Ernest F. J. Block

Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension.

OBJECTIVE To assess the clinical utility of abdominal perfusion pressure (mean arterial pressure minus intra-abdominal pressure) as both a resuscitative endpoint and predictor of survival in patients with intra-abdominal hypertension. METHODS 144 surgical patients treated for intra-abdominal hypertension between May 1997 and June 1999 were retrospectively reviewed. Multivariate logistic regression and receiver operating characteristic curve analysis of common physiologic variables and resuscitation endpoints were performed to determine the decision thresholds for each variable that predict patient survival. RESULTS Abdominal perfusion pressure was statistically superior to both mean arterial pressure and intravesicular pressure in predicting patient survival from intra-abdominal hypertension and abdominal compartment syndrome. Multiple regression analysis demonstrated that abdominal perfusion pressure was also superior to other common resuscitation endpoints, including arterial pH, base deficit, arterial lactate, and hourly urinary output. CONCLUSION Abdominal perfusion pressure appears to be a clinically useful resuscitation endpoint and predictor of patient survival during treatment for intra-abdominal hypertension and abdominal compartment syndrome.

Guidelines for Management of Small Bowel Obstruction

STATEMENT OF THE PROBLEMThe description of patients presenting with small bowel obstruction (SBO) dates back to the third or fourth century, when early surgeons created enterocutaneous fistulas to relieve a bowel obstruction. Despite this success with operative therapy, the nonoperative management o

Percutaneous dilational tracheostomy: a comparison of single- versus multiple-dilator techniques.

Objective To compare the safety and efficacy of single- vs. multiple-dilator techniques in the performance of percutaneous dilational tracheostomy. Design Prospective randomized trial. Setting Intensive care units at a level 1 trauma center. Patients Fifty consecutive patients requiring tracheostomy for airway control or prolonged mechanical ventilatory support. Interventions Patients were randomized to receive a percutaneous dilational tracheostomy by either the single- or multiple-dilator technique described by Ciaglia. Measurements and Main Results Percutaneous dilational tracheostomy was performed using the single-dilator technique in 6:01 ± 3:03 mins and by the multiple-dilator technique in 10:01 ± 4:26 mins (p < .0006). There were no statistically significant differences in complication rates between the two techniques. No major complications occurred with either technique. Conclusion The single-dilator percutaneous tracheostomy technique is a safe, cost-effective, and more rapidly performed method for bedside tracheostomy in the intensive care unit.

Preload assessment in patients with an open abdomen.

BACKGROUND Intra-abdominal hypertension and abdominal compartment syndrome cause significant morbidity and mortality in surgical and trauma patients. Maintenance of intravascular preload and use of open abdomen techniques are essential. The accuracy of pulmonary artery occlusion pressure (PAOP) and central venous pressure (CVP) in patients with intra-abdominal hypertension has been questioned. METHODS Twenty surgical and trauma patients with intra-abdominal hypertension requiring open abdominal decompression were monitored using volumetric thermodilution pulmonary artery catheters. Hemodynamic, oxygenation, inspiratory, and intravesicular pressure measurements were collected prospectively. PAOP, CVP, and right ventricular end-diastolic volume index (RVEDVI) were compared as estimates of preload status. RESULTS Multiple regression analysis demonstrated that cardiac index correlated significantly better with RVEDVI (r = 0.69) than with PAOP (r = -0.27) or CVP (r = -0.28) during resuscitation after open abdominal decompression (p < 0.0001). CONCLUSION RVEDVI is superior to PAOP and CVP as an estimate of preload status in patients with an open abdomen.

Long-term physical, mental, and functional consequences of abdominal decompression.

BACKGROUND The long-term physical, mental, and functional consequences of abdominal decompression for intra-abdominal hypertension are unknown. METHODS Thirty patients in various stages of abdominal decompression and delayed fascial closure for massive incisional hernia completed the SF-36 Health Survey and answered questions regarding their employment and pregnancy status. RESULTS Patients awaiting abdominal wall reconstruction demonstrated significantly decreased perceptions of physical, social, and emotional health (p < 0.05), whereas patients who had completed definitive fascial closure demonstrated physical and mental health scores equivalent to the U.S. general population. Ultimately, 78% of patients employed before decompression returned to work. CONCLUSION Abdominal decompression with skin grafting and delayed fascial closure initially decreases patient perception of physical, social, and emotional health, but subsequent abdominal wall reconstruction restores physical and mental health to that of the U.S. general population. Abdominal decompression does not prevent return to gainful employment and should not be considered a permanently disabling condition.

Mathematical coupling does not explain the relationship between right ventricular end-diastolic volume and cardiac output

ObjectiveTo evaluate the clinical significance of mathematical coupling on the correlation between cardiac output and right ventricular end-diastolic volume (RVEDV) through measurement of cardiac output by two independent techniques. DesignProspective, observational study. SettingSurgical intensive care unit in a level 1 trauma center. PatientsTwenty-eight critically ill surgical patients who received mechanical ventilation and hemodynamic monitoring with a pulmonary artery catheter. InterventionsA pulmonary artery catheter designed to measure right ventricular ejection fraction (RVEF) and cardiac output by the intermittent bolus thermodilution (TDCO) method and continuous cardiac output by the pulsed thermal energy technique was placed. A computerized data logger was used to collect data simultaneously from the RVEF/TDCO system and the continuous cardiac output system. Measurements and Main Results Two hundred forty-nine data sets from 28 patients were compared. There is statistical correlation between TDCO and continuous cardiac output measurements (r = 0.95, p < 0.0001) with an acceptable bias (−0.11 L/min) and precision (±0.74 L/min). The correlation was maintained over a wide range of cardiac outputs (2.3–17.8 L/min). There is a high degree of correlation between RVEDV and both TDCO (r = 0.72, p < 0.0001) and independently measured continuous cardiac output (r = 0.68, p < 0.0001). These correlation coefficients are not statistically different (p = 0.15). ConclusionsThe continuous cardiac output technique accurately approximates cardiac output measured by the TDCO method. RVEDV calculated from TDCO correlates well with both TDCO and independently measured continuous cardiac output. Because random measurement errors of the two techniques differ, mathematical coupling alone does not explain the correlation between RVEDV estimates of preload and cardiac output.

Regionalization of surgical services in central Florida: the next step in acute care surgery.

BACKGROUND There is a national loss of access to surgeons for emergencies. Contributing factors include reduced numbers of practicing general surgeons, superspecialization, reimbursement issues, emphasis on work and life balance, and medical liability. Regionalizing acute care surgery (ACS), as exists for trauma care, represents a potential solution. The purpose of this study is to assess the financial and resources impact of transferring all nontrauma ACS cases from a community hospital (CH) to a trauma center (TC). METHODS We performed a case mix and financial analysis of patient records with ACS for a rural CH located near an urban Level I TC. ACS patients were analyzed for diagnosis, insurance status, procedures, and length of stay. We estimated physician reimbursement based on evaluation and management codes and procedural CPT codes. Hospital revenues were based on regional diagnosis-related group rates. All third-party remuneration was set at published Medicare rates; self-pay was set at nil. RESULTS Nine hundred ninety patients were treated in the CH emergency department with 188 potential surgical diseases. ACS was necessary in 62 cases; 25.4% were uninsured. Extrapolated to 12 months, 248 patients would generate new TC physician revenue of >

Trauma on the Internet: Early Experience with a World Wide Web Server Dedicated to Trauma and Critical Care

155,000 and hospital profits of >

Compartment syndrome in the critically injured following massive resuscitation : case reports

1.5 million. CH savings for call pay and other variable costs are >

Management of BB shot wounds to the heart

100,000. TC operating room volume would only increase by 1%. CONCLUSION Regionalization of ACS to TCs is a viable option from a business perspective. Access to care is preserved during an approaching crisis in emergency general surgical coverage. The referring hospital is relieved of an unfavorable payer mix and surgeon call problems. The TC receives a new revenue stream with limited impact on resources by absorbing these patients under its fixed costs, saving the CH variable costs.