Corrado P. Marini

Lesiones duodenales secundarias a traumatismo: revisión de la literatura

Duodenal injuries constitute a challenge to the Trauma Surgeon, mainly due to their retroperitoneal location. When identified, they present associated with other abdominal injuries. Consequently, they have an increased morbidity and mortality. At best estimates, duodenal lesions occur in 4.3% of all patients with abdominal injuries, ranging from 3.7% to 5%, and because of their anatomical proximity to other organs, they are rarely an isolated injury. The aim of this paper is to present a concise description of the anatomy, diagnosis, surgical management and treatment of complications of duodenal trauma, and an analysis of complications and mortality rates of duodenal injuries based on a 46-year review of the literature.

The impact of early flow and brain oxygen crisis on the outcome of patients with severe traumatic brain injury.

BACKGROUNDnMultimodality monitoring and goal-directed therapy may not prevent blood flow and brain oxygen (Flow/BrOx) crisis. We sought to determine the impact of these events on outcome in patients with severe traumatic brain injury (sTBI).nnnMETHODSnTwenty-four patients with sTBI were treated to maintain intracranial pressure (ICP) less than or equal to 20xa0mm Hg, cerebral perfusion pressure (CPP) greater than or equal to 60xa0mm Hg, brain oxygen greater than or equal to 20xa0mm Hg, and near infrared spectroscopy greater than or equal to 60%. Flow/BrOx crisis events were recorded. The 14-day predicted mortality was compared with actual mortality.nnnRESULTSnNonsurvivors had a significantly higher number of crisis events nonresponsive to treatment (P < .05). Mortality was 87.5% in patients with greater than or equal to 20 events versus 6.3% in patients with less than 20 events. The predicted mortality was 58%, whereas actual mortality was 33.3% (8/24), yielding a 42% reduction in mortality.nnnCONCLUSIONSnA multimodality monitoring and goal-directed therapy may decrease mortality in sTBI. However, Flow/BrOx crisis events still occur and predict a poor outcome.

Isolated transverse process fractures: insignificant injury or marker of complex injury pattern?

IntroductionThis study investigates the incidence of isolated transverse process fractures (ITPFx) amongst vertebral fractures in trauma patients, and specific-associated injury patterns present in patients with ITPFx.Materials and methodsA retrospective, 4-year review of our Level 1 Trauma Center registry was performed. Patients with blunt spinal column fractures were identified. Data collected included patient demographics, Injury Severity Score (ISS), type of imaging obtained, and concomitant injuries, including rib and pelvic fractures, liver, spleen, and kidney injury (SOI).ResultsOf the 10,186 patients admitted during the study period, 881 (8.6%) suffered blunt thoraco-abdominal trauma resulting in vertebral fractures; 214/881 (24%) had ITPFx. All patients (10,186) underwent dedicated spinal multi-detector CT (MDCT) imaging; 26/214 (12.1%) patients had MRI. In all 26 patients, the MRI confirmed the CT findings. 202/214 (94.4%) had associated injuries: rib and pelvic fractures, 45.5 and 20.2%, respectively, and splenic, liver and kidney injury with an incidence of 13.8, 10.9, and 9.4%, respectively. A higher incidence of rib fractures was associated with ITPFx at the T1–4 levels, whereas ITPFx at the level of L5 were associated with pelvic fractures and SOI. Multiple logistic regression analysis identified T1–4 and L5 fractures as predictors of rib fractures and pelvic fractures independent of ISS, with OR: 2.55 (95% CI: 1.12–5.82) and 6.81 (95% CI: 3.14–14.78), respectively.ConclusionsBased on the results of this study, we conclude that: (1) the use of MDCT imaging has increased the rate of identification of ITPFx; (2) dedicated spinal MDCT reconstruction and MRI may not be necessary to diagnose isolated thoracic and lumbar ITPFx; and (3) ITPFx of the thoracic spine and lower lumbar spine are markers of associated rib fractures and pelvic ring fractures, respectively, as well as of solid organ injuries.

The efficacy of platelet-rich plasma gel in MRSA-related surgical wound infection treatment: an experimental study in an animal model

IntroductionThe wound healing properties of platelet-rich plasma (PRP) gel have been documented in many studies. PRP gel has also become a promising agent for treating surgical site infections. In this study, we investigated the antibacterial activity and wound healing effectiveness of PRP in an animal model of Methicillin-resistant Staphylococcus aureus subsp. aureus (MRSA N315)-contaminated superficial soft tissue wounds.Materials and methodsSubcutaneous wounds in Wistar Albino male rats were created by making two cm midline incisions followed by inoculation of microorganisms. Study groups comprised of Sham (no treatment), PRP alone, MRSA alone, MRSAu2009+u2009PRP, MRSAu2009+u2009Vancomycin, and MRSAu2009+u2009Vancomycinu2009+u2009PRP groups. We inoculated 0.1xa0mL (3u2009×u2009108 CFU/mL) of MRSA in contaminated groups. After 8 days, all rats were killed, wounds were excised and subjected to histopathologic examination, and MRSA counts were determined.ResultsMRSA counts in MRSA, MRSAu2009+u2009PRP, MRSAu2009+u2009Vancomycin and MRSAu2009+u2009Vancomycinu2009+u2009PRP groups were 5.1u2009×u2009106 (SDu2009±u20090.4) CFU/mL, 4.3u2009×u2009106 (SDu2009±u20090.7) CFU/mL, 2.3u2009×u2009106 (SDu2009±u20090.3) CFU/mL, 1.1u2009×u2009106 (SDu2009±u20090.4) CFU/mL, respectively. The inflammation scores of MRSAu2009+u2009PRP, MRSAu2009+u2009Vancomycin, and MRSAu2009+u2009Vancomycinu2009+u2009PRP groups were significantly lower than the MRSA group. MRSAu2009+u2009Vancomycinu2009+u2009PRP group inflammation score was significantly lower than the MRSAu2009+u2009PRP group.DiscussionAll treatment groups were effective in wound healing and decreasing the MRSA counts. MRSAu2009+u2009PRP combined created identical inflammation scores to the PRP group. More in vivo studies are required to corroborate these findings.

Orientación terapéutica del traumatismo pancreático: revisión de la literatura

Pancreatic injury is an uncommon event often difficult to diagnose at an early stage. After abdominal trauma, the surgeon must always be aware of the possibility of pancreatic trauma due to the complications associated with missed pancreatic injuries. Due to its retroperitoneal position, asociated organs and vascular injuries are almost always present, which along with frequent extra abdominal injuries explain the high morbidity and mortality. The aim of this study is to present a concise description of the incidence of these injuries, lesional mechanisms, recommended diagnostic methods, therapeutic indications including nonoperative management, endoscopy and surgery, and an analysis of pancreas-specific complications and mortality rates in these patients based on a 60-year review of the literature, encompassing 6,364 patients. Due to pancreatic retroperitoneal position, asociated organs and vascular injuries are almost always present, which along with frequent extraaabdominal injuries explain the high morbidity and mortality of these patients.

Contemporary wars and their contributions to vascular injury management

IntroductionMan’s inhumanity for man still knows no boundaries, as we continue as a species as a whole to engage in war. According to Kohn’s Dictionary of Wars [1], of over 3,700xa0years of recorded history, there have been a total of 3,010 wars. One is hard pressed to actually find a period of time in which here has not been an active conflict in the globe. The world has experienced two world wars: WWI (1914–1918) and WWII (1939–1945). The total number of military casualties in WWI was over 37 million, while WWII so far, has been the deadliest military conflict in history with over 60 million people killed accounting for slightly over 2.5xa0% of the world’s population.Material and methods The purpose of this study is to review contemporary wars and their contributions to vascular injury management. It is precisely wartime contributions that have led to the more precise identification and management of these injuries resulting in countless lives and extremities saved. However, surgeons dealing with vascular injuries have faced a tough and arduous road. Their journey was initiated by surgical mavericks which undaunted, pressed on against all odds guided by William Stewart Halsted’s classic statement in 1912: “One of the chief fascinations in surgery is the management of wounded vessels.”ConclusionContemporary wars of the XX–XXI centuries gave birth, defined and advanced the field of vascular injury management.

Traumatic injuries to the pregnant patient: a critical literature review

IntroductionTrauma during pregnancy is the leading non-obstetrical cause of maternal death and a significant public health burden. This study reviews the most common causes of trauma during pregnancy, morbidity, and mortality, and the impact upon perinatal outcomes associated with trauma, providing a management approach to pregnant trauma patients.Materials and methodsA systematic review of the current literature from January 2006 to July 2016 was performed.ResultsFifty-one articles were identified, including a total of 95,949 patients. Motor vehicle crash was the most frequent cause of blunt trauma, followed by falls, assault both domestic and interpersonal violence, and penetrating injuries (gunshot and stab wounds).ConclusionsTrauma in pregnant women is associated with high rates of adverse maternal and neonatal outcomes. Knowledge of the mechanism of injury is important to identify the potential injuries and the complexity of the management of these patients. As in all traumatic events, prevention is of paramount importance.

The impact of measurement of respiratory quotient by indirect calorimetry on the achievement of nitrogen balance in patients with severe traumatic brain injury

BackgroundThis study evaluated the impact of IC on the optimization of nutritional support and the achievement of +NB in patients with TBI.Materials and methods27 patients (GCSxa0≤xa08), treated with a 5-day multimodality monitoring and goal-directed therapy protocol, received enteral nutrition on day 1 followed by IC on days 3 and 5 and assessment of NB on day 7. In the first cohort (nxa0=xa011), no adjustment in kcal was made. In the second cohort (nxa0=xa016), nutrition was targeted to an RQ of 0.83 by day 3. The first cohort was analyzed with respect to NB status; the second cohort was compared to patients with (−) and +NB of the first cohort. Data (meanxa0±xa0SD) were analyzed with unpaired t test, and Chi square and Fisher exact tests.Results4/11(36xa0%) patients in the first cohort had +NB. The predicted mortality by TRISS, substrate utilization, and RQ was significantly lower compared to the second cohort. The mortality predicted by the CrasH model did not differ between the two cohorts. A RQ of 0.74 was associated with the preferential use of fat and protein and −NB, whereas a RQ of 0.84 favored utilization of carbohydrates and +NB. All patients whose kcal intake was adjusted based on the RQ on day 3 reached a +NB by day 7.ConclusionAn increase in kcal ≥25xa0% in patients with a RQxa0<xa00.83 on day 3 improves substrate utilization, decreases protein utilization and optimizes the achievement of +NB by day 7.

Planning and Preparing for the Operation: Guidelines and the Evidence-Based Decision Tree

Surgical interventions induce a stress response whose magnitude depends on the pathology being treated, as well as many other factors such as the surgical approach, and the acuity of the procedure, among others. Additional factors accounting for the surgical risk include the complexity of the surgery and the patient’s premorbid conditions. There are different predictive models to estimate cardiac risks for patients undergoing non-cardiac surgery. One of the first described is the Goldman Multifactorial Risk Index developed in 1977, followed by the Detsky’s Cardiac Risk Index in 1986, the Eagle’s Cardiac Risk Index in 1989, and more recently by the Revised Cardiac Risk Index popularized by Lee in 1999. One of the most widespread tools used by anesthesiologist is the American Society of Anesthesiologist Physical Status Classification, which stratifies patients in six classes. There are several factors to be considered to decrease the overall risk of cardiac-related and all-cause surgical morbidity and mortality. The type and length of anesthesia is one of them, along with the impact that each organ specific pathology may have on the planned operation. This review highlights some of the more important aspects of planning and preparing for an operation, starting with the assessment of its risk and benefits based on the preoperative evaluation and the outcome expected.

Intraoperative Endpoints of Resuscitation

Perioperative evaluation and management of the patient has become a major focus of the strategy needed to minimize the risk of complications and to decrease surgical mortality. The endpoints of intraoperative resuscitation depend on the patient’s preoperative condition, including comorbidities, and the type and duration of the surgery being performed. Certain physiological principles apply from the standpoint of the relationship between cellular oxygen delivery and consumption during major surgical procedures, depending on the depth and duration of anesthesia, the magnitude of the planned procedure, and on the risk stratification of the patients with its associated predicted mortality. Attention should be directed to the intraoperative variables that may affect the postoperative course of the patient. The degree and type of hemodynamic monitoring should be selected based on the preoperative condition of the patient and the type of surgery being performed. Simple endpoints that could assure a safe intraoperative and postoperative course in a standard low-risk patient, such as measurement of heart rate, blood pressure, central venous pressure, and urine output, may be inadequate in an operation in a high-risk patient associated with massive fluid shift and blood loss.