[show abstract][hide abstract] ABSTRACT: Patients with cervical spine injury may require both anterior cervical spine fusion and tracheostomy, particularly in the setting of associated cervical spinal cord injury (SCI). Despite the close proximity of the two surgical incisions, we postulated that tracheostomy could be safely performed after anterior spine fixation. In addition, we postulated that the severity of motor deficits in patients with cervical spine injury would correlate with the need for tracheostomy.
A retrospective review was undertaken of all adult trauma patients diagnosed with cervical spine fractures or cervical SCI admitted between June 1996 and June 2001 at our university Level I trauma center. Demographic data, severity of neurologic injury based on the classification of the American Spinal Injury Association (ASIA), complications, and use and type of tracheostomy were collected. In the subgroup of patients with unstable cervical spine injury that underwent anterior stabilization and tracheostomy, data regarding timing and technique of these procedures and wound outcomes were also collected. Categorical data were analyzed using chi analysis using Yates correction when appropriate, with p <0.05 considered significant.
During this time period, 275 adult survivors were diagnosed with cervical spinal cord or bony injury. Forty-five percent of patients with SCI (27 of 60) and 14% of patients without SCI (30 of 215) underwent tracheostomy (p <0.001). Moreover, on the basis of the ASIA classification system, 76% of ASIA A and B patients, 38% of ASIA C patients, 23% of ASIA D patients, and 14% of ASIA E patients were treated with tracheostomy (p <0.001). In the subgroup that underwent both anterior spine fixation and tracheostomy (n=17), the median time interval from spine fixation to airway placement was 7 days (interquartile range, 6-10 days), with 71% of these tracheostomies performed percutaneously. No patient developed a wound infection or nonunion as a consequence of tracheostomy placement, and there were no deaths because of complications of either procedure.
These data support the safety of tracheostomy insertion 6 to 10 days after anterior cervical spine fixation, particularly in the presence of cervical SCI. The presence of severe motor neurologic deficits was strongly associated with the use of tracheostomy in patients with cervical spine injury. Percutaneous tracheostomy, which is our technique of choice, may be advantageous in this setting by virtue of creating only a small wound. The optimal timing and use of tracheostomy in patients with cervical spine injury requires further study.
The Journal of trauma 11/2004; 57(4):855-60. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: The severity of abdominal injury is the determining factor for the development of enterocutaneous fistula and ventral hernia after absorbable mesh prosthesis closure (AMPC) for trauma.
We conducted a retrospective analysis of case series that included 140 consecutive trauma patients with AMPC surviving more than 48 hours from October 1, 1989, to March 31, 2000, at a Level I trauma center. The days until abdominal wall reconstruction was used as a measure of exposure of the viscera to the mesh. The abdominal trauma index (ATI) was used as the measure of injury severity. Statistical analysis included t test comparisons, logistic regression analysis, and life-table analysis for hernia development.
Enterocutaneous fistula occurred in 10 patients (7.1%). The ATI (mean, 32.5 +/- 23.1) was the only variable independently associated with fistula formation (p = 0.01). The risk of fistula increased by 4% for each 1 unit increase in ATI (95% confidence interval [CI], 1-7%). One hundred seventeen patients (84%) survived to completion of abdominal wall reconstruction over a mean of 18.9 +/- 22.5 days and 3.6 +/- 1.9 operations. The number of days until abdominal wall reconstruction was the only variable independently associated with ventral hernia development (p < 0.001). The likelihood of fascial closure decreased by 26% (95% CI, 16-44%) per day and the risk of ventral hernia increased by 16% (95% CI, 9-23%) per day. The hernia development rate at 4 years (per life table) was 67% for the total, 13% for patients with delayed fascial closure, and 80% for patients requiring other closure techniques.
Although the severity of abdominal injury is the most important factor for fistula formation, the most important factor for ventral hernia development is the duration of AMPC. Daily interventions, such as mesh tightening, may be necessary to limit ventral hernia in these high-risk patients.
The Journal of trauma 07/2004; 57(1):157-62; discussion 163-3. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: Severely injured patients have been observed to acutely develop ascites; however, the pathogenesis of this rare phenomenon is poorly understood.
To report the factors common among severely injured patients developing ascites and to formulate a hypothesis regarding its origin.
Retrospective review of case series.
We identified 9 injured patients between January 1, 1993, and December 31, 1998, who acutely developed significant amounts of ascites. The mean +/- SD estimated ascites volume was 2.0 +/- 0.8 L. All 9 patients had severe shock and were mechanically ventilated before abdominal decompression for the abdominal compartment syndrome. The mean +/- SD peak inspiratory pressure was 39.0 +/- 5.8 cm H2O. The mean +/- SD volumes of crystalloid and blood product infusion before decompression were 16.1 +/- 10.2 L and 5.2 +/- 4.8 L, respectively, in a mean +/- SD of 17 +/- 15 hours. In comparison, the mean +/- SD volumes of crystalloid and blood product transfusion among 100 contemporary, randomly selected patients undergoing trauma laparotomy were 5.1 +/- 5.5 L and 1.1 +/- 2.5 L, respectively (P<.001). Eight patients had only extra-abdominal injuries, while 1 patient had a combination of extra- and intra-abdominal injuries. Two patients were found to be cirrhotic by liver biopsy, but the other 7 patients had no known preexisting hepatic disease. Eight patients had absorbable mesh temporary abdominal closure, and 1 patient had primary fascial closure. There was persistent ascitic drainage in 5 patients; however, in all but 1 patient with cirrhosis, the drainage did not persist beyond 3 days. Two patients died, 1 of sepsis and the other of a closed head injury.
Common denominators of posttraumatic ascites include shock, massive fluid resuscitation, and elevated intrathoracic pressure. The rapid onset of ascites in the setting of elevated intrathoracic pressure suggests that the patient's ability to clear ascitic fluid is overwhelmed.
Archives of Surgery 07/2003; 138(7):773-6. · 4.10 Impact Factor
[show abstract][hide abstract] ABSTRACT: Management of blunt liver injury is predominantly nonoperative. However, complications occur in 10% to 25% of patients, with half taking place more than 24 hours after injury. Few reports have addressed the management of the new pattern of these delayed complications, which is the objective of this study.
Adult patients admitted to our level one trauma center from 1995 to 2000 with blunt liver injury were identified. Demographic, physiologic and laboratory data, computed tomography (CT) and operative findings, and complications were reviewed.
Blunt liver injury was identified in 192 patients. Thirty-nine patients (20%) underwent immediate celiotomy. The remaining 153 patients were initially managed nonoperatively. Liver-related complications developed in 19 (12%) patients. Fifteen patients underwent delayed celiotomy to treat secondary inflammatory processes, from bile leak (6), hemorrhage (5), and hepatic abscess (1), and to treat abdominal compartment syndrome (2), and decompress hepatic compartment syndrome (1). Although no deaths or complications were directly caused by delayed celiotomy, 2 deaths (11%), occurring early in this series, were attributed to liver-related complications.
These complications, occurring in 12% of patients with liver injuries, may be a consequence of initial nonoperative management. Although these findings do not negate nonoperative management of blunt liver injury, this approach can be hazardous and requires diligence to recognize and treat delayed and potentially fatal complications.
The American Journal of Surgery 06/2003; 185(5):492-7. · 2.52 Impact Factor
[show abstract][hide abstract] ABSTRACT: We report the case of a 55 year old woman who developed abdominal compartment syndrome [ACS] following total gastrectomy for caustic ingestion. Contributing factors for the development of ACS included peritonitis and massive fluid resuscitation for cardiovascular support of septic shock. The adverse cardiovascular and pulmonary effects of intra-abdominal hypertension [IAH] were reversed with pharmacological neuromuscular blockade [NMB]. Surgical decompression of ACS was, therefore, postponed, but the patient required re-operation for intra-abdominal sepsis several days later and subsequently died. Although medical management of ACS with NMB may lower IAH and reverse its negative cardiopulmonary effects, surgical decompression may still be required for definitive treatment.
Asian Journal of Surgery 08/2002; 25(3):244-6. · 0.54 Impact Factor
[show abstract][hide abstract] ABSTRACT: In many critical care units percutaneous dilational tracheotomy (PDT) has become an alternative to open tracheotomy. Although significant tracheal stenosis after PDT has been reported, the exact incidence is unknown. We report our findings on endoscopic laryngotracheoscopy for a group of patients who had undergone PDT more than 6 months before their examination.
We did a retrospective review of 108 trauma patients who underwent PDT at least 6 months before enrollment in the study. Twenty-eight patients were either deceased or ineligible. Participation requests were mailed to the last recorded address of 80 patients. Thirty-four of those patients were contacted by phone, and 14 indicated their willingness to participate. Only 10 patients were able to make it to the clinic for examination. After transorally anesthetizing the hypopharynx and larynx with 4% lidocaine, each patient underwent flexible laryngotracheoscopy. Findings were categorized as normal or tracheal stenosis (<25%, 25% to 50%, or >50%).
The tracheotomy site was virtually undetectable in 5 patients. In 4 patients, a scar was visible at the tracheotomy site, but there was no decrease in cross-sectional area. In 1 patient there was a 25% to 50% stenosis. All patients were completely asymptomatic with regard to airway and voice quality.
One out of 10 patients in our series had a significant but asymptomatic stenosis after PDT. The risk of tracheal stenosis in PDT appears to be the same as that of open tracheotomy.
Otolaryngology Head and Neck Surgery 01/2002; 126(1):58-62. · 1.63 Impact Factor
[show abstract][hide abstract] ABSTRACT: The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy.
To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy.
Prospective analysis of case series from August 1, 1995 to August 31, 1998.
A university-based Level I trauma center.
A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared.
The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had "bull" or "thick" necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral position (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy.
Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.
Critical Care Medicine 11/2000; 28(10):3436-40. · 6.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting.
A retrospective review of trauma patients (August 1996-January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival.
Fifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 +/- 5.4 days (n = 37).
Implementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.
The Journal of trauma 09/2000; 49(2):224-30; discussion 230-1. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: Minimally invasive surgical techniques have gathered tremendous momentum. Most patient benefit is realized in the ambulatory setting. Smaller incisions result in less pain and earlier return to activities. Critically ill patients typically do not benefit from minimally invasive techniques in this manner; however, they do benefit from other aspects of minimally invasive tracheostomy and gastrostomy. Small tracheostomy wounds are associated with reduced wound problems (infection and breakdown). The small stab wounds of minimally invasive gastrostomy are associated with less pain and with an absence of fascial dehiscence. Furthermore, because these procedures are performed easily and safely at the bedside, transport and operating room costs are avoided. Although these procedures are minimally invasive, they are major procedures. Devastating complications can become life-threatening. Attention to detail is required to avoid or respond promptly to complications. In this way, patients receive maximal benefit at minimal risk.
Critical Care Clinics 02/2000; 16(1):113-30. · 1.95 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine the current opinion of American trauma surgeons on the use of the open abdomen to prevent the abdominal compartment syndrome (ACS).
On a questionnaire survey of expert trauma surgeons regarding 12 clinical factors influencing fascial closure at trauma celiotomy, surgeons graded their willingness to close the fascia in various scenarios on a scale of 1 to 5. The impact of six signs of clinical deterioration on willingness to perform abdominal decompression in a patient with postceliotomy elevated intra-abdominal pressure (IAP) was also queried. Of 292 members of the American Association for the Surgery of Trauma active in abdominal trauma management, 248 members (85%) had experience with ACS one or more times in the previous year.
Surgeons' responses to factors found at trauma celiotomy were divided into two distinct categories: factors decreasing willingness to close the fascia, and factors not changing or increasing willingness to close the fascia (p < 0.001). Factors disfavoring fascial closure were pulmonary or hemodynamic deterioration with closure, massive bowel edema, subjectively tight closure, planned reoperation, and packing. Factors not changing or favoring fascial closure were fecal contamination/peritonitis, massive transfusion, hypothermia, multiple abdominal injuries, acidosis, and coagulopathy. Five of the six signs of clinical deterioration increased surgeons' willingness to decompress a patient with elevated IAP (increased O2 requirement, decreased cardiac output, increased acidosis, increased airway pressures, and oliguria). Lowered gastric mucosal pH did not affect willingness. Seventy-one percent of surgeons indicated they would decompress elevated IAP in postceliotomy patient if one or two signs of clinical deterioration were present, but only 14% would decompress a patient for elevated IAP alone.
A majority of expert American trauma surgeons have experience with ACS and would leave the abdomen open if ACS occurred. A majority would reopen a closed abdomen in cases of elevated IAP with signs of clinical deterioration. A minority would leave the abdomen open when there was only a risk of developing ACS.
The Journal of trauma 10/1999; 47(3):509-13; discussion 513-4. · 2.35 Impact Factor
[show abstract][hide abstract] ABSTRACT: A high-pressure liquid chromatography (HPLC) assay for measuring picomole quantities of nitrosothiol in biological samples was developed. The assay utilizes the catalytic reduction of nitrosothiol by mercuric cation (Hg2+). Released nitrogen oxide reacts with sulfanilamide (SA) and N-(1-napthyl)ethylenediamine (NNED) to form a stable azo dye. The azo dye is then separated from N-(1-napthyl)ethylenediamine and quantified by reversed-phase HPLC. In addition to nitrosothiol, nitrite and atmospheric nitrogen oxides are sources of nitrogen oxide that react with the reagents, SA and NNED, to form the azo dye. Therefore, a reference sample, which includes the nitrosothiol sample and all reagents except Hg2+, is utilized for the subtraction of nitrite and atmospheric nitrogen oxides which "contaminate" the nitrosothiol sample and reagents. This method is a sensitive (approximately 3 pmol; approximately 10(-1) microM) and accurate means to measure nitrosothiol concentration in biologic samples.
[show abstract][hide abstract] ABSTRACT: Sepsis is an intriguing pathological condition associated with many complex metabolic and physiological alterations. In this review a novel hypothesis in the pathophysiology of oxygen metabolism during sepsis is explored. It is proposed that the hypermetabolic response to sepsis results from enhanced reactive oxygen generation by phagocytes. Reactive oxygen detoxification by host enzyme systems subsequently leads to alterations in oxidative metabolism. The similarities between the metabolic consequences of reactive oxygen metabolism and the metabolic changes observed during sepsis are outlined. A unified concept is presented to help explain the pathophysiological changes in oxygen metabolism during sepsis.
British Journal of Surgery 08/1995; 82(7):870-6. · 4.84 Impact Factor