Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Treatment of an amebic liver abscess with intravenous metronidazole.

A case of amebic liver abscess was treated in which the abscess was not visualized by hepatic ultrasonography, thus delaying the diagnosis and initiation of appropriate therapy. The abscess was surgically drained because of imminent rupture. Postoperatively, the patient was unable to take oral medications and was successfully treated with intravenously administered metronidazole. Hepatic ultrasonography should not be relied on to rule out liver abscesses. We suggest that parenteral metronidazole should be considered as an alternate therapy to dehydroemetine in patients who are not able to take oral medications.

Congenital rectal stenosis: a sign of a presacral pathologic condition.

Congenital rectal stenosis may be detected in the newborn during the initial physical examination. Failure of conservative therapy (dilatation) should alert the physician to the presence of an associated pathologic condition in the presacral space. Presacral teratoma, anterior sacral meningocele, or bony anomalies may be the underlying extrinsic causes of congenital rectal stenosis. Prompt recognition and appropriate operative management directed at the presacral lesion will relieve obstructive symptoms and minimize morbidity.

Geriatric trauma hospitalization in the United States: a population-based study.

The objective of this study was to characterize elderly trauma hospitalizations nationwide. Elderly Medicare beneficiaries hospitalized in 1989, with trauma as a primary or secondary diagnosis, were studied cross-sectionally. Descriptive analyses and primary mortality rates among different levels of trauma center designation were provided. Estimated relative risks, chi-square tests of association, and multivariate logistic regression were performed. There were 577,193 geriatric trauma patients admitted to 5227 short-stay U.S. hospitals. Level one trauma centers constituted less than 4% of hospitals, but admitted 7.5% of patients, including disproportionate numbers of blacks, males, and patients with more severe primary injury diagnoses. Risk of inpatient death increased with age, male gender, black race, and severity of injury. Level one trauma center patients displayed a 1.49 greater risk for inpatient death even after controlling for confounding variables in a multivariate model. This population-based study provides a detailed national picture of the elderly trauma hospitalization experience, contrasting profiles and outcomes between hospitals with and without designated trauma centers. Although demonstrating higher inpatient mortality rates, Level one trauma centers admit a decidedly different patient population than other hospitals, which is disproportionately younger, black and male and includes the most severely injured geriatric patients. Additional confounding factors should be explored.

The effect of fiberoptic bronchoscopy on cerebral hemodynamics in patients with severe head injury.

STUDY OBJECTIVE: Concerns exist about the effect of flexible fiberoptic bronchoscopy (FFB) on intracranial pressure (ICP). We studied the effect of FFB on cerebral hemodynamics in patients with severe head injury. DESIGN: Prior to FFB, patients were anesthetized and muscle relaxants were given as necessary to eliminate coughing. Comparisons were made of mean arterial pressure (MAP), ICP, and cerebral perfusion pressure (CPP) prior to, during, and after FFB, as well as comparisons of mean cerebral hemodynamic values in an 8-hour period before and after FFB. Observations were made of changes in neurologic status post-FFB. SETTING: Surgical intensive care unit of Level 1 Trauma Center. PATIENT POPULATION: Fifteen patients with severe head injury in whom ICP was monitored and who required FFB for diagnosis of nosocomial pneumonia or treatment of lobar collapse. RESULTS: Pre-FFB ICP averaged 14.3 mm Hg (range, 6 to 26 mm Hg). During FFB, patients experienced a mean increase in ICP of 13.5 mm Hg above basal values (p = 0.0001). At peak ICP, MAP increased from a baseline of 92.3 mm Hg (SD +/- 16.1) to 111.5 mm Hg (+/- 13.9). Mean CPP was 83.7 mm Hg at peak ICP (range, 52 to 121 mm Hg), a 14.0% increase over baseline. The ICP and MAP returned to basal levels following bronchoscopy. No patient had a clinically significant increase in ICP or demonstrated any deterioration in Glasgow Coma Scale score or neurologic examination findings post-FFB. CONCLUSIONS: Although FFB causes an increase in ICP in patients with severe head injury, MAP also rises, and an adequate CPP is maintained. The ICP returns to basal levels after the procedure. When properly performed, FFB does not adversely affect neurologic status in patients with severe head injury.

Acuity of biopsy needles.

The acuities of the conventional biopsy device and of a new design of biopsy needle holder were determined in an in vitro study using fresh pork kidney. A second study, using fresh beef kidney, evaluated the effect of different surface treatments on the acuity of biopsy needles. Only minor clinical differences were found in the acuities of the two types of biopsy needle. It was established, however, that silicone surface treatment and cryogenic treatment of biopsy needles significantly increases their acuity.

Outcome of serious blunt cardiac injury.

BACKGROUND: Although serious blunt cardiac injury (BCI) is usually fatal, patients who reach the hospital alive can have a spectrum of abnormalities. We attempted to define the clinical features that helped identify serious BCI and to evaluate outcome. METHODS: Patients with serious BCI at a level I trauma center were identified during a 3-year period. RESULTS: Twelve patients had serious BCI. Six patients had cardiac arrest, and six had unexplained hypotension. Specific injuries included acute myocardial rupture (two patients); valvular disruption (two); myocardial contusion associated with either cardiac failure (two), complex ventricular arrhythmias (two), or delayed myocardial rupture (one), or present at autopsy (two); and coronary artery thrombosis (one). Seven of eight patients who did not have associated fatal injuries survived. Electrocardiography suggested cardiac injury in all nine patients in whom it was done, and echocardiography was useful to establish the diagnosis in four of five patients. Creatine phosphokinase isoenzyme levels did not distinguish serious injuries. CONCLUSIONS: The outcome of serious blunt cardiac injury can be favorable if patients have signs of life on arrival at the hospital, the signs of injury are recognized promptly, and other injuries do not supervene.

The risk of infection after colon injury.

We reviewed 137 patients with colon injury and applied multiple regression analysis to determine the influence of various parameters on colon-related infection. The complications of intra-abdominal abscess, wound infection, and peristomal abscess occurred in 25% of patients. The mortality rate was 3.6%, and four of five late deaths were caused by infection. Multiple regression analysis identified the amount of blood transfused, patient age, number of associated injuries, and injury to the spleen as significantly associated with infection (p less than 0.05). In the absence of these risk factors, the likelihood of infection is low, suggesting that primary repair or resection and anastomosis are safe methods of management for colon injury. When these factors are present, the risk of infection is high, and colostomy is the preferred method of management.

Necrotizing fasciitis: a preventable disaster.

Twenty-eight cases of necrotizing fasciitis (NF) were treated in 27 patients. Most commonly these infections were caused by perineal disease, operative procedures, and cutaneous ulcers. Associated chronic diseases were present in 21 patients. Postoperative fasciitis occurred when prophylactic antibiotics were omitted or used inappropriately during clean-contaminated or contaminated procedures and when primary skin closure was done in the presence of intra-abdominal contamination. All but four infections were polymicrobial. The overall mortality rate was 73% (20 of 27). Death was due to persistent would sepsis in nine, systemic septic complications despite apparent local control of the infection in nine, and myocardial infarction in two patients. Five of seven survivors had NF limited to one region (leg, perineum, or abdomen). Only 2 of 15 patients survived when more than one debridement was necessary to control ongoing wound necrosis. Eleven of 12 patients who had a delay in treatment for more than 12 hours died. These results suggest that prompt recognition and treatment of NF are essential for survival. The presence of chronic debilitating diseases may contribute to the uncontrollable nature of both local and systemic infection, further emphasizing the need for early diagnosis. Postoperative fasciitis is potentially preventable by strict adherence to the principles for management of contaminated procedures.

Treatment of intra-abdominal infections is appropriate with single-agent or combination antibiotic therapy.

In a prospective, randomized, single-blind trial, we studied 112 adults with intra-abdominal infections and compared antibiotic therapy with cefoxitin plus placebo to therapy with tobramycin plus clindamycin. Seventy-five percent of patients receiving tobramycin-clindamycin and 71% of those receiving cefoxitin-placebo had either shock, bacteremia, malnutrition, alcoholism, rapidly or ultimately fatal underlying disease, infection originating from the distal small bowel or colon, or had had failed therapy before treatment ("high-risk" group). One third of the patients in both groups grew bacteria in the initial culture resistant to the antibiotic regimen used. Ten patients receiving cefoxitin-placebo (17%) and 11 receiving tobramycin-clindamycin (21%) had recurrence of infection or died of infection (clinical failures). Nineteen failures occurred in high-risk patients (p less than 0.05) and 17 were in patients that had antibiotic-resistant bacteria in the initial culture (p less than 0.01). Adverse effects were rare and remitted after antibiotics were stopped. Our results suggest that both cefoxitin and tobramycin-clindamycin are appropriate antibiotic regimens to treat intra-abdominal infections. Clinical failure is more common in high-risk patients and when antibiotic-resistant organisms are isolated from initial cultures.

Management of lateral duodenal fistulas: a study of fourteen cases.

Fourteen patients with lateral duodenal fistulas were treated over an 8-year period. Fistulas occurred after abdominal trauma (7) or as complications of operations for peptic ulcer (4) and biliary tract disease (3). Six patients with posttraumatic fistulas had had a delay of longer than 24 hours in recognition of the initial duodenal injury. Immediate correction of fluid and electrolyte imbalances, aggressive control of infection with surgical drainage and antibiotics, localization of the fistulous discharge, and early total parenteral nutrition were paramount in treatment. Ten patients had fistulas that persisted despite these measures; they required definitive operation. Surgical treatment consisted largely of diversion and decompression of the involved duodenum (8 patients); duodenorrhaphy reinforced with a jejunal serosal patch and resection of the involved bowel was done once each. Definitive operations performed in the presence of uncontrolled infection and with inadequate duodenal decompression were followed by fistula recurrence (3 patients). There was one fistula-related death (a 7% mortality rate). These results suggest that (1) lateral duodenal fistulas have a low rate of spontaneous closure; (2) when maximal nonoperative management fails, operative diversion and decompression of the duodenum can simplify management and reduce the mortality rate; and (3) definitive therapy is best reserved for situations in which infection is controlled.

Admitting service influences the outcomes of patients with small bowel obstruction.

BACKGROUND: Small bowel obstruction (SBO) is a common problem that often requires operation. We tested the hypotheses that patients admitted to a surgical service have improved outcomes and that these outcomes are related to early operation. METHODS: Retrospective review of 281 patients with 336 episodes of SBO between 1992 and 1998 was performed. Parametric and nonparametric analysis was used as appropriate. RESULTS: There were 222 admissions to a surgical service and 114 admissions to a medical service. Patient characteristics were similar between groups. Eighty-seven percent of patients had a previous abdominal or pelvic operation. There were 211 patients (217 admissions) who required operation. Operated patients admitted to the surgical service had a shorter preoperative (2.7 vs 6.3 days, P <.01) and overall length of stay (LOS) (17.9 vs 22.8 days, P <.0001). There was no difference in time to resumption of diet between groups. The number of previous admissions or operations did not affect the need for operative intervention. Unoperated patients admitted to a medical service had a shorter time to resumption of diet (3.1 vs 4.3 days) and LOS (4.8 vs 7.2 days, both P <.05) than the surgical service group. Operative mortality was 3.4%. The likelihood of developing a complication was related to the occurrence of an enterotomy (n = 21, odds ratio = 2.69; 95% confidence interval [CI]: 1.1-6.7, P =.014) or the need for bowel resection (odds ratio = 1.97; 95% CI: 1.2-3.5, P =.02). The occurrence of a complication resulted in a 46% increase in LOS (P <.0001). Patients operated on within 24 hours of admission had a decreased LOS (P <.05) and mortality, with no difference in the occurrence of postoperative complications. CONCLUSIONS: Patients with SBO who require operation benefit from a shorter time to operation and reduced LOS when admitted to a surgical service. Early operation is associated with a reduction in mortality, and avoidance of enterotomy decreases the risk of complications.

Inguinal hernia repair before and after prostatic resection.

From 1976 through 1981, 864 men had inguinal hernia repairs and 328 had prostatic resections at our Veterans Administration Hospital. Forty-four patients had symptomatic prostatic obstruction that required either transurethral or open prostatic resection within 12 months of hernia repair. Twenty-seven patients had prostatectomy prior to hernia repair, 16 had hernia repair before prostatic resection, and one had simultaneous procedures. There were no urinary tract infections (UTIs) after hernia repair in patients who had had prostatectomy first, while five patients who had hernia repair before prostatectomy developed UTI after hernia repair (P less than 0.01). The incidence of UTI after hernia repair correlated with the need for and duration of bladder catheterization as a result of prostatic obstruction. Complications after prostatectomy were similar regardless of the order of operation. There were no episodes of incarceration or strangulation in patients awaiting hernia repair after prostatectomy. These results suggest that, when an inguinal hernia and symptomatic prostatic obstruction occur together, the performance of prostectomy before hernia repair lowers the risk of morbidity by decreasing the incidence of UTI after hernia repair. This approach does not expose the patient to any additional risk related to the inguinal hernia.

Factors influencing the risk of early and late serious infection in adults after splenectomy for trauma.

We reviewed the clinical course of 245 adults who underwent splenectomy for trauma to assess the risk of both early and late serious infection. Twenty-one patients (9%) had an early serious infection (sepsis) during hospitalization for splenectomy. The mortality rate was 62% in patients with early sepsis, and encapsulated bacteria were isolated from the blood of 43% of patients with sepsis. Only one of 58 patients with isolated splenic injury had sepsis (2%), and the risk of early sepsis increased when three or more concomitant injuries were present (p less than 0.05). Stepwise multiple regression analysis revealed that patients with injuries to the pancreas, colon, or central nervous system or with extremity fractures had an increased risk of sepsis (p less than 0.05). The risk of sepsis was not influenced by age, the type of injury, delay in operation, use of drains, or other individual injuries. Sufficient information was available to assess the risk of late serious infection for 140 surviving patients (63%). Follow-up ranged from 2 to 277 months. Three late infections occurred at 2, 8, and 15 years after splenectomy; two were due to Streptococcus pneumoniae. None of these patients died. There were no identifiable factors influencing the risk of late infection. These results suggest that the risk of early serious infection in adults after splenectomy for trauma is low when isolated splenic injury is present but that this risk is increased by both the degree of injury and the presence of certain associated injuries. Encapsulated bacteria are frequent pathogens in both early and late infections. The mortality rate related to an early septic episode is high, but the risk of late serious infection is low and is not related to identifiable factors that decrease host defenses.

Lithium effects on dispersed bovine parathyroid cells grown in tissue culture.

It is not clear whether hypercalcemia and hyperparathyroidism associated with lithium therapy are the result of an unmasking of preexisting disease or a direct effect of lithium on the parathyroid glands. To investigate this phenomenon, parathyroid hormone (PTH) secretion and cytosolic calcium concentrations [( Ca]i) were measured in normal and lithium-treated dispersed bovine parathyroid cells grown in tissue culture and incubated with varying concentrations of extracellular calcium [( Ca]e) (0.5 to 2.5 mmol/L). Results indicate that lithium has two effects on parathyroid secretory response: (1) a decrease in low calcium-stimulated PTH release and (2) a potentiation of PTH release at physiologic concentrations of extracellular calcium. [Ca]i was assessed by use of fura-2, a calcium-sensitive fluorescent indicator. Resting [Ca]i levels were unaffected by lithium (103 +/- 13 nmol/L in controls vs 101 +/- 5 nmol/l in lithium-treated cells, mean +/- SE). Subsequent increases in [Ca]i in response to increases in [Ca]e were significantly less in lithium-treated cells, with no difference at maximal [Ca]e. Increases in [Ca]i in response to a submaximal concentration of extracellular magnesium were also blunted in cells pretreated with lithium. In conclusion, our data suggest that, at physiologic calcium concentrations, lithium decreases parathyroid cell sensitivity to changes in [Ca]e, reducing [Ca]i levels and increasing PTH secretory response.

Optimizing the management of blunt splenic injury in adults and children.

BACKGROUND: The treatment for splenic injury is evolving to an increased use of nonoperative management. We studied patients with blunt injury to the spleen to determine the overall success with splenic salvage and the reason that adults and children have different outcomes. METHODS: Patient records were reviewed retrospectively for information and parameters that may influence outcome. Patients were categorized by age and type of management. RESULTS: Two hundred sixty-seven patients (222 adults; 45 children < 16 years old) with blunt splenic trauma were treated over a 7.5-year period. Adults had a significantly higher injury severity score (ISS; 27.2 +/- 0.9 vs 19.9 +/- 2.0; P < .05), splenic injury score (SIS; 2.8 +/- 0.1 vs 2.3 +/- 0.1; P < .01), and mortality rate (11.7% vs 2.2%; P < .05) compared with children. Eighty-six adults and 3 children had emergent operation; 23 patients had splenorrhaphy. Nonoperative management was selected initially in 178 patients; 83% (105 adults and 42 children) were treated successfully. The ISS and SIS of patients in whom nonoperative management failed were different from those patients in whom treatment was successful (ISS, 27.5 +/- 2.1 vs 20.6 +/- 1.0; SIS, 3.6 +/- 0.2 vs 2.1 +/- 0.1; P < .05) but were similar to those patients who needed initial emergent operation. Adults and children who had successful nonoperative management had similar ISSs (21.4 +/- 1.1 vs 18.4 +/- 2.0) and SISs (2.0 +/- 0.1 vs 2.3 +/- 0.1). Overall splenic salvage was achieved in 64% of patients (57% of adults and 96 % of children). Salvage increased from 50% to 85% during the study period. CONCLUSIONS: Splenic preservation is possible in most adults and children with blunt injury with the appropriate use of both operative salvage and nonoperative treatment. The higher salvage rate and decreased need for operation in children is due to their lower severity of overall injury and splenic injury. Operative salvage has become less common in adults because more patients are selected for nonoperative management.

Antibiotic prophylaxis for injured patients.

Infection is the major cause of serious complication in injured patients. This article addresses antibiotic use in the injured patient and clarifies the limitations of antimicrobials in the prevention of infection.

Gas-liquid chromatography for rapid diagnosis of intra-abdominal infection.

We assessed the usefulness of gas-liquid chromatography in detecting fecal anaerobes in patients with suspected intra-abdominal infection related to the lower gastrointestinal tract. Twenty-five (89%) of 28 cultures with and five (26%) of 19 cultures without anaerobic isolates were positive for succinate. Data analysis showed that Bacteroides but not Enterobacteriaceae organisms were responsible for succinate production. Volatile acids other than acetate (VAs) were present in 16 (57%) of 28 culture-positive and one (7%) of 14 culture-negative specimens. Sixteen (94%) of 17 VA-positive and seven (28%) of 25 VA-negative specimens had anaerobic isolates shown by culture. The presence of certain VAs was associated with the recovery of specific groups of anaerobic bacteria. The presence of succinate or VA in intra-abdominal fluid provides a specific, useful method for the rapid detection of fecal anaerobes in patients with intra-abdominal infections.

Interferon gamma and tumor necrosis factor alpha. Use in gram-negative infection after shock.

Shock increases the propensity to develop infection after injury or operation. This study evaluated the effect of cefoxitin, interferon gamma (INF-gamma), and tumor necrosis factor alpha (TNF-alpha) on the development of a polymicrobial soft-tissue infection. After sham operation or hemorrhagic shock and resuscitation, Sprague-Dawley rats were inoculated with 1 x 10(8) Escherichia coli and 1 x 10(9) Bacteroides fragilis in a 5% fecal suspension. Animals received either no treatment, cefoxitin, recombinant rat INF-gamma, recombinant human TNF-alpha, or cefoxitin/cytokine combinations. Cefoxitin reduced abscess size by 57% in animals without shock but only by 26% after shock. Although neither INF-gamma nor TNF-alpha alone had a salutary effect when given with cefoxitin in animals after shock, INF-gamma and TNF-alpha reduced abscess size by 50% and 55%, respectively. These results suggest that INF-gamma and TNF-alpha may be useful to reduce the severity of mixed gram-negative infections after shock with bacterial contamination.

The comparative clearance rates of the pleural and peritoneal cavities.

We compared the rates of bacterial clearance from the pleural and peritoneal cavities of rats after contamination with 1 x 10(6) live Escherichia coli. Pleural clearance was enhanced beginning at 30 minutes after injection and extended to at least six hours. At 24 hours, the clearance was similar for both the pleural and peritoneal groups. Blood and organ bacterial cultures were similar between these two groups. White blood cell populations were similar at rest, but there was a greater increase in the leukocyte population in the pleural cavity six hours after E coli stimulation. We postulate that the increased clearance of E coli from the pleural cavity may be due to differences in lymphatic absorption, recruitment of leukocytes, or fibrin trapping of bacteria.