Cervical spine clearance and neck extension during percutaneous tracheostomy in trauma patients.

INTRODUCTION: The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy. OBJECTIVE: To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy. DESIGN: Prospective analysis of case series from August 1, 1995 to August 31, 1998. SETTING: A university-based Level I trauma center. PATIENTS: A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared. RESULTS: The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had "bull" or "thick" necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral position (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy. CONCLUSION: Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.

Weaning injured patients with prolonged pulmonary failure from mechanical ventilation in a non-intensive care unit setting.

BACKGROUND: Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting. METHODS: A retrospective review of trauma patients (August 1996-January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival. RESULTS: Fifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 +/- 5.4 days (n = 37). CONCLUSIONS: Implementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.

Minimally invasive surgery. Bedside tracheostomy and gastrostomy.

Minimally invasive surgical techniques have gathered tremendous momentum. Most patient benefit is realized in the ambulatory setting. Smaller incisions result in less pain and earlier return to activities. Critically ill patients typically do not benefit from minimally invasive techniques in this manner; however, they do benefit from other aspects of minimally invasive tracheostomy and gastrostomy. Small tracheostomy wounds are associated with reduced wound problems (infection and breakdown). The small stab wounds of minimally invasive gastrostomy are associated with less pain and with an absence of fascial dehiscence. Furthermore, because these procedures are performed easily and safely at the bedside, transport and operating room costs are avoided. Although these procedures are minimally invasive, they are major procedures. Devastating complications can become life-threatening. Attention to detail is required to avoid or respond promptly to complications. In this way, patients receive maximal benefit at minimal risk.

Surveyed opinion of American trauma surgeons on the prevention of the abdominal compartment syndrome.

OBJECTIVE: To determine the current opinion of American trauma surgeons on the use of the open abdomen to prevent the abdominal compartment syndrome (ACS). METHODS: On a questionnaire survey of expert trauma surgeons regarding 12 clinical factors influencing fascial closure at trauma celiotomy, surgeons graded their willingness to close the fascia in various scenarios on a scale of 1 to 5. The impact of six signs of clinical deterioration on willingness to perform abdominal decompression in a patient with postceliotomy elevated intra-abdominal pressure (IAP) was also queried. Of 292 members of the American Association for the Surgery of Trauma active in abdominal trauma management, 248 members (85%) had experience with ACS one or more times in the previous year. RESULTS: Surgeons' responses to factors found at trauma celiotomy were divided into two distinct categories: factors decreasing willingness to close the fascia, and factors not changing or increasing willingness to close the fascia (p < 0.001). Factors disfavoring fascial closure were pulmonary or hemodynamic deterioration with closure, massive bowel edema, subjectively tight closure, planned reoperation, and packing. Factors not changing or favoring fascial closure were fecal contamination/peritonitis, massive transfusion, hypothermia, multiple abdominal injuries, acidosis, and coagulopathy. Five of the six signs of clinical deterioration increased surgeons' willingness to decompress a patient with elevated IAP (increased O2 requirement, decreased cardiac output, increased acidosis, increased airway pressures, and oliguria). Lowered gastric mucosal pH did not affect willingness. Seventy-one percent of surgeons indicated they would decompress elevated IAP in postceliotomy patient if one or two signs of clinical deterioration were present, but only 14% would decompress a patient for elevated IAP alone. CONCLUSION: A majority of expert American trauma surgeons have experience with ACS and would leave the abdomen open if ACS occurred. A majority would reopen a closed abdomen in cases of elevated IAP with signs of clinical deterioration. A minority would leave the abdomen open when there was only a risk of developing ACS.

Nitrosothiol quantification in human plasma.

A high-pressure liquid chromatography (HPLC) assay for measuring picomole quantities of nitrosothiol in biological samples was developed. The assay utilizes the catalytic reduction of nitrosothiol by mercuric cation (Hg2+). Released nitrogen oxide reacts with sulfanilamide (SA) and N-(1-napthyl)ethylenediamine (NNED) to form a stable azo dye. The azo dye is then separated from N-(1-napthyl)ethylenediamine and quantified by reversed-phase HPLC. In addition to nitrosothiol, nitrite and atmospheric nitrogen oxides are sources of nitrogen oxide that react with the reagents, SA and NNED, to form the azo dye. Therefore, a reference sample, which includes the nitrosothiol sample and all reagents except Hg2+, is utilized for the subtraction of nitrite and atmospheric nitrogen oxides which "contaminate" the nitrosothiol sample and reagents. This method is a sensitive (approximately 3 pmol; approximately 10(-1) microM) and accurate means to measure nitrosothiol concentration in biologic samples.

Teacher consultation: impact on teachers' effectiveness and students' cognitive competence and achievement.

Teachers from six ethnically diverse inner-city schools participated in weekly mental health consultation for more than two years. Using a quasi-experimental design, a longitudinal sample of 91 teachers and 209 students was assessed periodically through multiple standardized measures. Results indicate that a low-cost, indirect intervention had a direct impact on teachers' sense of professional competence and was linked to positive changes in students' sense of cognitive competence and their academic achievement.

New concepts in the pathophysiology of oxygen metabolism during sepsis.

Sepsis is an intriguing pathological condition associated with many complex metabolic and physiological alterations. In this review a novel hypothesis in the pathophysiology of oxygen metabolism during sepsis is explored. It is proposed that the hypermetabolic response to sepsis results from enhanced reactive oxygen generation by phagocytes. Reactive oxygen detoxification by host enzyme systems subsequently leads to alterations in oxidative metabolism. The similarities between the metabolic consequences of reactive oxygen metabolism and the metabolic changes observed during sepsis are outlined. A unified concept is presented to help explain the pathophysiological changes in oxygen metabolism during sepsis.

The effect of valvulotomy on the flow rate through the saphenous vein graft: clinical implications.

Potential differences in flow rates between reversed and in situ saphenous vein bypass grafts were evaluated. One hundred ten greater saphenous vein segments containing isolated valves were examined with fiber-optic angioscopy during pulsatile and nonpulsatile flow. Valve competency was determined, and the degree of luminal obstruction caused by the valve during reversed flow was calculated with caliper measurements of the video image. Flow measurements were obtained before and after valvulotomy, in reversed and nonreversed vein orientations. Increased flow rates occurred during pulsatile irrigation only, after valvulotomy in vein segments with diameters less than 2.5 mm (p less than 0.001, Bonferroni t test). In these small-diameter vein segments, the flow rate in reversed valve-intact vein was 94.4 +/- 28.9 ml/min (mean +/- 1 standard deviation), the flow rate in reversed valve-disrupted vein was 136.4 +/- 36.5 ml/min, and the flow rate in nonreversed valve-disrupted vein was 137.8 +/- 31.3 ml/min. In 22 vein segments, luminal obstruction caused by the intact valve was measured angioscopically. A small valve orifice was found to be related to a large increase in flow rate after valvulotomy (p less than 0.02, least-squares regression). In addition, veins with diameters less than 2.5 mm have significantly smaller valve orifices compared with veins with diameters greater than 2.5 mm. These results present important clinical implications as the number of distal extremity reconstructions increases.

Toward the development of a rational scale in the use of human-figure drawings as a kindergarten screening measure.

The Draw-A-Person Test was individually administered to 120 kindergartners from diverse socioeconomic backgrounds, ranging in age from 4 yr. and 10 mo. to 6 yr. and 4 mo. This study was conducted to validate and expand Goldman and Warren's earlier work (1976) on the development of a rational scale for use as a kindergarten screening measure. Correlational analyses corroborate the earlier findings that body-part omissions are the most predictive items of emotional high risk. Factor analyses of the current data also replicate earlier findings in which two underlying cohesive factors emerged. The first factor has high loadings on peripheral body-part omissions; the second factor has high loadings on central body-part omission. The results suggest that an interchangeable number of body-part omissions together, rather than any one item, predict high emotional risk. Structural and content characteristics do not contribute significantly to the development of a kindergarten screening measure.