Yi-Szu Wen

Hypothermic retrograde jugular perfusion reduces brain damage in rats with heatstroke

ObjectiveTo determine whether direct retrograde ice saline infusion in the jugular vein without cardiopulmonary bypass protects rat brains after heatstroke. DesignRandomized, controlled, prospective study. SettingUniversity physiology research laboratory. SubjectsSprague-Dawley rats (270–320 g, males). InterventionsRats were randomized into three groups and given a) no resuscitation after onset of heat stroke (HS, n = 8); b) ice saline infusion in the femoral vein after onset of heat stroke (HS + F, n = 8); or c) retrograde ice saline infusion in the external jugular vein after onset of heat stroke (HS + J, n = 8). Rats were exposed to an ambient temperature of 43°C after vessel cannulation. Their mean arterial pressure, heart rate, colonic temperature, and brain temperature were continuously recorded. Survival time and brain pathology were checked. Measurements and Main ResultsAlthough colonic temperature decreased 0.8–1.0°C 15 mins after heatstroke in all groups, no treatment-related changes in colonic temperature were noted in any group. However, significant changes were observed in brain temperature. Fifteen minutes after heatstroke, brain temperature was 37.6 ± 0.4°C, 36.1 ± 0.4°C, and 33.6 ± 0.8°C in HS, HS + F, and HS + J, respectively. Survival time was 16.1 ± 2.1, 33.0 ± 3.8, and >120 mins in these groups, respectively. Neuron damage score was significantly lower in HS + J and without lateralization. ConclusionsWe successfully demonstrated that direct retrograde hypothermic perfusion via the jugular vein without cardiopulmonary bypass protected the brain after heat stroke. This technique cooled the brain but did not significantly interfere with body temperature.

Rapid brain cooling by hypothermic retrograde jugular vein flush

BACKGROUND Although whole-body hypothermia recently has been reported effective in improving the neurologic outcome after cardiac arrest, it is contraindicated in the management of trauma patients with hemorrhagic shock. To provide selective brain cooling in this situation, the authors speculated about the feasibility of hypothermic retrograde jugular vein flush (HRJVF). This preliminary study was conducted to test the effectiveness of brain cooling after HRJVF in rats without hemorrhagic shock. METHODS After jugular vein cannulation with cranial direction, Sprague-Dawley rats were randomized into a normal control group, a group that underwent flush with cold saline at 4 degrees C, or a group that underwent flush with saline at a room temperature of 24 degrees C. A Servo-controlled heat lamp was applied for all the rats to keep their rectal temperature at 37 +/- 0.5 degrees C. Their brain temperature and cerebral blood flow were checked. RESULTS Within the 10-minute period of cold saline flush (1.7 mL/100 g), brain temperature was immediately decreased, and this cooling effect could be maintained for at least 20 minutes. Cerebral blood flow was significantly increased after HRJVF, then returned gradually to the baseline as brain temperature elevated. CONCLUSIONS This study successfully demonstrated a significant cooling effect in rat brain by HRJVF. For preservation of brain function, HRJVF may be useful in resuscitation for trauma patients with hemorrhagic shock after further studies on animals with shock.

Prognostic factors for mortality following falls from height

AIM To identify the potential prognostic factors for mortality after falls from height. METHOD A retrospective clinical observational study included victims of fall of >6m from October 2000 to December 2007. Variables studied comprised each casualtys age, gender, height of fall, Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale scores, Injury Severity Score, heart rate, Mean Arterial Pressure (MAP), White Blood Cell (WBC) count, haemoglobin, serum glucose, Creatine Kinase and duration of hospital stay. The relationships between these variables and outcomes were evaluated. RESULTS Among the 66 patients studied the mortality rate was 22.7%, i.e. 7 out-of-hospital and 8 in-hospital deaths. In univariate analysis, Glasgow Coma Score < or =14, Injury Severity Score > or =16, head/neck Abbreviated Injury Scale score > or =4, chest Abbreviated Injury Scale score > or =4, heart rate > or =100 or < or =50 beats/min, Mean Arterial Pressure < or =60 and serum glucose > or =140 mg/dl were significantly related to mortality. In multivariate analysis, head/neck Abbreviated Injury Scale score > or =4 was independently correlated with mortality. CONCLUSIONS Severe head injury (head/neck Abbreviated Injury Scale score > or =4) is a significant factor for mortality following falls from >6 m.

Early repair of traumatic ventricular septal defect and mitral valve regurgitation

Traumatic ventricular septal defect with valvular injury is an uncommon blunt trauma. It may develop either immediately or be delayed, but it should be corrected electively. With hemodynamic instability and cardiopulmonary deterioration, however, early repair is necessary as a lifesaving procedure. Two-dimensional echocardiography and Doppler color flow mapping are very important for rapid detection in patients who are critically injured. This is a case report of the successful repair of ventricular septal defect and posterior leaflet disruption of mitral valve right after blunt trauma.

Spleen artery embolization aggravates endotoxin hyporesponse of peripheral blood mononuclear cells in patients with spleen injury.

BACKGROUND : Spleen artery embolization (SAE) increases the success of nonoperative management of spleen injury; however, the immune alternation after SAE is unclear. This study searched the endotoxin responses of peripheral blood mononuclear cells (PBMCs) in injured patients who received SAE. METHODS : Patients were subsequently enrolled when their spleen injuries were confirmed by computed tomographic scan. Peripheral blood samples were obtained within first, at third, fifth, and seventh postinjury days. PBMCs were isolated; nuclear factor (NF)-kB translocations, phosphorylated I-kB expressions, and in vitro tumor necrosis factor (TNF)-alpha levels were assayed after endotoxin stimulation (ES). RESULTS : Sixteen patients who received nonoperative managements were enrolled. Five patients received SAE (embolized patients) and 11 patients did not (nonembolized patients). Compared with those in controls, NF-kB translocations, phosphorylated I-kB expressions, and TNF-alpha levels after ES decreased significantly early in injured patients. NF-kB translocation and TNF-alpha levels after ES were indifferent at seventh day between nonembolized patients and controls, whereas significantly lower NF-kB p65 translocation and TNF-alpha levels after ES were found at seventh postinjury day in embolized patients than in controls. Compared with nonembolized patients, embolized patients had significantly lower levels of NF-kBp50 translocations after ES from first to third postinjury days and lower levels of NF-kB p65 translocations, TNF-alpha, and phosphorylated I-kB expressions after ES from first to fifth postinjury days. CONCLUSIONS : SAE dysregulates the NF-kB system and aggravates the cytokine hyporesponse upon ES of PBMCs in patients with spleen injury. These results implicate that SAE alters immune response and may increase susceptibility to infections in injured patients.

Spleen artery embolization increases the success of nonoperative management following blunt splenic injury

Background: Spleen artery embolization (SAE) may increase the success rate of nonoperative management (NOM). The present study investigated the clinical outcome after the installation of SAE in the management of blunt splenic injury. Methods: A retrospective review of hospital records was performed to enroll patients with blunt injury of the spleen. Demographic data and information about the injury severity score, organ injury scale, hospitalization days, management and final outcomes were evaluated. Patients were separated into early and late groups according to the year that SAE was selectively used (2003–2004 and 2005–2008). Results: Six of eleven (55%) patients in the early group were successfully managed without surgery for blunt splenic injury, whereas all of the 38 patients (100%) in the late group were successfully managed without surgery. Eleven patients (11 of 38; 28.9%) received SAE in the late group. The rate of NOM increased from 55% in the early group to 100% in the late group (p < 0.001). Both early and late groups had similar injury severity score, length of hospitalization, blood transfusion, and complications, and there was no mortality. Conclusion: Performance of SAE for the patients with blunt splenic injury could increase the successful rate of NOM significantly and safely. An algorithm including the angioembolization might be beneficial in the management of patients with blunt spleen trauma.

The role of diagnostic algorithms in the management of blunt splenic injury

Background: Diagnostic algorithms for patients with blunt abdominal trauma have been in use since 1995. This study investigated the role of diagnostic algorithms in the management of adult patients with blunt splenic injury at our institution. Methods: A retrospective review of hospital records was performed to enroll patients with blunt injury of the spleen. Demographic data and information about injury severity, diagnostic methods, management and final outcomes were evaluated. Patients were separated into an early and late group according to the year that diagnostic algorithms were used (1990–1994 or 1995–1999). Results: One hundred and twenty‐one patients were enrolled. Initially, 71 patients had an operation (OP group), whereas 50 received non‐operative management (NOM group). Patients in the OP versus NOM group had lower blood pressure and greater transfusion volumes in the emergency room, higher grade splenic injury, and a greater rate of intra‐abdominal‐related injury. NOM failed in 7 patients (14%). Early‐versus late‐group patients were less likely to have NOM and high grade splenic injury; however, the rate of NOM failure was not different between the early and late groups. Conclusion: Diagnostic algorithms using sonograms for screening provide an initial means of selecting patients for NOM. Patients with higher grades of splenic injury can then be managed non‐operatively.

Analysis of the causes of surgery-related medical disputes in Taiwan: Need for acute care surgeons to improve quality of care.

Background This study investigated surgery‐related medical disputes and analyzed disease etiologies and the main causes of disputes in order to identify key points for the purpose of improving the quality of surgical patient care in Taiwan. Methods Reports on all surgery‐related cases appraised by the Taiwan Witness Examiner Committee of the Department of Health between 2004 and 2008 were reviewed retrospectively by three senior physicians from the emergency department who specialize in both trauma and emergency general surgery. The causes of the various medical disputes were categorized under the following descriptions: operation‐ or procedure‐related complication, anesthesia complication, inappropriate management or decision, delayed diagnosis or misdiagnosis, and unsatisfactory result. Results A total of 154 cases were reviewed, of which 39 were trauma‐related and 115 were disease‐related. The two leading causes of disputes in this review were found to be operation‐ or procedure‐related complications (35.7%) and unsatisfactory results (31.8%), followed by delayed diagnoses or misdiagnoses, inappropriate management, and anesthesia complications. Among these, 74 cases (48.1%) required the care of an acute care surgeon and 40 cases (26.0%) required emergency general surgery intervention. Conclusion Surgery‐ or procedure‐related complications and unsatisfactory treatment results constituted the major causes of medical disputes in Taiwan. The majority of these cases involved acute care surgery; thus, the establishment of an acute care surgery system should be considered to improve patient care. The management of hemorrhagic shock and incarcerated hernia should be reinforced in future medical training.

Management of hemodynamically unstable, ruptured multiple hepatic artery pseudoaneurysms by open surgery combined with endovascular embolization

Hepatic artery pseudoaneurysm is a type of visceral artery aneurysm, which may cause life-threatening situation if the diagnosis and treatment are delayed after rupture. Increased clinical awareness and aggressive, definitive management are necessary in obtaining optimal outcomes. In general, surgery is the preferred treatment for extrahepatic lesions, whereas embolization is appropriate for intrahepatic aneurysms. However, exploratory laparotomy for vascular ligation or anastomosis is the only way in emergency if the hemodynamic status is unstable. Since the cases of ruptured pseudoaneurysm in both intra- and extra-hepatic artery is rare, we present a case of ruptured hepatic artery pseudoaneurysms with hemorrhagic shock rescued by surgery to stabilize the patient, followed by angioembolization to manage the multiple hepatic aneurysms and provide a review of the current literature on this topic, focusing on appropriate decision-making under multidisciplinary management.