A case of pyogenic liver abscesses in a previously healthy adolescent man.

An 18-year-old, previously healthy man admitted with abdominal pain, high-grade fevers, nausea and emesis was found to have multiple hepatic abscesses. Aspiration cultures grew Fusobacterium necrophorum, a rare bacterium causing potentially fatal liver abscesses in humans. Following sequential percutaneous drainages and narrowing of antibiotics, the patient was discharged on a 6-week antibiotic course and showed no signs of infection. A week after presentation it was discovered that he had experienced upper respiratory symptoms and sore throat prior to presentation. Because oropharyngeal infections are a potential source of bacteremia, they must be considered in the differential diagnosis of patients presenting with hepatic abscesses and no evidence of immunocompromise.

Use of continuous local anesthetic infusion in the management of postoperative split-thickness skin graft donor site pain.

Donor sites from split-thickness skin grafts (STSG) impose significant pain on patients in the early postoperative period. We report the use of continuous local anesthetic infusion as a method for the management of postoperative STSG donor site pain. Patients undergoing single or dual, adjacent STSG harvest from the thigh (eight patients) or back (one patient) were included in this study. Immediately after STSG harvest, subcutaneous catheters were placed for continuous infusion of local anesthetic. Daily donor site-specific pain severity scores were prospectively recorded in nine patients receiving local anesthetic infusion. Patient characteristics, technical aspects, and postoperative complications were identified in the study. The thigh was the anatomic location chosen for most donor sites. A single catheter was placed for donor sites limited to 4 inches in width or less. A dual catheter system was used for those wider than 4 inches. An elastomeric pump delivered continuously a total of 4 ml/hr of a solution of 0.5% bupivacaine. The average anesthetic infusion duration was 3.1 days. A substantial decrease in worst, least, and average donor site pain scores was found from the first 24 hours to the second postoperative day in our patients, a treatment trend that continued through postoperative day 3. One patient developed minor anesthetic leakage from the catheter insertion site; and in three cases, accidental dislodgement of the catheters occurred. There were no cases of donor site secondary infection. All donor sites were completely epithelialized at 1-month follow-up. Continuous local anesthetic infusion is technically feasible and may represent an option for postoperative donor site pain control after STSG harvesting. Relative cost-benefit of the technique remains to be determined.

"Roll-bar" for protective posture splint limits potential trauma to dorsal hand grafts.

The expectation of excellent functional and cosmetic outcomes adds to the challenges of managing the burned hand. The initial fragility of the grafted surface warrants extra measures of protection. A "roll-bar " attached to a splint over a grafted area can serve as protection against mechanical trauma. Two "intrinsic plus " protective posture splints were fabricated; one had a roll-bar extending from the D2 ray to the distal forearm. Three simulated patients wearing each of the splints attempted to contact the bed rail from supine. Pictures, transferred ink, observation, and subjective comments were used to establish percentage of the surface at risk because of bed rail contact and its ease. Without the roll-bar 100% of the dorsal surface of the hand was accessible to contact with the bed rail. With the roll-bar all subjects were prevented from contact to the dorsum of the hand and contact to the dorsal fingers was less than 40% in all subjects, decrease of risk at the wrist was also significant. The roll-bar can prevent mechanical trauma to grafts on the fingers and dorsum of the hand because of contact with the bed rail. The ease of the application and the potential benefits to patient outcome make it an appropriate addition to the protective posture splint when seeking to minimize area of the surface at risk.

The role of advance directives and family in end-of-life decisions in critical care units.

PURPOSE: To define the extent and nature of the End-of-Life (EOL) decision-making process in critically ill patients. MATERIALS AND METHODS: Retrospective review of all deaths in adult medical and surgical intensive care units of a tertiary care hospital over a one-year period. RESULTS: There were sixty-one deaths in the study period. The mean age was 68 years, and 30 patients (49%) were female. Nearly one-third of patients had advance directives: eight patients presented advance directives on hospital admission, and 10 families produced advance directives at EOL. Seventy-six percent were admitted to the ICU as Code I (full care) and 24% were Code II (selective modification of care). At EOL, 10 patients were Code I, 14 were Code II, and 38 were transitioned to Code III (comfort care only). In the Code III population, the change in code status was initiated by the family in 12 cases. CONCLUSIONS: In a substantial number of instances transitioned to comfort care at EOL, the family initiated the code-status change. Interestingly, in several cases the family initially withheld advance directives. Critically ill patients and their families are assuming an active role in EOL care.

Renal artery to inferior vena cava fistula following gunshot wound to the abdomen.

Traumatic fistula involving the renal artery and IVC is a rare event, and typically is a result of penetrating injury. A case of right renal artery to IVC fistula following a gunshot wound to the abdomen is reported, and illustrates the significant hemodynamic changes that accompany these fistulae. We also emphasize the importance of thorough initial exploration of retroperitoneal hematomas following penetrating trauma, and review management options in the treatment of renal arteriovenous fistulae.