Percutaneous Tracheostomy under Bronchoscopic Visualization Does Not Affect Short-Term or Long-Term Complications

Percutaneous tracheostomy is a safe and effective bedside procedure. Some advocate the use of bronchoscopy during the procedure to reduce the rate of complications. We evaluated our complication rate in trauma patients undergoing percutaneous tracheostomy with and without bronchoscopic guidance to ascertain if there was a difference in the rate of complications. A retrospective review of all tracheostomies performed in critically ill trauma patients was performed using the trauma registry from an urban, Level I Trauma Center. Bronchoscopy assistance was used based on surgeon preference. Standard statistical methodology was used to determine if there was a difference in complication rates for procedures performed with and without the bronchoscope. From January 2007, to April 2016, 649 patients underwent modified percuteaneous tracheostomy; 289 with the aid of a bronchoscope and 360 without. There were no statistically significant differences in any type of complication regardless of utilization of a bronchoscope. The addition of bronchoscopy provides several theoretical benefits when performing percutaneous tracheostomy. Our findings, however, do not demonstrate a statistically significant difference in complications between procedures performed with and without a bronchoscope. Use of the bronchoscope should, therefore, be left to the discretion of the performing physician.

Percutaneous Tracheostomy under Bronchoscopic Visualization Does Not Affect Short-Term or Long-Term Complications

Percutaneous tracheostomy is a safe and effective bedside procedure. Some advocate the use of bronchoscopy during the procedure to reduce the rate of complications. We evaluated our complication rate in trauma patients undergoing percutaneous tracheostomy with and without bronchoscopic guidance to ascertain if there was a difference in the rate of complications. A retrospective review of all tracheostomies performed in critically ill trauma patients was performed using the trauma registry from an urban, Level I Trauma Center. Bronchoscopy assistance was used based on surgeon preference. Standard statistical methodology was used to determine if there was a difference in complication rates for procedures performed with and without the bronchoscope. From January 2007, to April 2016, 649 patients underwent modified percuteaneous tracheostomy; 289 with the aid of a bronchoscope and 360 without. There were no statistically significant differences in any type of complication regardless of utilization of a bronchoscope. The addition of bronchoscopy provides several theoretical benefits when performing percutaneous tracheostomy. Our findings, however, do not demonstrate a statistically significant difference in complications between procedures performed with and without a bronchoscope. Use of the bronchoscope should, therefore, be left to the discretion of the performing physician.

Incidence and Outcomes of Critical Illness-Related Corticosteroid Insufficiency in Trauma Patients

The spectrum of critical illness-related corticosteroid insufficiency (CIRCI) in trauma is not fully defined. This study describes our trauma experience with hydrocortisone-treated patients experiencing CIRCI. We conducted a 5-year retrospective analysis from a Level II trauma center using biochemical and clinical criteria for adrenal insufficiency. Seventy patients met the inclusion criteria for CIRCI. There was a 34 per cent mortality rate despite therapy. Nonsurvivors were older with larger admission base deficits and experienced higher rates of sepsis, bacteremia, and pneumonia. Nonsurvivors had prolonged vent days (mean 53 ± 64 days) when compared with survivors (mean 30 ± 22 days; P = 0.029). Renal replacement therapy was a strong predictor of mortality. Spinal cord-injured patients had high Injury Severity Scores (mean 34 ± 18), elevated baseline Cortisol levels (mean 56 ± 84 vs 18 ± 14; P = 0.004), and required prolonged duration of steroid therapy (30 ± 52 vs 15 ± 15 days; P = 0.080) when compared with the nonspinal cord-injured group. Our data suggest that CIRCI in trauma is associated with significant mortality and morbidity even when patients are treated appropriately.

Incidence and outcomes of critical illness-related corticosteroid insufficiency in trauma patients

The spectrum of critical illness-related corticosteroid insufficiency (CIRCI) in trauma is not fully defined. This study describes our trauma experience with hydrocortisone-treated patients experiencing CIRCI. We conducted a 5-year retrospective analysis from a Level II trauma center using biochemical and clinical criteria for adrenal insufficiency. Seventy patients met the inclusion criteria for CIRCI. There was a 34 per cent mortality rate despite therapy. Nonsurvivors were older with larger admission base deficits and experienced higher rates of sepsis, bacteremia, and pneumonia. Nonsurvivors had prolonged vent days (mean 53 ± 64 days) when compared with survivors (mean 30 ± 22 days; P = 0.029). Renal replacement therapy was a strong predictor of mortality. Spinal cord-injured patients had high Injury Severity Scores (mean 34 ± 18), elevated baseline cortisol levels (mean 56 ± 84 vs. 18 ± 14; P = 0.004), and required prolonged duration of steroid therapy (30 ± 52 vs. 15 ± 15 days; P = 0.080) when compared with the nonspinal cord-injured group. Our data suggest that CIRCI in trauma is associated with significant mortality and morbidity even when patients are treated appropriately.

Retrievable Inferior Vena Cava Filters: Initial Clinical Results

Anticoagulation is the accepted therapy for patients with thromboembolic disease. When contraindications to anticoagulant therapy are present, however, interruption of the inferior vena cava (IVC) may prevent pulmonary embolism (PE). The objective of this study was to report our early technical and clinical results with retrievable IVC filters (IVCFs) for the prevention of PE. One hundred and twenty-seven multitrauma patients between December 1, 2002, and December 31, 2004, underwent placement of Gunther-Tulip (n = 49), Recovery (n = 41), or OptEase (n = 37) retrievable IVCFs under real-time intravascular ultrasound (IVUS) guidance. All patients had abdominal X-rays to verify filter location. Prior to IVCF retrieval, all patients underwent femoral vein color flow ultrasonography to rule out deep vein thrombosis (DVT) and vena-cavography to assess the IVCF for trapped emboli, filter tilt, or retrained thrombus. Thirty-nine patients died of their injuries; no deaths were related to IVCF placement. One PE occurred during follow-up after filter retrieval, and two femoral vein insertion-site DVTs occurred. One hundred twenty (94.4%) of IVCFs were placed without complication at the L2-3 level, as verified by abdominal X-rays. Filter-related complications included three groin hematomas (2.9%) and three IVCFs misplaced in the right iliac vein early in our experience (2.3%); these filters were uneventfully retrieved and replaced in the IVC within 24 hr. Sixty-six patients underwent uneventful retrieval of IVCFs after DVT or PE anticoagulation prophylaxis was initiated. Forty-five IVCFs were not removed: 41 due to contraindications due to anticoagulation and four because of trapped thrombus within the filter. The role of retrievable IVCFs continues to evolve, but in this study of 127 patients, prophylactic temporary IVCF placement was simple and safe, prevented fatal PE, and served as an effective "bridge" to anticoagulation. Further investigation of this bedside IVUS technique and the role of temporary IVCFs in different patient populations is warranted.

Role of prophylactic temporary inferior vena cava filters placed at the ICU bedside under intravascular ultrasound guidance in patients with multiple trauma

OBJECTIVE

Patients with multiple trauma often have injuries that preclude the use of anticoagulation therapy or sequential compression device prophylaxis. Temporary inferior vena cava (IVC) filters (IVCFs) offer protection against pulmonary embolism during the early immediate injury and perioperative period, when risk is highest, while averting potential long-term sequelae of permanent IVCFs. The objective of this study was to evaluate the efficacy of prophylactic, temporary IVCF placement at the intensive care unit bedside under real-time intravascular ultrasound (IVUS) guidance in patients with multiple trauma.

INTERVENTIONS

Ninety-four patients with multiple trauma seen between July 1, 2002, and November 1, 2003, underwent placement of OptEase (Cordis Endovascular) retrievable IVCFs under real-time IVUS guidance. Mean (+/-SD) Injury Severity Score was 25.1 +/- 2.2). Abdominal x-ray films were obtained in all patients to verify filter location. Before IVCF retrieval all patients underwent femoral vein color-flow ultrasound scanning to rule out deep vein thrombosis (DVT), and pre-procedure and post-procedure vena cavography to identify possible IVCF thrombus entrapment and post-retrieval inferior vena cava injury.

RESULTS

Nineteen patients died of their injuries; no deaths were related to IVCF placement. One pulmonary embolism occurred during follow-up after filter retrieval, and 1 insertion site femoral vein DVT occurred. As verified on abdominal x-ray films, 96.8% (91 of 94) of IVCFs were placed without complications at the L2-3 level. Filter-related complications included 2 groin hematomas (2.1%) and 3 IVCFs misplaced in the right iliac vein (3.2%), early in our experience; the filters were uneventfully retrieved and replaced in the inferior vena cava within 24 hours. Thirty-one patients underwent uneventful retrieval of IVCFs after DVT or pulmonary embolism anticoagulation prophylaxis was initiated. Forty-four filters were not removed, 41 because severity of injury prevented DVT or pulmonary embolism prophylaxis and 3 because of thrombus trapped within the filter.

CONCLUSIONS

Prophylactic, temporary IVCF placement at the intensive care unit bedside under IVUS guidance in patients with multiple trauma is simple and safe, and serves as an effective "bridge" to anticoagulation therapy until venous thromboembolism prophylaxis can be initiated. Further investigation of this bedside technique and the role of temporary IVCFs in patients with multiple trauma is warranted.

CLINICAL RELEVANCE

Patients with multiple trauma often have injuries that preclude the use of anticoagulation therapy or sequential compression device prophylaxis. Temporary inferior vena cava filters (IVCFs) offer protection against pulmonary embolism during the perioperative and immediate injury period, when risk is highest. Ninety-four patients with multiple trauma underwent prophylactic, temporary IVCF placement at the intensive care unit bedside under real-time intravascular ultrasound. One pulmonary embolism occurred during follow-up after filter retrieval, and 1 insertion site femoral vein deep venous thrombosis occurred. Ninety-one of 94 IVCFs (96.8%) were placed without complication. Thirty-one patients underwent uneventful retrieval of IVCFs after anticoagulation prophylaxis was initiated. Forty-four filters were not removed, because of severity of injury (n = 41) or because of trapped thrombus within the filter (n = 3). Prophylactic, temporary IVCFs placed under intravascular ultrasound guidance at the bedside in patients with multiple trauma is simple, safe, and an effective bridge to anticoagulation therapy.

Real-Time Intravascular Ultrasound-Guided Placement of a Removable Inferior Vena Cava Filter

BACKGROUND

Reports have demonstrated the benefit of prophylactic inferior vena cava filter (IVCF) placement to prevent pulmonary embolism. This series evaluates the potential for the bedside placement of a removable IVCF under "real-time" intravascular ultrasound (IVUS) guidance.

METHODS

Twenty trauma patients underwent intensive care unit placement of a removable IVCF with IVUS guidance. All patients had ultrasonography of the femoral veins after placement to rule out postprocedure femoral vein thrombosis and radiographs to identify filter location.

RESULTS

Nineteen of 20 IVCFs were placed at approximately the L2 level as verified by radiography. One patient had a large IVC (34 mm) and underwent bilateral common iliac IVCF placement under IVUS. Within 3 weeks of placement, 12 IVCFs were retrieved. Of the remaining eight patients, six had indications for permanent implantation, two had contralateral deep venous thrombosis, and one had ipsilateral deep venous thrombosis.

CONCLUSION

Bedside insertion of a removable IVCF with IVUS guidance and its removal are simple, safe, and accurate.

Primary duodenal low-grade mucosa-associated lymphoid tissue lymphoma presenting with outlet obstruction

Low-grade lymphoma arising in mucosa-associated lymphoid tissue (MALT) of the duodenum represents a very rare neoplasm. We report an unusual presentation of primary duodenal MALT lymphoma in a 78-year-old man. The patient initially presented with a suspected pulmonary embolus and was anticoagulated, which precipitated a major gastrointestinal hemorrhage. A large atypical ulcer with narrowing of the duodenum beyond the bulb was seen on endoscopy. Biopsies revealed atypical lymphoid cells. Abdominal CT scan revealed a mass in either the duodenum or head of the pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, which revealed a normal pancreatic duct with a large calculus in the common bile duct, which was extracted after sphincterotomy. Elective surgery was planned for suspected lymphoma of the duodenum. The patient developed severe nausea, vomiting, and fullness after meals. The patient underwent pancreaticoduodectomy for a neoplastic mass causing duodenal obstruction. Pathological examination of the resected specimen revealed a low-grade B-cell lymphoma (MALToma) arising in the duodenum and invading the pancreas. Flow cytometry confirmed the phenotype typical of MALT lymphoma. Celiac, peripancreatic, pelvic, and cervical nodes were also involved with tumor. Bone marrow was also positive for metastasis. The patient was postoperatively treated with chemotherapy for stage IV disease.

Multiple myeloma in a patient with hoarseness, dysphagia, aspiration, and cervical lymphadenopathy

Multiple myeloma, which primarily affects the elderly, is rare in the head and neck. We report the case of a 71-year-old man who came to us with hoarseness, dysphagia, intermittent aspiration, and cervical lymphadenopathy. Our work-up included laboratory tests, radiographic examinations, analysis of bone marrow aspiration, and histopathologic evaluations. Cervical lymph node biopsy confirmed a diagnosis of multiple myeloma. Despite treatment with chemotherapy and radiation, the patient died of his disease 6 months later.

Multiple Myeloma in a Patient with Hoarseness, Dysphagia, Aspiration, and Cervical Lymphadenopathy

Multiple myeloma, which primarily affects the elderly, is rare in the head and neck. We report the case of a 71-year-old man who came to us with hoarseness, dysphagia, intermittent aspiration, and cervical lymphadenopathy. Our work-up included laboratory tests, radiographic examinations, analysis of bone marrow aspiration, and histopathologic evaluations. Cervical lymph node biopsy confirmed a diagnosis of multiple myeloma. Despite treatment with chemotherapy and radiation, the patient died of his disease 6 months later.

Retrohepatic vena cava and hepatic vein injuries: a simplified experimental methods of treatment by balloon shunt

BACKGROUND

Fecal contamination from colon injury has been thought to be the most significant factor for the development of surgical site infection (SSI) after trauma. However, there are increasing data to suggest that other factors may play a role in the development of postinjury infection in patients after colon injury. The purpose of this study was to determine the impact of gastric wounding on the development of SSI and nonsurgical site infection (NSSI) in patients with colon injury.

METHODS

Post hoc analysis was performed on data prospectively collected for 317 patients presenting with penetrating hollow viscus injury. One hundred sixty-two patients with colon injury were subdivided into one of three groups: patients with isolated colon wounds (C), patients with colon and stomach wounds with or without other organ injury (C+S), and patients with colon and other organ injury but no stomach injury (C-S) and assessed for the development of SSI and NSSI. Infection rates were also determined for patients who sustained isolated gastric injury (S) and gastric injury in combination with organ injuries other than colon (S-C). Penetrating Abdominal Trauma Index, operative times, and transfusion were assessed. Discrete variables were analyzed by Cochran-Mantel-Haenszel chi2 test and Fisher's exact test. Risk factor analysis was performed by multivariate logistic regression.

RESULTS

C+S patients had a higher rate of SSI infection (31%) than C patients (3.6%) (p = 0.008) and C-S patients (13%) (p = 0.021). Similarly, the incidence of NSSI was also significantly greater in the C+S group (37%) compared with the C patients (7.5%) (p = 0.07) and the C-S patients (17%) (p = 0.019). There was no difference in the rate of SSI or NSSI between the C and C-S groups (p = 0.3 and p = 0.24, respectively). The rate of SSI was significantly greater in the C+S patients when compared with the S-C patients (31% vs. 10%, p = 0.008), but there was no statistical difference in the rate of NSSI in the C+S group and the S-C group (37% vs. 24%, p = 0.15).

CONCLUSION

The addition of a gastric injury to a colon injury has a synergistic effect on the rate of postoperative infection.

Malignant Duodenal Somatostatinoma Presenting in Association with von Recklinghausen Disease

Somatostatinomas are extremely rare periampullary malignant neuroendocrine tumors that may be associated with von Recklinghausen disease or type-I neurofibromatosis. Duodenal somatostatinomas are distinguished from pancreatic somatostatinomas by their frequent association with type-I neurofibromatosis and typically absence of somatostatinoma syndrome. We report a very rare and atypical case of malignant duodenal somatostatinoma presenting with somatostatinoma syndrome in association with type-I neurofibromatosis.

Malignant duodenal somatostatinoma presenting in association with von Recklinghausen disease

Somatostatinomas are extremely rare periampullary malignant neuroendocrine tumors that may be associated with von Recklinghausen disease or type-I neurofibromatosis. Duodenal somatostatinomas are distinguished from pancreatic somatostatinomas by their frequent association with type-I neurofibromatosis and typically absence of somatostatinoma syndrome. We report a very rare and atypical case of malignant duodenal somatostatinoma presenting with somatostatinoma syndrome in association with type-I neurofibromatosis.

Parathyroid cysts: a case report and review of the literature

OBJECTIVES/HYPOTHESIS

Parathyroid cysts are rare clinical entities. They frequently present as a clinical diagnostic problem. They may mimic solitary thyroid nodules. The purpose of the study was to review the literature and present a case of a 22-year-old euthyroid woman presenting with recurrent swelling in the neck. Her complaints included choking and dysphagia. Fine-needle aspiration of the mass revealed clear, watery fluid with an extremely high level of calcium and c-terminal midmolecule parathyroid hormone assay in excess of 8000 pg/mL. Treatment consisted of neck exploration and removal of a 6 x 5-cm cystic encapsulated mass. Pathological diagnosis revealed a benign parathyroid cyst. The role of needle aspiration in diagnosing thyroid masses and the importance of parathyroid hormone assay in diagnosing parathyroid cyst are emphasized.

The Chest Radiograph in Critically Ill Surgical Patients is Inaccurate in Predicting Ventilator-Associated Pneumonia

Chest radiographs (CXRs) are frequently obtained in surgical intensive care unit (SICU) patients when a diagnosis of ventilator-associated pneumonia (VAP) is suspected. The purpose of this study was to determine if the interpretation of the CXR correlated with a diagnosis of VAP in SICU patients. Prospective evaluation of 20 SICU patients clinically suspected of VAP was performed from July 1997 through December 1998. All patients required mechanical ventilation for at least 48 hours, and antibiotic use was discontinued 24 hours before entry into the study. Bronchoscopy with protected specimen brush (PSB) sampling of secretions from the right and left lung was performed. A positive PSB was present if quantitative analysis yielded ≥104 colony-forming units/mL of bacteria. VAP was diagnosed if either the right or left PSB was positive and ruled-out if both the right and left PSB yielded <104 colony-forming units/mL. Twelve of 20 patients (60%) were diagnosed to have VAP by PSB criteria. Eight of 20 patients (40%) had CXRs interpreted as negative for infiltrates; four patients had VAP by PSB criteria. There were four patients with focal infiltrates; two patients had VAP. The remaining eight patients had radiographs interpreted as bilateral infiltrates (one) or pulmonary edema (seven); of these, six patients (75%) had VAP. The sensitivity of the CXR in determining the presence of VAP was 25 per cent, the specificity was 75 per cent, and the accuracy was 0.45. The CXR does not improve the clinician's ability to diagnose VAP: a normal CXR does not exclude the presence of VAP and the finding of a focal infiltrate does not confirm the diagnosis of VAP.

The chest radiograph in critically ill surgical patients is inaccurate in predicting ventilator-associated pneumonia

Chest radiographs (CXRs) are frequently obtained in surgical intensive care unit (SICU) patients when a diagnosis of ventilator-associated pneumonia (VAP) is suspected. The purpose of this study was to determine if the interpretation of the CXR correlated with a diagnosis of VAP in SICU patients. Prospective evaluation of 20 SICU patients clinically suspected of VAP was performed from July 1997 through December 1998. All patients required mechanical ventilation for at least 48 hours, and antibiotic use was discontinued 24 hours before entry into the study. Bronchoscopy with protected specimen brush (PSB) sampling of secretions from the right and left lung was performed. A positive PSB was present if quantitative analysis yielded > or = 10(4) colony-forming units/mL of bacteria. VAP was diagnosed if either the right or left PSB was positive and ruled-out if both the right and left PSB yielded < 10(4) colony-forming units/mL. Twelve of 20 patients (60%) were diagnosed to have VAP by PSB criteria. Eight of 20 patients (40%) had CXRs interpreted as negative for infiltrates; four patients had VAP by PSB criteria. There were four patients with focal infiltrates; two patients had VAP. The remaining eight patients had radiographs interpreted as bilateral infiltrates (one) or pulmonary edema (seven); of these, six patients (75%) had VAP. The sensitivity of the CXR in determining the presence of VAP was 25 per cent, the specificity was 75 per cent, and the accuracy was 0.45. The CXR does not improve the clinician's ability to diagnose VAP: a normal CXR does not exclude the presence of VAP and the finding of a focal infiltrate does not confirm the diagnosis of VAP.

Clinical observation of the temporal association between crack cocaine and duodenal ulcer perforation

HYPOTHESIS

To determine if a cause-effect relationship exists between crack cocaine use and duodenal ulcer perforation (DUP).

PATIENTS AND METHODS

A retrospective study was conducted of all patients undergoing emergency surgical management for peptic ulcer disease over a 6-year period at a large inner-city municipal teaching hospital. The hospital records of 78 consecutive patients presenting with complications of peptic ulcer disease between April 1990 and April 1996 were reviewed. Group A (n = 24) consisted of patients with confirmation of crack cocaine usage within 8 hours of clinical presentation; group B (n = 54) consisted of patients with no antecedent history of crack cocaine use. Demographic data, timing of drug use, clinical presentation, laboratory and radiographic findings, toxicology screening, operative findings, and postoperative course were compared between the two groups.

RESULTS

Both groups revealed a similar gender distribution, tobacco use, prior peptic ulcer symptoms, and laboratory findings. Group A patients were younger (t test, P = 0.01) and more likely to present with perforation, whereas patients in group B presented with a combination of symptoms (chi square, P = 0.03). Duodenal ulcer perforation was present in 75% of patients in group A compared with 46% of patients in group B (chi square, P = 0.04). Group B patients had a significantly longer hospital stay compared with those in group A (t test, P = 0.01). Both crack cocaine and alcohol are independent predictors of duodenal ulcer perforation.

CONCLUSIONS

Patients with recent use of crack cocaine and/or alcohol are more likely to present with duodenal perforations. Although a temporal association between crack cocaine use and duodenal ulcer perforation was demonstrated, this study does not confirm a cause-effect relationship. A prospective cohort study is needed to clarify the pathogenesis of this potential cause-effect relationship.

Necrotizing soft-tissue infections

OBJECTIVES

To evaluate the causes of necrotizing soft-tissue infections (NSTls) and to determine the outcomes of patients with NSTls.

DESIGN

A restrospective survey of the causes and factors associated with the outcomes.

SETTING

An urban community hospital serving an indigent population.

PATIENTS

A consecutive series of patients with NTSls who were treated between December 11, 1990, and December 28, 1995.

INTERVENTIONS

Patients were treated with operative debridement, intravenous antibiotics, and supportive measures.

MAIN OUTCOME MEASURES

Patient outcomes, causes, the extent of infection, the health status of the patients, causative organisms, and treatment delays.

RESULTS

Forty-five patients with NSTls were identified. Twenty-eight cases (62%) have occurred since January 13, 1994. Parenteral drug abuse, the causative event in 25 cases (56%), accounted for 21 (75%) of the 28 cases identified since January 13, 1994. Skin flora were the primary isolates in 18 (40%) of the cases; 78% of these flora were polymicrobial. Clostridial species were isolated in 8 (18%) of the cases. The overall mortality was 27%. Survivors had less extensive infections and were more stable hemodynamically than nonsurvivors. Patients with necrosis and cellulitis greater than 250 cm2 were less likely to survive than those with less extensive infections. Logistic regression analysis identified the extents of infection, the initial blood pressure, and the initial temperature as independent predictors of outcome in this patient series.

CONCLUSIONS

This is 1 of the largest reported series of patients with NSTls in which parenteral drug abuse is a prevalent causative factor. The proportion of NSTls attributable to the injection of illicit substances has increased notably in the past 2 years and has reached epidemic proportions. Survivors of NSTls had less extensive infections and were more often hemodynamically stable than nonsurvivors. Clostridial species were common in patients with NSTls related to parenteral drug abuse, underscoring the need for awareness of the potential for wound botulism in these patients.

Emerging and reemerging microbial threats. Nosocomial fungal infections

The incidence of nosocomial fungal infections had been increasing steadily for the past 25 years. Although they were once believed to be of little clinical consequence, there is now compelling evidence that fungal agents represent a bona fide microbial threat with substantial morbidity and high mortality. Reporting on a series of 30447 nosocomial fungal infections that occurred in the decade from 1980 to 1990, Beck-Sague and Jarvis noted increases in incidence from 90% to 175%. Infection rates rose from 2.0 per 1000 discharges to as high as 6.6 infections per 1000 discharges. Fungal infections increased at all major anatomic sites, including surgical wounds, lung, urinary tract, and bloodstream. Candida species accounted for 78.3% of nosocomial fungal infections, while torulopsis species and aspergillus species accounted for 7.3% and 1.3%, respectively.

Videothoracoscopy an effective method for evaluating and managing thoracic trauma patients

BACKGROUND

The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients.

METHODS

The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2).

RESULTS

The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient.

CONCLUSIONS

Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.

Laparoscopic surgery without pneumoperitoneum. A preliminary report

Laparoscopic surgery using pneumoperitoneum to create an operating field is known to have cardiopulmonary side effects. Conventional laparoscopic techniques require operating in a sealed environment. In July 1992, we initiated an investigation of the use of an electric-powered abdominal-wall lifter to expose an operating field. In our preliminary study, we have successfully completed 16 of 20 cases (80%) using this method of exposure. One trocar-related small-bowel injury was recognized immediately and repaired uneventfully. Two patients with dense adhesions made laparoscopic cholecystectomy impossible. One case of laparoscopic cholecystectomy was completed by conversion to pneumoperitoneum. Conventional instruments can be used through small incisions. Digital examination of abdominal contents can be achieved through the periumbilical incision or through other small incisions with the guidance of this retractor; this is superior to pneumoperitoneum since the surgeon can use more than just visual examination of intraabdominal pathology in laparoscopic surgery.

Gasless laparoscopy using a planar lifting technique

In clinical use, the mechanical lifting technique has demonstrated the ability to displace the abdominal wall and create a useful cavity for visualization and surgical manipulation. By forming a planar ceiling, as opposed to the domed ceiling of conventional pneumoperitoneum, the abdominal organs are brought into closer proximity of the surgeon. Instrument length may be shortened, imparting greater surgical control. Without the necessity for gas sealing, entry portals are simplified. Conventional instruments (right angle clamps) may be introduced through the fan retractor insertion sites or by way of separate stab incisions. The planar lifting technique has the potential for simplifying laparoscopy and restoring instrument control to the operating surgeon.

Cardiac injuries: analysis of an unselected series of 251 cases

Retrospective analysis was performed on the medical records of 251 patients treated for cardiac injuries at Highland General Hospital trauma facility in Alameda County, California, to identify factors that contribute to patient survival and predict death. Thirty-six patients (14%) had blunt injuries, 153 patients (61%) had gunshot wounds (GSW), and 62 patients (25%) had stab wounds. The overall survival rate was 18.7%, GSW survival was 6.5%, stab wound survival was 37.1%, and blunt injury survival was 40%. Patients who arrived with some vital signs had 62.2% survival and patients who arrived with absent vital signs had < 1% survival. Stepwise multiple logistic regression analysis revealed that for patients with absent vital signs the only significant predictor of outcome was GSW as the mechanism of injury and for patients with vital signs the ISS and the presence of combined right and left heart injuries were significant independent predictors of outcome. We conclude that the routine and aggressive use of emergency room thoracotomy for patients with penetrating cardiac injury must be re-examined.

The success of duplex ultrasonographic scanning in diagnosis of extremity vascular proximity trauma

OBJECTIVE

To determine if duplex ultrasonographic scanning is diagnostically equivalent to arteriography and/or operative exploration in the diagnosis of extremity vascular proximity trauma.

DESIGN

A prospective evaluation comparing duplex scanning with arteriography or operative exploration in 50 patients. Subsequently, duplex scanning was used alone for 175 extremity vascular proximity injuries, with other diagnostic methods used when injury was indicated on the duplex scan.

SETTING

A busy urban trauma center.

PATIENTS

Consecutive sample of 200 patients with 225 extremity injuries.

SELECTION CRITERIA

Vascular proximity injury or diminished strength of the extremity pulse.

MAIN OUTCOME MEASURES

The presence or absence of vascular proximity injury confirmed on angiography and/or operative exploration.

RESULTS

Duplex scanning had 100% sensitivity and 100% specificity compared with arteriography and/or operative exploration in the first 50 cases. In the remaining 175 cases of extremity trauma, vascular injuries were diagnosed with duplex scanning alone. Duplex scanning detected 18 injuries, 17 of which were confirmed by correlation with arteriograms and/or operative exploration. One false-positive result--spasm of the superficial femoral artery--was found on arteriography. Seven unsuspected venous injuries were also diagnosed.

CONCLUSIONS

Duplex scanning is a noninvasive, safe, effective method for the initial evaluation of potential extremity vascular proximity injury. It has replaced arteriography in the initial diagnosis of extremity vascular proximity trauma by our trauma service.

Gasless laparoscopy and conventional instruments. The next phase of minimally invasive surgery

OBJECTIVE

To assess the capability of a retractor system that permits laparoscopic surgery without pneumoperitoneum and to determine if the system facilitates the use of conventional surgical instruments during minimally invasive surgery.

DESIGN

Prospective evaluation and data collection with review.

SETTING

University-affiliated county hospital.

PATIENTS

Twenty-nine male and 29 female subjects evaluated prospectively via 27 trauma-related and 31 elective procedures.

METHODS

Fifty-eight laparoscopic procedures were performed between July 1992 and February 1993 with a system consisting of an intra-abdominal fan retractor and an electrically powered mechanical arm using conventional surgical and laparoscopic instruments.

RESULTS

Gasless laparoscopy was used in the evaluation of 27 patients with abdominal trauma (11 gunshot wounds, 11 stab wounds, and five blunt injuries). The need for celiotomy was obviated in 20 (74%) of 27 cases. Three enterotomies, two diaphragmatic lacerations, and one gastric perforation were repaired with conventional instruments. Gasless laparoscopic techniques were also used in cholecystectomy (n = 26), diagnostic laparoscopy (n = 3), and appendectomy (n = 2). Exposure similar to that obtained by pneumoperitoneum was obtained in 30 (97%) of 31 cases. One major (trocar tip enterotomy) and two superficial wound infections occurred in this group. The ability to use conventional surgical instruments was advantageous in several cases.

CONCLUSIONS

Comparable exposure was achieved in this cohort of patients with gasless laparoscopy. The use of conventional surgical instruments provides an advantage with this technique. Further improvements in abdominal wall lift systems and modification of existing surgical instruments may expand the role of gasless laparoscopy.

Negative trauma celiotomy

A retrospective review of 525 consecutive exploratory celiotomies for abdominal trauma occurring between January 1987 and June 1990 in an urban trauma center was conducted. One hundred-fifteen patients sustained blunt abdominal trauma (21%), and 410 patients sustained penetrating abdominal trauma (78%). Penetrating injuries included 260 gunshot wounds and 150 stab wounds. Patients were divided into three groups: Group A (16%), no visceral injuries identified at exploration (true negative); Group B, positive operative findings at celiotomy requiring no operative repair (10%) (nontherapeutic celiotomy); and Group C (74%), injuries encountered requiring operative repair (true positive). A positive exploration rate of 90 per cent with blunt trauma is acceptable using diagnostic techniques currently available. Similarly, a positive exploration rate of 85 per cent in gunshot wounds warrants our continued use of mandatory celiotomy. A 36 per cent combined incidence of true negatives and nontherapeutic celiotomies (Group A and B) is unacceptably high. To reduce this high incidence will require improved clinical surveillance and the controlled implementation of newer diagnostic techniques.

Autologous pericardium versus a xenograft substitute in myocardial wound healing

This study compared repair of myocardial wounds covered with autologous pericardium to healing of wounds covered with glutaraldehyde-preserved bovine pericardium in an experimental canine model. Right (RV) and left (LV) full thickness ventriculotomies were made and closed. In the control group (n = 12), the pericardium was closed over the wound; in the experimental group (n = 12), wounds were covered with bovine pericardium. Animals were sacrificed at 14, 21, 28, and 42 days. After excising the pericardium, 6 mm punch biopsies of normal RV, RV wound, normal LV, and LV wound were assayed for hydroxyproline (HPro). Both autologous and bovine pericardium became densely adherent to the wounds. Bovine pericardium was mildly adherent over unwounded areas, while autologous pericardium was usually free. Normal RV contained more than twice as much HPro as normal LV (5.4 +/- 0.57 micrograms/mg vs 1.7 +/- 0.35 micrograms/mg, P less than 0.0002). A gradual rise in HPro over time was seen in both groups, but this increase was statistically significant only at 42 days (P less than 0.05). There was no significant difference in HPro between wounds covered with autologous pericardium and those covered with bovine grafts (P = 0.13) at any of the sample times in this study. In this experimental canine model, the pericardium does not appear to play a prominent role in myocardial wound healing by contributing collagen-producing fibroblasts. Furthermore, the bovine pericardial xenograft becomes densely adherent to LV and RV incisions. In the clinical setting, such may make reoperation more hazardous when the heart has been previously incised or coronary bypass grafts have been constructed.

Biochemical (functional) adaptation of "arterialized" vein grafts

Canine venous autografts and allografts were interposed in the femoral and carotid arterial positions in 29 dogs; grafts were harvested at three postoperative intervals (1-2 weeks, 4-6 weeks, and 8-10 weeks) for light and scanning electron (SEM) microscopy and lumenal surface prostacyclin (PGI2) production. Normal veins and arteries were used as controls. Radioimmunoassay for tritiated 6-k-PGF1 alpha, the stable metabolite of PGI2, was performed using a flow surface template incubation chamber during basal and arachidonic acid stimulated conditions. Using SEM, the autografts revealed normal endothelial cell (EC) surfaces at all time intervals; conversely, allografts exhibited extensive EC loss at 1-2 weeks with gradual reparation by 10-12 weeks (such that the EC surface was virtually indistinguishable from that of control veins or autografts). PGI2 production was significantly greater in control arteries than veins (p = 0.0001). At 1-2 weeks and 4-6 weeks, lumenal production of PGI2 in both the autografts and allografts was not significantly different from control vein; however, PGI2 production after 10-12 weeks was identical to normal arterial levels (and significantly [p less than 0.0044] higher than venous levels) in both basal and stimulated conditions. Although the mechanisms responsible for this functional (biochemical) "arterialization" process remain conjectural, increased biosynthesis and/or release of PGI2 by endothelial cells, acute phase inflammatory cells (allografts) mediated by interleukin-1 or myointimal cells seems most likely. Further elucidation of these sources of PGI2 is necessary, but these data demonstrate for the first time that venous grafts placed in the arterial circulation undergo complete functional adaptation (in addition to the well known morphological changes).