Open abdominal management for perforative peritonitis with septic shock: a retrospective analysis on usefulness of a standardized treatment protocol.

BACKGROUND: Damage control surgery (DCS) with open abdominal management (OAM) has been increasingly expanded to include critically ill non-trauma patients. However, there is limited data regarding the usefulness of this protocol for the treatment of severe perforative peritonitis (PP), especially with septic shock (SS). Here, we retrospectively evaluated the usefulness of our OAM protocol for PP with SS. METHODS: We retrospectively reviewed patients with from June 2015 to September 2018. The proposed protocol was composed of the following steps: (1) rapid control of contamination; (2) temporary abdominal closure; (3) repeated washout of the abdominal cavity; and (4) delayed definitive surgery. For temporary abdominal closure, a negative pressure wound therapy device was used. The end points were the morbidity and 30-day mortality rates. Logistic backward regression was performed to identify factors associated with complications. RESULTS: The mortality rate was 4% (1/25) and the overall morbidity rate of surviving patients was 58.3% (14/24). The mean duration of the first DCS was 67.36 ± 22.83 min. The median durations of ventilation and intensive care unit stay were 5 and 7 days, respectively. Although not significant, morbidity might be associated with age, diabetes mellitus, initial operative time, and OAM duration. CONCLUSIONS: A standardized protocol for OAM may improve the outcomes of patients with SS due to PP. This damage control approach can be applied for the treatment of severe abdominal sepsis.

Novel laparoscopic methods for inguinal hernia post pelvic fracture: A case report.

INTRODUCTION: Pelvic fractures can occur in minor injuries, such as falls, in the elderly. Extensive adhesion of preperitoneal space is common after pelvic fracture surgery; hence, surgical interventions for inguinal hernia may be challenging. We treated a case of inguinal hernia after pelvic fracture surgery, using novel laparoscopic methods: iliopubic tract repair (IPTR) and modified intraperitoneal onlay mesh (mIPOM) approach. PRESENTATION OF CASE: This is the case of an elderly male with pelvic fracture. Open reduction and internal fixation were performed. Eighteen months after the procedure, a right inguinal bulge appeared, swelling increased, and he opted for surgery. We chose laparoscopic surgery to determine the status of the hernia and anatomy around the pelvis. He was diagnosed with an indirect inguinal hernia, and the inner inguinal ring was widely open. We chose the mIPOM approach and IPTR. He was discharged on day 3 post-operation. He developed a seroma after surgery, which disappeared after a month. Six months post-operation, no recurrence or neurologic pain observed. DISCUSSION: The transabdominal preperitoneal approach (TAPP) was initiated at first; however, the adhesion inside the inferior epigastric vessels was very strong, challenging to break into the preperitoneal space. We switched to the mIPOM method because the peritoneum was fragile and difficult to suture. Additionally, the internal ring was widely opened; hence, we proceeded with IPTR on confirmation that no tension on the abdominal wall was applied. CONCLUSIONS: Laparoscopic surgery is useful in flexibility of surgical options, such as TAPP, IPTR, IPOM, in addition to hybrid conversion.

Intraluminal Apple as a Rare Cause of Small Bowel Obstruction.

Small bowel obstruction due to ingested foreign bodies is rare in adults. A 48-year-old male visited our hospital with abdominal pain and vomiting. Computed tomography revealed intestinal obstruction by a 3 × 4 cm apple-shaped foreign body. Emergency surgery was performed to clear the obstruction which, upon inspection, was caused by a sexual toy made of rubber. Flexible rubber products that are ingested should be carefully followed after they pass thorough the pylorus. For obstructions related to sexual behavior, the patient's sense of shame often delays the process of seeking medical attention, thereby making preoperative diagnosis difficult.

[Japan Trauma Data Bank (JTDB) managed by Japan Trauma Care and Research (JTCR)].

Japan Trauma Care and Research (JTCR) was founded for operating the trauma care education and research in 2005. Japan Advanced Trauma Evaluation and Care (JATEC) is an educational program of trauma care established by The Japanese Association for The Surgery of Trauma (JAST) and the Japanese Association of Acute Medicine (JAAM), managed by JTCR. The Japan Trauma Data Bank (JTDB) is the only database organization of Japan trauma registry that was also established by JAST and JAAM, and managed by JTCR. Registry data that is collected from the JTDB is compiled annually and disseminated in the forms of hospital benchmark reports, data quality reports, and research data sets.

Extremity injuries as predictors of emergency care resource needs among blunt trauma patients in Japan.

This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.

Bridging classification for injury diagnoses that can be converted to both the International Classification of Diseases and the Abbreviated Injury Scale.

BACKGROUND: The International Statistical Classification of Diseases and Related Health Problems (ICD) is currently undergoing a revision process to develop the Eleventh Revision (ICD-11), but substantial modification of chapter 19 has not been proposed despite its known problems in describing injury severity and multiple injuries. Many facilities treating trauma patients perform duplicate coding for trauma diagnoses using two different classification systems, the ICD for administrative purposes and the Abbreviated Injury Scale (AIS) for trauma registry, because unambiguous conversion of codes between the ICD and AIS is not always possible due to structural differences. AIM: We developed a new bridging classification system which can be unambiguously converted to both ICD and AIS. METHODS AND RESULTS: The bridging classification adopted multidimensional coding and addressed differences in granularity and classification boundaries by adopting the more detailed categorizations whenever the granularity and classification boundaries differed between the ICD and AIS. Then we showed that the bridging classification codes could unambiguously converted to both ICD and AIS. CONCLUSION: Once injuries are coded using the bridging classification, the ICD and AIS codes are readily available. Integrating the new bridging classification into the ICD-11, possibly as a clinical modification, would eliminate the necessity of complicated procedures for code conversion and duplicate coding, and benefit users by building on the strengths of both the ICD and AIS.

Traumatic retroperitoneal hematoma spreads through the interfascial planes.

BACKGROUND: The purpose of this study was to reevaluate extension of traumatic retroperitoneal hematoma (RH) and related management strategies in light of the new concept of retroperitoneal fascias as interfascial planes communicating with three compartments. METHODS: Diagnostic computed tomographic images of 169 patients with traumatic RH treated between 1997 and 2003 were retrospectively reviewed. The extension of RH was measured in relation to 10 components: 3 compartments and 7 parts of the interfascial planes. On the basis of careful horizontal and vertical assessment of computed tomographic images, distribution, extent, and volume in each component of RH were assessed. RESULTS: In 88.8% of patients, RH was detected in interfascial planes. Interfascial planes absorbed a large amount of hematoma (mean, 223 +/- 309 mL; range, 0-1,519 mL), whereas the anterior and posterior pararenal spaces absorbed only 5 +/- 16 mL and 21 +/- 30 mL, respectively. The volume of RH in interfascial planes accounted for 78.1% of the total volume. In all cases, RH spread within interfascial planes with regularity: transversely by means of retromesenteric planes and vertically by means of combined interfascial planes. Regular extension patterns allowed RH to be classified by bleeding source. RH originating from retrorenal or combined interfascial plane had a poor prognosis; 51.7% of such patients died as a result of uncontrollable hemorrhage. CONCLUSION: RH was based in the interfascial planes, not the three compartments. Our findings that RH extends and is largely confined within interfascial planes, regardless of cause or volume, could be useful in estimating the extent of RH and developing breakthrough strategies for RH.

Fluid resuscitation of trauma patients: how fast is the optimal rate?

The Advanced Trauma Life Support guidelines recommend an initial rapid infusion of fluid (1-2 L) in trauma and hemorrhage victims as a diagnostic procedure to aid treatment decisions. Although patient response to initial fluid resuscitation is the key to determining therapeutic strategies, the appropriate rate of infusion is not clearly defined. Ninety-nine adult (age >16 years) blunt trauma victims with hypotension were enrolled. Patients were classified into 3 groups according to hemodynamic state after initial fluid resuscitation and requirement of surgical intervention. Total volume and rate of infusion differed significantly between the groups (P < .05). Patients requiring fluid administration at higher rate were all hemodynamically unstable and required immediate surgical intervention. Moreover, rate of infusion was the best predictor of the patients who required immediate surgical intervention. Moderate fluid infusion rate should be considered to allow identification of the patient's response to initial fluid resuscitation.

Incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrest with cardiac etiology in Osaka, Japan: a population-based study according to the Utstein style.

PURPOSE: To clarify the incidence and survival rate of bystander-witnessed out-of-hospital cardiac arrests (OHCA) with cardiac etiology in Osaka Prefecture, Japan, with a population of nearly 9 million according to the Utstein style. SUBJECTS AND METHODS: 5047 consecutive OHCA cases were treated by ambulance personnel during the 12-month period starting since 1 May 1998. 974 cases were considered to be bystander-witnessed OHCA with cardiac etiology and analyzed using the Utstein style. RESULTS: Of the 974 cases (100%), 50 cases (5.1%) survived after 1 month and 28 (2.9%) of them after 1 year. The Ventricular fibrillation (VF)/ventricular tachycardia (VT) group comprised 164 (16.8%) cases and there were statistically differences between the two groups as below (the VF/VT group vs. the non-VF/VT group): gender (male: 76.8 vs. 60.7%), age (61.7+/-14.7 vs. 68.7+/-17.1), history of ischemic heart disease (IHD) (30.5 vs. 15.3%), performance rate of bystander cardiopulmonary resuscitation (CPR) (34.1 vs. 21.4%) and time interval between receipt of an emergency call and arrival at the scene (5.5+/-2.9 vs. 6.0+/-2.9 min). CONCLUSION: The incidence of bystander-witnessed (OHCA) with cardiac etiology and VF or VT were remarkably low compared with those reported by other studies conducted in some areas of Europe or the USA.

Impact of mobile clinical analyzers on disaster medicine: a lesson from crush syndrome in the 1995 Hanshin-Awaji earthquake.

The Great Hanshin-Awaji earthquake caused many people to develop crush syndrome. Analysis of these patients revealed that the severity is not related to their hemodynamics but to hematocrit, base deficits, and potassium concentrations soon after their extrications. In the disaster site, these parameters can only be measured using whole-blood samples by mobile instruments. The present study was made to evaluate the possibility of uses of a mobile measuring device, ABL77, for the triage of crush syndrome patients in disaster sites. Heparin-added blood samples and serum samples were collected from patients admitted to Senshu Critical Care Medical Center. Blood gases, electrolytes, and hematocrit of the heparin-added blood samples were measured using ABL77 and compared with those measured using the stationary device ABL725. Potassium concentrations of the heparin-added blood samples measured by the ABL77 were compared with those of the serum samples measured by the stationary EA06T. Significant correlations were observed between the measurements. We conclude that the ABL77 was satisfactorily compatible with stationary devices in the hospital. Medical institutions should have simplified, mobile measuring devices as a precaution against disasters, so that they can get ready to take appropriate action promptly.

[Examination of drugs and poisons in institutions not equipped with an analyzer of them and poisons--focusing on the simple qualitative test of surfactants].

We examined the simple qualitative test of surfactants, and discussed its possible usefulness in clinical emergency medicine and the analysis system in institutions not equipped with an analyzer of drugs and poisons. The procedures for the cobalt thiocyanate ammonium test, methylene blue chloroform test, and bromphenol blue test are easy, if reagents are prepared beforehand. If concomitantly used, these tests enable analysis of ion properties of surfactants. These tests thus seem useful for the screening of drugs and poisons in emergency medicine. We think that it is possible for institutions not equipped with an analyzer of drugs and poisons to establish a system to support clinical practice by giving priority to the establishment of drugs and poisons that frequently cause intoxication as well as of items for the simple qualitative test that are specified in "proposals for the guidelines for the analysis of drugs and poisons" advanced by the Japanese Society for Clinical Toxicology.

Assessment of effective hepatic blood flow in critically ill patients by noninvasive pulse dye-densitometry.

PURPOSE: Effective hepatic blood flow (EHBF) is thought to reflect splanchnic perfusion and the metabolic state of the liver. This study was conducted to examine the relationship between cardiac output (CO) and EHBF using pulse dye-densitometry (PDD) in nonseptic and septic patients, and to assess the prognostic value of this relationship. METHODS: The subjects were 33 critically ill patients, 16 of whom met the criteria for sepsis. Indocyanine green (ICG) was given via a central venous catheter to each patient. CO (l/min) and EHBF (l/min) were assessed with PDD. RESULTS: CO and EHBF were significantly correlated in the nonseptic patients ( r = 0.92, P < 0.001), but not in the septic patients ( r = 0.38, P = 0.15). The ratio of EHBF to CO (EHBF/CO) in the septic patients was significantly lower than that in the nonseptic patients (0.08 +/- 0.04 vs 0.22 +/- 0.05; P < 0.001). Moreover, in the septic patients, the EHBF/CO ratios of nonsurvivors were significantly lower than those of survivors (0.06 +/- 0.04 vs 010 +/- 0.02; P < 0.01). CONCLUSIONS: In nonseptic patients, the EHBF decreased in relation to the CO. However, the EHBF/CO ratio of septic patients was lower than that of nonseptic patients, suggesting that inadequate splanchnic perfusion or metabolic change occurs in septic patients. Furthermore, the lower EHBF/CO ratio was related with a fatal outcome in septic patients. PDD could be a clinically useful method of assessing splanchnic conditions in critically ill patients.

[Paradigm shift from standard surgery to damage control surgery in major trauma].

"Damage control surgery (DCS)" is currently the most commonly used term to describe the surgical strategy for major trauma. Standard surgical approaches to trauma consist of a priority-driven sequence of steps, including exposure, homeostasis, repair, resection, and reconstruction. Patients with massive exsanguination, however, will not survive complex procedures. It is well known that those patients are more likely to die from intraoperative physiological deterioration resulting from a failure to complete surgical repair. The surgical team must undergo a paradigm shift, focusing on saving life or resuscitation. DCS has three separate components. The first is abbreviated resuscitative surgery for rapid control of hemorrhage and contamination. This is achieved as quickly as possible in the operating room, but traditional repairs are deferred in favor of rapid measures that control hemorrhage, restore flow where needed, and control or contain contamination. The second step in DCS is systemic management in the ICU, where the care consists of ongoing core rewarming, correction of coagulopathy, fluid resuscitation, and optimization of hemodynamic status, as well as reexamination to diagnose all injuries. When normal physiology has been restored, reoperation is undertaken for definitive repairs of injuries and abdominal closure. In addition to the above three components, an earlier phase before the initial operation, referred to as "DC ground zero" has recently been added.