Single-dose antibiotic prophylaxis for biliary surgery. Cefazolin vs moxalactam.

Cefazolin was compared with moxalactam for single-dose prophylaxis against infection in a double-blind, prospective, randomized trial of 90 patients undergoing cholecystectomy. Risk factors for infection were present in 65 (72%) of the 90 patients and were evenly distributed. Antibiotic levels in plasma, bile, and tissue measured when the cystic duct was divided were similar for both drugs. Age greater than 65 years but not recent cholecystitis or type of antibiotic was predictive of recovery of bacteria from bile cultures. Wound infections occurred in two patients receiving cefazolin and one patient receiving moxalactam for an overall infection rate of 3%. No toxic reactions to antibiotics, including bleeding disorders, were observed. In conclusion, no significant difference in prophylactic efficacy was detected in this comparison of a first-generation with a third-generation cephalosporin. Because of its lower cost and narrower antimicrobial spectrum, however, cefazolin should remain the agent of choice.

The acridine orange fluorochrome microassay: a new technique for quantitation of neutrophil function in burned patients.

A new assay for determination of neutrophil bacterial killing and phagocytosis is presented. The acridine orange (AO) fluorochrome microassay is a simple, reliable technique for assessing polymorphonuclear (PMN) function. It requires small amounts of blood and provides a rapid and reproducible quantitation of neutrophil activity. Using this technique, bacterial killing and phagocytosis were assessed in a group of five severely burned patients admitted to the Medical College of Virginia Burn Unit. All patients studied demonstrated a significant decrease in bacterial killing at some point during their clinical course. The AO assay was found to be a reliable and effective means of quantitating PMN bacterial phagocytosis and killing in this group of burned patients.

Cimetidine therapy for burn shock: a quantitative assessment.

Optimal cardiac output (CO) resuscitation for severely burned guinea pigs is obtained with intravenous volumes of lactated Ringer's (LR) calculated at 4 cc/kg/%burn/24 hr. When one half this volume of LR is given (2 cc/kg/%burn/24 hr) CO is significantly (p less than 0.05) reduced at 2, 4, and 8 hours after injury. When early postburn cimetidine therapy (0.5 hours after injury) is added to only 1 cc/kg/%burn/24 hr LR, CO is significantly elevated for the same time periods and is not significantly different from CO values of LR at 4 cc/kg/%burn/24 hr for the first 24 hours after injury. However, postburn cimetidine therapy delayed until 1 hour after burn injury did not improve CO compared to treatment with LR at 2 cc/kg/%burn/24 hr. These observations suggest that early postburn cimetidine therapy administered within 1/2-hour of severe scald injury will result in significant CO improvement while simultaneously reducing resuscitative fluid volume requirements by as much as 70% for the first 24 hours after injury.

Evaluation of an emergency medical service referral system for burn patients.

It is the purpose of this report to examine the process of burn care of hospitalized burn patients in the Commonwealth of Virginia over a 21 month period. Eighty-nine per cent of the hospitals within the state participated in the study, the results of which provide a positive indication of the performance of our statewide emergency medical service referral system. This system was successful in redistributing patients, with the more severely burned patients being treated in the specialty burn treatment facilities. The process of burn care within the hospital setting was also consistent with the patient's severity of injury.

Infections in burned patients.

Prevention and treatment of burn wound infection requires knowledge of the epidemiology of such infections. Prevention of infection rests on removal of reservoirs or sources of microorganisms from the burn patient's environment and interruption of transfer of microorganisms to the surface of the wound. When prevention fails and burn wound infection develops, successful therapy may depend on an understanding of the epidemiology of the burn wound during therapy. Contrary to the oft stated concept that antibiotics penetrate the avascular burn wound poorly, our study demonstrated that gentamicin and tobramycin achieved therapeutic concentrations in burn wound tissue. As in other types of infections, susceptible microorganisms were eradicated and resistant microorganisms persisted. Of most importance was the observation that resistant microorganisms may repopulate the wound within four days of starting therapy. It would appear that failure of therapy is not due to failure of antibiotics to penetrate the burn wound but rather to rapid development of superinfection during therapy.

Gentamicin and tobramycin penetration into burn eschar. Pharmacokinetics and microbiological effects.

This study was designed to determine whether intravenously administered gentamicin sulfate and tobramycin sulfate penetrate into the eschar of patients with severe burns. In addition, each antibiotic's pharmacokinetics in serum and the effect on eschar microbiology were determined. Twenty patients with suspected burn wound sepsis received either gentamicin or tobramycin. The microbiology of the baseline eschar was determined and repeated on days 2, 4, and 7. All patients had measurable aminoglycoside tissue concentrations, and elimination from serum was not unusually rapid. Thirteen patients had baseline eschar cultures positive for Pseudomonas aeruginosa or Serratia marcescens; eight patients were initially bacteremic. Pseudomonas aeruginosa strains were sensitive to both antibiotics and usually declined in concentration with time or were eliminated; the more drug-resistant isolates of S marcescens persisted or caused super-infection and bacteremia. Aminoglycoside antibiotics penetrate into burn eschar and appear to have a substantial effect on eschar microbiology.

The effect of prophylactic drainage on subhepatic fluid collections after elective cholecystectomy: a prospective randomized ultrasonographic study.

Seventy-six patients undergoing elective cholecystectomy were randomly divided into drained and nondrained subjects and studied with sonography preoperatively and postoperatively to determine the incidence and fate of subhepatic fluid collections. In the drained group, detectable subhepatic fluid was seen in 5 per cent of patients, whereas it occurred in 20 per cent of nondrained patients. Although this difference achieved statistical significance (P less than 0.05), there were no complications directly attributable to the retained subhepatic fluid. On the contrary, this study supports previous observations that patients undergoing cholecystectomy without drainage have less postoperative fever. Subhepatic fluid collections occurred in a small number of patients so managed but were of no clinical significance in this study.

Limb loss following Military Anti-Schock Trousers (MAST) application.

External counterpressure is a safe and effective method to treat shock and restore central circulation. Experience with the short-term use of MAST has been favorable. If external counterpressure is maintained for extended periods, however, altered peripheral hemodynamics may result in permanent damage. The development of compartment syndrome requiring amputation is reported in two patients with associated leg fractures. This unfortunate experience suggests that the sustained use of MAST in patients with shock and comminuted lower extremity fractures may jeopardize limb survival.

Penetrating wounds of the buttock.

Results of a study of 15 patients with penetrating wounds of the buttock managed during a recent five year period suggest that penetrating trauma to the buttock is a distinct injury syndrome accompanied by serious intestinal, bladder or vascular damage. Following a complete history, physical examination and appropriate roentgenograms, most injuries can be anticipated, but proctoscopy and cystography should be performed upon all patients at risk. Intravenous pyelography, a poor test of bladder integrity, may be misleading and should by supplemented by additional techniques. If a retroperitoneal or intraperitoneal injury is suspected, preoperative antibiotic therapy, followed promptly by aggressive intraoperative management of all injuries, is recommended.

Enterobacter cloacae septicemia in a burn center: epidemiology and control of an outbreak.

An outbreak of infections due to Enterobacter cloacae occurred in the burn center at the Medical College of Virginia (Richmond, Virginia) in 1976. Fifteen patients had bacteremia due to E. cloacae; 10 cases of bacteremia occurred during a six-week period in January and February. The development of bacteremia was significantly related to the extent of third-degree burn and to admission to the burn center in January and February but not to the presence of an intravenous cannula, underlying disease, or antimicrobial therapy. E. cloacae was spread by contaminated hands of personnel and by cross-contamination of hydrotherapy water. A shortage of staff appeared to be an important factor in the occurrence of the outbreak. Control measures included an increase in the number of personnel, instruction of personnel in proper aseptic technique, and adoption of a new hydrotherapy protocol.

Resistant Enterobacter cloacae in a burn center: the ineffectiveness of silver sulfadiazine.

Enterobacter cloacae sepsis was found in 15 burn center patients in 1976, of whom 13 died. Nine of the deaths occurred in the first 60 days. The Burn Center isolates were resistant to silver sulfadiazine (AgSD) in agar cup-plate tests and confirmed by tube dilution tests. Hospital, non-burn isolates of E. cloacae were sensitive to AgSD. All E. cloacae isolates were sensitive to mafenide acetate (MA) in the agar cup-plate tests, but this was not confirmed by the tube dilution tests. The agar cup-plate susceptibility test is a simple, rapid and effective technique for determining resistant and sensitive isolates of E. cloacae. Patients who were changed from AgSD to MA because of resistant E. cloacae infection did not have improved survival. An animal study showed that AgSD was ineffective against this strain of E. cloacae and that MA was more effective than AgSD when applied 24 hr postburn but neither were effective at 48 hr postburn. MA was bacteriostatic but not bactericidal with this E. cloacae strain.

Emergency Department treatment, triage and transfer protocols for the burn patient.

Emergency department treatment, triage and transfer protocols for patients with major thermal injury have been devised by the three burn centers in Virginia. A burn nurse educator has presented these guidelines to the emergency departments of Virginia. The development of these protocols has considerably improved the immediate care of the victims of thermal injury who are transferred to the burn centers in the Commonwealth of Virginia.

The integrated trauma service concept.

An integrated trauma service, through coordination of pre-existing manpower and resources, insures the availability of medical care to patients suffering unforeseen or critical physical injuries and their sequelae. Provided an examination of the overall emergency medical service capabilities of the community dictates the need for a trauma service, the first step is to secure a surgeon interested in the care of the trauma patient. Cooperation of physician colleagues is gained by a policy of mandatory consultation whenever injuries involve specialty areas. Trauma service involvement begins with prioritization, resuscitation, and assessment of the patient in the emergency department and extends through definitive care, management of injury sequelae and rehabilitation. The "isolated injury" is defined by the trauma service and the appropriate specialty service notified. Injuries involving two or more body systems dictate admission to the trauma service except for the patient with an unstable cervical spine injury or deteriorating neurologic status. Under such circumstances, a neurosurgical admission is instituted and the trauma service consults. When the trauma service is operational, educational programs, data collection and retrieval, and follow-up care are enhanced.