Gerard A. Burns

Abdominal Compartment Syndrome in Patients With Burns

Abdominal compartment syndrome (ACS) is a well-recognized perioperative complication that occurs in patients who undergo intra-abdominal operations and who require extensive fluid resuscitation. The classic presentation of this syndrome includes high peak airway pressures; oliguria, despite adequate filling pressures; and intra-abdominal pressures of more than 25 mm Hg. A decompressive laparotomy performed at the bedside can alleviate ACS. If left untreated, sustained intra-abdominal hypertension is often fatal. In the literature, ACS has been described in pediatric patients with burns but not in adult patients with burns. This article describes 3 adults who sustained burns of more than 70% of their body surface areas, who required more than 20 L of crystalloid resuscitation, and who developed ACS during their resuscitation after the burn injury. The mortality rate among these patients was 100%, which confirms the grave consequences of this syndrome. In our institution, intra-abdominal pressure is now routinely measured as part of the burn resuscitation process in an attempt to diagnose and treat this syndrome earlier and more efficaciously. It is recommended that the possibility of ACS be considered when diagnosing any patient with burns who develops high airway pressures, oliguria, or both.

Prospective ultrasound evaluation of venous thrombosis in high-risk trauma patients.

UNLABELLED To determine the incidence of venous thrombosis (VT), high-risk trauma patients were evaluated prospectively biweekly with Doppler ultrasound (US). Fifty-seven patients during an 8-month period met high-risk criteria for VT including age > 45 years, > 2 days bed rest, previous history of thromboembolism, spine fracture, coma, spinal cord injury, pelvic fracture, lower extremity injury, or femoral vein catheter. Doppler ultrasound showed 16 VTs in 12 patients. Venous thrombosis occurred despite prophylaxis (heparin or compression devices) in 9 of 12 patients. Iliac VT was noted in four patients, two of whom had no lower extremity VT. Upper extremity VT occurred in two patients who had received central venous catheters. CONCLUSIONS (1) US surveillance may be valuable in high-risk trauma patients because VT is a common finding (21%), despite prophylactic measures. (2) Examination of the upper extremity and pelvic venous system appears to be important, since 33% (4 of 12) of our patients with VT developed thrombi isolated to these regions. These would not have been identified during routine lower extremity duplex studies.

Management of Blunt splenic trauma in patients older than 55 years

BACKGROUND Many experts have suggested that blunt splenic trauma in patients older than 55 years should not be managed by observation because of supposed increased fragility of the spleen and decreased physiologic reserve in elderly patients. We sought to determine the outcome of nonoperative management of blunt splenic trauma in patients older than 55 years. METHODS For the years 1994 through 1996, data for patients with splenic injury older than 55 years from seven trauma centers in a single state were reviewed. RESULTS Blunt splenic trauma occurred in 41 patients older than 55 years. Eight patients were excluded from further analysis because of death from massive associated injuries within 24 hours of admission. The remaining 33 patients (mean age, 72+/-10 years) were divided into two groups: immediate exploration (10 patients) and observation (23 patients). Observation of blunt splenic injury failed in 4 of 23 patients (17%). No patient deaths were related to the method of management of the splenic injury. CONCLUSIONS Observation of the elderly patient with blunt splenic trauma has an acceptable failure rate of 17%.

Renal artery pseudoaneurysm after blunt abdominal trauma : Case report and literature review

Renal vascular injuries such as transection, thrombosis, dissection, and arteriovenous fistula formation are unusual but well-recognized consequences of blunt abdominal trauma. We discuss a rare case of renal artery pseudoaneurysm presenting 6 weeks after blunt abdominal trauma that was successfully treated with selective embolization.

Organ failure, infection, and the systemic inflammatory response syndrome are associated with elevated levels of urinary intestinal fatty acid binding protein: study of 100 consecutive patients in a surgical intensive care unit.

BACKGROUND Intestinal mucosal ischemia and subsequent barrier dysfunction have been related to the development of organ dysfunction and death in the critically ill. We hypothesized that urine concentrations of intestinal fatty acid binding protein (IFABP), a sensitive marker of intestinal ischemia, might predict the development of the systemic inflammatory response syndrome (SIRS) and organ dysfunction. METHODS One hundred consecutive critically ill patients were prospectively studied for the development of infectious complications, organ dysfunction, and SIRS. Urine was collected daily for measurement of IFABP. RESULTS A total of 58 males and 42 females (mean age, 56 years; range,16-85 years) were studied. Of these 100 patients, 40 patients developed complications and 5 patients developed SIRS. IFABP was significantly elevated in all patients with SIRS, and IFABP levels peaked an average of 1.4 days (range, 0-7 days) before the diagnosis of SIRS. CONCLUSION Elevated concentrations of urine IFABP correlated with the clinical development of SIRS. Studies to assess the utility of IFABP as a predictor of organ dysfunction and SIRS in the critically ill are warranted.

Esmarch Closure of Laparotomy Incisions in Unstable Trauma Patients

Fascial closure after laparotomy may be time-consuming and extremely difficult, especially in the setting of massive bowel edema. In the trauma patient with deteriorating hemodynamic status, hypothermia, or worsening hypoxia, expeditious abdominal wall closure is essential to facilitate rapid transport to the intensive care unit for further stabilization. With the increasing utilization of the abbreviated laparotomy in unstable trauma patients, innovative techniques for speedy fascial closure must be evaluated. We developed the Esmarch closure--a simple, rapid method for closing the abdominal wall at the end of abbreviated laparotomies.

Exclusion of aortic tear in the unstable trauma patient: the utility of transesophageal echocardiography.

OBJECTIVE The goal of this study was to investigate the value of biplanar transesophageal echocardiography (TEE) as a screening tool for aortic tear in unstable trauma patients. METHODS During a 1-year period, a prospective trial to exclude aortic tear was conducted at a level I trauma center. Ten of 53 patients (19%) sustaining severe blunt thoracic trauma were deemed too unstable to undergo safe transport to aortography and underwent TEE. Mechanism of injury was motor vehicle crash in eight patients and pedestrians struck in two. Patients had a mean Injury Severity Score = 34 (range, 17 to 59) and mean age = 43 years (range, 18 to 77). Indications for aortic tear evaluation were chest x-ray findings in seven and mechanism of injury alone in three. Patients were not transportable because of hemodynamic instability in five individuals, severe unstable head injury in three individuals, and unstable cervical spine fracture in two individuals. RESULTS Transesophageal echocardiography was performed in the emergency department in one instance, in the operating room in one instance, and in the surgical intensive care unit in the remaining eight instances. Patients underwent the procedure less than 8 hours after admission in seven and more than 48 hours after admission in three. One patient had a complication during TEE (ventricular dysrhythmias). In one of ten patients, TEE was positive. This patient required medical management (beta-blockade) for aortic tear until severe hypoxia secondary to pulmonary contusion improved after 36 hours. Repair of aortic tear was then successfully performed. CONCLUSIONS The TEE procedure is valuable in identifying aortic injury in high-risk trauma patients who are too unstable to undergo transport to the aortography suite.

Dilatational percutaneous tracheostomy : Modification of technique

BACKGROUND Major inherent risks associated with percutaneous dilatational tracheostomy include loss of airway during endotracheal tube manipulation, inability to cannulate the trachea below the endotracheal tube, and difficulties related to neck anatomy. METHOD Percutaneous dilatational tracheostomy technique was modified to make the incision in the suprasternal area, and the use of air leak technique confirmed tracheal penetration below the endotracheal cuff. Bronchoscopy was not used. RESULTS One hundred patients underwent percutaneous dilatational tracheostomy using the modification mentioned above. Although three patients had minor bleeding complications, there was no loss of airway; nor were there other complications. CONCLUSION This technique provides improved safety from loss of airway and illuminates the need for concomitant bronchoscopy.

Sump syndrome complicating Roux-en-Y hepaticojejunostomy: Case report and review of the literature

Sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by gastrointestinal debris after choledochoduodenostomy, resulting in cholangitis or, less commonly pancreatitis. Obstruction of the biliary tree by gastrointestinal contents after Roux-en-Y choledochojejunostomy or hepaticojejunostomy has not been described in the English-language literature. This report details the diagnostic and operative management of the first patient with sump syndrome after hepaticojejunostomy. The presumed pathophysiology was reflux of vegetable matter up the efferent limb, resulting in hepatic duct obstruction and cholangitis. The patient ultimately required complex choledochoscopic drainage of the intrahepatic biliary tree and revision of the previous Roux-en-Y hepaticojejunostomy.

The protection of resident curriculum by work redesign

Abstract In recent years at the Yale School of Medicine, operative services work volume has increased dramatically, including a 24% increase in cases and a 17% increase in inpatient discharges. At the same time, ambulatory care has surged, reducing hospital length of stay by 26%. The institution has also been through 2 budget reviews, which reduced the operating budget by 10% each time. The result has been a rise in patient acuity, a rise in patient volume, an increase in outpatient work, and a reduction in hospital personnel available to participate in patient care. As a result, the hours of our residents have increased as they have assumed responsibility for both the volume increase and the decrease in hospital personnel. At the same time, the number of house staff positions has been reduced as a result of a training program amalgamation, and preliminary positions and time spent by specialty categorical residents in general surgery have decreased. Therefore, a work redesign project was undertaken to examine the activities of first-year trainees. The tasks of first-year trainees were divided into educational benefit (OR, rounds, conferences), service (paperwork, finding films), and tasks that were indeterminate. The service tasks were redistributed within a new service structure to include a physician associate (PA) role. The trainees were then available for educational activities, including the OR. The relationships among the nurse, PA, attending surgeon, senior resident, and patient were redefined to emphasize the role of the trainee. Under the new system, the PA spanned the roles of the attending surgeon, trainees, and nurses during the day to support managed care pathways, paperwork, nursing care plans, and questions that in the past were directed to the house staff. While reporting directly to the associate program director, the PA performed the patient care tasks on assignment from both the house staff and attending surgeons during the day, leaving little in the way of accumulated tasks for the evening. The PA also participated in the check-out rounds of the house staff and in the nursing shift meetings. Physician associates were hired for the major general surgery services and did not perform night duty. They were never perceived as replacements for house staff but rather as health care workers in a new role as defined by work redesign. The first-year trainees continued to perform 80–100 cases per year despite drastic changes in the work expectations that otherwise would have fallen to them. The evaluation of services by the residents increased substantially. Nursing evaluation of the program was completely positive, and the attending surgeons found the new system completely acceptable. Work redesign is a tactic that can preserve the educational aspects of resident training even in the face of severe resource constraints and conflicting demands on time.