Proximity penetrating extremity trauma: the role of duplex ultrasound in the detection of occult venous injuries.

The diagnosis and management of occult vascular injuries caused by penetrating proximity extremity trauma (PPET) remains controversial. Over 18 months, we prospectively screened 37 patients (43 lower extremities) with PPET for occult arterial and venous injuries using noninvasive studies (physical examination, ankle-brachial indices, color-flow duplex ultrasonography (CFD)) and angiography (arteriography, venography). Eight isolated, occult venous injuries were detected (incidence, 22%). CFD detected seven of eight (88%) venous injuries. Venography was technically difficult to perform in this patient population and failed to detect four femoral-popliteal vein injuries. Major thromboembolic complications (pulmonary embolism, symptomatic deep vein thrombosis, venous claudication) occurred in 50% of the patients identified with femoral-popliteal vein injuries. Arterial injuries were detected in 4 of 42 (10%) extremities (arteriography, n = 3; CFD, n = 1) and were clinically benign. We conclude that following PPET, (1) isolated, occult venous injuries are common and are associated with significant complications and (2) CFD is useful for screening for occult venous injuries.

Surgical repair of a celiac axis aneurysm and renal oncocytoma: a single case report.

Visceral artery aneurysms are unusual lesions. However the frequency of diagnosis has increased in recent years as a result of increased utilization of arteriogram and computed tomographic (CT) scan. When diagnosed in conjunction with other syndromes, alternative treatment options can be utilized. The present case discusses a 67-year-old black male who presented with a right renal mass and celiac artery aneurysm. The renal mass was diagnosed as an oncocytoma. This unique anatomy enabled us to perform a right nephrectomy in conjunction with a celiac artery aneurysmectomy with primary anastomosis between the right renal artery and common hepatic artery. This case demonstrates our approach to an unusual problem.

Pneumonia: incidence, risk factors, and outcome in injured patients.

One hundred thirty (44.2%) of 294 patients hospitalized for trauma and admitted to the Surgical Intensive Care Unit for mechanical ventilation developed hospital-acquired bacterial pneumonia. The predominant pathogens isolated were gram-negative enteric bacilli (72%), but there was not an increase in mortality associated with gram-negative pneumonia compared with similar patients without pneumonia. Of the seven admission risk factors univariately associated with the development of acquired bacterial pneumonia, only emergent intubation (p less than 0.001), head injury (p less than 0.001), hypotension on admission (p less than 0.001), blunt trauma as the mechanism of injury (p less than 0.001), and Injury Severity Score (p less than 0.001) remained significant after stepwise logistic regression. Not surprisingly, as mechanical ventilation is continued, the probability of pneumonia emerging increases. The consequences of hospital-acquired bacterial pneumonia are a significant seven-, five-, and two-fold increase in mechanically ventilated days, intensive care, and hospital stay, respectively. We conclude that the incidence of hospital-acquired pneumonia in injured patients admitted to the ICU for mechanical ventilation occurs in nearly half the patients, is associated with specific risk factors, and significantly increases morbidity but does not increase mortality.

Indomethacin treatment of human adult respiratory distress syndrome.

The purpose of this investigation was to evaluate the magnitude and duration of changes in lung function and oxygen transport in patients with adult respiratory distress syndrome (ARDS) receiving indomethacin. Ten patients with ARDS were randomized to receive intravenously either a single 50 mg dose of indomethacin or placebo. Comparing 1 hr postinfusion levels to baseline observations in the indomethacin group, PaO2 increased to 125 +/- 13 torr from 93 +/- 8 torr, PaO2/FIO2 ratio increased to 223 +/- 24 from 160 +/- 5, and Qs/Qt dropped to 0.20 +/- 0.03 from 0.27 +/- 0.03 (all P less than 0.05). These alterations in oxygenation gradually returned to baseline levels over the ensuing 8 hr. No such changes were noted in the placebo group.

The role of percutaneous transhepatic internal biliary drainage in preoperative patients.

Routine percutaneous transhepatic drainage (PTD) has been recommended for minimizing morbidity after operations for obstructive jaundice. This approach assumes that early complications of PTD are rare or insignificant. It has also been suggested that internal (transsphincteric) drainage is superior to external drainage. To assess its safety, a consecutive series of 18 patients in whom PTD was performed prior to definitive operations for obstructive jaundice was reviewed. Internal biliary drainage was attempted in every instance. The biliary system was successfully cannulated in 100 per cent and the drainage catheter was passed into the duodenum in 16 patients (88%). Five patients (28%) had serious complications of PTD requiring emergency operations; three died. Complications after internal PTD were no rarer or less serious than those after transhepatic cholangiography without drainage. We recommend early surgical exploration once the site of complete biliary obstruction is demonstrated by cholangiography.