In emergently ventilated trauma patients, low end-tidal CO2 and low cardiac output are associated and correlate with hemodynamic instability, hemorrhage, abnormal pupils, and death.

BACKGROUND: In a smaller experience, the authors previously demonstrated that end-tidal carbon dioxide (PetCO2) and cardiac output (CO) had a positive association in emergently intubated trauma patients during Emergency Department resuscitation. The aim of this larger study was to reassess the relationship of PetCO2 with CO and identify patient risk-conditions influencing PetCO2 and CO values. METHODS: The investigation consists of acutely injured trauma patients requiring emergency tracheal intubation. The study focuses on the prospective collection of PetCO2 and noninvasive CO monitor (NICOM®) values in the Emergency Department. RESULTS: From the end of March through August 2011, 73 patients had 318 pairs of PetCO2 (mm Hg) and CO (L/min.) values. Mean data included Injury Severity Score (ISS) ≥15 in 65.2%, Glasgow Coma Score of 6.4 ± 4.6, hypotension in 19.0%, and death in 34.3%. With PetCO2 ≤ 25 (15.9 ± 8.0), systolic blood pressure was 77.0 ± 69, CO was 3.2 ± 3.0, cardiac arrest was 60.4%, and mortality was 84.9%. During hypotension, CO was lower with major blood loss (1.9), than without major loss (5.0; P = 0.0008). Low PetCO2 was associated with low CO (P < 0.0001). Low PetCO2 was associated (P ≤ 0.0012) with ISS > 20, hypotension, bradycardia, major blood loss, abnormal pupils, cardiac arrest, and death. Low CO was associated (P ≤ 0.0059) with ISS > 20, hypotension, bradycardia, major blood loss, abnormal pupils, cardiac arrest, and death. CONCLUSIONS: During emergency department resuscitation, a decline in PetCO2 correlates with decreases in noninvasive CO in emergently intubated trauma patients. Decreasing PetCO2 and declining NICOM CO are associated with hemodynamic instability, hemorrhage, abnormal pupils, and death. The study indicates that NICOM CO values are clinically discriminate and have physiologic validity.

Modified rotational bowel vaginoplasty after total pelvic exenteration.

Vaginal reconstructive options commonly include the use of split-thickness skin grafts or intestinal conduits. When a colonic segment is chosen, the sigmoid colon is favored because of its location, size, and durability. When circumstances preclude the use of sigmoid colon and a colonic conduit is preferred, creative means of mobilization are required. This article describes a case and technique utilizing the descending colon in a tension-free vaginoplasty.

Evaluation of mechlorethamine, vinblastine, procarbazine, and prednisone for the treatment of resistant multicentric canine lymphoma.

Multi-agent chemotherapy successfully induces remission in most naïve, high-grade canine lymphoma patients; however, disease recurrence is common. MOPP (mechlorethamine, vincristine, procarbazine, and prednisone) is an effective rescue protocol used to re-induce remission, but is associated with gastrointestinal toxicity and can be a less desirable option for patients that previously failed vincristine-containing protocols. Therefore, alternative members of the vinca alkaloid family, such as vinblastine, could be potentially advantageous as substitutes for vincristine to reduce gastrointestinal toxicity and chemoresistance. The objective of this study was to report the clinical outcomes and toxicity of 36 dogs with relapsed or refractory multicentric lymphoma treated with a modified MOPP protocol whereby vincristine was replaced with vinblastine (MVPP). The overall response rate to MVPP was 25% with a median progression free survival of 15 days and a median overall survival of 45 days. MVPP at the prescribed doses resulted in modest and transient clinical benefit, but was well tolerated with no treatment delays or hospitalizations secondary to side effects. Given the minimal toxicity, dose intensification could be considered to improve clinical responses.

Abdominal ventral hernia repair with current biological prostheses: an experimental large animal model.

Biologic prostheses have emerged to address the limitations of synthetic materials for ventral hernia repairs; however, they lack experimental comparative data. Fifteen swine were randomly assigned to 1 of 3 bioprosthetic groups (DermaMatrix, AlloDerm, and Permacol) after creation of a full thickness ventral fascial defect. At 15 weeks, host incorporation, hernia recurrence, adhesion formation, neovascularization, inflammation, and biomechanical properties were assessed. No animals had hernia recurrence or eventration. DermaMatrix and Alloderm implants demonstrated more adhesions, greater inflammatory infiltration, and more longitudinal laxity, but near identical neovascularization and tensile strength to Permacol. We found that porcine acellular dermal products (Permacol) contain following essential properties of an ideal ventral hernia repair material: low inflammation, less elastin and stretch, lower adhesion rates and cost, and more contracture. The addition of lower cost xenogeneic acellular dermal products to the repertoire of available acellular dermal products demonstrates promise, but requires long-term clinical studies to verify advantages and efficacy.

Prospective Evaluation of Feline Sourced Platelet-Rich Plasma Using Centrifuge-Based Systems.

Objective: To evaluate the hematologic components of platelet-rich plasma (PRP) generated using feline blood with two commercially available centrifuge-based systems,. Materials and methods: Twenty healthy adult cats were enrolled in this prospective study from November 2018 to January 2019. Feline blood samples were obtained for analysis of whole blood (WB) cellular components and preparation of PRP product. PRP was prepared using two commercial systems and complete blood count (CBC) testing was performed on both WB and PRP samples. The cellular composition of the PRP product was compared to the WB sample for each patient. Results: Both systems showed significant decrease of median RBC concentration in PRP products compared to WB samples (P = 0.002 for both systems). System 1 significantly decreased median WBC concentration (P = 0.002). System 2 decreased WBC concentration, though statistical significance was not reached (P = 0.63). Median platelet concentration was decreased by 3% using System 1, and increased by 187% using System 2. Platelet aggregation presented a challenge with 8/20 (40%) of samples demonstrating platelet aggregation. Clinical relevance: Commercial systems available for generation of PRP may be useful for creating a feline sourced product and in this study showed promise in decreasing RBC and WBC concentration. Neither system tested achieved 2-5 times platelet concentration from baseline. Platelet aggregation presented a significant obstacle to reliable generation of PRP products using feline blood. This treatment modality may be particularly beneficial for feline patients with osteoarthritis and soft tissue injuries, though first characterizing the PRP product made using feline blood is critical to validate its use in further clinical studies.

Sample Size Determination for Evaluation of Time Domain Heart Rate Variability Indices in Canine Lameness.

Heart rate variability (HRV) is a physiologic phenomenon that occurs due to changing autonomic tone resulting in variable RR intervals. A reduction in HRV is used as an index of pain in neonatal human patients. Objective measures of pain would be valuable in the evaluation of canine patients and assessment of response to pain management strategies. We hypothesized that dogs with diseases associated with discomfort (osteoarthritis and bone neoplasia) would have reduced HRV compared with normal, healthy dogs. The aim of the study was to calculate the sample size necessary to investigate this hypothesis. Seventeen dogs from the Ryan Veterinary Hospital of the University of Pennsylvania patient population or owned by Ryan Veterinary Hospital of the University of Pennsylvania staff were enrolled in this single-blind, prospective pilot study. A 30 min electrocardiogram (ECG) was obtained from each dog using an ambulatory electrocardiographic monitor. All ECGs were obtained between 10 a.m. and 2 p.m. ECGs were analyzed and time-domain HRV indices computed. Sample size calculations suggest that 207 dogs would be necessary to ascertain if HRV is reduced in dogs experiencing discomfort or pain (50 in the arthritis group, 79 in the bone cancer group, and 78 in the control group).

Emergency department noninvasive (NICOM) cardiac outputs are associated with trauma activation, patient injury severity and host conditions and mortality.

BACKGROUND: Anoninvasive cardiac output (CO) monitor (NICOM), using Bioreactance technology, has been validated in several nontrauma patient studies. We hypothesized that NICOM CO would have more significant associations with clinical conditions than would systolic blood pressure (sBP). METHODS: This is a prospective observational study of consecutive trauma activation patients during the first 10 to 60 minutes after emergency department arrival. RESULTS: Analysis includes 270 consecutive trauma activation patients with 1,568 observations. CO was decreased (p ≤ 0.002) with major blood loss, hypotension, red blood cell transfusion, Injury Severity Score (ISS) higher than 20, low PetCO2, abnormal pupils, elderly, preexisting conditions, low body surface area level, females, hypothermia, and death. CO was increased (p < 0.0001) with base deficit, ethanol positivity, and illicit drug positivity. The sBP was decreased (p ≤ 0.0005) with major blood loss, red blood cell transfusion, low PetCO2, low body surface area level, and illicit drug positivity. The sBP was increased (p e 0.01) with ISS higher than 20, elderly, and preexisting conditions. Total significant condition associations were CO 83% (15 of 18 patients) and sBP 47% (8 of 17 patients; p = 0.03). In hypotensive patients, CO was lower with major blood loss (3.3 ± 2.1 L/ min) than without (6.0 ± 2.2 L/min; p < 0.0001). Of survivors with ISS 15 or higher, NICOM patients experienced a shorter hospital length of stay (10.5 days) when compared with 2009 and 2010 patients (14.0 days; p = 0.03). CONCLUSION: The multiple associations of CO with patient conditions imply that NICOM provides an objective and clinically valid, relevant, and discriminate measure of cardiac function in acutely injured trauma activation patients. NICOM use may be associated with a shorter length of stay in surviving patients with complex injuries.