A new immunomodulatory therapy for severe sepsis: Ulinastatin Plus Thymosin {alpha} 1.

OBJECTIVES: To study the effect of immunomodulatory therapy with ulinastatin plus thymosin alpha( 1) on septic patients. METHOD: A total of 56 sepsis patients were randomized into a treatment group, receiving immunomodulatory therapy, and a placebo group, a placebo. Acute Physiology and Chronic Health Evaluation II scores, clinical data, lymphocyte subsets, immunological indexes, and coagulation parameters were determined before admission and on the 3rd, 8th, and 28th day after admission to the Intensive Care Unit. RESULTS: The treatment group experienced a 78% cumulative survival, the placebo group experienced a 60% cumulative survival; the survival difference was mirrored by Acute Physiology and Chronic Health Evaluation II scores and more quickly improved leukocyte counts, lymphocyte counts, coagulation parameters, and cytokine levels in the treatment. CONCLUSIONS: Combined immunomodulatory therapy with ulinastatin plus thymosin alpha(1) appears to yield improved survival for patients with sepsis; this finding should be verified in larger clinical trials.

Survivin expression in ovarian cancer.

AIM: To examine the expression of survivin in benign ovarian tumors, ovarian carcinomas of different stages. METHODS: We screened the expression of survivin mRNA by reverse transcription polymerase chain reaction in 114 ovarian tissue samples. Quantitative real-time PCR was used to estimate survivin mRNA levels in the samples with positive survivin expression. RESULTS: No survivin mRNA was expressed in all normal ovarian specimens, while it appeared in 73% of ovarian carcinomas, 47% of borderline ovarian carcinomas and 19% of benign ovarian tumors. The survivin mRNA expression rate was positively associated with clinical stage (P = 0.026) and differentiation grade (P = 0.049). There was notably statistically significant difference in the survivin mRNA expression rate dependent on different histological types (serous, mucinous, endometrioid, P = 0.008), but not - dependent on lymph node metastasis (P = 0.921) and ascites (P = 0.87). In tissues with positive expression of survivin, we also found that mean survivin mRNA expression levels were higher in ovarian carcinomas than that in benign ovarian tumors and borderline ovarian carcinoma tissues (P < 0.001). Among ovarian carcinomas, the high survivin mRNA expression levels correlated with the clinical stages, differentiation grade, lymph node metastasis, but not - with ascites and histological type. CONCLUSION: Our study suggest that survivin is associated with progression of ovarian carcinoma.

Minimally invasive open cystgastrostomy for pancreatic pseudocyst.

One of the complications of pancreatitis is pancreatic pseudocyst. Many different techniques have been described for internal drainage of pancreatic pseudocyst. Indication for surgery is either symptomatic or large cysts that can turn into complications such as hemorrhage, obstruction, infection, rupture and malignancy. Our technique includes an incision between 5 cm to 9 cm below the left subcostal margin and the opening of the anterior stomach and a posterior cystgastrostomy performed with a reticulated laparoscopic staple. We have been able to perform surgery in a very large pseudocyst (up to 26 cm) in a small amount of time, within 45 min, and with a shorter length of hospital stay (36 h). In this paper, we present our technique on how to approach large pseudocysts utilizing a minimally invasive small incision.

Laparoscopic re-exploration in mechanical bowel obstruction after laparoscopic gastric bypass for morbid obesità.

AIM: This study reports a series of 7 patients who experienced small-bowel obstruction (SBO) after laparoscopic gastric bypass (LGBP). METHODS: Between July 2001 and June 2004, 211 patients underwent surgery for morbid obesity in 2 different institutions and 7 of them required reoperative laparoscopic surgery or laparotomy for mechanical SBO. RESULTS: Seven patients in the series (3%) developed a postoperative bowel obstruction requiring operative management. Their mean body mass index was 49 (range: 38-65) and the average age was 48 years (range 29-60). Six (86%) had undergone an initial LGBP. One (14%) had been converted to open surgery because of the presence of thick adhesions. One percent of the patients (14%) had undergone abdominal surgery prior to gastric bypass. The most common cause of SBO was internal hernia through a mesenteric defect (57%), followed by adhesions (14%), obstruction at the entero-enterostomy (14%) and Petersen hernia (14%). The obstruction was managed laparoscopically. Small-bowel resection was required in 14% with no death encountered after the second revision of the entero-enterostomy. Recovery time was less than 72 h after laparoscopic approach and more than 92 h following the open procedure. CONCLUSIONS: Laparoscopic surgical correction of SBO following LGBP in morbidly obese patients is feasible. Reoperation of morbidly obese patients after LGBP can be achieved successfully through laparoscopic techniques.

A single proposed algorithm for the surgical treatment of hepatic hemorrhage.

Angiographic embolization safely and effectively controls hemorrhage from the liver. Contrasting algorithms and protocols have, however, created confusion as to how and when to use this procedure. After performing a Medline search, a proposed protocol for the use of angiographic embolization was created. This algorithm, which focuses on general hepatic response to injury, not to any particular disease, is best applied in busy tertiary hospitals. The generalized applicability of the proposed protocol may allow for a more uniform, easily remembered, and effective treatment of liver hemorrhage.

Influence of obesity on the risk of developing colon cancer.

Obesity is a risk factor for many diseases. Thirty per cent of Americans are viewed as super obese; therefore, we need to find a solution. We already know about the diseases associated with obesity such as high blood pressure, diabetes, sleep apnoea, etc. Lately, there has been an increased interest in understanding if cancer is related to obesity. In this paper, we review the incidence of colon cancer and obesity. Insulin is the best established biochemical mediator between obesity and colon cancer. Hyperinsulinaemia, such as occurs in type II diabetes, is important in the pathogenesis of colon cancer. All adipose tissue is not equal. Visceral abdominal fat has been identified as the essential fat depot for pathogenetic theories that relate obesity and colon cancer. The genders differ as regards to how the relationship between obesity and colon cancer has been evaluated. Obesity imposes a greater risk of colon cancer for men of all ages and for premenopausal women than it does for postmenopausal women. Regular exercise reduces the risk of developing colon cancer and the risk of death from colon cancer should it develop. We believe that a combination of waist circumference (WC) and body mass index (BMI) measurements is recommended to assess the obesity related risk of developing colon cancer. Radiographic assessments of visceral abdominal fat may eventually prove to be the best means of assessing a patient's obesity related risk of developing colon cancer. Although WC is better established as a measure of obesity than BMI, the evidence for colon cancer risk is not secure on this point; combining BMI and WC measurements would appear, at present, to be the wisest approach for colon cancer risk assessment. Doctors who wish to decrease their patients' risk of dying of colon cancer should advise weight loss and exercise. Conversely, physicians and public health authorities should consider both exercise and obesity when designing colon cancer screening protocols. Morphometric cut offs should be adjusted, if possible, for age, sex, ethnicity, and height.

Venous thromboembolism in morbid obesity and trauma. A review of literature.

Deep venous thromboembolism (DVT) is common and leads to disability, economic loss and even death. The aims of this paper are to start from the basic knowledge that we have about DVT and to tailor our knowledge to the treatment and diagnosis of thromboembolism in obese patients and trauma patients, which are among the patients who have a high risk of developing DVT and pulmonary embolism. Venous thromboembolism is a common complication in patients with major trauma, and effective, safe prophylactic regimens are needed. The patients are treated effectively with heparin and low molecular weight heparins, which are shown to be safe and effective. Morbid obesity is a disease that affects 10% of Americans and increases the incidence of DVT. Forty mg of enoxaparin subcutaneously twice a day seems to be a better DVT prophylaxis than the 30 mg twice a day. Many patients admitted to the hospital are morbidly obese; therefore, we suggest they start on low molecular heparin. The high morbidity of these patients is because most of them are bedridden, which increases the chance of DVT and death from pulmonary embolism. Trauma increases the chance of having DVT. Low molecular weight heparin or heparin is a safe and extremely effective method of preventing DVT in high-risk trauma patients.

Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The purpose of this study was to determine the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on symptomatic control of gastroesophageal reflux disease (GERD). METHODS: Morbidly obese patients (n = 435) who underwent LRYGBP for morbid obesity were assessed for changes in GERD symptoms, quality of life, and patient satisfaction after surgery. RESULTS: A total of 238 patients (55%) had evidence of chronic GERD, and 152 patients (64%) voluntarily participated in the study. The mean body mass index (BMI) was 48 kg/m2. The mean excess weight loss was 68.8% at 12 months. There was a significant decrease in GERD-related symptoms, including heartburn (from 87% to 22%, p<0.001); water brash (from 18% to 7%, p<0.05); wheezing (from 40% to 5%, p<0.001) laryngitis (from 17% to 7%, p<0.05); and aspiration (from 14% to 2%, p<0.01) following LRYGBP. Postoperatively, the use of medication decreased significantly both for proton pump inhibitors (from 44% to 9%, p<0.001) and for the H2 blockers (from 60% to 10%, p<0.01). SF-36 physical function scores and the mental component summary scores improved after the operation (87 vs 71; p<0.05 and 83 vs 66; p<0.05, respectively). Overall patient satisfaction was 97%. CONCLUSION: LRYGBP results in very good control of GERD in morbidly obese patients with follow-up as late as 3 years. Morbidly obese patients who require surgery for GERD may be better served by LRYGBP than fundoplication because of the additional benefit of significant weight loss.

Laparoscopic resection of a large periadrenal nonmalignant pheochromocytoma.

This is, to our knowledge, the first case description of an extraadrenal pheochromocytoma located in the periadrenal fat. Pheochromocytoma is a tumor that originates in the chromaffin tissue. Extraadrenal pheochromocytomas have been described commonly in locations such as the organ of Zuckerkandle (29%); the bladder (12%); the sacrum, testis, rectum, and pelvic floor (2%); the upper abdomen in association with celiac, superior mesenteric, and inferior mesenteric ganglia (43%); the thorax (12%); and the neck (2%), most commonly in association with the ninth or tenth cranial nerve ganglion. Our patient was a 40-year-old woman known to have had an adrenal mass for the last 4 years. She was referred for surgery because of an increase in the size of the mass to 11 cm. Laparoscopic adrenalectomy was performed via a posterior flank approach. The pathology report was of periadrenal fat pheochromocytoma, with positive staining for synaptophysin, chromogranin, and vimentin. The patient was discharged on postoperative day 3. The unique feature in this case was the uncommon location of the extraadrenal tumor: the supraadrenal fat. The other unique finding in this case was that the pheochromocytoma was neither symptomatic nor malignant, common features of extraadrenal masses.

Extensive liver resection: can it be applicable to laparoscopic surgery?

Due to major technical barriers, the safety and efficacy of laparoscopic hepatic resection is not well established. Laparoscopic liver resection has been described. Wedge resections or marginal resections rather than more formal hepatic resections for benign diseases only have been described lately. Anatomic hepatic resection and nonanatomical resection were also reported. But the technique still needs to be standardized and applied in a large-scale population. During the last 20 years, there has been a trend toward direct control of hepatic injury by adequate debridment of nonviable hepatic tissue along nonanatomical lines. The trauma experience emphasized two important concepts: the search for the most expedient method of hemorrhage control in the nonstable trauma patient, and a hepatic resection that need not be based on precise anatomic planes. The aim of this paper is to present the data and instruments available to apply toward laparoscopic liver resection.

Local and general anesthesia in the laparoscopic preperitoneal hernia repair.

OBJECTIVE: The extraperitoneal laparoscopic approach (EXTRA) has been shown to be an effective and safe repair for primary (PIH), recurrent (RIH) and bilateral hernia (BIH). There is very little data examining the merits of laparoscopic repair for hernias under local anesthesia. In this' paper, we compare EXTRA performed under both general and local anesthesia. METHODS: This nonrandomized prospective study was performed selectively on a male population only. Patients with associated pulmonary disease and high risk for general surgery were selected. Patients with recurrence and previous abdominal operations were excluded to decrease confounding variables in the study. A Prolene mesh was used in all patients. RESULTS: Between May 1997 and September 1998, 92 male patients underwent the repair of 107 groin hernias using the EXTRA technique. The procedure was explained to them, and different anesthesia options were given. Fourteen of these repairs were performed under local anesthesia and 93 under general anesthesia. Of the 10 patients who underwent a repair under local anesthesia, there were 8 indirect, 5 direct and 1 pantaloon. The mean age was 53 years. In the group of general anesthesia, the types of hernias repaired were 45 indirect, 30 direct and 11 pantaloon. The mean age was 45 years. The mean follow-up was 15 months. Each patient was sent home the same day. Two peritoneal tears were recorded in the first group. The operative time was longer in the local group (47 +/- 11 vs 18 +/- 3). None of the patients required conversion to an open technique or change of anesthesia. No recurrences were found in either group. The average time of return to work and regular activity was 3.5 +/- 1 and 3 +/- 1 days, respectively. CONCLUSION: There appears to be no significant difference in recurrence and complication rates when the EXTRA is performed under local anesthesia as compared to general. Blunt dissection of the preperitoneal space does not trigger pain and does not require lidocaine injection. The most painful area is the peritoneal reflection over the cord structure. The laparoscopic repair under local anesthesia represents an advantage in the repair of the inguinal hernia, particularly in the population where general anesthesia is contraindicated.

Commentary: quality of care and cost containment are the hospital-based ambulatory surgery challenges for the future.

Cost containment and quality of care represent the most important objectives of all health care professionals. Because of its progressive growth over the past decade, ambulatory surgery has become an area where these 2 issues need to be addressed. The goal of this paper is to discuss the economic and quality of care challenges faced by hospitals as they strive to become competitive in the 21st century. The quality of care in ambulatory surgery has been improving because of multidisciplinary activities. Hospitals tend to hire the staff on the basis of their expertise in certain areas, and those personnel do not have to cover other hospital roles. Moreover, the hospital staff is able to seek information at any time from coworkers in other areas of specialty. Ambulatory surgery in a hospital offers advantages, such as multiple operating rooms, multiple skilled health care providers, and the ability to stay overnight if needed. The consolidation of supplies makes it easier to contract for a better price. Aggressive contract negotiations and implementation of cost-effective and cost-efficient strategies are the keys to success in the future. Quality improvement (QI) initiatives and quality of care (QC) indicators need to be developed to address various problems in the ambulatory surgery setting such as unnecessary admissions, inadequate staffing, efficient operating room (OR) utilization, quality of care, and assessment outcome. These initiatives should be addressed at regular meetings where opportunities to improve the ambulatory services are discussed. The number of ambulatory surgery procedures performed each year will continue to increase, although perhaps not at the rate we experienced in the past. Procedures that once were performed in an inpatient setting can now be accomplished on an outpatient basis or even in the physician's office. We will continue to see this shift of volume as technologic advancements and anesthetic agents allow more complex procedures to be performed on an outpatient basis.

Minimal debridement in the treatment of Fournier's gangrene.

Scrotal and perineal gangrene of the male genitalia was first described by Fournier in 1883. Treatment of the disease remains surgical despite the availability of modern antibiotics. Many authors advocate a wide debridement of all tissue superficial to the involved fascial layers. We have reviewed our experience of using wide and minimal debridement as the surgical technique of choice. In our retrospective study, nine patients were diagnosed and treated over a 2-year period for Fournier's gangrene. The mean age was 65+/-28 years. Two patients were admitted from chronic care facilities, four were diabetic, and two had taken oral steroids. Five of the nine patients were treated with the technique of minimal tissue debridement. In brief, the scrotum was bivalved along the median raphe, each scrotal sac was drained, and the testicles were exteriorized. Orchiectomy was performed if the testicles were grossly necrotic. Penrose drains were inserted from each scrotal sac to the counterincision at the level of the internal rings. All of the tissue involved was irrigated with betadine and peroxide, after debridement of the necrotic tissue. Broad-spectrum antibiotics along with daily packing were continued for 4 to 6 weeks; at the end of that time the testicles were returned to the scrotum and the skin was loosely reapproximated. Three of the nine patients were treated with wide debridement of all the soft tissue including the fascia. One of the patients displayed gangrene of the entire abdominal wall; he was not a surgical candidate and died 3 days later. The four patients treated with minimal debridement all obtained successful treatment of their fasciitis. However, one died of complications related to a duodenal ulcer. The mean hospital stay was 45+/-10 days. Two of the three patients treated with wide debridement required plastic reconstruction using a skin-muscle flap of the perineum. The remaining patient treated with wide debridement died of complications related to metastatic renal carcinoma. The mean hospital stay of this group was 62+/-12 days. The specific flora included: Bacteroidis fragilis in 87 per cent, Peptostreptococcus and Streptococcus in 75 per cent, Clostridia group, Escherichia coli, Enterobacter and Pseudomonas in 62 per cent, Klebsiella in 50 per cent, Staphylococcus in 37 per cent, and Proteus in 12 per cent of the patients. In the surgical management of Fournier's gangrene, wide drainage with minimal debridement resulted in similar morbidity and shorter hospital stay when compared with extensive debridement.

Competency-based instruction to improve the surgical resident technique and accuracy of the trauma ultrasound.

In a surgical trauma center, programs and workshops have improved the performance on focused abdominal sonogram for trauma (FAST). The purpose of this single-blind study was to prove that a cadaver laboratory competency-based instruction program may be an effective method of FAST training to acquire the skills that would be applied in the trauma room. The study was divided in two parts, laboratory and clinical. Nine surgical residents were divided into two groups: Group I performed the test only once, and Group II performed the training twice. A third "group" was the senior ultrasound technician, whose readings served as our "gold standard" with which to compare the resident readings (Group III). Using cadavers, a 2-cm catheter was introduced into the peritoneal cavity. Sequential aliquots of normal saline were introduced into the abdominal cavity at 0-, 200-, 400-, 600-, and 1000-cc increments in each group tested. The residents were asked to describe their examinations for the presence or absence of fluid in the abdomen. The ultrasound examination was then performed with the cadaver in three different positions to study if there was any difference of fluid detection in varied positions. True positive, true negative, and accuracy were then calculated comparing the three different groups of test sonographers. In the second part of the study, the same residents were then followed in the trauma room, where they performed the FAST in the absence of the ultrasound technician during emergencies. As in the laboratory, the accuracy of their reading compared with that of the ultrasound technician was also evaluated. From 400 cc and upward, Group II began having an overall significantly superior accuracy than the first group and the technician in most quadrants examined. The trend was apparent for more accurate results in all quadrants and positions by all groups as the fluid was increased. Overall, group II was most superior in detection of intra-abdominal fluid in the cadaver. In the clinical scenario, the residents as a whole had similar accuracy (92% vs 96%) in reading FAST as the ultrasound technician. Our results suggest that surgical residents have the ability to detect fluid in the abdomen, there exists a fast learning curve, and the minimum detection level of fluid was between 200 and 400 cc in the peritoneal cavity in the laboratory. Surgical residents were able to detect intra-abdominal fluid in the trauma situation, as shown by the 92 per cent accuracy of the FAST in the emergency situation. We conclude that a cadaver laboratory training program is an important adjunct to improve the skills of the resident in performing and reading FAST.

Factors influencing the potential organ donation: a 6-yr experience of the New Jersey Organ and Tissue Sharing Network.

UNLABELLED: The demand for organ transplants in the United States is increasing by 16% every year. Unfortunately, organ donation figures are not increasing at the same rate. Factors that influence the process of organ donation in New Jersey were analyzed. METHODS: A retrospective study in which the charts of actual and potential organ donors identified by the New Jersey Organ and Tissue Sharing Network (OTSN) between January 1990 and December 1995 were reviewed. Potential donors who were not identified by the OTNS or the United Network for Organ Sharing (UNOS) were not considered because no data relative to these cases were available. The conversion ratio (CR) between actual donor from potential donor was determined. A statistical analysis of the data was performed using multivariate regression logistic analysis. RESULTS: Organ donation increased, both in the male and female population, by 14% over the last 6 yr. The 0-5-yr age group experienced an increment in CR from 7.7 to 37.7% (p < 0.001). All other age groups had a continuous improvement, but a statistically significant increase over time was not observed. The CR of all races increased over the 6-yr study period. The Afro-American population donated significantly less than the white population (32.1 vs. 59.9%) (p < 0.001). The three transplant centers in New Jersey had a CR less than that seen in the non-transplant centers (38.1 vs. 44.1%). The number of total donations (78.7 vs. 21.3%) was significantly greater in the non-transplant centers (p < 0.001). Moreover, the number of lost donors was higher at transplant centers (p < 0.001). Over the 6-yr period, the difference between donations coming from non-urban (70.8%) versus urban areas (29.27%) was highly significant (p < 0.001). Traumatic deaths were associated with a greater CR (55.3%) than all other causes of death. The CR for donors dying as a result of motor vehicle accidents (MVA) (p < 0.001), penetrating trauma, and child abuse all increased. Level II trauma centers had a better CR (53.7%) than level I centers (48.4%) and non-trauma centers (51.1%). The donation rate was similar for level II and non-trauma centers (60%). CONCLUSIONS: The organ donation rate in New Jersey is not sufficient to meet the needs of organ recipients in New Jersey. Pediatric donations increased considerably, specifically from child abuse. MVA deaths are associated with the greatest CR. Urban areas have a worse CR than non-urban areas, even if they are associated with transplant or trauma

Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair.

BACKGROUND: In 1975, researchers introduced the use of a large unsutured polyester mesh prosthesis placed in the preperitoneal space for inguinal hernia repair. Different stapling devices have been used to secure this mesh, and the most common complication of the procedure is nerve damage secondary to the staples. The necessity of stapling has never been demonstrated. We designed a prospective randomized study of the need for stapling in laparoscopic extraperitoneal repair of inguinal hernias with 1-year and 3-year followup. STUDY DESIGN: Inclusion criteria of the study were men older than 18 years and first-time inguinal hernia repair. Patients with recurrence and previous abdominal operations were excluded to avoid confounding variables. Each patient's hernia was assigned a consecutive random number chosen by computer, with each number corresponding to an assigned group. The first group had stapled mesh and the second had unstapled mesh. RESULTS: Data were collected over a 15-month period, with each procedure having a mean followup time of 8 months. A total of 100 procedures was performed in 92 patients. The two groups of patients were well matched for age and the type of hernia repaired. There were no recurrences in either group and no complications or deaths. CONCLUSIONS: The initial 12-month followup showed no significant differences in recurrence or complication rates between the stapled and unstapled groups. Both groups returned to work within an average of 4 days. A net savings of $120 was realized for each hernia repair performed without stapled mesh. In addition, stapling presents an inherent risk of nerve damage.

Is 30 minutes the golden period to perform emergency room thoratomy (ERT) in penetrating chest injuries?

BACKGROUND: Emergency room thoracotomy (ERT), a controversial procedure, was introduced to improve resuscitation of trauma patients. No study has been conducted to evaluate the importance of the time in the field (down time) in the initial survival of penetrating chest trauma requiring ERT. In addition to this, many factors have been considered to predict the success of ERT, but they are multiple and are not easy to assess in the brief period of decision making to perform an ERT. We decided, therefore, to see if the pre hospital time could be used as the principal parameter to predict whether TERT in emergency Department (ED) with the arrival of penetrating chest trauma is useful. METHODS: Records of the Howard University Hospital Emergency Department (ED) were reviewed for all trauma patients between June 1992 and January 1995. The pre-admission data were obtained from Emergency Medical Service (EMS) reports, including the "down time". All patients who underwent ERT had vital signs documented by EMS in the field. Forensic autopsies were performed within 48 hours after death following practice standards already described. RESULTS: Between January 1987 and June 1994, 58 adult patients presented with penetrating chest trauma at the Howard University Hospital Emergency Department. Pre-admission data were available for 49 of 58 chest trauma patients. Sixteen patients (33%), with no documented vital signs in the field, were pronounced dead on arrival in the ED, and no ERT was performed on them. The remaining thirty-three patients (57%) underwent ERT. In all patients with chest injury, the Revised Trauma Score (RTS) was below 4 on arrival to the ED. Considering only the patients (n=33) that underwent ERT 82% (n=27) of patients had vital sings upon arrival in ED, 19% (n=6) had no vital signs until arrival to the ED. Patients with multiple wound GS or SW (more than four) died on arrival (18%; n=6). The patients with single gun shot wounds or stab wounds (GSW/SW) survived initially and underwent ERT (82%; n=27). Of the patients who underwent ERT, (n=6; 18%) had GSW and (12%), (n=4) had SW. Among those patients that died in ED, 12% (n=4) had a drop of SBP of more than 50 mmHg and only 24% (n=8) presented with a SBP less than 70 mmHg. Average scene time was 11.2+/-8.1 min, the transit time was 7.9+/-5.6 min and the average ED resuscitation time was 10+/-3.2 min. Of the patients that arrived in ED within 30 minutes 63% (n=20) survived the first 24 hours, and of these only 9% (n=3) had no vital signs upon arrival. The remaining 28% (n=6), who arrived in ED after half hour, either died during the transportation or upon arrival to the ED; none of them had vital signs upon arrival. All the patients transferred to the ICU died within 24 to 78 hr, secondary to severe arrhythmia or cerebral hypoxia. Autopsy was performed in all the patients. Among the patients that died upon arrival in the ED, the most common injury responsible for death was ventricular injury with exanguination in the first 24 hours. Of the 9% of patients that died in the ED after ERT, the injury was caused by a 9 mm caliber gun, which created a major laceration to the ventricle which was not possible to repair during the ERT. In the patients that died after stab wound (12%; n=4), the patients were stabbed at least 3 times in the chest and they died of arrhythmia. Among the survivors of ERT that were transported in ICU, uncontrollable arrhythmia and acute lung injury was the cause of death within 24-72 hours in 45% (n=15) of patients while cerebral hypoxia complicated irreparably the life expectancy with death at 72 hours in 60% (n=20) of patients. CONCLUSIONS: The only role of ERT in our opinion is in patients who arrive within 30 minutes of pre hospital time, with a witnessed vital signed in the field. Multiple wounds, low SBP and higher caliber bullet injuries are also negative prognostic factors.

Surgical residents and ultrasound technician accuracy and cost-effectiveness of ultrasound in trauma.

The purpose of this study is 2-fold: 1) to assess the accuracy of the Focused Abdominal Sonogram for Trauma (FAST) as an important evaluative tool for the trauma victim as compared with other objective testing resources (i.e., computerized axial tomography scan); and 2) to analyze the cost-effectiveness of FAST as performed by surgical residents as compared with ultrasound (US) technicians. FAST was performed on 650 trauma victims over a period of 12 months. Testing was completed in a trauma room of the emergency department by an US technician or a trauma surgical resident as determined by the availability of the US technician. Hypotensive patients required two FASTs to be completed for comparison of results. Persistent difficulty interpreting the FAST required the addition of a computerized axial tomography scan to help clarify the results. Statistical analysis was performed using chi2 and analysis of variance. False positive, false negative, and true positive, true negative, along with the accuracy of FAST were calculated as compared with other diagnostic testing. The finding indicated that FAST was both specific (99 per cent) and sensitive (68 per cent) in the sample used. Of the 650 patients receiving FAST, true negative was 95 per cent, true positive was 3 per cent as compared with false negative at 1 per cent, and false positive at 0.5 per cent. US technicians performed 81 per cent of the FASTs with an accuracy of 92 per cent. In comparison, surgical residents had a 92 per cent rate of accuracy in the remaining 19 per cent of the population. The mean accuracy of both was 94 per cent. Furthermore, FAST as performed by resident incurred a single fee of $88 for radiological readings as compared with $274 for an US technician fee plus the radiological reading fee of $88. FAST as performed by surgical residents is more cost-effective than FAST as performed by an US technician.

Entrapment of a Swan Ganz catheter in an IVC filter requiring caval exploration. A case report.

The placement of Swan Ganz (SW) catheters and inferior vena cava (IVC) filters are common procedures performed in critically ill patients. Many reports describe the independent misplacement of SG catheters and IVC filters, and others have reported migration of IVC filters and entanglement of various intravascular devices in IVC filter. Our patient is a 70-year-old Caucasian woman who underwent an aortic valve replacement and coronary artery bypass grafting. The patient developed a deep venous thrombosis and an infrarenal IVC filter was placed without incident. A Swan Ganz catheter was placed later in the postoperative period and became entangled in the IVC filter. We advised operative removal after several unsuccessful percutaneous attempts to retrieve the catheter. IVC filters are indicated for prevention of fatal pulmonary emboli in patients with a contraindication to anticoagulants or with recurrent embolism despite adequate anticoagulant therapy. Complications of IVC filters include caval thrombosis, retroperitoneal hemorrhage and perforation of the IVC, hepatic veins, duodenum and aorta. We describe our evaluation and operative approach and make recommendations for prevention of entangling the SG into the IVC filter.