Frederic S. Bongard

Hypothermia in trauma patients

Hypothermia occurs commonly in severely injured patients and is associated with a high mortality rate. It perturbs the normal homeostatic response to injury and affects multiple organ systems and physiologic processes. In trauma patients, hypothermia-induced coagulopathy often leads to marked bleeding diathesis and frequently provides a challenge for the surgeon. Once hypothermia occurs, it is often difficult to correct. Efforts to prevent and treat hypothermia in trauma patients should be instituted in the field and continued as an integral part of the resuscitation process. Hospital personnel and physicians at various levels caring for trauma patients from the initial injury and thereafter should bear in mind that a patients temperature is as important as any other vital sign. Appropriate measures for preventing and treating hypothermia should be instituted promptly and tended to with utmost vigilance.

Acute appendicitis in the pregnant patient

Acute appendicitis is the most common surgical problem in pregnancy requiring emergent intervention. To establish a contemporary patient profile and formulate an effective management strategy, a retrospective review was conducted of 84 pregnant patients who underwent laparotomy with a preoperative diagnosis of acute appendicitis. Gestational stage at presentation included the first trimester in 27 patients (32%), the second trimester in 37 patients (44%), the third trimester in 13 patients (16%), and the puerperium in 7 patients (8%). Fifty-four patients (64%) had pathologically proven acute appendicitis; the incidence did not vary by trimester. Other intra-abdominal conditions were detected in 15 patients (18%). There were no significant differences between patients with positive and negative laparotomies (or among trimesters) regarding frequency of presenting symptoms and signs or laboratory results. Operation occurred within 24 hours of symptom onset in 19 of 54 (35%) instances of proven acute appendicitis. Perforation occurred in 23 of 54 patients (43%), all of whom had symptoms exceeding 24 hours (p

Adverse Consequences of Increased Intra-abdominal Pressure on Bowel Tissue Oxygen

OBJECTIVE Demonstrate the effect that increased intra-abdominal pressure (IAP) has on visceral oxygen delivery and bowel tissue oxygenation (TPO2). METHODS Six Duroch swine underwent abdominal insufflation with helium to pressures of 15 and 25 mm Hg for 1 hour. Animals were instrumented with a pulmonary artery flotation catheter to measure cardiac output and calculate systemic oxygen delivery. Fluorescence quenching optodes were implanted in the terminal ileum and the subcutaneous tissue of an axillary fold to measure bowel and systemic (control) tissue oxygen levels, respectively. RESULTS Bowel tissue oxygen fell from 43 +/- 12 mm Hg at baseline to 31 +/- 12 mm Hg, with 15 mm Hg of abdominal pressure at 60 minutes. With 25 mm Hg IAP, bowel TPO2 fell from 24 +/- 12 to 12 +/- 8 mm Hg (p < 0.02). No change in axillary TPO2 was observed during either period of increased IAP. Cardiac output (CO), systemic oxygen delivery, and mixed-venous oxygen saturation (Svo2) also declined, although blood pressure and oxygen consumption remained constant. CONCLUSIONS Increased IAP produces significant decreases in bowel submucosal TPO2 without similar changes in extra-abdominal (subcutaneous) TPO2. This decline is dependent on the extent and duration of the elevation in IAP. Readily accessible parameters, such as CO and Svo2, also decline with increased IAP and may be useful variables to monitor as relative indicators of bowel hypoperfusion and TPO2.

Patient volume per surgeon does not predict survival in adult level I trauma centers.

BACKGROUND The 1999 American College of Surgeons resources for optimal care document added the requirement that Level I trauma centers admit over 240 patients with Injury Severity Score (ISS) > 15 per year or that trauma surgeons care for at least 35 patients per year. The purpose of this study was to test the hypothesis that high volume of patients with ISS > 15 per individual trauma surgeon is associated with improved outcome. METHODS Data were obtained from the trauma registry of the five American College of Surgeons-verified adult Level I trauma centers in our mature trauma system between January 1, 1998, and March 31, 1999. Data abstracted included age, sex, Glasgow Coma Scale (GCS) score, intensive care unit length of stay, hospital length of stay, probability of survival (Ps), mechanism of injury, number of patients per each trauma surgeon and institution, and mortality. Multiple logistic regression was performed to select independent variables for modeling of survival. RESULTS From the five Level I centers there were 11,932 trauma patients in this time interval; of these, 1,754 patients (14.7%) with ISS > 15 were identified and used for analysis. Patients with ISS > 15 varied from 173 to 625 per institution; trauma surgeons varied from 8 to 25 per institution; per-surgeon patient volume varied from 0.8 to 96 per year. Logistic regression analysis revealed that the best independent predictors of survival were Ps, GCS score, age, mechanism of injury, and institutional volume (p < 0.01). Age and institutional volume correlated negatively with survival. Analysis of per-surgeon patient caseload added no additional predictive value (p = 0.44). CONCLUSION The significant independent predictors of survival in severely injured trauma patients are Ps, GCS score, age, mechanism of injury, and institutional volume. We found no statistically meaningful contribution to the prediction of survival on the basis of per-surgeon patient volume. Since this volume criterion for surgeon enpanelment and trauma center designation would not be expected to improve outcome, such a requirement should be justified by other measures or abandoned.

Blunt disruption of the abdominal aorta: Report of a case and review of the literature ☆ ☆☆

A 71-year-old woman had an abdominal aortic disruption as a belted passenger in a motor vehicle accident. The diagnosis was unexpected, and the patient died during surgery. There have been 54 patients operated with this diagnosis since 1953; our patient was the fifty-fifth. This is an unusual injury, because the aorta is well protected in this position. Thoracic aortic injuries are much more common (20 times) than abdominal injuries. The causes are motor vehicle accidents, blows to the abdomen, explosions, and falls. Obstructing lesions such as thrombosis and intimal dissection are the more common presentation. False aneurysms occur occasionally. Free rupture has a very high and immediate mortality rate, and few patients arrive at the hospital alive. Diagnosis can be clinical, based on distal ischemia and neurologic abnormalities, or made with Doppler scanning, ultrasonography, computed tomography, or arteriography. Two thirds present acutely and one third subsequently months or even years after the original injury. Treatment consists of flap suture, thrombectomy, bypass grafting in more extensive injury, or extra-anatomic bypass in the face of severe contamination. Recently, endoluminal stenting has successfully been used, avoiding an abdominal operation completely.

Septic embolism complicating infective endocarditis

Embolic phenomena in patients with infective endocarditis may complicate the placement of a cardiac valvular prosthesis. To evaluate the vascular consequences of these emboli, a 15-year review of 102 patients undergoing valve replacement for proven infective endocarditis was undertaken. Thirty-one patients with 36 episodes of septic embolization were identified. Ten of these were separate extremity occlusive events. All patients with extremity emboli were admitted with pain; four had limb-threatening emboli. All patients grew gram-positive bacteria from their blood except a single Candida albicans isolate. Appropriate antimicrobial therapy was used in all patients. Angiography confirmed the diagnosis in 11 of 12 patients. Embolic targets included the lower extremities in all except a single instance. Four patients had multiple emboli. All but one of the vascular procedures were carried out subsequent to or simultaneously with cardiac valve replacement. Initial operative management included embolectomy (4) and primary amputation (2). Two delayed procedures were required. One patient died. Four patients had limited ischemia that resolved with antibiotics and anticoagulation. This report suggests that infective endocarditis requiring valvular replacement is associated with embolization in one third of patients. The presentation of peripheral vascular emboli is that of acute extremity ischemia. The diagnosis should be confirmed by angiography to rule out the possibility of multiple emboli. When possible, valve replacement should precede peripheral vascular management, which may include operative or medical components as dictated by the extent of limb ischemia.

Iliac vessel injuries

Trauma to the iliac vasculature continues to pose a significant challenge to management. In several large series, mortality for penetrating injuries is reported as approaching 40%. Uncontrollable hemorrhage originating from an anatomically inaccessible source and multiple associated injuries often contribute to this high mortality rate. This article discusses the current existing management strategies and the controversial role of PTFE in vascular reconstruction within a contaminated field. Concomitant injuries to the enteric viscera and genitourinary system are also addressed. Postoperative management including anticoagulation and the complications of liberal fasciotomy are mentioned. The evolving role of endovascular therapy as an adjunctive modality in the armamentarium of the trauma surgeon is also presented briefly.

Are blood cultures effective in the evaluation of fever in perioperative patients

Blood cultures are routinely performed as part of the evaluation of fever in the perioperative period. Results of 364 blood culture vials representing 108 consecutive febrile events (temperature greater than or equal to 101.5 degrees F) in 72 patients on adult surgical services without evidence of sepsis in a metropolitan hospital were prospectively studied. Eighty-nine percent of patients had undergone an operation prior to the febrile episode. Microorganisms were isolated in blood culture vials from 9 of 108 patient febrile events. Of these blood cultures, five were positive (contained pathogens), and four represented contaminants. Two of five positive blood cultures occurred in patients with an identifiable source of bacteremia. The cost of processing all blood culture vials was

From deadly weapon to toy and back again: the danger of air rifles.

13,992, which amounted to

Crystalloid resuscitation of patients with pulmonary contusion

2,798 spent to identify each of the five patients with positive blood cultures. Blood culture vials were more likely to be positive if blood was drawn during postoperative days 4 through 10, as opposed to days 1 through 3, or if it was drawn from patients with factors depressing immune function or who had indwelling devices. Neither the magnitude of the absolute leukocyte count nor the maximum temperature at the time of phlebotomy predicted a positive blood culture. The use of resin vials produced sterile cultures in the 10 vials submitted. In no case did a positive blood culture have a measurable effect on reducing patient morbidity or mortality.