS in a trauma center operating on 25, 50, 75, or 100 patients per year is 0.23, 0.9, 1.6, and 3.66 patients per year. Fewer than one patient (0.75) per year will wait more than 30 min in a trauma center doing 225 emergency ORs when two neurosurgeons are on-call. One patient in 10 years would wait more than 30 min in a trauma center doing 300 ORs with a third NS on-call. Mathematical modeling of patient data helps define optimal hospital resources. Mandatory NS backup for TC performing fewer than 25 neurosurgery procedures is unneeded.

Rate of tendon gap closure in an in vitro collagen gel matrix.

Tendon gap closure was examined in a tissue culture model and found to have a similar time course as skin wound closure. Foot tendons from White Rock chickens were mounted in a collagen gel matrix and maintained with the use of Dulbecco's modified Eagle medium, containing fetal calf serum and antibiotics, for 4 weeks at 37 degrees C in an incubator. Gap distances between tendons were measured every 1 to 3 days and plotted against time as the contraction curve. After an initial lag period of 4 to 8 days, gap distance showed a progressive decrease. Gap closure rate was defined as the slope of the contraction curve, and it was found to be a function of initial gap distance (r = 0.643, p 0.045). The time necessary to reduce the initial gap distance by half had a significant correlation with the initial gap distance (r = 0.986, p < 0.001). Fibroblast migration began on days 2 to 3 after a 1- to 2-day lag period. Fibroblasts were visible in the tendon gap region before the start of collagen gel contraction. At this time, the fibroblast migration rate was 0.33 mm/day. A critical density of fibroblasts was necessary to start collagen gel contraction. Once the gap distance began to diminish, fibroblast migration measurements were hampered because the measurable area was decreasing. Collagen gel contraction reduced the measurable fibroblast migration rate by nearly half to 0.18 mm/day. A linear correlation was found between fibroblast distance traveled and time in culture during both the gel lag and gel contraction time periods. This tendon culture model may be potentially useful for wound healing studies because it allows for studies of fibroblast activity in the early lag phase when the cells populate the collagen lattice but before contraction of the gel occurs.

Hemodynamic, plasma volume, and prenodal skin lymph responses to varied resuscitation regimens.

The theoretical efficacy of hypertonic saline (HS) resuscitation for hemorrhagic shock purportedly stems from the osmolar extraction of intracellular fluid into the plasma. This hypothesis presumes a concomitant expansion of the interstitial fluid space. Colloid resuscitation, in theory, expands the plasma volume by extracting interstitial fluid. These hypotheses were tested in a canine-modified Wigger's model of hemorrhagic shock. Forty, male, splenectomized dogs were anesthetized and instrumented. Animals underwent a baseline equilibration period followed by shock for 120 minutes. Each animal was randomized to one of four groups and received equal amounts of Na+ either as lactated Ringer's (LR) solution, 10% dextran 40 (Dex) in normal saline, 7.5% saline (HS), or 7.5% saline plus Dex (HSD). Parameters measured at baseline, shock, and at postresuscitation 30 minutes, 60 minutes, 90 minutes, and 120 minutes, included: mean pressure (MAP), output, pulmonary capillary wedge pressure, prenodal skin lymph flow, serum and lymph albumin, wet-to-dry skin ratios, and plasma volume. MAP, cardiac output, and plasma volume were most quickly restored with LR and Dex resuscitation (MAP = 106 and 118 mm Hg) compared to HS and HSD (MAP = 98 and 92 mm Hg). Lymph flow and lymph albumin flux were best restored with LR and HSD (mean = 85 and 48 microL/min) compared to Dex and HS (mean = 36 and 37 microL/min). Wet/dry skin ratios were greatest at 60 minutes in the LR group but similar at 120 minutes in all four groups. These data suggest that interstitial fluid space remains contracted during the first hour after HS, HSD, and Dex resuscitation compared with LR resuscitation, even though the restoration of plasma volume, MAP, and cardiac output is greatest with the Dex regimen. Further studies with total body water and intracellular water are needed in this model.

Plasma supplementation is beneficial for coagulation during severe hemorrhagic shock.

BACKGROUND: Hemorrhagic shock (HS) often causes coagulopathy due, in part, to decreased coagulation proteins. This study assessed the efficacy of fresh frozen plasma (FFP) in preventing this coagulopathy following a canine model of HS designed to mimic bleeding with shock as seen in the emergency department followed by bleeding without shock as seen during operation for control of bleeding. METHODS: Twenty-two dogs had acute HS for 2 hours followed by resuscitation with red blood cells (RBC) plus lactated ringers (LR) or RBC and LR with FFP. After resuscitation, bleeding was continued for 1 hour while intravenous replacement of RBC and LR with or without FFP was provided. Baseline, postshock, postresuscitation, post-1 hour exchange, postoperative day one and day two measurements included coagulation Factors I, II, V, VII, VIII, and X, and the prothrombin (PT), partial thromboplastin (PTT), and thrombin times (TT). RESULTS: Baseline, postshock, and postresuscitation hemodynamic responses, coagulation factor levels, and coagulation times were similar for both groups. By contrast, the 1-hour postexchange factors were depleted in the LR dogs compared to the FFP dogs. This depletion correlated with prolonged PT, PTT, and TT in the LR dogs (mean 14, 35, and 8 seconds) compared to FFP dogs (9, 24, and 6 seconds). CONCLUSIONS: Severe HS beyond one blood volume exceeds the interstitial stores of coagulation protein, thus necessitating FFP supplementation.

The value of the medical examiner as a member of the multidisciplinary trauma morbidity-mortality committee.

The multidisciplinary trauma peer review process collects, reviews, discusses, and collates all morbidities and mortalities of injured patients to institute corrective action in a timely manner. The resultant remedial activity may include professional education, physician counseling, restriction of privileges, or changes in the trauma care system. Effective corrective action necessitates timely data input from the postmortem examination. Faced with an inordinate delay, skimpy reports, and expense in obtaining such reports from the medical examiner's office, the chief medical examiner was invited to become a member of the peer review committee. During a 12-month interval as a full-fledged member of the peer review process, the medical examiner was able to provide complete verbal reports on all deaths resulting in a synergistic benefit to the peer review process and to the medical examiner office. Two of 53 nonpreventable deaths were reclassified as possibly preventable in one and preventable in the other. Four of 15 possibly preventable deaths were reclassified based on the medical examiner report. In turn, the physician members of the team were able to augment the medical examiner's knowledge in certain areas that were critical for his analysis of accidents or homicide. Based on these findings, the medical examiner is recommended as a participating member of the trauma peer review committee.

Prediction of rib fracture injury outcome by an artificial neural network.

Outcome-based therapy is becoming the standard for assessing patient care efficacy. This study examines the ability of an artificial neural network to predict rib fracture injury outcome based on 20 intake variables determined within 1 hour of admission. The data base contained 580 patient records with four outcome variables: Length of hospital stay (LOS), ICU days, Lived, and Died. A 522-patient training set and a 58-patient test set were randomly selected. Nine networks were set up in a feed-forward, back-propagating design with each trained under different initial conditions. These networks predicted the test set outcome variables with an accuracy as high as 98% at the 80% testing level. Internal weight matrix examination indicated that age, ventilatory support, and high trauma scores were strongly associated with both ICU days and mortality. Being female, injury severity, and injury type were associated with increased LOS. Smoking and rib fracture number were low-level predictors of the four outcome variables.

Retrograde gastroesophageal intussusception complicating chronic achalasia.

We treated a patient with retrograde gastroesophageal intussusception complicating chronic achalasia. Operation consisted of diaphragmatic division in the median plane to facilitate reduction, followed by Heller myotomy and fundoplication for the achalasia. The patient was able to eat normally after recovery.

Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury.

Early nutrition is advocated for patients with head injury to counter the postinjury hypermetabolic state. The gastric route of feeding often leads to vomiting and aspiration pneumonitis. This study was designed to identify the role of lower esophageal sphincter (LES) function in this complication. The LES function was assessed within 72 hours of admission in 16 patients with a head injury and a Glasgow Coma Scale (GCS) score less than 12 (range, 3-11). Other admission assessments included an APACHE II score of 11.7, Injury Severity Score (ISS) of 30.5, and a Revised Trauma Score (RTS) of 6.4. These studies were repeated 1 week postinjury in five patients. Dysfunction of the LES was present in all 16 patients; the average gastric-to-esophageal pressure difference was -0.49 mm Hg (range, -0.59 to 2.5) compared with a normal value of greater than 20 mm Hg. The five patients restudied at 1 week had a gastric-to-esophageal pressure difference of 13.3 mm Hg (range, -3.4 to 36.6 mm Hg). The single patient with a GCS score below 12 at 1 week had a low LES tone. These data show that LES dysfunction accompanies acute head injury and contributes to aspiration pneumonitis after early gastric feeding. Nutrition in patients with low GCS scores should be parenteral or via the jejunum.