Results of AlloDerm use in abdominal hernia repair.

BACKGROUND: AlloDerm (decellularized human cadaveric dermis) is increasingly being used for tissue reconstruction and hernia repairs. This article presents the results of AlloDerm use in treating abdominal wall hernias by analyzing all patients who underwent repair with AlloDerm at our institution. METHODS: A series of 70 consecutive patients starting in October 2003 with abdominal wall hernia repair using AlloDerm was studied. This study began as a retrospective chart review, which included subsequent postoperative follow-up. SPSS version 11.5 was used for statistical analysis, and parametric tests were conducted. Various technical variables (type of AlloDerm placement, mesh-suture technique, suture type) and nontechnical variables (steroids use, obesity, smoking status, diabetes, prior surgeries, number of comorbidities) were evaluated. RESULTS: Of 70 study patients, 31 were men and 39 were women, with a mean age of 58 (range 25-88) years. Fifty-six patients (80%) had no complications, whereas 14 (20%) suffered one or more complications. Of those patients with complications, there was one rejection, two infections, and 14 hernia recurrences. The overall complication rate was 24%. Of patients with hernia recurrences, one had the initial repair with AlloDerm implant of <1.8-mm thickness (thick) and 13 patients had their initial repair with AlloDerm implant of >1.8-mm thickness (ultrathick). The 14 patients with recurrences include three who had a prior AlloDerm repair with ultrathick implant. Two of these three patients reported abdominal wall protrusion, and one had a recurrence between two pieces of AlloDerm used in the initial repair. Of these 14 patients, nine had subsequent repair of their recurrence with synthetic mesh, and four had subsequent repair with AlloDerm with satisfactory outcomes; one patient was yet to have a repair at the time of this paper. Recurrence rates with ultrathick and thick AlloDerm were 23% and 6%, respectively. None of the patients who were on steroid therapy had complications. Mesh-suture technique had no effect on recurrence. Type of placement was positively correlated with infection (Pearson's R 0.575, p 0.05), showing that onlay mesh is better than underlay/interpositional mesh in having a lower infection rate. Diabetes was associated with mesh infection (Pearson's R 0.548, p 0.05), and redo hernia repair was associated with longer length of hospital stay (LOS). The average number of comorbidities was five for the series. LOS positively correlated with presence of comorbidities. CONCLUSIONS: Early results in repair of abdominal hernia with AlloDerm appear to have a complication rate of 24%. Recurrence is the most common complication. Thinner AlloDerm use has better outcomes with less recurrence. Careful analysis regarding the technical aspects and presence of comorbidities may be explored to improve the present outcomes to prevent recurrences.

The trauma score: a simple method to evaluate quality of care.

In recent years, trauma care delivery has come under close scrutiny from within and outside the medical profession. With the development and designation of trauma centers, two problems have become evident. First is a reliable, simple means of triaging patients to the appropriate facility. The second problem is evaluation of the quality of care provided. The assessment of results is difficult due to the large number of variables, such as mechanisms of injury, anatomic sites of injury, and comorbidity found in these patients and has led to the use of complex statistical analysis. The trauma score, originally developed as a triage tool, has also proven to be a reliable, simple means of assessing the quality of care. The expected survival for each trauma score value has been established and each hospital's or surgeon's results can, therefore, be evaluated against that standard. A deviation from the expected survival curve may or may not be clinically significant as determined by careful review of those patients. From July 1, 1985 through June 30, 1986, 495 patients were admitted to the trauma service at the Medical College of Georgia. All patients were given a trauma score on arrival to the emergency department. The trauma score can be used as a quality assurance tool by any physician or hospital providing trauma services as will be demonstrated by analyzing our data.

Bilaminate synthetic dressing for partial thickness burns. Lack of cost reduction for inpatient care.

Forty-nine cases of second degree burns initially treated as inpatients from April 1984 through December 1987 are reviewed. Thirty-four patients were treated with bilaminate synthetic dressing (Biobrane) application, while 15 were treated with a topical antimicrobial, usually silver sulfadiazine. The burns ranged from 1 to 25 per cent total body surface area and were comparable in both groups. The mean age in each group was 30 years. Thirty patients were successfully treated with Biobrane, and their average hospital stay was 9.1 +/- 5.4 days compared with 9.2 +/- 8.6 days for the topically treated group. The mean hospital cost for dressings and supplies for the Biobrane group was $360 +/- $90 compared with $310 +/- $190 for the topical group. Four patients (12%) required Biobrane removal during their hospitalization, one due to increasing burn depth and three due to purulent fluid collections beneath the Biobrane. These burns were subsequently treated with topical antimicrobial agents and healed primarily. The mean total hospital stay for this group was 18.0 +/- 11.9 days with the costs being much higher secondary to the initial cost of the Biobrane, the costs associated with topical antibiotic therapy, and extended hospital stay. Although there was a decrease in nursing time and a subjective decrease in patient discomfort associated with using synthetic dressing, no benefit was found in either decreasing hospital stay or total cost of hospitalization and supplies used for inpatients treated at this institution.

Acute airway management. Role of cricothyroidotomy.

Thirty-four cases of emergency cricothyroidotomy performed formed from September 1984 through January 1988 are reviewed. Thirty-one of the cases were required out of 2,200 acute-trauma patients. The indication for cricothyroidotomy was inability to establish an airway by intubation usually in a situation of possible neck injury or severe facial trauma. Fourteen of the patients died as a result of their injuries, 13 of these in the first several hours after injury. The 20 surviving patients are studied in two groups: eleven patients whose cricothyroidotomy remained in place until decannulation (group I) and nine patients who underwent tracheostomy subsequent to cricothyroidotomy (group II). Clinical follow-up included physical examination in all survivors and endoscopic evaluation in twelve patients. Three minor complications were discovered in each of the two groups and two major complications were noted in group II. The major complications included a case of tracheal stomal stenosis requiring tracheal resection and a case of partially obstructing tracheal granulation tissue requiring endoscopic resection. This study supports the use of emergency cricothyroidotomy in situations in which intubation is not successful or thought to be safe. Data is also presented that suggests that tracheostomy subsequent to emergency cricothyroidotomy does not necessarily reduce airway-related morbidity in these patients.

Trauma victims: field triage guidelines.

Trauma kills more Americans from age 1 to 34 than all diseases combined. Until recently, trauma care in the United States was delivered in a nonorganized, nonintegrated fashion, with trauma victims being transported to the medical facility closest to the scene of the accident. Many recent studies confirm an unacceptably high incidence--up to 75% in some studies--of preventable deaths in trauma victims treated under the nearest hospital system. This has resulted in the development of specialized trauma centers. The concept of a regional trauma center requires restrictive medical practice in which a limited number of hospitals and physicians provide care for those 5% to 12% of patients who are critically injured. The decision on whether to take a patient to the closest hospital or to the regional trauma center is a form of triage, with far-reaching consequences medically, ethically, and financially. Various triage instruments have been developed to try to identify those patients who would benefit from the resources of a trauma center, and to avoid overcrowding those centers with patients having less serious injuries. These triage tools are based on a combination of mechanism of injury, anatomic criteria, physiologic criteria, and co-morbidity factors.

Mechanisms of protection in acute renal failure.

It has been generally accepted that renal ischemia, tubular obstruction, and the back-leak of glomerular filtrate are major factors involved in the pathogenesis of acute renal failure (ARF). Experimental studies have been conducted using various therapeutic measures to eliminate the adverse effects of these factors and thereby preserve renal function. These therapeutic measures include the use of pharmacologic agents such as vasodilators, diuretics, and calcium channel blockers, and saline or Ringer's volume expansion. Though experimental results appear encouraging, attempts to prevent ARF in humans have been generally unsuccessful. The administration of furosemide, however, has resulted in the conversion of oliguric ARF to nonoliguric ARF in some patients. With the development of experimental ARF models in which renal function is preserved, such as our splenectomized model, the mechanism(s) involved in the pathogenesis of ARF can be further delineated. Thus, more effective therapeutic interventions may be available for the treatment and prevention of human ARF.

Tracheostomy in the intensive care unit: a safe alternative to the operating room.

Severely injured patients frequently require endotracheal intubation, either by the nasotracheal (NT) or orotracheal (OT) route, for airway control and/or ventilatory support. If intubation is required for more than two to four weeks, an elective tracheostomy is usually indicated. Transferring these patients to the operating room is difficult, and it impairs their continued monitoring and care. Over a period of 48 months at our institution, 74 patients had tracheostomy done in the intensive care unit (ICU) by a surgical resident (PG2 level) assisted by a chief resident or attending faculty member. Local anesthesia was supplemented with intravenous sedatives, and operating room technique was used, with complete surgical instrument pack and adequate lighting. There were no deaths from the procedure. There were no complications specifically attributed to the performance of tracheostomy in the ICU, though one patient each suffered tracheitis, tracheostomy tube dislodgement, and tracheomalacia. Tracheostomy in the ICU avoids the risks of moving these patients with all their monitoring and infusion lines, and saves operating room time and charges. Trained surgical personnel using adequate instruments and lighting can safely perform a tracheostomy in the intensive care unit.

Air evacuation of thermally injured patients: principles of treatment and results.

During the 12-month period January through December 1978 148 thermally injured patients were aeromedically transported to our burn unit by either helicopter or fixed-wing aircraft. One hundred twenty-nine patients (87%) were evacuated within 48 hours of injury. Treatment by a general surgeon and ICU nurse sent to the local hospital consisted of: insertion of 87 catheters, immediate pulmonary care in 20 patients, escharotomy in six patients, and adjustment of intravenous fluid administration in 42 patients. Thirty-six per cent of patients were considered too unstable clinically to transport until therapy had been rendered. No patients died in flight, and six per cent of all patients aeromedically evacuated were considered clinically unstable when they arrived on the burn ward. Overall mortality was not adversely affected by transportation of acutely burned patients over long distances.

Diagnosis and treatment of cannula-related intravenous sepsis in burn patients.

Suppurative thrombophlebitis was identified in 193 (4.2%) of 4,636 burn patients treated during the years 1960-1978. A single vein was involved in 162 patients, while 31 had multiple vein involvement. The distribution and incidence of suppuration in individual veins reflected the frequency of cannulation, with an increase in the use of central vein cannulae, during the last 10 years, paralleled by a rise in central vein suppuration. The infecting organisms reflected the patients' surface flora. Local signs of infection were present in less than half (35%) of the patients and recovery of a positive blood culture in a clinically septic patient was the most frequent clinical presentation prompting exploration of previously cannulated veins. Pathogenetic mechanisms are identified and criteria defined for determining the extent of excision necessary. Ninety veins were excised from 75 patients during the 1969-1978 period, of whom 30 (40%) survived (three other patients with antibiotic treated central vein disease also survived). Treatment failure was attributable to inadequate excision in 12 patients, suppuration within another unexcised vein in eight patients, hematogenous dissemination of infection in five patients in whom the local disease had been eradicated, and other disease in 20 patients. Prophylaxis must emphasize limited duration of cannulation. Timely diagnosis and treatment can effect maximum salvage and reduce the likelihood of systemic dissemination.

Hypertonic sodium resuscitation is associated with renal failure and death.

OBJECTIVE: The use of hypertonic sodium solutions (HSS) and lactated Ringer's (LR) solution in the resuscitation of patients with major burns was compared. SUMMARY BACKGROUND DATA: Hypertonic sodium solutions have been recommended for burn resuscitation to reduce the large total volumes required with isotonic LR solution and their attendant complications. METHODS: To evaluate the efficacy of this therapy in our adult burn center, we resuscitated 65 consecutive patients with HSS (290 mEq/L Na) between July 1991 and June 1993 and compared them with 109 burn patients resuscitated with LR (130 mEq/L Na) between July 1986 and June 1988 (LR-1). A subsequent 39 patients were resuscitated with LR between September 1993 and August 1994 (LR-2). RESULTS: Patients receiving hypertonic sodium solutions versus LR-1 were similar with respect to age (46.0 vs. 43.6 years), total burn size (39.2% vs. 39.9%), incidence of inhalation injury (41.5% vs. 47.7%), and predicted mortality (34.6% vs. 30.2%). Total resuscitation volumes during the first 24 hours were lower among patients treated with HSS than those in the LR-1 group (3.9 +/- 0.3 vs. 5.3 +/- 0.2 mL/kg/% body surface area [BSA], p < 0.05). After 48 hours, however, cumulative fluid loads were similar (6.6 +/- 0.6 vs. 7.5 +/- 0.3 mL/kg/%BSA), and total sodium load was greater with the HSS group (1.3 +/- 0.1 vs. 0.9 +/- 0.1 mEq/kg/%BSA, p < 0.002). During the first 3 days after burn, serum sodium concentrations were moderately elevated in the HSS patients (153 +/- 2 vs. 135 +/- 1 mEq/L, p < 0.001). Patients resuscitated with HSS had a fourfold increase in renal failure (40.0 vs. 10.1%, p < 0.001) and twice the mortality of LR-1 patients (53.8 vs. 26.6%, p < 0.001). In patients resuscitated with HSS, renal failure was an independent risk factor (p < 0.001, by logistic regression). Analysis of these results prompted a return to LR resuscitation (LR-2). Age (41.6 +/- 2.9 years), burn size (37.8 +/- 3.9 %BSA), and incidence of inhalation injury (51.3%) were similar to the earlier groups. Total sodium load was less among LR-2 patients than the HSS group (0.7 +/- 0.1 mEq/kg/%BSA, p < 0.01), but similar to the LR-1 patients. Renal failure developed in only 15.4%, and 33.3% died, similar to the LR-1 group and significantly lower than patients treated with HSS (p < 0.001 and p < 0.05, respectively). CONCLUSION: Hypertonic sodium solution resuscitation of burn patients did not reduce the total resuscitation volume required. Furthermore, it was associated with an increased incidence of renal failure and death. The use of HSS for burn resuscitation may be ill advised.

Percutaneous peritoneal lavage in blunt trauma patients: a safe and accurate diagnostic method.

We reviewed the records of 395 patients seen from January 1983 through May 1988, who after sustaining blunt thoracoabdominal trauma had diagnostic peritoneal lavage (DPL) performed percutaneously by the Seldinger wire technique of Lazarus and Nelson. The test was considered grossly positive if 10 cc of blood were aspirated from the catheter immediately after its insertion into the peritoneal cavity. Microscopic criteria for positivity included more than 100,000 RBC or 500 WBC/cc of lavage return, elevated amylase or bilirubin, or the presence of vegetable fibers or bacteria. Seventy-two (18%) of the patients were true positives and 315 (80%) were true negatives. There were four false positives (1.3%) and one false negative (0.2%), giving the test a sensitivity of 99% and a specificity of 98%. Complications occurred in three patients, for a rate of 0.8%, and included catheter insertion into a large ovarian dermoid cyst, needle perforation of the ileum, and needle perforation of the sigmoid colon. This technique of DPL can consistently be performed much more rapidly than the open method. Therefore we conclude that percutaneous DPL is as accurate as, as safe as, and quicker than open DPL for determining intra-abdominal injury in blunt trauma patients.

Effect of cardiotonic and vasoactive drugs on transmural flow distribution and ventricular volume in the fibrillating heart on cardiopulmonary bypass.

Subendocardial hemorrhagic necrosis in an important cause of death following cardiopulmonary bypass. The transmural distribution of flow across the left ventricle (LV), septum (SP), and right ventricle (RV) is a complex interaction of vascular resistance and myocardial compressive resistance. We studied the change in transmural blood flow in LV, SP, and RV, and left ventricular volume, following administration of cardiotonic and vasoactive drugs in the fibrillating heart. The drugs studied included calcium with and without ATP-induced vasodilation, isoproterenol, epinephrine, angiotensin, and ouabain. Calcium produced underperfusion of LV subendocardium with or without previous ATP vasodilation. Isoproterenol also caused underperfusion of LV subendocardium. Both calcium and isoproterenol decreased ventricular volume. Angiotensin increased resistance in the subepicardium and increased flow in the subendocardium, with no change in ventricular volume. Epinephrine and ouabain caused no consistent changes in transmural flow. The decreased ventricular volume produced by calcium and isoproterenol restricts flow in the subendocardium because of increased compressive resistance. Increased subendocardial flow with angiotensin indicates that subepicardial vasodilation in the fibrillating heart causes epicardial "steal," which contributes to subendocardial ischemia.