Preventative antibiotics for penetrating abdominal trauma--single agent or combination therapy?

In this open, prospective, comparative study, 75 patients who sustained penetrating abdominal trauma were randomised to receive 1 of 3 antibiotic regimens preoperatively and for 3 to 5 days postoperatively. Group I received cefotaxime 2g 8-hourly, group II received cefoxitin 2g 6-hourly and group III received clindamycin (900 mg 8-hourly) and gentamicin 3 to 5 mg/kg/day in divided doses 8-hourly. The 3 groups were not statistically different in terms of age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions or positive intra-operative cultures. Septic complications occurred in 8% of patients in group I, in 4% of group II patients and in 8% of group III patients. Cefotaxime was the least costly regimen, followed by cefoxitin, then clindamycin and gentamicin. It may be concluded that single agent therapy with a broad spectrum cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, less toxicity and lower costs.

Biliary obstruction in a canine model: sequential study of the sonographic threshold.

Complete occlusion of the common bile duct was surgically created in eight dogs. Sequential gray-scale ultrasound studies were performed with serum bilirubin determinations. Dilatation of the intrahepatic biliary radicles was first recognized sonographically from five to eight days postoperatively (average 6.4 days). The findings indicate a temporal lag between the onset of obstruction and recognition by ultrasound. In the appropriate clinical setting, a delayed repeat examination may be advisable. No correlation between ductal dilatation and serum bilirubin levels was ascertained.

Final inline filtration: a means of decreasing the incidence of infusion phlebitis.

Infusion phlebitis is the most common complication of intravenous therapy. Six methods of reducing the incidence of infusion phlebitis including inline final filtration, buffers, heparin, hydrocortisone, heparin-hydrocortisone combinations, and frequent set changes were tested in a two part randomized prospective double-blind study of 266 surgical patients. Patients who received filtered fluids had a significantly decreased incidence of infusion phlebitis as compared with that of controls (P = 0.0000001). Of the other methods tested, only the heparin-hydrocortisone combinations achieved any significant decrease in phlebitis (P less than 0.5). Therefore, inline filtration is a highly effective means of decreasing the incidence of infusion phlebitis and should be considered as a routine part of intravenous therapy.

The role of contrast radiography in presumed bowel obstruction.

A retrospective review of 229 patients with a final diagnosis of small-bowel obstruction was undertaken to evaluate the role of contrast radiography in the management of their conditions. In 84 patients (37%) the clinical findings and plain abdominal roentgenograms were sufficient for diagnosis and subsequent management. Of the remaining 145 patients with equivocal findings, 27% had an upper gastrointestinal series, 29% a barium enema, and 44% had both. Useful information (complete obstruction, unobstructed passage of contrast, or diagnosis other than adhesional obstruction) was obtained from 86% of the radiographic studies. Three patients had negative contrast studies yet eventually underwent adhesiolysis (enterolysis) and were classified as false-negative. Two patients had evidence of high-grade obstruction yet had nonoperative resolution and were classified as false-positive. The mortality in the contrast group (7%) was not statistically different than that in the no-contrast group (7%). Contrast radiography is a safe and effective means of increasing diagnostic accuracy in patients with presumed small-bowel obstruction.

Radiation-induced arterial injuries.

In a 20-year period from 1961 to 1981 at the University of Kentucky Medical Center, there were 20 patients with vascular lesions directly attributable to irradiation. Two distinct patterns of arterial injury attributable to radiotherapy were identified--arterial disruption and occlusion. Arterial disruption occurred in 12 patients--11 carotid blowouts and 1 iliac artery rupture. Two patients underwent prophylactic carotid artery ligation for impending rupture. In the 11 carotid artery ruptures, ligation of the artery in nine patients resulted in stroke or death in five patients. Iliac artery disruption necessitated ligation, which eventually led to severe ischemia requiring hip disarticulation. Unusual arterial stenosis or occlusion occurred in six patients 7 to 24 years after irradiation. Three patients had severe stenosis or occlusion of the common, internal, or external carotid arteries leading to cerebrovascular insufficiency. Three other patients with focal stenosis of the iliofemoral region were successfully treated with bypass grafting.

Pancreatic transection. A concept of evolving injury.

We describe the difficulties in diagnosing a pancreatic injury in two patients with multiple injuries who did not have an obvious need for a celiotomy. Multiple diagnostic tests were employed, but in each patient, there was a delay in the diagnosis of the injury. A pancreatic injury may evolve over time so that repetitive clinical diagnostic studies may be required to evaluate the condition of these patients.

Hemosuccus pancreaticus (hemoductal pancreatitis): gastrointestinal hemorrhage due to rupture of a splenic artery aneurysm into the pancreatic duct.

A patient with recurrent upper gastrointestinal bleeding was found to have pancreatitis and a pseudoaneurysm of the splenic artery that communicated with the pancreatic duct. Similar pathology noted in ten other patients found in an extensive review of the literature suggest that this rare entity must be considered in the diagnosis of gastrointestinal hemorrhage of obscure origin. In this collected experience, the combination of recurrent left upper quadrant pain, a history of pancreatitis, and recurrent bouts of gastrointestinal bleeding of obscure origin were usually present in those patients who were found to have a splenic artery aneurysm as the source of the blood loss. Distal pancreatectomy with resection of the splenic artery aneurysm is curative.

Inaccuracy of diagnostic peritoneal lavage in penetrating colonic trauma.

As part of an ongoing study of the operative treatment of colon injuries, 33 patients proved to have colon injury at operation had diagnostic peritoneal lavage as part of their preoperative examination. Gunshot wounds were the cause of injury in 22 (67%) of these patients and stab wounds in 11 patients (33%). The lavage was positive in only 23 (70%) of the 33 patients with operatively proved penetrating injuries of the colon. Lavage was accurate in 16 (73%) of 22 patients with gunshot wounds of the colon and seven (64%) of 11 patients with stab wounds. The overall false-negative rate for this series of patients was 30%. This study indicates that diagnostic peritoneal lavage is relatively inaccurate in the evaluation of colonic injury secondary to penetrating abdominal trauma.

Electronic flow control and roller clamp control in intravenous therapy: a clinical comparison.

In a prospective clinical study, an electronic intravenous (IV) rate controller was compared with a standard roller clamp for control of IV infusions. The electronic IV rate controller was associated with fewer complications and more accurate fluid therapy than was the roller clamp. There was also a substantial savings of nursing time and a potential for cost savings when the electronic IV rate controller was used.

Morbid implications of above-knee amputations. Report of a series and review of the literature.

In a retrospective review of 100 consecutive patients requiring above-knee amputation for arterial occlusive disease, the operative mortality was 15%. An additional 26% mortality occurred during a two-year follow-up period. Principal causes of death were sepsis in 54%, heart disease in 16%, and stroke in 11%. The poor prognosis of patients requiring amputation was related to progression of systemic diseases and to generalized debility among these patients.

Diagnostic errors with peritoneal lavage in patients with pelvic fractures.

Diagnostic peritoneal lavage, considered to be a highly accurate, technique for detecting intraperitoneal blood in the trauma patient, may be less reliable in the presence of a pelvic fracture. In a retrospective review of 222 patients with pelvic fractures, 61 patients were found who had had a diagnostic peritoneal lavage performed as part of the initial evaluation of their condition. Twenty-six of these patients had had a negative lavage result negative lavage result. There had been no false-negative results in this group, although six patients required operations for extraperitoneal injuries. Of the 35 patients with a positive lavage results, 10 (29%) were found to have false-positive lavage results with no intraperitoneal source of bleeding. The only deaths in this series occurred in the group requiring operations, eight of 41 (20%). Four of the eight detahs were due to uncontrollable bleeding that resulted from exploration of the retroperitoneal hematoma. These data suggest that a negative lavage result is highly reliable in the patient with a pelvic fracture and should allow management with confidence that there is no severe intraperitoneal injury. Positive lavage results, however, must be interpreted with caution.

Dopamine-phenytoin interaction. A cause of hypotension in the critically ill.

Five critically ill patients received dopamine hydrochloride intravenously to support their blood pressure. When seizures developed, intravenous phenytoin sodium therapy was begun. Coincident with the infusion of phenytoin, the blood pressure, which was stable on the dopamine infusion, declined rapidly. Analysis of these cases led to a hypothesis that the interaction of dopamine and phenytoin produced the hypotension. When this hypothesis was tested in the normovolemic dog, intravenous dopamine produced no change in the blood pressure, and the addition of a phenytoin infusion had little effect. In animals rendered hypovolemic and hypotensive by bleeding, intravenous dopamine returned the blood pressure to the prebleeding level. At this point, an infusion of phenytoin produced a sustained decrease in the blood pressure. The mechanism of this action may be related to a combination of catecholamine depletion and myocardial depression.

Bacterial endocarditis in the critically ill surgical patient.

The association of endocarditis with persistent intraperitoneal sepsis and right-sided heat catheterization (Swan-Ganz catheter and central venous catheter) was found in four (27%) of 15 patients with endocarditis identified at the University of Kentucky Medical Center, Lexington, during a 14-year period. These four patients had (1) intra-abdominal abscesses as a persistent source of sepsis, (2) documented septicemia, (3) long-term use of right sided heart catheters, and (4) prolonged hospitalization with a fatal outcome. In each case, endocarditis with persistent septicemia was considered a major factor contributing to a fatal outcome. Identification of a new cardiac murmur associated with septicemia was the most reliable means of diagnosis in these patients. The best form of treatment seems to be prevention by (1) eliminating septic foci, (2) using central catheters for specific indications for as short a period as possible, and (3) promptly discontinuing use of the catheter when septicemia is suspected.

Experiences with conversion of jejunoileal bypass to gastric bypass: its use for maintenance of weight loss.

Jejunoileal bypass for morbid obesity has been associated with a variety of long-term adverse sequelae, including excess diarrhea, electrolyte imbalance, kidney dysfunction, liver abnormalities, and polyarthropathy. Takedown of the bypass without providing a means of maintenance of weight reduction will lead to recurrence of morbid obesity. We studied 32 patients who underwent conversion of jejunoileal bypass to gastric bypass either in one procedure (27 patients) or more than one procedure (five patients). There were no operative deaths, but significant morbidity. Nevertheless, the conversion has maintained weight reduction and reversed the adverse effects of the small-bowel bypass. We concluded that conversion of the jejunoileal bypass to the gastric bypass, particularly with a Roux-en-Y anastomosis, in a single procedure is relatively safe, simple, and effective.

Primary retroperitoneal cysts: report of an unusual case and a survey of the literature.

A case of a primary retroperitoneal cyst was associated with the chemical abnormalities of Cushing's disease and pheochromocytoma. Review of the literature failed to uncover a similar endocrinologically active retroperitoneal cyst. Primary retroperitoneal cysts, defined as those cysts lying in the retroperitoneal fatty tissue that have no apparent connections with any adult anatomical structure, are rare. These cysts are thought to arise from the mesonephros. They become symptomatic by virtue of their size or position. Diagnosis is suggested by an abnormal intravenous pyelogram and may be confirmed by arteriography. Treatment of choice is excision.

Preoperative and postoperative assessment of nutrient intakes in patients who have undergone gastric bypass surgery.

The study of 25 morbidly obese patients who had undergone gastric bypass surgery was undertaken to determine the fat, carbohydrate (CHO), protein, and total caloric intake before and at 1, 3, 6, and 12 months postoperatively. No postoperative complications occurred, and all patients lost weight appropriately. The nutrient intakes were estimated from dietary recall. Dramatic decreases occurred in average total caloric intake from a preoperative value of 3979.4 to 351.6 kcal at 1 month, 471.3 kcal at 3 months, 932.7 kcal at 6 months, and 1091 kcal at 12 months. Fat, CHO, and protein intake decreased equally until 12 months when fat intake had reached a plateau while CHO and protein intake continued to rise. Weight reduction after gastric bypass surgery is related to decreased caloric intake, predominantly in the fat component.

Technical complications of Roux-en-Y gastrojejunostomy.

The Roux-en-Y gastrojejunostomy has become an increasingly popular technique for gastrointestinal tract reconstruction since it is purported to obviate many of the classic complications of the Billroth II gastrojejunostomy. In a review of over 900 Roux-en-Y gastrojejunostomies, seven patients with complications mimicking those seen with Billroth II reconstruction were identified. These complications included duodenal stump blowout, proximal blind loop or afferent loop syndrome, and bile-reflux gastritis. These complications resulted from technical problems in construction of the Roux-en-Y. Once the complications were diagnosed, they were amenable to operative correction. Recognition of the potential for these complications following Roux-en-Y gastrojejunostomy should aid in early diagnosis and treatment.

Fat overload with a 10% soybean oil emulsion.

A 10% soybean oil emulsion (Intralipid) has been demonstrated to be an effective means of delivering an adequate caloric intake via a peripheral vein. This emulsion has generally been considered safe and free of significant complications. This is a report of a child who initially thrived on this intravenously administered fat emulsion, then suddenly developed a lifethreatening intolerance to the infusion, which appeared to be the "fat overload syndrome." This syndrome, seen frequently with earlier fat emulsions, has not been reported previously as a complication of the 10% soybean oil emulsion.

Membrane filters. Additional safety for intra-arterial infusions.

The addition of a 0.45mu in-line membrane-filter to the delivery system for intra-arterial infusion therapy is a simple and inexpensive means of providing additional safety. The filter decreases particulate and microorganism infusion by removing all measurable particles and most bacterial and fungal organisms. Since air will not pass through the filter, air embolism is prevented. In addition, in the event of set disruption, the filter will prevent bleeding via red blood cells clogging the membrane.

Nitrogen balance in adult hospitalized patients with the use of a pediatric amino acid model.

Normalization of plasma amino acid patterns and that relationship to improved nitrogen balance was studied using a pediatric-specific amino acid solution in 21 adults requiring total parenteral nutrition therapy. There was a significantly positive correlation between improved nitrogen balance and the amino acids cystine, tyrosine, total cysteine/cystine, and ornithine. When additional cysteine was added to the solution of 11 subjects, taurine also correlated with nitrogen balance. Despite higher amounts of histidine in solution, plasma amino acid levels were not normalized. These amino acids, heretofore considered nonessential, may be required in specific molar ratios in stress. The use of a 30% branched-chain pediatric-balanced amino acid solution resulted in near normalization of plasma amino acid levels and group mean positive nitrogen balance.