Management of and indications for tracheostomy in care of the critically ill patient

Tracheostomy is a procedure which has evolved over many hundreds of years. In the 21st century, the majority of tracheostomies are now inserted by intensivists in the intensive care unit (ICU). Commonly performed to assist in weaning patients from mechanical ventilation, the procedure is performed using a percutaneous dilatational technique (PDT). Percutaneous tracheostomy can generally be performed safely in ICU, although a number of contraindications and complications do exist. Recent publications have highlighted weaknesses in the quality of care both in the immediate and longer term. Consequently, a number of organizations, based in the UK and internationally, have turned the focus in recent years to improving the quality of care delivered to these patients. Clinicians caring for patients with tracheostomies should not only be familiar with the indications, anatomy and insertion techniques, but also current guidance on routine care and the emergency management of complications.     

Management of and indications for tracheostomy in care of the critically ill patient

Tracheostomy is a procedure that has evolved over many hundreds of years. In the 21st century, the majority of tracheostomies are now inserted by intensivists in the intensive care unit (ICU). Commonly performed to assist in weaning patients from mechanical ventilation, the procedure is performed using a percutaneous dilatational technique. Percutaneous tracheostomy can generally be performed safely in the ICU, although a number of contra-indications and complications do exist. Recent publications have highlighted weaknesses in the quality of care both in the immediate and longer term. Consequently, a number of organizations, based in the UK and internationally, have turned the focus in recent years to improving the quality of care delivered to these patients. Clinicians caring for patients with tracheostomies should not only be familiar with the indications, anatomy and insertion techniques, but also current guidance on routine care and the emergency management of complications.     

Indications for splenectomy in the pediatric patient

The rationale for splenectomy in blood dyscrasias of children is based on the removal of an organ in which gross aberrations of one or more of its functions develop. Removal of the spleen is therefore indicated in patients with hereditary spherocytosis, autohemolytic anemia and thalassemia because in each case the spleen is associated with specific factors that promote excessive hemolysis. The massive size of the organ in thalassemia is an additional indication for its removal, but in this stage transfusion requirements as a result of the hemolytic mechanism are already excessive. The spleen may be responsible for platelet destruction as in thrombocytopenic purpura. It generates a destructive and/or humoral factor which inhibits the bone marrow not only with regard to platelets but other blood cell precursors as in Banti's and Gaucher's disease resulting in pancytopenia.The increased susceptibility to infection after splenectomy in the young patient emphasizes the need for close supervision for at least two years postoperatively.     

Hand-assisted laparoscopic splenectomy: indications and technique.

INTRODUCTION: Laparoscopic splenectomy has become the procedure of choice for those patients who need to have a splenectomy. The skills required to perform a laparoscopic splenectomy are not easy to learn and therefore may limit the availability of this procedure to patients. METHODS: We present a hand-assisted technique that allows the performance of a laparoscopic splenectomy safely and rapidly by surgeons without a great deal of experience with this procedure. RESULTS: A laparoscopic hand-assisted splenectomy was performed by a chief resident who had not performed this procedure before. The operative time was comparable to that of a laparoscopic splenectomy performed by an experienced laparoscopic surgeon at our institution (65 vs 62 min). CONCLUSIONS: The hand-assisted technique is useful in a number of laparoscopic situations. We suggest that hand-assisted laparoscopic surgery might be used as an adjunct for surgeons with limited laparoscopic experience and for residents who are learning advanced laparoscopic skills.     

Splenic enlargement and hyperfunction as indications for splenectomy in chronic leukemia.

The chronic leukemias are associated with significant morbidity from splenic enlargement and hyperfunction. Although some patients with chronic leukemia benefit from splenectomy, the indications for operation are unclear. To identify those patients who benefit most from splenectomy, nine patients with chronic lymphocytic leukemia (CLL) and eight patients with chronic granulocytic leukemia (CGL) who had splenectomy to palliate the symptoms of massive splenic bulk or to improve the hematologic sequelae of splenic hyperfunction were studied. Splenectomy for bulk symptoms provided good palliation of symptoms, but the duration of the benefit was limited by the stage of the disease. Five of eight patients with CGL with bulk symptoms died within 6 months of operation. Splenectomy for hyperfunction was limited to a short-term hematologic response. In three of four patients with CLL who were Coombs positive, the presence of autoantibodies correlated with a recurrent transfusion requirement within 3 months of splenectomy. Thus, the benefit of splenectomy for bulk symptoms must be weighed against the risk of surgery and the patient's limited life expectancy. The benefit of splenectomy for treatment of splenic hyperfunction depends on the stimulus to hyperfunction and may not be beneficial for patients with refractory autoimmune anemias.     

Elective splenectomy in the elderly patient

This report reviews 10 years' experience with elective splenectomy in patients over 55 years of age. Of 55 patients, 25 were over the age of 65. The majority of splenectomies (41) were performed for hematological disorders exclusive of lymphoma, but including ITP, hypersplenism (both primary and secondary), Felty's syndrome and myeloid metaplasia. Sixty-eight per cent of these patients responded to splenectomy with sustained elevation of platelet counts while 70 per cent responded to sustained elevation of leukocyte counts. Sixteen of the hematological patients received a preoperative trial of steroid therapy in an attempt to alleviate leukopenia or thrombocytopenia with a 37.5 per cent (6 of 16) success rate. There was no correlation between the response to preoperative steroid therapy and response to splenectomy. These data correspond favorably to previous published material in the younger aged patients. There was no difference in the postoperative complication rate related to drainage or nondrainage of the splenic bed. However, eight other complications occurred for a morbidity rate of 14.5 per cent in addition to complications related to drainage of the splenic bed (8%). A 9 per cent (5 of 55) mortality rate was related to the patients' pre-existing diseases and appears acceptable in light of hematological response rate and quoted mortality rates for splenectomy over age 65.     

Time lapse and comorbidities influence patient knowledge and pursuit of medical care after traumatic splenectomy

BACKGROUND: There is insufficient knowledge of infectious risk in patients after splenectomy; minimal data exists specifically for trauma patients. This study evaluated patient knowledge and practices regarding infection risk after traumatic splenectomy. Our hypothesis was that patients with poor knowledge regarding their asplenic state would be less likely to pursue medical care in the event of an illness than those with good knowledge. METHODS: Non-randomized, cohort study of all posttraumatic splenectomy patients < or =11 years after injury in 2 rural trauma centers. Patients received a validated questionnaire; weighted responses determined knowledge about infection risks and appropriate follow-up actions. RESULTS: Fifty-four percent of patients responded to the questionnaire. Overall, 47% of responders were identified as having adequate knowledge regarding infectious risk, and only 28% would pursue appropriate medical care. Of patients with adequate knowledge, 42% were more likely to pursue appropriate care versus 15% of patients with inadequate knowledge (p = 0.06). Patients with adequate knowledge were more likely to receive an annual influenza vaccine (p = 0.03) and contact their provider with fewer symptoms (p = 0.03). Logistic regression revealed significant interactions between knowledge and presence of comorbidities (p = 0.04). Focusing on patients with poor knowledge and absence of comorbidities, none would engage in appropriate action in the event of illness (p < 0.01). A longer time since injury, >3 years, was associated with a diminished likelihood of appropriate action (p = 0.03). The relationship between knowledge and action was not accounted for by other potential confounders. CONCLUSIONS: Trauma patients retain minimal knowledge about infection risk after splenectomy and are not likely to pursue appropriate medical care. Time since injury negatively influences patient actions. Healthcare providers must be more proactive to develop new strategies in educating these patients, particularly those without comorbidities and those greater than 3 years postsplenectomy.     

The indications and contraindications for the use of lung resection for tuberculoma in a diabetic patient]

Basing on retrospective analysis of clinico-radiological and morphological investigations, studying of immediate and late (follow-up from 1 to 15 years) results of the tuberculoma surgical treatment in 132 patients with diabetes mellitus (DM) the indications and contraindications for pulmonary resection conduction were elaborated. An optimal term of the chemotherapy course conduction before the operation, constituting 2-5 m.o., was determined. In differential diagnosis between tuberculoma and the tumor, when the tuberculosis is stabilized and DM is compensated the operation is performed without preliminary chemotherapy conduction.     

External fixation indications and patient selection

Since its modest beginnings in the mid-nineteenth century, external fixation has seen great changes in its design and application. Once thought of as chiefly a fracture management tool, this modality has found its way into the arenas of corrective osteotomies, Charcot management, limb lengthening, nonunion treatment, and malalignment correction. As external fixation has evolved, great improvements in associated complications have also occurred. This is attributed to evolving frame design, subsequent increased stability, and advances in pin/wire insertion techniques. Paley and Herzenberg describe three factors to consider when evaluating whether to use external or internal fixation [2]. 1. Risk versus benefit of the method used for that specific indication. 2. Surgeon's experience with the specific method. 3. Ability to treat the potential complications of the surgery. The authors agree with these factors but would also include psychological tolerance, compliance with postoperative self-treatment, and personal hygiene. In this article the indications for external fixation were described in terms of pathology and individual patient factors were discussed for the surgeon's consideration. The surgeon must consider the patient's bone quality, age, cognitive ability, psychological tolerance, and compliance level. With these factors kept in mind and evaluated appropriately, the surgeon should be able to select the patient and indications for which external fixation will yield a superior result.     

The indications and controversies for the use of corticosteroids in respiratory deficits in the multiple-trauma patient]

The rational use of corticosteroids in terms of doses, timing and methods of administration, has proved useful in management of the effects of morbidity and mortality in respiratory insufficiency in multiple trauma patients. MPSS (methyl prednisone sodium succinate) is the drug of choice because, compared to other steroids, it penetrates lung tissue more easily (as demonstrated using autoradiographic techniques). The effect of reducing permeability, shown by MPSS, is more marked in the first 6 hours, followed by a progressive diminution. For this reason, it is advisable to administer the drug every 6-8 hours, irrespective of T 1/2 (12-36 h). However, in syndromes of post-traumatic respiratory distress, corticosteroid therapy is only symptomatic, namely it reduces short term mortality, but does not influence the prognosis in the event of persistent microembolism. On the other hand, it is important not to overlook the disadvantages and possible damaging effects linked to the use of corticosteroids in multiple trauma patients. With regard to the use of "alternative" type or support treatments to corticosteroids, the lack of markers documented using atraumatic and reliable techniques hinders the development and clinical application of specific and effective antioxidising treatments. However, alongside the perfection of methods of detecting markers, among the antioxidant drugs, a decisive contribution is expected from the lazaroids or 21-aminosteroids (synthesis steroids). With powerful scavenger activity and antioxidant properties (twice those of MPSS), the lazaroids can provide more suitable solutions to the complex therapeutic problems of these patients, also because they lack glucocorticoid and mineralocorticoid activity.     

Clinical indications for cervical spine radiographs in the traumatized patient

During a 4 1/2 year period, 4,941 trauma patients were admitted to a hospital, and details of their injuries and treatment were entered in a computerized trauma registry. Using that database, patients with cervical spine injury were studied. Of the 4,941 patients, 1,823 (38 percent) had radiographs of the cervical spine. Ninety-four patients (5 percent) of these patients had injuries of the cervical spine or spinal cord. Sixty five of the 94 patients with cervical spine injury were alert. All had either neck pain or neck tenderness. We do not recommend screening cervical spine radiographs for the alert trauma patient without neck pain; however, we do recommend screening for all patients with decreased levels of consciousness and an injury that could have conceivably injured the cervical spine, for all patients with neurologic deficits compatible with a cervical origin, and for all patients with neck pain or tenderness. Lateral cervical spine radiographs were obtained in all injured patients. They demonstrated cervical spine injury in 70 patients (74 percent) and missed the injury in the remaining 24, which resulted in an unacceptable false-negative rate of 26 percent. We believe that all patients at risk for cervical spine injuries must have complete radiographic examinations of the cervical spine. Computerized axial tomography was the most useful modality to confirm a cervical spine injury in those patients whose lateral cervical spines appeared normal radiographically, especially in patients with associated head injury requiring computerized axial tomography of the brain. Computerized axial tomography diagnosed the injury in 14 of the 24 patients requiring study beyond initial screening. Also presented herein is a radiologic screening algorithm for cervical spine injuries in trauma patients.     

手助腹腔镜巨脾和胆囊联合切除术

目的 :总结手助的腹腔镜巨脾切除手术技术。方法 :用手助技术完成腹腔镜巨脾和胆囊联合切除术治疗 1例脾肿大、脾功能亢进伴胆囊结石患者。结果 :4 5h完成手术 ,术中出血较少。患者术后恢复良好。结论 :手助的腹腔镜巨脾和胆囊联合切除术操作安全 ,手术时间短 ,技术上完全可行