FAST Enough? A Validation Study for Focused Assessment with Sonography for Trauma Ultrasounds in a Level II Trauma Center

The Focused Assessment with Sonography for Trauma (FAST) is widely used as the initial screening tool for abdominal trauma. Several recent studies have questioned its use. Using the Trauma Registry, 1 year of data at a Level II trauma center were reviewed. All trauma patients with dictated FAST examinations were identified. Disconcordant findings were reviewed. Predictive values for determining intraperitoneal injuries were calculated. Nine hundred seventy-four designated trauma patients were entered into the Trauma Registry. Of these, 633 had dictated FAST examinations. There were 533 true-negatives, 11 true-positives, 77 false-negatives, and six false-positives. Of the 77 false-negatives, 33 had retroperitoneal injuries and 25 had intra-peritoneal injuries. No adverse outcomes were identified from diagnostic delay. For predicting intraperitoneal injury, FAST had a negative predictive value of 96 per cent, positive predictive value of 63 per cent, sensitivity of 29 per cent, specificity of 99 per cent, and accuracy of 95 per cent. Our data demonstrate that FAST was useful for the initial assessment of intraperitoneal injuries. FAST was 95 per cent accurate and allowed for rapid triage to operative management when indicated. The data also confirm that a negative FAST does not exclude abdominal injury.

Long-Term Safety and Efficacy of Programmable Implantable Insulin Delivery Systems

Objectives

Since only short-term studies of continuous intraperitoneal insulin infusion (CIPII) therapy using implantable programmable insulin delivery systems have been performed to show this method of diabetes therapy to be safe and efficacious, we have performed long-term studies to assess its safety and efficacy.

Research design and methods

For 78 patient-years of follow-up, we have longitudinally studied the incidence of diabetic ketoacidosis and severe hypoglycemia in 25 type 1 diabetic patients treated with CIPII. We also compared, cross-sectionally, the long-term safety and efficacy of CIPII to intensive subcutaneous insulin therapy using intermittent injections or continuous subcutaneous insulin infusion. Finally, we examined the relationship between glycated hemoglobin levels and the standard deviation of daily blood glucose excursion.

Results

Cross-sectional analysis revealed similar degrees of metabolic control accompanied by significantly decreased rates of both ketoacidosis (0.013 events/patient/year) and severe hypoglycemia (0.05 events/patient/year) during CIPII compared to intermittent injections and continuous subcutaneous insulin infusion therapy. A four-fold decrease in the rate of severe hypoglycemia was observed during longitudinal comparison of pre- and post-implantation complication rates. A relationship was also shown between decreased levels of mean glycated hemoglobin and the standard deviation of blood glucose excursions during CIPII therapy.

Conclusions

Our data demonstrate that long-term therapy with CIPII is as effective as other methods in achieving near-normal levels of glycated hemoglobin, which in CIPII is associated with a decreased standard deviation of blood glucose excursions. Further, CIPII using implantable programmable insulin delivery systems is the safest method described for intensive insulin therapy in home blood glucose monitoring type 1 diabetic patients.

FAST enough? A validation study for focused assessment with sonography for trauma ultrasounds in a Level II trauma center

The Focused Assessment with Sonography for Trauma (FAST) is widely used as the initial screening tool for abdominal trauma. Several recent studies have questioned its use. Using the Trauma Registry, 1 year of data at a Level II trauma center were reviewed. All trauma patients with dictated FAST examinations were identified. Disconcordant findings were reviewed. Predictive values for determining intraperitoneal injuries were calculated. Nine hundred seventy-four designated trauma patients were entered into the Trauma Registry. Of these, 633 had dictated FAST examinations. There were 533 true-negatives, 11 true-positives, 77 false-negatives, and six false-positives. Of the 77 false-negatives, 33 had retroperitoneal injuries and 25 had intraperitoneal injuries. No adverse outcomes were identified from diagnostic delay. For predicting intraperitoneal injury, FAST had a negative predictive value of 96 per cent, positive predictive value of 63 per cent, sensitivity of 29 per cent, specificity of 99 per cent, and accuracy of 95 per cent. Our data demonstrate that FAST was useful for the initial assessment of intraperitoneal injuries. FAST was 95 per cent accurate and allowed for rapid triage to operative management when indicated. The data also confirm that a negative FAST does not exclude abdominal injury.

Providing endoscopy for underserved patients benefits public health and resident education

OBJECTIVE

To determine the clinical and educational value of a new model for providing endoscopy for medically indigent patients.

HYPOTHESIS

A model can be developed at minimal cost to provide essential endoscopy services for underserved patients while providing resident education.

DESIGN

In our community, there was limited access to endoscopy for indigent patients, and surgical resident endoscopy experience was inadequate. To address these problems, a new endoscopy program was developed. Procedures were performed during underused times in a hospital endoscopy clinic. Endoscopies were performed on patients referred from the public health clinics. All procedures were performed by senior surgical residents supervised by attending endoscopists. The data were collected over 30 months. Colonoscopies were performed for both diagnostic and screening purposes.

INTERVENTIONS

In all, 205 colonoscopies, 65 upper endoscopies, and 14 combined endoscopies were performed.

OUTCOME MEASURES

Positive findings on endoscopy were documented. The cost-effectiveness was calculated.

RESULTS

Of 205 colonoscopies, 35% had positive findings. Sixty-six (32%) patients had polyps and 6 (3%) patients had carcinomas. Of 65 upper endoscopies, 34 (55%) patients had positive findings. Thirty (47%) patients had moderate to severe gastritis/esophagitis or ulcers, 2 (3%) patients had esophageal varices, 2 (5%) patients had carcinomas, 10 (15%) patients had positive H. pylori biopsies, and 2 (3%) patients had Barrett's esophagus. The program incurred minimal incremental costs, and large cost savings were realized in prevention and early detection of colon and gastric carcinomas.

CONCLUSIONS

Our 30-month experience resulted in clinical benefits to patients at minimal incremental cost while reducing future medical costs by preventing and detecting disease. Surgical residents received essential training.

Management of postoperative ileus

Postoperative ileus is an abnormal pattern of gastrointestinal motility that is common after both abdominal and nonabdominal surgeries. There are many causes of ileus, including postoperative pain and the use of narcotics for analgesia, electrolyte imbalances, and manipulation of the bowel during surgery. Despite its prevalence, there is still no reliable treatment to prevent ileus or shorten its course. This article discusses the causes of postoperative ileus and the treatment options currently available. The literature on early refeeding, gum chewing, and the use of tube feeds is reviewed. In addition, new and experimental drugs currently in development are discussed.

Predictors of postoperative urinary retention

Postoperative urinary retention (PUR) rates vary greatly depending on the population studied. PUR leads to urinary tract instrumentation, which causes increased hospital costs and morbidity. We sought to determine our PUR rate and the risk factors that associated with it. One hundred seventy-six adult surgical inpatients were included in the study. Excluded were those receiving intraoperative catheterization, epidural anesthesia, and urologic procedures. The study population included 42 per cent spinal, 24 per cent laparoscopic abdominal, 20 per cent neck surgeries excluding the spine, and 14 per cent miscellaneous surgeries. Patient bladder volumes were determined using ultrasound scanning at three different intervals: a postvoid residual just before transfer to the operating suite, immediately on arrival in the recovery unit, and then immediately before transfer to the ward. Our overall rate of PUR was 5.7 per cent (10 of 176), defined as the need for catheterization during the postoperative hospitalization. Associated with PUR were advanced age (P = 0.0292) and postoperative bladder volume (P = 0.0246). Preoperative bladder volume, intraoperative fluid, and operative time did not reach statistical significance as being predictive of urinary retention. Our data suggest that PUR is associated with increased bladder volumes on arrival to the recovery room. A prospective study to determine whether identification of patients at risk will lead to decreased incidence of urinary tract infection is warranted.

Bleeding complications with Drotrecogin alfa activated (Xigris): a retrospective review of 31 operative and 68 non-operative patients with severe sepsis

We reviewed 100 consecutive patients who received Drotrecogin alfa (activated) (DAA) (Xigris, Eli Lilly, Indianapolis, IN) for the treatment of severe sepsis and compared the incidence of bleeding complications in surgical (n = 30) and nonsurgical cohorts (n = 70). Thirty patients who received DAA therapy for severe sepsis underwent one or more contemporaneous surgical procedures. These were compared with 70 DAA patients who did not undergo surgery. During the course of DAA administration, transfusion of greater than three units of blood, an intracranial hemorrhage, or other bleeding serious adverse event were qualified as bleeding complications. Overall, we identified seven patients who fulfilled the designated bleeding complication criteria, four in the surgical cohort, and three in the nonsurgical cohort. There was no significant difference in the rate of bleeding complications between surgical and nonsurgical cohorts (P = 0.1063). Moreover, there were no mortalities ascribed to bleeding and there were no intracranial hemorrhage events. All bleeding complications were due to a drop in hemoglobin or platelets only, and were treated with transfusion. Our experience demonstrates that there is an equivalent risk of bleeding for surgical patients treated with DAA compared with nonsurgical patients. Additionally, all bleeding complications were amenable to simple transfusion.

Bleeding Complications with Drotrecogin Alfa Activated (Xigris®): A Retrospective Review of 31 Operative and 68 Non-Operative Patients with Severe Sepsis

We reviewed 100 consecutive patients who received Drotrecogin alfa (activated) (DAA) (Xigris®, Eli Lilly, Indianapolis, IN) for the treatment of severe sepsis and compared the incidence of bleeding complications in surgical (n = 30) and nonsurgical cohorts (n = 70). Thirty patients who received DAA therapy for severe sepsis underwent one or more contemporaneous surgical procedures. These were compared with 70 DAA patients who did not undergo surgery. During the course of DAA administration, transfusion of greater than three units of blood, an intracranial hemorrhage, or other bleeding serious adverse event were qualified as bleeding complications. Overall, we identified seven patients who fulfilled the designated bleeding complication criteria, four in the surgical cohort, and three in the nonsurgical cohort. There was no significant difference in the rate of bleeding complications between surgical and nonsurgical cohorts (P = 0.1063). Moreover, there were no mortalities ascribed to bleeding and there were no intracranial hemorrhage events. All bleeding complications were due to a drop in hemoglobin or platelets only, and were treated with transfusion. Our experience demonstrates that there is an equivalent risk of bleeding for surgical patients treated with DAA compared with nonsurgical patients. Additionally, all bleeding complications were amenable to simple transfusion.

Ruptured abdominal aortic aneurysm: does trauma center designation affect outcome?

Ruptured abdominal aortic aneurysm (RAAA) continues to be a major cause of mortality in the United States. Rapid diagnosis and uncomplicated surgical repair remain paramount to improving survival in this population. We proposed that the addition of an organized trauma service and subsequent improved management of critically ill patients who present with RAAA would positively impact overall mortality. A retrospective analysis was performed on all patients treated for RAAA at Santa Barbara Cottage Hospital for the years 1985-2004. Patients treated before level II trauma center designation (1985-1999) were compared to those treated after the trauma center was instituted. A total of 76 patients were included in this analysis. The two groups were similar with regard to demographics. However, significant decreases in transport time from the emergency department to the operating room and overall 30-day mortality were seen in patients after the trauma center designation. This designation also led to an increase in the number of cases performed per year, centralizing the treatment for these critically ill patients. Institution of a well-prepared and organized service, such as trauma, improved the outcome for patients treated with RAAA, with a particular benefit in the unstable patient.

The Use of Tagged White Blood Cell Scans to Diagnose Appendicitis in Pregnant Patients

A prompt and accurate diagnosis of appendicitis in pregnant patients is important in avoiding premature labor and fetal loss. Computed tomography (CT) scans are accurate, but fetal radiation exposure is high. Ultrasound avoids radiation exposure, but is less accurate as the uterus enlarges. A third option involves the use of technetium-99 tagged white blood cell scans (TWBCS), which have less than 5 per cent of the fetal radiation exposure of CT scans. However, in pregnancy, the value of TWBCS has not been studied. Therefore, a retrospective review of all patients who were pregnant and underwent a nuclear medicine study as part of their evaluation was performed. Thirteen patients were identified from 1999 through 2005. Before receiving a TWBCS, each patient had an indeterminate physical examination and an ultrasound or CT. Patients with negative TWBCS were admitted and observed clinically. There was no relationship between the results of TWBCS and the presence of appendicitis (P = 0.538). The sensitivity of the TWBCS was 50 per cent, whereas the specificity was 73 per cent. TWBCS had a false-positive rate of 27 per cent and a false-negative rate of 50 per cent, and its positive predictive value was 25 per cent. The data suggest that TWBCS in pregnancy is not reliable in evaluating for appendicitis.

The use of tagged white blood cell scans to diagnose appendicitis in pregnant patients

A prompt and accurate diagnosis of appendicitis in pregnant patients is important in avoiding premature labor and fetal loss. Computed tomography (CT) scans are accurate, but fetal radiation exposure is high. Ultrasound avoids radiation exposure, but is less accurate as the uterus enlarges. A third option involves the use of technetium-99 tagged white blood cell scans (TWBCS), which have less than 5 per cent of the fetal radiation exposure of CT scans. However, in pregnancy, the value of TWBCS has not been studied. Therefore, a retrospective review of all patients who were pregnant and underwent a nuclear medicine study as part of their evaluation was performed. Thirteen patients were identified from 1999 through 2005. Before receiving a TWBCS, each patient had an indeterminate physical examination and an ultrasound or CT. Patients with negative TWBCS were admitted and observed clinically. There was no relationship between the results of TWBCS and the presence of appendicitis (P = 0.538). The sensitivity of the TWBCS was 50 per cent, whereas the specificity was 73 per cent. TWBCS had a false-positive rate of 27 per cent and a false-negative rate of 50 per cent, and its positive predictive value was 25 per cent. The data suggest that TWBCS in pregnancy is not reliable in evaluating for appendicitis.

Gum chewing reduces ileus after elective open sigmoid colectomy

HYPOTHESIS

Gum chewing after elective open colon resection may stimulate bowel motility and decrease duration of postoperative ileus.

DESIGN AND SETTING

Prospective, randomized study in a community-based teaching hospital.

PATIENTS

Thirty-four patients undergoing elective open sigmoid resections for recurrent diverticulitis or cancer.

MAIN OUTCOME MEASURES

First feelings of hunger, time to first flatus, time to first bowel movement, length of hospital stay, and complications.

RESULTS

A total of 34 patients were randomized into 2 groups: a gum-chewing group (n = 17) or a control group (n = 17). The patients in the gum-chewing group chewed sugarless gum 3 times daily for 1 hour each time until discharge. Patient demographics, intraoperative, and postoperative care were equivalent between the 2 groups. All gum-chewing patients tolerated the gum. The first passage of flatus occurred on postoperative hour 65.4 in the gum-chewing group and on hour 80.2 in the control group (P = .05). The first bowel movement occurred on postoperative hour 63.2 in the gum-chewing group and on hour 89.4 in the control group (P = .04). The first feelings of hunger were felt on postoperative hour 63.5 in the gum-chewing group and on hour 72.8 in the control group (P = .27). There were no major complications in either group. The total length of hospital stay was shorter in the gum-chewing group (day 4.3) than in the control group (day 6.8), (P = .01).

CONCLUSIONS

Gum chewing speeds recovery after elective open sigmoid resection by stimulating bowel motility. Gum chewing is an inexpensive and helpful adjunct to postoperative care after colectomy.

The Use of Vacuum-Assisted Closure Therapy for the Treatment of a Large Infected Facial Wound

Chronic wounds in difficult locations pose constant challenges to health care providers. Negative-pressure wound therapy is a relatively new treatment to promote wound healing. Laboratory and clinical studies have shown that the vacuum-assisted closure (VAC) therapy increases wound blood flow, granulation tissue formation, and decreases accumulation of fluid and bacteria. VAC therapy has been shown to hasten wound closure and formation of granulation tissue in a variety of settings. Accepted indications for VAC therapy include the infected sternum, open abdomen, chronic, nonhealing extremity wounds and decubitus ulcers. We report the first case of VAC therapy successfully used on a large infected wound to the face to promote healing.

The use of vacuum-assisted closure therapy for the treatment of a large infected facial wound

Chronic wounds in difficult locations pose constant challenges to health care providers. Negative-pressure wound therapy is a relatively new treatment to promote wound healing. Laboratory and clinical studies have shown that the vacuum-assisted closure (VAC) therapy increases wound blood flow, granulation tissue formation, and decreases accumulation of fluid and bacteria. VAC therapy has been shown to hasten wound closure and formation of granulation tissue in a variety of settings. Accepted indications for VAC therapy include the infected sternum, open abdomen, chronic, nonhealing extremity wounds and decubitus ulcers. We report the first case of VAC therapy successfully used on a large infected wound to the face to promote healing.

Preoperative Oral Rofecoxib and Postoperative Pain in Patients after Laparoscopic Cholecystectomy: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial

Cyclooxygenase-2 (COX-2) inhibitors are a class of drugs that may avoid some of the side effects of narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs). We performed a randomized, double-blinded, placebo-controlled trial giving a single oral dose of the COX-2 inhibitor rofecoxib 25 mg or placebo preoperatively to determine the impact upon postoperative pain, complications, narcotic use, and hospital stay after laparoscopic cholecystectomy. Investigators and patients were blinded. Pain was measured on a 10-point visual analogue scale. Eighty patients were randomized: 40 to the rofecoxib group and 40 to the placebo group. The amount of pain between the two groups postoperatively was equivalent. Pain was recorded at 1 hour, 4.03 ± 1.93 in the rofecoxib group versus 4.38 ± 1.34 in the placebo group ( P = 0.36); at 6 hours, 3.00 ± 1.12 in the rofecoxib group versus 2.78 ± 0.78 in the placebo group ( P = 0.42); and at 24 hours, 1.64 ± 0.67 in the rofecoxib group versus 2.68 ± 1.90 in the placebo group ( P = 0.17). The amount of pain medication received and lengths of hospital stay was not significantly different between the two groups. Our data demonstrate no significant benefit of preoperative oral rofecoxib in patients undergoing laparoscopic cholecystectomy.

Preoperative oral rofecoxib and postoperative pain in patients after laparoscopic cholecystectomy: a prospective, randomized, double-blinded, placebo-controlled trial

Cyclooxygenase-2 (COX-2) inhibitors are a class of drugs that may avoid some of the side effects of narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs). We performed a randomized, double-blinded, placebo-controlled trial giving a single oral dose of the COX-2 inhibitor rofecoxib 25 mg or placebo preoperatively to determine the impact upon postoperative pain, complications, narcotic use, and hospital stay after laparoscopic cholecystectomy. Investigators and patients were blinded. Pain was measured on a 10-point visual analogue scale. Eighty patients were randomized: 40 to the rofecoxib group and 40 to the placebo group. The amount of pain between the two groups postoperatively was equivalent. Pain was recorded at 1 hour, 4.03 +/- 1.93 in the rofecoxib group versus 4.38 +/- 1.34 in the placebo group (P = 0.36); at 6 hours, 3.00 +/- 1.12 in the rofecoxib group versus 2.78 +/- 0.78 in the placebo group (P = 0.42); and at 24 hours, 1.64 +/- 0.67 in the rofecoxib group versus 2.68 +/- 1.90 in the placebo group (P = 0.17). The amount of pain medication received and lengths of hospital stay was not significantly different between the two groups. Our data demonstrate no significant benefit of preoperative oral rofecoxib in patients undergoing laparoscopic cholecystectomy.

Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol

BACKGROUND

Prompt identification of cervical spine injuries has been a critical issue in trauma management. In 1998, the authors developed a new protocol to evaluate cervical spines in blunt trauma. This protocol relies on clinical clearance for appropriate patients and helical computed tomography instead of plain radiographs for patients who cannot be clinically cleared. The authors then prospectively collected data on all cervical spine evaluations to assess the sensitivity and specificity of their approach.

METHODS

Any patient without clinical evidence of neurologic injury, alcohol or drug intoxication, or distracting injury underwent cervical spine evaluation by clinical examination. Patients who did not meet these criteria underwent helical computed tomographic scanning of the entire cervical spine. For patients who had neurologic deficits, a magnetic resonance image was obtained. If the patient was not evaluable secondary to coma, the computed tomographic scan was without abnormality, and the patient was moving all four extremities at arrival in the emergency department, the cervical spine was cleared, and spinal precautions were removed. Data were collected for all patients admitted to Santa Barbara Cottage Hospital trauma service between 1999 and 2002. The authors selected for analysis patients with blunt trauma and further identified those with closed head injuries (Glasgow Coma Scale score < 15 and loss of consciousness). In addition, all blunt cervical spine injuries were reviewed.

RESULTS

During the period of study, 2,854 trauma patients were admitted, of whom 2,603 (91%) had blunt trauma. Of these, 1,462 (56%) had closed head injuries. One hundred patients (7% of patients admitted for blunt trauma) had cervical spine or spinal cord injuries, of which 99 were identified by the authors' protocol. Only one injury was not appreciated in a patient with syringomyelia. Fifteen percent of patients with spinal cord injury had no radiographic abnormality; all of these patients presented with neurologic deficits. The sensitivity for detecting cervical spine injury was thus 99%, and the specificity was 100%. The risk of missing a cervical spine injury in these blunt trauma patients was 0.04%. The authors missed no spine injuries in patients with head injuries.

CONCLUSION

The use of the authors' protocol resulted in excellent sensitivity and specificity in detecting cervical spine injuries. In addition, it allowed early removal of spinal precautions.

Is repeated head computed tomography necessary for traumatic intracranial hemorrhage?

This study was performed to determine the need for repeat head computed tomography (CT) in patients with blunt traumatic intracranial hemorrhage (ICH) who were initially treated nonoperatively and to determine which factors predicted observation failure or success. A total of 1,462 patients were admitted to our level II trauma center for treatment of head injury. Seventeen per cent (255/1,462) were diagnosed with ICH on initial head CT. Craniotomy was initially performed in 15.7 per cent (40/255) of patients with ICH. Two hundred sixteen patients with ICH were initially observed. Ninety-seven per cent (179/184) of observed patients with ICH and repeat head CT never underwent a craniotomy, 2.7 per cent (5/184) of patients with ICH initially observed underwent craniotomy after repeat head CT, and four patients (80%) had deteriorating neurologic status. Multivariate analysis revealed the following significant admission risk factors were associated with a need for repeat head CT indicating the need for craniotomy: treatment with anticoagulation and/or antiplatelet medications, elevated prothrombin time (PT), and age greater than 70 years. In patients with blunt traumatic intracranial hemorrhage initially observed, there is little utility of repeated head CT in the absence of deteriorating neurologic status. The only admission risk factors for a repeat CT indicating the need for craniotomy were advanced age and coagulopathy.

Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits

HYPOTHESIS

Trauma patients with normal motor examination results and normal cervical spine helical computed tomographic (CT) scans with sagittal reconstructions do not have significant cervical spine injury.

DESIGN

Prospectively collected registry data.

SETTING

Level II community-based trauma center.

PATIENTS

All patients admitted to the trauma service from January 1, 1999, to December 31, 2003.

MAIN OUTCOME MEASURES

Injury detected by CT and/or magnetic resonance imaging (MRI) of the cervical spine. Neurologic examination and need for surgery were secondary outcomes.

RESULTS

During the study period, 2854 trauma patients were admitted, of whom 91.2% had blunt trauma. Of these patients, 56.2% had a closed head injury. One hundred patients had cervical spine and/or spinal cord injuries. Eighty-five patients had a cervical spine injury diagnosed by CT. Fifteen patients had admission neurologic deficits not seen on CT, and 7 of these patients had non-bony abnormalities on MRI. Ninety-three patients had a normal admission motor examination result, a CT result negative for trauma, and persistent cervical spine pain, and were examined with MRI. All MRI examination results were negative for clinically significant injury. Seventeen patients had MRIs that showed degenerative disc disease, and 6 had spinal canal stenosis secondary to ossification. Twelve comatose patients (Glasgow Coma Scale score, <9), moving all 4 extremities on arrival, with normal CT results of the cervical spine, were examined with MRI. All of these MRI examination results were negative for injury. None of the patients experienced neurologic deterioration. No patient required operative management of spinal injury.

CONCLUSION

Blunt trauma patients with normal motor examination results and normal CT results of the cervical spine do not require further radiologic examination before clearing the cervical spine.

Is Repeated Head Computed Tomography Necessary for Traumatic Intracranial Hemorrhage?

This study was performed to determine the need for repeat head computed tomography (CT) in patients with blunt traumatic intracranial hemorrhage (ICH) who were initially treated nonoperatively and to determine which factors predicted observation failure or success. A total of 1,462 patients were admitted to our level II trauma center for treatment of head injury. Seventeen per cent (255/1,462) were diagnosed with ICH on initial head CT. Craniotomy was initially performed in 15.7 per cent (40/255) of patients with ICH. Two hundred sixteen patients with ICH were initially observed. Ninety-seven per cent (179/184) of observed patients with ICH and repeat head CT never underwent a craniotomy, 2.7 per cent (5/184) of patients with ICH initially observed underwent craniotomy after repeat head CT, and four patients (80%) had deteriorating neurologic status. Multivariate analysis revealed the following significant admission risk factors were associated with a need for repeat head CT indicating the need for craniotomy: treatment with anti-coagulation and/or antiplatelet medications, elevated prothrombin time (PT), and age greater than 70 years. In patients with blunt traumatic intracranial hemorrhage initially observed, there is little utility of repeated head CT in the absence of deteriorating neurologic status. The only admission risk factors for a repeat CT indicating the need for craniotomy were advanced age and coagulopathy.

Local anesthetic infusion pumps improve postoperative pain after inguinal hernia repair: a randomized trial

Pain after an open inguinal hernia repair may be significant. In fact, some surgeons feel that the pain after open repair justifies a laparoscopic approach. The purpose of this study was to determine if the use of local anesthetic infusion pumps would reduce postoperative pain after open inguinal hernia repair. We performed a prospective, double-blind randomized study of 45 open plug and patch inguinal hernia repairs. Patients were randomized to receive either 0.25 per cent bupivicaine or saline solution via an elastomeric infusion pump (ON-Q) for 48 hours, at 2 cc/h. The catheters were placed in the subcutaneous tissue and removed on postoperative day 3. Both groups were prescribed hydrocodone to use in the postoperative period at the prescribed dosage as needed for pain. Interviews were conducted on postoperative days 3 and 7, and patient's questionnaires, including pain scores, amount of pain medicine used, and any complications, were collected accordingly. During the first 5 postoperative days, postoperative pain was assessed using a visual analog scale. Twenty-three repairs were randomized to the bupivicaine group and 22 repairs randomized to the placebo group. In the bupivicaine group, there was a significant decrease in postoperative pain on postoperative days 2 through 5 with P values <0.05. This significant difference continued through postoperative day 5, 2 days after the infusion pumps were removed. Patients who had bupivicaine instilled in their infusion pump had statistically significant lower subjective pain scores on postoperative days 2 through 5. This significant difference continued even after the infusion pumps were removed. Local anesthetic infusion pumps significantly decreased the amount of early postoperative pain. Pain relief persisted for 2 days after catheter and pump removal.

Local Anesthetic Infusion Pumps Improve Postoperative Pain after Inguinal Hernia Repair: A Randomized Trial

Pain after an open inguinal hernia repair may be significant. In fact, some surgeons feel that the pain after open repair justifies a laparoscopic approach. The purpose of this study was to determine if the use of local anesthetic infusion pumps would reduce postoperative pain after open inguinal hernia repair. We performed a prospective, double-blind randomized study of 45 open plug and patch inguinal hernia repairs. Patients were randomized to receive either 0.25 per cent bupivicaine or saline solution via an elastomeric infusion pump (ON-Q) for 48 hours, at 2 cc/h. The catheters were placed in the subcutaneous tissue and removed on postoperative day 3. Both groups were prescribed hydrocodone to use in the postoperative period at the prescribed dosage as needed for pain. Interviews were conducted on postoperative days 3 and 7, and patient's questionnaires, including pain scores, amount of pain medicine used, and any complications, were collected accordingly. During the first 5 postoperative days, postoperative pain was assessed using a visual analog scale. Twenty-three repairs were randomized to the bupivicaine group and 22 repairs randomized to the placebo group. In the bupivicaine group, there was a significant decrease in postoperative pain on postoperative days 2 through 5 with P values <0.05. This significant difference continued through postoperative day 5, 2 days after the infusion pumps were removed. Patients who had bupivicaine instilled in their infusion pump had statistically significant lower subjective pain scores on postoperative days 2 through 5. This significant difference continued even after the infusion pumps were removed. Local anesthetic infusion pumps significantly decreased the amount of early postoperative pain. Pain relief persisted for 2 days after catheter and pump removal.

Marathon Pancreatitis: Is the Etiology Repetitive Trauma?

Abdominal pain frequently occurs after long-distance running. The cause of the pain may be due to dehydration, diaphragmatic ischemia, muscular spasm, or myonecrosis. However, data regarding the frequency of these purported causes are currently lacking. Pancreatitis can also occur after long-distance running, but few cases have been reported, and the etiology is controversial. We report a case of pancreatitis in a thin, muscular marathon runner. We suggest the etiology in this case may be traumatic as the pancreas may have suffered repetitive injury against the posterior abdominal wall and spine.

Marathon pancreatitis: is the etiology repetitive trauma?

Abdominal pain frequently occurs after long-distance running. The cause of the pain may be due to dehydration, diaphragmatic ischemia, muscular spasm, or myonecrosis. However, data regarding the frequency of these purported causes are currently lacking. Pancreatitis can also occur after long-distance running, but few cases have been reported, and the etiology is controversial. We report a case of pancreatitis in a thin, muscular marathon runner. We suggest the etiology in this case may be traumatic as the pancreas may have suffered repetitive injury against the posterior abdominal wall and spine.

Disability and Chronic Pain after Open Mesh and Laparoscopic Inguinal Hernia Repair

Proponents of laparoscopic inguinal hernia repair maintain that the associated costs and risks are offset by faster recovery and less postoperative pain. It was our hypothesis that the incidence of chronic pain in both groups of our patients was not as high as reported in the literature. Patients for the study were identified from a community hospital medical record database. A total of 229 patients were available and agreed to participate in the study. Data collected included the patient's current pain level at the hernia site, pain medication currently used, narcotics currently used, return to normal work, and return to normal activity. Overall, 19.7 per cent of patients complained of mild pain, but only 2.2 per cent classified this as moderate or severe. Mild pain was noted more often in the open repair patients compared with the laparoscopic group. However, there was no difference in the frequency of moderate or severe pain. The time to return to work was longer in the open repair group than the laparoscopic repair group, but there were large ranges in both groups. The inability to return to full preoperative activity was infrequent and equivalent in both open and laparoscopic hernia repair groups. In our study of 229 patients undergoing elective open or laparoscopic inguinal hernia repair at a community hospital, we have found a low incidence of moderate or severe chronic pain. In addition, we found that this procedure did not interfere with return to work at 6 months or return to daily activities in either the laparoscopic or open repair group.

Appendicitis, 2002: Relationship between Payors and Outcome

As the status of health-care insurance changes in the United States, studies have indicated that uninsured patients are less likely to receive timely and quality health care. Previous studies of appendicitis have shown that insurance status may effect the stage of presentation and outcome. However, these studies were based on databases lacking information regarding stage of presentation, timeliness of diagnosis and treatment, and character of hospitalization (length of stay, duration of antibiotic therapy, hospital costs). We accomplished a case control study, retrospective analysis of 975 patients treated for acute appendicitis between January 1996 and December 1999. Times to operation, number of preoperative outpatient visits, number of studies, severity of presentation, length of antibiotics and hospital stay, and hospital costs were analyzed [analysis of variance (ANOVA) techniques, P < 0.05 significant]. We sought answers to the following: (1) Did insurance status affect the timeliness of diagnosis and treatment? (2) Did insurance status affect the stage of presentation? (3) Did insurance status affect hospitalization, as measured by length of stay, duration of antibiotic therapy, and hospital costs? (4) Did age affect outcome independent of insurance status? There were no correlations between insurance status and timeliness of diagnosis or severity of presentation. Length of stay and hospital costs were also not different between insurance categories. Pediatric patients (<12 years old) and the elderly (>65 years old) presented with more advanced appendicitis, independent of insurance category. In contrast to previously published data, the treatment of acute appendicitis is not affected by insurance coverage in the sample community. Age and timeliness of presentation were the only factors correlating to outcomes.

Disability and chronic pain after open mesh and laparoscopic inguinal hernia repair

Proponents of laparoscopic inguinal hernia repair maintain that the associated costs and risks are offset by faster recovery and less postoperative pain. It was our hypothesis that the incidence of chronic pain in both groups of our patients was not as high as reported in the literature. Patients for the study were identified from a community hospital medical record database. A total of 229 patients were available and agreed to participate in the study. Data collected included the patient's current pain level at the hernia site, pain medication currently used, narcotics currently used, return to normal work, and return to normal activity. Overall, 19.7 per cent of patients complained of mild pain, but only 2.2 per cent classified this as moderate or severe. Mild pain was noted more often in the open repair patients compared with the laparoscopic group. However, there was no difference in the frequency of moderate or severe pain. The time to return to work was longer in the open repair group than the laparoscopic repair group, but there were large ranges in both groups. The inability to return to full preoperative activity was infrequent and equivalent in both open and laparoscopic hernia repair groups. In our study of 229 patients undergoing elective open or laparoscopic inguinal hernia repair at a community hospital, we have found a low incidence of moderate or severe chronic pain. In addition, we found that this procedure did not interfere with return to work at 6 months or return to daily activities in either the laparoscopic or open repair group.

Appendicitis, 2002: relationship between payors and outcome

As the status of health-care insurance changes in the United States, studies have indicated that uninsured patients are less likely to receive timely and quality health care. Previous studies of appendicitis have shown that insurance status may effect the stage of presentation and outcome. However, these studies were based on databases lacking information regarding stage of presentation, timeliness of diagnosis and treatment, and character of hospitalization (length of stay, duration of antibiotic therapy, hospital costs). We accomplished a case control study, retrospective analysis of 975 patients treated for acute appendicitis between January 1996 and December 1999. Times to operation, number of preoperative outpatient visits, number of studies, severity of presentation, length of antibiotics and hospital stay, and hospital costs were analyzed [analysis of variance (ANOVA) techniques, P < 0.05 significant]. We sought answers to the following: (1) Did insurance status affect the timeliness of diagnosis and treatment? (2) Did insurance status affect the stage of presentation? (3) Did insurance status affect hospitalization, as measured by length of stay, duration of antibiotic therapy, and hospital costs? (4) Did age affect outcome independent of insurance status? There were no correlations between insurance status and timeliness of diagnosis or severity of presentation. Length of stay and hospital costs were also not different between insurance categories. Pediatric patients (< 12 years old) and the elderly (> 65 years old) presented with more advanced appendicitis, independent of insurance category. In contrast to previously published data, the treatment of acute appendicitis is not affected by insurance coverage in the sample community. Age and timeliness of presentation were the only factors correlating to outcomes.

Preoperative sestamibi localization combined with intraoperative parathyroid hormone assay predicts successful focused unilateral neck exploration during surgery for primary hyperparathyroidism

A retrospective review of 54 cases of primary hyperparathyroidism operated upon by five general surgeons at Santa Barbara Cottage Hospital between March 1998 and March 2001 was performed to determine whether positive preoperative sestamibi localization (PSL) of a solitary adenoma combined with intraoperative parathyroid hormone assay (IOPHA) could predict successful focused unilateral neck exploration. A solitary adenoma was found in each of 50 patients (93%). PSL for solitary adenomas had an accuracy of 87 per cent, positive predictive value (PPV) of 96 per cent, sensitivity of 90 per cent, and specificity of 50 per cent. Forty-five patients (83%) achieved a 50 per cent reduction in IOPHA at 10 minutes after excision of a solitary adenoma for an accuracy of 85 per cent, PPV of 97 per cent, sensitivity of 88 per cent, and specificity of 50 per cent. All patients remain eucalcemic. The combination of PSL and IOPHA resulted in a PPV of 97.5 per cent and a sensitivity of 100 per cent. From these data we conclude that a focused unilateral neck exploration could have been performed successfully in 78 per cent of the cases.

Does gallbladder ejection fraction predict pathology after elective cholecystectomy for symptomatic cholelithiasis?

Patients with symptomatic cholelithiasis are selected for elective cholecystectomy with the expectation that their symptoms will improve after operation. However, some patients fail to improve because their preoperative symptoms were not related to gallbladder disease. A test that would indicate the severity of gallbladder disease in patients with gallstones would therefore have great potential benefit. Twenty-five patients who presented as outpatients with episodic abdominal pain and gallstones were scheduled for elective cholecystectomy. On the day before operation patients underwent nuclear medicine cholescintigraphy with measurement of ejection fraction. All patients then underwent laparoscopic cholecystectomy. Pathologic specimens were reviewed by a pathologist who was blinded to the ejection fraction results and scored for degree of inflammation on a scale of zero to three. There was a wide range of ejection fractions measured (0-84%). There was, however, no correlation between ejection fractions and degree of gallbladder inflammation. We conclude that gallbladder ejection fraction does not predict the degree of gallbladder inflammation at the time of elective cholecystectomy. This test is therefore unlikely to predict which patients with cholelithiasis will have symptomatic relief after cholecystectomy.

Does Gallbladder Ejection Fraction Predict Pathology after Elective Cholecystectomy for Symptomatic Cholelithiasis ?

Patients with symptomatic cholelithiasis are selected for elective cholecystectomy with the expectation that their symptoms will improve after operation. However, some patients fail to improve because their preoperative symptoms were not related to gallbladder disease. A test that would indicate the severity of gallbladder disease in patients with gallstones would therefore have great potential benefit. Twenty-five patients who presented as outpatients with episodic abdominal pain and gallstones were scheduled for elective cholecystectomy. On the day before operation patients underwent nuclear medicine cholescintigraphy with measurement of ejection fraction. All patients then underwent laparoscopic cholecystectomy. Pathologic specimens were reviewed by a pathologist who was blinded to the ejection fraction results and scored for degree of inflammation on a scale of zero to three. There was a wide range of ejection fractions measured (0–84%). There was, however, no correlation between ejection fractions and degree of gallbladder inflammation. We conclude that gallbladder ejection fraction does not predict the degree of gallbladder inflammation at the time of elective cholecystectomy. This test is therefore unlikely to predict which patients with cholelithiasis will have symptomatic relief after cholecystectomy.

Intravenous Interleukin-6 Levels Predict Need for Laparotomy in Patients with Bowel Obstruction

Interleukin-6 (IL-6) has been identified as a marker of ischemia. However, its association with bowel obstruction has not been studied. Fifty-seven patients diagnosed with bowel obstruction were evaluated in a prospective blinded study and managed either medically (n = 29) or surgically (n = 28) per decision of attending surgeon. Serum IL-6 levels were obtained at the time of diagnosis and serially during hospitalization. Mean IL-6 levels at the time of diagnosis were significantly higher in patients who required operation compared with medically treated patients (63.9 vs 19.6 pg/mL respectively; P = 0.027). Levels returned to those seen in medically treated patients 3 days after operation. There was no difference in temperature, white blood cell count, or lactic acid levels. Five patients required resection for ischemic bowel. Patients with ischemic bowel had significantly higher initial mean IL-6 (146.6 vs 45.9 pg/mL; P = 0.034) and lactic acid (23.6 vs 11.8 mg/dL; P = 0.035) at time of diagnosis compared with surgically treated patients without bowel ischemia. No difference in white blood cell count was seen. IL-6 was a sensitive predictor of patients with bowel obstruction requiring operation and for presence of ischemic bowel. IL-6 screening may allow for earlier and more selective operation potentially decreasing morbidity and mortality.

Intravenous interleukin-6 levels predict need for laparotomy in patients with bowel obstruction

Interleukin-6 (IL-6) has been identified as a marker of ischemia. However, its association with bowel obstruction has not been studied. Fifty-seven patients diagnosed with bowel obstruction were evaluated in a prospective blinded study and managed either medically (n = 29) or surgically (n = 28) per decision of attending surgeon. Serum IL-6 levels were obtained at the time of diagnosis and serially during hospitalization. Mean IL-6 levels at the time of diagnosis were significantly higher in patients who required operation compared with medically treated patients (63.9 vs 19.6 pg/mL respectively; P = 0.027). Levels returned to those seen in medically treated patients 3 days after operation. There was no difference in temperature, white blood cell count, or lactic acid levels. Five patients required resection for ischemic bowel. Patients with ischemic bowel had significantly higher initial mean IL-6 (146.6 vs 45.9 pg/mL; P = 0.034) and lactic acid (23.6 vs 11.8 mg/dL; P = 0.035) at time of diagnosis compared with surgically treated patients without bowel ischemia. No difference in white blood cell count was seen. IL-6 was a sensitive predictor of patients with bowel obstruction requiring operation and for presence of ischemic bowel. IL-6 screening may allow for earlier and more selective operation potentially decreasing morbidity and mortality.

The Effect of Abrupt Cessation of Total Parenteral Nutrition on Serum Glucose: A Randomized Trial

The common clinical practice of gradually tapering total parenteral nutrition (TPN) to prevent hypoglycemia may be unnecessary. This randomized prospective study assessed the blood glucose profiles of patients whose TPN was abruptly discontinued in comparison with those whose TPN was gradually tapered to determine whether abrupt cessation can be performed safely. Patients were randomized into the abrupt cessation or the tapered protocol. A symptomatic hypoglycemic questionnaire was administered at regular intervals. Fingerstick glucose sampling was performed at 30-minute intervals and compared prospectively. From October 1996 through July 1997, 21 patients receiving TPN consented to participate in this study. Inclusion criteria included 1) duration of TPN infusion >24 hours, 2) age >18 years, and 3) establishment of enteral feeding at the time of TPN discontinuation. Patients had a baseline blood glucose level followed by repeat glucose measurements at 30-minute intervals until 90 minutes after TPN was completely discontinued in the tapered group and 120 minutes after cessation in the abrupt group. The rate of TPN tapering was in 25 per cent increments over 90-minute intervals. Ten patients were randomized into the tapered group and 11 patients in the abrupt group. None of the patients developed symptomatic hypoglycemia. There was no difference between the lowest blood glucose in the abrupt group in comparison with that of the tapered group (108.6 ± 11.5 vs 108.2 ± 9.8 respectively; P = 0.98). No patient had a significant change in hypoglycemia questionnaire score. There was no significant difference in age, duration of TPN, steroid use, or enteral caloric intake between the two groups. We conclude that there was no symptomatic hypoglycemia, and glucose profiles returned to a similar baseline level in those whose TPN was abruptly stopped when compared with those in the tapered group. These data demonstrate that patients receiving TPN can have parenteral nutrition abruptly stopped without the development of significant hypoglycemia.

The effect of abrupt cessation of total parenteral nutrition on serum glucose: a randomized trial

The common clinical practice of gradually tapering total parenteral nutrition (TPN) to prevent hypoglycemia may be unnecessary. This randomized prospective study assessed the blood glucose profiles of patients whose TPN was abruptly discontinued in comparison with those whose TPN was gradually tapered to determine whether abrupt cessation can be performed safely. Patients were randomized into the abrupt cessation or the tapered protocol. A symptomatic hypoglycemic questionnaire was administered at regular intervals. Fingerstick glucose sampling was performed at 30-minute intervals and compared prospectively. From October 1996 through July 1997, 21 patients receiving TPN consented to participate in this study. Inclusion criteria included 1) duration of TPN infusion >24 hours, 2) age >18 years, and 3) establishment of enteral feeding at the time of TPN discontinuation. Patients had a baseline blood glucose level followed by repeat glucose measurements at 30-minute intervals until 90 minutes after TPN was completely discontinued in the tapered group and 120 minutes after cessation in the abrupt group. The rate of TPN tapering was in 25 per cent increments over 90-minute intervals. Ten patients were randomized into the tapered group and 11 patients in the abrupt group. None of the patients developed symptomatic hypoglycemia. There was no difference between the lowest blood glucose in the abrupt group in comparison with that of the tapered group (108.6+/-11.5 vs 108.2+/-9.8 respectively; P = 0.98). No patient had a significant change in hypoglycemia questionnaire score. There was no significant difference in age, duration of TPN, steroid use, or enteral caloric intake between the two groups. We conclude that there was no symptomatic hypoglycemia, and glucose profiles returned to a similar baseline level in those whose TPN was abruptly stopped when compared with those in the tapered group. These data demonstrate that patients receiving TPN can have parenteral nutrition abruptly stopped without the development of significant hypoglycemia.

Lactated Ringer's solution resuscitation causes neutrophil activation after hemorrhagic shock

PURPOSE

To determine the degree of neutrophil activation caused by hemorrhagic shock and resuscitation.

METHODS

Awake swine underwent 15-minute 40% blood volume hemorrhage, and a 1-hour shock period, followed by resuscitation with: group I, lactated Ringer's solution (LR); group II, shed blood; and group III, 7.5% hypertonic saline (HTS). Group IV underwent sham hemorrhage and LR infusion. Neutrophil activation was measured in whole blood using flow cytometry to detect intracellular superoxide burst activity.

RESULTS

Neutrophil activation increased significantly immediately after hemorrhage, but it was greatest after resuscitation with LR (group I, 273 vs. 102%; p < 0.05). Animals that received shed blood (group II) and HTS (group III) had neutrophil activity return to baseline state after resuscitation. Group IV animals had an increase in neutrophil activation (259 vs. 129%; p < 0.05).

CONCLUSION

Neutrophil activation occurring after LR resuscitation and LR infusion without hemorrhage, but not after resuscitation with shed blood or HTS, suggests that the neutrophil activation may be caused by LR and not by reperfusion.

Factors related to outcome in blunt intestinal injuries requiring operation

Associated factors related to outcome following blunt intestinal trauma requiring operative therapy were retrospectively reviewed in all trauma patients admitted to one Level I trauma center. Over 4.5 years, 7598 trauma patients were evaluated, with 62 patients having sustained 92 blunt intestinal injuries requiring operative intervention. Mean age was 34.5 years; mean Injury Severity Score was 22. Mechanism of injury was motor vehicle accident in 50 (81%), with 80 per cent being drivers. Associated intra-abdominal injuries occurred in 46 (74%) patients. Extra-abdominal injuries occurred in 56 patients (90%). Thirty-one patients suffered 82 complications or 2.6 complications per patient (comp/pt). Mortality from operative blunt trauma was associated with admission blood pressure < or = 90 mm Hg (57 vs 13%; P < 0.05), age > or = 24 years (26 vs 0%; P < 0.05), and Injury Severity Score > or = 35 (70 vs 8%; P < 0.05). Morbidity was associated with age > or = 24 years (1.5 vs 0.7 comp/pt; P < 0.05) and delay in operative therapy > or = 24 hours (3.3 vs 1.1 comp/pt; P < 0.05). Overall mortality was 18 per cent.

Limited value of routine followup CT scans in nonoperative management of blunt liver and splenic injuries

The objective was to determine the utility of a second CT scan in nonoperative management of blunt liver and splenic trauma. The design was a retrospective review of consecutive cases over a 2-year period in two trauma centers. Subjects were 152 patients with blunt abdominal trauma and isolated injuries to liver and/or spleen. Thirty patients received immediate laparotomy, whereas 122 patients (80%) underwent CT scanning that showed splenic (n = 64), liver (n = 44), or combined (n = 14) injuries. Nonoperative management was undertaken in 99 of the 122 (81% of the patients who received CT scans; 65% of the overall series) and was ultimately successful in 94 (95%). Second CT scans were used in 26 patients (26%), one of whom received laparotomy for drainage of a bile leak and three for ongoing bleeding. None of the followup scans showed major progression of injury, and scan findings did not influence decisions for operation in any patients. Routine followup CT scanning is not a justifiable component of nonoperative management protocols for blunt liver and splenic injuries.

Lisofylline decreases white cell adhesiveness and improves survival after experimental hemorrhagic shock

OBJECTIVE

Lisofylline is an enantiomer-specific, alkyl-substituted methylxanthine, which has specific and potent activity in down-regulating leukocyte activation. This study was designed to test the efficacy of lisofylline in the resuscitation of rats subjected to experimental hemorrhagic shock.

DESIGN

Prospective, randomized, and blinded survival studies were performed with two lisofylline dosing regimens added to fluid resuscitation in a shock model. In addition, white cell adhesiveness was measured to assess the effects of lisofylline.

SETTING

Animal laboratory.

SUBJECTS

Sixty Sprague-Dawley rats.

INTERVENTIONS

Lisofylline or placebo was added to the resuscitation regimen, either as a single dose or over 24 hrs.

MEASUREMENTS AND MAIN RESULTS

The 72-hr survival rate, white blood cell count, and platelet adhesiveness were determined. When a single 1-hr infusion of lisofylline was added to the initial resuscitation regimen, the 72-hr survival rate increased from 20% in controls to 50% (p < .009). When repeated doses of lisofylline were given over 24 hrs, the 72-hr survival rate increased from 40% in controls to 70% (p < .02). Control animals significantly increased leukocyte adhesiveness after shock and resuscitation. This increased adhesiveness was completely eliminated by lisofylline infusion. Platelet adhesiveness was not affected by lisofylline.

CONCLUSIONS

Lisofylline improves survival in this model of hemorrhagic shock. Its beneficial effect may be related to down-regulation of leukocyte adhesiveness.

Anti-oxidant treatment for shock: vitamin E but not vitamin C improves survival

Anti-oxidant therapy has been effective for treatment of experimental shock. In this study, the efficacy of Trolox (Aldrich Chemical Co., Milwaukee, WI), a water-soluble vitamin E analogue, and ascorbic acid (vitamin C) was evaluated in a rat model of hemorrhagic shock and resuscitation. In two prospective trials, rats were phlebotomized (27 mL/kg) and left in shock for 45 minutes. Resuscitation was then instituted by continuous IV infusion with lactated Ringer's (LR) (54 mL/kg) over 60 min. In Trial 1, rats were randomized to receive either placebo (LR) or Trolox (50 mg/kg) in LR. In Trial 2, rats were randomized to LR alone or ascorbic acid (50 mg/kg) in LR. Survival for ascorbic acid-treated rats (35 per cent) was not different than for control rats (35 per cent). However, the addition of Trolox to infusion significantly improved 72 hour survival, 75 per cent versus 40 per cent respectively, for Trolox-treated and control animals. These data demonstrate that Trolox is of survival benefit when added to resuscitation in this model. This benefit does not appear to be related to blood pressure or white cell adhesion. Trolox is more effective than ascorbic acid in this model.