Omer Cakir

Open Fixation in Flail Chest: Review of 64 Patients

The strategy for treatment of flail chest remains controversial. Various alternatives were assessed by reviewing the records of 64 patients treated from 1991 through 2000. Patients were classified according to therapeutic approach: group 1 was 27 patients who underwent open fixation of the fractured ribs, group 2 was 19 patients managed by intermittent positive-pressure ventilation, and group 3 was 18 patients managed mainly by synchronized intermittent mandatory ventilation. Two patients initially treated by ventilation underwent successful open fixation. In group 1, ventilatory support was required in 21 (77.8%) patients postoperatively, the mean duration of ventilation was 3.1 days, mean hospital stay was 18.3 days, morbidity was 11.1% (3/27), and mortality was 11.1%. In groups 2 and 3, the mean time for stabilization of paradoxical chest wall movement was 6.6 days, and mean duration of ventilation was 7.2 days. Mortality was 27.0% (10/37) in patients treated nonsurgically; 21.0% (4/19) in group 2, and 33.3% (6/18) in group 3. In groups 2 and 3, pain control required epidural analgesia in 13 (35.1%) cases, intercostal nerve blockade in 16 (43.2%), and narcotic or nonnarcotic parenteral analgesia in 8 (21.6%). Open fixation is a successful treatment modality for traumatic flail chest.

Neuroprotective effect of N-acetylcysteine and hypothermia on the spinal cord ischemia–reperfusion injury

The purpose of this study was to investigate the effect of N-acetylcysteine (NAC) on spinal cord ischemia-reperfusion (I-R) in rabbits. Thirty rabbits were divided into five equal groups, group I (sham-operated, no I-R), group II (control, only I-R), group III (I-R+NAC), group IV (I-R+hypothermia), group V (I-R+NAC+hypothermia). Spinal cord ischemia was induced by clamping the aorta both below the left renal artery and above the aortic bifurcation. Forty-eight hours postoperatively, the motor function of the lower limbs was evaluated in each animal according to Tarlov Score. Spinal cord samples were taken to evaluate the histopathological changes. The sham-operated rabbits (group I) showed no neurologic deficit (Score=4). Paraplegia (Score=0) developed in all rabbits in the control group (group II). Administration of 50 mg/kg of NAC (group III) resulted in significant reduction of motor dysfunction (Score=3.1+/-1.3, p=0.002). Application of hypothermia alone (group IV) showed significant recovery of motor functions (Score=3.0+/-1.1, p=0.002), and combination of hypothermia and 50 mg/kg of NAC (group V) showed complete recovery of lower limb motor function (Score=4, p=0.001). Histologic examination of the spinal cord in rabbits with paraplegia revealed several injured neurons. The cords of animals with no motor function deficits showed only minimal cellular infiltrates in the gray matter, and there was good preservation of nerve cells. NAC showed protective effects of the spinal cord. Moderate hypothermia alone also showed protective effects. Combined use of NAC and hypothermia resulted in highly significant recovery of spinal cord function.

Treatment of vascular injuries associated with limb fractures.

INTRODUCTION The goal of therapy in all patients with combined orthopaedic and vascular injuries of the extremities is salvage of a functional limb. In this study, we have evaluated our experience with a subset of patients who had a combination of vascular injury and limb fracture. PATIENTS AND METHODS The records of 192 patients with vascular injuries of the lower and upper limbs associated with bone fractures were reviewed. Of these, 168 were males and 24 were females; the mean age was 26 years. RESULTS The mechanism of injury was a penetrating wound in 97 (51%) patients and blunt trauma in 95 (49%) patients. Injured vessels included 6 subclavian/axillary, 39 brachial, 14 radial/ulnar, 11 radial, 8 ulnar, 36 femoral, 43 popliteal, 35 tibial arteries. Saphenous vein graft was the most common conduit of choice in arterial repair (55%). Amputations were needed for 20 patients. The limb salvage rate was 88%. Three patients died. CONCLUSIONS This study established that delay in surgery, blunt trauma and extensive soft tissue defect in combined orthopaedic and vascular injuries are associated with increased risk of amputation.

Surgical treatment of thoracic outlet syndrome: effect and results of surgery

BACKGROUND Because of the difficulty in diagnosis and different treatment options, debate on thoracic outlet syndrome (TOS) has continued. Our aim is to report our surgical experience. METHODS Forty-seven patients with thoracic outlet syndrome were operated on between 1985 and 2000. Mean age was 37.9 years (range, 17 to 58 years); female/male ratio was 41/6. The most frequent symptom was paresthesia (72.3%). Seventeen patients (36%) had bilateral symptoms. Of all, 89.3% (42 cases) were neurologic thoracic outlet syndrome, and 10.7% (five cases) were vascular. Lower plexus (C8-T1/ulnar nerve) compression was present in 36 patients and upper plexus (C5-C7/median nerve) compression in 6 patients. Doppler ultrasonography in 11 patients, angiography in 8, and lymph node scintigraphy in 1 patient were also performed. Main operative indications were persistence of symptoms after conservative therapy and reduced (< 60 m/s) ulnar nerve conduction velocity. RESULTS Fifty-five operations were performed on the 47 patients. First (59.6%) and cervical costae (21.3%) resections were the most frequent operations. Mean ulnar nerve conduction velocity was 54.8 m/s (range, 43 to 68 m/s) preoperatively and 69.4 m/s (range, 47 to 70 m/s) postoperatively (p < 0.05). The morbidity rate was 17% (8 of 47). No difference was observed between transaxillary and supraclavicular incisions. No brachial plexus injuries occurred. The most frequent cause of morbidity was incisional pain. Two reoperations were performed for recurrences. Follow-up was 4.6 years, and 75% of lower plexus and 50% of upper plexus compressions remained asymptomatic. Severe and long-term pain occurred in 1 patient. CONCLUSIONS Surgical decompression for thoracic outlet syndrome is efficient and dependable, but results deteriorate over time.

Effects of N-acetylcysteine on pulmonary function in patients undergoing coronary artery bypass surgery with cardiopulmonary bypass

Cardiopulmonary bypass (CPB) has been implicated in causing poor pulmonary gas exchange postoperatively in patients undergoing coronary artery bypass grafting (CABG) procedures. In this prospective, randomized, double-blind, placebo-controlled study, we examined the pulmonary effects of N-acetylcysteine (NAC) in patients undergoing CABG. Twenty patients undergoing elective CABG and early tracheal extubation were randomized into two groups. Group I (ten patients) received a physiologic salt solution as a placebo in a continuous intravenous infusion for one hour before CPB and 24 hours after CPB; Group II (ten patients) received 100 mg/kg NAC intravenously for one hour before CPB and 40 mg/kg/day at 24 hours after CPB. Perioperative hemodynamic and pulmonary data were recorded. Postoperative tracheal extubation was accomplished at the earliest appropriate time. The postoperative clinical course was similar in the two groups. Both groups exhibited significant postoperative increases in A-a oxygen gradient (p<0.01), but patients in Group II exhibited significantly lower increases in postoperative A-a oxygen gradient (p<0.006). Other hemodynamic and pulmonary data (pulmonary capillary wedge pressure, pulmonary vascular resistance (PVR), cardiac index (CI), shunt flow, dynamic lung compliance and static lung compliance) exhibited no differences between the groups. There was no significant difference in terms of intubation time. The malondialdehyde (MDA) increase in Group II following CPB was found to be significantly lower than in Group I (p=0.043). This clinical study reveals that administration of NAC to patients undergoing elective CABG with CPB improves systemic oxygenation. There was no effect in other pulmonary parameters and in terms of intubation time.

The effect of aprotinin on ischemia-reperfusion injury in an in situ normothermic ischemic lung model

OBJECTIVES In the context of the physiopathology of damage due to ischemic preservation and reperfusion injury following preservation, we aimed to demonstrate the positive effects of the addition of aprotinin, a serine protease inhibitor, to low potassium dextran (LPD), used as a single-flush solution in normothermic ischemic animal models, on lung protection and the prevention of reperfusion injury. METHODS In the study, 21 New Zealand white rabbits were used as experimental subjects. The subjects were ventilated with the assistance of a manual mechanical ventilator at 30 breaths/min and 10 ml/kg tidal volume. Lung protection solution was supplied to the pulmonary artery via a catheter. After applying the solution, ischemia was carried out for 120 min. At the end of this period, reperfusion was carried out for 90 min. The subjects were divided into three groups of seven subjects each. In the control group, pulmonary perfusion solution was not employed, whereas in the second group LPD was employed, and in the third group LPD and aprotinin (LPD+A) were perfused. Blood gas analysis, bronchoalveolar lavage (BAL) fluid examination, tissue malondialdehyde (MDA) level analysis and morphological examinations were performed. RESULTS The LPD+A group showed the significantly highest levels of oxygenation at the 15th and 60th minutes of reperfusion (297+/-76.7 and 327+/-97.4 mmHg) in comparison to the LPD (157+/-20.6 and 170+/-53.6 mmHg) and control (64+/-8.4 and 59+/-7.2 mmHg) groups (P<0.001). The LPD+A group showed the significantly lowest levels of alveolar-arterial oxygen difference at the 60th minute of reperfusion (389+/-15 mmHg) in comparison to the LPD (478+/-19 mmHg) and control (542+/-23) groups (P<0.001). The BAL fluid neutrophil percentage was significantly lower in the LPD+A group (22+/-2.4%) compared to the LPD (31+/-6.1%) and control (38+/-2.4%) groups. MDA levels were significantly lower in the LPD+A group (119.8+/-5.3 nmol MDA/g) when compared to the LPD (145.06+/-9.5 nmol MDA/g) and control (147.3+/-3.9 nmol MDA/g) groups (P<0.05). Morphological examinations revealed pathological lesions and alveolar hemorrhaging in all samples, with the LPD+A group having statistically more significant levels than the LPD and control groups (P<0.005). The LPD+A group had a significantly lower percentage of pathological lesions and alveolar hemorrhage grade values than the LPD and control groups (P<0.005). CONCLUSIONS It was observed that the addition of aprotinin to LPD solution as a pulmonary flush solution in an in situ normothermic ischemic lung model prevents reperfusion injury by means of various mechanisms and also protects the morphological, functional and biochemical integrity of the lung. In our view, therefore, the addition of aprotinin to lung protection solution will provide positive results in lung transplantation protocols.

A young adult with coronary artery and jugular vein thrombosis: a case report of combined protein S and protein C deficiency.

Abstract Protein C and protein S deficiencies increase the risk of thromboembolic events. We report a case of combined protein C and S deficiency in a young woman, with resulted in acute myocardial infarction and asymptomatic jugular vein thrombosis. The patient was treated successfully with coronary artery hypass graft surgery and systemic anticoagulation. Our report emphasizes that a combined deficiency of protein C and S may be a high risk factor for arterial thromboembolic events in young adults.

Unilateral post-traumatic pulmonary contusion : Findings of a review

PurposeThere is still much controversy regarding the optimal treatment for pulmonary contusion. Therefore, we examined the variables affecting patient outcomes over a 10-year period.MethodsWe retrospectively reviewed 107 consecutive patients with a mean age of 28 years, who were treated for pulmonary contusion during a 10-year period. Pulmonary perfusion scans were obtained for 11 patients. We used a pulmonary contusion score (PCS) of one-third of a lung = 3 and the entire lung = 9.ResultsOverall mortality was 15%, which increased to 24.4% in patients with a PCS of 7–9. The time taken for contusions to resolve was longer based on scan results than chest X-rays (42.6 vs 15.5 days, respectively). Concomitant thoracic injures were present in 64.5% of patients, and 29% had a flail chest. The factors predictive of mortality were age ≥60 years, an injury severity score (ISS) ≥25, transfusion of ≥4 units of blood, a PaO2/FIO2 ratio of <300, concomitant flail chest, and a PCS of 7–9. The predictors for mechanical ventilation were age ≥60 years, concomitant flail chest, a PCS of 7–9, and an ISS ≥25. Mortality and the need for mechanical ventilation were higher in patients with nonisolated contusions than in those with isolated contusions.ConclusionsOptimizing patient outcome requires prompt diagnosis, appropriate maintenance of fluid volume, and selective mechanical ventilation.

Does sodium nitroprusside reduce lung injury under cardiopulmonary bypass

OBJECTIVE We hypothesized that direct pulmonary arterial infusion of sodium nitroprusside (SNP) would ameliorate lung injury under cardiopulmonary bypass. METHODS Experiments were performed on 12 adult mongrel dogs of both sexes weighing 20-28 kg. The animals were randomly divided into two groups of six animals each. All animals were subjected to total cardiopulmonary bypass (CPB) and moderate hypothermia (28 degrees C core temperature). During total CPB, the aorta was clamped together with the pulmonary artery to prevent any antegrade flow to the lungs. After cardioplegic arrest for 120 min, the animals were rewarmed, weaned from CPB, and their condition stabilized for another 90 min. After the release of the aortic cross-clamp, the dogs received either a 5% glucose solution as a placebo (group I) or SNP (0.5 microg/kg per min) (group II), both infused into the pulmonary arterial line. The infusion was stopped after 60 min. To measure lung tissue malondialdehyde (MDA), water content and polymorphonuclear leukocytes count, lung tissue samples were taken before CPB and after weaning from CPB. In addition, alveolar-arterial oxygen difference (AaDO(2)) for tissue oxygenation was calculated by obtaining arterial blood gas samples. RESULTS Values of MDA before CPB of 42.0+/-5.3 nmol/g of tissue rose to 67.6+/-5.7 nmol/g of tissue after weaning from CPB in group I (P=0.028). In group II MDA values also increased from 43.1+/-4.3 to 52.4+/-5.7 nmol MDA/g of tissue after weaning from CPB (P=0.046). The MDA increase in group II after CPB was found to be significantly lower than that for group I (P=0.004). The wet-to-dry lung weight ratio in the sodium nitroprusside group was 5.1+/-0.2, significantly lower than in the control group (6.8+/-0.4), (P=0.01). AaDO(2) increased significantly in group I (P=0.028). There was no statistically significant difference (P=0.065) between groups I and II. During histopathological examination it was observed that neutrophil counts in the lung parenchyma rose significantly after CPB in both groups. The increase in group I was significantly larger than that in group II (P<0.001). CONCLUSIONS The results represented in our study indicate that pulmonary arterial infusion of sodium nitroprusside during reperfusion can reduce lung injury under cardiopulmonary bypass.

Thoracic firearm injuries in children: management and analysis of prognostic factors

OBJECTIVE Thoracic firearm injuries (TFI) have become increasingly prevalent in children. Our purpose is to assess the injury pattern, Injury Severity Score (ISS), length of hospital stay (LOS), management and outcome of children with TFI with respect to the type of injury and to evaluate the value of ISS for predicting injury severity and the eventual need for thoracotomy, as well as the rate of morbidity and mortality. METHODS Between January 1987 and June 2002, 110 children (88 boys and 22 girls) </=16 years of age with firearm injuries to the chest were evaluated. The children were divided in four groups according to cause of injury. An ISS was calculated for each child. Those children who died before admission were excluded from the study. The relationship between ISS and prognostic factors was analyzed in all four groups. RESULTS The mean age was 11.1+/-3.0 (range 3-16) years. Eighty-eight (80%) were male and 22 (20%) were female. The causes of firearm injuries were high-velocity gunshot wounds (HVGSW) in 52 (47.2%), low-velocity gunshot wounds (LVGSW) in 23 (20.9%), shotgun wounds (SGW) in 18 (16.3%), and explosives wounds (EW) in 17 (15.4%). Lung injury occurred in 72 (65.5%) patients. Tube thoracostomy was sufficient in 76.3% (84 of 110) for thoracic injury. The morbidity rate was 16.3% (18/110) and the mortality rate was 4.5% (5/110). Mean ISS was 16.62+/-8.2 (range 4-48). Fifty-eight patients (52.7%) had an ISS </=16, while 31 (28.2%) had a score between 17 and 25, and 21 (19.1%) had a score greater than 25. The need for thoracotomy, as well as the rate of morbidity and mortality were significantly higher in children for those with an ISS >25. SGW and EW groups had a significantly higher ISS. The mean LOS was 10.84+/-4.7 days (range 4-42). The value of LOS was significantly higher in children with SGW and EW. CONCLUSION The majority of TFI in children can be treated successfully by tube thoracostomy if there are no gross pulmonary lacerations and airway injuries. SGW and EW were commonly associated with higher ISS and LOS. The ISS was found to be an independent predictor of the need for thoracotomy, as well as for rates of morbidity and mortality.