Percutaneous endoscopic vs surgical gastrostomy.

The percutaneous endoscopic gastrostomy (PEG) has replaced the surgical gastrostomy (GT) on our service. We reviewed our data in an effort to determine relative efficacy and cost effectiveness of the two techniques. Thirty-five patients with PEGs were matched for age and diagnosis with 35 patients with GTs done by the same surgical service. PEGs were done in the endoscopy suite; GTs were done in the operating room: both under local anesthesia. Patients in PEG and GT groups were comparable in sex, diagnosis, and age. The PEG took less time to insert (15.3 vs 25.4 min, p less than 0.001). Major postoperative morbidity was similar with 10 systemic complications for each group and 11 deaths for the PEG vs 12 deaths for the GT group (at 90 days). Minor morbidity was higher for the PEG group with nine complications vs 1. Estimated cost for PEG was half the cost of GT. Hospital stay for the two groups was similar (36 vs 45 days, p greater than 0.1), but postop stay for the PEG group tended to be shorter (17 vs 24 days, p less than 0.08). The PEG is faster and cheaper to insert than the GT, however major morbidity and mortality are the same.

An improved method for transpyloric placement of nasoenteric feeding tubes.

Post pyloric placement of small bore feeding tubes can be an elusive goal. Failure to achieve the post pyloric position can result in fatal complications. The following study presents a cost-effective, rapid technique for achieving post pyloric placement of feeding tubes utilizing gastric insufflation and right lateral decubitus positioning. Four study groups were identified. Group I utilized the new technique as first attempt (n = 21). Group 2 utilized the traditional, standard technique of insertion as first attempt (n = 20). Group 3 consisted of Group I failures after which the new technique was utilized (n = 19) Group 4 consisted of Group 3 failures after which the new technique was reattempted. Overall success rate of the new technique was 93%. This was highly significant with p < 0.0001. No significant difference was noted between inserters or type of tube used. The new technique described required no expensive equipment, minimal training and consistently allowed for transpyloric passage of the feeding tube.

Trauma in pregnancy: uterine rupture.

Trauma during pregnancy is a unique situation. Understanding injury patterns, anatomic and physiologic changes, and the initial approach to resuscitation is essential for all emergency nurses. Maternal resuscitation is the only means of fetal resuscitation. Meticulous attention must be given to the ABC's, with some minor modifications. Cervical spine immobilization is done in conjunction with positioning on the left side. Oxygen is used liberally, but may not benefit the fetus if hypovolemia exists. IV access and aggressive fluid resuscitation should proceed quickly. Diagnostic testing, including radiologic evaluation, is performed as necessary--the mother's life must not be jeopardized on the basis of fetal risk. Continuous fetal monitoring should be instituted, even with seemingly minor injuries. In the rare event of maternal arrest, a postmortem cesarean section may be lifesaving for the infant. Policies should be formulated jointly by ED, obstetric, and neonatal staffs in advance to speed this difficult decision-making process. The keys to survival, for both mother and infant, are an organized approach to resuscitation and teamwork among all professionals.

Laparoscopic vs. open wedge biopsy of the liver.

This study was a post-hoc evaluation of laparoscopic versus open wedge biopsy of the liver performed as part of prospective phase I antibiotic trial. Consenting patients undergoing elective cholecystectomy were enrolled in a protocol which required samples of bile, blood, the gallbladder, and 1 gram of liver tissue. The study occurred during the evolution of laparoscopic surgery. Liver biopsy was done in standard fashion and laparoscopic liver biopsy was accomplished with cauterized scissors. Twenty-four patients, 4 male and 20 female averaging 42.1 years of age, were entered in this study. Eighteen patients underwent laparoscopic surgery and six patients underwent open surgery. They did not differ significantly in age (43.9 vs 42.1 years), operating room time (58.3 min vs 55.8 min), or complications (2/18 vs 2/6). Patients undergoing laparoscopic surgery, however, did have a shorter hospital stay (1.1 days vs 3.5 days, p < 0.001). All liver specimens were considered adequate. There were no complications related to the liver biopsy. Laparoscopic wedge biopsy of the liver is both a feasible and viable alternative to open wedge biopsy.

Occurrence of nosocomial pneumonia in mechanically ventilated trauma patients: a comparison of sucralfate and ranitidine.

OBJECTIVE: To determine if there is a difference in nosocomial pneumonia frequency rate in mechanically ventilated trauma patients treated with sucralfate vs. ranitidine for stress ulcer prophylaxis. DESIGN: Prospective, randomized trial. SETTING: A 640-bed urban teaching hospital and trauma center. PATIENTS: Ninety-two mechanically ventilated trauma patients. INTERVENTIONS: Thirty-nine patients received sucralfate and 44 patients received intravenous ranitidine for stress ulcer prophylaxis; nine patients were excluded from the study for protocol breaks. MEASUREMENTS AND MAIN RESULTS: The study population was severely injured and critically ill. The Trauma Score averaged 11.3, the Injury Severity Score averaged 27.7, and the Acute Physiology and Chronic Health Evaluation (APACHE) score averaged 18.1. There were no significant differences in demographics, mechanisms of injury, Trauma Score, Injury Severity Score, APACHE score, length of hospital stay, length of surgical intensive care unit stay, or duration of endotracheal intubation between the sucralfate and ranitidine groups. Eleven (13.2%) patients developed nosocomial pneumonia: six (15.4%) of 39 patients in the sucralfate group and five (11.4%) of 44 patients in the ranitidine group; these numbers were not significantly different (chi 2 = 0.0226, p = .8805). There were no episodes of significant upper gastrointestinal bleeding. Six patients died during hospitalization, all secondary to severe head injury and none with pneumonia. CONCLUSIONS: There was no statistically significant difference in pneumonia rate in mechanically ventilated trauma patients receiving stress ulcer prophylaxis with sucralfate vs. ranitidine.

Colorectal trauma: primary repair or anastomosis with intracolonic bypass vs. ostomy.

This prospective, randomized, controlled study was undertaken to compare primary repair or anastomosis with intracolonic bypass vs. ostomy in severe colon and intraperitoneal rectal injury. Patients were randomized at surgery following confirmation of injury. Data collected included demographics, mechanism and location of injury, trauma score (TS), injury severity score (ISS), penetrating abdominal trauma index (PATI), complications, length of hospital stay, and hospital charges. Twenty-two patients were studied: 11 with intracolonic bypass and 11 controls. The experimental and control groups were statistically similar in demographics and mechanism of injury, severity of injury (TS = 13.8 vs. 12.8; ISS = 27.5 vs. 24.2; PATI = 40.5 vs. 35.0), and complication rate. Length of stay (12.2 days vs. 20.7 days) and charges $27,885 vs. $53,599) tended to be greater in controls, and the comparison did not include subsequent colostomy closure. This study supports intracolonic bypass as a safe alternative to ostomy in severe colon and intraperitoneal rectal trauma.

Correlation of metabolic acidosis with outcome following injury and its value as a scoring tool.

This study looked at preresuscitation arterial pH as a predictor of outcome in injury. Seriously injured patients admitted to the Trauma Service over a 5-month period were evaluated prospectively. Data collected included basic patient demographics, initial arterial blood gas determinations (ABGs) including pH, bicarbonate (HCO3), base deficit or excess (BASE), admitting trauma score (TS), discharge injury severity score (ISS), total blood products used for initial resuscitation (TBP), and outcome. There were 191 patients averaging 34.7 years old with average TS 13.6, ISS 19.5, initial pH 7.38 +/- 0.09, HCO3 20.9 +/- 4.0, and BASE -3.3 +/- 4.7. The average TBP was 1309 cc, and overall mortality was 13/191 (6.8%). Comparing survivors to nonsurvivors, the ISS (18.2 vs. 38.3), TS (14.1 vs. 7.8), TBP (976 vs. 5881 cc), HCO3 (21.1 vs. 17.6), and BASE (-3.1 vs. -5.8) data were significantly different; pH (7.38 vs. 7.36) and age (34.4 vs. 38.5) were not. Using multiple regression with TBP as the dependent variable, BASE, age, TS, and to a lesser extent pH and HCO3 correlated (r = 0.536; p < 0.001); using outcome as the dependent variable, only TS and age correlated (r = 0.465; p < 0.0001). Although metabolic acidosis (pH, HCO3, BASE) predicts the TBP used, it does not improve on TS and age for predicting outcome.

Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve.

OBJECTIVE: Although sonographic screening for blunt abdominal trauma is gaining acceptance, standards for implementation, training, credentialing, and quality control remain to be established. DESIGN: This prospective study examines a Level I trauma service experience with the de novo establishment of a trauma ultrasound (US) program credentialed through the Department of Surgery under the auspices of Continuous Quality Improvement. MATERIALS AND METHODS: All trauma surgeons attended a combined didactic and "hands on" 8-hour trauma US course. Abdominal sonography was subsequently performed on patients with potential blunt abdominal trauma followed by a standard diagnostic evaluation, which included computed tomographic scan, diagnostic peritoneal lavage, or observation. MEASUREMENTS AND MAIN RESULTS: Three hundred patients were studied over a 4-month period. They averaged 35 years of age with an average injury severity score of 12. The time required to perform the US examination averaged less than 3 minutes. Standard diagnostic evaluation included computed tomographic scan (21%), diagnostic peritoneal lavage (45%), and observation (34%). US examinations resulted in 277 true negatives, 17 true positives, two false positives, and four false negatives for a sensitivity of 81.0%, a specificity of 99.3%, and an accuracy of 98.0%. Annualized cost savings with the use of US evaluation versus standard diagnostic evaluation would amount to over $100,000.00. CONCLUSIONS: This experience with the de novo implementation of a trauma US program suggests that the training and credentialing requirements in this study are sufficient to provide surgeon ultrasonographers with acceptable competence in US diagnosis of blunt abdominal trauma.