Resuscitation of hypotensive head-injured patients: is hypertonic saline the answer?

Hypertonic saline (HTS) may decrease intracranial pressure (ICP) in severe traumatic brain injury (STBI) and effectively resuscitates hypotensive patients. No data exist on institutional standardization of HTS for hypotensive patients with STBI. It remains unclear how HTS affects brain tissue oxygenation (PbtO2) in STBI. We hypothesized HTS could be safely standardized in patients with STBI and would lower ICP while improving cerebral perfusion pressure (CPP) and PbtO2. Under institutional guidelines in a Level I trauma center, 12 hypotensive STBI intensive care unit subjects received HTS. Inclusion criteria included mean arterial pressure (MAP) < or = 90 mmHg, Glasgow Coma Scale (GCS) < or = 8, ICP > or = 20 mmHg, and serum [Na+] <155 mEq/L. All patients underwent ICP monitoring. Hemodynamics, CPP, ICP, and PbtO2 data were collected before and hourly for 6 hours after HTS infusion. Guideline criteria compliance was greater than 95 per cent. No major complications occurred. Mean ICP levels dropped by 45 per cent (P < 0.01) and this drop persisted for 6 hours. CPP levels increased by 20 per cent (P < 0.05). PbtO2 remained persistently elevated for all time points after HTS infusion. Institutional use of HTS in STBI can be safely implemented in a center caring for neurotrauma patients. HTS infusion in hypotensive STBI reduces ICP and raises CPP. Brain tissue oxygenation tends to improve after HTS infusion.     

Large inguinal hernia in infants: is laparoscopic repair the answer?

PURPOSE: Infants with large hernias present a challenge to the pediatric surgeon. We present our experience of laparoscopic repair of large hernias in 16 infants, the youngest aged 40 days. Fifteen of the infants were younger than 18 months and one was < or = 2 years old. MATERIALS AND METHODS: Sixteen male infants with large inguinal hernias (hernia extending to the bottom of the scrotum and the diameter of the open internal ring > 2 cm on laparoscopy) underwent laparoscopic hernia repair. Diagnostic laparoscopy was performed under general anesthesia with a telescopic port at the umbilicus. If the internal ring was open, two working ports were introduced pararectally on either side. An open internal ring was considered an indication for hernia repair. The needle, carrying 3-0 nylon nonabsorbable sutures, was introduced through the groin skin at the internal inguinal ring and the internal ring was closed by taking continuous sutures to approximate the edges of the ring. The needle was then taken out through the entry point and the knot was tied extracorporeally and buried in the subcutaneous tissue. In 4 patients in the initial part of the study, intracorporeal (knot tied internally) suturing was done to close the internal ring. A contralateral repair was done if the internal ring was open. RESULTS: A total of 18 repairs were performed in 16 patients: 10 had a right sided hernia, 4 had a left sided hernia, and 2 had an open contralateral ring (suggestive of contralateral patent processus vaginalis). The contents of the hernia were bowel (1 patient), omentum (3 patients), and bowel adhesions at the internal ring (1 patient). There was 1 conversion. The mean operative time was 23 minutes for unilateral repair and 29 minutes for bilateral repair. The mean follow-up was 19 months (range, 3 months to 3 years). There are no recurrences to date. There was no morbidity or mortality. CONCLUSION: Laparoscopy is safe and feasible for repair of large inguinal hernias in infants 2 years and provides treatment of contralateral patent processus vaginalis in the same setting with no significant increase in operating time. Extracorporeal knot tying has made the procedure feasible in the limited working space available in these babies. Though there were no recurrences or post-operative hydrocele, the number of patients in the study is too small to comment on rates of recurrence or hydrocele.     

Molecular regulation of kidney development: is the answer blowing in the Wnt?

Development of the metanephric kidney is a complicated process regulated by reciprocal signals from the ureteric bud and the metanephric mesenchyme that regulate tubule formation and epithelial branching morphogenesis. Over the past several years, several studies have suggested that Wnt signaling is involved in multiple aspects of normal kidney development as well as injury response and cancer progression. We will review these data here.     

Alternative dosing of prophylactic enoxaparin in the trauma patient: is more the answer?

Background

Inadequate anti–factor Xa levels and increased venous thromboembolic events occur in trauma patients receiving standard prophylactic enoxaparin dosing. The aim of this study was to test the hypothesis that higher dosing (40 mg twice daily) would improve peak anti-Xa levels and decrease venous thromboembolism.

Methods

A retrospective review was performed of trauma patients who received prophylactic enoxaparin and peak anti-Xa levels over 27 months. Patients were divided on the basis of dose: group A received 30 mg twice daily, and group B received 40 mg twice daily. Demographics and rates of venous thromboembolism were compared between dose groups and patients with inadequate or adequate anti-Xa levels.

Results

One hundred twenty-four patients were included, 90 in group A and 34 in group B. Demographics were similar, except that patients in group B had a higher mean body weight. Despite this, only 9% of group B patients had inadequate anti-Xa levels, compared with 33% of those in group A (P = .01). Imaging studies were available in 69 patients and revealed 8 venous thromboembolic events (P = NS, group A vs group B) with significantly more venous thromboembolic events occurring in patients with low anti-Xa levels (P = .02).

Conclusions

Although higher dosing of enoxaparin led to improved anti-Xa levels, this did not equate to a statistical decrease in venous thromboembolism.     

Pseudomeningocele presenting with cauda equina syndrome: is a 'ball-valve' theory the answer?

Pseudomeningocele is an uncommon complication of spinal surgery. The condition is most often asymptomatic and self-limiting. A proportion of patients may present with lower back pain, dural fistulas, radiculopathy or myelopathy. Cauda equina syndrome due to a pseudomeningocele has been reported due to herniation of the Cauda equina roots through the dural defect. We report a case of large pseudomeningocele causing an impending Cauda equina syndrome by acting as an extradural mass lesion.     

Shoulder outcome measures: is there a right answer?

Purpose

A number of outcome measures (instruments) are used to assess shoulder pain and function in clinical practice. No clear ??gold standard?? exists and it is thought that different instruments will give a different answer. Our aim is to statistically compare four commonly used outcome measures in a group of trauma patients and to identify whether instruments which combine objective and subjective components differ from those which are purely subjective.

Methods

Forty-four patients undergoing internal fixation of proximal humeral fractures were recruited between 2003 and 2008. Each was asked to complete a number of outcome measures: University of Los Angeles score (UCLA); Constant and Murley score (Constant); Oxford Shoulder Score (OSS); Quick form of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Each were measured on a different scale but were standardised to 0?C100 for comparison.

Results

Purely subjective instruments gave higher scores (better function and/or less pain). Statistical differences were found between each pair of instruments (p?<?0.001), except for the comparison between UCLA and QuickDASH (p?=?0.403). The study found inconsistencies between instruments, with outcomes varying depending on whether subjective or objective measurements were being assessed.

Conclusions

Outcome measures are useful tools, but clinicians need to be aware that their choice of instrument should be made carefully, taking into account the reason behind its use with regard to outcome.     

Anesthesia for laparoscopic donor nephrectomy: is nitrous oxide contraindicated?

PURPOSE: We performed this study to test the hypothesis that nitrous oxide produces clinically significant bowel distention during laparoscopic abdominal surgery. MATERIALS AND METHODS: Laparoscopic kidney donors were randomized into 2 groups. Group 1 received N2O and oxygen inhalation through anesthesia, and group 2 received a mixture of air and oxygen. All patients received the same preanesthetic and anesthetic medications. The surgeon was blinded to the use of N2O. The surgeon was given the option to discontinue N2O use (if it was used) if he/she thought that the bowel distention was increasing surgical risk. Postoperative data were collected on bowel symptoms, pain and recovery. RESULTS: A total of 28 patients were enrolled in the study, 12 of whom received N2O (group 1) and 16 who did not receive N2O (group 2). Mild to moderate bowel distention was reported by the surgeons in 6 patients (50%) in group 1 and 1 patient only in group 2 (6%, p=0.007). Severe bowel distention was encountered in 4 patients, 3 of whom received N2O (25% of group 1). Nausea and vomiting on postoperative day 1 was reported by 50% of patients in group 1 and 25% of group 2. There was no difference in the pain scores between the 2 groups. No intraoperative or postoperative complications were encountered. CONCLUSIONS: The use of N2O anesthetic causes bowel distention in 50% of abdominal laparoscopic donor nephrectomy operations. The distention was severe enough to interfere with the progress of surgery in 25% of cases and the use of N2O had to be discontinued.     

Contralateral slip prediction in slipped capital femoral epiphysis: is bone age the answer?

Prophylactic pinning of an asymptomatic hip in Slipped Capital Femoral Epiphysis (SCFE) is controversial. Bone age has been used as a predictor of future contralateral slip risk and also in the decision making for prophylactic intervention. The efficacy of bone age at predicting a contralateral slip was tested in this study. Eighteen Caucasian children prospectively had bone age assessment using wrist and hand radiographs when presenting with a unilateral SCFE. After in situ fixation of the affected side prospective monitoring was performed at regular intervals in the outpatient department. Surgical intervention was undertaken if the contralateral hip was symptomatic. Three children (2 boys and 1 girl) went on to develop a contralateral slip at a mean of 20 months from initial presentation. Six children were deemed at risk of contralateral slip due to a bone age of > or = 12.5 years for boys and > or = 10.5 years for girls. Only one from this group developed a contralateral slip. The relative risk of proceeding to a contralateral slip when the bone age is below the designated values was 1 (95% confidence interval of 0.1118 to 8.95). The sensitivity and specificity were 33% and 66% respectively. The positive predictive value was 15% and the diagnostic efficiency was 61%. Although this is a small study, it would appear that delayed bone age by itself is not a good predictor of future contralateral slip. Routine prophylactic pinning is not justified based on bone age alone, with the risks of surgical fixation it carries. A prospective long term longitudinal study is required.