ANALYSIS OF MORTALITY OF EXTRADURAL HAEMATOMA IN A GENERAL SURGICAL UNIT

Extradural haematoma complicating head injury still has a formidable mortality despite recent advances in neurological surgery. The experience of 60 cases of extradural haematoma treated in a general surgical unit was reviewed retrospectively. The mortality was 35%. Analysis of the 21 deaths showed that 13 (62%) of them were possibly avoidable. Lack of index of suspicion, delay in instituting surgical treatment and inadequate surgical intervention were the main causes of the avoidable motality.     

Acute Pancreatitis: A Review

A series of 68 patients with acute pancreatitis admitted to the Royal North Shore Hospital of Sydney in a three-year period is discussed. An ætiological diagnosis was made in 68% of these. There were three cases associated with a parathyroid adenoma and a 10% incidence of hæmorrhagic pancreatitis, and pseudocysts occurred in 6%. There was no mortality in the 22 patients who underwent laparotomy. The ætiological mechanisms, diagnosis and treatment of acute pancreatitis are reviewed.     

Extradural hematoma: toward zero mortality. A prospective study

This is a prospective analysis of 107 consecutive cases of extradural hematoma treated during the last 3 years at the Department of Neurosurgery of the University Hospital of Verona (Italy). The overall mortality was 5%; 89% of the patients made a good recovery or had only moderate residual disability. We regard this as meaningful progress compared to recent reports from other sources showing mortality rates of approximately 20%. The majority of our patients (57%) underwent operation within 6 hours of injury; 60% went into surgery with a Glasgow coma scale (GCS) score between 8 and 15. No deaths occurred among patients reaching surgery with a GCS score of 8 or better; all patients with scores of 8 to 15 made a good recovery (63 cases). Seventeen patients went into surgery while still free of neurological signs, and 8 had only one dilated pupil; all 25 made good recoveries. A flexion posture at admission cuts the chances of a good outcome by one-half; an extension posture cuts the chances to one-fourth. Ninety-five per cent of the patients had fractures of the skull; only 21% had the classical lucid interval. The cause of all 5 deaths was identified as stemming from avoidable errors in management in outlying hospitals (2 cases) or in our own department (3 cases). The results of this study indicate that zero mortality from extradural hematoma is a realistic goal for a modern, well-run care system for head-injured patients that includes prompt referral by community doctors and suitable hospital facilities for constant access to emergency neurosurgery.     

Hæmodilution in Clinical Extracorporeal Circulation: Some Effects of Human Serum Albumin

Two groups of seven patients with uncomplicated septal defects or pulmonary valve stenosis were perfused by the use of “Travenol” bag oxygenators and a heat-exchanger for open heart surgery. A dilute perfusate was used, to which human serum albumin was added in one group for comparison with the other group. No clinical differences were found between the two groups, but hæmatocrit values suggested that the albumin prolonged the duration of hæmodilution into the postoperative period. The probable advantages of maintaining hæmodilution in this way are discussed.     

Intramural Hæmorrhage of the Bowel Complicating Anticoagulant Therapy

Patients receiving anticoagulant therapy may present with the clinical features of small-bowel obstruction due to intramural hæmorrhage of the bowel. Four patients with this syndrome are described, and the clinical problems in diagnosis and management are discussed. Awareness of this complication is necessary so that the diagnosis can be confirmed by barium studies of the small bowel, particularly in patients in whom other anticoagulant complications such as hæmaturia, bruising and increased prothrombin time are absent. Once the diagnosis is established, treatment is by conservative rather than operative methods.     

ACUTE MESENTERIC ISCHÆMIA

The experience of acute mesenteric ischæmia at St Vincent's Hospital, Melbourne, has been reviewed over 17 years. The mortality remains appallingly high. This applies particularly to those patients who had thrombosis of the superior mesenteric artery, amongst whom the mortality in this series was 97%. The mortality was slightly less in the group suffering from embolic occlusion of the superior mesenteric artery (66%), and in those suffering from thrombosis of the superior mesenteric vein (60%). A mortality of 66% was also found in patients suffering from non-occlusive gut ischæmia. Delay in diagnosis accounted for this high mortality. Early diagnosis is all-important, and this depends on the performance of mesenteric angiography in any patient suspected of having mesenteric ischæmia. Appropriate surgery may then be carried out in the occlusive group and supportive treatment, including intraarterial papaverine infusion, given to those with non-occlusive ischæmia. There is a pressing need for simple non-invasive tests to segregate those patients suffering from acute mesenteric ischæmia from those whose acute abdomen is due to some other cause.     

Complications in surgical patients

HYPOTHESIS: Complications are common in hospitalized surgical patients. Provider error contributes to a significant proportion of these complications. DESIGN: Surgical patients were concurrently observed for the development of explicit complications. All complications were reviewed by the attending surgeon and other members of the service and evaluated for the severity of sequelae (major or minor) and for whether the complication resulted from medical error (avoidable) or not. SETTING: University teaching hospital with a level I trauma designation. PATIENTS: All inpatients (operative or nonoperative) from 4 different surgical services: general surgery, combined general surgery and trauma, vascular surgery, and cardiothoracic surgery. MAIN OUTCOME MEASURES: Total complication rate (number of complications divided by the number of patients) and the number of patients with complications. Complications were separated into those with major or minor sequelae and the proportion of each type that were due to medical error (avoidable). Rates of complications in a recent Institute of Medicine report were used as a criterion standard. RESULTS: The data for the respective groups (general surgery, vascular surgery, combined general surgery and trauma, and cardiothoracic surgery) are as follows. The number of patients was 1363, 978, 914, and 1403; number of complications, 413, 409, 295, and 378; total complication rate, 30.3%, 42.4%, 32.3%, and 26.9%; minor complication rate, 13.3%, 19.9%, 13.5%, and 13.0% (percentage of minor complications that were avoidable, 37.4%, 59.0%, 51.2%, and 49.5%); major complication rate, 16.2%, 21.1%, 18.1%, and 12.9% (percentage of major complications that were avoidable, 53.4%, 60.7%, 38.8%, and 38.7%); and mortality rate, 1.83%, 3.33%, 2.28%, and 3.34% (percentage of mortality that was avoidable, 28.0%, 44.1%, 19.0%, and 25.0%). CONCLUSIONS: Despite mortality rates that compare favorably with national benchmarks, a prospective examination of surgical patients reveals complication rates that are 2 to 4 times higher than those identified in an Institute of Medicine report. Almost half of these adverse events were judged contemporaneously by peers to be due to provider error (avoidable). Errors in care contributed to 38 (30%) of 128 deaths. Recognition that provider error contributes significantly to adverse events presents significant opportunities for improving patient outcomes.     

RENAL ANGIOGRAPHY AND THE MANAGEMENT OF SEVERE CLOSED RENAL TRAUMA1

The purpose of this study was to determine the place of selective renal angiography in the assessment of major renal trauma. Thirty-one cases of renal injury assessed by urography and angiography were reviewed, and the radiological features correlated with the subsequent clinical course. Based on the angiographic findings, a classification of these more severe injuries is proposed, and the prognostic significance of renal ischæmia demonstrated. Because conservative treatment in those cases with significant ischæmia is likely to fail, early elective surgery is recommended. In this selected group, viable renal tissue can be preserved, and the necessity for subsequent nephrectomy due to secondary hæmorrhage, or continuing urine leakage, is avoided.     

Cardiac Valve Replacement with Heterologous Aortic Valves1

Eighty-six formalin-prepared heterologous aortic valves have been used to replace the human aortic valve over a three-year period, with encouraging clanical resuts. In a more recent ten-month pertoct, similarly prepared valves mounted in a suitable frame have been usea as a mitral valve prosthesis tn 11 patients without any operative mortality. Clinical and hæmodynamic follow-up has shown excellent long-term function in the aortic valve replacement group, although one-third of patients have developed some evidence of valve incompetence. Only four patients have had severe incompetence, and in two this was shown to be due to dehiscence of the implanted valve from the host tissues and related to late infection. Pathological studies have shown no evidence of degenerative changes in the valves after implantation, the coliagen and elastic tissue remaining histologically near normal.     

ACUTE PANCREATITIS: THE QUEENSLAND SCENE

One hundred patients suffering from acute pancreatitis and studied in two large teaching hospitals in Brisbane between 1959 and 1973 were reviewed. Gallstones were present in 43 patients (of whom 31 were female), and a history of alcoholic excess was elicited in 23. Sixty-three patients were aged over 50 years. Characteristic clinical features included spreading epigastric pain with radiation to either of the upper quadrants of the abdomen. Left-sided upper abdominal peritonitis associated with severe repetitive vomiting was suggestive of the diagnosis. The serum amylase level in most cases fell below the arbitrary diagnostic level of 500 Somogyi units/100 ml within 72 hours of the onset of the pain. Acute hæmorrhagic necrosis of the pancreas was positively diagnosed in 15 patients, six of whom died. The overall mortality rate in the series was 9%.     

Traumatic extradural haematomas in children: Experience with 62 cases

Summary Sixty-two children with traumatic extradural haematomas are considered. According to the clinical history presented—often atypical— and to the grade of neurological impairment, patients have been divided into different clinical groups. Nearly 50% of patients sustained a minor injury, and 26% did not lose consciousness after trauma. Twenty-four per cent of patients did not show fractures on skull X-rays. Atypical location of the haematoma was noted in 22 cases, mainly in the anterior fossa (19 cases).Sixty patients were operated on, while two patients were conservatively treated, owing to the limited size of the haematomas and to the absence of neurological deficits. Associated brain lesions were discovered at surgery in 40% of cases.The overall mortality rate has been 17%, the operative mortality rate 14%. The morbidity rate has been 6%, with 3% of patients presenting severe disability. Morbidity and mortality have been shown to be affected by age—with better prognosis in patients under 10 years of age, by the clinical history presented, by the preoperative conditions, and, mainly, by the presence of associated brain lesions. As regards location, frontal haematomas have shown a better prognosis and a slower course than convexity haematomas. Finally, prognosis of extradural haematomas in children has improved to some extent in the last years with the advent of the CT scan, possibly due to speed and accuracy of diagnosis.     

Hæmorrhage into an Abscess Cavity: An Uncommon Complication of Pelvic Abscess

This case report illustrates the difficulty in diagnosis and management of unilateral pelvic infection in adolescent gynæcology. It also describes a rare complication of an intraabdominal abscess-delayed massive hæmorrhage into the abscess cavity.     

THE CREATION OF ARTIFICIAL SUBCUTANEOUS ARTERIOVENOUS FISTULAS IN PATIENTS WITH MALIGNANT HEMATOLOGICAL DISEASE

Creation of an artificial subcutaneous arteriovenous fistula was attempted in five patients with malignant hæmatological disorders (two with Hodgkin's disease, two with acute lymphatic leukæmia, and one with acute myeloid leukæmia). The average time from the start of treatment to attempted creation of the fistulæ was four years. Neither direct arteriovenous anastomosis nor an interposition mandril graft was successful in any patient. Failure was attributed to impaired venous run-off secondary to previous episodes of thrombophlebitis induced by the intravenous administration of cytotoxic drugs. The use of an arteriovenous fistula early in the course of the disease might minimize these later problems.     

Intrapartum-related birth asphyxia in South Africa--lessons from the first national perinatal care survey.

BACKGROUND: The recent amalgamation of data by users of the Perinatal Problem Identification Programme (PPIP) throughout South Africa has culminated in the publication of the Saving Babies report. OBJECTIVES: To determine the absolute rate of death from intrapartum-related birth asphyxia, and the contribution of intrapartum-related asphyxia to total perinatal mortality in South African hospitals, and to identify the primary obstetric causes and avoidable factors for these deaths. METHODS: The amalgamated PPIP data for the year 2000 were obtained from 27 state hospitals (6 metropolitan, 12 town and 9 rural) in South Africa. In PPIP-based audit, all perinatal deaths are assigned primary obstetric causes and avoidable factors, and these elements were obtained for all deaths resulting from intrapartum-related birth asphyxia. RESULTS: There were 123,508 births in the hospitals surveyed, with 4,142 perinatal deaths among infants > or = 1,000 g, giving a perinatal mortality rate of 33.5/1,000 births. The perinatal mortality rate from intrapartum-related birth asphyxia was 4.8/1,000 births. The most frequent avoidable factors were delay by mothers in seeking attention during labour (36.6%), signs of fetal distress interpreted incorrectly (24.9%), inadequate fetal monitoring (18.0%) and no response to poor progress in labour (7.0%). The perinatal mortality rates for metropolitan, town, and rural areas were 30.0, 39.4 and 30.9/1,000 births respectively. The contribution of intrapartum-related birth asphyxia to perinatal mortality in these areas was 10.8%, 16.7% and 26.4% respectively. CONCLUSION: The high rates of perinatal death from intrapartum-related birth asphyxia in South Africa are typical of those in underdeveloped countries, with the most serious deficiencies in rural areas. Most of these deaths are avoidable and the reduction of these rates presents an important challenge to providers of perinatal care in this country. Areas worthy of research and action include provision of mothers' waiting facilities in rural regions, improvements in fetal monitoring, partogram-based labour management, and the establishment of midwifery staffing norms for South African labour units.     

Severe traumatic coma in infancy and childhood: results after surgery and resuscitation.

This study deals with 390 cases of severe traumatic coma in infancy, childhood and youth, aged between 4 months and 19 years. Cases in which unconsciousness lasted less than 24-48 hours have not been considered here. 161 patients were operated upon for intracranial space-occupying lesions or for open head injury: extradural haematomas 60; extradural haematomas + brain lacerations and/or subdural haematomas 16; acute subdural haematomas 18; brain laceration 36; open head injuries 17; decompressive operations, hydromas and contusions 14. 102 patients recovered and 59 died. 229 subjects were given only to resuscitation treatment. 164 recovered and 65 died. Recovery and mortality rate are discussed in relation to the pathologicial lesions and to the clinical picture (severity, evolution and duration of coma). Overall mortality rate was 31%. Mortality was higher in operated patients (36.6%) and lower in patients in whom space-occupying lesions were not demonstrated by angiography and who underwent only resuscitation treatment (28%). The lowest rate was observed in cases of extradural haematoma (25.4%) and open head injury (23%). Highest mortality rate have been observed in cases of decerebrated coma (with or without signs of low brain stem impairment). Complete recovery can be achieved even after prolonged decerebration. 31 patients showed the typical picture of the "apallic syndrome": in 28 cases after prolonged decerebrated coma, in 3 cases after coma without decerebration. Of our 31 cases, 4 died, 4 are still in a chronic apallic state and 23 recovered. Of these, 10 patients had a remarkable recovery and 13 remained severely disabled.     

Acute Hydrocephalus in Hæmophilia: Report of a Case

A case of life-threatening hydroccphalus occurring in a hæmophiliac child is reported, and attention is drawn to the possibilities of successful surgical treatment in an apparently moribund patient. The pertinent literature is reviewed.     

The hitch stitch: an obsolete neurosurgical technique?

The objective was to assess the efficacy of dural tenting sutures as a prophylactic measure against extradural haemorrhage following craniotomy. A comparison was made of postoperative extradural haemorrhage between a surgeon always using tenting sutures and a surgeon who never uses them. The subjects consisted of 130 adult patients, 44 with postoperative scans, with normal blood coagulation who underwent elective supratentorial craniotomy (September 1998 to December 2000). Outcome measures were haematoma volume and midline shift as measured on CT and reoperation due to extradural haematoma. The group using tenting sutures had larger median extradural haematoma (2.5 vs 2.0 ml) and midline shift (3 vs 0 mm) than the omitting group. These differences were not significant (P = 0.74 and 0.84). Reoperation due to extradural haemorrhage occurred in 3.6% of the group using tenting sutures and in 0% of the group omitting them. Prophylactic dural tenting sutures do not reduce the size of extradural haematomas in this study. A prospective, randomized trial is needed to eliminate surgeon bias.     

Mycotic Aneurysms of the Aortic Root1

The clinical details of six patients presenting with mycotic aneurysms as complications of aortic valve endocarditis are presented. A distinction is made between this little-described condition and congenital sinuces and fistulæ. The lesion was demonstrated in all of the patients by cineangiography, and this investigation is strongly recommended. The mortality in the series was high, due to a combination of preoperative toxæmia and resistant heart failure. It is suggested that early investigation of patients presenting with unresponsive aortic endocarditis may reduce the mortality of surgery and will commonly demonstrate the presence of sinuses and fistulæ, facilitating both the planning and performance of the operation.     

Traumatic Hæmobilia

A series of laboratory experiments is described, in the course of which central liver injuries were produced by the use of a sharp instrument introduced through a laparotomy incision. After this, appropriate blood chemistry investigations were carried out, and the fæces were examined for occult blood. The significance and implications of the findings of hæmobilia in the human subject are discussed.     

Spontaneous Intramural Hæmatoma in the Sigmoid Colon of a Hæmophiliac

This paper describes a case of intramural hamatoma of the colon occurring spontancously in a patient with hæmophilia so mild that the diagnosis was unsuspected before operation. Successful resection was achieved with a minimun of blood loss. During subsequent surgery, it was necessary to control bleeding with repeated infusions of cryoprecipitate.