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Biomedical subjects

G Minard

Publications and source records attributed to G Minard.

At least 37 records · Page 2Linked to original sources
PubMed1995

Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management.

Nonoperative management of blunt splenic trauma is widely accepted; however, reported failure rates have ranged as high as 40%. There are few factors available to identify failures reliably. To characterize failures of nonoperative management better, we retrospectively reviewed 309 blunt splenic injuries treated at our level I trauma center over a 5-year period. Eighty-nine patients were initially managed nonoperatively (29%), and 12 patients failed this approach (13%). Upon review of the initial computed tomography scans, a hyperdense collection of contrast media in the splenic parenchyma, or "contrast blush," was noted in 8 of 12 (67%) patients who failed and in 5 of 77 (6%) of those who were successfully managed nonoperatively (p < 0.0001). These data suggest that the presence of a contrast blush is an important consideration when deciding the method for management of the splenic injury. If these results are confirmed in a prospective fashion, the failure rate of nonoperative management of blunt splenic trauma could be reduced by identification of the contrast blush.

Adolescent↗
PubMed1995

Using bronchoalveolar lavage to distinguish nosocomial pneumonia from systemic inflammatory response syndrome: a prospective analysis.

OBJECTIVE: Ventilator-associated pneumonia (PN) is difficult to distinguish from trauma-induced systemic inflammatory response syndrome (SIRS), especially in patients with multiple injuries. Previous work using bronchoscopy and quantitative cultures demonstrated significant bacterial growth in about one-third of patients with clinical evidence of PN. In this prospective study, antibiotic therapy for PN was based solely on quantitative bronchoalveolar lavage (BAL) cultures. METHODS: Mechanically ventilated trauma patients underwent bronchoscopy with BAL when they developed clinical evidence of PN: fever (temperature > 100.5 degrees F), white blood cells > 10,000 or > 10% immature forms, purulent sputum, and new or changing infiltrate on chest roentgenogram. Patients with other infections or those receiving antibiotics for any other reason were excluded. Empiric antibiotic therapy for PN was started at the time of BAL. If the quantitative cultures revealed > or = 10(5) colony-forming units (CFU)/mL, that patient was defined as having PN and was treated. If the cultures revealed < 10(5) CFU/mL, that patient was defined as having SIRS, and empiric therapy was stopped. RESULTS: Forty-three patients (88% blunt, 12% penetrating) underwent bronchoscopy with BAL 55 times. Mean age was 40 and Injury Severity Score was 25. Twenty patients had > or = 10(5) CFU/mL (47%) and 23 had < 10(5) CFU/mL (53%). There were no differences in age, Injury Severity Score, temperature, white blood cell count, or ventilator days before BAL between groups. Sixty-five percent of those with SIRS improved after empiric therapy was stopped (average 3.3 days), and 35% underwent repeat BAL. Three patients with the initial diagnosis of SIRS developed PN (13% of SIRS). Mortality for PN was 15%, compared with 17% for SIRS; no deaths were related to antibiotic therapy. CONCLUSIONS: SIRS, which can mimic PN, is common in trauma patients. These entities can be distinguished by bronchoscopy with BAL. Basing antibiotic therapy solely on quantitative BAL cultures is efficacious in trauma patients.

Adolescent↗
PubMed1994

Is resection with primary anastomosis following destructive colon wounds always safe?

Resection with primary anastomosis was associated with a 14% anastomotic leak rate in this review of 60 patients with destructive colon wounds. The presence of an underlying medical illness or massive blood transfusion was associated with anastomotic complications. In the high-risk subset of patients who had one or both of these risk factors, the anastomotic leak rate was 42%. The incidence of anastomotic leak in previously healthy patients without massive transfusion was 3%. Ileocolostomies were no safer than colocolostomies. We conclude that resection with anastomosis should not be performed on all patients with destructive colon injuries, as the risk of anastomotic leak is prohibitive in those with either massive blood loss or underlying medical illness. We continue to perform primary anastomosis in healthy patients without excessive blood loss.

Adolescent↗
PubMed1994

Planned ventral hernia. Staged management for acute abdominal wall defects.

OBJECTIVE: Analysis of a staged management scheme for initial and definitive management of acute abdominal wall defects is provided. METHODS: A four-staged scheme for managing acute abdominal wall defects consists of the following stages: stage I--prosthetic insertion; stage II--2 to 3 weeks after prosthetic insertion and wound granulation, the prosthesis is removed; stage III--2 to 3 days later, planned ventral hernia (split thickness skin graft [STSG] or full-thickness skin and subcutaneous fat); stage IV--6 to 12 months later, definitive reconstruction. Cases were evaluated retrospectively for benefits and risks of the techniques employed. RESULTS: Eighty-eight cases (39 visceral edema, 27 abdominal sepsis, 22 abdominal wall resection) were managed during 8.5 years. Prostheses included polypropylene mesh in 45 cases, polyglactin 910 mesh in 27, polytetrafluorethylene in 10, and plastic in 6. Twenty-four patients died from their initial disease. The fistula rates associated with prosthetic management was 9%; no wound-related mortality occurred. Most wounds had split thickness skin graft applied after prosthetic removal. Definitive reconstruction was undertaken in 21 patients in the authors' institution (prosthetic mesh in 12 and modified components separation in 9). Recurrent hernias developed in 33% of mesh reconstructions and 11% of the components separation technique. CONCLUSIONS: The authors concluded that 1) this staged approach was associated with low morbidity and no technique-related mortality; 2) prostheses placed for edema were removed with fascial approximation accomplished in half of those cases; 3) absorbable mesh provided the advantages of reasonable durability, ease of removal, and relatively low cost--it has become the prosthesis of choice; and 4) the modified components separation technique of reconstruction provided good results in patients with moderate sized defects.

Abdominal Muscles↗
PubMed1994

Analysis of charges associated with diagnosis of nosocomial pneumonia: can routine bronchoscopy be justified?

Many ventilated trauma patients thought to have nosocomial pneumonia have pulmonary contusion or systemic inflammatory response syndrome with tracheobronchial colonization. Fiberoptic bronchoscopy with quantitative culture techniques of protected specimen brush (PSB; threshold 10(3) cfu/mL) or bronchoalveolar lavage (BAL; threshold 10(5) cfu/mL) can potentially eliminate the false positive cultures of the upper airway seen with routine sputum aspirates (RS). However, bronchoscopy is expensive, and routine use may not be cost effective. This prospective study evaluated the patient charges associated with bronchoscopy and quantitative cultures compared with RS for the diagnosis of nosocomial pneumonia. Specimens were obtained by RS, PSB, and BAL from the lower airway in 107 trauma patients (136 sets of triplicate cultures). All patients had clinical evidence suggestive of pneumonia (fever, leukocytosis, purulent sputum, abnormal roentgenographic findings). Typical oral flora were considered contaminants; no gram-negative specimens were excluded. Mean age was 40 years and mean ISS was 29. Seventy-eight percent had blunt injuries, 22% penetrating, and 42% had chest injuries. The incidence of nosocomial pneumonia according to each method was: RS-73%; PSB-34%; BAL-25%. Considering all charges involved (bronchoscopy, equipment, microbiologic analysis, and antibiotics), and based on a 14-day course of ceftazidime and vancomycin, the charges for PSB were 58% of RS, and charges for BAL were 43% of RS. We conclude that the charges associated with bronchoscopy are high, but can be offset by antibiotic savings. Side effects of unnecessary antibiotic therapy would be avoided. Further study is needed to determine the efficacy of PSB or BAL in trauma patients.

Adult↗
PubMed1994

Enteral access.

The enteral route is the preferred method of nutrition support in patients with functional gastrointestinal tracts. Many techniques for obtaining enteral access are available, and the decision regarding which one to use depends on several issues, including anticipated duration of support, aspiration risk, and local expertise. Using laparotomy, laparoscopy, fluoroscopy, or endoscopy, tubes can be placed into the stomach, the duodenum, and the jejunum. Nasogastric and nasoenteric tubes are useful for short-term supplementation; however, patients needing support for more than 6 weeks may be better served with a more permanent tube. In this review, specific methods for obtaining enteral access are discussed along with their advantages and disadvantages.

Enteral Nutrition↗
PubMed1994

Visceral protein response to enteral versus parenteral nutrition and sepsis in patients with trauma.

BACKGROUND: Sepsis and the route of nutrient administration are clearly related to visceral protein levels; however, the mechanisms and amount of influence are not completely defined. METHODS: Constitutive and acute-phase protein levels were measured on days 1, 4, 7, and 10 in 68 severely injured patients with abdominal trauma indexes of 15 or more randomized to enteral or parenteral feeding. Groups were matched for age, abdominal trauma index, injury severity score, and length of stay. RESULTS: Significantly higher levels of constitutive proteins and lower levels of acute-phase proteins were found in patients randomized to enteral feeding. Although some "hepatic protein reprioritization" appeared to be caused by nutrient route, this appeared only in the less severely injured patients. A more important factor in visceral protein levels is a reduction in septic morbidity associated with enteral feeding. CONCLUSIONS: Enteral feeding produces greater increase in constitutive proteins and greater decreases in acute-phase proteins after severe trauma primarily caused by reduced septic morbidity with enteral feeding.

Abdominal Injuries↗
PubMed1994

Management of nutrition in the critically ill patient.

Many recent clinical studies focus on the critically ill or injured hypermetabolic patient and investigate nutritional factors and regimens that can potentially reduce septic complications and improve clinical outcome. In addition to better defining the amount and type of nutrients appropriate for this population, these studies provide insight into important variables such as route of nutrient administration, supplementation of formulas with immune-enhancing (or nonimmunosuppressive) nutrients, and anabolic agents that promote increased nitrogen retention and lean body mass accumulation.

Critical Care↗
PubMed1994

Effect of route of feeding on the incidence of septic complications in critically ill patients.

The increased risk of septic complications accompanying severe illness and injury is compounded by the presence of malnutrition. Total parenteral nutrition (TPN) has been used extensively to prevent or rectify this problem. Although enteral nutrition is frequently more difficult to administer, a growing body of laboratory and clinical research shows a significant reduction in the incidence of secondary infection with its use. The mechanism proposed is that the enteral route helps maintain the gut barrier, decreasing passage of bacteria and other toxins. Translocation of these products has been implicated as a cause of nosocomial infection and organ failure. Therefore, when possible, the use of the enteral route of nutrition should be part of the overall approach to the care of the critically ill or injured patient.

Adult↗
PubMed1994

Is early feeding beneficial? How early is early?

Nutritional support is a vital part of the therapy of most hospitalized patients. Early initiation, particularly via the enteral route, has a significant effect on septic complications in a wide variety of patients. Early enteral feeding may also attenuate the hypercatabolic response that follows burn injury, although the evidence is somewhat conflicting. The mechanisms for the benefit of early nutrition have not been fully elucidated. However, preservation of gut mass, prevention of increased gut permeability to bacteria and other toxins, and maintenance of the gut-associated lymphoid tissue all probably play a role. The question "How early is early?" is important, since maintenance of early feeding requires time, patience, and dedication. It appears that starting nutrition within 24 hrs of major surgery, injury, or burn is ideal, but within 48 hours is acceptable. However, hemodynamic stability is a prerequisite to initiation of enteral feeding. Although labor intensive, the provision of early feeding, particularly via the enteral route, is a worthwhile goal for all clinicians.

Adult↗
PubMed1994

Acute subdural hematoma: nonsurgical management of selected patients.

There is a current trend toward nonsurgical therapy for small, minimally symptomatic acute subdural hematomas (ASDH), but data supporting such a scheme have been lacking. We evaluated 83 patients with minimally symptomatic ASDH (Glasgow Coma Scale scores of 11-15) and found 58 managed nonsurgically (70%) and 25 managed with craniotomy (30%). Patients managed without surgery had a lower incidence of focal neurologic deficits (12% vs. 40%; p < .01), open cisterns (90% vs. 28%; p < .001), and small (< or = 1 cm) ASDHs (92% vs. 62%; p < .001). Ninety-three percent of patients managed nonsurgically had functional recovery compared with 84% of patients with craniotomy. Age and injury Severity Score were significantly associated with patient outcome. Timing of surgery had no association with outcome. Six percent of patients managed nonsurgically developed chronic SDH requiring craniotomy. We conclude that unless the hematoma is causing clinical evidence of intracranial hypertension or significant neurologic dysfunction, there appears to be no advantage in evacuating the clot. Selected patients with ASDH and GCS scores of 11-15 can safely be managed without craniotomy.

Acute Disease↗
PubMed1993

Risk of abdominal septic complications after feeding jejunostomy placement in patients undergoing splenectomy for trauma.

Compared with total parenteral nutrition, enteral feeding via jejunostomy reduces septic complications in patients with severe trauma. However, violation of the bowel with insertion of a jejunostomy tube may increase the risk of intra-abdominal abscess (IAA), particularly if no simultaneous gastrointestinal tract injury exists. The records of 123 patients requiring splenectomy for trauma at a level I trauma center during a 6-year period (1986 to 1992) were reviewed to examine the incidence of IAA in patients with and without simultaneous jejunostomy placement in the presence and absence of gastrointestinal tract injuries. Thirty patients had jejunostomies placed (J), and 93 did not (NoJ). There were no significant differences between the groups in age, Abdominal Trauma Index, Injury Severity Score, or transfusion requirements. The incidence of IAA was not significantly different between the J and NoJ groups in the presence or absence of gastrointestinal tract injuries. Thus, jejunostomy placement does not increase the incidence of IAA after splenectomy regardless of the presence of a gastrointestinal tract injury.

Abdomen↗
PubMed1993

A prospective analysis of diagnostic laparoscopy in trauma.

OBJECTIVE: This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed. SUMMARY BACKGROUND DATA: Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps. METHODS: Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy. RESULTS: Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol. CONCLUSIONS: DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management.

Abdominal Injuries↗
PubMed1993

Empiric monotherapy versus combination therapy of nosocomial pneumonia in trauma patients.

Combination therapy for nosocomial pneumonia with a beta-lactam and aminoglycoside is widely accepted because of synergy and reduction of resistant bacteria. This prospective study of 109 trauma patients (94 blunt, 15 penetrating) with nosocomial pneumonia was performed in consecutive phases. In phase 1, patients were randomized to an anti-pseudomonal third-generation cephalosporin--cefoperazone or ceftazidime. Gentamicin was added to each regimen in phase 2. The mean age of the patients was 37 years, the mean ISS was 31, and there were no differences among the four treatment groups relative to associated injuries. Patients receiving monotherapy had a 56% cure rate compared with 31% for combination therapy (p < 0.04). Persistence rates were similar in these two groups (15% and 20%), but superinfection was significantly higher in the combination group (49% vs. 28%; p < 0.04). The predominant superinfecting organism was methicillin-resistant Staphylococcus aureus (MRSA). Nine patients died (5% monotherapy, 10% combination), and eight had a superinfection. We conclude that monotherapy had a higher cure rate than combination therapy for empiric therapy of pneumonia in our trauma patients. Combination therapy failed because of superinfection (primarily MRSA). Emergence of MRSA may be from host overgrowth or plasmid-mediated induction of resistance, possibly caused by gentamicin.

Adolescent↗
PubMed1993

Shotgun wounds to the abdomen.

In 1963 Sherman and Parrish (Sherman RT, Parrish RA. Management of shotgun Injuries: A Review of 152 Cases. J Trauma 1963;3:76-86) classified shotgun wounds into three types based upon distance and penetration. Because distances are often unknown, we redefined Sherman's groups by pellet scatter. Type I patients had > 25 cm of scatter, Type II had < 25 cm but > 10 cm, and Type III had < 10 cm. Seventy-one abdominal shotgun wound patients were admitted over 8 years. Eight tangential wounds were managed by local wound care. Of the remaining 63, 27 were Type I, 10 were Type II, and 26 Type III. Two Type II and six Type III patients died within 24 hours. All required laparotomy. Nine of the Type I patients required laparotomy; eight had peritoneal signs and one had progressive abdominal tenderness, hypotension, and intra-abdominal pellets. Eighteen Type I patients without peritoneal signs were observed without complications. Type III patients suffered more vascular injuries and presented more frequently with hypotension than Type II patients. Of the patients surviving greater than 24 hours, Type IIIs received more transfusions and stayed longer in the intensive care unit and hospital than Type IIs. They also suffered more complications than Type IIs. Seven Type III patients required complicated reconstruction of the abdominal wall. Classification of abdominal shotgun injuries using pellet spread is a more useful system in determining patient management and prognosis compared to systems based on distance. Type II and III abdominal shotgun injuries require laparotomy, debridement of soft tissue injuries and frequently reconstruction of abdominal wall defects. Type I injuries can be managed effectively using signs of peritoneal irritation or progressive abdominal tenderness as the best indicator of the need for operation.

Abdominal Injuries↗
PubMed1992

Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma.

To investigate the importance of route of nutrient administration on septic complications after blunt and penetrating trauma, 98 patients with an abdominal trauma index of at least 15 were randomized to either enteral or parenteral feeding within 24 hours of injury. Septic morbidity was defined as pneumonia, intra-abdominal abscess, empyema, line sepsis, or fasciitis with wound dehiscence. Patients were fed formulas with almost identical amounts of fat, carbohydrate, and protein. Two patients died early in the study. The enteral group sustained significantly fewer pneumonias (11.8% versus total parenteral nutrition 31.%, p less than 0.02), intra-abdominal abscess (1.9% versus total parenteral nutrition 13.3%, p less than 0.04), and line sepsis (1.9% versus total parenteral nutrition 13.3%, p less than 0.04), and sustained significantly fewer infections per patient (p less than 0.03), as well as significantly fewer infections per infected patient (p less than 0.05). Although there were no differences in infection rates in patients with injury severity score less than 20 or abdominal trauma index less than or equal to 24, there were significantly fewer infections in patients with an injury severity score greater than 20 (p less than 0.002) and abdominal trauma index greater than 24 (p less than 0.005). Enteral feeding produced significantly fewer infections in the penetrating group (p less than 0.05) and barely missed the statistical significance in the blunt-injured patients (p = 0.08). In the subpopulation of patients requiring more than 20 units of blood, sustaining an abdominal trauma index greater than 40 or requiring reoperation within 72 hours, there were significantly fewer infections per patient (p = 0.03) and significantly fewer infections per infected patient (p less than 0.01). There is a significantly lower incidence of septic morbidity in patients fed enterally after blunt and penetrating trauma, with most of the significant changes occurring in the more severely injured patients. The authors recommend that the surgeon obtain enteral access at the time of initial celiotomy to assure an opportunity for enteral delivery of nutrients, particularly in the most severely injured patients.

Abdominal Injuries↗
PubMed1992

Correlation of abdominal trauma index and injury severity score with abdominal septic complications in penetrating and blunt trauma.

The Abdominal Trauma Index (ATI) was designed to stratify patients with penetrating injuries, and has been used to classify patients with blunt trauma. The Injury Severity Score (ISS) was originally designed to stratify victims of blunt trauma, and it has also been used for victims of penetrating trauma. We attempted to validate the use of ISS and ATI for both penetrating and blunt trauma. A total of 592 penetrating and 334 blunt trauma patients who underwent laparotomy over a 5-year period were evaluated. The overall rate of abdominal sepsis was 7.5% for blunt trauma and 7.6% for penetrating trauma. Mortality (excluding deaths within 48 hours) was 7% for blunt trauma and 1% for penetrating trauma. In the penetrating injury population, an ATI value greater than 15 and an ATI value greater than 25 were significantly associated with abdominal septic complications (ASCs) (p less than 0.001, both comparisons). An ISS greater than or equal to 16 was also associated with ASCs (p less than 0.001). The ASC rate for gunshots was higher than that for stab wounds (11% vs. 2%; p less than 0.001). In the blunt group, an ATI value greater than 15 and an ATI value greater than 25 were associated with ASCs (p less than 0.01 and p less than 0.001, respectively). The association of ASCs and ISS was linear with increasing ISS in patients with blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗