Successful implementation of a packed red blood cell and fresh frozen plasma transfusion protocol in the surgical intensive care unit

Background

Blood product transfusions are associated with increased morbidity and mortality. The purpose of this study was to determine if implementation of a restrictive protocol for packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusion safely reduces blood product utilization and costs in a surgical intensive care unit (SICU).

Study Design

We performed a retrospective, historical control analysis comparing before (PRE) and after (POST) implementation of a restrictive PRBC/FFP transfusion protocol for SICU patients. Univariate analysis was utilized to compare patient demographics and blood product transfusion totals between the PRE and POST cohorts. Multivariate logistic regression models were developed to determine if implementation of the restrictive transfusion protocol is an independent predictor of adverse outcomes after controlling for age, illness severity, and total blood products received.

Results

829 total patients were included in the analysis (PRE, n=372; POST, n=457). Despite higher mean age (56 vs. 52 years, p=0.01) and APACHE II scores (12.5 vs. 11.2, p=0.006), mean units transfused per patient were lower for both packed red blood cells (0.7 vs. 1.2, p=0.03) and fresh frozen plasma (0.3 vs. 1.2, p=0.007) in the POST compared to the PRE cohort, respectively. There was no difference in inpatient mortality between the PRE and POST cohorts (7.5% vs. 9.2%, p=0.39). There was a decreased risk of urinary tract infections (OR 0.47, 95%CI 0.28-0.80) in the POST cohort after controlling for age, illness severity and amount of blood products transfused.

Conclusions

Implementation of a restrictive transfusion protocol can effectively reduce blood product utilization in critically ill surgical patients with no increase in morbidity or mortality.

Plasma cell gingivitis apparently related to the use of khat: report of a case

Plasma cell gingivitis (PCG) is characterized by massive infiltration of plasma cells into the subepithelial tissue. It is a rare condition; the cause of which is still not fully understood. A case of PCG is reported in the mandibular gingiva probably caused by chewing khat. This report is the first, as far as we know, that relates PCG to the use of khat. The histological examination revealed infiltration of polyclonal plasma cells without signs of fungus, tuberculosis or malignancy. It is concluded that the changes were compatible with an allergic-like reaction. The patient, a 30-year-old immigrant from Somalia, revealed in a subsequent consultation that he regularly used khat. The leaves are placed in the buccal sulcus. The PCG disappeared within two weeks of the use of khat being discontinued. Dental surgeons (periodontists) in Europe and the New World will, due to increasing immigration from Africa and the Arabian Peninsula, meet more patients who regularly use khat. This means that PCG and other khat related intraoral changes will become more common in the future.

The BMP family member Gdf7 is required for seminal vesicle growth, branching morphogenesis, and cytodifferentiation

Epithelial-mesenchymal interactions play an important role in the development of many different organs and tissues. The secretory glands of the male reproductive system, including the prostate and seminal vesicles, are derived from epithelial precursors. Signals from the underlying mesenchyme are required for normal growth, branching, and differentiation of the seminal vesicle epithelium. Here, we show that a member of the BMP family, Gdf7, is required for normal seminal vesicle development. Expression and tissue recombination experiments suggest that Gdf7 is a mesenchymal signal that acts in a paracrine fashion to control the differentiation of the seminal vesicle epithelium.

Fractures of the mandibular condyle. Part 1: patterns of distribution of types and causes of fractures in 348 patients

This prospective study was designed to record relevant characteristics of mandibular condyle fractures and to evaluate the relationship between these. Data were recorded on sex, age, cause of trauma, level of fracture, dislocation of the mandibular head, dental state and associated fractures of all patients diagnosed in our hospital during the period 1984-1996 with mandibular condyle fractures. Data were analysed in our Computer Department. The sample comprised 348 patients with 444 fractures, and a male:female ratio of 2:1. Traffic accidents were the most common cause: 103 (41%) of the unilateral and 54 (56%) of the bilateral fractures, followed by alleged assault and falls. Low fractures were the most common -n = 314 of 444 (71%). The causes that involved considerable force (traffic accidents and falls) resulted in more dislocations of the mandibular head, more bilateral fractures, a tendency to fractures higher on the condyle and significantly more intracapsular fractures. Absence of molar occlusion also gave more high and fewer low fractures, but played no part in dislocation of the mandibular head from the glenoid fossa.

Fractures of the mandibular condyle. Part 2: results of treatment of 348 patients

This study was designed to record the results of conservative treatment of condylar fractures and to find out if there were any variables that were predictive of complications. Data were analysed in our computer department. During the period 1984-1996, all patients who presented with a fracture of the mandibular condyle and who attended for control examination one year after treatment were recorded at the end of treatment and one year later. The ability to open the mouth, deviation and occlusion were recorded. After one year 45 of the 348 patients (13%) had minor physical complaints such as reduced ability to open the mouth, deviation, or dysfunction. Ten of them (3%) had pain in the joint or muscles or both. Eight patients (2%) had malocclusion, which in seven could be related to dislocation of the condylar head out of the fossa. Five of the eight patients had had bilateral fractures. We conclude that conservative treatment of condylar fractures is non-traumatic, safe, and reliable and in only a few cases may cause disturbances of function and malocclusion. The risk associated with the latter is greatest with bilateral fractures and dislocation of the condylar head from the fossa.

Clonidine prevents insulin resistance and hypertension in obese dogs

The role that the central sympathetic nervous system plays in the development of obesity hypertension and insulin was evaluated by feeding dogs a high fat diet with or without clonidine treatment. Thirteen adult mongrel dogs were chronically instrumented and randomly assigned to receive either a high fat diet and no clonidine (n=6) or a high fat diet plus clonidine (n=7), 0.3 mg BID. Blood pressure, heart rate, plasma insulin, and electrolytes were measured daily. Insulin resistance was assessed with a multiple-dose euglycemic clamp (1, 2, and 30 mU. kg-1. min-1) before and after 1, 3, and 6 weeks of the high fat diet. Clonidine prevented the hypertension, tachycardia, and insulin resistance associated with feeding dogs the high fat diet but did not affect weight gain. The present study suggests that the central sympathetic nervous system plays a critical role in the development of both insulin resistance and hypertension associated with feeding dogs a high fat diet.

Comparative study of pain control by cryotherapy of exposed bone following extraction of wisdom teeth

A study was conducted to determine whether cryotherapy of bone exposed during the surgical removal of wisdom teeth is able to reduce the intensity of pain and general discomfort. Study design. A prospective investigation of 107 patients who required extraction of two wisdom teeth, one on the left and one on the right side of the lower jaw. Cryotherapy was carried out on one side only. Employing a visual analogue scale, the intensity of pain and general discomfort (swelling, inflammation, insomnia etc.) was recorded. Other parameters such as swelling, patient preference, and duration of the operation were also recorded. The chi-squared test was employed to compare the results between the treated and non-treated sides. There was significantly less pain, swelling and discomfort following the use of cryotherapy. Patient preference was also for cryotherapy. Operation time and the occurrence of inflammation were similar in both groups. In conclusion, cryotherapy is an effective procedure for reducing pain, swelling and general discomfort following extraction of a wisdom tooth in the lower jaw without creating irreversible sequelae.

Cancer of the nasal cavity and paranasal sinuses: a series of 115 patients

A total of 115 patients with sinonasal cancer was assessed during the period 1978-1995. Ninety-one patients received treatment with curative intent. A combination of irradiation and operation was used. The 5-year crude survival for patients, who were treated with curative intent, was 41%; the disease-specific survival throughout the period was 48%. Primary irradiation followed by maxillectomy was widely used in the first half of the period. Treatment in the last part was changed to primary lateral rhinotomy with post-operative irradiation whenever possible. Twelve maxillectomies were performed during the first half of the period, and during the last part, only two. Disease-specific survival was equal in the first and the second halves of the period.

Osseointegrated implants for prosthetic rehabilitation after treatment of cancer of the oral cavity

The treatment of oral cancer usually involves extensive resection of the mandible, excision of oro-facial soft tissue and often radiotherapy. This causes difficulty in the subsequent oral rehabilitation. The present paper reports our experience with implant treatment of this patient group. The material comprises 38 implants in 12 patients. Four patients died during follow-up, two before loading the implants. The observation time after implantation was 7 to 47 months with a median of 14 months. Six of the patients had been subjected to preoperative radiation therapy. All 38 implants osseointegrated without complications. It is concluded that healing after implantation in irradiated mandibles can be achieved without hyperbaric oxygen. Provided certain guidelines are complied with i.e. careful surgical technique, use of antibiotics and prolonged period of healing prior to loading of the implants, a radiation dosage of up to 50 Gy appears to be of little significance.

Time course of insulin resistance associated with feeding dogs a high-fat diet

The current study evaluated both the time course of insulin resistance associated with feeding dogs a high-fat diet and the relationship between the development of insulin resistance and the increase in blood pressure that also occurs. Twelve adult mongrel dogs were chronically instrumented and randomly assigned to either a control diet group (n = 4) or a high-fat diet group (n = 8). Insulin resistance was assessed by a weekly, single-dose (2 mU.kg-1.min-1) euglycemic-hyperinsulinemic clamp on all dogs. Feeding dogs a high-fat diet was associated with a 3.7 +/- 0.5 kg increase in body weight, a 20 +/- 4 mmHg increase in mean blood pressure, a reduction in insulin-mediated glucose uptake [(in mumol-kg-1.min-1) decreasing from 72 +/- 6 before to 49 +/- 7 at 1 wk, 29 +/- 3 at 3 wk, and 30 +/- 2 at 6 wk of the high-fat diet, P < 0.01]. and a reduced insulin-mediated increase in cardiac output. In eight dogs (4 high fat and 4 control), the dose-response relationship of insulin-induced glucose uptake also was studied. The whole body glucose uptake dose-response curve was shifted to the right, and the rate of maximal whole body glucose uptake was significantly decreased (P < 0.001). Finally, we observed a direct relationship between the high-fat diet-induced weekly increase in mean arterial pressure and the degree to which insulin resistance developed. In summary, the current study documents that feeding dogs a high-fat diet causes the rapid development of insulin resistance that is the result of both a reduced sensitivity and a reduced responsiveness to insulin.

Immediate obturation of the surgical defect after partial maxillectomy in the endentulous patient

Closure of the surgical defect immediately after partial maxillectomy is the treatment of choice. The advantages are: maintaining facial contour, rapid re-establishment of speech, swallowing and mastication. A number of methods for the fixation of the immediate obturator in patients without teeth have been described. A new technique is reported where a transnasal wire holds the existing denture in position after partial maxillectomy. The method has been carried out on 7 patients with sino-nasal cancer during the period 1978-1994. The advantages of the technique are that the wire acts as an axis of rotation which together with the sponge in the cavity provide good stability of the denture. There is minimal preoperative laboratory work and simplification in replacing the surgical dressing.

Treatment of large odontogenic keratocysts by decompression and later cystectomy: a long-term follow-up and a histologic study of 23 cases

OBJECTIVE

The purpose of this study was to determine the course of healing, the frequency of recurrence, and the changes in the epithelium of keratocysts after decompression treatment.

STUDY DESIGN

The treatment of 23 keratocysts, which had been divided into two groups (12 and 11 patients, respectively), was carried out in two phases: (1) insertion of a polyethylene drain and removal of a biopsy specimen from the cyst wall, and (2) cystectomy and removal of the drain approximately 1 year later. Histologic examination of the biopsy material from the two phases was carried out, and the material classified according to Forssell.

RESULTS

Reduction in cyst volume together with bone healing occurred in all cases, although there was recurrence in two patients. Decompression resulted in substantial histologic changes in the epithelium in 19 cases (83%).

CONCLUSIONS

(1) Decompression results in new bone formation and thickening of the cyst wall. (2) This treatment conserves bone and anatomic structures. (3) The frequency of recurrence is low. (4) The keratocyst epithelium is modulated histologically to nonkeratocyst after decompression.

Metabolic and hemodynamic effects of a graded intracoronary insulin infusion in normal and fat anesthetized dogs: a preliminary study

This study evaluated both cardiac hemodynamic and metabolic effects of a graded intracoronary artery infusion of insulin in four normal and five obese anesthetized dogs. Dogs were anesthetized with isoflurane, a catheter was advanced under fluoroscopic guidance into the coronary sinus and great cardiac vein, and a 20-MHz 3F coronary Doppler catheter was advanced into either the mid left anterior descending or circumflex coronary artery. A graded intracoronary insulin infusion was administered (starting at 0.3 mU/min and doubling every 40 minutes until a maximum dose of 2.4 mU/min was achieved). Coronary glucose extraction, coronary blood flow velocity, and coronary artery size were measured at each infusion rate. An intracoronary artery infusion of insulin stimulated myocardial glucose uptake in normal dogs. However, in high-fat-fed dogs, weight gain was associated with a reduction in the ability of insulin to promote glucose uptake by cardiac muscle and a rightward shift in the dose-response curve. In normal dogs, an intracoronary insulin infusion resulted in an increase in coronary blood flow and coronary vasodilation (with insulin coronary vascular resistance index decreases to 0.72 +/- 0.06, P<.01), whereas with weight gain the vasodilator response to insulin was lost. The loss of coronary artery vasodilation to local hyperinsulinemia in fat-fed dogs is consistent with other reports in obese or hypertensive humans that document an impairment in the action of insulin to increase skeletal muscle blood flow.

Incompletely erupted third molars in the line of mandibular fractures. A retrospective analysis of 57 cases

A retrospective investigation was carried out of 57 cases of mandibular angle fractures, where a completely or partially impacted third molar was present in the line of fracture. Closed reduction was used in all of the cases, using intermaxillary fixation over a period of 42 days. Antibiotics were given to all patients for a period of 1 week. Thirty-one patients (55%) were treated within the first 24 hours and 43 (75%) within 48 hours. Infection at the fracture site occurred in two patients (3.5%). Both of these patients had been treated within the first 24 hours. It is concluded that closed reduction with retention of the mandibular third molar within the line of a mandibular angle fracture can be carried out with less morbidity compared with cases in which rigid fixation is used and movement of the jaws permitted immediately. Because of the size of the study group, no relationship could be demonstrated between cases with infection and the time from trauma to fixation.

[Lymphangioma of the tongue: case report and review of the literature]

A case of lymphangioma in the tongue is discussed with special reference to diagnosis, treatment and prognosis. The patient is a boy, aged 13, with a congenital malformation in the right half of the tongue. The lesion was removed by surgery. Histologic examination showed lymphangioma. In cases of minor, localized lymphangiomas the clinical diagnosis may be difficult. A past history information of recurring swellings can be regarded as almost diagnostic. The treatment of choice is surgery, if necessary in several settings. Recurrences are often seen.

[Dislocation of mandibular condyle into middle cranial fossa]

A case of dislocation of the mandibular condyle into the middle cranial fossa is presented. The patient was a 8-year-old girl. Immediate conservative reposition was performed successfully with an intermaxillary fixation for two weeks. Two years after the accident her dental occlusion had remained stable, although there was a slight limitation in opening. Based on the present case and previous case reports it is concluded that early diagnosis and treatment is important. Manual reduction and fixation should be the first choice of treatment. The risk of intracranial complications necessitates a close cooperation with a neurosurgeon. Follow-up studies have revealed that most of the patients develop laterognatism and/or limited movements of the mandible.

Metastases to the mouth and jaws from hepatocellular carcinomas. A case report

Hepatocellular carcinoma metastasis to the jaw and soft tissue of the oral cavity is a rare phenomenon. A case of metastatic hepatocellular carcinoma to the mandible is described. A review of the literature showed that only 19 such cases have been reported so far. As severe haemorrhage may occur during surgical removal of these metastases, it is advisable to carry out fine needle aspiration biopsy when metastasis from a hepatocellular carcinoma is suspected.

A case of benign lymphoepithelial lesion of the hard palate

The benign lymphoepithelial lesion is a rare condition, most frequently affecting the parotid gland. A review of the literature brought to light 4 earlier cases with localization in the accessory salivary glands in the oral cavity. The present report presents a 5th case arising from the accessory salivary glands on the left side of the hard palate. Destruction of the underlying bone was demonstrated radiologically; the latter has not previously been described. The present report contains a survey of the literature, as well as a review of the pathogenesis, clinical aspects and treatment of the disease.