Tracheal repair with fibrin glue.

This animal study evaluated Fibrin Sealant, a multicomponent biologic adhesive, in tracheal operations. We conclude that the use of Fibrin Sealant in tracheal reconstruction results in a stable, leakless trachea, has good systemic and local compatibility, promotes tracheal wound healing, and reduces significantly the number of sutures required for end-to-end anastomosis.

Determination of optimal positive end-expiratory pressure by means of conjunctival oximetry.

A method for determining the optimal level of positive end-expiratory pressure (PEEP) by means of noninvasive conjunctival oxygen (PcjO2) monitoring and arterial blood gas analysis was developed from the pattern of changes in PcjO2 tension, invasive hemodynamic parameters, and oxygen transport variables during PEEP titration in a series of patients with adult respiratory distress syndrome. All patients had radial and pulmonary artery (PA) catheters inserted and blood volume was measured with 125I serum albumin before each study. During progressive increases in the level of PEEP, PcjO2 tensions reflected changes in both PaO2 and cardiac index (CI), depending on whether PEEP produced a significant decrease in CI. In patients with a stable CI, PcjO2 tensions tracked PaO2 values (rw = 0.92); in patients with a greater than a 15% decrease in CI, the conjunctival index, CjI (defined as the PcjO2/PaO2 ratio), tracked CI (rw = 0.87), excluding one patient with high cardiac output-septic shock and severe hypoxemia. PcjO2 correlated with PaO2 in the latter patient (r = 0.99) probably because conjunctival oxygen transport was limited by arterial oxygen content (PaO2 = 34 torr) rather than blood flow (CI greater than 6 L/min X m2). In patients with a greater than a 10% decrease in CI as a result of PEEP, the greater the decrease in CI, the better CjI values correlated with CI. We conclude that PcjO2 monitoring combined with repeated arterial blood gas analysis may be used to titrate PEEP therapy in patients with adult respiratory distress syndrome. In patients whose CjI significantly decreases because of PEEP, PA catheterization and measurement of cardiac output are indicated because of the likelihood of a significant (greater than 15%) decrease in CI. In the absence of a significant decrease in the CjI, optimum PEEP occurs at the level producing maximum PcjO2. It is hoped that by following the described algorithm, many patients will be spared the cost and morbidity of unnecessary PA catheterization.

Fibrin glue achieves hemostasis in patients with coagulation disorders.

Fibrin glue (FG), made with highly concentrated human fibrinogen and clotting factors, was used to achieve parenchymal organ hemostasis in patients with disordered coagulation secondary to massive transfusion, chronic disease, and disseminated intravascular coagulation; it was effective in controlling liver hemorrhage in seven patients and in the performance of a splenorrhaphy in one other patient. The coagulation profile was grossly abnormal in all patients, and the mean +/- SD intraoperative blood loss was 5.1 +/- 4.2 L; patients received 14 +/- 10 U of blood perioperatively. The amount of FG required to achieve hemostasis varied directly with the extent of injury and intraoperative blood loss (r = .84), and all patients with a blood loss greater than 4 L required at least 25 mL of FG to stop bleeding. Two patients died postoperatively secondary to cardiac arrest and adult respiratory distress syndrome. Because FG does not depend on adequate platelet or clotting factor levels to be effective, it is especially useful in patients with parenchymal organ hemorrhage and disordered coagulation.

The efficacy of central venous and pulmonary artery catheters and therapy based upon them in reducing mortality and morbidity.

The purpose of this study was to (1) evaluate the relative cost effectiveness of the central venous pressure and flow-directed pulmonary artery catheters used to maintain normal hemodynamic values as therapeutic goals in the control groups vs supranormal values empirically observed in critically ill postoperative survivors in the protocol groups, and (2) to evaluate tissue perfusion and oxygenation in relationship to organ failure and mortality. In two prospective clinical trials there were no significant differences in outcome between the central venous pressure and pulmonary artery control groups that used normal values as therapeutic goals. However, there were marked and significant reductions in morbidity and mortality of the protocol groups using the supranormal cardiac index, oxygen delivery, and oxygen consumption values as goals. The cumulative oxygen debt was less and organ failures were fewer and less severe in the protocol groups than in the control groups.

Noninvasive conjunctival oxygen monitoring during carotid endarterectomy.

Conjunctival oxygen tension (PcjO2) was measured continuously during carotid endarterectomy in 15 patients to evaluate its sensitivity in patients receiving shunts. These studies suggest that PcjO2 tracks brain perfusion during periods of carotid artery occlusion. Reduced PcjO2 was clearly demonstrated with systemic hypotension, carotid artery clamping, and carotid shunt obstruction and clamping. Monitoring of PcjO2 is noninvasive, easy to perform, offers no danger to the patient, and allows real-time assessment of the local tissue perfusion. It provides valuable information on the effectiveness of carotid oxygen transport and, in conjunction with arterial blood gas values, expresses carotid artery perfusion relative to systemic oxygen transport. Further investigations using the PcjO2 sensor may define criteria for intraoperative carotid arterial shunting in patients with tenuous cerebral perfusion, and for prompt intervention in patients with deteriorating perfusion prior to the onset of life-threatening cerebral ischemia.

Firearm injuries in girls and women. The unaddressed imperative.

OBJECTIVE: To describe the trends in firearm fatalities in California between 1987 and 1991 and the 153 firearm injuries in girls and women treated at the King/Drew Medical Center, Los Angeles, Calif, from September 1, 1991, to December 31, 1992. DESIGN: Retrospective study. SETTING: The study was conducted at the King/Drew Medical Center, a university-based county hospital, one of the major trauma centers in Los Angeles. PATIENTS: At the King/Drew Medical Center, 32 patients (21%) required at least one major procedure. Of the 16 patients who died, 14 (88%) died in the emergency department of wounds to the head (six patients), chest (five patients), and abdomen (three patients). The odds ratio of dying if injured in the head, face, or neck was 2.23, and in the abdomen, 1.0. Surgeons rarely probe for the underlying cause of injury. MAIN OUTCOME: The outcome has been a 2.28-fold increase in deaths in girls and women aged 10 to 19 years. RESULTS: Much of the violence against girls and women is perpetrated by those known to them. CONCLUSION: Firearms are the most frequently used weapon in female homicides. Firearm fatalities in women represent a significant problem among all ethnic groups. Trauma centers must take the lead in the collection of meaningful data to implement effective gender- and ethnic-specific violence prevention strategies.

Injury and violence in Los Angeles. Impact on access to health care and surgical education.

The Los Angeles County (California) Trauma Hospital System was designed to ensure that all patients requiring specialized trauma care would be transported directly to a trauma center using established trauma triage criteria. The designation and implementation of all level 1, 2, and 3 (rural) trauma centers were completed between October 1983 and July 1985. However, by February 1, 1985, one level 2 trauma center withdrew, and nine other level 2 and 3 trauma centers followed suit over the next few months and years. The reasons for closure of these 10 trauma centers were almost exclusively related to economic factors. The major impact of trauma center closure on surgical educational programs at the Drew University of Medicine and Science and the Martin Luther King, Jr/Charles R. Drew Medical Center have been additive and cumulative. The high volume of patients with trauma has been cited, sometimes correctly and sometimes incorrectly, as the primary reason for a lack of access to health care for patients without trauma. We have developed a blueprint for survival that, when fully implemented, will improve access to health care for all residents in our catchment area and optimize surgical education. While the Los Angeles County Trauma Hospital System has had many difficulties during the last 9 years, the population it serves is greater than that in 42 states in the United States. The experiences gained in Los Angeles County may be beneficial to statewide systems in the United States and in countries of comparable size.

An analysis of the isoenzymes of creatine phosphokinase and lactic dehydrogenase in the esophagus.

Surgical manipulation of muscular organs can cause alterations of the serum isoenzymes of creatine phosphokinase (CPK) and lactic dehydrogenase (LDH), which are frequently used to confirm the diagnosis of myocardial infarction (MI). Since the content of these enzymes and their isoenzymes has not been established for the esophagus, an experiment was conducted to evaluate and compare the enzymes in postmortem specimens from humans and fresh canine specimens. One gram transmural esophageal sections were taken from specimens having no demonstrable disease. All samples were homogenized individually in Ringer's lactate solution and centrifuged, and the supernatants were analysed for the respective isoenzyme distributions by agarose gel electrophoresis. From the study we drew the following conclusions: (1) all three isoenzymes of CPK (including CPK-MB, the myocardialisoenzyme) are present in the esophagus; (2) LDH, the isoenzyme of LDH most prevalent in myocardium, is the least common of the five isoenzymes of LDH in the esophagus; (3) the dog is an appropriate model for studying changes of these isoenzymes after operation; and (4) any potential confusion in diagnosing postoperative MI due to esophageal CPK-MB in the serum can be resolved, theoretically, by analyzing LDH serum isoenzymes. In myocardial infarction, LDH becomes the predominant isoenzyme, whereas esophageal injury should be associated, theoretically, with a serum LDH isoenzyme pattern in which LDH is the least prevalent isoenzyme.

Initial and long-term results in the management of primary chest wall neoplasms.

One hundred ten patients with primary chest wall neoplasms were analyzed for long-term results. The diagnosis of 59 malignant and 51 benign tumors was confirmed by the Armed Forces Institute of Pathology. No deaths were associated with primary definitive therapy. Among the five most frequently encountered malignant tumor types, five-year survivals were obtained in 9 of 17 (53%) patients with fibrosarcoma, 8 of 9 (89%) patients with chondrosarcoma, 2 of 8 (25%) patients with solitary chest wall plasmacytoma (multiple myeloma), 1 of 6 (17%) patients with Ewing's sarcoma, and 2 of 4 (50%) of patients with osteogenic sarcoma. Although the five-year survival appears to indicate therapeutic success in patients with Ewing's sarcoma and osteogenic sarcoma, patients with chondrosarcoma or fibrosarcoma may have a more protracted course, and those with solitary plasmacytoma usually develop multiple myeloma. The findings suggest that radical surgical excision is the treatment of choice for chondrosarcoma; radical surgical excision combined with chemotherapy, for fibrosarcoma and osteogenic sarcoma; surgical excision combined with radiation and chemotherapy, for Ewing's sarcoma; and systemic surveillance and therapy, for pathologically confirmed solitary plasmacytoma.

Evaluation of a blunt and penetrating trauma algorithm for truncal injury.

The authors objective was to develop and test a single branch-chain decision tree for blunt and penetrating truncal injury. Over the 4-month study period there were 979 patients evaluated in the emergency department; 674 of these patients were admitted to the hospital. Thirty-four (5%) of the 674 admitted patients died of truncal injury. The study group consisted of 239 of the most severely injured patients; 41 of these (17%) died. Of the 44 patients managed with major deviations from the algorithm, 27 (61%) died. Only 14 of the 195 patients (7%) whose management complied with the algorithm died. The authors conclude that following the specific management criteria outlined by the algorithm may improve the survival of severely traumatized patients.

Total coronary blood flow measurements and myocardial metabolism during cardiopulmonary bypass in a canine model.

Myocardial respiratory function and total coronary blood flow were evaluated during cardiopulmonary bypass in 18 dogs. The fibrillating heart was found to be associated with an increase in myocardial oxygen utilization and metabolic rate which was compensated for by a corresponding increase in total coronary blood flow. Following anoxic arrest of the heart, there appears to be an initial impairment to oxygen utilization. Oxygen consumption does not return to normal after 15 minutes of restoring coronary blood flow. The stability of the experimental model as outlined in this study is thought to be related to the use of autologous blood in priming the extracorporeal circuit.

Vertical banded gastroplasty vs gastric bypass in the treatment of obesity.

Two hundred consecutive patients undergoing surgical intervention for morbid obesity had either the gastric bypass or the vertical banded gastroplasty. Both groups were similar in patient composition. In the vertical banded gastroplasty patients, operating room time was lessened by 70 minutes, blood loss lessened by 225 mL, and hospital stay shortened by two days as compared with the gastric bypass patients. At 30 months, a 64-percent mean excess weight loss was observed in the gastric bypass vs a 56-percent mean excess weight loss in the vertical banded gastroplasty group. The vertical banded gastroplasty procedure is preferred because there is no late stomal dilation with weight gain, no vitamin B(12) deficiency, and most important, this procedure leaves the remainder of the stomach and duodenum available for endoscopic and radiologic evaluation.

Geographic and temporal patterns of recurrent intentional injury in south-central Los Angeles.

To better understand geographic and temporal patterns of recurrent intentional injury, 285 consecutive trauma patients were evaluated prospectively. Fifteen were excluded because of immediate death or severe brain injury. The remaining 270 patients were interviewed. Of these, 59 (22%) had been treated in a hospital for a total of 75 previous episodes of intentional trauma (mean: 1.3 episodes/patient). In 66 of the 75 episodes, the patient recalled where treatment had been received (88%). Twenty-eight (42%) of the 66 episodes had been treated at King/Drew Medical Center (KDMC), 36 (55%) had been treated at a hospital within a 3-mile radius of KDMC, 48 (73%) within an 8-mile radius, and 63 (95%) within a 10-mile radius. Sixty-five percent of the episodes occurred 5 years or less prior to the current injury (range: 11 days to 30 years; mean: 4.9 years). Patients currently admitted for intentional injury were more likely to have had intentional injury previously than those with unintentional injury (27% versus 12%). Based on these findings, we conclude that intentional trauma patients in our community remain in a defined geographic region and that there is a definable high-risk period for recurrent intentional injury. These conclusions should enhance the development of a framework on which future violence prevention programs can be designed.

Injuries to the profunda femoris artery and its branches.

Six cases of uncommon profunda femoris artery injury are analyzed. One half of the cases were not treated surgically at the time of injury and resulted in chronic arteriovenous fistulas. Even after operative correction, residual symptoms persisted in two of these three cases. The generous use of arteriography is recommended in cases of proximal thigh penetrating injuries to avoid this problem. Either repair or ligation of the injured vessel yielded the same good results. The postoperative hospital stay was short in all instances, ranging from four to eight days, and there were no deaths.

Time-related effects of heparin sulfate on regional and systemic anticoagulation.

Optimal timing of vascular clamping to anticoagulation during cardiovascular surgical procedures is poorly defined. This study uses a canine model to determine the effectiveness of three different methods of heparin administration. Heparin sulfate (150 IU/kg) was administered by: injection into the jugular vein 5 minutes before infrarenal aortic clamping (Group 1), injection into the terminal aorta immediately after infrarenal aortic clamping (Group 2), and injection into the jugular vein immediately after infrarenal aortic clamping (Group 3). Thrombin clotting times and partial thromboplastin times were measured in venous blood from the upper and lower extremities before (baseline) heparin administration, and 1, 3, and 5 minutes following heparin administration. Activated clotting times were assessed in lower extremity blood at baseline, and at 1 and 5 minutes after heparin injection. Significant differences existed between groups in both upper and lower extremities. Systemic anticoagulation occurred within 1 minute after intravenous heparin administration in Groups 1 and 2 in the lower extremity, and Groups 1 and 3 in the upper extremity. Delayed anticoagulation in the lower extremity was noted with systemic injection after aortic clamping in Group 3, and after regional intra-aortic administration in the upper extremity of Group 2 subjects. Complete anticoagulation was noted by 5 minutes in all groups in both the upper and lower extremities. These results suggest that the safe time period between heparin administration and vascular clamping varies with the route and the timing of its administration. Intravenous administration prior to aortic cross-clamping provided adequate anticoagulation in this canine model in both the upper and lower extremity blood after 1 minute of heparin circulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of extraperitoneal rectal injuries.

Twenty-eight consecutive extraperitoneal rectal injuries for a period of 34 months ending in May 1990 were reviewed retrospectively. All injuries were due to penetrating gunshot wounds. The rectal exam was positive in 75% of patients versus 80.8% with proctosigmoidoscopy. All 28 patients had diversion of the fecal stream. Diverting colostomies were performed in 17 patients, Hartmann's colostomies in 7 patients, and proximal loop colostomies in 4 patients. Presacral drainage was used in 25 patients (89.3%). Distal irrigation was performed in 13 patients (46.4%) and primary repair in 9 patients (32.1%). There was one infectious complication (3.6%) and no deaths (0%). Fecal diversion and presacral drainage are the mainstay of therapy for civilian rectal injuries. The importance of distal irrigation of the rectum has not been established. Primary repair of the rectum has no effect on morbidity and mortality.

Management of penetrating colon injuries.

The management of colon injuries remains an area of major controversy. Selecting the patients who can undergo primary repair safely remains undefined. To address this issue, 231 consecutive patients with penetrating colon injuries were reviewed to determine those factors that affected outcome. Overall, there were 54 (25.2%) septic complications, with 36 (16.8%) wound infections and 18 (8.4%) intra-abdominal abscesses. There were seven (3.3%) deaths in the entire series. The surgical management method of the colon injury was not significant in wound infections (P > .39), intra-abdominal abscesses (P > .24), or mortality (P > .39). A more aggressive approach of primary repair should be performed for civilian colon injuries.

The utilization of cross-sectional anatomy in a surgical residency training program.

The education of students and residents in a surgical department involves a thorough knowledge of three-dimensional anatomical relationships in the body. In addition, the advances in new imaging modalities demand an in-depth study of cross-sectional anatomy by both students and residents. Traditionally, surgical training incorporated dissections of cadavers and the progressive involvement of the resident in the surgical theater. At the King/Drew Medical Center cross-sectional anatomy has been incorporated into the teaching program. The central focus of this instructional program utilizes problem-solving learning modules that emphasize important surgical and anatomical principles.LEARNING MODULES FOR EACH MAJOR REGION OF THE BODY WERE ESTABLISHED AND INCLUDE THE FOLLOWING: (1) serial cross sections, corresponding computerized tomographic scans and roentgenograms; (2) an atlas (cross sections), case histories, and examination questions; and (3) audiovisual presentation of the normal anatomy, the surgical principles involved, and a discussion of the examination questions. The serial cross sections were prepared at the King/Drew Medical Center.A selected case study is used to illustrate how the knowledge of three-dimensional anatomy can be critical in the evaluation and surgical plan of a patient. Entire learning modules of the thorax and abdomen were used.