ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundRestoration of oxygen delivery, especially to the splanchnic bed, is of critical importance during trauma resuscitation. Acute normovolemic hemodilution (ANH) has been used to reduce blood transfusion requirement during elective surgery. The effect of hemodilution on the splanchnic circulation during hemorrhagic shock (HS) is not well defined.MethodsSwine were instrumented to measure systemic and splanchnic circulation effects of ANH after HS. The adequacy of the splanchnic circulation was assessed by changes in measured mucosal blood flow, mucosal tonometry, as well as by portal venous blood O2saturation, portal venous CO2saturation, and lactate.ResultsANH after HS resulted in a final hematocrit of 18 ± 2%. Superior mesenteric artery blood flow was returned to baseline levels; however, mucosal blood flow was still only 64% of baseline levels. However, at the same time mucosal Pco2and intramucosal pH as well as portal venous O2and CO2saturation had normalized.ConclusionAs long as an adequate intravascular volume is maintained, hemodilution is well tolerated by the gut after HS. Concern about the adequacy of gut perfusion should not be a transfusion trigger after HS.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundDysregulation of monocyte/macrophage cytokine production after exposure to multiple inflammatory stimuli may contribute to multiple organ failure and sepsis. Endotoxin (lipopolysaccharide [LPS]) activation of murine macrophage results in the phosphorylation of kinases in the mitogen-activated protein kinase cascade. Pretreatment of murine macrophages with LPS induces LPS-tolerance, with inhibition of LPS-stimulated activation of kinases (ERK1/2 and p38) and diminished release of tumor necrosis factor (TNF). We sought to determine whether similar alterations in LPS-dependent signal transduction are present in LPS-tolerant human peripheral blood monocytes.MethodsHuman peripheral blood monocytes from healthy volunteer donors (n = 12) were incubated in RPMI 1640 culture medium ±10 ng/mL of LPS for 18 hours, then stimulated with 0 to 1,000 ng/mL of LPS. Supernatant TNF and interleukin-1 (IL-1) levels were measured after 5 hours by enzyme-linked immunosorbent assay. Activation of the p42/p44 kinases (ERK1/2) was measured 15 minutes after LPS with monoclonal antibodies to diphosphorylated (active) ERK1/2 using novel flow cytometric methods.ResultsLPS-tolerant (10 ng/mL LPS pretreatment) human monocytes had significant inhibition of LPS-stimulated TNF secretion but augmented IL-1 release (p< 0.05). Nontolerant human monocytes had a dramatic increase in the percentage of ERK1/2-positive cells in response to an initial stimulation with LPS. This did not occur in the LPS-tolerant cells. Phorbol-12-myristate-13 acetate restored ERK1/2 activation in LPS-tolerant human monocytes.ConclusionLPS-tolerance in human monocytes is associated with inhibition of LPS-stimulated TNF secretion, augmented release of IL-1, and defective activation of mitogen-activated protein kinase cascade (ERK1/2). These results suggest a method of identifying LPS-tolerance and monocyte dysfunction in patients with sepsis.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundThe purpose of this study was to compare the safety and therapeutic efficacy of a 24-hour versus 5-day course of ampicillin/sulbactam for the prevention of postoperative infections in high-risk patients sustaining hollow viscus injury from penetrating abdominal trauma.MethodsA total of 317 patients from four Level I trauma centers with penetrating abdominal injuries and at least one hollow viscus perforation each received one preoperative and three postoperative doses of ampicillin/sulbactam 3 g intravenously. After receiving 24 hours of unblinded ampicillin/sulbactam, patients were then randomized into one of two groups. Group 1 received 4 additional days of blinded ampicillin/sulbactam (5 days total of antibiotic), and Group 2 received 4 days of placebo (24 hours of antibiotic). Patients were assessed postoperatively for occurrence of deep surgical-site infections (intra-abdominal abscess, fasciitis, and peritonitis) and superficial (wound) surgical-site infections. Development of nonsurgical-site infections (e.g., pneumonia, urinary tract infection, phlebitis, and cellulitis) was also recorded. Continuous variables were analyzed by analysis of variance and discrete variables by the Cochran-Mantel-Haenszel &khgr;2test. Multivariate logistic regression analyses were also performed to identify independent risk factors for postoperative infection.ResultsA total of 159 patients were randomized into Group 1, and 158 patients were randomized into Group 2. The Injury Severity Score and penetrating abdominal trauma index were 18 ± 8 and 21 ± 13, respectively, for Group 1 and 18 ± 9 and 20 ± 15, respectively, for Group 2. A total of 162 (51%) patients sustained one or more colon injuries (82 in Group 1 and 80 in Group 2). There were 16 (10%) surgical-site infections in Group 1 and 13 (8%) surgical-site infections in Group 2 (p= 0.74). Group 1 patients experienced 17 (11%) nonsurgical-site infections, whereas Group 2 had 32 (20%) nonsurgical-site infections. This difference, however, was not statistically significant (p= 0.16). Only the total number of blood units transfused and the presence of a PATI score greater than or equal to 25 were found to be independently associated with the development of a postoperative surgical- and nonsurgical-site infections (p= 0.001 andp= 0.003, respectively). Of note, the presence of a colon injury was not found to be an independent risk factor (p= 0.11) for either surgical or nonsurgical site postoperative infection in our study.ConclusionHigh-risk patients with colon or other hollow viscus injuries from penetrating abdominal trauma are at no greater risk for surgical-site or nonsurgical-site infection when treated with only a 24-hour course of a broad-spectrum antibiotic.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundProfessional compensation is an important consideration for all physicians. Few objective data specific to trauma surgery are available to those seeking employment or contract renegotiation in the United States. National benchmark salary data should assist trauma surgeons in securing fair and equitable compensation. The purpose of this study was to survey trauma surgeons who are members of the Eastern Association for the Surgery of Trauma regarding current salary levels, benefits, contract arrangements, practice descriptors, and opinions on professional reimbursement.MethodsAnonymous self-report questionnaires were mailed to active members of the Eastern Association for the Surgery of Trauma. Only general surgeons practicing in the United States were included. Data were maintained in a confidential database.ResultsOf 385 surveys mailed, 207 (53.7%) were returned. There were 172 useable questionnaires, for an overall response rate of 44.6%. Nearly 93% of respondents worked in states east of the Mississippi River. Mean age was 42.4 years (range, 33–50 years) and 94.7% were male. Over 66% of the surgeons were fellowship trained in trauma, and 44% were chiefs of trauma services. The mean years of experience was 8.8 years (range, 1–17 years). Most respondents worked at teaching institutions (88%) and Level I centers (66%). The mean annual compensation was $229,142 ± $78,045 (range, $90,000–$528,000). These salaries were comparable to ranges from academic surveys of general surgeons. Few surgeons had professional guidance negotiating their compensation. Survey respondents were aware of few objective data specific to trauma surgery.ConclusionThis preliminary survey provides a unique benchmark for trauma surgeon salaries. Trauma surgeons should benefit from a more informed and structured approach to salary negotiations. Detailed trauma surgeon–specific data obtained periodically are essential to ensuring fair and equitable compensation in this specialty.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundVenous thromboembolism (VTE) is an important complication in blunt trauma patients. At our Level I trauma center, we had a deep venous thrombosis (DVT) rate of 3.2% from 1993 to 1997 despite an aggressive VTE prophylaxis program. During this time period, we placed vena caval filters (VCF) for both traditional and prophylactic indications. This project was developed to establish a VCF registry for trauma patients to determine the long-term complications of VCF placement.MethodsA letter was sent to all trauma patients who had a VCF placed from 1993 through 1997. Patients were asked to return for a history and physical examination to detect signs and symptoms related to VTE, a duplex ultrasound of the inferior vena cava, and a plain abdominal radiograph to determine filter migration.ResultsThere were 191 VCFs inserted in our trauma population from 1993 to 1997. There were 105 patients (75 male and 30 female) available for evaluation, with a mean follow-up of 28.9 months. Forty-one VCFs were placed in patients with DVT or pulmonary embolism, and 64 were placed in patients for prophylactic indications as per the guidelines developed by the Eastern Association for the Surgery of Trauma. There were no clinically identifiable complications related to insertion of the VCF. There were no pulmonary embolisms detected after VCF insertion. In follow-up, only one filter (0.95%) migrated, and this was minimal (1 cm cephalad). One (0.95%) vena cava was occluded, based on duplex ultrasonography, and 11 patients (10.4%) had signs or symptoms of leg swelling after hospital discharge. Twenty eight (44%) of the 64 patients with prophylactic VCFs developed a DVT after filter placement.ConclusionVCFs placed in trauma patients have acceptable short- and long-term complication rates. Consideration should be given to prophylactic VCF placement in patients at high risk for VTE. Randomized controlled trials are needed to evaluate whether VCF insertion increases the risk for subsequent DVT.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

BackgroundEdema of tissue not directly injured by heat is a common complication after resuscitation of burn shock. Hypertonic 7.5% NaCl 6% dextran (HSD) infusion reduces early fluid requirements in burn shock, but the effects of HSD on peripheral and visceral tissue edema are not well-defined.MethodsWe measured the microcirculatory absorptive pressures of burned and nonburned skin and tissue water content of skin and other tissues in anesthetized sheep after 70% to 85% total body surface area scald and resuscitation. Fluid infusion was initiated 30 minutes after injury using 10 mL/kg HSD (n = 11) or lactated Ringer’s (LR) (n = 12), with infusion rates titrated to restore and maintain preburn oxygen delivery (Do2). Thereafter, both groups received LR infusions as needed to maintain Do2until the study’s end at 8 hours. Colloid osmotic pressure was measured in plasma, and combined interstitial colloid osmotic and hydrostatic pressures were measured in skin.ResultsBoth treatments successfully restored Do2, but fluid requirements were less with the HSD group than with the LR group (43 ± 19 mL/kg vs. 194 ± 38 mL/kg, respectively,p< 0.05). The peripheral and visceral tissue water contents at 8 hours postinjury until the end of the study in both burn groups were significantly higher than in nonburn controls. However, HSD-treated sheep had significantly less water content in the colon (↓ 28%), liver (↓ 9%), pancreas (↓ 55%), skeletal muscle (↓ 21%), and nonburned skin (↓ 12%) compared with LR-treated sheep (p< 0.05 for each). HSD-treated sheep maintained significantly higher (3 to 5 mm Hg) plasma colloid osmotic pressure than LR-treated sheep.ConclusionThere were no observed differences in edema in burn skin between the two treatment groups. The early volume-sparing effect of HSD and reduction in tissue edema are likely attributed to an increased extracellular osmolarity and a better maintenance of the plasma oncotic pressure.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

ObjectiveRotational malalignment that may happen during closed nailing of humeral fractures is, to date, an unexplored area of investigation. The purpose of this study was to examine the effect of arm position during surgery on humeral rotational alignment and the effect of this alignment on shoulder motion and function.MethodsThirty patients with eventual fracture healing after closed humeral locked nailing were retrospectively studied: 15 had retrograde nailing; 15, antegrade. Retrograde nailing was performed with the patient in a decubitus position and with the upper arm anteriorly flexed and the forearm perpendicular to the operating table. Antegrade nailing was performed with the patient in a semisitting position and with the upper arm in the so-called resting position. The humeral retroversion angle as measured by computed tomographic scan, range of shoulder rotation, and Neer score of the shoulder for the fractured and the intact humeri were determined, and the discrepancy (i.e., value for the intact subtracted from that for the fractured) between the two was noted. To test the effect on alignment of positioning during retrograde nailing, we similarly determined retroversion angles for another 15 patients treated in a supine resting position.ResultsBetween antegrade nailing and retrograde nailing in decubitus position, there was a significant difference in the mean discrepancies for the retroversion angles and the range of external rotation of the shoulder in the neutral and abduction positions, but no significant difference for internal rotation of the shoulder and Neer score. Between antegrade nailing and retrograde nailing in supine resting position, there was no significant difference in the mean discrepancy for the retroversion angle.ConclusionPositioning of the arm may significantly affect humeral rotational alignment and range of motion during closed nailing. Until a reliable method for intraoperative measurement of humeral rotation is devised, we recommend that closed nailing of humeral shaft fractures be performed with the patient’s upper arm in the resting position shown in this study.

ISSN:0022-5282    

出版商:OVID    

年代:2000

数据来源: OVID