Major bronchial trauma in the pediatric age group.

Tracheobronchial injuries are rare among all age groups and are extremely rare among the pediatric age group. Yet, the incidence has seemed to increase. Most of these patients die before reaching the hospital from severe associated injuries. Isolated bronchial injury is even more rare than tracheal injury, and it is the focus of the present study. A retrospective national survey was conducted among all tertiary referral and trauma centers in Israel regarding the period between the years 1983 and 1998. Only six cases (3 males and 3 females) of isolated bronchial rupture were found the throughout the country. Ages of the patients ranged from 2 to 14 years; all were involved in motor vehicle accidents, four of them as pedestrians. Ruptures occurred in the bronchus intermedicus (2 cases), left and right main bronchus (2 cases each). All but one patient went through primary repair. We give a full description of the procedure and discuss the literature regarding incidence, diagnosis, treatment, and outcome.

Complications of tracheal and thoracic surgery: the role of multisection helical CT and computerized reformations.

Helical computed tomography (CT) has an important role in the evaluation of a wide range of congenital and acquired thoracic abnormalities. The development of advanced computerized reformations enables the generation of bronchographic and bronchoscopic images of the tracheobronchial tree, as well as angiographic images of pulmonary arteries and veins. Additionally, it provides coronal and sagittal reconstruction imaging of parenchymal abnormalities. This information is obtained by a 20-30s procedure on a typical single channel system, which makes helical CT an optimal technique for the evaluation of patients undergoing major upper airways and thoracic interventions. The recent introduction of multisection CT scanners allows faster imaging of patients with thinner collimation, thus improving spatial resolution along the longitudinal (z) axis of the patient along with reduction of motion artefacts. This article demonstrates the use of dual and quad-section helical CT in the postoperative evaluation of patients undergoing laryngo-tracheal and thoracic interventions, including laryngoplasty, tracheal endoscopic laser ablation, lobectomy, pneumonectomy, lung transplantation, sleeve resection, pulmonary angioplasty, and pulmonary artery thromboendarterectomy. Emphasis is given to the additive value of using computerized reformations over axial images, especially for delineation of complex postoperative anatomical details in the tracheobronchial tree and pulmonary vasculature.

Diaphragm plication following phrenic nerve injury: a comparison of paediatric and adult patients.

BACKGROUND: A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury. METHODS: A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated. RESULTS: One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication. CONCLUSIONS: Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults.

Hyperthermic pleural perfusion with cisplatin: early clinical experience.

BACKGROUND: The preferred treatment for patients with pleural tumors or tumors with pleural extension has not been determined. Systemic and local modalities were studied, including intrapleural chemotherapy and hyperthermia, which mainly have been investigated separately. The objective of this study was to investigate the feasibility, toxicity and early results of a multimodality treatment consisting of surgery, chemotherapy, and hyperthermia in one session for the treatment of patients with pleural malignancies. METHODS: From November 1994 to September 1998, 26 patients (7 patients with mesothelioma, 11 patients with thymic neoplasms, and 8 patients with other tumors) underwent intraoperative hyperthermic pleural perfusion (HPP). Perfusion was performed with a roller pump and a heat exchanger. Cisplatin was added when the temperature stabilized to a mean of 40.8 degrees C (range, 40.2-41.5 degrees C). Dosages of cisplatin used were 60 mg in 2 patients, 100 mg in 2 patients, 120 mg in 1 patient, 150 mg in 18 patients, and 200 mg in 3 patients. The patients underwent the following associated surgeries: extended extrapleural pneumonectomy in 8 patients, resection of tumor without pleurectomy in 4 patients, resection of tumors with pleurectomy in 10 patients, and exploration and HPP only in 4 patients (thoracotomy in 2 patients and video-assisted thoracoscopy in 2 patients). RESULTS: There were no technical problems during the perfusion period. The systemic temperature rose to a maximum of 38 degrees C. There was no renal or hematologic toxicity, except in one patient who experienced thrombocytopenia. One patient died from complications related to a technical error. Eight patients had complications; the most bothersome were in four patients with empyema (early in two patients and late in two patients). The median postoperative hospital stay was 7 days (range, 2-50 days). Ten patients were alive 28-69 months after surgery. The overall 1-year, 2-year, and 3-year survival rates were 72%, 65%, and 44%, respectively. Complete ipsilateral pleuropulmonary control was achieved in 17 patients (9 patients who are alive and 8 patients who have died). CONCLUSIONS: Intraoperative HPP with cisplatin is feasible, easy to perform, and relatively safe. This method may offer excellent local control for patients with pleural tumors.

Prevalence of the juxtaphrenic peak after upper lobectomy.

OBJECTIVE: The purpose of this study was to determine the prevalence of the juxtaphrenic peak after upper lobectomy in a large number of consecutive patients. MATERIALS AND METHODS: Available chest radiographs of 172 of 199 sequential patients who had undergone upper lobectomy in a university hospital were evaluated for the presence of a juxtaphrenic peak. The study included 98 cases with right upper lobectomy and 74 with left upper lobectomy. Radiographs were grouped in three postoperative periods: period I, within 7 days after lobectomy (n = 142); period II, between 8 and 30 days (n = 113); and period III, 31 days or more after lobectomy (n = 101). Four experienced radiologists in consensus determined the prevalence of the "juxtaphrenic peak sign," in relation to age, sex, side of lobectomy, positioning (erect or supine), presence of juxtadiaphragmatic abnormalities, and time interval since surgery. RESULTS: The prevalence of the juxtaphrenic peak sign gradually increased from 40.6% in period I to 71.9% in period III after right upper lobectomy (p < 0.01), and from 19% to 47.7%, respectively, after left upper lobectomy (p < 0.01). Its overall prevalence was significantly higher after right upper lobectomy (58.2%) than after left upper lobectomy (40.5%) (p = 0.02), and on erect chest films (51.4%) than on supine ones (28.9%). CONCLUSION: The prevalence of the juxtaphrenic peak sign increases gradually during the weeks following lobectomy. It is more frequent on erect films and after right upper lobectomy. The juxtaphrenic peak may serve as an additional useful radiologic sign suggesting upper lobectomy.

Resection and perfusion thermochemotherapy: a new approach for the treatment of thymic malignancies with pleural spread.

BACKGROUND: Thymoma and thymic carcinoma with pleural spread have a high rate of locoregional recurrence and poor prognosis. Maximal debulking coupled with aggressive local treatment could offer a chance for cure. This study evaluates the early and midterm results of operation and hyperthermic pleural perfusion with cisplatinum for thymic malignancies. METHODS: Fifteen patients (11 men), 20 to 67 years old (10 thymoma, 4 thymic carcinoma, 1 carcinoma in thymic cyst) underwent resection and hyperthermic pleural perfusion between 1995 to 2000. All had pleural spread proven before or intraoperatively. Six of the thymoma cases were recurrent. Current operation included resection without pleurectomy (9 patients), resection with pleurectomy (5), and extrapleural pneumonectomy (1 patient) with intraoperative hyperthermic pleural perfusion in all. Intrapleural temperature reached 40.3 degrees C to 43 degrees C. The total dose of cisplatinum was 150 mg or more in 14 patients. RESULTS: Complete resection (R0) was achieved in 10 patients, subtotal (R1) in 3, and partial (R2) in 2. There was no operative mortality, no hemodynamic or respiratory disturbances during perfusion, and no hematologic, neurologic, or renal complications. Complications consisted of significant bleeding (2 patients), fever (2), and air leak (1 patient). Two patients with thymic carcinoma died after 27 and 34 months, and 1 is alive with no evidence of disease at 54 months. Two patients with thymoma died after 7 and 36 months. Eight are alive after 9 to 70 months. Four patients (all R0) are alive without local recurrence more than 60 months after operation and hyperthermic pleural perfusion. CONCLUSIONS: Operation and thermochemotherpy is feasible and safe in patients with thymic tumors. This method seems to offer excellent local control for patients with stage IV-a thymic malignancies. Midterm results suggest that operation plus hyperthermic pleural perfusion may lengthen survival in stage IV-a thymoma.

Factors influencing ulcer healing in patients with combined arterial and venous insufficiency.

PURPOSE: The purpose of this study was to determine the effectiveness of treatment of patients with combined arterial and venous insufficiency (CAVI), evaluate variables associated with successful ulcer healing, and better define criteria for interventional therapy. STUDY DESIGN: We retrospectively reviewed the records of patients treated at four institutions from 1995 to 2000 with lower extremity ulcers and CAVI. Arterial disease was defined as an ankle/brachial index less than 0.9, absent pedal pulse, and at least one in-line arterial stenosis > 50% by arteriography. Venous insufficiency was defined as characteristic clinical findings and duplex findings of either reflux or thrombus in the deep or superficial system. Clinical, demographic, and hemodynamic parameters were statistically analyzed with multiple regression analysis and correlated with ulcer healing and limb salvage. RESULTS: Fifty-nine patients with CAVI were treated for nonhealing ulcers that had been present from 1 to 39 months (mean, 6.4 months). All patients had edema. The mean ankle/brachial index was 0.55 (range, 0-0.86). Treatment included elastic compression and leg elevation in all patients and greater saphenous vein stripping in patients with superficial venous reflux. Fifty-two patients underwent arterial bypass grafting, three underwent an endarterectomy, one underwent superficial femoral artery percutaneous transluminal angioplasty, and three underwent primary below-knee amputation. For purposes of analysis, patients were divided into four groups according to the pattern of arterial and venous disease and the success of arterial reconstruction. Group 1 consisted of 22 patients with a patent arterial graft, superficial venous incompetence, and normal deep veins. Group 2 consisted of seven patients with a patent graft, superficial reflux, and deep venous reflux. Group 3 included 22 patients with a patent graft and deep venous thrombosis (DVT), and group 4 included eight patients with an occluded arterial graft. Follow-up ranged from 2 to 47 months (mean, 21.6 months). Forty-nine patients remained alive, and 10 died of unrelated causes. During follow-up, 48 of the 56 treated arteries remained patent and eight occluded. Thirty-four ulcers (58%) healed, 18 ulcers (31%) did not heal, and 7 patients (12%) required below-knee amputation for nonhealed ulcers and uncontrolled infection. No patient with graft occlusion was healed, and 12 ulcers persisted despite successful arterial reconstruction. Twenty-one (78%) of 27 patients undergoing greater saphenous vein stripping were healed, but none of these patients had DVT. The mean interval from bypass graft to healing was 7.9 months. Thirty-two (68%) of 46 patients without prior DVT were healed, whereas only two (15%) of 13 patients with prior DVT were healed, and this variable, in addition to graft patency, was the only factor statistically significant in predicting healing (P <.05). CONCLUSIONS: Ulcers may develop anywhere on the calf or foot in patients with CAVI, and healing requires correction of arterial insufficiency. Patients with prior DVT are unlikely to heal, even with a patent bypass graft. Ulcer healing is a lengthy process and requires aggressive treatment of edema and infection, and successful arterial reconstruction. Patients with a prior DVT are unlikely to benefit from aggressive arterial or venous reconstruction.

Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature.

OBJECTIVE: To determine the characteristic features and outcome of pulmonary carcinoid tumors in Israel. METHODS: Retrospective analysis of the clinicopathologic data and outcome of patients from four major hospitals in Israel in the last 20 years. RESULTS: There were 142 cases of pulmonary carcinoid tumors: typical (n = 128) and atypical (n = 14). We calculated an annual incidence of about 2.3 to 2.8 cases per 1 million population. The ratio of female to male patients was 1.6:1. The prevalence of smoking was similar to the general population in patients with typical carcinoids and twice as high in the atypical group. Bronchial obstruction was the cause of most of the presenting symptoms and signs and included obstructive pneumonitis, pleuritic pain, atelectasis, and dyspnea (41%). Carcinoid syndrome was extremely rare and occurred in only one patient with metastatic disease. Most of the tumors (68%) arose in the major bronchi. Diagnosis was made using fiberoptic bronchoscopy in 52% of patients without evidence of endobronchial hemorrhage. Nodal involvement and distant metastases occurred in 57% and 21%, respectively, in the atypical group, and 10% and 3%, respectively, in the typical group. The treatment of choice was surgical: lobectomy (56%) or pneumonectomy (16%). The respective 5-year survival rates for patients with typical and atypical tumors were 89% and 75% (not significant), and the 10-year survival rates were 82% and 56% (p < 0.05). A review of large series from the literature is presented. CONCLUSION: Pulmonary carcinoid is an uncommon tumor in the Israeli population. With early diagnosis and aggressive surgical therapy, long-term prognosis is excellent.

Laryngotracheal anastomosis: primary and revised procedures.

OBJECTIVES: Acquired upper airway stenosis is usually associated with a complex of pathological conditions at the high tracheal and the subglottic levels. Reported reconstructive techniques include widening by incorporation of grafts, segmental resection, and anastomosis or combined procedures. The management of recurrent stenosis after reconstructive surgery is a major challenge and has rarely been discussed in the literature. The purposes of the present study are to compare the clinical course of primary versus revised reconstructive procedures and to analyze the effect of age, diabetes, chronic lung disease, grading of stenosis, extent of resection, and revised procedures on the operative rate of success. STUDY DESIGN: A cohort study in a tertiary referral medical center. METHODS: The clinical course of 23 consecutive patients undergoing laryngotracheal anastomosis was studied comparing a group of 13 primary with 10 revision procedures. Seventeen patients underwent cricotracheal and six patients thyrotracheal anastomoses. All patients but one were tracheotomized before the definitive reconstructive procedure. Suprahyoid release was routinely performed except for two cases, and only one patient required sternotomy. The Wilcoxon test was used to examine the relationship between preoperative clinical parameters and the postoperative success (i.e., airway patency). RESULTS: Twenty-two of 23 patients (95.6%) had successful decannulation. Four patients required a revision procedure because of repeat stenosis at the site of the anastomosis (2) or distal tracheal malacia (2). Residual airway stenosis of less than 50% was noted in six patients, although only three complained of dyspnea during daily-activity exertion. There was no associated mortality. Complications included subcutaneous emphysema (4), granulation tissue formation (3), pneumonia (2), cardiac arrhythmia (2), and one each of pneumomediastinum, neck hematoma, and urosepsis. Protracted aspirations were noted in one patient who had revision surgery. Age was the only parameter that correlated with postoperative airway patency (P <.07), whereas the presence of chronic obstructive lung disease and diabetes, grade of stenosis, type of surgery, and revision surgery were found to be insignificant. CONCLUSIONS: The clinical course of laryngotracheal anastomosis in primary and revised procedures was similar in our group of patients. The operation can be performed safely, with an expected high rate of success and acceptable morbidity.

Wound infections involving infrainguinal autogenous vein grafts: a current evaluation of factors determining successful graft preservation.

PURPOSE: The purpose of this study was to review the natural history and clinical outcome of patients with infrainguinal autogenous graft infection (IAGI), to evaluate the effectiveness of attempted graft preservation, to determine those variables associated with graft salvage, and to better determine optimal treatment. STUDY DESIGN: We retrospectively reviewed the records of patients undergoing infrageniculate vein grafts at three hospitals between 1994 and 2000 who had a wound infection involving the graft. Clinical and bacteriologic variables were analyzed and correlated with graft salvage, limb salvage, and clinical outcome. RESULTS: During this 7-year period, 487 patients underwent an infrageniculate vein graft, and 68 (13%) had clinical evidence of IAGI. Twenty-seven patients presented with drainage from the wound, 15 with wound separation and cellulitis, 18 with soft tissue infection extending to the graft, 4 with an abscess and cellulitis, and 4 with bleeding. Ten patients (15%) had systemic symptoms (defined as a white blood cell count > 15,000 and temperature > 38.5 degrees C). Forty infections developed in the thigh, 17 in the groin, and 11 in the lower leg. An anastomosis was exposed in 15 patients. Wound cultures were positive for bacteria in 52 patients, and most infections were due to Staphylococcus aureus (18 patients) and S epidermidis (12 patients). Pseudomonas was cultured from seven infections. Twelve patients had polymicrobial infections. The interval from operation to infection ranged from 7 to 180 days. All patients were treated with oral antibiotics, 48 after intravenous antibiotics. Forty-five patients had operative debridement, including 18 who had muscle flap coverage. Four patients presented with hemorrhage, and three had immediate graft ligation and one graft excision. Follow-up ranged from 5 to 68 months (mean, 24.3 months), with 61 patients currently alive. Two patients died as a result of the IAGI (mortality rate, 2.9%). One had undergone a below-knee amputation, and one had a nonhealed wound but intact limb. Overall, 61 wounds (91%) healed, 4 patients required below-knee amputations, and 3 wounds did not heal. Fifty-eight grafts remained patent, 6 thrombosed, and 4 were ligated to control hemorrhage. Of the 61 wounds that healed, the time required for healing ranged from 7 to 63 days. No patient with bleeding died because of the acute episode. No patient had delayed hemorrhage. All 18 patients treated with a muscle flap healed. Bleeding (P <.001), elevated white blood cell count (P <.029), fever (P <.001), and renal insufficiency (creatinine level > 1.5; P <.056) were the only variables statistically significant in predicting graft failure or limb loss. With the use of life-table analysis, graft patency was 94%, 72%, and 72% at 1, 3, and 5 years, and limb salvage was 97%, 92%, and 92% at the same intervals, respectively. CONCLUSIONS: Most patients with an IAGI can be successfully treated with graft and limb preservation. In contrast to earlier studies, an exposed anastomosis, interval to infection, or Pseudomonas infection is not associated with graft failure. Graft salvage is less likely in patinets with fever, leukocytosis, and renal insufficency, but because most grafts remained patent, graft preservation is recommended for these patients. Graft ligation or excision should be reserved for patients presenting with bleeding or sepsis.

Multimodal treatment of metastatic thymic carcinoma including high-dose chemotherapy with autologous stem cell transplantation: report of a case with more than 4-year disease-free survival.

Thymic carcinoma is a rare epithelial malignancy differentiated from thymoma by the presence of cytologically malignant cells. There are few reports of the treatment of locally advanced or metastatic thymic carcinoma. We describe a patient who sought treatment for thymic carcinoma metastatic to pleura, pericardium, retroperitoneum, and neck nodes. He was treated with neoadjuvant etoposide, ifosfamide, and cisplatin, and underwent resection. We then administered high-dose chemotherapy with autologous stem cell support, followed by radiation therapy. The patient remains in complete remission more than 4 years after diagnosis. To our knowledge, this is the first report of metastatic thymic carcinoma treated with neoadjuvant therapy and postoperative high-dose chemotherapy. Metastatic thymic carcinoma may be curable by aggressive combined therapies.

Cervical vascular injuries: carotid and jugular venous injuries.

This article explores the management of carotid arterial injuries, detailing the historical evolution for the management of these injuries and delineating techniques for cerebral perfusion and preservation with shunts. It discusses the role of autogenous versus synthetic grafts in the management of these injuries and the issue of vascular complications and potential pitfalls. Jugular venous injuries are addressed also, with emphasis on the controversies of primary repair versus ligation.

CT diagnosis of malpositioned chest tubes.

Insertion of a chest tube into the pleural space is standard management for various pleural disorders. Malpositioning of chest tubes in extrathoracic, intraparenchymal and mediastinal locations and in the fissures is common. Malpositioning results not only in inadequate drainage of air and fluid but may also result in increased morbidity and mortality. Diagnosis of a malpositioned tube is sometimes difficult to establish on a chest radiograph. CT, however, has proven to be extremely accurate in evaluating the position of a chest tube and has often provided additional valuable information with significant therapeutic impact.

Psammomatous melanotic schwannoma: presentation of a rare primary lung tumor.

A 30-year-old nonsmoking man underwent a left lower lobectomy with bronchoplasty for an obstructing lesion of the left lower lobe. Pathology results demonstrated a psammomatous melanotic schwannoma, a rare pigmented neural tumor of which only 25 cases have been reported as originating in the respiratory tract.

Acquired tracheoesophageal fistula in critically ill patients.

Acquired benign tracheoesophageal fistula (TEF) is an infrequent complication of prolonged intubation and tracheostomy. Not infrequently, it is associated with severe circumferential malacia of the trachea and a need for concomitant correction of both. Controversy exists as to whether this should be performed in a single-stage or a 2-stage procedure. Four patients with acquired TEF underwent operation in a tertiary referral medical center between 1995 and 1997. The operations were performed through either an anterior (3) or a lateral (1) neck approach. Three patients underwent closure of the fistula with tracheal resection and anastomosis in a single stage and are doing well. One patient with complete subglottic stenosis underwent closure of the TEF and was planned for tracheal reconstruction in a second stage. This patient died in the early postoperative period. The complications included aspiration of blood leading to pneumonia (2), spontaneously resolving pneumomediastinum (1), subcutaneous emphysema (2), and cardiac arrhythmia ( 1). Residual fistula, noted in 1 patient, was treated conservatively and resolved spontaneously within several weeks. We conclude that acquired TEF is amenable to repair through a cervical approach. A single-stage correction of the TEF with reconstruction of the trachea is suitable and successful in most patients. Several stages seem justified when concurrent laryngotracheal reconstruction is needed.

Comparison of intravenous/oral ciprofloxacin plus metronidazole versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections.

OBJECTIVE: To compare the safety and efficacy of intravenous (IV) ciprofloxacin plus IV metronidazole (CIP+MET) with that of IV piperacillin/tazobactam (PIP/TAZO) in adults with complicated intraabdominal infections, and to compare the efficacy of sequential IV-to-oral CIP+MET therapy with that of the IV CIP-only regimen. SUMMARY BACKGROUND DATA: Treatment of intraabdominal infections remains a challenge, mainly because of their polymicrobial etiology and attendant death and complications. Antimicrobial regimens using sequential IV-to-oral therapy may reduce the length of hospital stay. METHODS: In this multicenter, randomized, double-blind trial involving 459 patients, clinically improved IV-treated patients were switched to oral therapy after 48 hours. Overall clinical response was the primary efficacy measurement. RESULTS: A total of 282 patients (151 CIP+MET, 131 PIP/TAZO) were valid for efficacy. Of these patients, 64% CIP+MET and 57% PIP/TAZO patients were considered candidates for oral therapy. Patients had a mean APACHE II score of 9.6. The most common diagnoses were appendicitis (33%), other intraabdominal infection (29%), and abscess (25%). Overall clinical resolution rates were statistically superior for CIP+MET (74%) compared with PIP/TAZO (63%). Corresponding rates in the subgroup suitable for oral therapy were 85% for CIP+MET and 70% for PIP/TAZO. Postsurgical wound infection rates were significantly lower in CIP+MET (11%) versus PIP/TAZO patients (19%). Mean length of stay was 14 days for CIP+MET and 17 days for PIP/TAZO patients. CONCLUSION: CIP+MET, initially administered IV and followed by CIP+MET oral therapy, was clinically more effective than IV PIP/TAZO for the treatment of patients with complicated intraabdominal infections.

In vitro activities of nontraditional antimicrobials against multiresistant Acinetobacter baumannii strains isolated in an intensive care unit outbreak.

Fifteen multiresistant Acinetobacter baumannii isolates from patients in intensive care units and 14 nonoutbreak strains were tested to determine in vitro activities of nontraditional antimicrobials, including cefepime, meropenem, netilmicin, azithromycin, doxycycline, rifampin, sulbactam, and trovafloxacin. The latter five drugs were further tested against four of the strains for bactericidal or bacteriostatic activity by performing kill-curve studies at 0.5, 1, 2, and 4 times their MICs. In addition, novel combinations of drugs with sulbactam were examined for synergistic interactions by using a checkerboard configuration. MICs at which 90% of the isolates tested were inhibited for antimicrobials showing activity against the multiresistant A. baumannii strains were as follows (in parentheses): doxycycline (1 microg/ml), azithromycin (4 microg/ml), netilmicin (1 microg/ml), rifampin (8 microg/ml), polymyxin (0.8 U/ml), meropenem (4 microg/ml), trovafloxacin (4 microg/ml), and sulbactam (8 microg/ml). In the kill-curve studies, azithromycin and rifampin were rapidly bactericidal while sulbactam was more slowly bactericidal. Trovafloxacin and doxycycline were bacteriostatic. None of the antimicrobials tested were bactericidal against all strains tested. The synergy studies demonstrated that the combinations of sulbactam with azithromycin, rifampin, doxycycline, or trovafloxacin were generally additive or indifferent.

Determinants of survival after inferior vena cava trauma.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.