Hiroharu Matsuda

Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients.

BACKGROUND We compared the clinical efficacy of surgical stabilization and internal pneumatic stabilization in severe flail chest patients who required prolonged ventilatory support. METHODS Thirty-seven consecutive severe flail chest patients who required mechanical ventilation were enrolled in this study. All the patients received identical respiratory management, including end-tracheal intubation, mechanical ventilation, continuous epidural anesthesia, analgesia, bronchoscopic aspiration, postural drainage, and pulmonary hygiene. At 5 days after injury, surgical stabilization with Judet struts (S group, n = 18) or internal pneumatic stabilization (I group, n = 19) was randomly assigned. Most respiratory management was identical between the two groups except the surgical procedure. Statistical analysis using two-way analysis of variance and Tukeys test was used to compare the groups. RESULTS Age, sex, Injury Severity Score, chest Abbreviated Injury Score, number of rib fractures, severity of lung contusion, and Pao2/Fio2 ratio at admission were all equivalent in the two groups. The S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24%; I group, 77%; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05). The percentage of patients who had returned to full-time employment at 6 months was significantly higher in the S group (11 of 18) than in the I group (1 of 19). CONCLUSION This study proved that in severe flail chest patients, surgical stabilization using Judet struts has beneficial effects with respect to less ventilatory support, lower incidence of pneumonia, shorter trauma intensive care unit stay, and reduced medical cost than internal fixation. Moreover, surgical stabilization with Judet struts improved percent forced vital capacity from the early phase after surgical fixation. Also, patients with surgical stabilization could return to their previous employment quicker than those with internal pneumatic stabilization, even in those with the same severity of flail chest. We therefore concluded that surgical stabilization with Judet struts may be preferably applied to patients with severe flail chest who need ventilator support.

The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showing transient response to fluid resuscitation.

BACKGROUND This study aimed to determine whether nonsurgical management using transcatheter arterial embolization (TAE) is safe for patients with blunt multiple trauma who transiently respond to the initial fluid resuscitation. METHODS Contrast computed tomography was performed for patients with blunt abdominal injuries, excluding those who did not respond to initial fluid resuscitation. Angiography was performed for patients with injuries showing contrast extravasation or solid organ injury classified, according to the American Association for the Surgery of Trauma, as grade 3 or higher on computed tomography. Transcatheter arterial embolization was performed when angiography showed arterial extravasation. The protocol was abandoned for any patients who became profoundly hypotensive (with systolic blood pressure 60 mm Hg or lower) during computed tomography or angiography. RESULTS Between January 2000 and December 2002, 269 patients with blunt abdominal injuries underwent TAE immediately after admission. Of these patients, 41 had injuries in at least two regions and underwent TAE for these regions. Among them, 22 patients were hemodynamically stable or showed rapid response to fluid resuscitation. The nonsurgical treatment was successful in all these cases. The remaining 19 patients (Injury Severity Score, 37.3 +/- 8.2), who showed a transient response, were the subjects of this study. Of these patients, 15 underwent TAE for injuries in two regions (13 pelvic fractures, 7 splenic injuries, 6 hepatic injuries, 3 facial bleeding, and 1 renal injury), and 4 patients underwent TAE for injuries in three regions (4 had splenic injuries, 3 hepatic injuries, 2 renal injuries, 2 pelvic fractures, and 1 facial bleeding). For all these patients, TAE was successfully performed. Before TAE, the systolic blood pressure was 79.9 +/- 8.4 mm Hg, and the shock index was 1.45 +/- 0.25 mm Hg. After TAE, the corresponding values were 120.6 +/- 19.3 mm Hg and 0.87 +/- 0.16 mm Hg, respectively (p < 0.001). The rate of fluid administration required after TAE (214.2 +/- 139.3 mL/hour) was significantly less than that required before TAE (1244.2 +/- 347.1 mL/hour; range, 632-1,728 mL/hour) (p < 0.001). The deaths of two patients were classified as nonpreventable on the basis of the Trauma and Injury Severity Score (TRISS), and their respective probabilities of survival were determined to be 0.13 and 0.03. CONCLUSION Nonsurgical management using TAE can be performed safely even for patients with blunt multiple trauma who are in hemorrhagic hypotension if their hemodynamics are improved by resuscitation with 2 L of fluid.

The efficacy and limitations of transarterial embolization for severe hepatic injury.

BACKGROUND The efficacy of transarterial embolization (TAE) for severe blunt hepatic injury has been reported. We performed a prospective study evaluating the efficacy and the limitation of TAE from January 1996 to December 2000. METHODS All patients with blunt abdominal injury who could be stabilized by fluid resuscitation underwent computed tomographic (CT) scan examinations. Patients with CT scan evidence of hepatic injury were classified into five grades according to CT scan findings on the basis of the injury scale of the American Association for the Surgery of Trauma (Mirvis classification). All patients with CT scan grade 3 to 5 injury underwent angiography. When angiography showed extravasation of contrast medium extending from hepatic arterial branches, TAE was performed. RESULTS Of 612 patients with blunt abdominal trauma, 51 had CT scan grade 3 to 5 injury. Thirty-seven of these patients had a CT scan grade 3 injury and 18 underwent TAE. One of 19 patients who did not undergo TAE developed a delayed hemorrhage on day 6 and required a laparotomy. All 13 patients with a CT scan grade 4 injury had angiographic findings of the extravasation. TAE was successful in 11 patients and unsuccessful in 2. Five patients with a CT scan grade 4 injury required laparotomy. One developed a delayed hemorrhage on day 4. The remaining four patients had a major venous injury (a right lobectomy was performed in two with inferior vena cava injury, and a gauze packing in two with hepatic venous injury). One patient with a CT scan grade 5 injury underwent immediate laparotomy after TAE. Laparotomy revealed inferior vena cava injury and a right lobectomy was performed. Only two patients who underwent a lobectomy died of an uncontrollable hemorrhage. All CT scans of patients with hepatic venous or inferior vena cava injury showed a large low-density area (> or = 10 cm) with involvement of these vessels. The volumes of fluid resuscitation needed from admission until TAE ranged from 2,109 to 2,638 mL/h. CONCLUSION It was considered that the combination of the presence of a CT scan grade 4 or 5 lesion and the fluid requirements of more than 2,000 mL/h to maintain normotension indicated the absolute necessity of surgery. We felt that these patients were not candidates for TAE, and should undergo immediate laparotomy.

The effects of high-dose vitamin C therapy on postburn lipid peroxidation

The effects of vitamin C treatment (14 mg/kg/hr) on postburn lipid peroxidation were evaluated in 12 dogs. A lymph duct above the ankle was cannulated bilaterally. Hourly lymph flow rates, plasma and lymph total protein concentrations, and plasma and lymph malondialdehyde concentrations were measured before the burn injury and for 24 hours after the burn injury. Four groups were employed: nonburn without treatment, nonburn with vitamin C treatment, burn without treatment, and burn with vitamin C treatment. The nonburn groups showed no significant differences in lymph flow rates, total protein flux, or lymph malondialdehyde level. In the burn groups the postburn hourly lymph flow rate increased by 850% without treatment and by 500% with vitamin C treatment, whereas the postburn hourly total protein flux increased by fiftyfold and twentyfold, respectively. There was a significant reduction in the postburn lymph malondialdehyde level in the group treated with vitamin C as compared with the nontreatment group. We conclude that high-dose vitamin C administration diminishes early postburn lipid peroxidation and reduces microvascular leakage of fluid and protein.

High-dose vitamin C therapy for extensive deep dermal burns

We studied the haemodynamic effects of antioxidant therapy with high-dose vitamin C administration (170 mg/kg/24 h) in guinea-pigs with 70 per cent body surface area deep dermal burns. The animals were divided into three groups of six animals each. Group 1 was resuscitated with Ringers lactate solution according to the Parkland formula; group 2 with 25 per cent of the Parkland formula with vitamin C; and group 3 with 25 per cent of the Parkland formula without vitamin C. There were no significant differences in heart rates or in blood pressures between the groups throughout the 24-h study period. Group 3 showed significantly higher haematocrit values at 3 h postburn and thereafter as compared with those of group 2. The cardiac output values of group 2 were significantly higher than those of group 3, but equivalent to those of group 1. The water content of the burned skin in group 2 was significantly lower than that in the other groups, indicating that increased postburn capillary permeability was minimized by the administration of vitamin C. With adjuvant high-dose vitamin C administration, we were able to reduce the 24-h resuscitation fluid volume from 4 ml/kg/per cent burn to 1 ml/kg/per cent burn, while maintaining adequate cardiac output.

Effects of high-dose vitamin C administration on postburn microvascular fluid and protein flux.

The effects of vitamin C treatment (14 mg/kg/hr) on burn injury were evaluated in the hind paws of 12 mongrel dogs. A lymph duct above one hind paw of each dog was cannulated. Hourly lymph flow rates (QL) and plasma and lymph total protein concentrations were measured before the burn injury and for 6 hours after the burn injury. Data from 24 paws were divided into four groups: nonburn without treatment, nonburn with treatment, burn without treatment, and burn with treatment. The nonburn groups showed no significant differences in QL or in total protein flux. In the burn groups the postburn hourly QL increased by sevenfold in the nontreatment group and only by threefold in the treatment group, whereas the postburn hourly total protein flux increased by fifteenfold and fivefold, respectively. We conclude that administration of high-dose vitamin C reduces early postburn microvascular leakage of fluid and protein.

Burn depth affects dermal interstitial fluid pressure, free radical production, and serum histamine levels in rats.

BACKGROUND We measured the amount of edema and the free radical production in burn-injured skin and the serum histamine levels, as well as changes in dermal interstitial fluid pressure. METHODS Thirty-six Wistar rats with 20% total body surface area burns of different depth were resuscitated by lactated Ringers solution intravenously. The rats were divided into a deep burn (DB) group (n = 12), a superficial dermal burn (SDB) group (n = 12), and a sham burn (Sham) group (n = 12). Dermal interstitial fluid hydrostatic pressure (Pif), total skin water and xanthine oxidase activity, and serum histamine levels were measured until 60 minutes postburn. RESULTS In the DB group, dermal Pif significantly fell to -35.9 +/- 11.0 and -40.9 +/- 7.0 mm Hg at 10 and 15 minutes postburn, respectively (p < 0.05); it returned to preburn values at 50 minutes postburn. In the SDB group, dermal Pif was slightly negative but did not markedly change. Total skin water was significantly higher than that of the DB and the Sham groups; however, in the SDB group, serum histamine and dermal xanthine oxidase were significantly higher than in the DB group at 15, 30, and 45 minutes postburn (p < 0.05). CONCLUSION The fluid-resuscitated DB produced a more negative dermal Pif than the SDB, but less dermal edema. In contrast, the SDB appeared to mainly generate dermal edema formation by wound free radical production and serum histamine release. The dermal Pif is one of the factors associated with edema formation immediately after deep burns. However, an increase in vascular permeability associated with oxygen radical production plays a more important role in dermal edema formation than does dermal Pif.

RIGHT VENTRICULAR DYSFUNCTION IN SEPTIC PATIENTS

ObjectiveTo compare right ventricular ejection fraction in trauma and septic patients during the hyperdynamic circulatory phase of these states. DesignProspective, consecutive study. SettingUniversity hospital ICU. PatientsEleven trauma patients (group 1) and ten septic patients (group 2) were studied. Patients with circulatory shock were excluded from the study. InterventionsRight ventricular ejection fraction was measured with a modified pulmonary artery catheter using the thermodilution method. Patients requiring catecholamines to maintain a systolic BP >90 mm Hg were excluded from the study. Measurements and Main ResultsBoth groups 1 and 2 had high mean cardiac output values (cardiac indices 4.7 ±PT 0.9 [SD] and 4.6 ±PT 1.4 L/min/m2, respectively). Right ventricular ejection fraction was significantly (p < .005) reduced in septic patients (47 ±PT 7.0% vs. 36 ±PT 9.7%; group 1 vs. group 2) and end-diastolic volume index was significantly (p < .01) increased (101 ±PT 34 vs. 122 ±PT 40 mL/m2; group 1 vs. group 2) in comparison with the trauma patients. However, there were no significant differences in afterload between the two groups. ConclusionsHemodynamic measurements comparing septic and trauma patients showed increased cardiac output in both groups and no differences in the pulmonary resistance. Right ventricular ejection fraction in the septic patients was significantly reduced compared with the trauma patients. Therefore, we concluded that right ventricular contractility may be decreased in septic patients. (Crit Care Med 1992; 20:630–634)

Hemodynamic effects of delayed initiation of antioxidant therapy (beginning two hours after burn) in extensive third-degree burns.

The hemodynamic effects of the delayed initiation of antioxidant therapy with high-dose vitamin C were studied in 12 guinea pigs with third-degree burns over 70% of their body surface area. All animals were resuscitated with Ringers lactate solution (RL) according to the Parkland formula (4 ml/kg/% burn during the first 24 hours) from 1/2 to 2 hours after burn, and the infusion rate was reduced thereafter to 25% of that of the Parkland formula. The vitamin C group (n = 6) received RL with vitamin C (14 mg/kg/hr), and the control group (n = 6) received RL only. The 24-hour fluid intake for each group was 32.5% of the Parkland formula volume. Burn wound edema in the vitamin C group was significantly less than that in the control group. The vitamin C group maintained adequate hemodynamic stability as determined with hematocrit and cardiac output values, but the control group did not. Even though the initiation of the vitamin C administration is delayed until 2 hours after burn, the hourly infusion rate of the resuscitation fluid can be reduced to 25% once it is started. Thus antioxidant therapy with adjuvant vitamin C administration may be applicable to the clinical setting in which a patient with burns arrives at the burn care facility a few hours after the burn injury occurred.

Laparoscopic drainage of an intramural duodenal hematoma.

Abstract: A 21-year-old man was admitted with vomiting and abdominal pain 3 days after sustaining blunt abdominal trauma by being tackled in a game of American football. A diagnosis of intramural hematoma of the duodenum was made using computed tomography and upper gastrointestinal tract contrast radiography. The hematoma caused obstructive jaundice by compressing the common bile duct. The contents of the hematoma were laparoscopically drained. A small perforation was then found in the duodenal wall. The patient underwent laparotomy and repair of the injury. Laparoscopic surgery can be used as definitive therapy in this type of abdominal trauma.