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Many students, residents, and learners have heard of the infamous bank robber, who when arrested was asked "Why do you rob banks?" He supposedly replied "Because that's where the money is." Except it did not happen that way. He did rob close to a hundred banks and jewelry stores and stole an estimated $2,000,000. 1 A well-known maxim in medicine and surgery, few know the details of the unrelated men behind "Sutton's Law."

Background: Accurate and timely injury identification is critical but difficult to achieve in trauma patients who die shortly after arrival to the hospital. Autopsy has historically been used to detect injuries, but few undergo formal autopsy. This study investigates the utility of post-mortem computed tomography (PMCT) for injury identification in a diverse trauma population., Methods: Cross-sectional study of adult trauma patients who died within 24 hours of arrival to a Level I trauma center were included. Among patients with PMCT, injury severity score (ISS) and number of injuries (NOI) were calculated either from physical exam alone (pre-PMCT) or exam and imaging (post-PMCT). ISS and NOI before and after PMCT were compared. A cause of death analysis was performed for patients who underwent comprehensive (ie, head, neck, and torso) PMCT. Non-parametric repeated measures tests were used, as appropriate., Results: 7.3% (N = 28) of patients received PMCT. Compared to pre-PMCT, median ISS (21 vs 3.5) and NOI (5 vs 2) were greater post-PMCT ( P < .001, respectively). Autopsy rate was 13.2% overall; 82.5% of autopsies were due to a penetrating mechanism, and median time to autopsy reporting was 38.5 days. Among 17 patients who received comprehensive PMCT, 64.7% had a single cause of death identified, and the remaining were classified as either multiple potential contributors or unknown., Discussion: PMCT is a readily available method to identify injuries in trauma patients who expire shortly upon presentation. Given the low autopsy rate for blunt trauma and delay in reporting, PMCT is an important adjunct for trauma providers.

Biliary sludge is a subjective, ill-defined term. Surgery is often consulted for laparoscopic cholecystectomy, regarded as a low risk procedure.After IRB approval, a word search was used to identify "sludge" in all ultrasounds performed in 2016. The number of patients undergoing cholecystectomy, complications, pathologic findings, and risk factors were identified. Non-operative patients were evaluated for subsequent symptoms and studies or procedures related to biliary pathology.2769 patients underwent RUQ US; 253 patients were found to have sludge. Of 48 (19%) cholecystectomy patients, 9 had cholelithiasis. No deaths occurred in the cholecystectomy group. Two surgical complications occurred. Fifty (24.4%) of the 205 non-operative patients underwent subsequent US imaging: 44% residual sludge, 28% normal, 18% stones, and 10% other.Sludge may resolve 28% of the time. Repeat ultrasound is prudent before proceeding with cholecystectomy. If an abnormality is seen on repeat imaging and risk factors persist, cholecystectomy may be reasonable.

Background: Junctional adhesion molecule-A (JAM-A) is an adhesion molecule whose overexpression on breast tumor tissue has been associated with aggressive cancer phenotypes, including human epidermal growth factor receptor-2 (HER2)-positive disease. Since JAM-A has been described to regulate HER2 expression in breast cancer cells, we hypothesized that JAM-dependent stabilization of HER2 could participate in resistance to HER2-targeted therapies., Methods: Using breast cancer cell line models resistant to anti-HER2 drugs, we investigated JAM-A expression and the effect of JAM-A silencing on biochemical/functional parameters. We also tested whether altered JAM-A expression/processing underpinned differences between drug-sensitive and -resistant cells and acted as a biomarker of patients who developed resistance to HER2-targeted therapies., Results: Silencing JAM-A enhanced the anti-proliferative effects of anti-HER2 treatments in trastuzumab- and lapatinib-resistant breast cancer cells and further reduced HER2 protein expression and Akt phosphorylation in drug-treated cells. Increased epidermal growth factor receptor expression observed in drug-resistant models was normalized upon JAM-A silencing. JAM-A was highly expressed in all of a small cohort of HER2-positive patients whose disease recurred following anti-HER2 therapy. High JAM-A expression also correlated with metastatic disease at the time of diagnosis in another patient cohort resistant to trastuzumab therapy. Importantly, cleavage of JAM-A was increased in drug-resistant cell lines in conjunction with increased expression of ADAM-10 and -17 metalloproteases. Pharmacological inhibition or genetic silencing studies suggested a particular role for ADAM-10 in reducing JAM-A cleavage and partially re-sensitizing drug-resistant cells to the anti-proliferative effects of HER2-targeted drugs. Functionally, recombinant cleaved JAM-A enhanced breast cancer cell invasion in vitro and both invasion and proliferation in a semi-in vivo model. Finally, cleaved JAM-A was detectable in the serum of a small cohort of HER2-positive patients and correlated significantly with resistance to HER2-targeted therapy., Conclusions: Collectively, our data suggest a novel model whereby increased expression and cleavage of JAM-A drive tumorigenic behavior and act as a biomarker and potential therapeutic target for resistance to HER2-targeted therapies.

Background: Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury., Methods: Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed., Results: During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred., Conclusions: The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient., Level of Evidence: Prognostic/Epidemiologic, level III.

Although the developments in cellular and molecular biology over the last few decades have significantly advanced our understanding of the processes and players that regulate invasive disease, many areas of uncertainty remain. This review will discuss the contribution of dysregulated cell⁻cell and cell⁻matrix adhesion to the invasion in both benign and malignant contexts. Using the endometrium as an illustrative tissue that undergoes clinically significant invasion in both contexts, the adhesion considerations in the cells ("seed") and their microenvironment ("soil") will be discussed. We hope to orientate this discussion towards translational relevance for the diagnosis and treatment of endometrial conditions, which are currently associated with significant morbidity and mortality.

Background: Informed consent is an essential component of medical practice, and especially so in procedural based specialties which entail varying degrees of risk. Breast cancer is one of the most common cancers in women, and as such is the focus of extensive research and significant media attention. Despite this, considerable misperception exists regarding the risk of developing breast cancer., Aims: This study aims to examine the accuracy of risk perception of women attending a breast cancer family history clinic, and to explore the relationship between risk perception accuracy and health literacy., Methods: A cross-sectional study of women attending a breast cancer family history clinic (n = 86) was carried out, consisting of a patient survey and a validated health literacy assessment. Patients' perception of personal and population breast cancer risk was compared to actual risk as calculated by a validated risk assessment tool., Results: Significant discordance between real and perceived risks was observed. The majority (83.7%) of women overestimated their personal lifetime risk of developing breast cancer, as well as that of other women of the same age (89.5%). Health literacy was considered potentially inadequate in 37.2% of patients; there was a correlation between low health literacy and increased risk perception inaccuracy across both personal ten-year (r s  = 0.224, p = 0.039) and general ten-year population estimations. (r s  = 0.267, p = 0.013)., Conclusion: Inaccuracy in risk perception is highly prevalent in women attending a breast cancer family history clinic. Health literacy inadequacy is significantly associated with this inaccuracy., (Copyright © 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: Four recent reports of the retrieval of optional vena cava filters (VCF) in trauma patients had average implant durations of 10, 19, and 19 days (one not specified). Two patients in these studies had pulmonary emboli after VCF removal. No evidence-based guidelines exist on the appropriate time to remove optional VCF. The purpose of this study was to examine the timing of pulmonary emboli (PE) and determine the optimal time to remove optional VCFs., Methods: A multicenter retrospective chart review of trauma patients who had a postinjury PE between January 2001 and December 2004 was performed. We examined the demographics, prophylaxis at the time of PE (pharmacologic [unfractionated or low molecular weight heparin] or sequential compression devices [SCD]), diagnostic test used, timing of PE from the date of injury, and survival outcome., Results: In all, 146 patients were identified, mean age 45.1 (+/- 21.1 SD); Injury Severity Score 18.0 (+/- 12.1 SD). Diagnosis was obtained by spiral computed tomography (N = 93), pulmonary arteriogram (N = 18), V/Q (N = 26), autopsy (N = 6), clinical (N = 6), and unknown (N = 3). Overall mortality was 17.8% (N = 26). Pulmonary embolism was felt to contribute to or was the cause of death in 85% (N = 22) of these patients. Two late PE deaths occurred (days 21 and 43). Sixty (37%) patients had pharmacologic prophylaxis at the time of PE and 83 (50.9%) had SCDs. Average time from injury to PE was 7.9 days (+/- 8.1 SD), the longest being 43 days postinjury. Eleven percent of PE occurred after 21 days, including fatal PE., Conclusions: Clinical criteria defining the time to remove optional VCFs without exposing patients to the risk of PE by removing a filter too soon should be determined.

Background: Low-molecular-weight heparin is effective for prevention of venous thromboembolism. The efficacy of daily dosing in critically ill patients is unknown., Methods: Seventeen critically ill patients on 40 mg of enoxaparin subcutaneously daily were studied. Anti-Xa activity was measured 4 hours after the third dose and before the fourth dose. Adverse events were recorded., Results: Mean peak anti-Xa activity was 0.19 +/- 0.09 International Units/mL and mean trough was 0.044 +/- 0.04 International Units/mL. The recommended target range is 0.1 to 0.2 International Units/mL. The trough was below therapeutic levels in all but two patients. One thrombosis occurred in a patient despite a therapeutic trough., Conclusion: Daily dosing of enoxaparin is inadequate for critically ill patients and should be abandoned. Further studies using twice daily dosing are needed. Patients with renal insufficiency may require an increased interval of administration (daily dosing). Anti-Xa levels may not correlate with the risk of thromboembolic complications. Patients with renal insufficiency and morbid obesity may require alternative dosing and monitoring of anti-Xa levels.

Introduction: Decompressive laparotomy for abdominal compartment syndrome has been shown to reduce mortality in critically ill patients, but little is known about the outcome of abdominal wall reconstruction. This study investigates the role of plastic surgeons in the management and reconstruction of these abdominal wall defects., Methods: We performed a retrospective review of 82 consecutive critically ill patients who underwent decompressive laparotomy for abdominal compartment syndrome, at a university level 1 trauma center, from April 2000 to May 2004. Patients reconstructed by trauma surgeons alone (n = 15) were compared with patients reconstructed jointly with plastic surgeons (n = 12), using Student t test and chi analysis., Results: Eighty-two patients underwent decompressive laparotomy for abdominal compartment syndrome, yielding 50 survivors (61%). Of the 27 patients who underwent abdominal wall reconstruction, 6 had early primary fascial repair, and 21 had staged reconstruction with primary fascial closure (n = 4), components separation alone (n = 3), components separation with mesh (n = 10), or permanent mesh only (n = 4). Compared with patients whose reconstruction was performed by trauma surgeons, patients who underwent a combined approach with plastic surgeons were older (50.5 versus 31.7 years, P < 0.05), had more comorbidities (P < 0.001), were less likely to have a traumatic etiology (P < 0.001), had a longer delay to reconstruction (407 versus 119 days, P < 0.05), and were more likely to undergo components separation (P < 0.05). Mean follow-up of 11.5 months revealed 2 recurrent hernias in the combined reconstruction group, both of which were successfully repaired., Conclusions: A multidisciplinary approach is essential to the successful management of abdominal wall defects after decompressive laparotomy for abdominal compartment syndrome. Although carefully selected patients can undergo early primary fascial repair, most of reconstructed patients had staged closure of the abdominal wall via components separation, with a low rate of recurrent hernia. High-risk patients with large defects and comorbidities appear to benefit from the involvement of a plastic surgeon.

Background: Management strategies for blunt solid viscus injuries often include blood transfusion. However, transfusion has previously been identified as an independent predictor of mortality in unselected trauma admissions. We hypothesized that transfusion would adversely affect mortality and outcome in patients presenting with blunt hepatic and splenic injuries after controlling for injury severity and degree of shock., Methods: We retrospectively reviewed records from all adults with blunt hepatic and/or splenic injuries admitted to a Level I trauma center over a 4-year period. Demographics, physiologic variables, injury severity, and amount of blood transfused were analyzed. Univariate and multivariate analysis with logistic and linear regression were used to identify predictors of mortality and outcome., Results: One hundred forty-three (45%) of 316 patients presenting with blunt hepatic and/or splenic injuries received blood transfusion within the first 24 hours. Two hundred thirty patients (72.8%) were selected for nonoperative management, of whom 75 (33%) required transfusion in the first 24 hours. Transfusion was an independent predictor of mortality in all patients (odds ratio [OR], 4.75; 95% confidence interval [CI], 1.37-16.4; p = 0.014) and in those managed nonoperatively (OR, 8.45; 95% CI, 1.95-36.53; p = 0.0043) after controlling for indices of shock and injury severity. The risk of death increased with each unit of packed red blood cells transfused (OR per unit, 1.16; 95% CI, 1.10-1.24; p < 0.0001). Blood transfusion was also an independent predictor of increased hospital length of stay (coefficient, 5.45; 95% CI, 1.64-9.25; p = 0.005)., Conclusion: Blood transfusion is a strong independent predictor of mortality and hospital length of stay in patients with blunt liver and spleen injuries after controlling for indices of shock and injury severity. Transfusion-associated mortality risk was highest in the subset of patients managed nonoperatively. Prospective examination of transfusion practices in treatment algorithms of blunt hepatic and splenic injuries is warranted.

Background: This study is aimed at evaluating the safety and efficacy of intrapleural tissue plasminogen activator (TPA) for complicated pleural effusions, including posttraumatic hemothorax., Methods: Data were retrospectively collected from hospitalized patients over a 4-year period (1999-2003) who were treated with intrapleural TPA after failing drainage by tube thoracostomy. Pre- and post-TPA imaging studies were reviewed and scored by a blinded radiologist., Results: Forty-one consecutive patients with 42 effusions were identified with the following indications: 6 traumatic hemothoraces (14%), 22 loculated pleural effusions (52%), 2 line-associated hemothoraces (5%), and 12 empyemas (29%). Nine patients (22%) required operative drainage including two with posttraumatic hemothoraces. All patients managed nonoperatively demonstrated radiographic improvement after TPA administration. One patient (2.4%) developed hematuria, requiring transfusion. No trauma patient required TPA-related blood transfusion and no deaths were attributable to TPA therapy., Conclusion: Intrapleural TPA administration appears safe for use in complicated pleural effusions and may decrease the need for operative intervention.

Percutaneous endoscopic gastrostomy (PEG) is well established as a safe and effective means of providing enteral feeding access in patients unable to tolerate oral feeding. There is some question, however, as to the true incidence of free air after PEG and the clinical significance of free air in these patients. We report our experience with 119 patients over 4 years who underwent placement of a percutaneous gastrostomy tube. This study is a retrospective review of percutaneous endoscopic gastrostomies performed by the Critical Care Service for Surgery (CCSS). A database of percutaneous endoscopic gastrostomies performed by the CCSS was maintained from September 1997 through December 2001. Complications of percutaneous gastrostomies were added to the database when noted. The electronic medical record of all patients was reviewed for the results of radiographic studies. Prior abdominal operations were noted as well as gastrostomy tube complications and outcome. A total of 115 intensive care unit patients underwent PEG placement by the CCSS. This total includes 18 patients who had undergone prior upper abdominal surgery, Three additional patients who underwent placement of a gastrostomy tube by vascular interventional radiology and one patient who underwent PEG placement by the ear, nose, and throat service were brought to the attention of CCSS secondary to complications for a total of 119 patients. Only four patients (3.4%) were found to have free air on subsequent chest radiograph. Six patients (5.2%) were found to have free air on abdominal CT scans. Two patients with free air on CT underwent exploratory celiotomy as a result of additional signs of peritonitis. Both were negative explorations. The incidence of free air after PEG in our experience is significantly less than the incidence in previous studies. In patients with free air after PEG placement exploratory celiotomy is not indicated in the absence of other clinical findings of peritonitis. Additionally it was noted that PEG placement could safely be performed in patients with prior upper abdominal surgery with a low incidence of complications.

Objective: The aim of this study was to evaluate the usefulness of needle thoracostomy catheter (NTC) placement in trauma., Methods: A consecutive case series was conducted from November 1996 to September 1997. All patients admitted to a level I trauma centre who had NTCs placed prior to arrival in the Emergency Department were included. No patients were excluded or omitted. During the course of the study 2801 patients were admitted to our trauma centre. Nineteen patients (0.68%) had NTCs placed prior to arrival in the emergency department., Results: Twenty-five needle thoracostomies were performed in 19 patients. This group represented 0.68% of the trauma admissions. Four patients were found to have evidence of a pneumothorax with an air leak (28%). The NTC failed to decompress the chest in one of two patients who had physiologic evidence of a tension pneumothorax. Eleven patients (58%) were endotracheally intubated prior to NTC., Conclusions: This study suggests that field NTC placements are often ineffective and may be over-used. Further study on the usefulness of NTC is required.

Objective: To determine the incidence and mortality of hypothermia in trauma patients., Methods: Retrospective review of patients admitted to the Surgical Intensive Care Unit (SICU) over 4 1/2 years. Hypothermia was defined as a temperature < 35 degrees C., Results: There were 7045 admissions to the SICU, of which 661 (9.4%) had a recorded temperature of < 35 degrees C. Over half (395) were trauma patients, with a mortality of 52.7%. The temperature ranged from 27.1 to 34.9 degrees C, with a mean for survivors of 34.0 degrees C and 33.1 degrees C for those that died. There was a significant difference in Apache II scores (16.6 vs 25.4) and Injury Severity Scores (26.1 vs 33.4) between survivors and non-survivors., Conclusions: The incidence of hypothermia in trauma patients is significant and is independent of the month of admission. Mortality is high but there is no threshold below which mortality is assured. Unlike historical data, 13 patients survived temperatures < 32 degrees C.

Objective: To demonstrate chest roentgenograms after central venous line changes over a guidewire delay the use of the central lines and increases charges with no change of morbidity or the rate of complication., Methods: Retrospective study using the Surgical Intensive Care database followed by a nonrandomized, prospective study of central venous line changes. The total time from the catheter change until chest radiograph confirmation and an analysis of charges was done., Results: The retrospective study of 1,201 central line changes demonstrated no pneumothorax and two central lines malpositioned. The prospective study of 100 patients demonstrated no pneumothorax and one catheter malpositioned. The average time from completion of the central line change until the radiographic confirmation was 60.2 minutes. The charge for the chest x-ray film was $156., Conclusions: The combined studies composed of 1,301 patients demonstrated no pneumothorax and three malpositioned catheters. This study demonstrates that radiographic confirmation of central venous line placement after routine line change is of no benefit as the malpositioned catheters caused no morbidity, produces significant delays and increases medical charges to the patient. Extrapolation predicts an annual reduction of $46,800 in the Vanderbilt Surgical Intensive Care Unit.

Objective: The success of elective minimally invasive surgery suggested that this concept could be adapted to the intensive care unit. We hypothesized that minimally invasive surgery could be done safely and cost-effectively at the bedside in critically injured patients., Summary Background Data: This case series, conducted between October 1991 and June 1997 at a Level I trauma center, examined bedside dilatational tracheostomy (BDT), percutaneous endoscopic gastrostomy (PEG), and inferior vena cava (IVC) filter placement. All procedures had been performed in the operating room (OR) before initiation of this study., Methods: All BDTs and PEGs were performed with intravenous general anesthesia (fentanyl, diazepam, and pancuronium) administered by the surgical team. IVC filters were placed using local anesthesia and conscious sedation. BDTs were done using a Ciaglia set, PEGs were done using a 20 Fr Flexiflow Inverta-PEG kit, and IVC filters were placed percutaneously under ultrasound guidance. Cost difference (delta cost) was defined as the difference in hospital cost and physician charges incurred in the OR as compared to the bedside., Results: Of 16,417 trauma admissions, 379 patients (2%) underwent 472 minimally invasive procedures (272 BDTs, 129 PEGs, 71 IVC filters). There were four major complications (0.8%). Two patients had loss of airway requiring reintubation. Two patients had an intraperitoneal leak from the gastrostomy requiring operative repair. No patient had a major complication after IVC filter placement. Total delta cost was $611,994. When examined independently, the cost was $324,224 for BDT, $164,088 for PEG, and $123,682 for IVC filter. OR use was reduced by 506 hours., Conclusions: These bedside procedures have minimal complications, eliminate the risk associated with patient transport, reduce cost, improve OR utilization, and should be considered for routine use in the general surgery population.

Objectives/hypothesis: At present, the optimal treatment for appropriately resuscitated, multiply injured patients includes fixation of long bone fractures within twenty-four hours of injury. This management approach has been shown to decrease the incidence of pulmonary complications, multiple organ failure, and death. Some investigators have hypothesized that acute reamed intramedullary nailing of the femur (RIMNF) may result in pulmonary dysfunction as a result of the pulmonary fat embolization generated during this procedure. Patients with concomitant thoracic trauma may be at particular risk for this potentially severe complication. In an attempt to determine whether RIMNF can be safely carried out regardless of the severity of a pulmonary injury, we monitored the pulmonary effects of RIMNF in sheep in which an acute respiratory disorder (ARDS)-like state had been induced. Our hypothesis was that, if the pulmonary fat embolization that occurs as a result of RIMNF has a clinically significant effect, it would be detectable in an animal model in which a severe lung injury had been induced prior to the start of RIMNF., Study Design: This was an acute experimental procedure performed on yearling sheep., Methods: Reamed intramedullary nailing of the femur was performed in two groups of instrumented sheep. The first group had no pulmonary injuries. The second group had an ARDS-like state induced by intravenous infusion of perilla ketone prior to RIMNF. Perilla ketone increases pulmonary microvascular permeability without changing filling pressures and is used to induce a model of human ARDS. Hemodynamic and oximetric parameters were measured or calculated, as was pulmonary dynamic compliance during the experiment., Results: Infusion of perilla ketone caused a significant pulmonary injury. RIMNF caused no additional significant effect on intrapulmonary shunt, mixed venous oxygen saturation, or dynamic compliance, which are clinically used to assess the severity of pulmonary dysfunction in injured patients., Conclusions: The fat embolization that occurs during RIMNF in an appropriately resuscitated sheep has no clinically significant effect on pulmonary function, even in the setting of a severe pulmonary dysfunction.

Objectives: To evaluate the utility of the right ventricular end-diastolic volume index (RVEDVI) as a method of preload assessment in trauma patients during large-volume shock resuscitation, and to compare the RVEDVI with the pulmonary artery occlusion pressure (PAOP) as a predictor of preload in this patient population., Design: Retrospective study of a consecutive series of 46 trauma patients, admitted between June 1, 1992, and June 1, 1993, who received a volumetric oximetry pulmonary artery catheter and greater than 10 L of fluid in 24 hours., Settings: University level 1 trauma center., Main Outcome Measures: Correlations of the RVEDVI and PAOP with the cardiac index (CI) during the defined study period., Results: Three hundred fourteen measurements of the RVEDVI, PAOP, CI, and other hemodynamic variables were evaluated. Patients received a mean +/- SD of 22.1 +/- 13.3 L of blood and fluid during the 24 hours. The RVEDVI correlated better (P < .001) with the CI (r = 0.39) than did the PAOP (R = 0.05). Furthermore, there was a better correlation (P < .04) between the RVEDVI and CI when the RVEDVI was 130 mL/m2 or less (r = 0.54) than when it was greater than 130 mL/m2 (r = 0.30)., Conclusions: The RVEDVI is a better predictor of preload than the PAOP in trauma patients during large-volume shock resuscitation. When the RVEDVI is 130 mL/m2 or less, volume administration will likely increase the CI.

We have recently developed an open-chest sheep model to monitor and study the effects of major orthopedic procedures on pulmonary physiology. In this pilot study, we focused on reamed intramedullary femoral nailing in animals without pulmonary injury. Details of the model are described herein. The control group consisted of sheep that underwent thoracotomy and invasive monitoring only, while the study group also underwent femoral osteotomy, reaming, and intramedullary nailing. Baseline, postthoracotomy, and post-reaming/nailing values were recorded for mean pulmonary arterial pressure, central venous pressure, left arterial pressure, dynamic compliance, arterial blood gas, mixed venous O2, cardiac index, and mean arterial pressure so that hemodynamic and oxygen transport data could be calculated. Postprocedure values were recorded at hourly intervals for 4 h. A physiologically stable, reproducible model was created. No statistically significant differences were found between the control and experimental groups, indicating no adverse effect of femoral reaming/nailing. In one animal, using echocardiography, pulmonary embolization was documented while reaming and inserting the intramedullary nail. Reamed femoral intramedullary nailing is not detrimental to sheep with otherwise normal lungs. This finding suggests that femoral reaming and nailing in trauma patients without associated pulmonary injuries and otherwise normal lungs may be carried out without risk of inducing significant respiratory complications.

Objective: To assess the outcome of patient education after splenectomy and vaccination and to determine the safety and efficacy of pneumococcal revaccination 2 or more years after primary vaccination., Main Outcome Measures: Titers to serotype no. 6 and no. 23 pneumococcus and cutaneous and systemic reaction to revaccination., Results: A total of 112 consecutive postsplenectomy patients receiving pneumococcal vaccine were identified; 45 were contacted and offered revaccination; 24 patients demonstrated a lack of understanding of the postsplenectomy state (unaware of splenectomy n = 2, unaware of splenectomy risk n = 8, unaware of vaccine n = 23); 3 patients had infections requiring hospitalization (pneumonia, strep throat and tonsillitis, pneumonia and bacteremia); 40 patients agreed to revaccination, and 33 patients returned for follow-up titers; 16 of 33 (48%) demonstrated at least a two-fold increase in at least one titer. Only 15% described the revaccination as worse than a tetanus shot., Conclusions: (1) Despite physician-patient conversations, pamphlets, and Medic Alert bracelets, patient retention was poor. (2) All splenectomy patients should be revaccinated and reeducated between two and six years after splenectomy. (3) Revaccination after two years was well tolerated. (4) There were no fatal episodes of pneumococcal sepsis in over 200 patient years.

Objective: To identify complications and interventions resulting from fiberoptic ICP monitoring in a large series of patients with closed head injury (CHI)., Setting/design: Level I trauma center/Consecutive case series., Methods: Of 11,962 consecutive trauma admissions from 1984-1991, 279 patients underwent fiberoptic ICP monitoring for CHI. We identified the last 100 consecutive blunt trauma patients who had received ICP monitoring. Ninety-eight of these patients had charts available and constitute the study group. We examined mortality, Glasgow Coma Score (GCS), and admission CT findings for the group. Indications, interventions, and complications (bleeding, meningitis, and wound infections) associated with ICP monitoring were identified., Results: Mortality for the group was 24%. Reasons for ICP monitoring included GCS < or = 8 and/or abnormal CT findings; 83% had GCS < or = 8. Admission CT findings included subarachnoid hemorrhage (48%), intracerebral hemorrhage (47%), edema (31%), intraventricular hemorrhage (20%), subdural hematoma (18%), and epidural hematoma (9%). Eighty-one per cent of patients had interventions based on ICP monitoring: osmolar therapy (81%), emergency CT (22%), surgical decompression (3%), or pentobarbital coma (2%). No complications resulted from ICP monitoring. Mean duration of monitoring was 4 days (maximum 13 days). Twenty patients (20%) required two or more monitors. Reasons for placing a second monitor included duration > 5 days (50%), questionable accuracy (20%), and accidental removal of the first monitor (10%)., Conclusions: 1) Fiberoptic intracranial pressure monitoring leads to specific interventions in the majority of patients. 2) The procedure is safe. 3) Prospective studies are needed to determine the impact of coagulopathy on the safety of fiberoptic intracranial pressure monitoring and to define those factors responsible for the low infection rate.

Hypothesis: Assessment of splanchnic perfusion by gastric intramucosal pH (pHi) adds to the information provided by systemic indicators of oxygen transport., Setting: University Hospital level I trauma center., Design: Prospective study in 20 critically ill trauma patients comparing pHi with base deficit, lactate, oxygen delivery, and oxygen consumption (indexed to body surface area), mixed venous oxygen saturation (Svo2), oxygen utilization coefficient, and arterial pH. All measurements were obtained at admission, 1, 2, 4, 8, 16, and 24 hours, or at death., Main Outcome Measures: Correlation of pHi with the measured systemic variables, prediction of organ dysfunction, development of multiple organ dysfunction syndrome, and mortality., Results: There was a poor correlation between pHi and the systemic hemodynamic and oxygen transport variables. Patients with a low pHi (< 7.32) on admission who did not correct within the initial 24 hours had a higher mortality (50% vs. 0.0%, p = 0.03) and incidence of organ dysfunction (2.6 organs/patient vs. 0.62 organs/patient, p = 0.02) than those who did. Using logistic regression analysis, only pHi, base deficit, and Svo2 were significantly associated with mortality during the study period. At 24 hours, only pHi was different between patients who developed multiple organ dysfunction syndrome and those who did not. There was a threshold value for pHi (7.10) which identified those patients who would go on to develop multiple organ dysfunction syndrome., Conclusions: Uncorrected splanchnic malperfusion is associated with a higher incidence of organ dysfunction and mortality. Gastric tonometry supplements information provided by systemic indicators of oxygen transport during resuscitation of critically ill trauma patients.

The aim of this study was to determine the relationship of the white blood cell (WBC) count to bacteraemia, and the risk of bacteraemia after splenectomy. The case series study was carried out at the Vanderbilt University Level I Trauma Center, and included 11,870 consecutive trauma admissions: 258 required a splenectomy (191) or splenorrhaphy (67). Bacteraemia was defined as the presence of a positive blood culture. Statistical analysis included ANOVA, the non-parametric Kruskal-Wallis test and logistical regression. Forty-two (22 per cent) of the splenectomy patients had positive blood cultures, while only six (9 per cent) of the splenorrhaphy patients had positive cultures. For the group of patients requiring a splenectomy, the mean WBC count was higher and more persistent in patients with bacteraemia. Logistical regression demonstrated that the type of surgery does not significantly correlate with bacteraemia after accounting for severity of injury (TRISS). The study conclusions were as follows (1) for the group of patients with bacteraemia after splenectomy, the peak WBC count was higher and more persistent than that which occurred in the group of patients without bacteraemia after splenectomy; (2) the WBC count cannot be used to predict bacteraemia for an individual patient, but a WBC count greater than 20,000 after 10 days should initiate a vigorous search for infection; (3) the severity of injury (and not splenectomy/splenorrhaphy) accounted for the increased risk of bacteraemia in population studied.

Interventricular septal defect following nonpenetrating trauma is a rare event. In a review of 207,548 autopsies, only 30 (0.01%) cases of traumatic ventricular septal defects were noted, and only 5 (0.002%) were isolated. We report an isolated interventricular septal defect following nonpenetrating trauma.

Objective: This article describes the important clinical events and decisions surrounding the reconstruction/unpacking portion of the staged celiotomy for trauma., Methods: Of 13,817 consecutive trauma admissions, 1175 received trauma celiotomies. Of these, 107 patients (9.1%) underwent staged celiotomy with abdominal packing. The authors examined medical records to identify and characterize: (1) indications and timing of reconstruction, (2) criteria for emergency return to the operating room, (3) complications after reconstruction, and (4) abdominal compartment syndrome (ACS)., Results: Fifty-eight patients (54.2%) survived to reconstruction, 43 (74.1%) survived to discharge; 9 patients (15.5%) were returned to the operating room for bleeding; 13 patients required multiple packing procedures. There were 117 complications; 8 patients had positive blood cultures, abdominal abscesses developed in 6 patients, and ACS developed in 16 patients., Conclusions: 1. Reconstruction should occur after temperature, coagulopathy, and acidosis are corrected, usually within 36 hours after the damage control procedure. 2. Emergent reoperation should occur in any normothermic patient with unabated bleeding (greater than 2 U packed cells/hr). 3. ACS occurs in 15% of patients and is characterized by high peak inspiratory pressure, CO2 retention, and oliguria. Lethal reperfusion syndrome is common but preventable.

Base deficit is an expeditious and sensitive measure of both the degree and duration of inadequate perfusion, and has utility in the clinical evaluation and management of victims of trauma. It is rapid, accurate, and widely available, and as such may be very useful in the initial evaluation of these patients; it may also be used to help guide and assess the adequacy of volume resuscitation. It has in addition both clinical value and research potential in predicting outcome in these patients, and may be a useful tool to both the clinician and the researcher.

Objective: To determine the association of base deficit with mortality and other factors affecting mortality., Design: Retrospective review., Setting: Tertiary care center., Participants: Consecutive samples of 3791 trauma patients admitted with an arterial blood gas sample taken in the first 24 hours., Main Outcome Measures: Age, injury mechanism, head injury, shock (systolic blood pressure less than 90 mm Hg), Revised Trauma Score, TRISS probability of survival Ps, and mortality., Results: Most (3038) patients (80.1%) exhibited a base deficit. Base deficit, age, injury mechanism, and head injury were associated with mortality using logistic regression. Age less than 55 years, no head injury, and a base deficit of -15 mmol/L were associated with 25% mortality. Age greater than or equal to 55 years with no head injury or age less than 55 years with a head injury and a base deficit of -8 mmol/L were associated with a 25% mortality. When shock was added to the model, all factors remained significant, and base deficit was supplemental to blood pressure. Base deficit also added significantly to the Revised Trauma Score and TRISS measurements., Conclusions: The base deficit is an expedient and sensitive measure of both the degree and the duration of inadequate perfusion. It is useful as a clinical tool and enhances the predictive ability of both the Revised Trauma Score and TRISS.

This study evaluated the effect of high-level positive end-expiratory pressure (PEEP) on mortality, barotrauma, intrapulmonary shunt (Qsp/Qt), and oxygen delivery (DO2) in posttraumatic adult respiratory distress syndrome (ARDS). All hypoxemic trauma patients admitted to the surgical intensive care unit (SICU) in 1989-1990 who received PEEP greater than 15 cm H2O were included. The PEEP was titrated to achieve an intrapulmonary shunt (Qsp/Qt) of approximately 0.20, and FIO2 was weaned to less than 0.50. Hemodynamic and pulmonary variables at four distinct intervals were recorded. Fifty-nine patients received PEEP greater than 15 cm H2O. Of these, 19 patients died of severe head injury or uncontrollable hemorrhage (16 within 48 hours). Forty (29 male, 11 female) were evaluated in detail. The PEEP levels ranged from 18-50 cm H2O with a mean of 27. PaO2/FIO2 ratios and Qsp/Qt improved as PEEP therapy was titrated. Cardiac index and oxygen delivery were maintained or improved throughout PEEP therapy by transfusion and fluid resuscitation, with a mean maximum positive fluid balance of 21.1 L and an average of 51 units of blood and blood products transfused per patients during their SICU stay. Twenty-nine (73%) had evidence of barotrauma, the majority being pneumothoraces clearly related to the initial trauma. Only three (7.5%) had evidence of barotrauma not related to trauma or line insertion. Eight of 40 patients (20%) died. Mean ISS and RTS for the entire group were 32 and 5.88, respectively. We conclude that titration of PEEP to achieve a Qsp/Qt of approximately 0.20 is an attainable goal. This was accomplished with minimal hemodynamic effects or barotrauma and a low mortality rate.

To determine differences in outcome between unilateral and staged bilateral carotid endarterectomies, we reviewed 850 carotid endarterectomies done by 14 surgeons in a community hospital. Results of 528 unilateral procedures were compared with those of 161 bilateral procedures. Data were abstracted from records for an 11-year period. Twelve of the patients in the unilateral group had nonfatal strokes, and 14 died within 30 days of surgery (stroke + death rate, 4.9%). There were no nonfatal strokes among patients in the bilateral group, and nine died (stroke + death rate, 5.6%). Seven of 14 deaths in the unilateral group and six of nine deaths in the bilateral group were due to neurologic events. In the bilateral group, death was associated with postoperative hypertension and a short intersurgical interval. The stroke + death rate was not significantly different between unilateral and bilateral procedures and compared favorably with North American Symptomatic Carotid Endarterectomy Trial guidelines and other published reports. Staged bilateral carotid endarterectomy can be safely performed in a community hospital.

Prospective identification of patients who will not survive has been proposed as a means of limiting utilization of medical resources including critical care. This study prospectively compared prediction of outcome for surgical ICU patients by clinical assessment and the APACHE II score. Five hundred seventy-eight patients were assessed within 24 hours of admission by the ICU attending physician and predicted to live or die. An APACHE II score was calculated in that same time period. All data were stored in a data base and compared with actual SICU outcome. There were 40 deaths in 578 patients (6.9%). The clinical assessment had an overall accuracy of 95.2% vs. 90.9% for APACHE II. The Pearson correlation coefficients for the two methods of prediction were 0.59 for clinical assessment and 0.44 for APACHE II. Predictive power was not greatly improved by combining both prediction methods. Over 40% of patients predicted to die by both methods actually survived. This study demonstrates that clinical assessment is superior to APACHE II in predicting outcome in this group of surgical patients, although the difference is small. In addition, this study suggests that neither clinical assessment nor the APACHE II score, when obtained within 24 hours of admission, is very reliable at predicting which surgical ICU patients will die.

The role of the surgeon in the ICU has the potential to move in two different directions. Inattention or a lack of commitment by surgery as a discipline will lead to withdrawal from the critical care setting. This would be a significant loss for surgery as well as for future generations of surgeons. Surgery instead may commit to a greater interest and involvement in ICUs, which would help to continue the surgeon's active role in all aspects of medical progress.

Objective: To assess the statistical association of the Acute Physiology and Chronic Health Evaluation (APACHE II) score with multiple intervention and outcome variables in surgical ICU patients., Design: Continuous data collection on every patient admitted to the surgical ICU for a 21-month period., Materials and Methods: For every admitted patient in the surgical ICU, APACHE II scores were calculated and the relationship between APACHE II score as an independent predictor of outcome was assessed with multiple outcome variables selected for study. The outcome and intervention variables tested included: treatment intervention measures such as days on ventilator; days with an arterial catheter, central venous catheter, triple lumen catheter, pulmonary artery catheter; days receiving total parenteral nutrition; days receiving tube feedings; number of transducers per days in the ICU; number of infusion pumps per ICU days, days in the hospital, number of complete blood counts; number of electrolyte determinations; number of blood gases; number of units of blood transfused; ICU and hospital mortality rates in the presence of complications, including: respiratory distress syndrome, renal failure, congestive heart failure, coma, requirement of cardiopulmonary resuscitation, and others., Results: The APACHE II score was statistically associated with each intervention and outcome variable tested. Unfortunately, the associations, although consistent, were weak with r2 values ranging from .03 to a maximum of .22 for Pearson's correlation coefficients., Conclusion: The APACHE II score was statistically associated with all the variables examined in our surgical patients, but its predictive power for the individual surgical patient was limited. These findings suggest that the score may be useful for retrospective analyses of large cohorts of patients but should not be used as a triage tool or as a predictor of outcome for the individual patient. Triage decisions should continue to be based on the best available clinical judgment.

We compared the prevalence of stroke and death in 133 patients aged 75 and older in whom 170 carotid endarterectomies were performed with that in 501 patients less than age 75 in whom 640 carotid endarterectomies were performed. There were three strokes (2%) in patients aged 75 and older and nine strokes (1%) in younger patients (p = 0.7). There were 8 deaths (5%) in patients aged 75 and older and 14 deaths (2%) in younger patients (p = 0.1). After controlling for the possible confounding effects of diabetes, prior stroke, history of angina, prior carotid artery disease, previous vascular surgery, history of myocardial infarction, preoperative hypertension requiring medication, and female gender, a logistic regression model showed that patients aged 75 and older were no more likely to have a stroke or death than patients under age 75. We conclude that age alone is not a contraindication to the safe performance of carotid endarterectomy in the community hospital.

We report a survivor of Campylobacter fetus septicemia from an infected abdominal aortic aneurysm who was successfully treated with an anatomic graft reconstruction and antibiotics. According to a survey of the English-language medical literature this was the fourth such patient successfully treated. C. fetus sepsis associated with an abdominal aortic aneurysm was first reported in 1971. The first patient to survive reconstruction of an aortic tube graft aneurysm infected with C. fetus was reported in 1983. Because the natural history of an aneurysm infected by C. fetus appears to be rapid progression to rupture, patients should be operated on promptly. All patients reported in the literature who were operated on before rupture survived. Survival was independent of the type of reconstruction. When the aneurysm ruptured all patients died. Whereas extraanatomic bypass is generally considered the procedure of choice for an infected abdominal aneurysm, the aneurysms of our patient and three other patients cited in the literature were reconstructed with anatomically placed prosthetic grafts. In the absence of other contraindications such as a grossly evident purulent infection, an abdominal aortic aneurysm infected by C. fetus may represent a subset of infected aneurysms that can be treated successfully with an anatomically placed prosthetic graft and antibiotics.

We reviewed demographic data on patients having 2,256 carotid endarterectomies in eight large hospitals in North Carolina to determine the frequency of blacks among these patients. Blacks comprised only 4.6% of the patients having carotid endarterectomy even though they comprised 26% of all patients discharged and 22% of the general population of the state. Data from the National Inpatient Profile of the Commission on Professional and Hospital Activities, which represents patients discharged from short-term, nonfederal hospitals throughout the United States, show that nationwide, blacks comprise only 2.7% of the patients having carotid endarterectomy, whereas they comprise 12.0% of all patients discharged, 12.1% of the general population, and 10.7% of patients discharged following Class I surgical procedures. Blacks have only 67 carotid endarterectomies per 100,000 patients discharged; this rate is five or more times higher in whites. Among black patients having carotid endarterectomy, women predominate, whereas men predominate among white patients having carotid endarterectomy (p = 0.006). The underrepresentation of blacks among patients having carotid endarterectomy lends support to the concept that carotid vascular disease in blacks is distributed intracranially rather than extracranially as opposed to the extracranial rather than intracranial distribution in whites.

We have reported a gonococcal infection in a surgical incision made ten months before the onset of urethral discharge. Gonococcal wound infections may arise from direct contamination or possibly by blood-borne dissemination. Principles guiding therapy are similar to those for wound infections from other organisms, with attention to adequate drainage, removal of foreign body, appropriate antibiotics, and elimination of contributing sources of infection.