Elcio Shiyoiti Hirano

Trauma hepático contuso: comparação entre o tratamento cirúrgico e o não operatório

OBJECTIVE: To examine the outcomes of blunt hepatic trauma, and compare surgical and non-surgical treatment in patients admitted with hemodynamic stability and with no obvious indications of laparotomy. METHODS: This is a retrospective study of cases admitted to a university teaching hospital between the years 2000 and 2010. Patients undergoing surgical treatment were divided into two groups: (a) all patients undergoing surgical treatment, and (b) patients with obvious need for surgery. RESULTS: In this period, 120 patients were admitted with blunt hepatic trauma. Sixty five patients (54.1%) were treated non-operatively and fifty five patients were operated upon. Patients treated non-operatively had better physiologic conditions on admission, demonstrated less severe injuries (except the grade of hepatic injury), received less blood components and had lower morbidity and mortality than the patients operated upon. Patients who underwent non-operative treatment had a lower need for blood transfusion but higher rates of complications and mortality than the patients operated upon. Patients who were operated upon, with no obvious indications for surgery, had higher rates of complication and mortality than patients not operated upon. CONCLUSION: A non-operative approach resulted in lower complications, a lower need for blood transfusions and lower mortality.

Exame radiográfico convencional do tórax no diagnóstico de hérnia diafragmática pós-traumática

OBJECTIVE To describe changes in the radiographic examination of the chest in patients with post-traumatic diaphragmatic hernia (PTDH) confirmed intra-operatively. METHODS Between January 1990 and August 2008 45 patients with PTDH were treated. We analyzed demographic data, cause of injury, changes in chest radiography (CXR), extent and location of the diaphragmatic lesion and herniated organs. We described the radiographic findings most frequently identified by surgeons and radiologists. RESULTS CXR was performed on 32 patients, predominantly male (27 cases, 84.4%) and the mean age was 34 years. The most common cause of injury was blunt trauma (25 cases, 78.1%). Radiographic examination of the chest showed changes suggestive of PTDH in 26 cases (81.3%). During exploratory laparotomy, left PTDH was found in 28 cases (87.5%) and right in four (12.5%). The most frequently herniated organ was the stomach. CONCLUSION The study showed that CXR is very useful in the initial diagnostic approach to PTDH. The difficulty is that diaphragmatic injuries, particularly after penetrating trauma, may initially go unnoticed, and without changes in the CXR images, diagnosis is made difficult.

Trauma da Veia Porta

OBJETIVO: O trauma da veia porta e raro e frequentemente fatal por causa de exsanguinacao e alta incidencia de lesoes de estruturas adjacentes. Devido as pecualiaridades desta lesao e diferentes condutas propostas na literatura, o objetivo dos autores e relatar a experiencia neste tipo de lesao. METODO: Estudo retrospectivo, de janeiro de 1994 e dezembro de 2001, de 1370 pacientes submetidos a laparotomia devido trauma abdominal. Entre esses, 15 pacientes apresentavam lesao da veia porta. As lesoes foram classificadas conforme a sua extensao e localizacao. RESULTADOS: O mecanismo de trauma predominante foi o penetrante. O diagnostico da lesao foi realizado no intraoperatorio. Os procedimentos executados foram: sutura, anastomose termino-terminal e ligadura da veia porta. A mortalidade foi de 53,3%. CONCLUSAO: A lesao da veia porta possui alta taxa de mortalidade e o atendimento adequado esta diretamente relacionado a sobrevida.

Total hepatic ischemia and reperfusion after state controlled hemorrhagic shock, with used of different solutions: effects of neutrophils sequestration in kidney of rats

Purpose: To evaluate and compare neutrophils sequestration in the renal cortex of rats, result of total hepatic ischemia and reperfusion after controlled hemorrhagic shock, with use of different electrolytic solutions. Methods: Used 18 rats Wistar, males, adult, divided into three groups as the solution used to reanimation: Group PSS: physiologic saline solution; Group HSS: hypertonic saline hypertonic (7,5%) followed by lactated ringer’s solution; Group LRS: lactated ringer’s solution. All the animals were submitted to the bleeding controlled until mean arterial pressure (MAP) 40 mmHg, for 20 minutes. Performed volemic replacement until PAM=80 mmHg with the solution according the studied group, followed by laparotomy and Pringle’s Maneuver for 15 minutes. The animals were accompanied until for two hours. To statistical comparisons between mean of neutrophils sequestration, in interstitium of the renal cortex, were made the tests One-way ANOVA and covariance analysis, adjusting itself for time of supervened. The hemodynamic parameters evaluated were: MAP, heat rate, cardiac index, vascular resistance system index. The analyzed metabolic variables were: pH, bicarbonate, base deficit and lactato, besides electrolytes. Results: The mean values of supervened, in minutes, for group were: Group PSS 79,0±12,0; Group LRS 97,0±11,0; Group HSS 67,0±10. The mean values of neutrophils/field in the renal cortex were: Group PSS 0,55±0,68; Group LRS 1,68±0,53; Group HSS 1,33±0,43. When adjusted for time of supervened: Group PSS 0,55; Group LRS 1,62; Group HSS 1,39. There was statistically significant difference in neutrophils sequestration, between Group PSS regarding the others groups, using itself or not the adjustment by time of supervened (p=0,016 and p=0,0128). Conclusion: Both critical situations in this model, controlled hemorrhagic shock followed by Pringle’s maneuver, promoted neutrophils sequestration in the interstitium renal of rat, and the physiologic saline solution demonstrated minor mean, differentiating statistically of the others solutionsPURPOSE To evaluate and compare neutrophils sequestration in the renal cortex of rats, result of total hepatic ischemia and reperfusion after controlled hemorrhagic shock, with use of different electrolytic solutions. METHODS Used 18 rats Wistar, males, adult, divided into three groups as the solution used to reanimation: Group PSS: physiologic saline solution; Group HSS: hypertonic saline hypertonic (7.5%) followed by lactated ringers solution; Group LRS: lactated ringers solution. All the animals were submitted to the bleeding controlled until mean arterial pressure (MAP) 40 mmHg, for 20 minutes. Performed volemic replacement until PAM=80 mmHg with the solution according the studied group, followed by laparotomy and Pringles Maneuver for 15 minutes. The animals were accompanied until for two hours. To statistical comparisons between mean of neutrophils sequestration, in interstitium of the renal cortex, were made the tests One-way ANOVA and covariance analysis, adjusting itself for time of supervened. The hemodynamic parameters evaluated were: MAP, heat rate, cardiac index, vascular resistance system index. The analyzed metabolic variables were: pH, bicarbonate, base deficit and lactato, besides electrolytes. RESULTS The mean values of supervened, in minutes, for group were: Group PSS 79.0+/-12.0; Group LRS 97.0+/-11.0; Group HSS 67.0+/-10. The mean values of neutrophils/field in the renal cortex were: Group PSS 0.55+/-0.68; Group LRS 1.68+/-0.53; Group HSS 1.33+/-0.43. When adjusted for time of supervened: Group PSS 0.55; Group LRS 1.62; Group HSS 1.39. There was statistically significant difference in neutrophils sequestration, between Group PSS regarding the others groups, using itself or not the adjustment by time of supervened (p=0.016 and p=0.0128). CONCLUSION Both critical situations in this model, controlled hemorrhagic shock followed by Pringles maneuver, promoted neutrophils sequestration in the interstitium renal of rat, and the physiologic saline solution demonstrated minor mean, differentiating statistically of the others solutions.

Fatores preditores de complicações da drenagem de tórax em pacientes vítimas de trauma

OBJECTIVE to identify predictors of chest drainage complications in trauma patients attended at a University Hospital. METHODS we conducted a retrospective study of 68 patients submitted to thoracic drainage after trauma, in a one-year period. We analyzed gender, age, trauma mechanism, trauma indices, thoracic and associated lesions, environment in which the procedure was performed, drainage time, experience of the performer, complications and evolution. RESULTS the mean age of the patients was 35 years and the male gender was the most prevalent (89%). Blunt trauma was the most frequent, with 67% of cases, and of these, 50% were due to traffic accidents. The mean TRISS (Trauma and Injury Severity Score) was 98, with a mortality rate of 1.4%. The most frequent thoracic and associated lesions were, respectively, rib fractures (51%) and abdominal trauma (32%). The mean drainage time was 6.93 days, being higher in patients under mechanical ventilation (p=0.0163). The complication rate was 26.5%, mainly poor drain positioning (11.77%). Hospital drainage was performed in 89% of cases by doctors in the first year of specialization. Thoracic drainage performed in prehospital care presented nine times more chances of complications (p=0.0015). CONCLUSION the predictors of post-trauma complications for chest drainage were a procedure performed in an adverse site and mechanical ventilation. The high rate of complications demonstrates the importance of protocols of care with the thoracic drainage.

Trauma de laringe

OBJETIVO: O trauma da laringe e pouco frequente. O objetivo do presente trabalho e avaliar os procedimentos e resultados no tratamento destas lesoes. METODO: Este trabalho baseou-se em estudo prospectivo de 35 de pacientes com trauma de laringe atendidos no periodo de janeiro de 1990 a abril de 2003. RESULTADOS: A media de idade foi de 31,4 anos, sendo 30 pacientes (85,7%) do sexo masculino. O mecanismo predominante foi o trauma penetrante (30 casos - 85,7%), a maioria causada por ferimento por projetil de arma de fogo (17 casos - 48,6%). Dez pacientes (28,6%) necessitaram de intubacao traqueal na admissao hospitalar e o valor medio do RTS foi de 7,28. As observacoes mais frequentes no exame clinico das vitimas de trauma penetrante foram exposicao de cartilagens da laringe (30%) e saida de ar pelo orificio do ferimento cervical (30%). Nos cinco pacientes (14,3%) com trauma contuso o achado mais frequente foi enfisema subcutâneo (80%).O tratamento foi cirurgico em 34 pacientes (97,1%), atraves de cervicotomia em colar na maioria dos casos (91,2%). A cartilagem tireoide foi a mais lesada (20 casos - 57,1%). Em 33 pacientes operados a lesao foi tratada com sutura, associada a traqueostomia em 24 casos (72,7%). Lesoes cervicais associadas ocorreram em 20 casos (57,1%), sendo mais comum as de veia jugular (10 casos). A media do ISS e do TRISS foram, respectivamente, 16,3 e 0,93. A morbidade relacionada diretamente a lesao laringea foi de 34,3% (12 casos), sendo mais frequente a disfonia (seis casos). Foi necessaria a reexploracao cervical em dois pacientes, um devido a abscesso cervical e outro, tardiamente, por estenose supra-glotica, este ultimo tratado com molde. Dois pacientes apresentaram complicacoes tardias, um com disfagia e outro com disfonia. A mortalidade pos-operatoria foi de 5,7% (dois casos), decorrente de complicacoes nao relacionadas ao trauma laringeo. CONCLUSOES: A utilizacao de condutas padronizadas na abordagem do paciente com trauma de laringe, tanto no diagnostico como no tratamento definitivo, resulta em menor taxa de sequelas definitivas.

Isquemia e reperfusão hepática total associada ao estado de choque hemorrágico controlado: efeitos no seqüestro de neutrófilos no fígado do rato

BACKGROUND:The purpose of this experimental study was to evaluate the effects of total hepatic ischemia and reperfusion on the accumulation of neutrophils in the liver of rats, under normal conditions and in rats submitted to controlled hemorrhagic shock . METHODS: Thirty two adult male Wistar rats, were divided into four groups: the Control group, was submitted to the standard procedures for a period of 60 min of observation; Shock group, was submitted to controlled hemorrhagic shock (mean arterial blood pressure = 40 mmHg, 20 min) followed by volume resuscitation (lactated Ringers solution + blood, 3:1) and reperfusion for 60 min; Pringle group, was submitted to total hepatic ischemia for 15 min and reperfusion for 60 min; The Total group, was submitted to controlled hemorrhagic shock for 15 min followed by volume resuscitation (lactated Ringers solution + blood, 3:1), total hepatic ischemia for 15 min and reperfusion for 60 min. Measurements of serum lactate and base excess were used to characterize the hemorrhagic shock state with low tissue perfusion. The counting of neutrophils on the liver tissue was performed after the euthanasia of animals. RESULTS: Values for the counting of neutrophils on the liver indicate that, the animals from Pringle group differed from Shock and Total groups (Control 10.30±3.20, Shock 13.94±2.84, Pringle 7.00±3.40, Total 12.45±3.65) but did not differ from Control group. CONCLUSIONS: Rats submitted to controlled hemorrhagic shock state associated to total hepatic ischemia for 15 minutes, followed by 60 minutes of reperfusion, did not present significant neutrophils accumulation on liver tissue.

Como reduzir complicações relacionadas à drenagem pleural utilizando uma técnica guiada por ultrassom

The article by Mendes and Hirano 1 addresses a relevant issue in the context of emergency surgery. In fact, complications related to emergency pleural drainage occur in 14% to 25%2,3 and may range from drain misplacement to lethal iatrogenic lesions4,5. Faced with this scenario, the understanding of factors related to the incidence of complications leads to the development of measures and techniques that can reduce this rate. One of the techniques is the ultrasound-guided pleural drainage, which has been standardized by our group and recently published6. Regarding the origin of the complications reported in the article, we consider that anatomical variations and pathological alterations can also result in drainage failure. Although the authors did not observe intercostal artery lesions, this is a common complication reported in literature7. The presence of vulnerable vessels in the intercostal space can be excluded, using ultrasound Doppler mode8. Some conditions favor iatrogenic lesions during pleural drainage. Atelectasis may result in diaphragmatic dome elevation and diaphragmatic hernias increase the risk of abdominal viscera lesions during drainage4. By using ultrasound, it is possible to identify the diaphragmatic excursion and define the safest intercostal space to perform the procedure6,9. Thus, drain insertion into the abdominal cavity, observed in two cases1, could have been avoided using the echoguided technique. Since there is no detailed description of the malpositioning in the article by Mendes and Hirano1, we identified three more cases in which the use of ultrasound could have avoided complications. In the case in which there was a gastric perforation, a diaphragmatic hernia, often not observed by digital exploration of the cavity, could have been visualized by ultrasound during an echo-guided pleural drainage. Regarding the two cases of drain placed in the subcutaneous, ultrasound could have prevented complication. With ultrasound, malpositionings quickly identified10. Instead of waiting for results of chest X-ray or tomography to confirm positioning, ultrasound allows the physician to promptly identify the necessity of re-drainage. Obviously, the ultrasound-guided pleural drainage technique has two important limitations. The first is related to resources and lack of training. The other limitation refers to drainage time. Although there are not yet prospective studies comparing the echo-guided technique with the traditional one, it is assumed that the first should take longer. The medical community is increasingly using ultrasound in emergencies and as an adjunct to invasive procedures. It is necessary that professionals understand the benefits of this tool and the importance of specific training. There are several point-of-care courses in Brazil. To our knowledge, the Discipline of General Surgery and Trauma of Hospital das Clinicas

Basic life support: medical students learning by teaching.

the final OSCE were reduced by 56%. Although we recognise that there are potential confounders in using a historical control, such as variations in grading pattern, differences in global class abilities and fluctuations in the informal curricular content, we believe that one of the key contributors to the improvement in our students’ performance was their systematic learning of real-time processing skills. The improvement was significant enough to allow us to conclude that our innovative and transferrable curriculum effected positive change and better prepared students for clinical clerkships.

Recruitment of neutrophils across the blood-brain barrier: the role of posttraumatic hepatic ischemia

PURPOSE: To study the effects of total hepatic ischemia, and reperfusion on the accumulation of neutrophils in the brain of rats submitted to normovolemic conditions as well as to controlled hemorrhagic shock state. METHODS: Thirty two adult male Wistar rats, were divided into four groups: the Control group, was submitted to the standard procedures for a period of 60 min of observation; Shock group, was submitted to controlled hemorrhagic shock (mean arterial blood pressure=40mmHg, 20min) followed by volemic resuscitation (lactated Ringers solution + blood, 3:1) and reperfusion for 60min; Pringle group, was submitted to total hepatic ischemia for 15min and reperfusion for 60min. The total group was submitted to controlled hemorrhagic shock for 20min followed by volemic resuscitation (lactated Ringers solution + blood, 3:1), total hepatic ischemia for 15min and reperfusion for 60min. Measurements of serum lactate and base excess were used to characterize the hemorrhagic shock state with low tissue perfusion. The counting of neutrophils on the brain was performed after the euthanasia of animals. RESULTS: The values for the counting of neutrophils on the brain indicate that did not occur difference among studied groups (p=0.196) (Control 0.12± 0.11, Shock 0.12± 0.13, Pringle 0.02± 0.04, Total 0.14± 0.16). CONCLUSION: Hemorrhagic shock associated to total hepatic ischemia for 15 minutes, followed by 60 minutes of reperfusion, did not causes significant neutrophils accumulation in the brain of rats.