Thomas S. Helling

Complications following blunt and penetrating injuries in 216 victims of chest trauma requiring tube thoracostomy.

Tube thoracostomy (TT) is required in the treatment of many blunt and penetrating injuries of the chest. In addition to complications from the injuries, TT may contribute to morbidity by introducing microorganisms into the pleural space or by incomplete lung expansion and evacuation of pleural blood. We have attempted to assess the impact of TT following penetrating and blunt thoracic trauma by examining a consecutive series of 216 patients seen at two urban trauma centers with such injuries who required TT over a 30-month period. Ninety-four patients suffered blunt chest trauma; 122 patients were victims of penetrating wounds. Patients with blunt injuries had longer ventilator requirements (12.6 +/- 14 days vs. 3.7 +/- 7.1 days, p = 0.003), longer intensive care stays (12.2 +/- 12.5 days vs. 4.1 +/- 7.5 days, p = 0.001), and longer periods of TT, (6.5 +/- 4.9 days vs. 5.2 +/- 4.5 days, p = 0.018). Empyema occurred in six patients (3%). Residual hemothorax was found in 39 patients (18%), seven of whom required decortication. Recurrent pneumothorax developed in 51 patients (24%) and ten required repeat TT. Complications occurred in 78 patients (36%). Patients with blunt trauma experienced more complications (44%) than those with penetrating wounds (30%) (p = 0.04). However, only seven of 13 patients developing empyema or requiring decortication had blunt trauma. Despite longer requirements for mechanical ventilation, intensive care, and intubation, victims of blunt trauma seemed to have effective drainage of their pleural space by TT without increased risk of infectious complications.

Infectious complications in patients with severe head injury.

Mortality and morbidity from head trauma have been substantially reduced by improved prehospital care and aggressive diagnostic and therapeutic management. However, a substantial number of patients will require prolonged periods of hospitalization, intensive care, and ventilator support during their recovery, placing them at risk for infectious complications. Eighty-two such patients were reviewed during a 30-month period at a Level I trauma center. Forty-one patients (50%) developed at least one infectious complication. The most common source was respiratory, occurring in 34 patients relatively early (average, 3.2 days) in their hospital course. The severity of head injury and presence of coexisting thoracic trauma correlated statistically; administration of prophylactic antibiotics and corticosteroids did not in the development of infectious problems. Only three patients died as a result of sepsis, indicating that early recognition and prompt treatment may control the severity of infectious complications.

Ten-year experience in transplantation of A2 kidneys into B and O recipients

BACKGROUND This article summarizes our 10-year multicenter experience with transplantation of 50 blood group A2 and A2B kidneys into B and O patients. METHODS Since 1986, we have transplanted kidneys from 46 cadaver donors and 4 living donors who were blood group A2 (47 donors) or A2B (3 donors) into 19 B and 31 O patients. In 1991, we began allocating these kidneys preferentially to B and O recipients who were selected based on a history of low (< or =4) anti-A IgG isoagglutinin titers. Immunosuppression was no different from that used in ABO-compatible grafts. RESULTS The 1-month function rate before thus selecting the patients was 68% (19/28), but is now 94% (17/18). Two-year cadaver-donor graft survival with this selection method is 94%, compared with 88% for 640 concurrent and consecutive ABO-compatible transplants (log-rank, 0.15). All four living-related transplants are still functioning, with a mean follow-up of 71 months. Since we began allocating A2 kidneys preferentially to B and O recipients, the percentage of the B patients who received A2 or A2B kidneys has increased from 29% (8/28) to 55% (10/18). CONCLUSIONS Transplantation of A2 or A2B kidneys into B and O patients is clinically equivalent to that of ABO-compatible transplantation when recipients are selected by low pretransplant anti-A titer histories. This approach increases access of blood group B recipients to kidneys.

A prospective evaluation of 68 patients suffering blunt chest trauma for evidence of cardiac injury.

The prevalence and significance of cardiac injury following blunt chest trauma is largely unknown. Although electrocardiography (ECG) and creatinine phosphokinase isoenzyme (CPK-MB) determination have traditionally been used in determining cardiac injury, recent developments in two-dimensional echocardiography (ECHO) as a noninvasive diagnostic tool have led to its use in detecting structural cardiac damage following trauma. In an attempt to determine the occurrence and consequences of cardiac injury we prospectively evaluated 68 patients at one institution using ECHO, serial ECG, and serial CPK-MB determinations in the first 3 days following hospital admission. Patients were selected who had evidence of blunt chest injury on examination or by mechanism of injury. The mean age of the 68 patients was 36.3 +/- 19.6 years and the mean Injury Severity Score, 21.5 +/- 11.6. Forty-nine patients (72%) were found to have an abnormal ECHO, ECG, or CPK-MB (greater than 3%). Eighteen patients (26%) had abnormal ECHOs consisting of seven right ventricular contusions, three left ventricular contusions, three contusions of both chambers, four pericardial effusions, and one small ventricular septal defect. Only three contusions were associated with elevated CPK-MB and seven with abnormal ECGs. Abnormalities of ECG included 18 patients with S-T, T wave changes, axis shifts (11 patients), and bundle branch or hemiblocks (10 patients). No patient died or experienced serious morbidity as a result of their cardiac injury, including 12 patients who underwent surgical procedures with general anesthesia within 30 days of admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term graft survival is improved in cadaveric renal retransplantation by flow cytometric crossmatching.

BACKGROUND Cadaveric renal retransplantation is associated with a higher risk of early graft failure than primary grafts. A large proportion of those graft losses is likely attributable to donor-directed HLA class I antibodies, detectable by flow cytometry cross-matching but not by conventional crossmatching techniques. METHODS Long-term graft survival in a group of 106 recipients of consecutive cadaveric renal regrafts between 1990 and 1997, in whom a negative flow T-cell IgG crossmatch was required for transplantation, was compared with two other groups of cadaveric transplant recipients. The first group consisted of 174 cadaveric regrafts transplanted between 1985 and 1995 using only a negative anti-human globulin (AHG) T-cell IgG crossmatch. The second group was primary cadaveric transplants done concurrently with the flow group (1990 to 1997) using only the AHG T-cell IgG crossmatch. RESULTS The long-term (7 year) graft survival rate of flow crossmatch-selected regraft recipients (68%; n= 106) was significantly improved over that of regraft recipients who were selected for transplantation by only the AHG crossmatch technique (45%; n=174; log-rank=0.001; censored for patients dying with a functioning graft). Graft outcome for the flow cross-matched regraft recipients was not significantly different from that of primary cadaveric patients (72%; n=889; log-rank=0.2; censored for patients dying with a functioning graft). Finally, a positive B-cell IgG flow cytometric crossmatch had no influence on long-term regraft outcome. CONCLUSIONS The use of the flow T-cell IgG cross-match as the exclusion criterion for cadaveric renal retransplantation yields an improved long-term graft outcome over that obtained when only the AHG cross-match is used and has improved survival of regraft recipients to the level of our primary cadaveric renal transplant population.

Current experience with renal transplantation across the ABO barrier.

Solid organ transplantation has traditionally been governed by the rules of blood group compatibility. Thus, it has been demonstrated that crossing the ABO blood group barrier generally results in hyperacute rejection. However, the A2 subtype of the blood group A is a weaker antigen. Under certain circumstances, organs from donors with blood group A2 can be transplanted across the ABO blood group barrier into recipients of O or B blood type. Since 1986, 33 patients including 24 blood group O and 9 blood group B patients received A2 (30) or A2B (3) donor kidneys. Both cadaver donor (31) and living-related grafts (2) have been undertaken. The mean follow-up since transplantation for the 21 patients with functioning grafts is 36 months, with a 67.2% current graft survival. Immunosuppression for these transplants consisted of azathioprine, prednisone, and cyclosporine, often in combination with prophylactic OKT3 or antilymphocyte globulin as protocol dictated. Special immunosuppressive protocols such as splenectomy or plasmapheresis were not used. The serum of the potential recipient was analyzed for immunoglobulin G (IgG) and immunoglobulin M (IgM) forms of antibody against A1 and A2 red blood cells. There is a strong correlation between a low (less than or equal to 1:8) anti-A1 IgG titer and both early and long-term graft function. Recipients with an IgG titer greater than 1:8 in the pretransplant serum had a much higher incidence of early graft failure. We no longer recommend transplantation of A2 kidneys into O or B recipients with a pretransplant titer of greater than 1:8 but found that recipients with low titers have graft function rates essentially equal to those of ABO-compatible patients. Patients with blood group B have, over time, lower anti-A IgG titers than do blood group O patients. In addition, the graft survival among blood group B patients is 89% compared with 58% among group O recipients. This may be due to the generally low titers found in blood group B recipients. Since instituting a policy in 1988 of not transplanting the kidney when the anti-A IgG titer is greater than 1:8, the survival in O patients is 88%. We recommend the screening of all organ donors with blood group A for the A2 subgroup and believe that transplantation can be safely and successfully performed in certain patients with blood group O or B.(ABSTRACT TRUNCATED AT 400 WORDS)

Determinants of the Need for Intensive Care and Prolonged Mechanical Ventilation in Patients Undergoing Bariatric Surgery

Background: Bariatric surgery at the upper extremes of weight can be associated with serious postoperative complications. In many cases, these complications will require the availability of critical care resources. The purpose of this study is to examine factors that increase the likelihood for prolonged postoperative intensive care unit (ICU) and extended mechanical ventilation (MV) >24 hours. Methods: A retrospective chart review was conducted of all patients undergoing bariatric surgery over a 7-year period at a tertiary care academic institution. There were 250 total patients undergoing either vertical banded gastroplasty (n=15) or Roux-en-Y gastric bypass (n=235). Age, Gender, BMI, pulmonary co-morbidity, revisional surgery (previous bariatric operations), and need for reoperation for suspected intra-abdominal complications were examined by univariate and multivariate analyses. Results: Mean age was 43.6±10.6 years and mean BMI 56±10.6 kg/m2. Pulmonary co-morbidity was present in 123/250 patients (49%), 42/250 (17%) had revisional surgery, and 21/250 (8%) required reoperation. ICU care was required in 60 patients (24%). By univariate analysis, age >50 yrs (P =0.047), male gender (P =0.038), and need for reoperation (P <0.001) were associated with need for ICU. By multivariate analysis, BMI >60 kg/m2, odds ratio (OR) 2.25, 95% confidence Interval (CI) 1.11-4.60, P =0.04, and need for reoperation, OR 39.8, 95% CI 10.41-264.7, P <0.0001, were associated with need for ICU. MV >24 hrs was required in 44 patients (18%). By univariate analysis, BMI >60 kg/m2 (P =0.013), pulmonary co-morbidiy (P =0.014), male gender (P =0.029), and reoperation (P <0.0001) were associated with need for MV. By multivariate analysis, BMI >60 kg/m2, OR 3.1, 95% CI 1.44-7.13, P =0.005, and need for reoperation, OR 22.3, 95% CI 7.4-79.2, P <0.0001, were associated with need for MV. Conclusions: Patients who are male, older (>50 yrs), heavier (BMI >60 kg/m2), and who have complications requiring reoperation will likely need intensive care. Additionally, males, heavier patients (BMI >60 kg/m2), pulmonary co-morbidity, and need for reoperation may warrant need for extended MV. Surgeons and hospitals should consider this when planning resources for bariatric surgery programs.

The presence of in-house attending trauma surgeons does not improve management or outcome of critically injured patients.

BACKGROUND The presence of a surgeon at the initial assessment and care of the trauma patient has been the focal point of trauma center designation. However, for Level I verification, the American College of Surgeons Committee on Trauma currently does not require the presence of an attending trauma surgeon in the hospital (IH), provided senior surgical residents are immediately available. Likewise, the state of Missouri does not mandate an IH presence of the attending trauma surgeon but requires senior (postgraduate year 4 or 5) level surgical residents to immediately respond, with a 20-minute response time mandated for the attending surgeon if IH or out of the hospital (OH). Nevertheless, some claim that IH coverage by attending surgeons provides better care for seriously injured patients. METHODS This retrospective study assessed patient care parameters over the past 10 years on critically injured patients to detect any difference in outcome whether the surgeon was IH or OH at the time of the trauma team activation (cardiopulmonary instability, Glasgow Coma Scale [GCS] score < 9, penetrating truncal injury). Patients were subcategorized into blunt/penetrating, shock (systolic blood pressure < 90 mm Hg) on arrival, GCS score < 9, Injury Severity Score (ISS) > 15, or ISS > 25. Response was examined from 8 am to 6 pm weekdays (IH) or 6 pm to 8 am weekdays and all weekends (OH). Patient care parameters examined were mortality, complications, time in the emergency department, time to the operating room, time to computed tomographic scanning, intensive care unit length of stay (LOS), and hospital LOS. RESULTS For all patients (n = 766), there was no significant difference in any parameters except intensive care unit LOS (IH, 4.90 +/- 7.96 days; OH, 3.58 +/- 7.69 days; p < 0.05). For blunt trauma (n = 369), emergency department time was shorter (99.71 +/- 88.26 minutes vs. 126.51 +/- 96.68 minutes, p < 0.01) and hospital LOS was shorter (8.04 +/- 1.02 days vs. 11.08 +/- 1.15 days, p < 0.05) for OH response. For penetrating trauma (n = 377), shock (n = 187), GCS score < 9 (n = 248), ISS > 15 (n = 363), and ISS > 25 (n = 230), there were no statistically significant differences in any patient care parameter between IH and OH response. For those in most need of urgent operation-penetrating injuries and shock-there were no differences in time to operating room or mortality for OH or IH response. CONCLUSION As long as initial assessment and care is provided by senior level IH surgical residents and as long as the attending surgeon responds in a defined period of time (if OH) to guide critical decision-making, the IH presence of an attending surgeon has not been shown in this retrospective study to improve care of the critically injured patient.

Intraabdominal surgery during pregnancy

Abstract Intraabdominal surgical disease during pregnancy can present a challenge in diagnosis and management for the obstetrician and surgeon. To examine the complications to the fetus and mother and the consequences of a delay in operative intervention, we retrospectively studied all pregnant patients over a 17-year period who had undergone abdominal surgery at one institution. A total of 92 abdominal operations were performed on 90 patients. During the same period, 41,532 deliveries occurred. One in 451 deliveries involved surgical procedures during pregnancy. Thirty-seven patients had surgery for acute appendicitis; 20 patients were operated on for ovarian abnormalities. Postoperatively, there were two maternal deaths: one from cardiac arrhythmia and the other from hepatic failure. The most common postoperative complication was premature labor (19 patients, 21 percent). In 16 of these patients, early tocolysis was begun without fetal loss. There were five fetal deaths. Forty-seven of 72 patients had term deliveries. Intraabdominal surgery during pregnancy carries an acceptable risk to the mother and fetus; complications are related to disease severity and operative delay rather than to the operative procedure itself.

Cold ischemia time: An independent predictor of increased HLA class I antibody production after rejection of a primary cadaveric renal allograft

Background. Cadaveric kidneys experiencing longer cold ischemia time (CIT) are associated with higher levels of delayed graft function, acute rejection, and early graft loss. One mechanism to explain these results is that ischemia/reperfusion (I/R) injury makes the allograft more immunogenic by upregulating molecules involved in the immune response (e.g., HLA Class I/II). Methods. We evaluated the influence of CIT on the production of HLA Class I antibody level, measured by an antihuman globulin panel reactive antibody (AHG PRA) level, in 90 unsensitized recipients of primary cadaveric renal transplants (from a total of 1442 between 1985 and 1997) who rejected their kidneys. Results. By multivariate analysis, a CIT of 15 hr or more (vs.<15 hr) independently increased the risk of the AHG Class I PRA level being ≥20% after unsensitized patients rejected their first kidneys (relative risk=3.57; 95% confidence interval=1.26 to 10.14;P =0.01), despite the same degree of Class I/II mismatch between the two CIT groups. The overall mean peak PRA level after primary kidney rejection was significantly lower for the CIT<15 hr group (25.9%±33.9; n=24) compared with the CIT≥15 hr group (46.3%±36.5; n=66) (P <0.001). Conclusion. Longer CIT induces a humorally more immunogenic kidney.