Caleb J. Mentzer

Peritoneal cavity lavage reduces the presence of mitochondrial damage associated molecular patterns in open abdomen patients

BACKGROUND Mitochondrial damage-associated molecular patterns (mtDAMPs), such as mitochondrial DNA and N-formylated peptides, are endogenous molecules released from tissue after traumatic injury. mtDAMPs are potent activators of the innate immune system. They have similarities with bacteria, which allow mtDAMPs to interact with the same pattern recognition receptors and mediate the development of systemic inflammatory response syndrome (SIRS). Current recommendations for management of an open abdomen include returning to the operating room every 48 hours for peritoneal cavity lavage until definitive procedure. These patients are often critically ill and develop SIRS. We hypothesized that mitochondrial DAMPs are present in the peritoneal cavity fluid in this setting, and that they accumulate in the interval between washouts. METHODS We conducted a prospective pilot study of critically ill adult patients undergoing open abdomen management in the surgical and trauma intensive care units. Peritoneal fluid was collected daily from 10 open abdomen patients. Specimens were analyzed via quantitative polymerase chain reaction (qPCR) for mitochondrial DNA (mtDNA), via enzyme immunoassay for DNAse activity and via Western blot analysis for the ND6 subunit of the NADH: ubiquinone oxidoreductase, an N-formylated peptide. RESULTS We observed a reduction in the expression of ND6 the day after lavage of the peritoneal cavity, that was statistically different from the days with no lavage (% change in ND6 expression, postoperative from washout: −50 ± 11 vs. no washout day, 42 ± 9; p < 0.05). Contrary to expectation, the mtDNA levels remained relatively constant from sample to sample. We then hypothesized that DNAse present in the effluent may be degrading mtDNA. CONCLUSION These results indicate that the peritoneal cavity irrigation reduces the presence of mitochondrial DAMPs in the open abdomen. It is possible that increased frequency of peritoneal cavity lavage may lead to decreased systemic absorption of mtDAMPs, thereby reducing the risk of SIRS. LEVEL OF EVIDENCE Prospective study, Case Series, Level V.

Traumatic panhypopituitarism resulting in acute adrenal crisis.

ABSTRACT Pituitary function plays an integral role in the physiologic response to traumatic injury. A significant proportion of trauma patients develop partial pituitary insufficiency. While isolated deficiencies of individual pituitary hormones are common, there are few reports in the literature of traumatic pan-pituitary failure with deficiency of all major pituitary hormones. We present a case of a patient involved in a motorcycle accident who sustained a sella turcica fracture, epidural hemorrhage, subdural hemorrhage, optic nerve palsy, and bilateral abducens nerve palsies. Three days after the accident, the patient became hypotensive and progressed to cardiopulmonary arrest. He was resuscitated and had spontaneous return of circulation. Despite adequate fluid resuscitation and vasopressor support, he remained profoundly hypotensive. Following administration of hydrocortisone, his blood pressures dramatically improved. He was found to have laboratory abnormalities, suggesting deficiencies of corticotropins, somatotropins, thyrotropins, gonadotropins, prolactin, and antidiuretic hormone. This is the first reported case of a patient with traumatic total panhypopituitarism complicated by acute adrenal crises during initial postinjury hospitalization. A review of the literature with comparison with other studies of trauma patients with deficiencies in five or more axes is presented. A high level of suspicion for central adrenal insufficiency and prompt administration of corticosteroids in the setting of symptomatic pituitary trauma can result in favorable outcomes. Screening for and treating posttraumatic hypopituitarism can result in improved rehabilitation and increased quality of life for trauma patients.

A low-cost, non-biologic, thoracentesis and thoracostomy simulator

Background: Increasing emphasis is being placed on simulation for education of practitioners. Simulation has been validated as a useful educational tool for learning invasive procedures in a low-stress environment where expert guidance can be used to increase proficiency and confidence for multiple skills. A low-cost, non-biologic simulator does not currently exist for thoracentesis. Materials and Methods: A home-made thoracentesis and percutaneous thoracostomy simulator was constructed from readily available materials. After viewing instructional videos and after a lecture and demonstration, students were asked to perform thoracentesis and thoracostomy. Results: All students were eventually able to use the model to perform the procedures without prompting or guidance. Some students had minor technical errors in catheter placement or advancement, which were corrected. After reviewing the error, they were then able to go on to successful placement of the catheter. No student caused a pneumothorax in the simulation. Conclusions: The model is a cost-effective, easy to make solution for teaching thoracentesis and thoracostomy.

Endovascular embolization for the treatment of right carotid-jugular arteriovenous fistula, with communicating left vertebral-right jugular arteriovenous fistula

Traumatic arteriovenous fistulas of the neck are a relatively uncommon injury, whose ramifications can include immediate or delayed neurological insults, massive bleeding, or death. Angiography and embolization have been increasingly used to manage this complex injury pattern. In this particular case, the patient underwent management of bilateral communicating arteriovenous fistulae using a commercially available plug occlusion device. Epidemiology, with an emphasis on patient management and outcomes, is discussed.