Complicated retroperitoneal diverticulitis presenting with abscess and acute limb ischemia.

This case highlights a rare presentation of diverticulitis of the sigmoid colon with perforation into the retroperitoneum complicated by abscess, vertebral osteomyelitis and acute lower extremity ischemia. A late 40-year-old man presented to an emergency department with acute ischemia of his left lower extremity. He was tachycardic with a leucocytosis, an unremarkable abdominal exam and a pulseless, insensate and paralysed left lower extremity. Imaging revealed sigmoid thickening, an abscess adjacent to iliac vasculature and occlusion of the left popliteal artery. The abscess came in contact with prior spine anterior lumbar interbody fusion (ALIF) hardware at L5-S1 vertebrae. The patient was taken urgently to the operating room for embolectomy, thrombectomy and fasciotomy. He was started on antibiotics and later underwent operative drainage with debridement for osteomyelitis. Non-operative management of the complicated diverticulitis failed, necessitating open sigmoidectomy with colostomy. 1 year later, he was symptom-free and the colostomy was reversed.

Tension pneumoperitoneum following upper endoscopy.

Perforation of the digestive tract is a rare complication of endoscopy. Massive accumulation of air within the peritoneum resulting in the abdominal compartment syndrome is much less common with <20 cases reported. In this report we present a case of jejunal perforation during an upper gastrointestinal endoscopy that resulted in tension physiology with mesenteric ischemia, severe acidosis, renal failure, coagulopathy and massive gastrointestinal hemorrhage. The patient had a sudden onset of shock as soon as her abdomen was decompressed, indicating that she possibly developed a reperfusion injury. She did not respond to resuscitative efforts and ultimately died.

Right atrial rupture from blunt thoracic trauma in a 4-year-old child.

Blunt cardiac injury in the pediatric population has been less frequently reported than in the adult population. Cardiac chamber rupture is a rare but highly lethal injury in both populations. The lethality of this condition is further enhanced by the multiplicity of injuries that are frequently present. The diagnosis of cardiac chamber rupture is often delayed while other injuries are being addressed. A high index of suspicion and early use of the appropriate imaging studies are essential for the timely diagnosis of this condition. In this report, we present a 4-year-old child who survived 10 hours of pericardial tamponade secondary to blunt right atrial rupture.

FRIEND or FOE: A prospective evaluation of risk factors for reintubation in surgical and trauma patients.

BACKGROUND: A Form for Re-Intubation Evaluation by Nurses and Doctors (FRIEND) was used to prospectively collect pre-extubation data, to determine failure of extubation (FOE) risk. METHODS: FRIENDs, including airway, breathing, and neurologic variables, were completed before extubation on trauma & surgical patients in one ICU from 1/1/16 to 5/31/17. Those with failed vs. successful extubation were compared. We excluded those with tracheostomy, comfort measures, or death before extubation. RESULTS: There were 464 eligible extubations in 436 patients. Thirty five reintubations (7.9% FOE rate) occurred in 32 patients within 96 h of extubation. FOE patients had higher ICU days (6 d vs. 2 d), ventilator days (6 d vs. 2 d), and mortality (15.6% vs. 2.7%) [all p < 0.001] compared to those without FOE. Odds of FOE (OR [CI]) increased with age (1.03, [1, 1.06]), delirium (3, [1.16, 7.76]), moderate/copious secretions (3.95, [1.46, 10.66]), and enteral opioid use (4.23, [1.28, 14.02]). CONCLUSIONS: Several characteristics present at the time of extubation were risk factors for FOE in trauma and surgical patients. Patients with FOE had higher mortality.

Nontraumatic clostridial myonecrosis: an indication for colonoscopy?

Clostridial myonecrosis (CM) is a rare infection that usually arises after traumatic injury. Spontaneous or nontraumatic CM is even more rare and has been described in association with colorectal malignancy. These infections carry a high mortality rate and require urgent surgical intervention and intensive antibiotic therapy. This report describes a patient who presented with nontraumatic CM of the lower extremity in association with adenocarcinoma of the cecum.

Experience with 161 cases of anterior exposure of the thoracic and lumbar spine in an acute care surgery model: impact of exposure level and underlying pathology on morbidity.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To evaluate the outcomes of anterior exposure of the thoracic and lumbar spine by an acute care surgery service. SUMMARY OF BACKGROUND DATA: Spine surgeons typically require an "approach surgeon" to provide anterior exposure of the thoracic and lumbar spine. We hypothesized that a dedicated acute care surgery service can perform those operations with acceptable morbidity and mortality. METHODS: A retrospective review of 161 trauma and nontrauma patients was performed. All cases were performed at a level I trauma center with a dedicated acute care surgery service. In-hospital morbidity and mortality were evaluated. A brief description of the operative techniques used by our group is also provided. RESULTS: Of the 161 patients, 59 (37%) were trauma patients. Ninety-three patients (58%) had anterolateral retroperitoneal exposure of the thoracic and lumbar spine. Sixty-eight patients (42%) had anterior retroperitoneal midline exposure of the lumbar and lumbosacral spine. Total morbidity was 9.3% (7.4% for trauma patients and 1.8% for non trauma patients). Morbidity was highest in patients who had anterolateral exposure of the thoracic and lumbar spine (6.8%). Morbidity in patients who had midline exposure of L4 to S1 was 0%. Total mortality was 1.2% (3.3% for trauma patients and 0% for nontrauma patients). The acute care surgery service gained 3141 physician work relative value units (RVU) by performing those operations. CONCLUSION: Anterior exposure of the thoracic and lumbar spine both for trauma and nontrauma related indications can be performed with acceptable morbidity and mortality by a dedicated acute care surgery service. Morbidity and mortality were higher in trauma patients and in those who underwent thoracolumbar procedures. Patients who had midline exposure of L4 to S1 for degenerative disc disease had the lowest morbidity. LEVEL OF EVIDENCE: 4.

Single-drug sedation with fentanyl for prehospital postintubation sedation in trauma patients.

BACKGROUND: A fentanyl-only (FO) regimen for prehospital postintubation sedation in trauma patients was compared with the standard protocol (SP) of fentanyl + benzodiazepine. METHODS: Intubated patients transported to a Level I trauma center from December 1, 2005, to April 30, 2009, were retrospectively reviewed. Before 2007, only SP was used; afterward both regimens were used. Groups were compared for hemodynamic and neurologic parameters in the prehospital setting and trauma bay, fluid volumes, time until general or neurosurgical intervention (NSI), and other outcomes. RESULTS: Groups were comparable with respect to age, sex, mechanism, alcohol level, intensive care unit length of stay, and hospital length of stay. Comorbidities were similar except hypertension (p = 0.019), and stroke (p = 0.029) were more frequent in FO patients. Prehospital heart rate and Glasgow Coma Scale (GCS) were similar. Trauma bay hemodynamic parameters and fluid resuscitation volumes were comparable, but pupil nonreactivity was more frequent in the FO group both overall (p = 0.032) and when comparing only patients with traumatic brain injury (TBI; p = 0.014). The incidence of TBI was comparable. Although the frequency of craniotomy (13% FO vs. 7% SP) and mortality (17% FO vs. 11% SP) were not statistically different overall, in patients with TBI, there was a higher incidence of NSI (28% vs. 14%, p = 0.015), craniotomy (14% vs. 3%, p = 0.02), and time to initial NSI (446 minutes vs. 193 minutes, p = 0.042) in the FO patients. CONCLUSIONS: In this study, an FO regimen was associated with similar hemodynamic but worse neurologic variables compared with the SP regimen. Prospective evaluation is warranted before adoption of this regimen, especially in TBI patients.

The esophageal Doppler monitor in mechanically ventilated surgical patients: does it work?

BACKGROUND: Assessment of cardiac volumes and cardiac output (CO) using a pulmonary artery catheter (PAC) in mechanically ventilated patients can be inconsistent and difficult. The esophageal Doppler monitor (EDM) is emerging as a potential alternative to the PAC. This prospective study evaluated the comparative accuracy between the PAC and EDM for preload assessment and CO in mechanically ventilated surgical patients. METHODS The EDM was placed in 15 patients with PACs in place. A total of 187 simultaneously measured EDM and PAC comparative data sets were obtained. The Pearson correlation (r) was used to compare measurements, with significance defined as a value of p < 0.05. RESULTS: CO measured by EDM and PAC correlated closely (r = 0.97, p < 0.0001). Corrected flow time (FTc), a measure of left ventricular filling, correlated with PAC CO to the same degree as pulmonary capillary wedge pressure (PCWP) when positive end-expiratory pressure (PEEP) was < 10 cm H2O (FTc, r = 0.51; PCWP, r = 0.56). When PEEP was > or = 10 cm H2O, FTc correlated with PAC CO better than PCWP (FTc, r = 0.85; PCWP, r = 0.29). CONCLUSION: FTc correlates with EDM and PAC CO better than PCWP. On the basis of the current study, it is reasonable to conclude that the EDM is a valuable adjunct technology for CO and preload assessment in surgical patients on mechanical ventilation, regardless of the level of mechanical ventilatory support.