Christopher P. Brandt

Is deep vein thrombosis surveillance warranted in high-risk trauma patients?

BACKGROUND Deep vein thrombosis (DVT) has been reported to occur in 20% to 40% of high-risk trauma patients if no prophylaxis is used. The purpose of this study was to determine the incidence of DVT and utility of a screening program in a high-risk group of trauma patients for whom routine DVT prophylaxis was utilized. PATIENTS AND METHODS Of 3,154 trauma admissions over a 20-month period, 343 patients (10.9%) identified as high risk based on established criteria (prolonged bed rest, Glasgow coma score (GCS) of 7, spinal injury, lower extremity or pelvic fracture) were placed on a prospective surveillance protocol using color-flow duplex scanning and received thromboembolic prophylaxis. RESULTS Twenty-three thromboembolic complications occurred, including 20 DVTs (5.8%) and 3 pulmonary emboli ([PE] 1%). Univariate analysis showed that the risk of DVT was related to age (52.6 + 19.9 years versus 38.1 + 18.5; P = 0.001), a longer hospital stay (31.4 versus 17.8 days; P = 0.001), or the presence of spinal fracture (12.6% versus 3.5%; P = 0.01). Discriminant function analysis revealed that length of stay, intensive care unit days, age, and GCS allowed correct classification of those who did not develop DVT in 97% of cases but was only correct in 15% of cases in predicting those who would develop DVT. Injury severity score (ISS) was not predictive in this multivariate analysis. Seventeen (85%) DVTs were unsuspected clinically. Study patients received an average of 3.5 studies at an overall charge of

Polypropylene mesh closure after emergency laparotomy: Morbidity and outcome

313,330 to detect 17 clinically unsuspected DVTs (5%). This represents about 5% of the total bed charges for these patients, or

Endoscopic placement of nasojejunal feeding tubes in ICU patients.

18,000 per DVT. CONCLUSIONS These results suggest that standard use of DVT prophylaxis in a high-risk trauma population leads to a low incidence of DVT and that a screening protocol is effective in detecting unsuspected DVTs. Use of a surveillance protocol, however, may reduce but will not eliminate the incidence of pulmonary emboli in this patient population.

Diagnostic laparoscopy in the intensive care patient

BACKGROUND Alternative methods for abdominal wall closure may be necessary after emergency laparotomy. The purpose of this study was to determine the morbidity and outcome of emergency fascial closure with polypropylene mesh. METHODS A retrospective review was performed of all patients undergoing emergency fascial closure with polypropylene mesh from January 1990 to March 1994. RESULTS Seventy patients were identified. Indications for mesh placement included visceral edema (40), infected/necrotic fascia (21), and planned reexploration (7). Enteric fistulas developed in five patients (7.1%). When omentum was interposed between intestine and mesh, the incidence of fistula was significantly reduced (0 of 51 vs 5 of 19, p < 0.01). Forty-two patients (60%) survived with wound closure, accomplished by skin flaps in 19 (45%), skin grafting in 11 (26%), and secondary healing in 6 (14%). The mesh was removed in six patients (14%). Complications of mesh extrusion and hernia occurred less often after skin flap closure compared with skin grafting or secondary healing (1 of 19 vs 9 of 17, p < 0.01). No mesh infection occurred. CONCLUSIONS Polypropylene mesh placement is an effective alternative for abdominal closure after emergency laparotomy, even when intraabdominal sepsis is present. Fistulas associated with its use may be effectively eliminated by the interposition of omentum between bowel and mesh. Wound closure with full-thickness skin flaps is the preferred method for soft tissue coverage when mesh is used.

Postoperative pain control.

AbstractBackground: Enteral nutrition is an important component in the management of critically ill patients, but it may be limited by gastric ileus and unreliable positioning of standard feeding tubes. The purpose of this study was to determine the risk, utility, and outcome of endoscopically placed nasojejunal feeding tubes (NJT) in intensive care unit (ICU) patients. Methods: We reviewed the records of all ICU patients who underwent endoscopic NJT placement from May 1995 to May 1997. A through-the-scope method was used with placement of either an 8-Fr or 10-Fr 240-cm tube. Comparison was made between tubes secured to a nasopharyngeal bridle and tubes secured without bridling. Results: A total of 66 NJT were placed in 56 patients. Previous gastric feeds had been attempted in 39 patients (70%) an average of 8.4 days prior to placing the NJT. Fifty tubes (76%) were placed in the ICU and 16 (34%) in the OR at the time of additional procedures. Procedure time ranged from 7 to 28 mins (mean, 15.2), and bridling was used in 24 of 66 placements (36%). Full caloric goal rates were achieved via 56 of 66 tubes (85%) at an average of 26.1 h after placement (range, 1–144). Goal rates were not achieved in 10 cases due to inadequate tube positioning in six, ileus in three, and early dislodgement in one. A procedure complication, consisting of aspiration, occurred in one case (1.5%). Length of tube use averaged 18.5 days (range, 1–74). Accidental tube dislodgement or migration occurred in 16 of 42 (38%) nonbridled tubes vs one of 24 (4%) bridled tubes (p < .05). Conclusions: Endoscopic placement of nasojejunal feeding tubes in critically ill patients is a safe, quick, and reliable option for enteral nutrition. Full caloric goal rates can be achieved rapidly in a high percentage of patients, even in cases where previous gastric feeds have not been tolerated. Use of a nasopharyngeal bridling system for tube security significantly decreases the risk of migration or accidental tube dislodgement.

Value of laparoscopy in trauma ICU patients with suspected acute acalculous cholecystitis

SummaryEvaluation of a potential acute abdomen in patients who require intensive care for concurrent medical/surgical problems is often difficult due to ambiguities in the physical exam and ancillary diagnostic tests. Between August 1990, and February 1992, 25 ICU patients underwent diagnostic laparoscopy to evaluate a suspected acute intraabdominal process. Thirteen laparoscopies were negative, and 12 were positive. The overall accuracy for laparoscopy was 96% as confirmed by subsequent laparotomy, autopsy, or clinical course. Laparoscopic findings led to a change in management in nine patients (36%), leading to earlier exploration in four patients, and avoidance of laparotomy in five. No significant hemodynamic effects were noted during laparoscopy, and the procedure-related morbidity was low (8.0%).Diagnostic laparoscopy is a safe and accurate guide for managing the ICU patient with a suspected acute surgical abdomen. The use of laparoscopy can help avoid nontherapeutic laparotomy or confirm the need for operative intervention in these complex cases.

Flexible sigmoidoscopy : A reliable determinant of colonic ischemia following ruptured abdominal aortic aneurysm

Prevention and control of postoperative pain are essential. Inadequate treatment of postoperative pain continues to be a major problem after many surgeries and leads to worse outcomes, including chronic postsurgical pain. Optimal management of postoperative pain requires an understanding of the pathophysiology of pain, methods available to reduce pain, invasiveness of the procedure, and patient factors associated with increased pain, such as anxiety, depression, catastrophizing, and neuroticism. Use of a procedure-specific, multimodal perioperative pain management provides a rational basis for enhanced postoperative pain control, optimization of analgesia, decrease in adverse effects, and improved patient satisfaction.

Improved survival of adults with extensive burns

Patients who require prolonged intensive care following traumatic injuries are at risk for developing acute acalculous cholecystitis (AAC). The diagnosis of AAC is often difficult to establish, resulting in increased morbidity and mortality in this critically ill population. We reasoned that diagnostic laparoscopy might provide a more accurate and timely method of diagnosis. Laparoscopy was performed in nine trauma ICU patients with suspected AAC. Four procedures were considered positive and five were negative. There were no false-positive or false-negative laparoscopic exams, and no procedure-related morbidity occurred. Comparison of multiple clinical, laboratory, and radiologic findings showed that only laparoscopy accurately distinguished between those patients with AAC and those without AAC. We conclude that diagnostic laparoscopy is safe and definitive in trauma ICU patients with suspected AAC and should be performed prior to proceeding with laparotomy.

Triage of minor burn wounds : Avoiding the emergency department

AbstractBackground: The development of colonic ischemia following repair of ruptured abdominal aortic aneurysm (AAA) is associated with significant morbidity and timely diagnosis is essential. The purpose of this study was to determine the efficacy of endoscopy in the diagnosis of colonic ischemia and in prediction of need for resection. Methods: Patients who underwent postoperative lower endoscopy after ruptured AAA from 1986 to 1995 were reviewed for endoscopic findings, clinical course, and patient outcome. Results: A total of 80 patients had ruptured AAA during the study period, of which 56 survived for longer than 24 h postoperatively. Flexible lower endoscopy was done in 18 patients (32%) on an average of 4.4 days following AAA repair (range 1–16). Indications for initial endoscopy included early or bloody stools in 12 (67%), hemodynamic instability or sepsis in eight (44%), and acidosis in four (22%). The extent of the examination was sigmoid or descending colon in 13, cecum in four, and transverse colon in one. Endoscopic findings were normal in four patients. Five examinations showed only areas of hemorrhagic mucosa. Absence of full-thickness ischemia was confirmed by clinical course or autopsy in these nine patients. Two examinations demonstrated full-thickness necrosis which was confirmed at subsequent laparotomy. In six examinations, ischemia was noted but judged to be limited to mucosa only. Absence of full-thickness disease was demonstrated by laparotomy in three and subsequent course in three. Eight patients (57%) with initial abnormal examinations underwent repeat endoscopy showing improved interval appearance in seven cases and progression to full-thickness ischemia in one patient. Conclusions: Flexible sigmoidoscopy reliably predicts full-thickness colonic ischemia following repair of ruptured aortic aneurysms. Patients with non-confluent ischemia limited to the mucosa can be safely followed by serial endoscopic examinations.

Rare bile duct anomalies

Before 1988, survival of adults with burns > or = 75% total body surface area was uncommon in our burn unit. In 1988 a revised treatment plan for adult patients with burns > or = 75% was instituted. This plan included rapid disciplined eschar removal to fascia within 7 days, sequential meshed autografting with concomitant fresh allograft application, and early enteral feedings.