Wayne E. Vanderkolk

Percutaneous Thrombin Injection of Splanchnic Artery Aneurysms: Two Case Reports

JVIR 2000; 11:469–472 THE diagnosis and management of splanchnic artery aneurysms is difficult. The first reported splanchnic artery aneurysm was discovered while Beaussier was injecting a cadaver for anatomic demonstration in 1770 (1). Since then, more than 3,000 cases of splanchnic artery aneurysms have been documented in the literature. However, the incidence of such aneurysms is not known. Although rare, these lesions are clinically important. Nearly 22% of all splanchnic artery aneurysms present as clinical emergencies. Of these, 8.5% result in death (2). The majority of aneurysms (63%) are symptomatic at the time of presentation and 23.9% present with rupture (3). The treatment of choice of splanchnic artery aneurysms classically has been operative ligation or resection. With the advancement of interventional radiology, percutaneous transcatheter embolization has been effective (4). Unfortunately, not all aneurysms can be successfully cannulated with these catheters (4). In 1986, Cope and Zeit described the successful treatment of pseudoaneurysms of the peripheral arteries by direct percutaneous injection of thrombin (5). In 1989, Rothbarth et al reported a case in which they successfully treated a large intraparenchymal hepatic artery aneurysm by percutaneously injecting thrombin after embolization with coils had failed (6). The purpose of this article is to describe the use of percutaneous thrombin injection for the treatment of ruptured aneurysms involving branches of the superior mesenteric artery. Two patients presented to our institution with symptoms related to rupture of splanchnic artery aneurysms.

Antiplatelet and anticoagulation therapies do not increase mortality in the absence of traumatic brain injury.

BACKGROUND : As the population continues to age, the number of patients undergoing traumatic injury while on antiplatelet or anticoagulation therapies is increasing. Mortality has been shown to increase in traumatic brain injury patients on warfarin therapy. Whether this increased mortality is seen in trauma patients without traumatic brain injury remains controversial. We investigated whether patients on antiplatelet and/or anticoagulation therapy were at increased risk of death from blunt traumatic injury in the absence of head injury. METHODS : A retrospective review of our Level I trauma center database was performed from 2002 to 2007. Inclusion criteria included all patients older than 60 years admitted to the trauma service. Only patients with a computed tomography scan negative for intracranial injury were analyzed. RESULTS : Two hundred twelve patients were found, of which 67 were found to be taking aspirin, warfarin, clopidogrel, or a combination of the three. Injury Severity Score (21 vs. 21), length of stay (11 days vs. 9 days), intensive care unit days (5 days vs. 4 days), and deaths (13% vs. 10%) were similar between those patients on antiplatelet/anticoagulation therapy and those who were not. CONCLUSION : In the absence of traumatic brain injury, the use of preinjury antiplatelet and/or anticoagulation therapy does not significantly increase the risk of mortality in the trauma patient. As the number of active seniors rises, this patient population will continue to present to the trauma service. To the best of our knowledge, this study is one of the largest addressing this question, and the only study examining the addition of antiplatelet therapy.

Cerebral perfusion pressure and intracranial pressure are not surrogates for brain tissue oxygenation in traumatic brain injury.

OBJECTIVE Utilization of brain tissue oxygenation (pBtO(2)) is an important but controversial variable in the treatment of traumatic brain injury (TBI). We evaluated the correlation between pBtO(2)/CPP and pBtO(2)/ICP and determined the parameter most closely related to survival. METHODS Consecutive, adult patients with severe TBI and pBtO(2) monitors were retrospectively identified. Time-indexed measurements of pBtO(2), CPP and ICP were collected and correlation coefficients were determined. Patients were then stratified according to survival and pBtO(2), CPP and ICP values were compared between groups. RESULTS There were 4169 time-indexed data points (i.e., pBtO(2) with respective CPP and ICP values) in 15 patients. The cohort consisted of a mean age of 37±17 years, ISS of 27±7 and GCS of 4.5±1.5. Survival was 53% (8/15). In a normal regression models, neither the ICP (p=0.58) nor the CPP (p=0.71) predict pBtO(2) significantly. There was a significant difference in pBtO(2) in survivors (31.5±3.1 vs. 25.2±4.8, p=0.010) but not in CPP or ICP. Survivors had a lower proportion of time with pBtO(2)<25 mmHg [20% (3.4-44.6) vs. 40% (16.2-89), p=0.049]. In contrast, survivors had a greater proportion of time with CPP<70 and no difference in the proportion of time with and ICP>20. CONCLUSIONS CPP and ICP should not be used as surrogates for pBtO(2) since cerebral oxygenation varies independently of cerebral hemodynamics and pressures. Brain tissue oxygen monitoring in patients with TBI provides unique information regarding cerebral oxygenation the utility of which remains to be fully described. SIGNIFICANCE CPP and ICP are not surrogates for pBtO(2). Brain tissue oxygenation monitoring provides unique information for the treatment of traumatically injured patients.

The first 72 hours of brain tissue oxygenation predicts patient survival with traumatic brain injury.

BACKGROUND: Utilization of brain tissue oxygenation (pBtO2) is an important but controversial variable in the treatment of traumatic brain injury. We hypothesize that pBtO2 values over the first 72 hours of monitoring are predictive of mortality. METHODS: Consecutive, adult patients with severe traumatic brain injury and pBtO2 monitors were retrospectively identified. Time-indexed measurements of pBtO2, cerebral perfusion pressure (CPP), and intracranial pressure (ICP) were collected, and average values over 4-hour blocks were determined. Patients were stratified according to survival, and repeated measures analysis of variance was used to compare pBtO2, CPP, and ICP. The pBtO2 threshold most predictive for survival was determined. RESULTS: There were 8,759 time-indexed data points in 32 patients. The mean age was 39 years ± 16.5 years, injury severity score was 27.7 ± 10.7, and Glasgow Coma Scale score was 6.6 ± 3.4. Survival was 68%. Survivors consistently demonstrated higher pBtO2 values compared with nonsurvivors including age as a covariate (F = 12.898, p < 0.001). Individual pBtO2 was higher at the time points 8 hours, 12 hours, 20 hours to 44 hours, 52 hours to 60 hours, and 72 hours of monitoring (p < 0.05). There was no difference in ICP (F = 1.690, p = 0.204) and CPP (F = 0.764, p = 0.389) values between survivors and nonsurvivors including age as a covariate. Classification and regression tree analysis identified 29 mm Hg as the threshold at which pBtO2 was most predictive for mortality. CONCLUSION: The first 72 hours of pBtO2 neurologic monitoring predicts mortality. When the pBtO2 monitor remains below 29 mm Hg in the first 72 hours of monitoring, mortality is increased. This study challenges the brain oxygenation threshold of 20 mm Hg that has been used conventionally and delineates a time for monitoring pBtO2 that is predictive of outcome. LEVEL OF EVIDENCE: III, prognostic study.

Tight blood glucose control in trauma patients: Who really benefits?

Background: This study was designed to evaluate the effect of intensive insulin control (IIT) on outcomes for traumatically injured patients as a function of injury severity score (ISS) and age. Patients and Methods: A retrospective review of 2028 adult trauma patients admitted to the surgical intensive care unit (SICU) in a Level I trauma center was performed. Data were collected from a 48-month period before (Pre-IIT) (goal blood glucose 80–200 mg/dL) and after (Post-IIT) (goal blood glucose level 80–110 mg/dL), an IIT protocol was initiated. Patients were stratified by age and ISS. The primary endpoint was mortality. Results: There were 784 Pre-IIT and 1244 Post-IIT patients admitted. There was no significant difference between Pre-IIT vs. Post-IIT for the mechanism of injury or ISS. Values for the Pre-IIT group were significantly higher for mortality (21.5% vs. 14.7%, P<0.001) and hospital, but not ICU length of stay were decreased. A significant improvement in mortality was demonstrated between Pre-IIT vs. Post-IIT stratified within the age groups of 41–50, 51–60, and 61 but not the groups 18–30 and 31–40. Mean glucose levels (mg/dL) decreased significantly after the institution of IIT (144.7±1.4 vs. 130.9±0.9; P<0.001). In addition, the occurrence per patient of blood glucose levels <40 mg/dL increased (0.77% vs. 2.86%; P=0.001) and blood glucose levels greater than 200 mg/dL was similar (39.1% vs. 38.8%; P=0.892) in the Pre-IIT and Post-IIT groups, respectively. Glycemic variability, reflected by the standard deviation of each patients mean glucose level during ICU stay, as well as mean glucose level were lower in survivors than in nonsurvivors. Finally, multivariable logistic regression analysis identified both mean glucose level and glycemic variability as independent contributors to the risk of mortality. Conclusions: The implementation of IIT has been associated with a decrease in both hospital length of stay as well as mortality. Average glucose value and glucose variability are independent predictors of survival. Trauma patients with moderate, severe, and very severe injuries benefit most from IIT. These observational data suggest that patients over 40 years of age benefited a great deal more than their younger counterparts from IIT. This study supports the need for a randomized controlled trial to investigate the role of IIT in traumatically injured patients.

Cecal-Colic Adult Intussusception as a Cause of Intestinal Obstruction in Central Africa

Abstract. During a 5-year experience in Central Africa, the most common cause of 78 adult intestinal obstructions was primary adult cecal-colic intussusception (n = 43; 55%). The symptom complex of colicky abdominal pain and obstipation was present in 100% of the patients with intussusception. Operative repair in 90% of patients consisted of simple reduction of the intussusceptum. There were no known recurrences. The etiology of adult cecal-colic intussusception is unknown. Patients typically present with a 3- to 4-day history of abdominal pain, obstipation, and usually a palpable mass. Treatment is surgical reduction. Right colectomy is reserved for intestinal gangrene. We treated 43 cases during a 5-year period with only one death.

Traumatic pancreatic fistula in children: early management with a somatostatin analogue and drainage.

The management of a high-output pancreatic fistula is often difficult, and can be even more challenging in the pediatric patient. Octreotide acetate (OA) (Sandostatin, Sandoz, East Hanover, NJ) has served to facilitate the treatment of this difficult problem, but experience has been limited to adults. Somatostatin is a hormone that decreases the production of pancreatic exocrine and endocrine secretions. The use of the long-acting somatostatin analogue, OA, has reduced pancreatic fistula output and facilitated resolution of pancreatic fistulae in adults. This report summarizes the IV use of OA and external drainage in the complete resolution of high-output traumatic pancreatic fistulae in three pediatric patients. The treatment was well tolerated without side effects, and resulted in a dramatic decrease in the amount of fistula drainage within the first 24 to 48 h. OA can be safely administered IV (5–10 μg/kg per day) and is valuable in the management of traumatic pancreatic fistula in children.