Yousheng Li

Goal-directed transfusion protocol via thrombelastography in patients with abdominal trauma: a retrospective study

IntroductionThe optimal transfusion protocol remains unknown in the trauma setting. This retrospective cohort study aimed to determine if goal-directed transfusion protocol based on standard thrombelastography (TEG) is feasible and beneficial in patients with abdominal trauma.MethodsSixty adult patients with abdominal trauma who received 2 or more units of red blood cell transfusion within 24xa0hours of admission were studied. Patients managed with goal-directed transfusion protocol via TEG (goal-directed group) were compared to patients admitted before utilization of the protocol (control group).ResultsThere were 29 patients in the goal-directed group and 31 in the control group. Baseline parameters were similar except for higher admission systolic blood pressure in the goal-directed group than the control group (121.8u2009±u200923.1xa0mmHg vs 102.7u2009±u200926.5xa0mmHg, pu2009<u20090.01). At 24xa0h, patients in the goal-directed group had shorter aPTT compared to patients in the control group (39.2u2009±u200916.3xa0s vs 58.6u2009±u200936.6xa0s, pu2009=u20090.044). Administration of total blood products at 24xa0h appeared to be fewer in the goal-directed group than the control group (10.2 [7.0-43.1]U vs 14.8 [8.3-37.6]U, pu2009=u20090.28), but this was not statistically significant. Subgroup analysis including patients with ISS ≥16 showed that patients in the goal-directed group had significantly fewer consumption of total blood products than patients in the control group (7[6.1, 47.0]U vs 37.6[14.5, 89.9]U, pu2009=u20090.015). No differences were found in mortality at 28d, length of stay in intensive care unit and hospital between the two groups.ConclusionsGoal-directed transfusion protocol via standard TEG was achievable in patients with abdominal trauma. The novel protocol, compared to conventional transfusion management, has the potential to decrease blood product utilization and prevent exacerbation of coagulation function.

Is it feasible to implement enteral nutrition in patients with enteroatmospheric fistulae? A single-center experience.

BACKGROUNDnPublished experience in feeding patients with enteroatmospheric fistulae is scarce. This study aimed to determine if enteral nutrition (EN) could be safely delivered in the presence of enteroatmospheric fistula.nnnMATERIALS AND METHODSnThis is a retrospective descriptive study from a major fistula treatment center in China. Medical records of patients who developed enteroatmospheric fistulae in the open abdomen after abdominal trauma were reviewed. The timing of initiation and achievement of full strength (25 kcal/kg/d) EN after enteroatmospheric fistula were noted, as well as the incidence of feeding-associated complications and weaning of parenteral nutrition (PN). The outcomes of open abdomen and enteroatmospheric fistula were also noted.nnnRESULTSnNine patients were included in this study. EN was successfully implemented in all patients. The median timing of initiation and achievement of full strength of EN after enteroatmospheric fistula was 9 (interquartile range [IQR], 3–22) and 27 (IQR, 22–43) days, respectively. Feeding-associated complications developed in 1 (11.1%) patient. All patients were liberated from PN at hospital discharge. Split-thickness skin grafting was performed in all patients, of whom 5 underwent successful delayed abdominal closure, and 4 were awaiting definitive closure. Repair or resection of enteroatmospheric fistula occurred in 8 (88.9%) patients.nnnCONCLUSIONnThis study showed that EN could be safely implemented in patients with enteroatmospheric fistulae without complicating the treatment of open abdomen and enteroatmospheric fistula.

Effects of recombinant activated factor VIIa on abdominal trauma patients.

Recombinant activated factor VIIa (rFVIIa) has been highlighted by correcting uncontrollable traumatic haemorrhage. Compared with routine coagulation tests, thromboelastography (TEG) can evaluate the coagulation function of trauma patients more rapidly, accurately and comprehensively, and can also diagnose trauma-associated coagulopathy (TAC) in an early stage. Thirty-eight cases conforming to rFVIIa indications were screened according to TEG results and divided into an rFVIIa group (nu200a=u200a20) and a nonrFVIIa group (nu200a=u200a18). Their coagulopathy was goal-directedly corrected under the guidance of TEG. The parameters examined by routine coagulation tests and TEG were compared. The blood components transfused in the two groups were also calculated. When rFVIIa was administered by an average dose of 52.3u200a&mgr;g/kg (24.0–95.6u200a&mgr;g/kg), blood coagulation function was significantly improved in 48u200ah. Compared with the nonrFVIIa group, the treatment group experienced decreased R time. Moreover, significant fewer red blood cells, platelet and fresh frozen plasma were transfused in the rFVIIa group. All patients underwent daily bedside vascular ultrasound screening within a week after haemostatic treatment, of which no thromboembolic events occurred. TEG can sensitively detect TAC. rFVIIa administered goal-directedly guided by TEG is more effectively in correcting TAC and decreasing the amount of blood product transfusion.

Limited Fluid Resuscitation Attenuates Lung and Intestine Injury Caused by Hemorrhagic Shock in Rats

ABSTRACT Background and Objective: Different volume fluid resuscitations were closely associated with different cytokine responses, which could influence shock-induced lung and intestinal destruction. The aim of the study is to compare the effects of limited and traditional resuscitation on the levels of inflammatory response and lung and intestinal injury of hemorrhagic shock (HS) rats. Method: Sprague–Dawley male rats were subjected to a blood pressure-controlled hemorrhage group following three kinds of resuscitation using lactated Ringers (LR) solution (45, 30, 15 ml/kg·hr, respectively) and unresuscitation group. Then six rats of each group were sacrificed at 24, 48, and 72 hr, respectively. Results: The levels of plasma TNF-α, the plasma lactic acid, the intestinal permeability, and the ratio of wet weight to dry weight of lung and intestinal were lower in the group of 15 ml/kg·hr than other groups (p < .05). The lung and intestinal injury were more severe in group 45 ml/kg·hr than other groups in 24, 48, and 72 hr (p < .05). Conclusion: Comparing with conventional fluid resuscitation, limited fluid resuscitation (LFR) could not only decrease the levels of lactic acid and pro-inflammatory factors but also attenuate the intestinal and lung injury.

Coordinated Hospital-Home Fecal Microbiota Transplantation via Percutaneous Endoscopic Cecostomy for Recurrent Steroid-Dependent Ulcerative Colitis.

Since its introduction as an alternative intestinal microbiota alteration approach, fecal microbiota transplantation (FMT) has been increasingly used as a treatment of choice for patients with ulcerative colitis (UC), but no reports exist regarding FMT via percutaneous endoscopic cecostomy (PEC). This report describes the case of a 24-year-old man with a 7-year history of recurrent, steroid-dependent UC. He received FMT via PEC once per day for 1 month in the hospital. After the remission of gastrointestinal symptoms, he was discharged from the hospital and continued FMT via PEC twice per week for 3 months at home. The frequency of stools decreased, and the characteristics of stools improved soon thereafter. Enteral nutrition was regained after 1 week, and an oral diet was begun 1 month later. Two months after the FMT end point, the patient resumed a normal diet, with formed soft stools once per day. The follow-up colonoscopy showed normal mucus membranes; then, the PEC set was removed. On the subsequent 12 months follow-up, the patient resumed orthobiosis without any gastrointestinal discomfort and returned to work. This case emphasizes that FMT via PEC can not only induce remission but also shorten the duration of hospitalization and reduce the medical costs; therefore, this approach should be considered an alternative option for patients with UC.

Double percutaneous endoscopic gastrojejunostomy tubes for decompression and refeeding together with enteral nutrients: three case reports and a review of the literature.

Percutaneous endoscopic gastrostomy had become a general technique for placement of indwelling feeding and decompressive tubes. There have been few reports that double percutaneous endoscopic gastrojejunostomy (PEGJ) tubes for decompression and refeeding together with enteral nutrients. We herein present 3 cases, characterized by chronic malnutrition and requiring long-term digestive decompression and enteral nutritional support, which were placed in double PEGJ tubes under endoscopic or fluoroscopic guidance. The procedures were successfully completed for all the patients. Two patients resumed oral intake and PEGJ tubes were removed. The second patient was provided home enteral nutrition while waiting for surgery. Three unusual cases were successfully treated by double PEGJ tubes for digestive decompression and refeeding together with enteral nutrients.

Perioperative Alanyl-Glutamine–Supplemented Parenteral Nutrition in Chronic Radiation Enteritis Patients With Surgical Intestinal Obstruction A Prospective, Randomized, Controlled Study

BACKGROUNDnA prospective, randomized, controlled study was performed to evaluate the effects of perioperative alanyl-glutamine-supplemented parenteral nutrition (PN) support on the immunologic function, intestinal permeability, and nutrition status of surgical patients with chronic radiation enteritis (CRE)-induced intestinal obstruction.nnnMETHODSnPatients who received 0.4 g/kg/d alanyl-glutamine and isonitrogenous PN were assigned to an alanyl-glutamine-supplemented PN (Gln-PN) group and a control group, respectively. Serum levels of alanine aminotransferase and glutamine, body fat mass (FM), immunologic function, and intestinal permeability were measured before and after surgery.nnnRESULTSnSerum glutamine levels of the Gln-PN group significantly exceeded that of the control group (P < .001; Gln-PN, baseline 460.7 ± 42.5 vs 523.3 ± 48.6 µmol/L on postoperative day 14 [POD14], P < .001; control, baseline 451.9 ± 44.0 vs 453.8 ± 42.3 µmol/L on POD14, P = .708). Lactulose/mannitol ratios of both groups decreased over time (Gln-PN, baseline 0.129 ± 0.0403 vs 0.024 ± 0.0107 on POD1 4; control, baseline 0.125 ± 0.0378 vs 0.044 ± 0.0126 on POD14, P < .001 in both groups). CD4/CD8-positive T-lymphocyte ratios significantly rose in both groups, with significant intergroup difference (P < .001; Gln-PN, baseline 1.36 ± 0.32 vs 1.82 ± 0.30 on POD14, P < .001; control, baseline 1.37 ± 0.25 vs 1.63 ± 0.31 on POD14, P < .001). In the Gln-PN group, FM increased from 3.68 ± 1.68 kg at baseline to 5.22 ± 1.42 kg on POD14 (P < .001). FM of control group increased from 3.84 ± 1.57 kg at baseline to 5.40 ± 1.54 kg on POD14 (P < .001). However, there were no significant intergroup differences (P = .614).nnnCONCLUSIONnGln-PN significantly boosted the immune state and decreased the intestinal permeability of CRE patients. However, Gln-PN was not superior to standard PN in improving the nutrition state and intestinal motility of surgical patients with CRE-induced intestinal obstruction.

Bacteriology and drug susceptibility analysis of pus from patients with severe intra-abdominal infection induced by abdominal trauma

The aim of the present study was to retrospectively analyze the bacteriology and drug susceptibility of pus flora from abdominal trauma patients with severe intra-abdominal infection (SIAI). A total of 41 patients with SIAI induced by abdominal trauma were enrolled in the study, from which 123 abdominal pus samples were obtained. The results from laboratory microbiology and drug sensitivity were subjected to susceptibility analysis using WHONET software. A total of 297 strains were isolated in which Gram-negative bacteria, Gram-positive bacteria and fungi accounted for 53.5 (159/297), 44.1 (131/297) and 0.7% (2/297), respectively. Anaerobic bacteria accounted for 1.7%. The five predominant bacteria were Escherichia coli (E. coli), Staphylococcus aureus (S. aureus), Klebsiella pneumoniae (K. pneumoniae), Enterococcus faecalis and Pseudomonas aeruginosa (P. aeruginosa). E. coli was highly susceptible to cefoperazone (91%) and imipenem (98%), while Gram-positive cocci were highly susceptible to teicoplanin (100%) and linezolid (100%). S. aureus was 100% susceptible to vancomycin and K. pneumoniae was highly susceptible to imipenem (100%) and amikacin (79%). P. aeruginosa was the most susceptible to ciprofloxacin (90%). Gram-negative bacterial infection was present in the majority of cases of SIAI. However, a large number of patients were infected by Gram-positive bacteria, particularly S. aureus that exhibited significant resistance to penicillin (100%), oxacillin (100%) and a third-generation cephalosporin antibiotic cefotaxime (95%). Amongst the pathogenic bacteria that cause SIAI, both Gram-negative and Gram-positive bacteria account for a high proportion, so high-level and broad-spectrum antibiotics should be initially used.

Laparoscopic surgery for radiation enteritis

BACKGROUNDnThe aim of this study was to determine the safety and feasibility of laparoscopic surgery for radiation enteritis-induced intestinal stenosis requiring ileocecal resection.nnnMETHODSnClinical records of radiation enteritis patients that underwent laparoscopic ileocecal resection and ileo-ascending colonic side-to-side anastomosis in a single center from January 2012-February 2014 were retrospectively analyzed. Thirty patients were identified and matched by abdominal adhesion grade, age, gender, primary malignancy distribution, previous abdominal surgery history, and body mass index to 30 patients that underwent open surgery for the same procedure from August 2009-December 2011. General information, operative findings, and short-term outcomes were compared between the two groups.nnnRESULTSnThe conversion rate of laparoscopic surgery was 23.3%. The length of skin incision in the laparoscopic group was significantly shorter than that of the open surgery group (6.8xa0cm versus 15.8xa0cm, Pxa0=xa00.001). Laparoscopic surgery significantly decreased recovery time to total enteral nutrition (10.3xa0d versus 15.6xa0d, Pxa0=xa00.037); however, postoperative hospital stay was not significantly different between the two groups (28.2xa0d versus 32.4xa0d, Pxa0=xa00.924). Intraoperative blood loss (125xa0mL versus 189xa0mL, Pxa0=xa00.000) and operation time (138xa0min versus 171xa0min, Pxa0=xa00.003) were significantly improved in the laparoscopic group compared with those in the open surgery group. Laparoscopic surgery did not significantly decrease postoperative morbidity but did decrease the pleural effusion rate.nnnCONCLUSIONSnLaparoscopic surgery is feasible for treatment of radiation enteritis-induced intestinal stenosis with a relatively low conversion rate. Laparoscopic surgery is as safe as open surgery and is superior to open surgery with decreased skin incision length, operation time, intraoperative blood loss, and postoperative recovery time to total enteral nutrition.

Early- Versus Late-Onset Prosthetic Mesh Infection: More than Time Alone

Prosthetic mesh used for ventral incisional hernia makes hernia repair surgery simple, effective, and safe. The mesh infection is a formidable complication and bimodal distribution. The differences between early- and late-onset are unknown. This is a cohort study of patients undergoing ventral incisional hernia (VIH) repair from January 2003 to September 2013. Data of specific risk variables were collected from electronic medical record systems in Jinling Hospital. And, the quality of lives was evaluated by WHO Quality of Life-BREF. A total of 102 VIH repair patients were analyzed and followed including the noninfection group and early- and late-onset group. There were significant differences between the early- and late-onset group in clinical manifestation, descriptive analysis of the study population, and postoperative quality of lives. These differences might imply the different pathophysiologic process of early- and late-onset mesh infection. Permanent prosthetic mesh should be used with caution, and the study of intraperitoneal onlay mesh is still needed in long-term follow-up.