R. Lawrence Reed

A review of available prosthetics for ventral hernia repair.

Objective:To review mesh products currently available for ventral hernia repair and to evaluate their efficacy in complex repair, including contaminated and reoperative fields. Background:Although commonly referenced, the concept of the ideal prosthetic has never been fully realized. With the development of newer prosthetics and approaches to the ventral hernia repair, many surgeons do not fully understand the properties of the available prosthetics or the circumstances that warrant the use of a specific mesh. Methods:A systematic review of published literature from 1951 to June of 2009 was conducted to identify articles relating to ventral hernia repairs and the use of prosthetics in herniorrhaphy. Results:Important differences exist between the synthetics, composites, and biologic prosthetics used for ventral hernia repair in terms of mechanics, cost, and the ideal situation in which each should be used. Conclusions:The use of synthetic mesh remains an appropriate solution for most ventral hernia repairs. Laparoscopic ventral hernia repair has created a niche for both expanded polytetrafluoroethylene and composite mesh, as they are suited to intraperitoneal placement. Preliminary studies have demonstrated that the newer biologic prosthetics are reasonable options for hernia repair in contaminated fields and for large abdominal wall defects; however, more studies need to be done before advocating the use of these biologics in other settings.

Major injury as a unique opportunity to initiate treatment in the alcoholic

A prospective study was performed on the use of a standard outpatient intervention technique to induce inpatient alcoholic trauma patients into accepting alcoholism treatment. Interventions were performed on 17 trauma patients. All patients who underwent intervention accepted treatment and were immediately transferred to a 28-day inpatient treatment facility. Alcoholic trauma patients are highly susceptible to intervention for their disease. We found that intervention performed upon discharge from the trauma service successfully initiates alcoholism treatment.

Blunt vascular injuries of the head and neck: is heparinization necessary?

BACKGROUND Blunt vascular injuries to the head and neck (BHVI) represent some of the most devastating and morbid injuries seen by a trauma surgeon. This series reviewed the experience of a single institution to determine if diagnostic and therapeutic guidelines can be established for these uncommon injuries. In particular, the utility of anticoagulation in the treatment of these injuries is examined. METHODS The institutional trauma registry of a single state-designated Level I trauma center was examined for patients with BHVI. Patients were identified and their charts reviewed individually with regard to multiple data points including the type of injury, its presentation, the treatment of the injury, and the functional outcome of the patient. RESULTS Twenty-nine BHVI in 23 patients were reviewed from 1989 to 1997. No mortalities were noted. Among the injuries noted were 14 internal carotid artery dissections and 8 carotid artery tears. Thirteen patients had accompanying closed head injuries. Ten patients were diagnosed after an abnormal neurologic examination, and eight others were diagnosed after having carotid canal fractures. Heparin was started within 48 hours of injury in 4 patients (17%) and was used in a total of 12 patients (52%). No patient worsened neurologically after diagnosis independent of the use of heparin. Thirteen patients (57%) had no or minimal deficits upon discharge. CONCLUSION BHVI represent a serious cause of morbidity in the patient with multiple injuries. Patients with closed head injuries and carotid canal fractures appear most at risk. A multicenter, randomized trial involving antiplatelet therapy, full systemic anticoagulation, or observation with a long-term functional assessment is indicated to determine the optimal management of these injuries.

Mucormycosis in trauma patients.

Cutaneous mucormycosis is a rare but often fatal infection in trauma patients. We retrospectively reviewed a 9-year experience with mucormycosis among injured patients. Eleven patients had biopsy- or culture-proven mucormycosis. Nine patients were victims of blunt trauma, two patients had burns measuring greater than 50% TBSA. No patient was at increased risk because of underlying disease or immunosuppression prior to injury. All 11 patients had open wounds on admission. Four patients died of mucormycosis. All nonsurvivors had phycomycotic gangrenous cellulitis of the head, the trunk, or both. In contrast, survivors had involvement of only the extremities. Because of underlying disease, contaminating wounds, antibiotic use, or immunocompromise secondary to shock and sepsis, trauma patients are at risk of developing mucormycosis. To successfully treat mucormycosis, diagnosis must be prompt and accompanied by aggressive debridement and parenteral administration of amphotericin B.

Ten year experience of burn, trauma, and combined burn/trauma injuries comparing outcomes.

BACKGROUND Percent total body surface area (TBSA) burn, inhalation injury (INH), and age all have been shown to be independent predictors of mortality in burn victims. Little is known regarding patients sustaining combined thermal and mechanical injuries in relation to either injury sustained in isolation or with regard to these variables. This descriptive study profiles the 10-year experience of a single American Burn Association/American College of Surgeons verified Level I trauma and burn center and the treatment of this patient population. METHODS A retrospective review of all burn and trauma patients admitted between 1990 and 2000. Patients were divided into three groups; Burn only (B), Trauma only (T), and combined Burn/Trauma (B/T). Groups were compared with respect to age, TBSA burn, length of stay (LOS), Injury Severity Score (ISS), INH and mortality. These groups were then compared with B, T and B/T patients from the National Burn Repository (NBR) and National Trauma Data Bank (NTDB). Students t test and chi tests were performed, as well as multiple logistic regression to identify independent predictors of mortality. p <0.05 was considered significant. RESULTS Through our trauma registry, 24,093 patients were identified (T=22,284, B=1717 and B/T=92). When comparing B and T, there was no difference in age, LOS, ISS, or mortality to those patients in the NBR or NTDB. B/T patients showed significantly increased percentage with INH (B/T=44.5% versus 11%), increased LOS (B/T=18 days versus 13.7 B and 5.3 T) and increased mortality (B/T=28.3% versus 9.8% B and 4.3% T). B/T were also significantly older (B/T=40.1 years versus 31.0 B and 35.1 T). When these variables are compared with the NBR and the NTDB benchmarks, mortality (28.3% versus 11.6% NBR and 7.0% NTDB) and ISS (23 versus 11.7 NTDB) were significantly higher with no difference in age (40.1 versus 33.4 NTDB, 35.9 NBR), LOS (18 days versus 23.3 NBR) or TBSA (20.8% versus 19.5% NBR). Multiple logistic regression comparing TBSA, age, ISS and INH of survivors versus non-survivors identified only ISS as an independent predictor of mortality. CONCLUSION B combined with T presents a rare injury pattern that has a synergistic effect on mortality. Physicians and caregivers should be aware of a 2-3 fold increase in the incidence of INH in this population, and increased mortality despite similar TBSA burned when compared with patients with B as the sole mechanism; ISS appears to be an independent predictor of mortality in this combined injury pattern.

Neurosurgical Coverage: Essential, Desired, or Irrelevant for Good Patient Care and Trauma Center Status

Summary and Background Data:As a result of many factors, the availability of neurosurgeons (NS) to care for trauma patients (TP) is increasingly sparse. This has precipitated a crisis in access to neurosurgical support in many trauma systems, often placing undue burden on level I centers. This study examines the profile of head-injured (HI) trauma patients and their actual need for the specific expertise of a neurosurgeon. Methods:The National Trauma Data Bank (NTDB) was queried for specific information relating to the volume, nature, timeliness, and outcome of HI TP. Study patients were identified by reported International Classification of Diseases, 9th Edition (ICD-9) codes denoting open (OHI) or closed head injury (CHI) in isolation or in combination with other injuries. Results:Total number of NTDB patients studied was 731,823, of which 213,357 (29%) had a reported HI. CHI represented 22% of all TP and 74% of HI. OHI was reported in 8% of all TP and was 26% of HI. Craniotomy (crani) was performed in 3.6% of all HI (1% of all TP). This was in 2.8% of OHI and 2.6% of CHI. Mean Glasgow Coma Scale score (GCS) of crani patients was 9, and 13 for the noncrani group. Subdural hematoma occurred in 18% of HI (5% of TP), with 13% undergoing crani. Epidural hematoma occurred in 10% of HI (3% of all TP), with 17% undergoing crani. Median time to OR for all cranis was 195 minutes (195 for CHI; 183 for OHI). Of all cranis, 6.5% were performed within 1 hour of hospital admission. intracranial pressure (ICP) monitoring was reportedly used in 0.7% of TP and 2.2% of HI. Conclusions:Care of TP with HI rarely requires the explicit expertise and immediate presence of a neurosurgeon due to volume and nature of care. HI was diagnosed in <30% of TP reported to the NTDB. Over 95% required nonoperative management alone, with only 1% of all TP and 2%–4% of HI TP requiring crani and/or ICP monitoring. Immediate availability of NS is not essential if a properly trained and credentialed trauma surgeon or other health care provider can appropriately monitor patients for neurologic demise and effect early transfer to a center capable of, and committed to, operative and postoperative neurosurgical care. A subgroup of patients known to have a high propensity for the specific expertise of a neurosurgeon may be able to be identified for direct transport to these committed centers.

The pharmacokinetics of prophylactic antibiotics in trauma

Despite prophylactic antibiotic use in abdominal trauma patients, infection rates remain high. A previous study from our institution indicated that higher doses of prophylactic antibiotics in trauma patients could significantly reduce subsequent infection rates. To determine if this resulted from altered pharmacokinetic profiles, we performed individualized pharmacokinetic analysis of the prophylactic amikacin regimens given to 28 trauma patients undergoing laparotomy. Patients were prospectively randomized to receive a standard regimen of 11 mg/kg of amikacin every 12 hours or to have their regimens adjusted based upon pharmacokinetic analysis. Repeated pharmacokinetic analyses were performed daily for the three-day prophylactic regimen. There was a significant expansion in the apparent volume of distribution for amikacin that correlated with fluid resuscitation. This, along with increased elimination rates, helps to explain the failure to achieve adequate amikacin levels using standard regimens in trauma patients. Such underdosing may contribute to relatively high infection rates following major abdominal injury.

Early fasciotomy for acute clinically evident posttraumatic compartment syndrome

Our understanding of the effectiveness of early decompressive fasciotomy for acute posttraumatic compartment syndrome is incomplete. Thirty-two patients who developed acute clinically evident compartment syndrome (23 in the leg, 9 in the forearm) were treated with decompressive fasciotomy an average of 16 hours after injury. Thirty patients (94 percent) underwent fasciotomy in conjunction with other urgent operative procedures mandated by concomitant injuries. Three patients required early amputation for a failed arterial repair. Only 2 of 29 patients with limb salvage (7 percent) had postoperative myoneural deficits after decompressive fasciotomy. Both of these patients had preoperative myoneural deficits. Decompressive fasciotomy before the development of ischemic myoneural deficits prevents the ischemic sequelae of acute clinically evident compartment syndrome.

Lung injury from gut ischemia : insensitivity to portal blood flow diversion

Gut ischemia/reperfusion (I/R) appears to produce pulmonary vascular injury through endotoxin release and cytokine activation. The ability of hepatic reticuloendothelial cells to clear bacterial products may also be impaired during I/R. To test this, diversion of the splanchnic blood flow from the liver into the systemic circulation was performed via a microsurgical portacaval transposition in anesthetized Sprague-Dawley rats (275-375 g). Shunted animals underwent portacaval transposition and were allowed to recover for 7-10 days; sham animals underwent exploration but no shunt was created. The I/R animals were subjected to 60 minutes of reperfusion. All shunts were patent at autopsy. Pulmonary vascular permeability was assessed by measuring tissue retention of Evans blue dye. Gut I/R produced significant increases in pulmonary vascular permeability (46.2% +/- 11.0% vs. 16.4% +/- 3.8% [I/R vs. control]; p < 0.05) regardless of the presence of hepatic bypass (32.7% +/- 9.0% vs. 10.0% +/- 1.4% [I/R vs. control]; p < 0.05). These data indicate that a mediator or mediators of gut origin are responsible for pulmonary vascular permeability changes following gut I/R and are not appreciably modulated by the liver.

Ventilator-associated pneumonia in injured patients: Do you trust your Gram's stain?

BACKGROUND The results of sputum or bronchoalveolar lavage (BAL) fluid Grams stain have been used to guide presumptive antibiotic therapy for ventilator-associated pneumonia (VAP) in injured patients, despite reported variability in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Our aim was to evaluate the utility of Grams stain of BAL fluid in the diagnosis of VAP. METHODS We conducted a retrospective chart review of all mechanically ventilated trauma patients who developed pneumonia over a 5-year period in whom Grams stain and final culture data were available. RESULTS One hundred fifty-five records with complete data sets were reviewed. VAP was diagnosed by Centers for Disease Control and Prevention criteria and confirmed by BAL and quantitative culture in all patients. Overall accuracy of Grams stain in diagnosing VAP for any organism was 88% (137 true-positives). When assessed for the ability to predict pneumonia caused by a specific organism, the accuracy decreased significantly, with only 63% of Gram-negative VAPs and 72% of Gram-positive VAPs accurately identified by Grams stain. However, the absence of Gram-positive organism of Grams stain excludes Gram-positive VAP in 80% of patients. CONCLUSION All trauma patients should be covered presumptively for gram-negative organisms, as they encompass 70% of infections, but are not reliably identified by Grams stain. As 88% of VAP can be identified by the presence of any organism on Grams stain, it may be useful in the early diagnosis of VAP but cannot reliably be used to guide presumptive therapy.