Directed cutaneous neurectomy for cutaneous neuralgia.

BACKGROUND: Cutaneous neuralgia (CN) is a common challenge for surgical consultation. This report describes directed cutaneous neurectomy (DCN) for persistent CN. METHODS: From 2010 through 2022, DCN was performed 112 times in 100 patients. All had complete temporary relief of CN by outpatient percutaneous proximal blockade. DCN involved a successful proximal blockade with blue dye added to the injectate, and all blue stained tissue was excised. The site of DCN included groin (49 patients), abdomen (38 patients), chest (7 patients), extremity (4 patients), or skull (2 patients). Relief was judged continuous (C), none (N), or temporary (T). RESULTS: Pain relief was C in 82 patients (27 â€‹± â€‹20 â€‹mo), N in 6 patients, and T in 12 patients (22 â€‹± â€‹2 â€‹mo). The presence of microscopic nerve fibers (46 patients) or mesh (42 patients) did not affect outcome. A second DCN was done in two N patients, followed by C relief. A second DCN was done in seven T patients, and a third DCN was done in three T patients after recurrent CN. CONCLUSIONS: Refractory CN can usually be successfully treated by DCN.

Nonoperative Management (NOM) of most liver injuries impairs the mastery of intraoperative hemostasis.

BACKGROUND: Nonoperative management (NOM) of most liver injury (LI) compromises teaching of technical skills required for intraoperative LI hemostasis. This study assesses this void. METHODS: The records of patients (pts) admitted for LI during two years (1/1/16-12/31/17) were compared to pts treated during two-year intervals for the last six decades. Treatment included NOM, operation only (OR/only), suture (Sut), tractotomy (Tra), dearterialization (HAL), and resection (Res). RESULTS: During 2016/2017, 41 pts had penetrating (23) or blunt (18) LI. Treatment for penetrating LI was NOM (4), OR/only (12), and hemostasis (7) with Sut (3), HAL (1), Tra (1), and Res (2). Treatment for blunt LI was NOM (16) and OR/only (2). 14 residents performed an average of 0.5 procedures. During six decades, LI requiring hemostasis was 121, 114, 30, 48, 17, and 7 per decade. Concomitantly, the percent having NOM or OR/only was 46%, 47%, 62%, 59%, 72%, and 83%. CONCLUSION: NOM precludes adequate training for hemostasis of LI. Technical proficiency for LI hemostasis requires training in Advanced Trauma Operative Management (ATOM), Advanced Surgical Skills for Exposure in Trauma (ASSET), and rotation through a liver transplant or hepatobiliary service.

The urban injury severity score (UISS) better predicts mortality following penetrating gunshot wounds (GSW).

BACKGROUND: The Injury Severity Score (ISS) and the New ISS (NISS) underscore injury severity after GSW. This study assesses the Urban ISS (UISS), which incorporates all injuries. METHODS: Complete trauma program registry (TPR) data and chart analyses were performed on 585 patients (pts) over 28 months. Factors analyzed included age, gender, ISS, NISS, UISS, time of admission, intent of injury, race, number GSW, weapon, and outcome. RESULTS: The 585 patients could be categorized within three groups. The first group included 98 pts with low ISS (1-2), no organ injuries, and early discharge; the second group included 47 patients with severe shock who died during operation; the third group of 442 pts were admitted after operation. All injury scores correlated (p < 0.001) with assault, number GSW, death, and length-of-stay (LOS). Death and LOS correlated closely with assault and the resultant number of GSW, best seen with UISS compared to ISS or NISS. Race and admission time did not correlate with death or LOS. CONCLUSIONS: UISS correlates better than ISS and NISS in victims of inner-city firearm injuries.

Variability of the f-cell ratio after treatment of traumatic hemorrhagic shock.

PURPOSE: Measuring total blood volume (TBV) in critically ill patients, using isotope techniques to determine red cell volume (RBCV) and plasma volume (PV) is laborious. Recently, PV measurement using a single bolus dose of tracers has been validated, thus, allowing TBV calculation using large venous hematocrit (LVHCT). However, this technique relies on using a correlation factor, the f-cell ratio, to adjust for differences in LVHCT and total body hematocrit (TBHCT). The normal f-cell ratio is 0.9 but has never been studied in patients recovering from hemorrhagic shock (HS). This study assesses the f-cell ratio at different phases after HS to determine accuracy in calculating TBV. METHODS: 114 injured patients requiring immediate operation for HS were studied. All patients had measurements of PV and RBCV via isotope dilution enabling measurements of TBHCT. Correlation of LVHCT and TBHCT were used to calculate the f-cell ratio in the fluid sequestration (n = 81) and in the fluid mobilization period (n = 108). RESULTS: The f-cell ratio (mean ±â€¯SD) averaged 0.89 ±â€¯0.15 and 0.90 ±â€¯0.01 in the first and second halves of the fluid sequestration period versus 0.90 ±â€¯0.2 and 0.80 ±â€¯0.07 in the first and second 48 h of the fluid mobilization period. The f-cell ratio was significantly lower (p=<0.001) in the mobilization period. CONCLUSIONS: These data show for the first time that using PV and LVHCT to calculate TBV after HS is unreliable. The mechanisms causing this variation in f-cell ratio is unknown but likely related to capillary/interstitial dynamics and needs further scientific study.

Failure of gastric prophylaxis against stress bleeding reflects inadequate pH control.

BACKGROUND: Gastric prophylaxis against stress ulceration with histamine 2 blockers or protein pump inhibitors is a quality standard in septic Surgical Intensive Care Unit (SICU) patients to reduce gastric pH below 3.5. This study assesses the efficacy of gastric prophylaxis with pH monitoring. METHODS: A total of 100 patients were studied for 481 days. All received histamine 2 blockers or protein pump inhibitors. Daily pH control was judged as poor (1-3), moderate (4-5), or good (>5). Patients with poor pH received double-dose or an infusion gastric prophylaxis. Nasogastric tube bile or blood and transfusions for stress ulceration were recorded. RESULTS: Gastric prophylaxis was poor for 37 days, moderate for 83 days, and good for 279 days. NGT blood occurred on 15 days (40%) with poor, 17 days (20%) with moderate, and 17 days (6%) with good control. Transfusions for stress ulceration occurred on 5 days (14%) during poor, 3 days (4%) during moderate, and 1 day (0.3%) during good control (P < .05). Enhanced gastric prophylaxis improved pH control and reduced nasogastric tube blood. Transfusion for stress ulceration after enhanced therapy was required on 1 day (8%) with poor control and never for moderate or good control. CONCLUSION: Gastric prophylaxis against stress ulceration should be monitored by nasogastric tube pH.

The diagnostic and surgical challenges of massive localized lymphedema.

BACKGROUND: Massive localized lymphedema (MLL) is a rare entity first described in 1998 in patients with morbid obesity; the incidence is rising with the increased prevalence of morbid obesity. This report defines the clinical presentation and surgical challenges in 6 patients with MLL. METHODS: The MLL in 6 patients with morbid obesity (weight range 270 to 585 lbs) involved the thigh in 3 patients, the calf in 1 patient, and the abdomen in 2 patients. The time from onset to presentation averaged 3 years (range 1 to 8 years). Two thigh lesions precluded ambulation because both legs could not be on the ground simultaneously; the 2 abdominal lesions were too heavy to permit ambulation. RESULTS: The surgical excision required the use of pulleys to elevate the MLL tissues, which, on excision, weighed between 24 and 78 lbs. A long oval horizontal incision and a long transverse incision were used for the 2 abdominal lesions. Long horizontal oval limb incisions with multiple perpendicular cross incisions had to be used to excise MLL in the 4 limb lesions. In 2 cases, the vessel-sealing device was employed successfully for dissecting subcutaneous edematous tissue. Loose wound closure permitted postoperative lymph leakage, which continued for 3 to 8 weeks. The histology demonstrated fibrotic lymphatic tissue with vascular and lymphatic proliferation and edema; all patients did well. CONCLUSIONS: MLL is rare and is best treated by surgical excision facilitated by pulleys and imaginative incisions to obtain primary closure. Long-term follow-up is necessary to assess for subsequent liposarcoma or angiosarcoma.

Colloid with high fresh frozen plasma/red blood cell resuscitation does not reduce postoperative fluid needs.

BACKGROUND: Recent data suggest that intraoperative (Phase I) colloid (human serum albumin [HSA]) and a high fresh frozen plasma (FFP)/red blood cell (RBC) resuscitation will reduce postoperative (Phase II) fluid uptake. This study compares a noncolloid (balanced electrolyte solution [BES]) plus low (≤ 0.35) FFP/RBC resuscitation (Group A) with an HSA plus high (>0.35) FFP/RBC resuscitation. METHODS: A previous randomized study of 94 patients included 48 BES patients and 46 HSA patients. A Subgroup A of 25 BES patients with low FFP/RBC was compared with a Subgroup D of 21 HSA patients with high FFP/RBC. Parameters monitored included Phase I vital signs and resuscitation needs; Phase II duration, BES needs, weight gain, and hourly urine output; and postoperative plasma volume (PV) by radioiodinated serum albumin (RISA), extracellular fluid (ECF) volume by inulin space, and interstitial volume by ECF-PV. RESULTS: Admission pulse (132 for A vs. 133 for D), systolic blood pressure (SBP) (74 for A vs. 74 for D) and Phase I shock time (SBP < 80 Torr; 25 for A vs. 35 for D) were similar. Phase I RBC needs (12.5 ± 1.3 for A vs. 14.9 ± 1.7 for D) and BES needs (8.4 ± 0.6 L for A vs. 8.4 ± 0.6 L for D) were similar. During Phase II, D patients had more RBC, comparable BES, and weight gain, with lower hourly urine output compared with Group A patients. CONCLUSION: HSA with high FFP/RBC does not prevent Phase II fluid uptake and causes lower urine output despite increased PV. Colloid reduces glomerular filtration, increases tubular reabsorption, and increases ECF, thus, prolonging Phase II. LEVEL OF EVIDENCE: Therapeutic study, level IV.

FFP:RBC resuscitation ratio and post-shock fluid uptake.

OBJECTIVE: To assess the effects of the fresh frozen plasma (FFP) to red blood cell (RBC) ratio and balanced electrolyte solution (BES) to RBC ratio during resuscitation of severely injured patients on the duration of the postoperative fluid uptake period (phase 2) as well as the fluid (BES) needs, weight gain, and hypoproteinemia in phase 2. DESIGN, SETTING, AND PATIENTS: The 316 patients were hypotensive (systolic blood pressure=81 mm Hg) and tachycardic (117/min), with an average shock time (systolic blood pressure 80 mm Hg) of 31 minutes in the operating room (OR); they received 14.2 RBC units, 854 mL of FFP, and 11.5 L of BES while in the OR. Phase 2 averaged 29.2 hours, where the patients gained 8.4 kg, had a serum albumin level of 2.6 g per day, and received 8.6 L of BES. The phase 2 time, BES needs, weight gain, and hypoproteinemia were correlated with systolic blood pressure, admission pulse rate, arterial pH, shock time, RBC, FFP, and BES; the FFP:RBC, BES:RBC, and BES: FFP ratios were given in the OR. RESULTS: Shock time had the best correlation with RBC, FFP, and BES administration in the OR as well as with phase 2 duration, BES needs, weight gain, and hypoproteinemia. There was no significant correlation with OR FFP: RBC, BES:RBC, or BES:FFP ratios and phase 2 hypoproteinemia or weight gain. The FFP:RBC ratio in the OR correlated directly with phase 2 duration and BES needs (P=.001); in contrast, the BES:RBC ratio in the OR correlated (P.001) inversely with phase 2 duration and BES needs. CONCLUSIONS: The severity of shock is best predicted by shock time and the RBC, FFP, and BES infusions in the OR. Contrary to recent reports, the FFP:RBC ratio in the OR correlates directly with duration and BES needs of phase 2, whereas the BES:RBC ratio correlates inversely with phase 2 duration and BES needs.

Directed neurectomy for treatment of chronic postsurgical neuropathic pain.

BACKGROUND: Chronic neurogenic pain after surgery, especially inguinal herniorrhaphy, remains a major cause of morbidity. The traditional treatment of postinguinal herniorrhaphy neurogenic pain has included triple neurectomy with the removal of any mesh. This report describes a directed, minimally invasive surgical neurectomy that provided pain relief in 28 patients with minimal morbidity. METHODS: After temporary but successful proximal peripheral nerve blockade, the nerve was blocked in the operating room using a small amount of blue dye mixed with the local anesthetic. After confirming pain relief with the dye-anesthetic mixture, the patient was then sedated, and all blue-stained tissue was excised through a small incision, avoiding both the previous surgical scar and mesh. RESULTS: All but 1 of the 28 patients had complete relief for a minimum of 12 months when discharged from follow-up. CONCLUSIONS: This simple directed neurectomy method typically provides long-term relief for patients suffering from chronic postsurgical neurogenic pain.

Changes in lymph proteome induced by hemorrhagic shock: the appearance of damage-associated molecular patterns.

BACKGROUND: Damage-associated molecular patterns (DAMPs) released from host tissue after trauma and hemorrhagic shock (HS) have been shown to activate polymorphonuclear cells (PMNs) and lead to acute lung injury and systemic inflammatory response syndrome. The avenue by which DAMPs reach the circulation is unclear; however post-HS lymph has been shown to contain biologically active mediators. We therefore studied the time course of DAMP detection in systemic lymph and the effect of isotonic versus hypertonic resuscitation on DAMPs production and PMN activation in vitro. METHODS: A canine HS/hind-limb lymph cannulation model was used. Animals were bled to a mean arterial pressure of 40 mm Hg and were resuscitated with shed blood plus equivalent amounts of Na+as either lactated Ringer's solution or 7.5% hypertonic saline solution (HSS). Lymph samples were collected at baseline, end-shock, and at various times after resuscitation. DAMPs were isolated from lymph samples and detected by Western blot for high-mobility group box 1 and mitochondrial DNA. Priming of naive PMNs was indexed by mitogen-associated protein kinase phosphorylation. Human pulmonary microvascular endothelial cell monolayers were established and exposed to the various lymph samples. Endothelial intracellular adhesion molecule expression, apoptosis, and monolayer permeability were determined. RESULTS: DAMPs were detected in lymph samples starting at the end of the shock period and peaking at 120 minutes after resuscitation. HSS resuscitation resulted in the highest levels of DAMPs detected in systemic lymph and plasma. PMN mitogen-associated protein kinase activation was noted during the resuscitation phase and peaked 120 minutes after resuscitation. Similar temporal changes in human pulmonary microvascular endothelial cell intracellular adhesion molecule expression and cellular injury were noted after shock with the greatest effect noted with the hypertonic saline resuscitation regimen. CONCLUSION: Lymph represents an important avenue for the delivery of DAMPs into the systemic circulation after HS. HSS lead to a significant increase in DAMPs production in the model. This finding may account for the conflicting data regarding the salutary effects of HSS resuscitation noted in clinical versus experimental shock studies. ).

Coagulation challenges after severe injury with hemorrhagic shock.

During the past 50 years, there have been huge changes in the approach to coagulopathic bleeding following the treatment of traumatic hemorrhagic shock (HS). Treatment during the 1960s consisted primarily of physiologic saline (balanced electrolyte solution [BES]) and whole blood supported with sodium bicarbonate for acidosis. Subsequent coagulopathy was assumed to be caused by lack of the labile factors (FV and FVIII) which were then replaced by fresh whole blood. The decade of 1970s saw the implementation of component therapy by the American Blood Banking Association so that HS was treated with BES and packed red blood cells (RBC). A new paradigm had to be learned to determine when and how much fresh frozen plasma (FFP) was needed to restore all coagulation factors. By the end of 1970s, most trauma centers were supplementing BES and RBC with FFP in patients with severe injuries requiring massive transfusion of more than one circulating blood volume. By the 1980s, the use of FFP skyrocketed, creating a crisis for the American Blood Banking Association. This led to a National Institute of Health Consensus Development Conference which concluded that FFP should be given to only those patients who had a documented coagulopathy as evidenced by a prolongation of the prothrombin time and the partial thromboplastin time. Restriction of FFP replacement to patients with proven coagulopathy after treatment for HS led to postoperative bleeding which was sometimes fatal. During the 1990s, uncontrolled clinical studies and rigorously controlled animal studies showed that FFP should be administered before the onset of proven coagulopathy with prolongation of the prothrombin time and partial thromboplastin time. Later during the 1990s, recombinant-activated factor VII (FVIIa) was purported to provide quicker hemostasis in patients treated with HS. The efficacy of FVIIa supplementation is still being assessed. During the 2010s, the military surgeons promoted the use of a hemostatic regimen which consists of platelets, RBC, and FFP in a 1:1:1 ratio. This recommendation is still being assessed with different authors reporting benefits and detriments. Throughout these years, an unusual entity of disseminated intravascular coagulation (DIC) was known to complicate the resuscitation of seriously injured patients with HS. This syndrome was typically seen after treatment of HS and was associated with abnormal bleeding plus respiratory failure and renal failure thought to be caused by a combination of micro- and macrothromboses. The early studies suggested that the best therapy for breaking this viscous cycle of bleeding and intravascular coagulation was by infusing fresh whole blood. The theoretical benefits of administering heparin to prevent the thrombosis and epsilon-aminocaproic acid to enhance lysis have not proven beneficial. DIC is also seen in association with toxic exposures, including snake bites. Epsilon-aminocaproic acid may be beneficial in that setting. Many of the intricate understandings of DIC remain elusive and are still being studied.

Fresh frozen plasma/red blood cell resuscitation regimen that restores procoagulants without causing adult respiratory distress syndrome.

BACKGROUND: Controversy exists about the ideal fresh frozen plasma/red blood cell (FFP/RBC) ratio for resuscitation of patients requiring massive transfusion (MT). This study correlates the FFP/RBC with clotting time (CT), prothrombin time (PT), partial thromboplastin time (PTT), and thrombin time (TT); with procoagulants (fibrinogen [FI], factor 5 [FV], and factor 8 [FVIII]); and with adult respiratory distress syndrome (pO2/FIO2). METHODS: The 32 patients studied in operating room (OR) were in shock for 47 minutes and received an average of 17.6 units RBC, 4.2 units FFP, and 14.2 L balanced electrolyte solution. The 53 patients (including 22 of the OR patients), studied an average of 9.5 hours after operation, had an average shock time of 42 minutes, and received 17.4 units RBC, 4.6 units FFP, and 12.3 L balanced electrolyte solution in OR. RESULTS: The FFP/RBC in OR averaged 0.3:1 (range: 0.1:1 to 0.9:1). The OR study, done after a minimum of 10 RBC units at 3.8 hours, showed a PT of 3.5 seconds off normal (international normalized ratio < 1.3), a PTT of 34 seconds, and TT of 7.9 seconds off normal. FI, FV, and FVIII were restored to 148 mg/dL, 54%, and 81%. The pO2/FIO2 was 282. The early post-OR study showed a PT of 2.3 seconds off normal (international normalized ratio = 1.2), a PTT of 32 seconds, a TT of 7.2 seconds off normal, an FI of 207 mg/dL, an FV of 64%, an FVIII of 102%, and a pO2/FIO2 of 332. Both OR and early post-OR CTs and procoagulant levels are associated with adequate coagulation. All patients with a 0.31:1 or higher FFP/RBC had sufficient restoration of CTs and procoagulants. CONCLUSION: These data show that an FFP/RBC ratio above 0.31:1 in injured patients requiring MT restores CTs and procoagulant to clinically effective levels while not causing adult respiratory distress syndrome. Future studies on defining the ideal FFP/RBC ratio for MT should monitor CTs, procoagulants, and organ function.

The significance of a serum creatinine in defining renal function in seriously injured and septic patients.

BACKGROUND: Most current analyses of multiple organ failure after injury use the serum creatinine (SCr) as a surrogate for defining renal insufficiency (RI) or renal failure (RF). This study correlates SCr with glomerular filtration rate, renal perfusion, and renal excretion in injured and septic patients. METHODS: The 289 injured patients were in shock for an average of 32 minutes and received an average of 13.9 transfusions by the end of the operation. The 34 septic patients were in shock for an average of 23 minutes and received 8.4 crystalloid during operation. The renal studies included (SCr), inulin clearance (CIn), and creatinine clearance (CCr), renal plasma flow (CPAH), renal blood flow, and the clearance of sodium (CNa++), osmolar clearance (COsm), and urine output. All clearance studies followed the classic methodologies described by Homer Smith, including weight-guided leading dose, steady-state serum levels, and urine collections made exactly 15 minutes after serum collections. RESULTS: The average SCr in 289 trauma and septic patients was 1.23 mg/dL and 1.3 mg/dL, respectively. The average CCr was 106 mL/min and 103 mL/min, whereas the average CIn was 96 mL/min and 95 mL/min, respectively. The CIn correlated (p<0.0005) with CCr in all patients, whereas the CIn was lower than CCr due to the tubular excretion of creatinine. For the group of patients with RI (CIn between 10 and 30 mL/min) and nonoliguric RF (CIn<10 mL/min), the average CCr was 3.1. Other values in this subgroup included an average CCr 23.6 mL/min, CIn 14.6 mL/min, CPAH 69.9 mL/min, renal blood flow 138 mL/min, CNa 0.7 mL/min, COsm 1.5 mL/min, and urine output 1.4 mL/min. Although nephrectomy in 15 of 36 patients with renal injury or death in 21 patients was associated with a higher SCr, the relationship between SCr and renal function studies remained the same as with survivors and patients without renal injury. The best SCr value for defining RI was 2.4 mg/dL and for RF was 3.1 mg/dL. CONCLUSION: Based on these findings, one can recommend that when SCr data are extracted from large trauma registries, the definition of RI should be inferred when the SCr exceeds 2.4 mg/dL, and RF should be diagnosed when the SCr exceeds 3.1 mg/dL.

Late association of hyperparathyroidism in septic patients with multiple organ failure.

BACKGROUND: Hypocalcemia after severe shock or sepsis stimulates release of parathyroid hormone (PTH), which abates with recovery. Sustained sepsis with multiple organ failure (MOF), however, may cause a resurgent release of PTH and life-threatening hypercalcemia. METHODS: Thirty critically ill patients with prolonged sepsis developed combined hypercalcemia with elevated serum PTH levels. The primary insult was trauma in 12 patients, peritonitis in 14, and pancreatitis in 4. MOF involved the lungs in 30 patients, kidney in 16, gut in 30, brain in 13, and a coagulopathy in 10. There were 12 deaths; hospital stay averaged 81 days. RESULTS: Hypercalcemia with increased serum levels of PTH occurred usually 3-4 weeks after the septic insult. Bradycardia, thought to be caused by the hypercalcemia, occurred in 19 patients, was attributed to a vasovagal reaction, and was treated with atropine. When asystole resulted, epinephrine and cardiopulmonary resuscitation were administered. Five patients required placement of an intravenous pacemaker. Bradycardia was acutely lethal in 4 patients; in a 5th patient, the decision was made for comfort care alone, and he died 9 days later. Bisphosphonate was given to 7 patients with this hypercalcemic-induced bradycardia and, prophylactically, to prevent bradycardia in 9 others. Hypercalcemia corrected in all patients; bradycardia abated in 7 patients. CONCLUSION: Hyperparathyroidism may occur with MOF secondary to sepsis. The mechanism is unclear, but the resultant bradycardia can be life threatening. Treatment with bisphosphonate corrects the hypercalcemia and bradycardia. Both the hypercalcemia and the bradycardia normalize when the MOF resolves.

Systemic not just mesenteric lymph causes neutrophil priming after hemorrhagic shock.

BACKGROUND: Inflammatory mediators in postshock mesenteric lymph have been causally linked to systemic polymorphonuclear cells (PMNs) priming resulting in acute lung injury (ALI) and multiple organ failure. Earlier human and animal studies demonstrated ALI after lower limb ischemia/reperfusion (I/R) injury. As hemorrhagic shock (HS) is in essence a systemic I/R insult, we postulated that systemic lymph after HS would exhibit PMN priming and this was studied in vitro. METHODS: Lymph was collected at intervals from the hind limb of dogs subjected to sham or HS and crystalloid resuscitation. Human PMNs isolated from heparinized blood of normal volunteers were incubated with buffer, sham lymph, or lymph after 120 minutes of shock or resuscitation. PMN priming was indexed by CD11b expression (mean fluorescence intensity), superoxide anion (O2(-)) generation (nanomoles/mg protein), and elastase release (%) after the addition of fMLP (1 micromol). PMNs with buffer served as control. RESULTS: PMN priming after exposure to either shock or postshock resuscitation lymph was noted by increased expression of CD11b, superoxide generation, and elastase release after exposure to fMLP. No priming effect was noted with sham lymph. Maximal bioactivity of shock or postresuscitation shock lymph was noted at 2 hours postresuscitation. CONCLUSIONS: Exposure with systemic lymph after HS resulted in PMN priming. These results question the unique properties attributed to post-HS lymph from the splanchnic bed in causing PMN priming and ALI after shock. The causal agent(s) for these effects are unclear.

The academic challenge of teaching psychomotor skills for hemostasis of solid organ injury.

BACKGROUND: This study highlights the inherent challenges of achieving psychomotor skills in an era of nonoperative therapy for solid organ injuries. Technical procedures on the liver, the most frequent intra-abdominal solid organ injured, were assessed in five decades. METHODS: Guided by prospective assessment and registry data, all patients with liver injury seen during 24 months in five consecutive decades were reviewed. Initially (1960s), all injuries were explored; currently (2000s), most injuries are observed. The number of patients was 235 (1960s), 228 (1970s), 79 (1980s), 116 (1990s), and 64 (2000s). The greater number in the 1990s reflects the diagnosis of minor, clinically insignificant, blunt injuries after abdominal CAT scan became available. Each injury was categorized by cause, severity (Abbreviated Injury Scale), associated shock, and primary therapy (observe [OBS], operation alone [OR], hepatorrhaphy [SUT], tractotomy [TRACT] with intraparenchymal hemostasis, hepatic dearterialization [HAL], and resection [RESECT]). Packing, used in each decade, was placed in one of the above primary treatment groups. RESULTS: The primary techniques for hemostasis are shown in the text table.Shock and Abbreviated Injury Scale correlated with mortality averaged 16%; 40 of 116 deaths (34%) exsanguinated from hepatic injury. During training, a resident performed an average of 12.0, 12.0, 2.4, 4.0, and 1.3 procedures for hemostasis. CONCLUSIONS: Reduced incidence and decreased therapeutic laparotomies for liver injury have created a training vacuum for future trauma surgeons. Surgical residents will need to supplement their clinical experience with solid organ hemostasis by practice on appropriate animal models of injury and cadaver dissections.

Systemic not just mesenteric lymph causes acute lung injury following hemorrhagic shock.

INTRODUCTION: Recent studies have demonstrated a significant role for factor(s) present in mesenteric lymph following hemorrhagic shock in the etiology of post-hemorrhagic shock acute lung injury (ALI). Earlier studies have shown that ischemia-reperfusion insults to systemic tissue beds can also result in ALI. We therefore hypothesized that factors in systemic lymph may cause lung injury after hemorrhagic shock; this was studied in vitro. METHODS: Confluent human pulmonary microvascular endothelial cells (HMVEC) maintained in a 2-chamber cell culture system were exposed to systemic lymph obtained from dogs exposed to sham operation or hemorrhagic shock and resuscitation. HMVEC injury was indexed by apoptosis (% Apo, Hoechst staining) and permeability to albumin (microL/min). HMVEC activation was indexed by surface expression of intracellular adhesion molecule-1 (ICAM-1) expressed as mean fluorescence intensity using flow cytometry. RESULTS: There was a 2-fold increase in HMVEC permeability and apoptotic rate after incubation with postshock systemic lymph. A similar effect was noted with ICAM expression, which was 2.5 fold higher after incubation with postshock lymph. These biologic effects were first noted with the 120-minute postresuscitation lymph. Lymph obtained during shock or from sham animals had no effect. CONCLUSIONS: Pulmonary microvascular endothelial dysfunction is evident after exposure to lymph obtained from systemic sites after hemorrhagic shock. The "unique" properties ascribed to post-hemorrhagic shock mesenteric lymph in causing ALI seem to be shared by lymph from systemic sites as well.

Smoking and home oxygen therapy--a preventable public health hazard.

Patients who continue to smoke while on home oxygen therapy endanger themselves, family members, neighbors, and firefighters and create an expense to society for their medical care. This phenomenon was studied in our burn center. Fourteen patients were identified prospectively during the last 2 years. All were smoking while on nasal oxygen. The 14 patients (10 males) were 45 to 87 years of age. All suffered facial burns. Only one patient had a significant burn (30% TBSA, 20% 3rd degree), but all suffered from an exacerbation of chronic obstructive pulmonary disease. Two patients gave a history of stage IV lung cancer and four patients had newly found squamous cell cancer seen on bronchoscopy. All six patients with lung cancer and one with severe chronic obstructive pulmonary disease died. Of the seven survivors, only one patient quit smoking. Total charges were $2,861,526 and total costs were $938,311. All patients had Medicare or Medicaid on admission. Hospital loss ($432,561) was incurred in those patients admitted more than 4 days whereas a profit ($33,285) was realized in patients admitted less than 4 days. These deaths and financial loss could be reduced by better testing and more precise guidelines as to which patients can safely receive home oxygen. Patients can have their saliva tested for the nicotine breakdown product of cotinine; the test takes 10 minutes. The American Burn Association, in conjunction with the American College of Chest Physicians, should address this issue and develop guidelines for physicians who order home oxygen therapy and for state departments of public health who should regulate the companies that deliver home oxygen.

Kindness kills: the negative impact of pain as the fifth vital sign.

BACKGROUND: The current emphasis on pain assessment as the fifth vital sign and the use of unscientific pain scales is causing serious injury and death from overmedication. STUDY DESIGN: This premise was tested by reviewing the case reports of all trauma center site surveys performed by the authors for the American College of Surgeons Committee on Trauma verification program during 2 separate time periods: 1994 through 1998 and 2000 through 2004. A total of 2,907 and 2,282 reports summarized by one of the authors, plus a total of 53 and 50 other reviewers, respectively, were analyzed from the records of 120 and 94 trauma centers. Most patients were men (71% and 66%) and had sustained blunt injury (83% and 79%). Average age was 35 years for both periods, with a range of 3 weeks to 97 years and 3 days to 98 years, respectively. The most common injuries involved head (33% and 34%), chest (13% and 13%), abdominal (22% and 21%), orthopaedic (18% and 18%), or multiple (9% and 14%). There were 1,459 and 867 deaths, respectively; all had a multidisciplinary peer review. RESULTS: Overmedication with sedatives/narcotics, during the two periods, clearly contributed to deaths in 13 and 32 patients and probably contributed to deaths in 5 and 14 patients, respectively. This occurred in 17 and 43 patients, respectively, after blunt injury and in 1 and 3 patients, respectively, after penetrating injury. Two clinical scenarios predominated, ie, overmedication in preparation for an imaging study and overmedication after discharge from ICU to the floor. The sequel of hypotension and compromised airway requiring intubation initiated a cascade of negative events that led to death. One patient in each period died as a result of prehospital overmedication. CONCLUSIONS: The current assessment of pain by computer-stored pain scales is in a state of imbalance, with excessive emphasis on undermedication at the same time ignoring overmedication. This imbalance reflects pain-service attempts to comply with external accrediting agencies. This preventable cause of death and disability in trauma patients is also occurring in noninjured patients. Surgeons must correct this problem by insisting on a balanced assessment of overmedication versus undermedication.