Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax

Diaphragmatic injury with accompanying hernia is a well-documented complication associated with both penetrating and blunt trauma. It occurs in approximately 3% of abdominal injuries with a 2:1 ratio of penetrating to blunt trauma. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress six years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and foul-smelling purulent drainage. Work-up revealed incarcerated transverse colon in a diaphragmatic hernia. Celiotomy demonstrated necrotic colon in the chest with gross fecal contamination in both the chest and abdomen. The diaphragmatic defect was closed and a Hartmann's procedure performed. The patient did well postoperatively except for the development of an empyema, which resolved with conservative management. Our patient is the eleventh reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases including the diagnostic work-up, operative approach, and ex ected postoperative course of this unusual condition.

Computed tomography and ultrasonography in the diagnosis of appendicitis: when are they indicated?

HYPOTHESIS

Relative merits and indications exist for ultrasonography (US) and computed tomography (CT) in the diagnosis of appendicitis.

DESIGN

Prospective study.

SETTING

General community and tertiary care hospital.

METHODS

Ninety-nine patients (50 males and 49 females) were studied. Following consent, the initial disposition was recorded, designating the patient for operation, observation, or discharge from the hospital. Each patient was studied by CT and US. Studies were independently evaluated by 2 radiologists, and the results were designated as positive, negative, or equivocal. The surgeon reevaluated patients before and after learning the results of US and CT, recording whether the CT scan, US, or reexamination influenced the final disposition.

RESULTS

Fifty patients had appendicitis; 6 appendixes were perforated. The initial clinical impression called for 44 operations, 49 observations, and 6 discharges. Thirty-four patients had their treatment plan changed from the initial disposition. Ultrasonography did not affect the initial impression. In contrast, 18 patients were rediagnosed solely on CT scan findings. Seven patients were rediagnosed by reexamination. Of 44 patients initially designated for operation, the CT scan and reexamination spared 6 females from surgery; the negative appendectomy rate potentially decreased from 50% to 17% (P =.03). The CT scan, US, or reexamination failed to spare 2 males from exploration with negative results. Of the 49 patients initially designated for observation, 23 were rediagnosed after reevaluation, 13 were discharged from the hospital, and 10 underwent expedient operation. One patient was spared from inappropriate discharge from the hospital. The reliability of the CT scan was good, with high sensitivities and specificities. Equivocal scan results lowered the diagnostic value.

CONCLUSIONS

Selective use of a CT scan with a second examination can improve the diagnostic accuracy and management of suspected cases of appendicitis by (a) reducing the negative appendectomy rate in females, (b) moving patients from observation to earlier operation or discharge from the hospital, and (c) preventing inappropriate discharge of patients with appendicitis.

Metoclopramide versus ondansetron in prophylaxis of nausea and vomiting for laparoscopic cholecystectomy

BACKGROUND

Postoperative nausea and vomiting are significant problems in laparoscopic surgery. This double-blind, randomized, prospective trial compares the prophylactic use of metoclopramide, ondansetron, and placebo for the treatment of postoperative nausea and vomiting in patients undergoing outpatient laparoscopic cholecystectomy.

METHODS

Two hundred thirty-two patients aged 18 to 73 years were randomized into three groups. Patients received intravenously 10 mg of metoclopramide, 4 mg of ondansetron, or placebo in a double-blinded manner prior to surgery.

RESULTS

The incidence of nausea was 32% for metoclopramide, 45% for ondansetron, and 44% for placebo in the postanesthesia care unit or day surgery, which was not statistically significant. The incidence of vomiting was 8% for metoclopramide, 4% for ondansetron, and 22% for placebo in the postanesthesia care unit or day surgery. These differences were statistically significant when comparing both drugs to placebo but not when comparing both drugs to each other.

CONCLUSION

Prophylactic administration of metoclopramide or ondansetron significantly reduces the incidence of postoperative vomiting for laparoscopic cholecystectomy, but neither drug was found to be significantly more effective than the other. Metoclopramide is a more cost-effective treatment.

Preventing patient falls

Falls are among the most common, yet potentially preventable, adverse events experienced by patients in hospitals. Such serious outcomes as physical and emotional injury, increased dependence, admission to a long-term care facility, and poor quality of life can result from falling. Traditionally, elderly patients have been at highest risk for falling, with many falls resulting in serious injury. These injuries cost billions of dollars and expose hospitals and their staff to liability. As the elderly population continues to increase, it is imperative that falls and associated injuries be prevented whenever possible identification of nontraditional patients at high risk for falls is emerging in the professional literature. Nurses are the first line of care in prevention of falls. Educating nurses about risk factors, prevention strategies and application of fall index and fall injury statistics can improve the safety of fall-prone patients. Refining, modifying and individualizing fall risk factors and prevention interventions for traditional and nontraditional high-risk groups is a necessary focus for future research.

Physical restraint of elderly patients in critical care: historical perspectives and new directions

The use of physical restraints in health care settings is being examined carefully at all levels. Experience with the elderly in long-term care settings teaches us that in many instances physical restraints are not only unnecessary, they are also not the best available therapy. There can be little doubt that careful evaluation of the use of restraints in the critical care unit is likely to reveal alternatives to their use in many situations. In the American health care system, nurses primarily determine restraint use. Professional nurses are leading the movement to find alternatives to restraints, and critical care nurses can contribute much to the effort. Nurses must recognize restraint application as a serious treatment decision, and must apply risk-to-benefit analysis to each decision. Continuing nursing education and nursing research on restraint reduction will lead to improved care for our elderly patients.

Discharge planning for the patient with a new tracheostomy

A patient with a new tracheostomy will face threatening changes upon discharge from hospital support. Nurses, particularly in the critical care unit, frequently and closely support a patient and family through new and often difficult situations during hospitalization. The patient leaving the hospital with a new tracheostomy will face problems with secretion management, increased risk of infections, alterations in body image, and impaired vocalization. To ensure a safe transition from the hospital to home, the patient and family must demonstrate competence in all aspects of tracheostomy care, must be able to recognize signs and symptoms that should be reported to the physician, and must have adequate support at home (such as homecare nurses, properly functioning equipment, and access to necessary supplies). These "musts" form the basis of the discharge care plan. Nurses can help a patient successfully manage these problems through comprehensive discharge planning. Although the critical care nurses who initiate the multidisciplinary discharge planning process may not remain involved in that process throughout the patient's hospitalization, their early efforts can provide an orderly, comprehensive discharge plan optimally suited to ensure that the patient and family acquire the necessary skills, confidence, supplies, and support for the eventual transition home. The information, encouragement, skills demonstrations, and referrals to other resources that critical care nurses provide help the patient adjust to a new tracheostomy.

Discharge planning for the patient with a new tracheostomy

A patient with a new tracheostomy will face threatening changes upon discharge from hospital support. Nurses, particularly in the critical care unit, frequently and closely support a patient and family through new and often difficult situations during hospitalization. The patient leaving the hospital with a new tracheostomy will face problems with secretion management, increased risk of infections, alterations in body image, and impaired vocalization. To ensure a safe transition from the hospital to home, the patient and family must demonstrate competence in all aspects of tracheostomy care, must be able to recognize signs and symptoms that should be reported to the physician, and must have adequate support at home (such as homecare nurses, properly functioning equipment, and access to necessary supplies). These "musts" form the basis of the discharge care plan. Nurses can help a patient successfully manage these problems through comprehensive discharge planning. Although the critical care nurses who initiate the multidisciplinary discharge planning process may not remain involved in that process throughout the patient's hospitalization, their early efforts can provide an orderly, comprehensive discharge plan optimally suited to ensure that the patient and family acquire the necessary skills, confidence, supplies, and support for the eventual transition home. The information, encouragement, skills demonstrations, and referrals to other resources that critical care nurses provide help the patient adjust to a new tracheostomy.

Red blood cell survival following admixture with heated saline: evaluation of a new blood warming method for rapid transfusion

We studied the in vivo survival of packed red blood cells (RBC's) which had been warmed using the new technique of admixture with high-temperature saline. Packed RBC's from five normal male subjects were stored in CPDA-1 at 4 degrees C for 14 days. They were then warmed via admixture with an equal amount of saline heated to 70 degrees C. Osmotic fragility, and supernatant hemoglobin and potassium levels of the warmed RBC's were not significantly different from baseline values. Aliquots of the warmed RBC's were labeled with 51Chromium and transfused into autologous donors. Mean radiolabeled RBC survival at 24 hours was 90.2% (S.D. 6.2%), and mean radiolabeled RBC survival time was 25.3 days (S.D. 2.7 days). These results are within the normal range for RBC's stored for 14 days. This study suggests that RBC survival after transfusion is not impaired by admixture blood warming using saline at 70 degrees C.

Red cell tolerance of admixture with heated saline

Red cell stability in the face of thermal stress has been evaluated only in the setting of prolonged incubation. This study was conducted to determine red cell tolerance of rapid mixture with heated saline, which exposes red cells to heat only until thermal equilibration, which is a matter of seconds. Half-units of 35-day-old red cells stored in CPDA-1 were mixed at 6 to 10 degrees C in the blood container with an equal weight of 60, 70, or 80 degrees C saline. This resulted in mean mixture temperatures of 30.9, 37.5, and 42.6 degrees C, respectively. Controls consisted of the same mixture, but with 6 to 10 degrees C saline. The red cells in the mixtures were assessed for osmotic fragility, and the supernatant was examined for plasma hemoglobin and potassium. Neither osmotic fragility curves nor supernatant hemoglobin or potassium changed significantly with saline temperatures of 60 or 70 degrees C. When 80 degrees C saline was used, osmotic fragility, supernatant hemoglobin, and potassium all increased significantly (p less than 0.01) over control values. Red cells tolerate rapid mixture with 70 degrees C saline without hemolysis or change in osmotic fragility.

Admixture bloodwarming: a technique for rapid warming of erythrocytes

Admixture of erythrocytes (packed red blood cells) with heated saline solutions may provide a faster and safer method of bloodwarming and infusion than is currently available. We developed and tested such a system for ease and efficacy. One-day-old aliquots of erythrocytes (6 to 10 C) were combined with equal amounts of saline that had been heated to a temperature of 50 or 60 C. After this rapid admixture, equilibrated temperatures were 29.1 and 34.0 C, respectively. The procedure also was performed using 35-day-old erythrocytes and 60-C saline. Samples were obtained for analysis immediately after admixture. There was no significant plasma hemoglobin elevation, indicating no significant hemolysis, in any sample at either temperature. Rapid admixture bloodwarming appears to be a technique in which erythrocytes and heated saline may be combined rapidly without causing significant hemolysis. However, further studies of red cell function and survival will be needed before this technique should be put into clinical practice.