Jerry M. Shuck

Risks, options, and informed consent for blood transfusion in elective surgery

Blood banking is undergoing a period of significant change as a result of several concurrent issues. Blood-transmitted diseases such as human immunodeficiency virus (HIV) and the alternatives to community-derived (homologous) blood such as autologous (patients own) and designated (blood donor known to transfusion recipient) blood have had an impact on surgical transfusion practice. Many of these issues comprise the medicolegal elements of informed consent for elective blood transfusion, so that increasingly the need for a dialogue incorporating these issues between the transfusing physician and the potential transfusion recipient is recognized. If the process is to be effective, then early involvement of the patient in a dialogue concerning informed consent is necessary. An overview of the medical elements and content of informed consent for elective blood transfusion is presented.

Intestinal disruption due to blunt abdominal trauma

: Twenty-three patients with thirty-one disruptions of the intestines due to blunt abdominal trauma are reviewed. The bowel disruptions occurred in the stomach (2 perforations), duodenum (9), proximal jejunum (18), and sigmoid colon (2). The causes of injury, diagnostic difficulties, delays in treatment, associated trauma, surgical correction, and results are analyzed. Deaths (4) and complications (6) are presented in detail. Intestinal disruptions can be due to a variety of types of blunt trauma, with the automobile being the most common etiologic agent. The bowel can perforate anywhere in its course. Intestinal perforations are often associated with severe injuries which will probably be the determining factors in survival. Persistence, particularly repeated physical examination, is required for the diagnosis of bowel injury. Routine diagnostic tests for duodenal injury are not reliable. Retroperitoneal hematomas around the duodenum must be explored. The injuries themselves are easy to repair, and repair is secure when performed at the primary operation. Prophylactic antibiotics are recommended.

Technical limitations in the rapid infusion of intravenous fluids

We compared fluid delivery, both in vitro and in vivo, using various combinations of fluid sets and intravenous catheters. Administration sets were a minidrip, a maxidrip, and a blood infusion set. The catheters included 14-, 16-, 18-, and 20-gauge short catheters, 16- and 19-gauge long catheters, and an 8 French catheter introducer for flow-directed pulmonary arterial lines. Blood infusion tubing alone delivered fluid at 3.12 +/- .07 mL/second, significantly faster than either the maxidrip (2.59 +/- .06, P less than .01) or the minidrip (0.56 +/- .02, P less than .001). The 8 French introducer provided no additional resistance to the flow of the maxidrip or blood infusion set when used in combination with an anesthesia extension. All the other catheters slowed flow significantly. Percutaneous insertion of an 8 French catheter introducer connected to blood administration tubing allows for rapid delivery of fluids and for subsequent insertion of a Swan-Ganz catheter, which is often necessary in critically ill patients.

Safeguards in the use of topical mafenide (Sulfamylon) in burned patients

Abstract Some practical guidelines are suggested for the use of Sulfamylon Acetate burn cream in major thermal injury. Knowledge and experience with the complications of this drug have permitted evolution of safeguards which lessen the incidence and minimize the severity of allergic and metabolic phenomena. Awareness of incipient acidosis and corrective measures may prevent fatal metabolic derangements. The usefulness of Sulfamylon Acetate burn cream is related to the ability of the surgeon to anticipate and prevent its complications.

Cognitive learning during surgical residency. A model for curriculum evaluation.

The program summary of the American Board of Surgery In-Service Training Exam (ABSITE) can be used to quantitate cognitive learning during a surgical residency and to identify areas of curricular weakness in a residency program. Knowledge on each question is categorized as high (known) or low (unknown) depending on the percentage of residents who answered correctly. Knowledge of Level 1 (entry) residents is then compared with Level 5 (exit) residents. Each ABSITE question can thus be categorized on entry versus exit as known-known, unknown-unknown, unknown-known, and known-unknown. Only about half of unknown knowledge on entry appears to become known on exit. Very little knowledge known on entry becomes unknown on exit. Weaknesses in specific subject areas can be readily identified by ranking questions according to the number of exiting residents who answer incorrectly. Use of this technique to quantitate cognitive learning in a residency program may allow objective assessment of changes in curriculum.

Selective management of penetrating neck wounds

Of 67 patients with penetrating neck wounds admitted to the hospital between 1969 and 1979, 22 (32.8%) were taken to the operating room and 14 (63.6%) were found to have major structural damage. Three patients died (4.4%), all as a direct result of their associated head injuries and none as a result of their neck wounds, regardless of management. Five patients (7.4%) had complications. The average hospital stay for patients undergoing surgery was 4.9 days; for those observed with multiple injuries, 4.6 days; and for those observed with isolated neck wounds, 2.4 days. Indications for selective exploration are presented.

Percutaneous peritoneal lavage using the veress needle: a preliminary report

A modification of past percutaneous methods for peritoneal lavage is described which combines the safety of the Veress Needle with the utility of a readily available introducer-dilator catheter. The technique has been used in 30 patients seen for blunt abdominal trauma and has been found to be a reliable and accurate method for peritoneal lavage.

Return of the physical examination

in lower chest and abdominal stab wounds. J Trauma 1977; 17: 642-8. 22. Baker LW, Chadwick SJD. Primary intraperitoneal closure and exteriorization of primarily sutured colon for colon injuries. Surg Rounds 1965; 6: 65-74. 23. Richter RM, Zaki MH. Selective conservative management of penetrating abdominal wounds. Ann Surg 1967; 166: 23644. 24. Stein A, Lissoos I. Selective management of penetrating wounds of the abdomen. J Trauma 1966; 6: 1014-25. 25. Wilder JR, Lotfi MW, Jurani P. Comparative study of mandatory and selective surgical intervention in stab wounds of the abdomen. Surgery 1971; 69: 546-9. 26. Granson MA, Donovan AJ. Abdominal stab wound with omental evisceration. Arch Surg 1963; 116: 57-9. 27. Lowe RJ, Boyd DR, Folk FA, et al. The negative laparotomy for abdominal trauma. J Trauma 1972; 12: 653-6 1. 26. Shah R, Max MH, Flint LM. Negative laparotomy: mortality and morbidity among 100 patients. Am Surg 1976; 44: 150-4. 29. Demetriades D, Rabincowitz B. Selective conservative management of penetrating abdominal wounds: a prospective study. Br J Surg 1984; 71: 92-4. 30. Thal ER, Shires GT. Peritoneal lavage in blunt abdominal trauma. Am J Surg 1973; 125: 64-9. 31. Olsen WR, Redman KC, Hildreth DH. Quantitative peritoneal lavage in blunt abdominal trauma. Arch Surg 1972; 104: 536-43. 32. Thal ER, May RA, Beesinger D. Peritoneal lavage. Its unreliability in gunshot wounds of the lower chest and abdomen. Arch Surg 1980; 115: 430-3. 33. Peck J, Berne TV. Posterior abdominal stab wounds. J Trauma 1981; 21: 298-306. 34. Jackson GC, Thal ER. Management of stab wounds of the back and flank. J Trauma 1979; 19: 660-4.

Homograft Skin: A Versatile Biologic Dressing

The most important step during the recovery of the burn patient is the conversion of the open wound to a closed wound. The covering may be from regeneration of skin from residual epidermal elements or by the application of autograft. In large or untidy wounds, attempts have been made to use substitutes for the patient’s own skin. Although artificial substances have been tested, none has been more effective than skin itself in providing protection of the open wound and in controlling bacterial growth. Homograft skin was applied as early as 1881 for treatment of a lightning victim, but not until the mid-twentieth century did enthusiasm for its use begin to develop.’-’ The homograft skin was allowed to remain in place until the rejection phenomenon resulted in slough.’ It became evident that the rejection period was unsatisfactory because it resulted in a febrile, irritable and anorectic patient whose wounds again were open, unhealthy, edematous and