Roger Seibel

The gut origin septic states in blunt multiple trauma (ISS = 40) in the ICU.

The association between support elements (ventilator days = Vd, enteral protein = EnP, number of antibiotics per day = AB/d) and the magnitude of the septic state (SSS) and its bacteriologic manifestations (bacti. log) in 66 patients with blunt multiple trauma (mean HTI-ISS = 40) over 1649 days have been studied restrospectively. SSS is measured by summing the standard deviation units of change in the septic direction for the 16 measurements taken every day in the intensive care unit. Increasing Vd is tightly associated with an increasing SSS (r = +0.52), after day 10 an increasing bacti. log (r = +0.21 to +0.32), and an increasing AB/d (r = +0.26) (all p < 0.001, N = 1615–1626). The independent variables that best predicted Vd were delayed operations (DORS), day of rising EnP, and total positive blood cultures (TPC) (adj. R sq. = 0.84, F = 104, dF = 3/59). An increasing AB/d was associated with an increasing SSS (r = +0.38), increasing Vd (r = +0.26), and an increased bacti. log (r = +0.14 to +0.18) (all p < 0.001, N = 1615). Only an increased EnP was consistently associated with a reduced SSS (r = −0.38) and a reduction in bacti. log (r = −0.10 to −0.21) (all p < 0.001, N = 1626–1636). The independent variables Vd, EnP, AB/d, and TPC best predicted SSS for all surviving patients (adj. R sq. = 0.42, F = 268, dF = 4/1496). The patients who died of sepsis were not different in terms of bacti. log from those with equal Vd but were distinguished by zero EnP, high AB/d, and persistent ventilatory support. In conclusion, DORS is tightly associated with increased Vd, SSS, AB/d, and zero EnP. If Vd exceeds 10, there is an increasing bacti. log and evidence of infection probably from the gut. This responds only to increased EnP and not to AB/d. Death due to sepsis is not associated with increased bacti. log but with zero EnP and high AB/d and their consequences.

Blunt multiple trauma (ISS 36), femur traction, and the pulmonary failure-septic state.

Fifty-six blunt multiple trauma patients (HTI-ISS 22-57) were studied for the effects of immediate versus delayed internal fixation of a femur or acetabular fracture on the pulmonary failure septic state. The pulmonary failure septic state may be defined as an alveolar arterial oxygen tension difference greater than 100, plus fever and leukocytosis. These patients were divided into four groups. Group I (N = 20) had immediate internal fixation, postoperative ventilatory support, and was sitting up at 30 hours. Group II (N = 20) had 10 days of femur traction and postoperative ventilatory support. Group III (N = 9) was immediately extubated after surgery and had 30 days of femur traction. Group IV (N = 7) had special circumstances that should increase the duration of the pulmonary failure septic state. These four groups of patients were statistically identical by 20 different criteria on admission except that Group I had more recognized chest injuries than Group II (12 vs. 9). Group I required 3.4 +/- 2.6 days of ventilator support and 7.5 +/- 3.8 intensive care unit (ICU) days; they had 12 +/- 8.8 elevated white counts, 3.8 +/- 4 febrile days, 0.05 positive blood cultures per patient, four fracture complications out of 93 fractures, 59 injections of narcotics, and 23 +/- 8.6 acute care days. Ten days of femur traction doubled the duration of the pulmonary failure septic state relative to Group I at a statistically significant level for nine out of 10 criteria, while increasing the number of positive blood cultures by a factor of 10, the number of fracture complications by a factor of 3.5, and the use of injectable narcotics by a factor of 2. Thirty days of femur traction increased the duration of the pulmonary failure septic state relative to Group I by a factor of 3 to 5 for all criteria at a statistically significant level, while increasing fracture complications by a factor of 17, positive blood cultures by a factor of 74, and the use of narcotics by a factor of 2. Group IV, which had four out of seven immediate internal fixations, behaved similarly to Group II. Femoral shaft traction should be avoided in the blunt multiple trauma patients because it greatly increases the cost of care and the risk of multiple systems organ failure.(ABSTRACT TRUNCATED AT 400 WORDS)

Shotgun wounds and pellet emboli: case reports and review of the literature.

Shotguns produce extensive tissue damage when victims are injured at close range. Arterio-arterial and veno-venous pellet emboli may result when major vessels or their tributaries are injured. Management of the pellet embolus is dictated by whether it is symptomatic or asymptomatic. Regardless of symptoms, the embolus is a sign of possible major vascular or venous tributary injury. We recently managed two cases of pellet emboli produced by close range shotgun wounds. This report describes our management of these injuries and collectively reviews the past 30 years of literature on shotgun wounds with arterio-arterial and veno-venous pellet emboli. Recommendations for management are suggested from collating the cases reported in the literature.

A program for documenting competency during surgical residency

The Department of Surgery at the State University of New York at Buffalo (SUNY/Buffalo) has designed a competency program for surgical residents to provide focused graduate experience and create a database that is acceptable to the American Board of Surgery. It uses a computer program (ResSolution) to manage the database. The Advanced Trauma Life Support (ATLS) provider course is used to document trauma credentials. A total of 221 residents have achieved satisfactory trauma credentials within six months of entering the program. All of the senior residents (PGY4/5) have instructor status. In 12 months, 66 residents have participated in 10,203 surgical procedures in five consortium hospitals. The majority (81.5%) were performed by the resident with direct faculty supervision. This resident credentialing program documents the acquisition of clinical skills and provides a template on which graduate training can be formalized. It may improve resident cognitive performance by identifying knowledge domains that ...

Survival following a gunshot wound of the abdominal aorta and inferior vena cava

A case with survival following a point-blank .32 caliber gunshot wound of the abdominal aorta and inferior vena cava is presented. The patient, a young male also had multiple other abdominal injuries. A Dacron graft was used in the aorta, lateral suture in the vena cava, other injuries were repaired, and antibiotic treatment and irrigation performed. Packed red blood cells, Ringers lactate, Plasmanate and nutritional support with medium chain triglycerides and ketones by mouth and amino acids by IV were given.

Budd-Chiari Syndrome: With Emphasis on Surgical Management Case Reports

Budd-Chiari syndrome (BCS) is a rare and often fatal disorder characterized by hepatic venous outflow obstruction. The occlusion is most often caused by thrombosis of the major hepatic veins and occasionally involves the inferior vena cava (IVC). This syndrome is associated with a variety of intraabdominal as well as systemic disorders. This report presents 2 cases of BCS in which both patients had polycythemia vera and 1 had a mildly decreased level of antithrombin III. A side-to-side portacaval shunt was performed in 1 patient and a mesoatrial shunt in the other owing to concomitant obstruction of the IVC. Dramatic improvement in the status of the liver was demonstrated by a follow-up biopsy in the latter patient.