The American surgeon
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The American surgeon · Feb 1997
Comparative StudyRandomized blinded study of aprotinin infusion for liver crush injuries in the pig model.
Repeat exploratory laparotomies for intra-abdominal bleeding in patients who sustain severe blunt intra-abdominal trauma are common. Reexploration usually reveals no single site of bleeding and the abdomen is closed with laparotomy pad packing, with a presumed diagnosis of coagulopathy. ⋯ The liver plays a major role in the balance of hemostatic systems, and this balance is disrupted by liver trauma. This study investigates the use of intravenous aprotinin, a naturally occurring serine protease inhibitor, in a pig liver crush model to evaluate its effectiveness in reducing intra-abdominal bleeding in experimentally induced shock and non-shock states.
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Since 1990, a selective management algorithm has been used in our Trauma Center to treat 91 patients with penetrating neck injuries. Group A (n = 37) sustained zone I, zone III, or multiple-zone injuries; Group B (n = 54) sustained zone II injuries [most (55, 66.4%) from gunshot or shotgun wounds]. Nineteen Group A and 21 Group B patients required mandatory neck exploration. ⋯ Unnecessary exploration was avoided in 52 per cent of cases regardless of the location of the wound. Mortality and morbidity rates were acceptable. Patients with penetrating neck injuries could be safely managed selectively regardless of the injury zone.
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In patients with inferior vena cava (IVC) injuries, predictors of survival are investigated. From 1987 to 1995, 27 IVC injuries were identified among 514 patients with vascular trauma. The ability of clinical determinants to predict survival were retrospectively assessed. ⋯ Four complications [venous hypertension (n = 2), IVC thrombosis (n = 1), and pulmonary embolus (n = 1)] occurred in the 14 survivors (28.6%). Blunt injury, revised trauma score, free perforation, injury location, intraoperative hypotension, and blood loss were predictive of mortality. IVC injuries remain extremely lethal, and improved survival is associated with infrarenal penetrating injuries and a contained hematoma.
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The American surgeon · Feb 1997
Primary repair of 58 consecutive penetrating injuries of the colon: should colostomy be abandoned?
Although primary repair of penetrating colon injuries in patients with low injury severity is now widely accepted, several "risk factors" continue to be viewed as relative contraindications to this method of management. The purpose of this study was to evaluate the septic complications and leak rate in a series of consecutive penetrating colon injuries managed exclusively with primary repair. The records of 58 consecutive patients with penetrating intra-abdominal colon injuries managed at an urban Level I trauma center from July 1991 to December 1995 were reviewed. ⋯ The presence of "risk factors" appeared to identify more severely injured patients as indicated by a higher mean PATI score and a higher incidence of intra-abdominal abscess, when compared to patients in whom the "risk factor" was absent. Primary repair can safely be used for virtually all penetrating colon injuries, as clinical leaks are rare, even in patients with "risk factors". Intra-abdominal abscess and other septic complications are dependent on the overall severity of the intra-abdominal injuries and probably result from contamination occurring at the time of injury rather than from postoperative leak from the primary repair.
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The American surgeon · Jan 1997
Randomized Controlled Trial Clinical TrialThe effects of epidural anesthesia on the neuroendocrine response to major surgical stress: a randomized prospective trial.
It has long been held that the acute-phase and neuroendocrine response to stress requires afferent neural input for its propagation. To further clarify the role of afferent neural impulses in this process and to determine the ability of epidural anesthesia to attenuate the normal perioperative stress response, 39 patients undergoing uncomplicated abdominal aortic replacement were randomized to receive either general anesthesia with postoperative patient-controlled intravenous morphine (n = 19) or combined regional/general anesthesia with intraoperative epidural catheter anesthesia using Bupivacaine to the T4 dermatome level followed by postoperative epidural morphine (n = 20). The stress response was quantitated by blinded measurement of baseline and postoperative (0, 12, 24, 48, and 72 hours) serum cortisol, epinephrine norepinephrine, total catecholamines, interleukin (IL)-1beta, IL-6, tumor necrosis factor (TNF)-alpha, and C-reactive protein (CRP). ⋯ Those patients with operative times greater than 5 hours (n = 10) developed significantly higher CRP, IL-1beta, IL-6, and TNF-alpha levels (P < 0.05) at 12 and 24 hours postoperatively than those with total operative times less than 4 hours (n = 16). The neuroendocrine response to major surgical stress is propagated normally despite epidural blockade and is intensified with prolonged operative times. The inflammatory cytokines appear to play a major role in this process.