摘要:

Pulmonary dysfunction and permeability were prospectively studied in a group of severely traumatized patients. Ventilatory parameters (i.e., PaO2/ FiO2, dynamic compliance, per cent shunt, and A-a DO2) and extravascular lung water (EVLW) measurements were compared with scintigraphic determinations of pulmonary albumin extravasation. Albumin extravasation data demonstrated a pulmonary capillary permeability increase occurring shortly following trauma. The median albumin extravasation value in the patients within 24 hours of trauma was 3.6 x 10-5/sec, compared to a control value of —0.1 ± 0.7 x 10-5sec. Intermediate levels of albumin extravasation were found in patients studied within 48 hours of total hip replacement (1.6 ± 0.9 x 10-5sec). Eighty per cent of patients studied within the first 48 hours of their trauma had albumin extravasation values exceeding the upper limit of normal as determined by the control value + 2 S.D. In contrast to albumin extravasation values, the PaO2/FiO2, dynamic compliance, per cent shunt, A-a DO2, and EVLW did not begin to deteriorate significantly until at least 48 hours after trauma. We conclude that severe multiple trauma induces an early increase in pulmonary capillary permeability as measured by albumin extravasation scintigraphy. This change is not detectable with other commonly used measures.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Several investigators have demonstrated a diminished rate of ketogenesis during inflammatory or infectious states despite the availability of free fatty acids supplied to the liver. The biochemical mechanism for this effect is unknown. Malonyl-CoA has been proposed to be a regulator of ketogenesis. Malonyl-CoA levels are low in states of rapid ketogenesis such as starvation or diabetes and high in states of reduced ketogenesis such as carbohydrate feeding. In the present study, the effect of an intra-abdominal abscess on the level of hepatic malonyl-CoA was investigated in four groups of animals (fed control, sterile inflammation, small chronic septic abscess, large chronic septic abscess). Liver samples were frozen in situ 5 days following the intraperitoneal introduction of a rat-fecal agar pellet inoculated with a known bacterial flora which generated an abscess [sterile inflammatory;B. fragilis108/ml +E. coli102/ml (small, 0.8 ml or large, 1.5 ml) abscess pellet]. The level of malonyl-CoA in normal fed rats was 5.0 ± 0.6 nmol/gm wet wt (n=9). The malonyl-CoA level was not altered in animals with a sterile inflammation. However, hepatic malonyl-CoA levels were significantly increased in small (10 ± 1 nmole/gm wet wt) (p<0.05; n=9) or large (12 ± 1 nmol/gm wet wt) (p<0.01; n=14) septic abscess rats compared to control fed and sterile inflammatory rats. Hepatic ketone bodies (β-hydroxybutyrate and acetoacetate) did not increase in sepsis over control or sterile inflammation. The level of acetyl-CoA, the precursor for ketone bodies, was 63 ± 10 nmole/ gm wet wt in control fed (n=9) and was decreased to 48 ± 12 nmol/gm wet wt (p<0.05; n=10) in sterile inflammatory animals. The level of hepatic acetyl- CoA was increased over sterile but not control animals in small (62 ± 14 nmole/gm wet wt; n=8) or large (67 ±15 nmole/gm wet wt; n=14) septic abscess animals. These results are compatible with the hypothesis that inhibition of the carnitine:acyl-CoA transferase I by increased malonyl-CoA may limit the formation of acetyl-CoA from long-chain fatty acids in sepsis. Increased acetyl-CoA levels are required for increased rates of ketogenesis. The increase in malonyl-CoA may differentiate the regulation of ketogenesis in sepsis from that in inflammation and implies an altered hepatic production of fuels in sepsis.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

The effect of prospective payment system (PPS) on reducing cost and quality of care is still unknown. Fifty-two patients (mean ± SD, 82.0 ± 6.5 years) with hip fracture classified as DRG 210 (hip and femur procedures except major joint, age>69 years and/or complication and/or comorbidity), treated by compression nail were separated into four groups: Group I—no comorbidity, no complications; Group II—no comorbidity but had complications; Group III—with comorbidity but no complications; and Group IV—with both comorbidity and complications. Compared to length of stay (LOS) in Groups I, II and III (mean 26 days), Group IV had significantly increased LOS (mean, 61.5 days) and 81% of the 16 who were day outliers (L.O.S.>40 days). Patients without comorbidity (I & II) even if they did develop complications were not financial losers. Those with comorbidity appear to be high-cost patients as they invariably end up with complications (78%), and reimbursement for Group IV was significantly less, resulting in net loss of this DRG. Our finding demonstrates the importance of preventing complications in patients with comorbidity. Present DRG reimbursement guidelines do not provide sufficient attention to LOS implications of both comorbidity and complications. Ideally, they should be considered as separate factors within the DRG category.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Oxygen-carrying perfluorocarbon (PFC) emulsions show clinical promise as blood supplements or substitutes. However, some evidence suggests that PFC emulsions may accumulate in the lungs to disrupt pulmonary function. This study was conducted to determine whether the infusion of a PFC emulsion (Fluosol-DA) would alter microvascular permeability in the isolated canine right lower lung lobe (RLL). RLL's, perfused at constant pressure with autogenous blood, were divided into three groups: Group I (n=6), the control group, was infused with bovine serum albumin (BSA) until the BSA solution equaled 10% of the total blood volume in the per fusion system; Group II (n=6) was infused with Fluosol-DA until the emulsion comprised 10% of the final blood volume; and Group HI (n=6) was infused with Fluosol-DA until it comprised 20% of the final blood volume. The pulmonary filtration coefficient (Kf), an index of microvascular permeability, was obtained in each group approximately 1 hour after infusion. The Kfvalues for the control, 10% Fluosol, and 20% Fluosol groups were 0.070 ± 0.018, 0.127 ± 0.024, and 0.115 ± 0.022 ml-min-1.mm Hg-1.100 gm-1, respectively, and were not significantly different (p>0.05) from each other. Perfusate oncotic pressure, lobar compliance, blood gas levels, and pulmonary arterial pressure did not vary significantly among the experimental groups. Under these experimental conditions, Fluosol-DA, in blood concentrations that might be used clinically, was not associated with an increased microvascular permeability in the isolated dog lung lobe

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

During a 9-year period, 60 patients with acutely ruptured diaphragms following blunt trauma were treated in our institution. Diaphragmatic injury was detected within 24 hours of hospital admission in all but two patients. The diagnosis was suggested by upright chest X-ray in 40% of the patients. Diaphragmatic tears were discovered at laparotomy for hemoperitoneum in the remaining patients. At initial evaluation hypotension was present in 67% of the patients, and respiratory distress was evident in 52%. In contrast to traditional teaching, there was a 30% incidence of right hemidiaphragmatic disruption. One patient experienced bilateral diaphragmatic rupture, and two had isolated tears of the pericardial diaphragm. Intra-abdominal organs were herniated through the diaphragmatic defect in only 32% of the patients. There was a 90% incidence of associated intra-abdominal injuries. The diaphragmatic tear was repaired via the abdomen in 53 patients, through a thoracoabdominal incision in five patients, and through the chest in only two cases. All defects were closed primarily. Twelve patients also required thoracotomy for resuscitation and/or correction of intrathoracic injury. Atelectasis was the most frequent postoperative complication, occurring in 65% of the patients. The mortality was 26.7% and was related to associated injuries in all cases.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

We studied 128 patients admitted over a 12½ -year period to the Cook County Hospital Trauma Unit with acute subdural hematoma (ASDH): 82 were admitted directly and 46 were admitted after transfer from another hospital; 59% of the entire group died and only 27% obtained a functional recovery. As a group, the transferred patients, who suffered delays of several hours before receiving definitive surgical care, fared significantly worse than the patients with equivalent trauma who were admitted directly. The mortality of the transferred patients was 76%, compared to 50% of the direct admit patients. The outcome was also worse for transfer patients who experienced a 'lucid interval' or with alcohol intoxication. We conclude that the delays associated with failure to admit patients with ASDH directly to a head trauma center cause an excessive mortality and morbidity which could potentially be avoided by proper triage.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

It has been suggested that acute respiratory distress syndrome (ARDS) is induced by a cybernetic imbalance of the central nervous system secondary to alarm reaction-provoked intravascular coagulation into cerebral microvessels. The brain metabolic and electrical resting state through the use of neurodepressant drugs might theoretically reduce the intensity and duration of the alarm reaction, thus diminishing the possibility of self-induced secondary brain lesions. In this work, Wistar rats were submitted to central (anterior hypothalamic electrolytic lesion) and peripheral (scald burn) trauma as effective models of reproducing an ARDS-like syndrome. Pretreatment of these animals with the following neurodepressant drugs: morphine, pentobarbital sodium, haloperidol, diazepam, chlorpromazine, and urethane, resulted in significant attenuation of the evolution of the ARDS-like syndrome, reinforcing the suggestion of a centrally-based origin of such pathologic manifestations.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

The injuries associated with traumatic hip dislocations and their quantitated morbidities were evaluated in this retrospective study of 38 patients. Ninetyfive per cent of the patients had associated injuries severe enough for hospitalization on their own merit. Head, chest, and abdominal injuries were seen most frequently. Central dislocations were associated with the most morbidity, but were not different in distribution of injuries. Using eight different measurements of morbidity, including the Injury Severity Score, hip dislocations, in general, had more morbidity than the national injury rates.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

Over the past decade, nonoperative management of most pediatric blunt abdominal trauma has emerged as accepted practice. It is possible that treatment of associated hollow visceral disruption might be missed or delayed because of this nonoperative approach. In a review of all cases of intestinal perforation from blunt trauma seen over the past 6 years, we found 12 cases of intestinal disruption in more than 600 cases of significant blunt trauma. Child abuse caused eight cases and four were motor vehicle related (MVR). Seven of eight battered children had a delay of more than 48 hours from injury to hospital presentation. Three of four MVR patients had an 18-hour delay from injury to operation.Ten of 12 patients survived. The two children who succumbed were both battered and were moribund and unstable when first seen and failed to respond to aggressive stabilization and surgery. Serial physical examinations, contrast radiographic studies, and peritoneal lavage were the most helpful diagnostic modalities. There were no significant complications and no patient required more than one operation (except for ostomy closure). All surviving patients are well at followup and seven of ten have been followed for more than 3 years; two are not yet 1 year from surgery and one is lost to followup. Several principles have emerged from this review: 1) motor vehicle trauma and child abuse are the major etiologic factors in childhood blunt trauma; 2) accurate and rapid diagnosis of intestinal perforation in children is difficult; 3) recovery in the presence of stable vital signs can be expected, even with the long delays; and 4) abused children must be carefully evaluated for abdominal trauma.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID

摘要:

The sera of 12 patients with mechanical trauma were studied to determine C3 levels and activation. The injury severity score (ISS) was then related to serum C3 levels and activation. It was found that in the immediate postinjury period, serum C3 activation occurred in cases where ISS was ≥ 12. The mean ISS of patients with complement activation was 25.2. In comparison, in patients with nonactivation of complement, the mean ISS was 9.5 (p<0.05). Serum C3 levels were inversely related to ISS. The mean serum C3 level of patients with ISS ≥12 was 73.3 mg% and mean serum C3 level with ISS ≤12 was 109.4 mg%. This difference was again statistically significant (p<0.05). There is indication that complement depletion occurs in the immediate post injury period in moderate to severe injury (ISS ≥ 12). This finding could explain, in part, the immunosuppressive effect of trauma and can be used as a marker to predict possible septic complications.

ISSN:0022-5282    

出版商:OVID    

年代:1986

数据来源: OVID