Fred Bongard

A contemporary perspective on superior vena cava syndrome

The superior vena cava (SVC) syndrome is usually associated with advanced malignancy and has a dismal prognosis. In order to analyze the impact of newer diagnostic and therapeutic modalities, we retrospectively examined the last 45 consecutive cases of SVC syndrome treated over a 12-year period. The underlying causes were advanced lung cancer (57%), mediastinal tumors (20%), and metastatic solid malignancy (5%). Forty-two patients (93%) were treated with external beam radiotherapy and/or chemotherapy with a mean patients survival of 3 months; 11 of 42 patients (26%) were treated without histologic diagnosis. Symptoms of SVC obstruction resolved in 80% of patients who underwent radiotherapy, with a mean interval of 4 weeks. The most common cause of death was respiratory arrest. Of the three patients with benign disease, two underwent caval reconstruction with greater than 3-year patency and relief of symptoms. We conclude that (1) SVC syndrome portends a grim prognosis when associated with malignancy but usually responds to radiation or chemotherapy; (2) CT scan is the best available method to document the extent and location of involvement; and (3) patients with benign disease should be evaluated for caval reconstruction, which may produce rewarding long-term results.

Multiple organ failure: By the time you predict it, it's already there

OBJECTIVE Validate an at-risk population to study multiple organ failure and to determine the importance of organ dysfunction 24 hours after injury in determining the ultimate severity of multiple organ failure. METHODS We evaluated 105 patients admitted to five academic trauma centers during a 1-year period who survived for more than 24 hours with Injury Severity Scores > or = 25 and who received 6 or more units of blood. Organ dysfunction was scored daily with a modified multiple organ failure scoring system made up of individual adult respiratory distress syndrome score, renal dysfunction, hepatic dysfunction, and cardiac dysfunction scores. Multiple organ failure (MOF) severity was quantitated using the maximum daily multiple organ failure score and the cumulative sum of daily multiple organ failure scores for the first 7 days (MOF 7) and 10 days (MOF 10). Independent variables included markers of tissue injury, shock, host factors, physiologic response, therapeutic factors, and organ dysfunction within the first 24 hours after admission. Data were subjected to a conditional stepwise multiple regression analysis, first excluding and then including 24-hour MOF as an independent variable. RESULTS Of the 105 high-risk patients, 69 (66%) developed a maximum daily multiple organ failure score > or = 1; 50 (72%) did so on day 1 one and 60 (87%) did so by day 2. In multiple regression models, the multiple correlation coefficient increased from 0.537 to 0.720 when maximum MOF was the dependent variable, from 0.449 to 0.719 when maximum daily MOF was the dependent variable, from 0.519 to 0.812 when MOF 7 was the dependent variable, and from 0.514 to 0.759 when MOF 10 was the dependent variable. CONCLUSION We have confirmed that the population of patients with Injury Severity Scores > or = 25 who received 6 or more units of blood represent a high-risk group for the development of multiple organ failure. Our data also indicate that multiple organ failure after trauma is established within 24 hours of injury in the majority of patients who develop it. It appears that multiple organ failure is already present at the time when most published models are trying to predict whether or not it will occur.

Candida sepsis in surgical patients

Candidemia in critically ill patients is a significant source of mortality. To identify perioperative risk factors accounting for patient death, we performed a retrospective study of 46 surgical patients with fungemia during the period from 1981 to 1990. Twenty patients survived (43%), and 26 died (57%). Mortality was associated with age older than 46 (p < 0.02, unpaired Students t-test) and concomitant renal failure, hepatic failure, postoperative shock, or adult respiratory distress syndrome (p < 0.0001, p < 0.0001, and p < 0.05, respectively, chi 2 test). Survival was not influenced by the presence of diabetes, chronic obstructive pulmonary disease, gastrointestinal hemorrhage, pneumonia, alcohol consumption, steroid use, or enteral/parental nutrition. Bacterial speticemia developed in 26 patients (11 lived, 15 died) and typically preceded or was concomitant with the onset of fungal sepsis (88%). Candida albicans was the fungal species most commonly isolated from blood cultures (30 of 46). Its was cultured from other sites in addition to blood in 30 patients. Candidemia carries a higher risk of mortality in older patients and in those with multiple organ dysfunction. Other immunocompromised conditions such as diabetes and steroid use did not increase mortality. These findings suggest that the pathogenicity of Candida sepsis is not solely related to opportunistic superinfections but may reflect failure of other host defense mechanisms. Moreover, the frequent occurrence of bacterial septicemia prior to the development of Candida sepsis further emphasizes the importance of fungal surveillance cultures to detect early fungal colonization in the critically ill.

Femoral hernia: The dire consequences of a missed diagnosis

Femoral hernia has always presented more difficulty in diagnosis than other external abdominal hernias. The incidence of incarceration and strangulation is higher in our series than the published literature would suggest. A retrospective study was performed at our institution from February 1990 to June 1995. In that period, 22 patients were operated on for femoral hernia. There were 16 women and 6 men, average ages 51 and 48 years, respectively. The men weighed on average 209 lb, and the women, 154 lb. Three of our patients had elective repair of their hernias (16%); 19 were performed urgently or emergently (86%). Of the emergency repairs, 3 had strangulated small bowel requiring resection (16%), 1 had a strangulated vermiform appendix with abscess formation (5%), 3 had strangulated omentum requiring excision (16%), giving a total of 7 patients with strangulation and necrosis of the hernial contents (36%). The remainder had viable contents in the hernia sac. The time from the onset of symptoms to presentation at the hospital varied from 1 day to 3 years. The time from strangulation to presentation was between a few hours and 4 days. Surgery was performed on the day of admission (within 24 hours) on all but 2 of our patients. Procedures performed were McVay repair, 13; Bassini, 4; laparoscopic with Marlex mesh, 1 patient; drainage of a groin abscess in 2 patients with later repair; and on 2 patients the type of repair was not specified. One of the patients died. Postoperative wound infection occurred in 2 heavily contaminated patients, and 3 had pneumonia. Patients with no regular physician and no routine physical examinations are at higher risk for developing strangulation of femoral hernias. Emergency physicians and general practitioners are in the best position to diagnose these hernias early, when treatment can be elective.

Capnographic Monitoring of Extubated Postoperative Patients

Postoperative respiratory monitoring of surgical patients requires assessment of both oxygenation and ventilation. Arterial blood gas (ABG) measurements traditionally have been used to detect elevated arterial carbon dioxide (PaCO2) concentrations. The recent availability of a noninvasive technique for end-tidal CO2 measurements (EtCO2) may allow substitution of this real-time modality for the more cumbersome blood gas determinations. This study examines 41 extubated postoperative patients monitored with both modalities and evaluates whether capnography can replace routine blood gas determinations in selected patients. Paired ABG and EtCO2 measurements were obtained at 30 and 90 min after admission to the recovery room. A new nasopharyngeal catheter was employed to obtain exhaled gas samples for EtCO2 measurement. Overall, EtCO2 was lower than PaCO2 by 2.8 torr (p < .05), with a precision of +/- 2.6 torr. Correlation between EtCO2 and PaCO2 was excellent (r = 0.87, p < .01). We conclude that on-line EtCO2 measurements provide a useful substitute for routine ABG determinations of PaCO2 in selected patients. The nasopharyngeal catheter provides both a patent airway and undiluted gas for evaluation. This methodology can improve patient comfort and safety considerably while decreasing cost and discomfort.

Complications of therapeutic laparoscopy.

Laparoscopic surgery holds great promise as a technique for reducing hospital stay and convalescence. Although advantages in hospital cost cannot be shown for all such procedures, improvements in technique and operator experience will undoubtedly improve the situation. Analysis of the pertinent physiologic aspects and complication rates indicates that laparoscopy is not minimally invasive, but rather exposes the patient to many of the risks normally incurred by open procedures. Enthusiasm for the use of these techniques must be tempered by good judgment and scientific evidence supporting equivalent or better long-term results at equal or lower rates of morbidity and mortality.

Gang warfare: the medical repercussions

Gang related violence in Los Angeles County has increased, with homicides increasing from 205 in 1982 to 803 in 1992. This study examines the medical and financial consequences of such violence on a level I trauma center. Of 856 gunshot injuries over a 29-month period, 272 were gang related. There were 55 pediatric and 217 adult patients. Eighty-nine percent were male and 11% were female. Trauma Score averaged 14.7 +/- 3.1, Glasgow Coma Scale average score was 13.7 +/- 3.4, and the mean Injury Severity Score was 10.8 +/- 14. Twenty-two percent of the gunshots were to the head and neck, 20% to the chest, 20% to the abdomen, 6% had a peripheral vascular injury, and 33% sustained an extremity musculoskeletal injury. Emergency surgery was performed on 43%, including laparotomy 58 (49%), craniotomy 16 (13%), laparoscopy 14 (12%), vascular procedures 10 (8%), orthopedic procedures 6 (5%), head and neck endoscopies 4 (3%), thoracotomies 2 (2%), and 10 (8%) unspecified. There were 25 deaths (9%), primarily caused by head injuries and exsanguinating hemorrhage. Eighty-six percent entered the hospital during the hours of minimal staffing that preempted the use of facilities for other emergent patients. Charges totaled

Vascular injuries in the urban battleground: experience at a metropolitan trauma center

4,828,828 (emergency room, surgical procedures, intensive care, and surgical ward stay) which equated to

Management strategy of complex extremity injuries

5,550 per patient per day. Fifty-eight percent had no third party reimbursement, 22% had Medi-Cal, and 20% had medical insurance. Because of dismal reimbursement rates, the costs of gang violence are passed on to the tax payer. The cost of gang related violence cannot be derived from hospital charges only, because death, disability, and pain are not entered into the calculation. Education, increased social programs, and strict criminal justice laws and enforcement may decrease gang related violence and the drain it has on financial and medical resources.

Helium Insufflation for Laparoscopic Operation

The increasing frequency and severity of urban violence and vehicular injuries have brought with them a rise in the number of complex vascular injuries. To examine the cause, incidence, management, and outcome of this problem, we created a vascular trauma registry which includes all such cases treated at a Level I metropolitan trauma center over the past nine years. This constitutes a summary report of that registry. During the period 1979-1988, 411 patients (355 men, 56 women) with 478 vascular injuries were treated. There were 18 deaths (4%). Primary diagnosis was grouped by anatomic region: (1) head and neck vessels, 62 (15%); (2) thoracic, 39 (10%); (3) abdominal and pelvic, 63 (15%); (4) upper extremity, 161 (39%); and (5) lower extremity, 86 (21%). Surgery was required in 241 cases (60%). Operative techniques consisted of ligation or resection in 26 (12%) and direct repair in 212 (88%). Associated procedures included: (1) laparotomy (n = 83); (2) craniotomy (n = 4); (3) thoracotomy (n = 49); (4) orthopedic procedures (n = 118); and (5) peripheral neurological repair (n = 70). Mechanisms of injury were: (1) gunshot wounds (32%); (2) stab wounds (45%); (3) motor vehicle accidents (18%); (4) fall (3%); and (5) other mechanisms (2%). We conclude: (1) vascular injuries were found frequently in the severely injured patient; (2) multiple vascular repairs were required in a significant proportion of these patients; and (3) outcome is dependent more upon associated trauma than on the vascular injuries themselves.