James K. Lukan

Evolution in the Management of Hepatic Trauma: A 25-Year Perspective

ObjectiveTo define the changes in demographics of liver injury during the past 25 years and to document the impact of treatment changes on death rates. Summary Background DataNo study has presented a long-term review of a large series of hepatic injuries, documenting the effect of treatment changes on outcome. A 25-year review from a concurrently collected database of liver injuries documented changes in treatment and outcome. MethodsA database of hepatic injuries from 1975 to 1999 was studied for changes in demographics, treatment patterns, and outcome. Factors potentially responsible for outcome differences were examined. ResultsA total of 1,842 liver injuries were treated. Blunt injuries have dramatically increased; the proportion of major injuries is approximately 16% annually. Nonsurgical therapy is now used in more than 80% of blunt injuries. The death rates from both blunt and penetrating trauma have improved significantly through each successive decade of the study. The improved death rates are due to decreased death from hemorrhage. Factors responsible include fewer major venous injuries requiring surgery, improved outcome with vein injuries, better results with packing, and effective arterial hemorrhage control with arteriographic embolization. ConclusionsThe treatment and outcome of liver injuries have changed dramatically in 25 years. Multiple modes of therapy are available for hemorrhage control, which has improved outcome.

Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients.

Background and Aims:Elevated residual volumes (RV), considered a marker for the risk of aspiration, are used to regulate the delivery of enteral tube feeding. We designed this prospective study to validate such use. Methods:Critically ill patients undergoing mechanical ventilation in the medical, coronary, or surgical intensive care units in a university-based tertiary care hospital, placed on intragastric enteral tube feeding through nasogastric or percutaneous endoscopic gastrostomy tubes, were included in this study. Patients were fed Probalance (Nestlé USA) to provide 25 kcal/kg per day (to which 109 yellow microscopic beads and 4.5 mL of blue food coloring per 1,500 mL was added). Patients were randomized to one of two groups based on management of RV: cessation of enteral tube feeding for RV >400 mL in study patients or for RV >200 mL in controls. Acute Physiology and Chronic Health Evaluation (APACHE) III, bowel function score, and aspiration risk score were determined. Bedside evaluations were done every 4 hrs for 3 days to measure RV, to detect blue food coloring, to check patient position, and to collect secretions from the trachea and oropharynx. Aspiration/regurgitation events were defined by the detection of yellow color in tracheal/oropharyngeal samples by fluorometry. Analysis was done by analysis of variance, Spearman’s correlation, Student’s t-test, Tukey’s method, and Cochran-Armitage test. Results:Forty patients (mean age, 44.6 yrs; range, 18–88 yrs; 70% male; mean APACHE III score, 40.9 [range, 12–85]) were evaluated (21 on nasogastric, 19 on percutaneous endoscopic gastrostomy feeds) and entered into the study. Based on 1,118 samples (531 oral, 587 tracheal), the mean frequency of regurgitation per patient was 31.3% (range, 0% to 94%), with a mean RV for all regurgitation events of 35.1 mL (range, 0–700 mL). The mean frequency of aspiration per patient was 22.1% (range, 0% to 94%), with a mean RV for all aspiration events of 30.6 mL (range, 0–700 mL). The median RV for both regurgitation and aspiration events was 5 mL. Over a wide range of RV, increasing from 0 mL to >400 mL, the frequency of regurgitation and aspiration did not change appreciably. Aspiration risk and bowel function scores did not correlate with the incidence of aspiration or regurgitation. Blue food coloring was detected on only three of the 1,118 (0.27%) samples. RV was ≤50 mL on 84.1% and >400 mL on 1.4% of bedside evaluations. Sensitivities for detecting aspiration per designated RV were as follows: 400 mL = 1.5%; 300 mL = 2.3%; 200 mL = 3.0%; and 150 mL = 4.5%. Low RV did not assure the absence of events, because the frequency of aspiration was 23.0% when RV was <150 mL. Raising the designated RV for cessation of enteral tube feeding from 200 mL to 400 mL did not increase the risk, because the frequency of aspiration was no different between controls (21.6%) and study patients (22.6%). The frequency of regurgitation was significantly less for patients with percutaneous endoscopic gastrostomy tubes compared with those with nasogastric tubes (20.3% vs. 40.7%, respectively; p = .046). There was no correlation between the incidence of pneumonia and the frequency of regurgitation or aspiration. Conclusions:Blue food coloring should not be used as a clinical monitor. Converting nasogastric tubes to percutaneous endoscopic gastrostomy tubes may be a successful strategy to reduce the risk of aspiration. No appropriate designated RV level to identify aspiration could be derived as a result of poor sensitivity over a wide range of RV. Study results do not support the conventional use of RV as a marker for the risk of aspiration.

Prehospital hypotension as a valid indicator of trauma team activation.

BACKGROUND Criteria for trauma team activation are continually being evaluated to ensure proper utilization of resources. We examined the impact of prehospital (PH) hypotension (systolic blood pressure < or = 90) on outcome (operative intervention and mortality) and its usefulness as an indicator for trauma team activation. METHODS A database was created by using the trauma registry for all nonburned, injured patients from July of 1993 through October of 1998 at our Level I trauma center. RESULTS Of 6,976 patients (83% blunt injury) in the database, 4,437 had a PH blood pressure recorded. Documented PH hypotension was present in 791 patients. Hypotension persisted in the emergency department (ED) in 299 patients, but 193 of them showed minimal or no signs of life on arrival. Four hundred ninety-two patients had PH hypotension but normal ED systolic blood pressure, and 130 patients developed ED hypotension after normal PH systolic blood pressure. Nearly half of the patients with hypotension were taken from the ED directly to the operating room primarily for hemorrhage control procedures. The early and late mortality rates of patients with PH and ED hypotension were 12% and 32%, respectively. Other PH interventions had minimal effect on mortality in the hypotensive patient. CONCLUSION Prehospital hypotension remains a valid indicator for trauma team activation. Even though most of the non-DOA patients (492 of 598) were stable on arrival to the ED, nearly 50% required operative intervention, and an additional 25% required intensive care unit admission. The trauma team should be activated and involved with these patients early.

Impact of recent trends of noninvasive trauma evaluation and nonoperative management in surgical resident education.

BACKGROUND The use of ultrasonography and nonoperative management of solid organ injury has become standard practice in many trauma centers. Little is known about the effects of these changes on resident educational experience. METHODS We retrospectively reviewed resident evaluation of abdominal trauma and trauma operative experience as reported to the residency review committee between 1994 and 1999. RESULTS A total of 4,052 patients underwent one or more of three diagnostic modalities. The nontherapeutic laparotomy rate as a result of positive diagnostic peritoneal lavages decreased from 35% to 14%. Although resident operative trauma experience was stable because of increases in operative burns and nonabdominal trauma, the number of abdominal procedures declined. CONCLUSION Noninvasive diagnostic tests have allowed more rapid trauma evaluation and fewer nontherapeutic laparotomies. As nonoperative experience grows, the opportunity for operative experience decreases. These trends may adversely affect the education of residents and suggest that novel approaches are needed to ensure adequate operative experience in trauma.

Toxicology screening results : Injury associations among hospitalized trauma patients

BACKGROUND Substance abuse is associated with injuries, but these associations have not been well characterized by type of substance and injury type. METHODS A cross-sectional study of patients selected for toxicology screening compared those with positive and those with negative test results for drugs and alcohol. RESULTS Patients with positive alcohol toxicology results were more likely to have violence-related and penetrating injuries than patients with negative results. However, after adjustment for positive cocaine toxicology results, the association between alcohol and penetrating injury was no longer significant. Positive test results for any drug were not associated with any specific injury type, but cocaine was independently associated with violence-related injury. The associations of alcohol and cocaine with violence-related injury appear to be additive. In contrast, opiates were independently associated with nonviolent injuries and burns. CONCLUSIONS Alcohol and cocaine use is independently associated with violence-related injuries, whereas opiate use is independently associated with nonviolent injuries and burns.

Risk factors for delirium tremens in trauma patients.

BACKGROUND The development of delirium tremens (DT) is associated with significant morbidity and mortality. This study identifies characteristics in trauma patients that are predictive of DT. METHODS Data from 1,856 trauma patients who either developed DT (n = 105) or had a positive blood alcohol concentration but did not develop DT (n = 1,751) were collected from the trauma registry of a Level I trauma center. Odds ratios were used to measure the association between predictors and DT as an outcome and between DT and length of stay as an outcome. RESULTS Of seven significant (p < 0.05) predictors of DT, four were retained after stepwise logistic regression: age >40, white race, burn as a mechanism of injury and, as a negative predictor, motor vehicle collision as a mechanism of injury. The DT group stayed an average of 6.5 and 5.2 days longer in the hospital and the intensive care unit, respectively, than those in the control group. CONCLUSION It is possible to determine which intoxicated trauma patients are at increased risk for DT using the above predictors. Patients who develop DT have worse outcomes than those who do not. Whether routine DT prophylaxis would improve outcomes among those at increased risk for DT is unknown, but deserves further study.

Enteral access for nutritional support: rationale for utilization.

Acquisition of enteral access and provision of a sufficient volume of enteral nutrients early in the hospital course of a critically ill patient afford an opportunity to improve the outcome of that patient through the progression of his or her disease process. Failure to use the enteral route of feeding not only squanders this opportunity, but may, in addition, promote a pro-inflammatory state, which exacerbates disease severity and worsens morbidity. Enteral feeding provides a conduit for the delivery of immune stimulants and serves as effective prophylaxis against stress-induced gastropathy and gastrointestinal hemorrhage. Tube placement beyond the stomach into the small bowel in hypermetabolic, severely ill patients prone to ileus and disordered gut motility aids delivery of enteral nutrients while reducing risk of aspiration. Endoscopic skills and expertise in gastrointestinal physiology are vital to the success of a nutrition support service and the provision of enteral tube feeding.

Revisiting endotracheal self-extubation in the surgical and trauma intensive care unit: Are they all fine?

OBJECTIVES Endotracheal self-extubation (ESE) is a serious health care concern. We designed this study to test our hypothesis that not all patients with ESE are successful in spontaneous breathing and reintubation has negative impact on outcomes. METHODS Data on all 39 patients of ESE in our surgical and trauma intensive care unit (ICU) in 2012 were prospectively collected and retrospectively analyzed. RESULTS There were 42 episodes of ESE in 39 of 939 intubated patients (frequency, 4.0%), with 54% of events requiring reintubation. Pre-ESE positive end-expiratory pressure was higher and Pao2/fraction of inspired oxygen ratio was lower, and the post-ESE respiration rate was higher in the reintubated group. On univariate analysis, weaning and spontaneous breathing trial before ESE were favorable predictors for nonreintubation. Multivariate regression analysis demonstrated that agitation before ESE was an independent predictor of reintubation. The need for reintubation was associated with increased risk of pulmonary infectious complications, ventilator days, the need for tracheostomy, and ICU and hospital LOS. The financial costs for ventilator days and ICU rooms were significantly higher in patients with reintubation. CONCLUSION Not all patients were fine after ESE. We have not decreased the frequency of ESE or improved outcomes if the patients were reintubated. The need for reintubation was not only associated with a high pulmonary complication rate but also prolonged duration on mechanical ventilation and hospital/ICU stay and increased the hospital costs.

Traumatic Lumbar Hernias: Difficulty with Diagnosis and Repair

Infrequently encountered, the traumatic lumbar hernia presents a challenge to the surgeon both in diagnosis and management. Repair is often complicated by a lack of viable fascia and a high incidence of associated injuries. The following review considers the natural history of lumbar hernias and their etiologies. Subsequently, the role of computed tomography (CT) in diagnosis is discussed. Finally, the multiple techniques of repair are presented, along with a discussion of the role of laparoscopy.Two case reports of traumatic lumbar hernias are presented, followed by a review of the literature and discussion. The case reports include a 36-year-old bicyclist who was thrown into a fixed roadway object and a 44-year-old victim of a side impact motor vehicle crash.The 36-year-old bicyclist underwent open repair with polytetrafluoroethylene (PTFE) and has done well at 7-month follow-up. The 44-year-old victim of a motor vehicle crash underwent open primary repair and has done well at 36-month follow-up.Traumatic lumbar hernias require a high index of suspicion in order to avoid the potential for incarceration and missed associated injuries. CT is helpful in making this diagnosis. Principles of hernia repair including freedom from tension and avoidance of compromised fascia are vital. Additionally, a thorough evaluation for associated injuries is paramount. Mesh should be used liberally and laparoscopy offers some advantage in the hands of the experienced.

The Role of Nutritional Support in Sepsis

The critically ill patient with sepsis experiences a unique pathophysiologic state that promotes deterioration of organ function and systemic immunity. Beyond its effect on nutritional status, providing nutritional support by the enteral route may modify the course of sepsis through maintenance of gut structure and function, thereby reducing the inflammatory response to sepsis, and improving clinical outcomes. Parenteral nutrition seems to have little role and may even worsen outcomes in sepsis. While use of immune-enhancing nutrients may be helpful in a variety of patient groups who are non-septic, evidence for possible deleterious effects may prevent their use in patients who have pre-existing infection. Careful selection and close monitoring should maximize efficacy and benefit from the nutritional support regimen in this complex patient population.