Richard H. Pearl

Prognosis and survival as determined by visceral amino acid clearance in severe trauma

Sepsis, the commonest cause of late death following severe trauma, is related in part to inadequate uptake of amino acids (AA) and synthesis by the liver and other central tissues of proteins essential to immunological defense. Since central plasma clearance rate of amino acids (CPCR-AA) has been found to reflect these functions, serial measurements of CPCR-AA were made in 32 seriously injured patients of whom ten died (31%), nine of sepsis. The mean Index Severity Score on admission for survivors was 31 +/- 1.8 and in deaths 34 +/- 3.9 (N.S.). The blood plasma AA concentrations were not significantly different. However, early in the course before the onset of infection, CPCR-AA in surviving patients was 227 +/- 30 and in those who ultimately died 83 +/- 24 ml/M2/min (p less than 0.001). Later during sepsis the values of CPCR-AA were 176 +/- 28 and 85 +/- 14 ml/M2/min, respectively (p less than 0.01). Thus CPCR-AA appears to be of value as an indicator of amino acid utilization by central tissues and as a predictor of survival or death following severe trauma.

Management of blunt splenic injury in children: evolution of the nonoperative approach

BACKGROUNDnNonoperative management of blunt splenic injury (BSI) was first proposed at our institution in 1948. Since that time, treatment of patients with BSI has evolved from routine splenectomy to an aggressive spleen-preserving philosophy. This report summarizes our institutional experience for the last 50 years.nnnMETHODSnAll children (0-18 years) admitted to our pediatric trauma center with BSI during 4 eras (1956-1965, 1972-1977, 1981-1986, and 1992-2006) were retrospectively reviewed for demographics, injury patterns, management, and complications.nnnRESULTSnDuring the 4 eras captured for the last 5 decades, 486 children experienced BSI. The mean age was 10 years with 347 males (71%). Nonoperative management rate increased from 42% to 97% with improvement in splenic salvage rate (42%-99%). Mean length of stay decreased from 17 to 5 days. In patients with isolated splenic injuries (50%), nonoperative management rate increased (36%-100%) and fewer received transfusions (60%-1%). Overall mortality rate improved (19%-6.6%, 8%-0.7% in isolated injuries).nnnCONCLUSIONnThe management of BSI in children has changed dramatically for the last 50 years. This study clearly demonstrates the safety of nonoperative management and documents progressively lower rates of splenectomy and transfusion, shorter hospitalization, and an extremely low risk of mortality.

Survival from hepatic transplantation. Relationship of protein synthesis to histological abnormalities in patient selection and postoperative management

Forty-one patients, all in end stage hepatic failure, underwent 46 liver transplantations with a long-term survival rate of 63%. Six patients died of uncontrollable bleeding due to primary graft malfunction at or immediately after operation. Nine died early or late with overwhelming infection. In addition to clinical assessment, needle liver biopsy, central plasma clearance rate of amino acids (CPCR-AA), and routine “liver function tests” were employed to aid in selection of patients for transplantation and for guidance in postoperative management. Although liver biopsies usually afforded an exact diagnosis, neither they nor the routine liver function tests quantitated the extent to which hepatocyte function was impaired. CPCR-AA, which measures the rate of amino acid uptake by the liver and other central tissues for oxidation, gluconeogenesis, and protein synthesis was 91 ± 9 ml/M2/min in the preoperative transplant group. This compares with a value of 97 ± 16 in a previously studied series of cirrhotics who died following other forms of surgery and a CPCR-AA of 220 ± 26 ml/m2/min in those who survived. In addition, the preoperative CPCR-AA was found to correlate with the in vitro hepatic protein synthetic rate of slices from the resected recipient liver (r = 0.72, p < 0.02). After operation, serial hepatic needle biopsies were classified by histology into four grades of injury, ranging from normal liver transplant (Grade I) to mild hypoxic or rejection injury (Grade II), viral hepatitis (Grade III), and severe hypoxic or rejection injury (Grade IV). Significant relationships of the histological grades to ultimate mortality, CPCR-AA, and prothrombin times were found. CPCR-AA and pro-thrombin time correlate inversely (r = 0.57, p < 0.001), further demonstrating the relationship of CPCR-AA to protein synthesis of clotting factors. These patterns of posttransplant response were delineated by serial CPCR-AA values. “Early” responders had values over 290 ml/M2/min and all survived. Twelve patients with delayed response were characterized by values of 150 ± 12, rising to over 200 ml/M2/min after 2 weeks. Two who failed to increase CPCR-AA died. In six “poor” responders, CPCR-AA with Grade IV injury remained below 110 ml/M2/min. All died except for one whose CPCR-AA subsequently rose following retransplantation. It is concluded that percutaneous hepatic needle biopsies and CPCR-AA measurements in combination arc of proven value, not only in understanding the nature of injury and functional impairment of the liver, but are also important as guides to selection of patients and for their posttransplant management.

What is the significance of contrast “blush” in pediatric blunt splenic trauma?

PURPOSEnContrast extravasation (CE) associated with blunt splenic injuries (BSIs) in adults is commonly treated with embolization or splenectomy. Whether this is necessary in children is unclear. We sought to determine if CE on initial computed tomography (CT) is associated with negative outcomes in children with BSI.nnnMETHODSnBlunt splenic injuries presented to our pediatric trauma center between January 21, 1999, and December 31, 2006, were reviewed (minimum follow-up = 2 years). Those with initial CTs available were reviewed by a pediatric radiologist blinded to outcomes. Descriptive analysis and multivariable logistic regression were performed using Stata S/E 10.0 (Stata Corporation, College Station, Tex).nnnRESULTSnOne hundred eighty-two BSIs were treated at our center. One hundred twenty-three had available CTs (mean age, 10.7 years; male, 70.7%; mean Injury Severity Score, 17; median injury grade, 3; transfusion rate, 13.8%; overall mortality, 2.44%). Those with associated injuries comprised 47.1%. No splenectomies or splenorrhaphies were performed. One delayed splenic bleed occurred. Eight patients (6.5%) had CE on initial CT. Multivariable logistic regression controlling for multiple injuries found no association between CE and the need for transfusion, mortality, delayed splenic bleeding, length of hospitalization, or splenectomy. Contrast extravasation was positively associated with low initial and lowest hemoglobin levels (<90 g/L) (odds ratio [OR], 6.45; 95% confidence interval [CI], 1.00-39.47; P = .044 and OR, 5.63; 95% CI, 1.20-26.49; P = .029), respectively.nnnCONCLUSIONnContrast extravasation occurred in 6.5% of our pediatric patients with BSIs. The presence of contrast blush on abdominal CT was not associated with negative outcomes after a minimum of 2 years of follow-up. Pediatric patients with CE can be treated without surgery and can be managed using the standard American Pediatric Surgical Association guidelines.

Death and dollars : the cost of dying in the surgical intensive care unit

INTRODUCTIONnThe effect of resuscitation status on the use of laboratory and radiologic studies was analyzed in patients at the Walter Reed Army Medical Centers Surgical Intensive Care Unit.nnnMETHODSnA retrospective assessment of laboratory and radiologic charges incurred during the last 48 hours of life by 81 patients who died in the Surgical Intensive Care Unit between 1990 and 1992 was performed. Data were analyzed after separation by patients resuscitation status. Each patient was assigned a resuscitation category: no limitation, do not resuscitate (no CPR in event of arrest), or limited therapy (specific order limiting care or monitoring).nnnRESULTSnThere were 4,095 laboratory tests performed for a total charge of

Abdominal and Genitourinary Trauma

191,247. Arterial blood gas testing accounted for over

Amino Acid Clearance in Cirrhosis: A Predictor of Postoperative Morbidity and Mortality

75,000 of these charges. Resuscitation status significantly affected test frequency.nnnCONCLUSIONSnDuring the last 48 hours of life in an intensive care unit, the use of laboratory tests and radiologic exams has a substantial effect on the cost of care and is modified by the patients resuscitation status.

Mechanisms of pediatric trauma deaths in Canada and the United States: the role of firearms.

15.3 Solid Organ Injury 145 15.3.1 Spleen and Liver 145 15.3.2 Complications of Nonoperative Treatment 146 15.3.3 Sequelae of Damage Control Strategies 146 15.3.4 Abdominal Compartment Syndrome 148 15.3.5 Bile Duct Injury 149