From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment.

Ultrasound is a ubiquitous and versatile diagnostic tool. In the setting of acute injury, ultrasound enhances the basic trauma evaluation, influences bedside decision-making, and helps determine whether or not an unstable patient requires emergent procedural intervention. Consequently, continued education of surgeons and other acute care practitioners in performing focused emergency ultrasound is of great importance. This article provides a synopsis of focused assessment with sonography for trauma (FAST) and the extended FAST (E-FAST) that incorporates basic thoracic injury assessment. The authors also review key pitfalls, limitations, controversies, and advances related to FAST, E-FAST, and ultrasound education.

Nasoenteric tube complications.

The use of nasoenteric tubes (NETs) is ubiquitous, and clinicians often take their placement, function, and maintenance for granted. NETs are used for gastrointestinal decompression, enteral feeding, medication administration, naso-biliary drainage, and specialized indications such as upper gastrointestinal bleeding. Morbidity associated with NETs is common, but frequently subtle, mandating high index of suspicion, clinical vigilance, and patient safety protocols. Common complications include sinusitis, sore throat and epistaxis. More serious complications include luminal perforation, pulmonary injury, aspiration, and intracranial placement. Frequent monitoring and continual re-review of the indications for continued use of any NET is prudent, including consideration of changing goals of care. This manuscript reviews NET-related complications and associated topics.

Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies.

Given the increasing complexity of both the modern health care environment and the overall patient population, reduction of medical errors is a high priority task for health policy makers and medical/surgical community alike. The problem of retained surgical foreign bodies (RSFB) has existed ever since the humans first performed surgical procedures. Retained surgical foreign bodies continue to be a significant problem with an incidence between 0.3 and 1.0 per 1,000 abdominal operations. Retained surgical foreign bodies have the potential to cause harm to the patient and carry profound professional and medico-legal consequences to surgical trainees, surgical practitioners, hospitals, and health systems. Currently, there are no known methods of entirely eliminating the occurrence of RSFB. In this manuscript, the authors discuss the available evidence with regards to risk factors associated with RSFB as well as methods of minimizing the incidence of RSFB. Modern technological advances designed to decrease the incidence of RSFB (radio-frequency tagging of surgical sponges) and improved perioperative patient processing (multiple 'checks and balances' and better provider-to-provider communication) are reviewed. The authors also explore the relationship between RSFB and surgical training with emphasis on education in early recognition, prevention, and focus on team-oriented training strategies.

Complications associated with pulmonary artery catheters: a comprehensive clinical review.

Care for the critically ill patient requires maintenance of adequate tissue perfusion/oxygenation. Continuous hemodynamic monitoring is frequently utilized to achieve these objectives. Pulmonary artery catheters (PAC) allow measurement of hemodynamic variables that cannot be measured reliably or continuously by less invasive means. Inherent to every medical intervention are risks associated with that intervention. This review categorizes complications associated with the PAC into four broad groups--complications of central venous access; complications related to PAC insertion and manipulation; complications associated with short- or long-term presence of the PAC in the cardiovascular system; and errors resulting from incorrect interpretation/use of PAC-derived data. We will discuss each of these four broad categories, followed by in-depth descriptions of the most common and most serious individual complications.

Vena cava filters: a synopsis of complications and related topics.

Deep venous thrombosis and pulmonary embolism constitute common preventable causes of morbidity and mortality. The incidence of venous thromboembolism (VTE) continues to increase. Standard anticoagulation therapy may reduce the risk of fatal PE by 75% and that of recurrent VTE by over 90%. For patients who are not candidates for anticoagulation, a vena cava filter (VCF) may be beneficial. Despite a good overall safety record, significant complications related to VCF are occasionally seen. This review discusses both procedural and non-procedural complications associated with VCF placement and use. We will also discuss VCF use in the settings of pregnancy, malignancy, and the clinical need for more than one filter.

Laparoscopic repair of traumatic diaphragmatic injuries.

BACKGROUND: Laparoscopy has been proposed as a diagnostic and potentially therapeutic modality for penetrating diaphragmatic lacerations. The purpose of this study was to assess the technical feasibility and strength of various laparoscopic repairs of diaphragmatic injuries. METHODS: Swine underwent either open suture repair or laparoscopic repair by staple, suture, or patch technique of a 2-cm laceration to both the right and the left muscular or tendinous diaphragmatic leaflets. Six weeks after operation, diaphragms were harvested for either histologic analysis or bursting strength measurements. RESULTS: All methods of repair proved technically feasible. There was no significant difference in bursting strength measurements between treatment groups. Bursting was due to tissue failure either at or adjacent to the repair site. Histologic analysis confirmed healing of all specimens with the laparoscopic patch technique inciting less inflammation and greater fibroblastic proliferation than the other techniques. CONCLUSIONS: Laparoscopic repair of diaphragmatic lacerations can be accomplished using any of the currently available techniques. Laparoscopic stapling, suturing, or patch techniques all result in complete healing with a strong and durable repair. When selecting a particular technique, familiarity of the surgeon should be used as a guideline.

Antioxidant enzymes are induced during recovery from acute lung injury.

OBJECTIVE: To determine the contribution of the pulmonary antioxidant defense enzymes of the hexose monophosphate (HMP) shunt and glutathione systems to recovery from oxidant-mediated lung injury in an animal model shown to closely resemble the clinical syndrome of acute respiratory distress syndrome. DESIGN: Prospective, controlled laboratory study on phorbol myristate acetate (PMA)-induced lung injury in rabbits. SETTING: Animal research laboratory. SUBJECTS: Rabbits were injected with PMA (80 microg/kg) for 3 consecutive days. Control animals received normal saline. MEASUREMENTS AND MAIN RESULTS: Lungs were harvested at 24, 48, 72, and 96 hrs (n = 5/time point) after PMA injection or after the third injection of normal saline in control animals (n = 6). The cytosolic fraction from lung and bronchial alveolar lavage (BAL) fluid was used for measurements of HMP shunt and glutathione enzymes. Pulmonary activity peaked at 48 hrs post-PMA injury with a 40% increase in glucose-6-phosphate dehydrogenase activity and a 32% increase in 6-phosphogluconate dehydrogenase activity over control levels. BAL activity was maximal at 72 hrs with an increase of 98% in glucose-6-phosphate dehydrogenase and 346% in 6-phosphogluconate dehydrogenase activities. Glutathione peroxidase was maximally induced by 77% at 48 hrs in BAL and by 107% at 24 hrs in lung. Glutathione reductase activity did not increase significantly in either lung or BAL. CONCLUSIONS: The observed induction of the antioxidant enzymes in response to PMA suggests that both the HMP shunt and the glutathione systems contribute to the recovery phase of oxidant-mediated lung injury. The inability of natural host defenses to regenerate reduced glutathione may explain failure of recovery from acute respiratory distress syndrome and suggests an avenue for clinical intervention.