Robert C. Grasberger

BETA-ENDORPHIN, CORTISOL AND POSTOPERATIVE DELIRIUM: A PRELIMINARY REPORT

A transient delirium, including hallucinations and disorientation, occurred at some time during a 48 to 72 hr postoperative period in patients recovering from elective surgery in an intensive care unit. The occurrence of delirium in these patients was associated with a significant and unusually prolonged postoperative increase in circulating levels of beta-endorphin (B-endorphin) and cortisol, and a total disruption of normal plasma circadian rhythms of B-endorphin and cortisol. Postoperative mean 24-hr plasma levels of B-endorphin and cortisol were not significantly different from preoperative baseline levels in those patients who did not exhibit post-surgical delirium. Circadian rhythms of B-endorphin and cortisol in the non-delirious patients also remained normal following surgery, although peak plasma concentrations were significantly phase-shifted to later in the day. A disruption in circadian rhythms of the endogenous opiate/hypothalamic-pituitary-adrenal axis may represent an important component of post-operative psychological changes that are frequently observed in the intensive care unit setting.

Rectal trauma. A retrospective analysis and guidelines for therapy.

Twenty patients seen at Boston City Hospital required general or spinal anesthesia for rectal injuries, and 17 required laparotomy. Findings on sigmoidoscopy were falsely negative in 4 of 13 patients examined. Diagnosis was delayed in two patients. Associated injuries occurred in 55 percent, with the lower genitourinary tract being the area most frequently injured. Complications occurred in eight patients (40 percent). Abscess formation and bacteremia were the most common, but iatrogenic complications occurred in four patients. Pulmonary embolism occurred in two patients and was suspected in a third patient. Routine treatment included diverting colostomy with distal irrigation and adequate drainage. Repair of the injury was performed when possible. Two of the 20 patients (10 percent) died, one after a prolonged septic course and one from recurrent pulmonary embolism. Rectal trauma continues to be a challenging injury.

Intraabdominal sepsis after hepatic trauma

In a review of 58 patients who survived liver trauma seen at Boston City Hospital, 10 patients had 13 intraabdominal abscesses and 1 died from overwhelming sepsis. Multivariate analysis of risk factors revealed that the number of units of perioperative, postoperative, and total blood transfused were each highly significant (p less than 0.0001). Mode of injury, hepatic resection, gastrointestinal tract perforation, and the number of associated injuries were not significant risk factors when transfusion requirements were accounted for. Fever and leukocytosis were unreliable predictors of abscess formation. The available literature suggests a strong relationship between intraperitoneal bleeding and septic complications.

Endorphins in primate hemorrhagic shock: Beneficial action of opiate antagonists

The endogenous opiate beta-endorphin is released concomitantly with adrenocorticotropin from the pituitary during stress. In the present study we investigated the possible involvement of opiate receptors in the cardiovascular depression associated with hypovolemic shock in the nonhuman primate. Changes in circulating levels in beta-endorphin were monitored during hemorrhagic shock in 18 female baboons. Plasma levels of beta-endorphin increased significantly during hemorrhagic shock and were significantly correlated with a decrease in cardiac output (P less than 0.05). Single bolus administration of the opiate receptor antagonist naloxone (2 or 5 mg/kg) produced a transient but significant improvement in cardiac output (P less than 0.05) and mean arterial pressure (P less than 0.05). Hemodynamic improvement was maintained with a constant infusion of naloxone. Opiate receptor blockade with the longer acting antagonist naltrexone (2 or 5 mg/kg) significantly increased mean arterial pressure (MAP; P less than 0.05), and CO (P less than 0.05), and decreased heart rate. Our results suggest that the baboon is an excellent model for the study of hemorrhagic shock and provide further evidence for endogenous opiate involvement in the cardiovascular pathophysiology of hemorrhagic shock.

Residents' experience in the surgery of trauma

Performance of surgery for trauma is an important part of residency training, yet what constitutes an adequate exposure to trauma surgery is ill defined. A retrospective review of records at a metropolitan receiving hospital was carried out for the academic year 1981-1982. Of the 50,902 patients treated in the Emergency Room more than one third were seen by a surgical resident. During this period 1,651 patients were admitted to General Surgery with traumatic injuries; 193 (12%) required intensive care. Two hundred twenty-seven major operations were performed by the General Surgical Service. For each patient operated on, 56 were seen in the Emergency Room and six required admission for nonoperative care of their injuries. Furthermore, less than 50% of patients admitted to the I.C.U. required surgery. An adequate education in trauma must be based on a large experience in the nonoperative resuscitation, diagnosis, and treatment of trauma victims. Nevertheless, the number of cases performed as operating surgeon provides a useful means of evaluation experience in trauma. Thirty cases are suggested as an appropriate level of exposure to the surgery of trauma, yet only one third of applicants to the American Board of Surgery attained this level.

Less-invasive cardiac output monitoring by earpiece densitometry.

Cardiac output was measured by thermodilution and ear densitometry in surgical ICU patients who had pulmonary arterial catheters. Overall comparison based on 56 sets of triplicate measurements revealed a correlation coefficient (r) of 0.76 between the two techniques. Although ear densitometry was more accurate with injection via the antecubital vein (r = 0.88) vs. more distal injection (r = 0.67), these data suggest that this technique lacks the accuracy for clinical application.

Severe combined respiratory and myocardial failure treated with high-frequency ventilation

High levels of positive end-expiratory pressure (PEEP) impair cardiac output. The subsequent lowering of mixed venous oxygenation, when coupled with a significant intrapulmonary shunt, may dramatically depress PaO2. We present a patient whose severe myocardial and respiratory insufficiency was unmanageable on conventional ventilation with high levels of PEEP and maximal inotropic support. High-frequency ventilation superimposed on conventional ventilation lowered peak airway pressure and dramatically improved both cardiac and pulmonary function.

Pericardial complications in hepatic trauma.

During a 5-year period, 35 of 70 patients with liver trauma required entry of the thoracic cavity, with nine deaths. Pericardial complications developed in four of the nine survivors who had both thoracic and abdominal incisions. Two patients resolved their problems (postpericardiotomy syndrome, late pericarditis) with medical therapy. One patient required emergency thoracotomy for pericardial tamponade, and one patient developed constrictive pericarditis that required pericardiectomy. Available data support closure of the pericardium after pericardiotomy. Thoracic extension of abdominal incisions is often necessary. Pericardial complications may occur with hepatic trauma in the early or late postoperative periods and are potentially fatal.