Pharmacokinetics and burn eschar penetration of intravenous ciprofloxacin in patients with major thermal injuries

Adequate penetration of antibiotics into burn tissue and maintenance of effective serum levels are essential for the treatment of patients sustaining major thermal injuries. The pharmacokinetics and burn eschar penetration of intravenous ciprofloxacin were determined in 12 critically ill patients with burn injuries. Mean age for the 12 patients was 45 +/- 17 (range 25-82 years), total body surface area burned (TBSAB) = 38 +/- 15% and Acute Physiology and Chronic Health Evaluation (APACHE) II score = 8 +/- 6. Patients received recommended doses of ciprofloxacin, 400 mg q12h iv, for three doses beginning 72 h post-burn. Serum concentrations were measured at t = 0, 0.25, 0.5, 0.75, 1.0, 1.25, 1.5, 2.0, 4.0 and 12.0 h after the first and third doses. Burn eschar biopsies were obtained after the third ciprofloxacin dose. Three of these 12 patients (25%) manifested later signs of clinical sepsis (TBSAB = 61 +/- 6% and APACHE II score = 11 +/- 3) and underwent a second infusion of three doses of intravenous ciprofloxacin, blood sampling and eschar biopsy. Serum and eschar concentrations were determined by high performance liquid chromatography. Serum ciprofloxacin concentrations were comparable to those of normal volunteers (C(max) = 4.0 +/- 1 mg/L and AUC = 11.4 +/- 2 mg.h/L) during the immediate post-burn period after dose 1 (C(max1) = 4.8 +/- 3 mg/L and AUC(0-12) = 12.5 +/- 7 mg. h/L) and dose 3 (C(max3) = 4.9 +/- 2 mg/L and AUC(24-36) = 17.5 +/- 11 mg.h/L). Mean burn eschar concentration during the 72 h post-burn was significantly lower than that found during clinical sepsis (18 +/- 17 compared with 41.3 +/- 54 microg/g; P < 0.05 by t test). Similar serum concentrations were achieved in patients with clinical sepsis (C(max1) = 4.2 +/- 0.2 mg/L and AUC(0-12) = 15.0 +/- 3 mg. h/L; C(max3) = 5.0 +/- 1 mg/L and AUC(24-36) = 22.8 +/- 9 mg.h/L). A positive correlation between burn eschar concentrations and C(max) (r = 0.71, r(2) = 0.51, P = 0.01) was found by linear regression analysis. A C(max)/MIC ratio > 10 (MIC = 0.5 mg/L) and an AUC/MIC ratio > 100 SIT(-1).h (serum inhibitory titre) (MIC = 0.125 mg/L) were achieved. High burn eschar concentrations and serum levels, similar to those found in normal volunteers, can be achieved after intravenous ciprofloxacin infusion in critically ill burns patients.

The epidemic of cocaine-related juxtapyloric perforations: with a comment on the importance of testing for Helicobacter pylori

OBJECTIVE

This is a report of 50 consecutive patients with juxtapyloric perforations after smoking "crack" cocaine (cocaine base) at one urban public hospital.

SUMMARY BACKGROUND DATA

Although the exact causal relation between smoking crack cocaine and a subsequent juxtapyloric perforation has not been defined, surgical services in urban public hospitals now treat significant numbers of male addicts with such perforations. This report describes the patient set, presentation, and surgical management and suggests a possible role for Helicobacter pylori in contributing to these perforations.

METHODS

A retrospective chart review was performed, supplemented by data from the patient log in the department of surgery.

RESULTS

From 1994 to 1998, 50 consecutive patients (48 men, 2 women) with a mean age of 37 had epigastric pain and signs of peritonitis a median of 2 to 4 hours (but up to 48 hours) after smoking crack cocaine. A history of chronic smoking of crack as well as chronic alcohol abuse was noted in all patients; four had a prior history of presumed ulcer disease in the upper gastrointestinal tract. Free air was present on an upright abdominal x-ray in 84% of patients, and all underwent operative management. A 3- to 5-mm juxtapyloric perforation, usually in the prepyloric area, was found in all patients. Omental patch closure was used in 49 patients and falciform ligament closure in 1. Two patients underwent parietal cell vagotomy as well. In the later period of the review, antral mucosal biopsies were performed through the juxtapyloric perforation in five patients. Urease testing was positive for infection with H. pyonri in four, and these patients were prescribed appropriate antimicrobial drugs.

CONCLUSIONS

Juxtapyloric perforations after the smoking of crack cocaine occur in a largely male population of drug addicts who are 8 to 10 years younger than the patient group that historically has perforations in the pyloroduodenal area. These perforations are usually 3 to 5 mm in diameter, and an antral mucosal biopsy for subsequent urease testing should be performed if the location and size of the ulcer allow this to be done safely. Omental patch closure is appropriate therapy for patients without a history of prior ulcer disease; antimicrobial therapy and omeprazole are prescribed when H. pylori is present.

Cost and morbidity associated with antibiotic prophylaxis in the ICU

BACKGROUND

Although the high cost and inappropriate use of antibiotics have been documented before, we are not aware of any data on nonsurgical site infectious morbidity associated with prolonged courses of prophylactic antibiotics (PA).

STUDY DESIGN

Data regarding antibiotic orders were collected using a custom designed microbiology database in the Surgical Intensive Care Unit of a teaching hospital from October 1, 1995 through April 30, 1997. The database was retrospectively reviewed. The cost of PA in excess of 1 day was calculated. Frequency of bacteremia and line infections were compared in patients receiving 1 day or less of PA versus more than 4 days of PA.

RESULTS

Sixty-one percent of PA orders were continued for more than 1 day. Cost of PA beyond 1 day totaled $44,893. Bacteremia and line infection were more frequent in the patients receiving more than 4 days of PA.

CONCLUSIONS

There was poor compliance with the protocol of stopping PA at 24 hours. The cost of noncompliance was $44,893. There were more bacteremias and line infections in patients with duration of PA of more than 4 days.

Management of casualties from the bombing at the centennial olympics

BACKGROUND

The explosion of a bomb 75 to 100 yards away from attendees at a concert who were in the process of being evacuated from Centennial Olympic Park at approximately 1:25 AM on July 27, 1996, resulted in a multiple-casualty event involving primarily four hospitals in proximity to the blast. The purpose of this study was to review triage and care of the victims, emphasizing those with significant injuries.

METHODS

Retrospective review of triage and care of injured patients.

RESULTS

Ninety-six of the 111 victims of the blast were triaged in the first half hour to four hospitals within 3 miles of the bombing. Only four minor operations were performed in 61 patients evaluated at community hospitals. Ten of 35 patients evaluated at the regional trauma center underwent emergency or urgent operations, and all who were seriously injured did well.

CONCLUSIONS

Although overtriage to the regional trauma center occurred, outcome was excellent in all seriously injured victims treated there.

Empiric therapy of sepsis in the surgical intensive care unit with broad-spectrum antibiotics for 72 hours does not lead to the emergence of resistant bacteria

BACKGROUND

It is our practice to treat suspected sepsis with imipenem/cilastatin and gentamicin (IMP/GENT) for 72 hours while awaiting culture results. We wanted to determine if this practice engenders antimicrobial resistance.

METHODS

Review of prospectively collected data regarding use of IMP/GENT and microbial sensitivity to imipenem/cilastatin during the first and last 7 months of a 19-month study period (October 1, 1995, to April 30, 1997).

RESULTS

The susceptibility of appropriate organisms to imipenem/cilastatin was 76% in the early period and 80% in the late period (p = 0.42). Pseudomonas aeruginosa was more susceptible in the late period (88 vs. 62%; p = 0.007). Resistance to gentamicin (30% early vs. 21% late; p = 0.02) and representative cephalosporins (cefoxitin, 52% early vs. 61% late; p = 0.35; ceftazidime, 26% early vs. 23% late; p = 0.76) did not develop during the study period. The incidence of fungemia was the same in both periods (4 of 467 admissions vs. 3 of 599 admissions; p = 0.48).

CONCLUSION

This protocol did not lead to the emergence of resistant bacteria.

Laparoscopic cholecystectomy in cirrhotic patients

BACKGROUND

Reported mortality for open cholecystectomy in patients with cirrhosis ranges from 10% to 80%. Laparoscopic cholecystectomy has gained acceptance in the general population and has become the procedure of choice for symptomatic cholelithiasis. We reviewed our experience with the use of laparoscopic cholecystectomy in this group.

STUDY DESIGN

We did a retrospective review of the records of 25 consecutive laparoscopic choleoystectomy procedures performed on cirrhotic patients from May 1992 to July 1996.

RESULTS

There were no mortalities in our group. All procedures were completed laparoscopically. Mean length of stay was 1.7 days (range, 1 to 8 days). Morbidity consisted of wound hematomas, pneumonia, and ascites for a rate of 32%. Only patients with Child's Class A and Class B cirrhosis were operated on.

CONCLUSIONS

Laparoscopic cholecystectomy can be performed safely in cirrhotic patients with well compensated liver function.

Spinal cord injuries in adolescents after gunshot wounds: an increasing phenomenon in urban North America

While much attention is focused on firearm fatalities, the purpose of this study was to determine the expense of acute medical care and the rehabilitation experience of surviving adolescent patients in the USA with spinal cord injury secondary to gunshot wounds. We analyzed a cohort of 19 patients, 18 of whom survived 12 months after spinal cord injury. The need for primary medical care related to the injury, current work and scholastic status, and satisfaction with the quality of rehabilitation were determined. Ten were not involved in any type of academic or meaningful activity, five had returned to school, three were undergoing rehabilitation, and one patient died. Major complications were present in 14 of the 18 patients. Thus, despite a high survival rate after spinal cord injury in this USA population, considerable long-term disability persists, and survivors report a low level of satisfaction with life.

Can surgeons evaluate emergency ultrasound scans for blunt abdominal trauma?

OBJECTIVE

To determine whether surgeons and residents with minimal training can evaluate accurately emergency ultrasound (US) examinations compared with radiologists for blunt abdominal trauma.

METHODS

Over 7 months, we conducted a prospective study comparing the evaluation of emergency US for blunt abdominal trauma by surgeons and attending radiologists. US readings from the surgical team and the radiologists were correlated with outcome.

RESULTS

One hundred-twelve patients were included in the study. Ninety-two patients had an US read as negative by the surgical and radiology services with no subsequent injuries identified. Eighteen patients had an US deemed positive by the surgical service and radiologists. Injuries were confirmed in this group by operation or computed tomography. One patient had an US deemed positive by the surgical team and subsequently negative by the radiologist. A diagnostic peritoneal lavage was performed which was negative. Another patient had an US interpreted as negative by the surgical evaluator and positive by the radiologist. Exploratory laparotomy was negative for intraabdominal hemorrhage or organ injury. Overall results reveal an accuracy on US reading of 99% for the surgical team and 99% for the attending radiologists.

CONCLUSION

Surgeons and surgical residents at different levels of training can accurately interpret emergency ultrasound examinations for blunt trauma from the real-time images, at a level comparable to attending radiologists.

Rapid detection of traumatic effusion using surgeon-performed ultrasonography

BACKGROUND

In the injured patient, rapid assessment of the thorax can yield critical information for patient management and triage.

OBJECTIVES

The objectives of this prospective study were (1) to determine if experienced surgeon sonographers could successfully use a focused thoracic ultrasonographic examination to detect traumatic effusion, and (2) to compare the accuracy and efficiency of ultrasonography with supine portable chest radiography.

METHODS

Surgeon-sonographers performed thoracic ultrasonographic examinations on patients with blunt and penetrating torso injuries during the Advanced Trauma Life Support secondary survey. All patients also underwent portable chest radiography. Performance times for ultrasonography and chest radiography were recorded. Comparisons were made of the performance times and accuracy of both tests in detecting traumatic effusion.

RESULTS

In 360 patients, there were 40 effusions, 39 of which were detected by ultrasonography and 37 of which were detected by chest radiography. The 97.5% sensitivity and 99.7% specificity observed for thoracic ultrasonography were similar to the 92.5% sensitivity and 99.7% specificity for portable chest radiography. Performance time for ultrasonography was significantly faster than that for chest radiography (1.30 +/- 0.08 vs. 14.18 +/- 0.91 minutes, p < 0.0001).

CONCLUSION

Surgeons can accurately perform and interpret a focused thoracic ultrasonographic examination to detect traumatic effusion. Surgeon-performed thoracic ultrasonography is as accurate but is significantly faster than supine portable chest radiography for the detection of traumatic effusion.

A reappraisal of the role of Gram's stains of tracheal aspirates in guiding antibiotic selection in the surgical intensive care unit

BACKGROUND

Tracheal aspirate Gram's stains are used to guide antibiotic selection in empiric pneumonia treatment in the surgical intensive care unit (SICU). We questioned whether Gram's stains predict the organism cultured.

METHODS

A retrospective review of prospectively collected data.

RESULTS

Gram's stains correlated with the cultured organism in 284 of 543 (52%) SICU cultures and in 226 of 403 (56%) trauma intensive care unit (TICU) cultures. Gram-negative rod (GNR) stains yielded GNR organisms in 182 of 205 (89%) SICU cultures and in 160 of 176 (91%) TICU cultures. Gram-positive coccus (GPC) stains yielded GPC organisms in 75 of 228 (33%) SICU cultures and in 52 of 149 (35%) TICU cultures. Noncorrelates in the GPC group were predominantly GNRs (185 of 250 (74%)).

CONCLUSION

When the clinical decision has been made that empiric antibiotic coverage is necessary, GNR coverage should be instituted regardless of Gram's stain result. The decision to institute GPC coverage needs to be supported by clinical data other than the Gram's stain.

Trends in resident experience in open and laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy (OC) as the most common operation for gallbladder disease. Our goal was to determine the effect of this phenomenon on resident training in biliary surgery. The numbers of all cholecystectomies (ACs), OCs, LCs, and advanced procedures (common bile duct exploration and choledochoscopy, (CBDE) performed by residents during academic years 1989 to 1994 were examined. Trends for the residency as a whole and for each cohort of residents completing the program were studied. The number of LCs performed by the residency as a whole per academic year over the 1989 to 1994 period has increased, whereas the number of OCs decreased. The net effect of these trends was an increase in the number of ACs. Although the percentage of LCs performed by postgraduate year 1, 2, and 3 residents (juniors) increased over the study period, the proportion of OCs and ACs performed by this group decreased. For each cohort of residents completing training in the years 1989 through 1994, the number of ACs and LCs performed increased, whereas the number of OCs decreased. Experience in CBDE for the residency as a whole and for the cohort was stable. In conclusion, experience in ACs and LCs has increased, and experience in OCs has decreased. Also, experience in biliary surgery has shifted to the senior level.

Spontaneous rupture of abdominal aortic aneurysms in patients with non-related blunt traumatic injuries

As the population ages, abdominal aneurysms are expected to increase in frequency, as well as in the number of elderly patients involved in automobile trauma. Therefore, the number of incidental abdominal aortic aneurysms found in elderly trauma patients should be expected to rise. The purpose of this paper is to report two cases of ruptured abdominal aortic aneurysms found after nonassociated blunt trauma. We review the literature and discuss possible etiologic factors and management associated with this problem.

Penetrating trauma secondary to heterotopic ossification in a laparatomy scar: a case report

Heterotopic ossification is a common complication of numerous procedures, including abdominal operation, but traumatic perforation by such ossification is extremely rare. A 45-year-old man suffered traumatic perforation of the jejunum by ossification in a laparotomy scar. The diagnosis was made only at operation. The calcified mass was completely excised and the patient made a smooth recovery. The authors caution that the ossification may recur, and they recommend that such ossifications be removed electively if they are symptomatic or if their morphology is such that any viscera are at risk of perforation.

Utility of admission chemistry and coagulation profiles in trauma patients: a reappraisal of traditional practice

To determine whether abnormal results of admission serum chemistry profiles (P7: sodium (Na), potassium (K), chloride (Cl), carbon dioxide content (CO2), blood urea nitrogen (BUN), creatinine (Cr), and glucose (GLU), amylase (AMY), and coagulation profiles (CP: prothrombin time (PT) and partial thromboplastin time (PTT) in trauma patients lead to clinical interventions, and to characterize frequency of abnormal results, we prospectively gathered laboratory data on 500 consecutive patients seen in our Level 1 trauma center. Clinicians were blinded to the study. Abnormal results were found in 93% of P7s, 7% of AMYs, and 59% of CPs. Interventions were made for < 1% of abnormal P7s, 0% of abnormal amylase, and 5% of patients with abnormal CP. We conclude that information provided by routine admission chemistry and coagulation profiles in trauma patients seldom lead to clinical interventions. These tests should not be ordered routinely on admission in trauma patients.

1,000 consecutive ultrasounds for blunt abdominal trauma

Diagnostic peritoneal lavage (DPL) and computed tomography (CT) are the primary diagnostic modalities used in the evaluation of patients with suspected blunt abdominal trauma (BAT). DPL is fast and accurate but is associated with complications. CT is also accurate, yet requires stability and transportability of the patients. Ultrasound (US) has been suggested as an aid in evaluating BAT. We evaluated US in the initial assessment of BAT in 1000 patients. Patients were eligible for the study if they met specified trauma criteria and had suspected BAT. We then followed the outcome of the patients and their further work-up. US showed a sensitivity of 88%, a specificity of 99%, and an accuracy of 97% for detecting intraabdominal injuries. We conclude that emergency ultrasound may be used as the initial diagnostic modality for suspected blunt abdominal trauma.

Laparoscopic colostomy for a gunshot wound to the rectum

The role of laparoscopy in the management of trauma patients is evolving. We describe a case of a laparoscopically created colostomy for treatment of a gunshot wound to the rectum.

Laparoscopic repair of a gunshot wound to the diaphragm: a case report

The application of laparoscopy to the surgery of trauma is rapidly expanding. We report a case of laparoscopic repair of a gunshot wound to the right diaphragm. We discuss a technique for repair, as well as a method to create and maintain pneumoperitoneum while avoiding tension pneumothorax.