Edmund J. Rutherford

The staged celiotomy for trauma. Issues in unpacking and reconstruction.

OBJECTIVE This article describes the important clinical events and decisions surrounding the reconstruction/unpacking portion of the staged celiotomy for trauma. METHODS Of 13,817 consecutive trauma admissions, 1175 received trauma celiotomies. Of these, 107 patients (9.1%) underwent staged celiotomy with abdominal packing. The authors examined medical records to identify and characterize: (1) indications and timing of reconstruction, (2) criteria for emergency return to the operating room, (3) complications after reconstruction, and (4) abdominal compartment syndrome (ACS). RESULTS Fifty-eight patients (54.2%) survived to reconstruction, 43 (74.1%) survived to discharge; 9 patients (15.5%) were returned to the operating room for bleeding; 13 patients required multiple packing procedures. There were 117 complications; 8 patients had positive blood cultures, abdominal abscesses developed in 6 patients, and ACS developed in 16 patients. CONCLUSIONS 1. Reconstruction should occur after temperature, coagulopathy, and acidosis are corrected, usually within 36 hours after the damage control procedure. 2. Emergent reoperation should occur in any normothermic patient with unabated bleeding (greater than 2 U packed cells/hr). 3. ACS occurs in 15% of patients and is characterized by high peak inspiratory pressure, CO2 retention, and oliguria. Lethal reperfusion syndrome is common but preventable.

Base deficit stratifies mortality and determines therapy.

OBJECTIVE To determine the association of base deficit with mortality and other factors affecting mortality. DESIGN Retrospective review. SETTING Tertiary care center. PARTICIPANTS Consecutive samples of 3791 trauma patients admitted with an arterial blood gas sample taken in the first 24 hours. MAIN OUTCOME MEASURES Age, injury mechanism, head injury, shock (systolic blood pressure less than 90 mm Hg), Revised Trauma Score, TRISS probability of survival Ps, and mortality. RESULTS Most (3038) patients (80.1%) exhibited a base deficit. Base deficit, age, injury mechanism, and head injury were associated with mortality using logistic regression. Age less than 55 years, no head injury, and a base deficit of -15 mmol/L were associated with 25% mortality. Age greater than or equal to 55 years with no head injury or age less than 55 years with a head injury and a base deficit of -8 mmol/L were associated with a 25% mortality. When shock was added to the model, all factors remained significant, and base deficit was supplemental to blood pressure. Base deficit also added significantly to the Revised Trauma Score and TRISS measurements. CONCLUSIONS The base deficit is an expedient and sensitive measure of both the degree and the duration of inadequate perfusion. It is useful as a clinical tool and enhances the predictive ability of both the Revised Trauma Score and TRISS.

Gastric tonometry supplements information provided by systemic indicators of oxygen transport.

HYPOTHESIS Assessment of splanchnic perfusion by gastric intramucosal pH (pHi) adds to the information provided by systemic indicators of oxygen transport. SETTING University Hospital level I trauma center. DESIGN Prospective study in 20 critically ill trauma patients comparing pHi with base deficit, lactate, oxygen delivery, and oxygen consumption (indexed to body surface area), mixed venous oxygen saturation (Svo2), oxygen utilization coefficient, and arterial pH. All measurements were obtained at admission, 1, 2, 4, 8, 16, and 24 hours, or at death. MAIN OUTCOME MEASURES Correlation of pHi with the measured systemic variables, prediction of organ dysfunction, development of multiple organ dysfunction syndrome, and mortality. RESULTS There was a poor correlation between pHi and the systemic hemodynamic and oxygen transport variables. Patients with a low pHi (< 7.32) on admission who did not correct within the initial 24 hours had a higher mortality (50% vs. 0.0%, p = 0.03) and incidence of organ dysfunction (2.6 organs/patient vs. 0.62 organs/patient, p = 0.02) than those who did. Using logistic regression analysis, only pHi, base deficit, and Svo2 were significantly associated with mortality during the study period. At 24 hours, only pHi was different between patients who developed multiple organ dysfunction syndrome and those who did not. There was a threshold value for pHi (7.10) which identified those patients who would go on to develop multiple organ dysfunction syndrome. CONCLUSIONS Uncorrected splanchnic malperfusion is associated with a higher incidence of organ dysfunction and mortality. Gastric tonometry supplements information provided by systemic indicators of oxygen transport during resuscitation of critically ill trauma patients.

Elective bedside surgery in critically injured patients is safe and cost-effective.

OBJECTIVE The success of elective minimally invasive surgery suggested that this concept could be adapted to the intensive care unit. We hypothesized that minimally invasive surgery could be done safely and cost-effectively at the bedside in critically injured patients. SUMMARY BACKGROUND DATA This case series, conducted between October 1991 and June 1997 at a Level I trauma center, examined bedside dilatational tracheostomy (BDT), percutaneous endoscopic gastrostomy (PEG), and inferior vena cava (IVC) filter placement. All procedures had been performed in the operating room (OR) before initiation of this study. METHODS All BDTs and PEGs were performed with intravenous general anesthesia (fentanyl, diazepam, and pancuronium) administered by the surgical team. IVC filters were placed using local anesthesia and conscious sedation. BDTs were done using a Ciaglia set, PEGs were done using a 20 Fr Flexiflow Inverta-PEG kit, and IVC filters were placed percutaneously under ultrasound guidance. Cost difference (delta cost) was defined as the difference in hospital cost and physician charges incurred in the OR as compared to the bedside. RESULTS Of 16,417 trauma admissions, 379 patients (2%) underwent 472 minimally invasive procedures (272 BDTs, 129 PEGs, 71 IVC filters). There were four major complications (0.8%). Two patients had loss of airway requiring reintubation. Two patients had an intraperitoneal leak from the gastrostomy requiring operative repair. No patient had a major complication after IVC filter placement. Total delta cost was

Acute posttraumatic renal failure: a multicenter perspective.

611,994. When examined independently, the cost was

Needle thoracostomy may not be indicated in the trauma patient

324,224 for BDT,

Prospective comparison of clinical judgment and APACHE II score in predicting the outcome in critically ill surgical patients.

164,088 for PEG, and

Stapled versus Sutured Gastrointestinal Anastomoses in the Trauma Patient: A Multicenter Trial

123,682 for IVC filter. OR use was reduced by 506 hours. CONCLUSIONS These bedside procedures have minimal complications, eliminate the risk associated with patient transport, reduce cost, improve OR utilization, and should be considered for routine use in the general surgery population.

Hypothermia in critically ill trauma patients

UNLABELLED Acute renal failure (ARF) following trauma is rare. Historically, ARF has been associated with a high mortality rate. To investigate this entity we conducted a retrospective review of 72,757 admissions treated at nine regional trauma centers over a 5-year period. Seventy-eight patients (0.098%) developed acute renal failure requiring hemodialysis. Detailed demographic, clinical, and outcome data were collected. Patients with pre-existing medical conditions (group I) had a 70% increase in mortality over those without pre-existing conditions (p less than 0.004). Twenty-four patients (31%) developed ARF less than 6 days after injury (group II). The remainder (group III) developed late renal failure (mean time to first dialysis, 23 days). The predominant cause of death was multiple organ failure (82%). There were no differences in mortality because of multiple organ failure among the three groups of patients. Of the 33 survivors, six (18%) were discharged with renal insufficiency, three (9%) were discharged on dialysis, 23 (70%) were discharged home or to rehabilitation, and 27 (82%) had no significant evidence of renal insufficiency. CONCLUSION Posttraumatic renal failure requiring hemodialysis is rare (incidence, 107 per 100,000 trauma center admissions), but the mortality rate remains high (57%). Two thirds of the cases of posttraumatic renal failure develop late and are secondary to multiple organ failure; one third of the cases of posttraumatic renal failure develop early and may result from inadequate resuscitation.

The futility of chest roentgenograms following routine central venous line changes

OBJECTIVE The aim of this study was to evaluate the usefulness of needle thoracostomy catheter (NTC) placement in trauma. METHODS A consecutive case series was conducted from November 1996 to September 1997. All patients admitted to a level I trauma centre who had NTCs placed prior to arrival in the Emergency Department were included. No patients were excluded or omitted. During the course of the study 2801 patients were admitted to our trauma centre. Nineteen patients (0.68%) had NTCs placed prior to arrival in the emergency department. RESULTS Twenty-five needle thoracostomies were performed in 19 patients. This group represented 0.68% of the trauma admissions. Four patients were found to have evidence of a pneumothorax with an air leak (28%). The NTC failed to decompress the chest in one of two patients who had physiologic evidence of a tension pneumothorax. Eleven patients (58%) were endotracheally intubated prior to NTC. CONCLUSIONS This study suggests that field NTC placements are often ineffective and may be over-used. Further study on the usefulness of NTC is required.