Does preexisting mental illness influence outcome in pediatric trauma?

Purpose. According to national estimates, up to 10% of American children suffer from some type of mental illness. Despite this high incidence, few studies have examined the role of a preexisting psychiatric disorder on childhood trauma. We hypothesize that children with such a diagnosis will have more severe injuries and poorer outcomes then other children. Methods. A 5-year (1998-2002) review of the Pennsylvania Trauma Outcome Study database was performed and information regarding children less than or equal to 16 years was abstracted. We evaluated the effects of a preexisting psychiatric diagnosis (not otherwise defined) and attention deficit disorder (ADD) on the type and mechanism of injury, injury severity, and outcome. Statistical analysis was performed using Student’s t-test, chi square, and Fisher’s exact test. Results. Over the study period 19,825 children were admitted to a Trauma Center: 530 (2.7%) had a preexisting psychiatric diagnosis (PD) and 189 (1%) had ADD. Children with ADD and PD were older than their peers (12.1 ± 3.3 versus 9.6 ± 5.6; P < 0.0001 and 13.7 ± 3.2 versus 9.5 ± 5.6; P < 0.0001), but did not differ in injury severity or overall mortality. However, those with PD were more likely to be victims of penetrating trauma (9.6% versus 7%; P < 0.022), and have longer ICU (2.2 versus 1.5 days; P = 0.0003) and hospital (5.7 versus 4.1 days; P < .0001) lengths of stay than unaffected children. Furthermore, children with PD were more likely to be discharged to a location other than home (P = 0.0006). Both the ADD and the PD groups were less likely to use protective devices (P < 0.03; P = 0.0011). Conclusions. Despite similar injury severity, children with a preinjury psychiatric history have longer hospitalizations than their nonaffected peers. This may be due in part to difficulty in finding appropriate postdischarge facilities for these children. Injury prevention strategies in this population should address the importance of protective equipment. Finally, the relatively low percentage of children identified as having ADD or PD in this study could be the result of underreporting and thus potentially affect the results.     

Can I improve postoperative outcome after abdominal surgery?

Most of the textbooks of anesthesia do not devote any chapter to anesthesia for abdominal surgery. Whereas the choice of anesthetics has minimal impact on postoperative outcome of the patient scheduled for these procedures global perioperative anesthetic management however affects postoperative recovery, convalescence, or even morbidity. This presentation highlights practical measures susceptible of reducing postoperative complications and of shortening patient convalescence.     

Does aprotinin influence the inflammatory response to cardiopulmonary bypass in patients?

OBJECTIVES: Aprotinin has been shown to have anti-inflammatory properties, but its effects on the inflammatory reaction to cardiopulmonary bypass remain controversial. This prospective, randomized, double-blind study evaluated the influence of aprotinin on various blood markers of inflammation during and after cardiopulmonary bypass. METHODS: Sixty male patients underwent coronary artery bypass grafting. The patients were randomized into 3 groups: a placebo group, a second group receiving 2,000,000 KIU of aprotinin followed by an infusion of 500,000 KIU/h and 2,000,000 KIU in the pump prime, and a third group receiving half this dosage. Measurements of tumor necrosis factor, interleukin 6, interleukin 8, interleukin 10, endotoxin, histamine, complement factors, prekallikrein, and prostaglandin D(2) were obtained at baseline, 30 minutes after study drug loading, 10 minutes after the beginning of cardiopulmonary bypass, before the end of bypass, 4 hours after bypass, and on the first and second postoperative days. RESULTS: Aprotinin had no significant effect on any of these parameters. As expected, aprotinin reduced early blood loss in both treated groups. CONCLUSIONS: These results indicate that aprotinin at doses currently used to reduce blood loss has no significant influence on the systemic inflammatory response during moderate hypothermic cardiopulmonary bypass in human subjects, as assessed by the mediators measured in this study.     

Timing and duration of the initial pelvic stabilization after multiple trauma in patients from the German trauma registry: is there an influence on outcome?

BACKGROUND: There is an ongoing debate about the systemic burden of early definitive fracture stabilization in multiply injured patients. In patients with extremity fractures, the benefit of limited initial surgery has been examined. In this retrospective analysis, we assessed whether differences in outcome can be attributed to the degree of initial surgery in polytrauma patients with pelvic-ring fractures. METHODS: Multiply injured patients of the German Trauma Registry (Injury Severity Score [ISS] > or =16) with pelvic-ring fractures in need of surgery were analyzed for independent effects of the duration and the timing of the initial surgical stabilization of the pelvis. We compared three subgroups according to duration (D) [short (S): <1 hour; intermediate (I): 1-3 hours; and long (L): >3 hours] and timing (T) [early (E): day 0; intermediate (I): days 1-3; and late (L): day >3]. In addition, a subgroup analysis dependent on injury severity was performed. Statistics included analysis of variance, post-hoc Tukey test, chi test, Student's t test, with significance at p < 0.05. RESULTS: Demographic data and injury severity were comparable between the groups. The duration of surgery was associated with a higher rate of liver failure (group D-S: 6%; D-I: 17%; D-L: 28%; p = 0.028). The timing of surgery was associated with a higher rate of renal failure (T-E: 17%; T-I: 3%; T-L: 5%; p = 0.021), multiorgan failure (T-E: 27%; T-I: 23%; T-L: 13%; p = 0.024) and mortality (T-E: 18%; T-I: 19%; T-L: 4%; p = 0.019). There was improved mortality, lower rates of multiorgan failure, and sepsis in patients with higher ISS for procedures less than 3 hours. CONCLUSIONS: In our retrospective analysis, both initial short as well as delayed surgery were associated with a lower rate of organ failure and mortality in multiply injured patients (ISS > or =16). This is especially supported for patients with high ISS.     

Are diagnostic peritoneal lavage or focused abdominal sonography for trauma safe screening investigations for hemodynamically stable patients after blunt abdominal trauma? A review of the literature

BACKGROUND: Assessment of patients in the emergency department who sustain blunt abdominal trauma represents a significant diagnostic challenge. Computed tomography (CT) is increasingly used as the principal investigation for these patients. A sensitive screening test could safely reduce the use of CT. OBJECTIVES: To appraise the evidence supporting the use of diagnostic peritoneal lavage and focused abdominal sonography for trauma as screening tests in the emergency department to reduce the use of CT in the initial assessment of patients sustaining blunt abdominal trauma. METHODS: A search of high-quality evidence resources was performed, followed by a hand search of the bibliographies of all relevant articles. RESULTS: Altogether, 55 articles were found during the initial search, of which 23 were relevant. An additional 11 were found by hand searching. Six relevant original research articles were found. CONCLUSION: Screening diagnostic peritoneal lavage and selective CT is a safe diagnostic strategy for the investigation of blunt abdominal trauma. Further research is needed to determine the role of focused abdominal sonography for trauma scanning in diagnostic protocols.     

Which factors influence the need for inpatient rehabilitation after severe trauma?

IntroductionDespite the importance of rehabilitation in the treatment of patients with severe trauma or even of severely injured patients, the cooperation between acute and rehabilitation hospitals is often inadequate. The present study aims to identify factors that make it probable that a severely injured patient requires inpatient rehabilitation following the acute treatment.Material and methodsA retrospective analysis of 75.357 cases from the TraumaRegister DGU^® (TR-DGU) was performed. All cases from 2002 until 2013 with an ISS ≥ 9, who were taken to the ICU were included. Regarding the discharge destination the subgroups “at home” and “rehabilitation hospital” were analyzed in detail. Finally, we performed a multivariate regression analysis based on the parameters previously collected.Results24.208 patients (32.1%) were transferred to a rehabilitation clinic. In the multivariate regression analysis the most relevant independent parameters for discharge in a rehabilitation hospital were age (18–54: OR 1.65; 55–74: OR 2.86 and 75 and older: OR 5.07, all p ≤ 0.001), AIS pelvis ≥ 2 (OD 1.94), AIS legs (OR 2.02), AIS spine (AIS 4: OR 5.78 and AIS 5–6: OR 6.36) and the AIS head (AIS 3: OR 1.88; AIS 4: OR 3.11 and AIS 5–6: OR 7.55) (all p ≤ 0.001). The length of stay in the ICU (3–7 days: OR 1.88; 8–28 Days: OR 5.42 and 29 and more days: OR 14.7, all p ≤ 0.001) was also a relevant parameter. The overall ISS presented no relevant influence with an OR of 1.02 (p = 0.03).Discussion and conclusionKnowing independent factors for a required inpatient rehabilitation helps the treating physicians to identify the patients at an early stage in acute hospitals. So the transfer to a rehabilitation clinic can be organized faster and more selective in future.     

Does thoracic injury impair the predictive value of base deficit in trauma patients?

Introduction

Base deficit (BD) has been shown to be a valuable indicator to be predictive of complications and mortality after trauma. Arterial carbon dioxide (PaCO₂) may be influenced by thoracic injuries, potentially diminishing the predictive value of BD. Therefore, the aim of this study was to assess the predictive value of admission BD for mortality and complications in trauma patients with thoracic injuries.

Methods

By a prospective database analysis of patients with an injury to the chest admitted to the University Medical Center Utrecht between 2000 and 2004 were studied. All patients with a blood gas analyses were included. Absolute BD was used for analyses. Clinical outcome parameters were recorded.

Results

The BD was higher in the non-surviving patients compared to the survivors (7.5 vs. 3.8, p < 0.001). Mortality rate of patients with an admission BD of ≥6 was increased in thoracic trauma patients (BD < 6 mortality rate 7%, BD ≥ 6 mortality rate 27%; p < 0.001). In patients who required ICU admittance the BD was increased compared to patients without ICU admission (5.2 vs. 2.9, p < 0.001). Within the subgroup of patients admitted to the ICU, the BD was higher in patients who required ventilation (3.8 vs. 5.5, p = 0.025). Patients who developed chest related complications had increased BD compared with those without complications (4.9 vs. 4.0, p = 0.025), the BD was particularly increased in patients who developed acute respiratory distress syndrome (ARDS) (4.1 vs. 6.4, p = 0.004). Carbon dioxide (PaCO₂) showed a predictive value for mortality (44 vs. 53, p < 0.001), ICU admission (42 vs. 46, p = 0.003) and hospital stay.

Conclusion

Admission BD is a predictive factor in thoracic trauma patients for mortality and chest related complications. Furthermore it is a predictive factor for ICU admission, required ventilation and hospital stay. The use of BD in thoracic trauma patients can potentially identify patients who require additional monitoring or early aggressive therapy.     

Efficacy of oncologic surgery. Does anesthesia influence the postoperative outcome?

Major surgical interventions in tumour surgery are still associated with perioperative cardiopulmonary, infectious, thromboembolic, cerebral, and gastrointestinal complications. There are different prophylactic and therapeutic possibilities to anticipate or counteract these perioperative complications. The most important, including beta blockers and alpha-2-agonists for patients at coronary risk, preoperative optimisation of oxygen transport in high risk surgical patients and the concept of multimodal perioperative therapy (analgesia, early mobilisation, early enteral nutrition, and others) combined with high perioperative inspiratory oxygen concentration and maintenance of normothermia to reduce wound infection and cardiac complications are described in this paper.     

Does tachycardia correlate with hypotension after trauma?

BACKGROUND: Tachycardia is believed to be closely associated with hypotension and is often listed as an important sign in the initial diagnosis of hemorrhagic shock, but the correlation between heart rate and hypotension remains unproved. STUDY DESIGN: Data were collected from all trauma patients, 16 to 49 years old, presenting to our university-based trauma center between July 1988 and January 1997. Moribund patients with a systolic blood pressure < or =50 or heart rate < or = 40 and patients with significant head or spinal cord injuries were excluded. Tachycardia was defined as a heart rate >or= 90 and hypotension as a systolic blood pressure < 90. RESULTS: Hypotension was present in 489 of the 14,325 admitted patients that met the entry criteria. Of the hypotensive patients, 35% (169) were not tachycardic. Tachycardia was present in 39% of patients with systolic blood pressure 120 mmHg. Hypotensive patients with tachycardia had a higher mortality (15%) compared with hypotensive patients who were not tachycardic (2%, P = 0.003). Logistic regression analysis revealed tachycardia to be independently associated with hypotension (p = 0.0004), but receiver operating curve analysis demonstrated that the sensitivity and specificity of heart rate for predicting hypotension is poor. CONCLUSIONS: Tachycardia is not a reliable sign of hypotension after trauma. Although tachycardia was independently associated with hypotension, its sensitivity and specificity limit its usefulness in the initial evaluation of trauma victims. Absence of tachycardia should not reassure the clinician about the absence of significant blood loss after trauma. Patients who are both hypotensive and tachycardic have an associated increased mortality and warrant careful evaluation.     

Changes in portal vein flow after adult living-donor liver transplantation: Does it influence postoperative liver function?

In adult living donor liver transplantation, using small grafts in cirrhotic patients with severe portal hypertension may have unpredictable consequences. The so-called small-for-size syndrome is present in most series worldwide. The goal of this study was to prospectively evaluate the influence of hemodynamic changes on postoperative liver function and on the percentage of liver volume increase, in the setting of living donor liver transplantation. Twenty-two consecutive adult living donor liver transplantations were performed at our institution in a 2-year period. We measured right portal flow and right hepatic arterial flow with an ultrasonic flow meter in the donor, and then in the recipient 1 hour after reperfusion. Postoperative liver function was measured by daily laboratory work. We also performed duplex ultrasounds on postoperative days 1, 2, and 7. Liver volume increase was estimated by magnetic resonance imaging graft volumetry at 2 months posttransplantation. We compared the blood flow results with the immediate liver function and its liver volume increase rate at 2 months. There was a significant increase in portal flow in the recipients compared with the donors (up to fourfold in some cases). Higher portal flow increase rates significantly correlated with faster prothrombin time normalization and faster liver volume increases. Median graft volume increase at 2 months was 44.9%. The increase in blood flow to the graft is well tolerated by the liver mass not affecting hepatocellular function as long as the graft-to body weight ratio is maintained (>0.8) and adequate outflow is provided. (Liver Transpl 2003;9:564-569.)     

Does effective postoperative pain management influence surgical morbidity?

It has been assumed that adequate postoperative pain relief will improve outcome from surgery, but several controlled trials have demonstrated that pain treatment with nonsteroidal anti-inflammatory drugs, patient-controlled analgesia or epidural techniques will not significantly improve outcome after major procedures. In lower body procedures, however, intra- and early postoperative pain relief with epidural or spinal anaesthesia reduces blood loss and thromboembolic complications. It is hypothesized that effective postoperative pain relief may significantly improve outcome only if integrated into a multimodal rehabilitation program.     

Does the learning phase influence the late outcome of patients with gastroesophageal reflux disease after laparoscopic fundoplication?

Background: Although the degree of surgical experience clearly affects early outcome of laparoscopic antireflux surgery, its influence on long-term results has not been fully evaluated. The aim of this study was to verify whether the initial experience in laparoscopic antireflux surgery could also influence the late clinical outcome. Methods: Clinical and endoscopic findings, together with quality of life, of the first 25 patients successfully submitted to laparoscopic fundoplication were compared with those of 25 matched controls operated on later. Results: At more than 2 years, follow-up, reflux symptoms, endoscopic findings, use of antisecretory drugs, side effects, and quality of life were not significantly different in both groups, despite a high occurrence of major anatomical failures (three vs one) in the first set of patients. Conclusion: The late clinical outcome of patients with gastroesophageal disease operated on during the learning phase or after gaining experience is not different, provided the surgeon is adequately trained in laparoscopic surgery.