Calcium homeostasis after parathyroidectomy in normal and shocked states

The natural history of parathyroidectomy was studied for 75 weeks in two dogs. After parathyroidectomy, the dogs required intravenous and intramuscular calcium supplementation for 1 week. Despite calcium supplementation, in 2 weeks the ionized calcium (Ca++) level fell from 4.67 mg/dl to 2.39 mg/dl. The Ca++ level rose to 4.25 mg/dl by 7 weeks after which the intramuscular calcium supplement was gradually weaned so that no calcium was given after 20 weeks. The Ca++ level stabilized at 3.15 to 3.25 mg/dl after 20 weeks. Postoperative parathormone (PTH) levels remained low. The response to hemorrhagic shock in these two calcium-independent dogs was compared with that seen in two calcium-dependent dogs 4 weeks after parathyroidectomy and to that seen in two euparathyroid dogs. Shock caused a sharp decrease in Ca++ in all animals that had parathyroid ectomy. Prostaglandin E2 (PGE2) was elevated preoperatively in these dogs and fell markedly during shock. Ca++ remained normal and PGE2 increased slightly after shock in the euparathyroid dogs. Cardiac output rose with resuscitation in the euparathyroid dogs but remained constant in the calcium-dependent dogs and increased slightly in the calcium independent parathyroidectomized animals. PTH levels were low in the parathyroidectomy groups and did not react to shock. PTH increased markedly after resuscitation in the euparathyroid dogs, suggesting its role as an acute-phase hormone. All levels returned to baseline levels within 3 days after shock. Adaptation to hypocalcemia occurs in parathyroidectomized dogs and involves PGE2 as well as other factors. Hemorrhagic shock exceeds this compensatory response which in euparathyroid dogs involves active PTH release in response to hypocalcemia.

The effect of steroids for shock on the immune response to tetanus toxoid

The effect of corticosteroids on the immune response after severe injury and hemorrhagic shock was studied in 88 patients, who received an average of 13 blood transfusions for injury and hemorrhagic shock, which caused the systolic blood pressure to be below 80 torr for an average of 29 minutes. The immune response to tetanus toxoid was tested in the postoperative period. Besides the administration of blood, crystalloid solution, and plasma for coagulation factor deficiency, 42 patients also received methyl-prednisolone 1 g during additional resuscitation followed by an average of 15 mg/kg given daily for the next 2 days. The total dose of methylprednisolone averaged 3.9 g. The two groups of patients were similar for resuscitation needs and for insult. The immune response to tetanus toxoid was not significantly different between the two groups of patients. These data show that a short-term bolus of massive steroids does not appear to alter, significantly, the immune mechanism following severe hemorrhagic shock.

The effects of treatment of renal trauma on renal function

Renal function studies were performed in 275 severely injured patients with hemorrhagic shock and massive transfusion. There were 230 patients without renal injury and 45 patients with renal injury treated without exploration of the kidney in 17 patients, with exploration and renorrhaphy in nine patients, and with partial or total nephrectomy in 19 patients. In addition, 45 patients without renal injury were randomly matched by computer to the 45 patients with renal injury based on the number of blood transfusions and severity of shock as indicators of physiologic insult. Renal function was adversely affected by partial or total nephrectomy in patients with renal injury. Significant decreases in renal filtration and excretion were seen when the nephrectomy group was compared to the patients without renal injury matched for injury insult. Creatinine clearance decreased from 103 ml/min to 55 ml/min, inulin clearance from 106 ml/min to 63 ml/min, and osmolar clearance from 4.8 ml/min to 3.3 ml/min. The 230 patients without renal injury had an incidence of renal failure of 7.4% and a mortality rate of 8.2% compared to 11.4% and 15.6%, respectively, in the 45 patients with renal injury. Death and renal failure occurred in 13 of the 230 patients without renal injury (5.6%) and in two of the 45 renal injury patients (4.4%). The incidence of renal failure in the 19 patients without renal injury who died was 68% versus 29% in the seven renal injury patients who died. Preservation of renal parenchyma is recommended to provide maximal renal function in severely injured patients.

Conservative therapy for missed esophageal perforation after blunt trauma

An 80-year-old man was treated, non-operatively, for a distal esophageal perforation, diagnosed nine days after blunt thoracic trauma. Emergency department diagnosis was impeded by absence of mediastinal air; right chest-wall emphysema was thought to result from associated rib fractures. Conservative therapy consisting of nasogastric suction, intravenous antibiotics, right-chest tube drainage of a large communicating empyema cavity, temporary nasotracheal intubation with ventilatory support, total parenteral nutrition, and, finally, nasoduodenal intubation for elemental feeding were employed. This mode of therapy may be best in comparable elderly patients with esophageal perforation that is overlooked during the initial 24 hours after injury. Possibly, routine barium swallow in all patients with chest-wall emphysema and rib fractures would circumvent missed esophageal rupture after blunt trauma.

Social, economic, and surgical anatomy of a drug-related abscess

The "letting of pus" has been a surgical triumph throughout medical history. This study was initiated to expand our knowledge of the etiologic, economic, and surgical aspects of an abscess. The records of 651 patients undergoing intraoperative incision and drainage of an abscess over a 12-month interval were analyzed. The abscesses were due to injection of illicit street drugs in 421 patients (64.7%), perirectal, pilonidal or sweat gland inflammation in 118 patients (18%), complications of diabetes in 22 patients (3.4%) and a prior operative procedure in only 18 patients (2.8%). Fifty-three of the 421 patients with a drug-related abscess were randomly selected for an indepth review. Eighty-three per cent of the patients had positive cultures including 75 per cent with a single organism and 25 per cent with mixed flora. Staphylococcus aureus was present in 62 per cent of the cultures and 41 per cent of the isolates were methicillin resistant. The average length of hospitalization was 12.4 days with a range of 1 to 61 days. The average cost of hospitalization was $10,651 which increased to $24,383 if the patient had a mycotic aneurysm. The estimated annual cost of treatment of this sequela of injected illicit drugs was 6.9 million dollars in our hospital.

Spatulated versus end-to-end anastomosis for small vessel injury

Spatulated anastomosis (SA) was compared to end-to-end anastomosis (EEA) with small arteries (3-4 mm) in nine conditioned dogs (22-30 kg). A 1-cm segment of both common femoral arteries with an average of 3.5-mm external diameter was resected and reconstructed by EEA and by contralateral SA using a running suture of 5/0 proline. Pre- and postoperative flow rates, flow rates at 1 year in three dogs, arteriography at 1 year in six dogs, and gross examination at 1 year were done. The preoperative flow rates averaged 86 ml/min for the SA and 76 ml/min for the EEA; early postoperative flow rates averaged 100 ml/min and 92 ml/min, respectively, whereas 1-year flow rates averaged 63 ml/min and 57 ml/min, respectively. None of these differences is significant. Preoperative and 1-year external diameters averaged 3.54 mm and 3.39 mm in the SA group compared to 3.5 mm and 3.44 mm in the EEA group. Arteriograms showed good flow except for slight narrowing in one SA which, on postmortem exam, was seen to result from a fibrous band which extended from the spatulated segment to the opposite wall. These data show that SA and EEA yield comparable results both acutely and long term. The choice of EEA versus SA for primary repair of injured small vessels should be determined by surgical preference.

Effect of fresh-frozen plasma resuscitation on cardiopulmonary function and serum protein flux

The adverse effects of albumin resuscitation on coagulation activity, cardiopulmonary function, and extravascular flux of nonalbumin protein have made fresh-frozen plasma (FFP) an attractive alternate volume expander for hemorrhagic shock. This study addresses the effects of FFP on cardiopulmonary hemodynamics and protein flux. Whole blood was collected three and six weeks before shock, separated into red blood cells (PRBCs) and FFP, and stored. In 24 conditioned splenectomized dogs, resuscitation from reservoir shock of two hours' duration consisted of autologous PRBCs and balanced electrolyte solution (BES) in control dogs and PRBCs, BES, and FFP in plasma-treated dogs. Hemorrhagic shock reduced serum albumin and IgG levels in both groups. Resuscitation with FFP led to a higher cardiac output, left ventricular stroke work (LVSW), and pulmonary capillary wedge pressure (PCWP). The PCWP/LVSW ratio was comparable for both groups. Postshock day 2 serum albumin and IgG levels and lymphatic albumin and IgG concentrations were increased in plasma dogs. Therefore, FFP supplement to PRBC and BES resuscitation does not derange the PCWP/LVSW ratio or reduce intravascular nonalbumin proteins.

Assessment of antimicrobial penetrance into the pancreatic juice in humans

The penetrance of mezlocillin, metronidazole and trimethoprim-sulfamethoxazole into the pancreatic juice of humans was measured in ten patients convalescing from acute pancreatitis at the time of endoscopic retrograde cholangiopancreatography. Therapeutic levels were obtained in the serum for all three antimicrobial agents; simultaneously aspirated nonbile stained pancreatic juice contained therapeutic levels of metronidazole and trimethoprim-sulfamethoxazole. Mezlocillin was not present in a therapeutic level in any patient with nonbile stained pancreatic fluid.

Research in trauma

Successful research in clinical trauma requires the researcher to be exposed to many injured patients, have a personal commitment to research conducted at inconvenient hours and be inquisitive so as to identify clinical problems that need scientific answers. Once initiated, a research project necessitates the collection and storage of clinical data on a weekly basis before patient discharge. A computer data program facilitates later retrieval and statistical analysis. Departmental support of the clinical investigator is mandatory. Although the personal commitments for producing first-rate clinical research may seem excessive, the rewards are commensurate.

Fresh frozen plasma supplement to massive red blood cell transfusion

The efficacy of supplemental fresh frozen plasma (FFP) therapy after massive packed red cell (PRBC) replacement for hemorrhagic shock was studied in 22 conditioned dogs. Ten dogs were randomized to received FFP, balanced electrolyte solution (BES), and PRBC, while 12 dogs received BES and PRBC. Coagulation factor activity for Factors I, II, V, VII and VIII, as well as antithrombin III (AT III), prothrombin time, partial thromboplastin time, and thrombin time, were measured at preshock, postshock, postresuscitation, and postshock day two. All coagulation factor activities fell with shock and decreased further with resuscitation in both groups. Factor II (a procoagulant) and AT III (an anticoagulant) fell significantly less after resuscitation in the plasma dogs; otherwise, no postresuscitation differences were seen. The changes in factor activity from postresuscitation until day two reflected factor half life and molecular weight, independent of FFP therapy. These data show that prophylactic FFP therapy does not efficiently restore coagulation activity. Consequently, routine FFP therapy for its procoagulant effects after hemorrhagic shock should be abandoned pending controlled studies in man.

Serial changes in primary hemostasis after massive transfusion

Primary hemostasis was studied in 22 injured patients in the operating room (OR) after a minimum of 10 transfusions, 6 and 15 hours after surgery, on postoperative days 2 and 4 and during convalescence (mean 25 days after surgery). The platelet count was low in the OR and continued to fall after surgery through the second postoperative day; it began to rise by day 4 and was above normal at convalescence. Most patients had prolonged bleeding time through day 4. Platelet aggregation with adenosine diphosphate and collagen was depressed in the OR and platelet aggregation remained depressed. The platelet-specific proteins, beta-thromboglobulin and platelet factor 4, were elevated in the OR and fell throughout the first 4 postoperative days. A secondary rise in these proteins occurred at convalescence. Despite severe alterations in both the number and function of platelets after massive transfusion for injury, no patient had clinical oozing. Therefore the routine administration of platelets in comparable patients without "medical bleeding" is unwarranted.

Effects of vinblastine, etoposide, cisplatin and bleomycin on rodent wound healing

Chemotherapy for malignant disease is usually deferred for three weeks postoperatively to prevent interference with wound healing. Recently, aggressive perioperative combination chemotherapy has improved survival rates in patients with germ cell tumors. Facial dehiscence at one month in a young man on combination chemotherapy for a pure choriocarcinoma prompted this experimental study. Laboratory rats receiving bleomycin, perioperatively and a combination of bleomycin, etoposide and cisplatin had a significant decrease in wound breaking strength five weeks after injection. These data suggest that patients receiving bleomycin alone or in combination should have fascial closure with nonabsorbable sutures.

The beneficial role of calcium supplementation during resuscitation from shock

The role of calcium (Ca) in resuscitation from hemorrhagic shock is controversial and in the present report three regimens were compared: supplementation (Ca-S), avoidance (No-Ca), and Ca channel blockade (Ca-B). This was studied in 40 splenectomized dogs subjected to reservoir shock (MAP 60 torr/90 min, then 40 torr/30 min) and treated with: a) 20 ml/kg balanced electrolyte solution (BES); b) shed blood; c) 30 ml/kg BES; and d) 250 ml autologous bank blood. Three groups of six dogs received Ca-S (0.5 mEq/kg), No-Ca, or Ca-B (verapamil 0.15 mg/kg) in BES. Postoperative therapy of 50 ml/kg/d BES with Ca-S, No-Ca, or Ca-B was given for 3 days. The effects of parathyroidectomy (P) via wide thyroidectomy in 22 dogs treated with calphosan (20 ml/d) and L-thyroxin (0.02 mg/kg) preceding shock was also studied as above: Ca-S/P, No-Ca/P, and Ca-B/P; four sham dogs had anesthesia but no shock (Anes/P). Studies done before, during, and after shock and on day three included systemic pressures (MAP), central pressures (CFP), cardiac output (CO), resistance (SVR), heart work (LVW), and outcome. Post-resuscitation Ca was significantly less in all groups (1.6-3.7 mg%) compared to Ca-S (4.8 mg%). Compared to Ca-S dogs, the post-resuscitation studies in the No-Ca and Ca-B dogs showed lower MAP, CO, and LVW in both intact and hypoparathyroid animals. Post-resuscitation CFP was also lower in the Ca-S and Ca-S/P dogs compared to the other euparathyroid and hypoparathyroid dogs. Death after the initiation of resuscitation occurred in two No-Ca/P and three Ca-B/P dogs. These data suggest that calcium supplementation plus an intact calcium-parathyroid axis enhance the resuscitation effort.

Societal impact on surgical education in trauma

Societal and demographic changes within Detroit have affected the incidence of trauma treated at the Detroit Medical Center. Using liver injury as an index, this phenomenon was studied by comparing 122 patients treated in 1972 with 38 patients treated in 1981. During 1972 76 patients had major injuries, compared to 13 patients in 1981. Intraoperative hemostasis of an actively bleeding liver in 1972 was achieved by liver suture (43 patients), resectional debridement through a nonanatomic plane (three patients), hepatic artery ligation (three patients), anatomic segmentectomy or lobectomy (four patients), and intrahepatic packing with later removal (one patient). During 1981, 13 patients had persistent bleeding requiring intraoperative hemostasis by liver suture (12 patients) or resectional debridement (one patient). This decline in trauma reflects a reduced city population, the dilutional effect of a four-quadrant emergency medical service begun in the mid 1970's, the implementation of a state gun law, and reduced citizen compliance to violence. These changes likely are not unique to Detroit and highlight the need for a National Trauma Registry which would not only help program directors design a meaningful trauma rotation but also help hospital planners accommodate to changes in patient exposure.

Assessment of pancreatic ductal penetration of antibiotics

Pancreatic ductal penetration of antibiotics is not uniform. Antibiotic therapy for pancreatic and pancreatic related infections, theoretically, is enhanced by drugs that reach the ductal system. The pancreatic ductal penetrance of Cefamandol (1 gm), Amikacin (7.5 mg/kg), and Chloramphenicol (1 gm) given as a single intravenous dose prior to endoscopic retrograde cholangiopancreatography was studied in ten patients. Serum and pancreatic juice were collected simultaneously, frozen, and later assayed for antibiotic concentration. Each antibiotic achieved its expected therapeutic serum level. In contrast, pancreatic ductal levels of Cefamandol and Amikacin were subtherapeutic, whereas Chloramphenicol levels were therapeutic. Further studies are needed to identify other antibiotics with good pancreatic ductal penetrance.

Parathyroid response to hypocalcemia after treatment of hemorrhagic shock

Hypocalcemia often follows resuscitation from hemorrhagic shock. The role of calcium supplementation is controversial, whereas, little data are available regarding the parathyroid (PTH) response. Therefore this response was studied in 41 injured patients who required 15 blood transfusions and 11.7 L balanced electrolyte solution during emergency room and operating room therapy. Postoperative reduced total calcium (7.5 +/- 0.8 mg/dl SD) and ionized calcium 1.85 +/- 0.2 mEq/SD) paralleled a rise in PTH (69.7 +/- 37 microliters Eq/ml SD) and the severity of insult as reflected by shock time and hypoalbuminemia. Renal function was normal. Increased PTH is probably homeostatic and belies the theoretical merits of calcium channel blocker administration after hemorrhagic shock. Calcium supplements may be of benefit during resuscitation when bone flow is low and calcium release from bone in response to PTH is reduced.

Mechanisms of impaired renal function with PEEP

Deterioration in renal function associated with positive end-expiratory pressure (PEEP) has been attributed to renal hypoperfusion from the fall in cardiac output and mean arterial blood pressure. Using a canine in vivo model, renal function was measured during control, zero end-expiratory pressure (ZEEP), and PEEP (5, 10, and 15 cm H2O) ventilatory cycles, while renal blood flow was maintained constant with a pump. High PEEP (15 cm H2O) led to a rise in renal vein pressure (RVP) and a fall in mean arterial pressure (MAP). PEEP resulted in no change in glomerular filtration rate (GFR) or solute exertion; however, free-water clearance (FWC) became less negative in the 15-cm H2O PEEP group. Intrarenal autoregulation maintains GFR during ventilation with PEEP when renal blood flow is constant, supporting the view that altered filtration and solute excretion clinically is secondary to changes in aortic pressure and renal perfusion.

Infected venous pseudoaneurysm. A complication of drug addiction

There has been an increase in the incidence of major vascular complications of intravenous drug addiction. We studied five patients who had infected venous pseudoaneurysms of the femoral vein. Patients may have cryptic sepsis or an infected hematoma from venous rupture. The vein containing pus may drain through a venipuncture site. Treatment is complete excision of the involved vein with packing of the wound. Complications due to septic embolization or metastatic infection from septicemia are common. Venous reconstruction is unwarranted.

The cardiopulmonary response to massive doses of steroids in patients with septic shock

The effects of massive doses of steroids on septic shock were tested in 48 patients being treated for extensive cellulitis, wet gangrene, or severe peritonitis. From diagnosis until maximum weight gain (average, 47 hours), they received an average of 17.7 L of crystalloid solution and 1.0 L of blood and voided 3.1 L of urine. Of the 48 patients, 23 were selected in random fashion to receive dexamethasone sodium phosphate (6 mg/kg) over 48 hours. The average age (55 years), duration of shock (36 minutes), and insult were similar for both groups. Each group received similar volumes of fluid and blood. Steroid therapy was associated with a statistically significant rise in diastolic pressure (88 v 78 mm Hg), mean arterial pressure (105 v 95 mm Hg), and central venous pressure (16 v 10 cm H2O). Concomitant blood volume was lower in patients treated with steroids (5.2 v 6.1 L). All differences between the two groups disappeared after 48 hours when steroid therapy was discontinued. No differences were noted in morbidity and five patients in each group died.

Effect of albumin resuscitation on canine coagulation activity and content

Prior work showed that albumin resuscitation in man leads to decreased coagulation activity and coagulation protein content. These observations were tested in 20 splenectomized dogs shocked by control hemorrhage and resuscitated with the sequential infusion of: (1) 20 ml/kg balanced electrolyte solution (BES) or 5% albumin/BES; (2) shed blood; (3) 30 ml/kg BES or 5% albumin/BES; (4) 250 ml blood stored from the time of splenectomy. Either BES or 5% albumin/BES was given for the next 3 days. Coagulation activity (fibrinogen, plasminogen, factor VIII, and prothrombin) and coagulation protein content (factor VIII by specific canine antigen) were measured preshock, post resuscitation, and daily for 3 days. Albumin resuscitation significantly (p = greater than 0.05) reduced coagulation activity of fibrinogen (423 +/- 145 vs. 274 +/- 80 mg/dl SD), factor VIII:C (64 +/- 24 vs 42 +/- 16% SD), prothrombin (195 +/- 44 vs. 141 +/- 22% SD) but did not alter CPC of factor VIII:RAg (142 +/- 83 vs. 156 +/- 141% SD). Lower coagulation activity after 5% albumin/BES resuscitation in conjunction with no change in factor VIII:RAg content which is produced by the vascular endothelium suggest that impaired hepatic synthesis may lead to the reduced coagulation activity after albumin resuscitation.

Effect of end-expiratory pressure on total oxygen dynamics

The role of altered end-expiratory pressure on total oxygen dynamics was studied prospectively in 18 patients with injuries and sepsis. Eight patients received high tidal volumes (12 to 18 ml/kg), continuous positive airway pressure, and intermittent mandatory ventilation (CPAP/IMV); 10 patients received low tidal volumes (8 to 10 ml/kg) with zero end-expiratory pressure and assist control mode of ventilation (ZEEP/A-CM). CPAP/IMV patients had better oxygen tension, reduced physiologic shunting in the lung (24% versus 18%), and an improved arterial tension: inspired oxygen concentration ratio. CPAP/IMV patients also had significantly higher central filling pressures that were associated with significant reductions in cardiac output (8.2 L/min versus 6.4 L/min). The reduced cardiac output appeared to be a result of a reduction in left ventricular stroke work index. Consequently, the total oxygen delivery was reduced for all 3 days following insult and for the cumulative data for all 3 days (266 versus 306 ml/min) in the CPAP/IMV patients. Oxygen consumption was also reduced in the CPAP/IMV patients; this reduction was not significant for each of the first 3 days but was significant when the data for the 3 days were added to the analysis (306 versus 272 ml/min). Future prospective randomized studies are needed to determine the most effective use of ventilatory support on total oxygen dynamics including oxygen delivery and oxygen consumption.

Effect of calcium infusion on heart function

The effects of calcium on heart function were studied in ten critically ill hypocalcemic patients (Ca++ = 1.93 +/- 0.08 mEq/L SD). Total calcium (TC), Ca++, blood pressure (MAP), venous pressure (CVP), pulmonary wedge pressure (PWP), cardiac output (CO), heart work (LVSW), systemic resistance (SPR), and pulmonary resistance (PVR) were measured before, during (15 and 30 minutes), and after (60 minutes) a 30-minute infusion of 1 gm CaCl2 (13.7 mEq). Calcium chloride infusion increased Ca++ significantly at 15 and 30 minutes (2.2 +/- 0.25 mEq/L) and remained elevated at 60 minutes (2.12 +/- 0.24). Cardiac output and LVSW rose at 15 minutes (9.4 leads to 10.6 L/min; 98 leads to 115 gm-m) but fell to below preinfusion levels by 60 minutes (8.9 +/- 2.0 L/min and 92 +/- 30 gm-m, respectively). These data show that calcium infusion for hypocalcemia does not provide meaningful improvement in cardiovascular function and is best avoided unless left heart function is closely monitored.