William M. Stahl

Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome.

OBJECTIVE To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS). METHODS Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H2O) was treated by bedside or operating room laparotomy. RESULTS Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11 patients, eight patients (72.7%) had acidotic pHi (7.10 +/- 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure. CONCLUSIONS IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications.

A Critical Evaluation Of Laparoscopy In Penetrating Abdominal Trauma

One hundred hemodynamically stable patients with penetrating abdominal trauma (65, stab wounds, 35, gunshot wounds) were evaluated with laparoscopy. Sixty percent of the patients had wounds in the thoracoabdominal area or the upper abdominal quadrants and 25% had injuries located in the lower abdomen and flanks. Fifteen percent had epigastric wounds. Twenty-two stabs and 21 gunshots had not penetrated the peritoneum (negative laparoscopic results). Fifty-seven patients had peritoneal penetration and were noted to have hemoperitoneum only (n = 14), hemoperitoneum and solid organ injuries (n = 23), diaphragmatic lacerations (n = 17), and hollow viscus injuries (n = 2) on laparoscopic examination. Three of the 57 patients, one with omental herniation only and two with low grade nonbleeding lacerations of the liver, were managed uneventfully without laparotomy. The remaining 54 patients underwent laparotomy with confirmation of the laparoscopic findings. Seven patients (three with stab wounds and four with gunshots) had additional GI tract injuries seen at laparotomy. The diagnostic accuracy of laparoscopy was excellent for hemoperitoneum, solid organ injuries, diaphragmatic lacerations, and retroperitoneal hematomas. For GI injuries, laparoscopy was found to have a 100% specificity but only a 18% sensitivity. The majority of these discordant findings occurred in epigastric SWs and flank and lower quadrant GSWs, all in patients with undetected hollow viscus injuries. The major role of laparoscopy in penetrating abdominal trauma is in avoiding unnecessary laparotomy in tangential SWs and GSWs. It is excellent for evaluating the diaphragm in thoracoabdominal wounds. Caution is urged in excluding hollow viscus injuries based on laparoscopy.

Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury.

Penetrating trauma to the intrathoracic abdomen is a difficult clinical problem, especially with reference to the detection of diaphragmatic injuries. A retrospective analysis of 657 laparotomies for penetrating abdominal trauma at our institution revealed 78 laparotomies with negative results. The majority (44.8%) were for wounds in the lower chest and upper abdomen. The role of laparoscopy in evaluating these difficult areas was studied in 40 (34 stab wounds and 6 gunshot injuries) patients. Fifteen stab wounds and five gunshot wounds were nonpenetrating. Laparoscopy revealed eight clinically unsuspected diaphragmatic lacerations in seven patients. Twenty patients had hemoperitoneum. Five patients with omental bleeding and abdominal wall bleeding and four with nonbleeding liver lacerations underwent nontherapeutic laparotomies. One patient with a nonbleeding liver laceration was observed successfully without laparotomy. Ten of the 20 patients with hemoperitoneum had therapeutic laparotomies. The incidence of diaphragmatic lesions discovered by laparoscopy in this series was comparable with that reported after a mandatory laparotomy for thoracoabdominal wounds. It is concluded that laparoscopy is an excellent modality for the evaluation of the intrathoracic abdomen and the diaphragm.

Candiduria as an early marker of disseminated infection in critically ill surgical patients: the role of fluconazole therapy.

The significance of candiduria in critically ill patients remains unclear. It may represent harmless colonization or a potentially life-threatening infection. We analyzed 47 patients in the surgical intensive care unit (SICU) (trauma: 20, general surgery: 15, neurosurgery: 12) who had candiduria, defined by a colony count greater than 100,000/mL. Twenty-seven of these patients were studied retrospectively. Twenty were evaluated prospectively. All patients were receiving broad-spectrum antibiotics for bacterial infections. Retrospective group: ten patients (group A) did not develop disseminated candidiasis, whereas 17 patients (group B) did. Group B had higher APACHE II scores on admission (13.4 +/- 7.8) and at the time of candiduria (13.7 +/- 4.4) when compared with group A [admission: 5.0 +/- 4.6; candiduria: 6.7 +/- 3.6 (p < 0.02)]. In group B, disseminated candidiasis was not diagnosed and treated until 9.9 +/- 4.4 days after development of candiduria. Prospective group: twenty patients with candiduria were treated with systemic fluconazole (group C) at the time of candiduria. The APACHE II scores of group C on admission (12.8 +/- 3.9) and at the time of candiduria (10.5 +/- 4.0) were comparable with those of group B. No patient in Group C developed disseminated candidiasis. The septic mortality rates of groups A, B, and C were 0%, 53%, and 5%, respectively (p < 0.05-0.0001). In patients exhibiting ongoing sepsis and organ failure (high APACHE scores), candiduria may be an early indicator of systemic infection. Diagnosis of disseminated infection and its treatment may be delayed if conventional criteria for candidiasis (positive blood cultures, multiple site isolation) are awaited.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute phase protein response to tissue injury

Macrophages activated at sites of tissue injury produce interleukin-1, which induces hepatocytes to synthesize acute phase proteins (APP). Daily serum levels of C-reactive protein (CRP), haptoglobin (HPT), transferrin (TRF), alpha-1 antitrypsin, and ceruloplasmin (CER) were measured in 60 patients, 30 having inguinal herniorrhaphy (H), 18 cholecystectomy (C), and 12 major abdominal trauma (MAT). APP response was proportional to the level of tissue injury. CRP rose in all groups, MAT greater than C, which was greater than H. HPT levels were depressed in MAT, presumably due to removal of hemoglobin-HPT complexes from the serum. TRF was severely depressed in MAT and may be implicated in the higher infection susceptibility in this group. CER was elevated in C, suggesting a stimulating mechanism in this group as opposed to H and MAT. Explanation for this is unknown. APP changes, especially CRP, may be useful as markers of the amount of tissue damage.

Penetrating thoracic injuries: in-field stabilization vs. prompt transport.

One hundred patients who were in extremis and required Emergency Room Thoracotomy (ERT) after sustaining penetrating thoracic injuries were analyzed to compare the results of attempted stabilization in the field (n = 51) with those who had immediate transportation (n = 49). The clinical status of the patients in the field and in the E.R. was quantified by Trauma Score (TS) as well as Physiologic Index (PI), ranging in severity from 20 (clinically dead) to 5 (stable). The anatomic injury severity was expressed by Penetrating Trauma Index (PTI). Survival was analyzed according to the type of injuries: noncardiac and cardiac. The overall survival was 10%. There was only one survivor with noncardiac injuries. Sixty-nine patients had cardiac penetration, 33 in Group I (stabilization) and 36 in Group II (immediate transport). Despite attempts at stabilization, none of the patients in Group I showed an improvement in clinical status from the scene to the emergency room. There were a higher number of patients arriving at the E.R. with signs of life in Group II compared to Group I. In Group II patients, survival was significantly improved overall (p = 0.01), in patients with signs of life on arrival at the hospital (p = 0.02) and in patients with isolated right ventricular wounds (p = 0.01) compared with Group I. The anatomic injury severity (PTI) as well as the mode of injury in the two groups was similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver Packing for Uncontrolled Hemorrhage: A Reappraisal

The efficacy of liver packing for uncontrolled hemorrhage was assessed in 345 patients with hepatic injuries divided into two groups: Group I (1977-1980; n = 177), when packing was not used and Group II (1981-1985; n = 168) when the technique was employed. Despite similar clinical details, mortality from bleeding was unchanged (19.2% and 19.4% overall, and 63.7% and 61.7% for Grade IV, V, VI liver injuries). Packing was used in 14 patients who were in clinical coagulopathy after debridement-resection of the injured liver: eight patients (57%) expired from continued bleeding; five of the six survivors (83.3%) developed intra-abdominal abscesses despite early removal of the pack. The incidence of sepsis was significantly (p less than 0.002) increased as compared to that of 15 similar patients who had debridement-resection without packing. Liver packing, in our experience, has not altered the mortality from major hepatic trauma and appeared to increase the incidence of abdominal sepsis.

Penetrating duodenal injuries. Analysis of 100 consecutive cases.

One hundred consecutive patients with penetrating duodenal injuries were reviewed retrospectively to analyze the results of various methods of treatment. The severity of the abdominal injury was quantified by the Penetrating Abdominal Trauma Index (PATI). The overall mortality was 25%. Sixteen per cent of the deaths were related to extensive associated organ injury, eight per cent to sepsis, and one per cent to concurrent head trauma. Duodenal fistulas occurred in four per cent and were associated with mortality in two per cent. The complications of duodenal fistula, abdominal sepsis, and mortality from sepsis were significantly higher in those patients treated by repair and decompressive enterostomy with or without a serosal patch than in those with repair or resection. The severity of duodenal and associated organ injuries, as well as the clinical status, were similar in both groups. It is concluded that the majority of duodenal injuries from penetrating trauma may be treated effectively by primary repair, and that the use of decompressive enterostomy or serosal patch appears to contribute to an increased morbidity rate.

Percutaneous tracheostomy after trauma and critical illness.

A method of percutaneous tracheostomy (PT) using a tracheostome, which permits insertion of a full-sized cuffed tracheostomy tube, was evaluated in 61 critically ill or injured patients (89% had trauma). Of the 54 trauma patients, 65% had brain injuries, 14% had injuries to the cervical spinal cord, 33% had face or jaw injuries, and 15% had lung injuries. The indications for PT were coma (46%), acute airway obstruction (5%), face or jaw injury (20%), pneumonitis (39%), adult respiratory distress syndrome (12%), and sepsis (21%). Tracheostomy was done in 51% of all cases specifically for managing pulmonary secretions, in 37% for prolonged intubation, and in 25% for neurologic lesions. The tracheostomy was done as an emergency in 5%, as urgent in 28%, and electively in 77%. Percutaneous tracheostomy was successful in 90% of the cases, and in 8% it was converted to a surgical tracheostomy after an initial percutaneous attempt. In 46% it was performed at the bedside, in 46% in the operating room, and in 7% in the emergency suite. A full-sized tracheostomy tube (#6 to #8) was used in all cases and was considered optimal or larger than needed in 87% of cases. With three exceptions the complications of PT were minor, but 30% of the patients died of their primary disease. In one case death occurred because of bronchospasm and cardiac arrest during the PT, but appeared to be independent of the type of tracheostomy. Healing after in-hospital removal (37%) was excellent in 95% of cases and 97% of physicians indicated that they would use the device again.

Experience with 115 civilian venous injuries.

Retrospective analysis of 115 patients with venous injuries managed at Lincoln Hospital in a 7-year period disclosed a total mortality of 15%. Retrohepatic caval injury was uniformly fatal; infrarenal caval injury was not. Fifty-six per cent of victims of truncal venoarterial injuries died. Isolated venous injury of the extremity was never lethal. Ligation of injured veins of the neck and upper extremities was well tolerated. Ligation of external iliac, or common femoral, or superficial femoral veins resulted in edema in 50% of the patients compared to 7% after repair (p less than 0.05). Venoarterial injuries of iliac or femoral-level veins resulted in 37% incidence of compartment syndrome against 5% in isolated arterial injuries (p less than 0.01). Therapeutic fasciotomy after the onset of clinically evident compartment syndrome did not prevent foot drop in any patient. We advocate that all major veins of the lower extremities be repaired with the same care as arterial injuries. Prophylactic fasciotomy for all patients with iliac or femoral venoarterial injuries should be considered as strongly as with popliteal venoarterial injuries. The caliber and patency of repaired veins must be assessed by venography at operation, and again before discharge from the hospital.