Brian L. McCroskey

Ten versus Tpn following Major Abdominal Trauma—reduced Septic Morbidity

Recent animal models suggest that enteral feeding (TEN) compared to parenteral nutrition (TPN) improves resistance to infection. This prospective clinical trial examined the impact of early TEN vs. TPN in the critically injured. Seventy-five patients with an abdominal trauma index (ATI) greater than 15 and less than 40 were randomized at initial laparotomy to receive either TEN (Vivonex TEN) or TPN (Freamine HBC 6.9% and Trophamine 6%); both regimens contained 2.5% fat, 33% branched chain amino acids, and had a calorie to nitrogen ratio of 150:1. TEN was delivered via a needle catheter jejunostomy. Nutritional support was initiated within 12 hours postoperatively in both groups, and infused at a rate sufficient to render the patients in positive nitrogen balance. The study groups (TEN = 29 vs TPN = 30) were comparable in age, injury severity and initial metabolic stress. Jejunal feeding was tolerated unconditionally in 25 (86%) of the TEN group. Nitrogen balance remained equivalent throughout the study period, at day 5 TEN = -0.3 +/- 1.0 vs. TPN 0.1 +/- 0.8 gm/day. Traditional nutritional protein markers (albumin, transferrin, and retinol binding protein) were restored better in the TEN group. Infections developed in 5 (17%) of the TEN patients compared to 11 (37%) of the TPN group. The incidence of major septic morbidity was 3% (1 = abdominal abscess) in the TEN group contrasted to 20% (2 = abdominal abscess, 6 = pneumonia) with TPN. This clinical study demonstrates that TEN is well tolerated in the severely injured, and that early feeding via the gut reduces septic complications in the stressed patient.

Hypothermia-Induced Coagulopathies in Trauma

Hemorrhage accounts for 90 per cent of deaths after abdominal injury, and half of these deaths are secondary to a recalcitrant coagulopathy. This review concentrates on our present knowledge of the role of hypothermia in trauma-related coagulopathies and notes that preventing as well as treating these disorders remains the focus and the challenge of many investigators in the field of trauma.

Gastrointestinal symptoms attributed to jejunostomy feeding after major abdominal trauma--a critical analysis.

Meeting the increased metabolic demands in the critically injured is a continuing challenge. Benefits of early enteral feeding after abdominal trauma have been previously reported, but the frequency of patient intolerance due to GI complaints remains unclear. One hundred twenty-three patients undergoing emergent laparotomy for major abdominal trauma with an abdominal trauma index greater than or equal to 15 were prospectively randomized to either a control group (n = 52, no enteral nutrition during the first 5 days) or an enteral-fed group (n = 71). The enteral group had a needle catheter jejunostomy (NCJ) placed at laparotomy and an elemental diet begun 12 h postoperatively, advanced in volume and concentration at 8-h intervals to 100-125 ml/h of full-strength diet. Symptoms of GI complaints (nausea, vomiting, cramping, distention, and diarrhea) were monitored daily and graded as minimal, moderate, or significant. Fifty percent of the control group had one or more GI complaints during the study period; six (12%) developed moderate discomfort. In the enteral group, 59 (83%) patients reported some GI discomfort; 11 had significant complaints (two nausea, seven cramping, six distention, two diarrhea). Nine (13%) of the enteral-fed patients ultimately required total parenteral nutrition supplementation due to GI complaints. The remaining 62 (87%) enteral patients were maintained on the elemental diet for a mean of 7 days (range 5 to 20). By postoperative day 5, patients received an average of 35 kcal/kg and 14.5 g N/day; 66% (41/62) were in positive N balance.(ABSTRACT TRUNCATED AT 250 WORDS)

Value of distal colon washout in civilian rectal trauma--reducing gut bacterial translocation.

Recent experience with civilian rectal trauma challenges the military dictum advocating routine distal colon washout. Opponents contend that septic morbidity is not influenced by perioperative removal of feces from the rectosigmoid region. In an effort to elucidate this issue, we reviewed 27 consecutive patients sustaining extraperitoneal rectal trauma over the past 5 years. One patient, exsanguinating from abdominal vascular injury, was excluded from further analysis. In the remaining 26 patients, rectal injury was due to gunshot wound in 16 (62%), pelvic fracture in 8 (31%), and stab wound in 2 (7%). The mean Revised Trauma Score was 6.9

A plea for sensible management of myocardial contusion

pM 0.4, Abdominal Trauma Index 20.9

Venous bullet embolism: rationale for mandatory extraction

pM 8.1, and Injury Severity Score 28.6

Aortoiliac reconstruction combined with nonvascular operations

pM 11.0. Proximal colostomy was done in all patients and presacral drains were placed in 23 (88%). Broadspectrum antibiotics were administered for a minimum of 5 days. Thirteen (50%) of the group underwent intraoperative washout of the distal rectosigmoid colon, dictated by attending surgeons preference; the other half did not. These two groups were otherwise comparable with respect to injury mechanism, shock on arrival, rectal wound severity, associated injuries, and perioperative blood transfusions. Major complications were greater in the nowashout versus washout groups: pelvic abscess, 46% vs. 8%; rectal fistulae, 23% vs. 8%; and sepsis, 15% vs. 8%. The single death (4%) occurred in the nowashout group. Although based on a small group of patients, these trends imply that distal colon washout reduces septic morbidity following civilian rectal trauma. This benefit is greatest for injuries due to pelvic fractures and high-energy gunshot wounds. Ultimate resolution of the distal colon washout controversy demands a multicenter prospective randomized trial.

Operative splenic salvage in adults: a decade perspective.

The purpose of this study was to define the relative risk of life-threatening sequelae in patients at risk for myocardial contusion. During a 3-year period, 280 patients sustaining blunt chest trauma were admitted to the surgical intensive care unit to exclude myocardial contusion. Patients were evaluated by electrocardiogram and creatine phosphokinase (CPK) MB enzyme levels every 8 hours for a minimum of 48 hours. Myocardial contusion was identified in 35 patients (13 percent); the diagnosis was established by transient electrocardiographic changes (30), CPK-MB more than 3 percent (9) or both criteria (4). Two patients (1 percent) died from cardiac decompensation 4 and 12 hours postinjury, and seven (3 percent) required early (12 hours postinjury) intensive care unit treatment of arrhythmias or myocardial failure. None of the remaining 271 patients developed cardiac symptoms. This clinical experience underscores the low incidence of cardiac sequelae among patients at risk for myocardial contusion. Complications were always manifest within 12 hours of injury. The clinical diagnosis of myocardial contusion can be excluded pragmatically in the asymptomatic patient with a normal electrocardiogram and CPK-MB levels during the initial 24-hour postinjury period.

Intraoperative hypogastric artery embolization for life-threatening pelvic hemorrhage: a preliminary report

Venous missile embolism is a rare complication of penetrating trauma which poses controversial management options. We report a case of hepatic vein bullet embolism treated by percutaneous transvenous basket relocation and extraction via femoral vein cutdown. A review of 102 reported bullet emboli since 1930 indicates that the morbidity of a retained projectile is substantial (25%), while removal using modern techniques has few complications. Salient features of early extraction include: 1) prevention of proximal migration, 2) transvenous relocation of the missile to an accessible vein, and 3) peripheral surgical removal. Delayed recognition of an asymptomatic bullet embolus demands further judgment in guiding selective operative removal. A management scheme based on time of recognition, patient status, and embolus characteristics is presented for this unusual problem.

The role of a regional trauma system in the management of a mass disaster: an analysis of the Keystone, Colorado, chairlift accident

Seventy-six patients with aortoiliac reconstruction and associated intraabdominal procedures were compared with 445 patients with aortoiliac revascularization alone to provide information about the associated morbidity and mortality of adding a nonvascular procedure to aortic reconstruction. Patients with aortoiliac reconstruction for limb salvage had a significant increase in complications when an abdominal procedure was performed in association with aortoiliac reconstruction (66 percent versus 14 percent, p less than 0.01). Additionally, patients with elective aortoiliac reconstruction had a significant increase in mortality when an abdominal procedure was performed in addition to aortoiliac reconstruction (9 percent versus 3 percent, p less than 0.01). A small bowel obstruction and a pancreatic pseudocyst occurred as a direct result of the associated abdominal procedure. None of the deaths could be directly attributed to a concomitant abdominal procedure. The demonstration of an increase in morbidity and mortality with the addition of nonvascular procedures to aortoiliac reconstruction, even though certain subgroups of patients underwent aortic revascularization, suggest that the surgeon must carefully weigh the benefits and risks before combining vascular and nonvascular operations.