The American surgeon
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The American surgeon · Oct 2012
The current role of magnetic resonance imaging for diagnosing cervical spine injury in blunt trauma patients with negative computed tomography scan.
Clearance of cervical spine (CS) precautions in the neurologically altered blunt trauma patient can be difficult. Physical examination is not reliable, and although computed tomography (CT) may reveal no evidence of fracture, it is generally believed to be an inferior modality for assessing ligamentous and cord injuries. However, magnetic resonance imaging (MRI) is expensive and may be risky in critically ill patients. ⋯ Although use of the single-slice scanner was significantly associated with MRI findings (odds ratio, 2.62; P=0.023), no significant clinical risk factors were identified. Patients with MRI findings were heterogeneous in terms of age, mechanism, and Injury Severity Score. We conclude that CS MRI continues play a vital role in the workup of neurologically altered patients.
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The American surgeon · Oct 2012
Closed-suction drain placement at laparotomy in isolated solid organ injury is not associated with decreased risk of deep surgical site infection.
The purpose of this study was to investigate the role of intra-abdominal closed-suction drainage after emergent trauma laparotomy for isolated solid organ injuries (iSOI) and to determine its association with deep surgical site infections (DSSI). All patients subjected to trauma laparotomy between January 2006 and December 2008 for an iSOI at two Level I urban trauma centers were identified. Patients with isolated hepatic, splenic, or renal injuries were included. ⋯ Subgroup analysis demonstrated those who sustained severe hepatic injury receiving a drain had a significantly increase risk of DSSI (P=0.02). There was no statistical difference in the rate of DSSI based on the presence or absence of an intra-abdominal drain after severe splenic injury (17 vs 18%, P=0.88). The use of intra-abdominal closed-suction drains after iSOI is not associated with decreased risk of DSSI.
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The American surgeon · Oct 2012
Enhanced recovery protocol: implementation at a county institution with limited resources.
The benefits of an enhanced recovery protocol (ERP) in colorectal surgery have been well described; however, data on the implementation process is minimal, especially in a resource-limited institution. The purpose of this study was to evaluate outcomes during implementation of a physician-driven ERP at a public-funded institution. We retrospectively reviewed all elective colorectal surgery during a transition from standard care to an ERP (implemented via a standard order sheet). ⋯ Late implementation of ERP diet, analgesics, and activity were the most common process errors. Full application of the ERP reduced mean LOS by 3 days (P=0.002), and there was a trend toward decreased postoperative morbidity without an increase in readmission rate (P=0.61). Full implementation of an ERP for colorectal surgery faces many challenges in a resource-limited county institution; however, when fully applied, the ERP safely reduced overall LOS, which is important in cost containment.
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The American surgeon · Sep 2012
Comparative StudyDamage control immunoregulation: is there a role for low-volume hypertonic saline resuscitation in patients managed with damage control surgery?
Hypertonic saline (HTS) is beneficial in the treatment of head-injured patients as a result of its potent cytoprotective effects on various cell lines. We hypothesize that low-volume resuscitation with 3 per cent HTS, when used after damage control surgery (DCS), improves outcomes compared with standard resuscitation with isotonic crystalloid solution (ICS). This is a 4-year retrospective review from two Level I trauma centers. ⋯ There was no difference for prevalence of renal failure at 5.3 versus 3.6 per cent (P = 0.58). Low-volume resuscitation with HTS administered after DCS on arrival to the TICU may have a protective effect on the polytrauma patient. We believe that this study demonstrates a role for low-volume resuscitation with HTS to improve outcomes in patients undergoing DCS.
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The American surgeon · Sep 2012
The role of repeat computed tomography scan in the evaluation of blunt bowel injury.
The precise role of repeat abdominal computed tomography (CT) imaging in the diagnosis and management of bowel injury is unclear. We reviewed 540 patients with blunt abdominal trauma managed at a Level II trauma center over a 5-year period to better define the role of repeat imaging. One hundred patients had a repeat abdominal CT scan within 72 hours of admission. ⋯ The repeat scan resulted in a change in clinical management in 26 patients. Regarding the presence of bowel perforation, the follow-up scan enhanced sensitivity from 30 to 82 per cent. The repeat abdominal CT is best used selectively in patients with blunt abdominal trauma and can provide clinically useful information to exclude bowel injury.