Thomas J. Schroeppel

Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure.

OBJECTIVE The options for abdominal coverage after damage control laparotomy or abdominal compartment syndrome vary by institution, surgeon preference, and type of patient. Some advocate polyglactin mesh (MESH), while others favor vacuum-assisted closure (VAC). We performed a single institution prospective randomized trial comparing morbidity and mortality differences between MESH and VAC. METHODS Patients expected to survive and requiring open abdomen management were prospectively randomized to either MESH or VAC. After randomization, an enteral feeding tube was inserted and the closure device placed. VAC patients returned to the operating room every 3 days for a total of three changes at which time polyglactin mesh was placed if closure was not possible. The MESH group had twice daily assessments for the possibility of bedside mesh cinching and closure. Both groups underwent split thickness skin grafting when granulation tissue was evident, if delayed primary closure was not possible. RESULTS Fifty-one patients were randomized. Both cohorts were matched for Injury Severity Scale score, gender, blunt/penetrating/abdominal compartment syndrome and age. Three patients died within 7 days and were excluded from closure rate calculation. There were no differences between delayed primary fascial closure rates in the VAC (31%) or MESH (26%) groups. The fistula rate in the VAC group was 21% but not statistically different from the 5% rate for MESH. Intraabdominal rates were not statistically different. All VAC fistulas were related to feeding tubes and suture line areas; the MESH fistula followed a retroperitoneal colon leak remote from the mesh. CONCLUSIONS MESH and VAC are both useful methods for abdominal coverage, and are equally likely to produce delayed primary closure. The fistula rate for VAC is most likely due to continued bowel manipulation with VAC changes with a feeding tube in place-enteral feeds should be administered via nasojejunal tube. Neither method precludes secondary abdominal wall reconstruction.

Diagnosis and management of blunt abdominal solid organ injury.

Purpose of reviewNonoperative management of solid organ injuries has become the standard of care for over 25 years. Benefits of this practice include reduced operative complications, reduced transfusions, lower infectious morbidity, and shorter length of stay. Patients eligible for this management practice include those who are hemodynamically stable and who do not have associated injuries that require celiotomy. Operative interventions need to occur expeditiously in hemodynamically unstable patients with hepatic and splenic injuries. Recent findingsRecent literature has focused on the continued success with nonoperative management of blunt solid organ injuries. The role of angioembolization for both splenic and hepatic injuries continues to be explored. Other authors are also questioning the appropriateness of clinical decisions for selection of hemodynamically unstable patients for nonoperative management. Operative management of blunt pancreatic trauma remains the rule. SummaryNonoperative management of solid organ injuries continues to have high success rates in the appropriate patient population. Minimally invasive adjuncts have a definite role in management of this patient population. Pancreatic trauma remains an operative injury. Surgeons must, however, temper the enthusiasm for nonoperative management of patients with solid organ injury, and exclude from this management scheme patients who would best be treated with surgery.

Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury.

BACKGROUND The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature. METHODS Patients with severe TBI (Abbreviated Injury Score 4-5) treated with DC for the management of increased ICP during 6-year period were identified from the trauma registry. Functional outcome was measured 1 year to 6 years postinjury using the Glasgow Outcome Score Extended (GOSE) via telephone interview and classified as good (GOSE 5-8) or poor (GOSE 1-4, including death). Outcomes were compared using Wilcoxon rank-sum and chi2 tests where appropriate. RESULTS One hundred and seventy-one patients were identified: 137 (80%) men and 34 (20%) women. Overall mortality (all in-hospital) was 32% (head-related = 22%). Of the 117 survivors, follow-up was obtained in all but 6 (95%). Good outcome was achieved in 96 patients (56% overall, 82% of survivors). Those with good outcome were younger (26 years vs. 43 years, p = 0.0028) and experienced a greater change in predecompression to postdecompression ICP (ICP reduced by 23 mm Hg vs. 10 mm Hg, p < 0.0001). Not surprisingly, unchanged ICP (predecompression to postdecompression) was associated with poor outcome (p = 0.0031). There was no difference in immediate predecompression ICP between survivors versus nonsurvivors. However, immediate predecompression Glasgow Coma Score was significantly higher in survivors compared with nonsurvivors (7 vs. 5, p < 0.0001). CONCLUSIONS DC resulted in good functional outcome in >50% of patients with severe TBI. The greatest benefit was observed in younger patients with a demonstrable reduction in ICP after decompression. The prospect of improved functional outcome offered by this procedure in the treatment of severe TBI warrants prospective investigation.

A ten-year review of enterocutaneous fistulas after laparotomy for trauma.

BACKGROUND In the era of open abdomen management, the complication of enterocutaneous fistula (ECF) seems to be increasing in frequency. In nontrauma patients, reported mortality rates are 7% to 20%, and spontaneous closure rates are approximately 25%. This study is the largest series of ECFs reported exclusively caused by trauma and examines the characteristics unique to this population. METHODS Trauma patients with an ECF at a single regional trauma center over a 10-year period were reviewed. Parameters studied included fistula output, site, nutritional status, operative history, and fistula resolution (spontaneous vs. operative). RESULTS Approximately 2,224 patients received a trauma laparotomy and survived longer than 4 days. Of these, 43 patients (1.9%) had ECF. The rate of ECF in men was 2.22% and 0.74% in women. Patients with open abdomen had a higher ECF incidence (8% vs. 0.5%) and lower rate of spontaneous closure (37% vs. 45%). Spontaneous closure occurred in 31% with high-output fistulas, 13% with medium output, and 55% with low output. The mortality rate of ECF was 14% after an average stay of 59 days in the intensive care unit. CONCLUSION With damage-control laparotomies, the traumatic ECF rate is increasing and is a different entity than nontraumatic ECF. Although the two populations have similar mortality rates, the trauma cohort demonstrates higher spontaneous closure rates and a curiously higher rate of development in men. Fistula output was not predictive of spontaneous closure.

Necessity of Repeat Head CT and ICU Monitoring in Patients With Minimal Brain Injury

BACKGROUND Recent publications have dismissed the need for routine repeat computed tomography (CT) scans in patients with minimal brain injury (MBI) (Glasgow Coma Scale score 13-15 with positive initial CT) unless physical examination changes. In an attempt to better allocate scarce resources, we hypothesized that not only was repeat head CT unnecessary but also routine intensive care unit (ICU) monitoring of these patients with MBI and stable examinations were unnecessary. METHODS All blunt injured patients admitted to a level I trauma center from January 2005 through December 2007 who met our criteria for MBI (Glasgow Coma Scale score 14-15 with positive initial CT) were reviewed. All patients had ICU monitoring and repeat CT done (at 12-24 hours) regardless of clinical examination. Patients with skull fractures, facial fractures needing urgent repair, those requiring immediate neurosurgical intervention and those with other injuries requiring ICU monitoring were excluded. Data including demographics, initial brain injury, follow-up CT scan results, changes in clinical examination, neurosurgical interventions, and ICU days were recorded. RESULTS Two hundred seven patients met criteria. Fifty-eight patients (28%) developed worsening findings on follow-up CT or examination. Eighteen required invasive neurosurgical intervention (6 intracranial pressure [ICP] monitors, 12 craniotomies) and 1 died (stroke). Those requiring ICP monitors had worsening intracranial hemorrhages (IPHs) with clinical examination changes or examination changes only, whereas those requiring craniotomy had worsening subarachnoid hemorrhage (2 patient), epidural hematoma (1 patient), and subdural hematoma (8 patients). Five of the subdural hematoma patients remained asymptomatic before craniotomy. ICU days were significantly increased in those patients with worsening CT findings who did not require neurosurgical intervention compared with those patients with unchanged or improved CT scans (5 days vs. 2.7 days, p < or = 0002). CONCLUSIONS Routine follow-up CT scans are beneficial in those patients with MBI and may lead to higher levels of medical management or neurosurgical intervention in patients with worsening CT findings. These patients should be kept in an ICU setting until head CT has stabilized. With these dissimilar results from previous studies, a prospectively randomized multicentered trial would be beneficial.

A reappraisal of nitrogen requirements for patients with critical illness and trauma.

BACKGROUND Studies regarding protein requirements for patients with critical illness are inconclusive owing to small sample size and population heterogeneity. The primary objectives of this study were to determine the amount of protein required to achieve nitrogen equilibrium or a positive nitrogen balance (NB, −4 g/d or better) and ascertain whether patients with traumatic brain injury (TBI) exhibit greater protein catabolism than those without TBI. METHODS Adult patients admitted to the trauma center, given specialized nutrition support, and had an NB determination within 5 days to 14 days after injury were evaluated. Patients with obesity, incomplete urine collection, kidney disease, corticosteroid or pentobarbital therapy, or an oral diet were excluded. RESULTS A total of 300 NB determinations from 249 patients were evaluated. Increasing the protein dosage generally resulted in improved NB; however, the data were highly variable. Of the patients who received a protein intake of 2 g/kg per day or greater, 54% achieved nitrogen equilibrium or positive NB (−4 g/d or better) in contrast to 38% and 29% of patients who received 1.5 g/kg per day to 1.99 g/kg per day and 1 g/kg per day to 1.49 g/kg per day, respectively (p < 0.001). There was no significant difference in NB between patients with and without TBI at similar protein intakes. CONCLUSION A higher protein intake was generally associated with an improved NB; yet, many patients remained having a negative NB. A protein dosage of 2 g/kg per day or greater was more successful in achieving nitrogen equilibrium than were lower-dosage intakes. Patients with TBI do not exhibit significantly greater protein catabolism than do patients without TBI. LEVEL OF EVIDENCE Prognostic study, level III.

Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: Results of a randomized trial

BACKGROUND Although benzodiazepines are the recommended first-line therapy for the prevention of alcohol withdrawal syndrome (AWS), the administration of intravenous ethanol as an alternative prophylactic agent persists in many surgical ICUs. Advocates of this therapy argue that ethanol provides effective prophylaxis against AWS without the excessive sedation observed with benzodiazepine therapy. No study to date, however, has compared the two therapies with regard to their sedative effects. The purpose of this study was to prospectively evaluate the efficacy of intravenous ethanol compared with benzodiazepines for the prevention of AWS with particular emphasis on the sedative effects of each therapy. METHODS During a 15-month period, trauma patients admitted to the ICU with a history of chronic daily alcohol consumption greater than or equal to five beverage equivalents per day were prospectively randomized to one of two 4-day prophylactic regimens: intravenous ethanol infusion (EtOH) versus scheduled-dose diazepam (BENZO). Patients were evaluated with the Riker sedation-agitation scale, a 7-point instrument for the subjective assessment of both sedation (1 = unarousable) and agitation (7 = dangerous agitation). According to protocol, regimens were titrated to achieve and maintain a Riker score of 4 (calm and cooperative). Deviation from a score of 4 during the course of treatment was compared between groups. RESULTS Fifty patients met study criteria and were randomized after obtainment of informed consent (EtOH, n = 26; BENZO, n = 24). Overall, the EtOH group had a significantly greater proportion of patients who deviated from a score of 4 during the course of treatment (p = 0.020). In both groups, the majority of deviation from a score of 4 reflected periods of under-sedation rather than over-sedation. One patient in the EtOH group failed treatment, requiring diazepam and haloperidol for control of AWS symptoms as per protocol, whereas no patient in the BENZO group failed treatment (p = NS). CONCLUSION Concerning the prophylaxis of AWS, intravenous ethanol offers no advantage over diazepam with respect to efficacy or adverse sedative effects. The purported benefit of intravenous ethanol as a prophylactic agent against AWS was not evident.

The evolution of blunt splenic injury: resolution and progression.

BACKGROUND Nonoperative management of blunt splenic injury (BSI) has become the standard of care for hemodynamically stable patients. Successful nonoperative management raises two related questions: (1) what is the time course for splenic healing and (2) when may patients safely return to usual activities? There is little evidence to guide surgeon recommendations regarding return to full activities. Our hypothesis was that time to healing is related to severity of BSI. METHODS The trauma registry at a level I trauma center was queried for patients diagnosed with a BSI managed nonoperatively between 2002 and 2007. Follow-up abdominal computed tomography scans were reviewed with attention to progression to healing of BSI. Kaplan-Meier curves were compared for mild (American Association for the Surgery of Trauma grades I-II) and severe (grades III-V) BSI. RESULTS Six hundred thirty-seven patients (63.9% mild spleen injury and 36.1% severe injury) with a BSI were eligible for analysis. Fifty-one patients had documented healing as inpatients. Ninety-seven patients discharged with BSI had outpatient computed tomography scans. Nine had worsening of BSI as outpatients and two (1 mild and 1 severe) required intervention (2 splenectomies). Thirty-three outpatients were followed to complete healing. Mild injuries had faster mean time to healing compared with severe (12.5 vs. 37.2 days, p < 0.001). Most healing occurred within 2 months but approximately 20% of each group had not healed after 3 months. CONCLUSION Although mild BSIs heal faster than severe BSIs, nearly 10% of all the BSIs followed as outpatients worsened. Close observation of patients with BSI should continue until healing can be confirmed.

Update on imaging for acute appendicitis.

Acute appendicitis is a common surgical emergency and the diagnosis can often be made clinically; however, many patients present with atypical findings. For these patients, there are multiple imaging modalities available to aid in the diagnosis of suspected appendicitis in an effort to avoid a negative appendectomy. Computed tomography is the test of choice in most patients in whom the diagnosis is not certain. Ultrasonography is particularly useful in children and pregnant women. Magnetic resonance imaging is recommended when ultrasonography is inconclusive. Appropriate use of these imaging studies avoids delays in treatment, prolonged hospitalization, and unnecessary surgery.

Beta-adrenergic blockade and traumatic brain injury: protective?

BACKGROUND Catecholamine surge after traumatic brain injury (TBI) is associated with infectious morbidity and potentially preventable mortality. Previous studies have supported the protective effect of beta-adrenergic blockade in patients with TBI. We hypothesize that suppression of the catecholamine surge in multiple-injured TBI patients with beta-adrenergic blockade decreases mortality. METHODS The trauma registry at an urban Level I trauma center was queried for blunt TBI from June 1, 2003, to December 31, 2007. Patients who received more than one dose of beta-blockers (BB) were identified by a review of the hospital pharmacy order database. χ² and Students t tests were used where appropriate. After adjusting for age, injury severity score, admission Glasgow Coma Score, and transfusions multivariable logistic regression was performed to analyze whether receiving BB was protective in patients sustaining TBI. RESULTS A total of 2,601 patients were admitted with blunt TBI during the study period. Of these, 506 patients (20%) received BB. Despite higher age (51 years vs. 38 years, p < 0.0001) and more severe head injury (head Abbreviated Injury Scale score 4.14 vs. 3.81, p < 0.0001), there was no difference in mortality (15% vs. 16%). Multivariable logistic regression identified BB as protective in patients sustaining head injury (odds ratio, 0.347; confidence interval, 0.246-0.490), when compared with those who did not receive BB, reducing mortality by 65%. CONCLUSIONS BB are associated with significantly reduced mortality in patients with TBI. This simple, inexpensive intervention may have a profound effect on mortality in this population of injured patients and requires further prospective study.