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Biomedical subjects

R R Ivatury

Publications and source records attributed to R R Ivatury.

At least 37 records · Page 2Linked to original sources
PubMed1998

In search of the optimal end points of resuscitation in trauma patients: a review.

Complete resuscitation from shock is one of the primary concerns of the surgeon taking care of injured patients. Traditionally, the return to normalcy of blood pressure, heart rate, and urine output has been the end point of resuscitation. Using these end points may leave a substantial number of patients, up to 50 to 85% in some series, in "compensated" shock, which if it persists may ultimately lead to the death of the patient. Because of this potential other end points are being used and include supernormal values for oxygen transport variables (cardiac index, oxygen delivery, and oxygen consumption), lactate, base deficit, and gastric intramucosal pH. We believe that the current data support the use of lactate, base deficit, and/or gastric intramucosal pH as the appropriate end points of resuscitation of trauma patients. The goal should be to correct one or all of three of these markers of tissue perfusion to normal within the initial 24 hours after injury.

Acidosis↗
PubMed1998

Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome.

OBJECTIVE: To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS). METHODS: Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H2O) was treated by bedside or operating room laparotomy. RESULTS: Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11 patients, eight patients (72.7%) had acidotic pHi (7.10 +/- 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure. CONCLUSIONS: IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications.

Abdomen↗
PubMed1998

Abdominal compartment syndrome.

The ACS is a clinical entity that develops from progressive, acute increases in IAP and affects multiple organ systems in a graded fashion because of differential susceptibilities. The gut is the organ most sensitive to IAH, and it develops evidence of end-organ damage before the development of the classic renal, pulmonary, and cardiovascular signs. Intracranial derangements with ACS are now well described. Treatment involves expedient decompression of the abdomen, without which the syndrome of end-organ damage and reduced oxygen delivery may lead to the development of multiple organ failure and, ultimately, death. Multiple trauma, massive hemorrhage, or protracted operation with massive volume resuscitation are the situations in which the ACS is most frequently encountered. Knowledge of the ACS, however, is also essential for the management of critically ill pediatric patients (especially those with AWD) and in understanding the limitations of laparoscopy. The role of IAH in the pathogenesis of NEC, central obesity co-morbidities, and pre-eclampsia/eclampsia remains to be fully studied.

Abdomen↗
PubMed1997

Intra-abdominal hypertension and the abdominal compartment syndrome.

IAH causes multiple and profound physiologic abnormalities both within and outside the abdomen. IAP monitoring is easily performed by bladder measurements. Careful monitoring and prompt recognition and treatment of IAP are critical in patients after damage control surgery because IAH is extremely common in these patients. Use of mesh fascial prostheses at the initial celiotomy in high-risk patients may prevent the deleterious effects of IAH. IAH should be considered an earlier manifestation of ACS. Surgical intervention should be indicated by IAH and not delayed until ACS is clinically apparent.

Abdomen↗
PubMed1997

Hemorrhage lowers the threshold for intra-abdominal hypertension-induced pulmonary dysfunction.

BACKGROUND: Intra-abdominal hypertension has been associated with pulmonary and cardiac dysfunctions. We have noted in the clinical scenario of hemorrhagic shock and resuscitation that avoidance of even moderate levels of increased intra-abdominal pressure, using prophylactic decompression, improves outcomes when compared with patients who were decompressed when intra-abdominal pressures went over 20 cm H2O. We hypothesized that prior hemorrhage and resuscitation exacerbates the cardiopulmonary dysfunction associated with intra-abdominal hypertension. METHODS: Ten anesthetized pigs underwent placement of arterial and pulmonary artery catheters and a Silastic intra-abdominal catheter for measuring and manipulating intra-abdominal pressure. Group 1 animals (n = 5) were subjected to increasing intra-abdominal pressures at 10 mm Hg increments up to a level of 40 mm Hg. Group 2 animals (n = 5) were exposed to a severe hemorrhage and resuscitation before the increasing intra-abdominal pressure protocol. RESULTS: Compared with baseline, hemorrhage and resuscitation caused a significant deterioration in cardiac output at intra-abdominal pressures of 10 mm Hg and above. Oxygenation was reduced at 30 and 40 mm Hg. These changes were not seen in group 1 animals. A significant difference was found between groups 1 and 2 in VT, PaCO2, and PaCO2/FIO2 ratio at an intra-abdominal pressure of 20 mm Hg. This difference was not seen at lower or higher pressures. CONCLUSIONS: Prior hemorrhage and resuscitation caused an earlier decline in cardiopulmonary function in the setting of increased intra-abdominal pressure. These data suggest that, when interpreting intra-abdominal pressures, the clinical scenario must be considered. Prior hemorrhage and resuscitation produce the adverse consequences of intra-abdominal hypertension at lower pressures than when intra-abdominal hypertension is the only insult.

Animals↗
PubMed1997

Extending the horizons of "damage control" in unstable trauma patients beyond the abdomen and gastrointestinal tract.

"Damage control" has become an accepted technique for the treatment of patients with exsanguinating injuries to the abdomen. We describe a case where the damage control philosophy was applied outside the confines of the abdominal cavity, a gunshot wound to the groin, and in which a temporary intraluminal shunt was used to maintain distal perfusion while the acidosis and coagulopathy were corrected in the intensive care unit. Successful vascular reconstruction was later completed with polytetrafluoroethylene.

Adult↗
PubMed1997

Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicenter experience.

BACKGROUND: Considerable skepticism still exists about the role of diagnostic laparoscopy in the evaluation of penetrating abdominal trauma. The reported experience with therapeutic laparoscopy has been limited. METHODS: Retrospective analysis of a collective experience from three large urban trauma centers with 510 patients (316 stab wounds, 194 gunshot wounds) who were hemodynamically stable and had no urgent indications for celiotomy. RESULTS: Laparotomy was avoided in 277 of the 510 patients (54.3%) either because of nonpenetration or insignificant findings on laparoscopy. All were discharged uneventfully after a mean hospital stay of 1.7 days. Twenty-six had successful therapeutic procedures on laparoscopy (diaphragmatic repair in 16 patients, cholecystectomy in 1 patient, hepatic repair in 6 patients, and closure of gastrotomy in 3 patients) with uneventful recovery. In the remaining 203 patients, laparotomy was therapeutic in 155. Fifty-two patients had nontherapeutic celiotomy for exclusion of bowel injuries or as mandatory laparotomy for penetrating gunshot wounds (19.7%). The overall incidence of nontherapeutic laparotomy was 10.2%. Complications from laparoscopy were minimal (10 of 510) and minor. CONCLUSIONS: Laparoscopy has an important diagnostic role in stable patients with penetrating abdominal trauma. In carefully selected patients, therapeutic laparoscopy is practical, feasible, and offers all the advantages of minimally invasive surgery.

Abdominal Injuries↗
PubMed1997

Inferior vena cava injuries: noninvasive follow-up of venorrhaphy.

BACKGROUND AND METHODS: Recent reports have documented a reduced mortality from injuries to the inferior vena cava (IVC). Few reports, however, have addressed the follow-up of the repaired IVC. From January of 1984 to December of 1995, we prospectively collected data on all patients with IVC injuries at Lincoln Medical and Mental Health Center, an urban Level I trauma center. RESULTS: There were 81 patients with IVC injuries: 60 gunshot wounds, 17 stab wounds, and four blunt injuries. Overall, 45 patients survived (56%). Excluding those who arrived without vital signs and those who did not have emergency department thoracotomies, the survival was 68%. Of the survivors, 38 patients received lateral venorrhaphy, and seven patients underwent ligation. Of the 38 survivors with lateral venorrhaphy, 30 patients (79%) underwent noninvasive follow-up: 13 patients by sonography, 11 patients by computed tomographic scan, and six patients by both modalities. The IVC was visualized in 28 patients (93%) and was found to be patent in 24 (86%). There were four thromboses documented noninvasively, with three cases being confirmed by contrast venorrhaphy. All three resolved with systemic anticoagulation. CONCLUSIONS: We conclude that sonography and computed tomographic scan provide reliable noninvasive evaluation of the repaired IVC. We recommend that all patients with an IVC injury, which has been repaired, undergo evaluation for patency before discharge.

Adult↗
PubMed1997

Exaggerated lithotomy position-related rhabdomyolysis.

A case report and review of the exaggerated lithotomy position, in particular, and other position-related rhabdomyolysis is presented. The objective is to emphasize that the exaggerated lithotomy position, although providing good exposure for urethral and prostatic surgery, is associated with a low but definite risk of rhabdomyolysis and acute renal failure. Certain risk factors for the complication have been outlined. Close perioperative monitoring, including the use of pulmonary artery pressure and lower-extremity compartment pressure measurements in high-risk cases, is suggested for the prevention and the early detection of these cases. Prompt volume replacement and diuresis is the cornerstone of therapy in preventing acute renal failure in patients who develop rhabdomyolysis and myoglobinuria.

Acute Kidney Injury↗
PubMed1997

Unwillingness to lie supine? a sign of pericardial tamponade.

The stable patient with an occult cardiac injury can represent a diagnostic dilemma. The trauma surgeon must maintain a high index of suspicion for cardiac injury with precordial penetrating trauma. Herein are reported two cases of stable patients with penetrating precordial trauma who refused to lie supine because of difficulty breathing, preferring to sit upright, who eventually had positive pericardial windows and sternotomies for repair of cardiac injuries. The presence of this clinical finding, unwillingness to lie supine, should make the trauma surgeon highly suspicious of a cardiac injury and to proceed quickly to echocardiography or, preferably, to subxiphoid pericardial window to rule out cardiac injury.

Adolescent↗
PubMed1996

Complex duodenal injuries.

Duodenal trauma, with early diagnosis and prompt treatment, can be managed effectively by simple surgical techniques. Severe duodenal injuries and those associated with major destruction of adjacent structures (the pancreaticobiliary complex or abdominal vessels) require a more thoughtful strategy that incorporates a careful consideration of the physiologic stability of the patient and the extent of local destruction. Figure 8 summarizes these concepts in an algorithm.

Algorithms↗
PubMed1996

A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study.

This prospective study assessed the role of Doppler pressure indices (Ankle-Brachial Index [ABI] or Brachial Brachial Index [BBI]) in the evaluation for occult arterial injury from penetrating proximity extremity trauma (PET). A total of 258 patients with 323 PETs were evaluated by physical examination and Doppler pressure (ABI/BBI) determination. An ABI/BBI of < 0.9 was considered abnormal. The findings were compared with those of arteriography in all patients. Eleven injuries (3.4%) found on arteriography were associated with normal indices. Five of these injuries were treated by repair (4 patients) or angiographic embolization of a bleeding vessel (1 patient), all in lesions proximal to the knee or elbow joints. The other six lesions were observed without intervention. All of the 29 injuries associated with abnormal indices had positive arteriographic findings. The 4 lesions that were treated operatively were proximal and the remaining 25, all with distal penetration, were observed without observation. As compared to angiography, Doppler indices yielded the following results: 283 true-negative, 11 false-negative, 29 true-positive, and 0 false-positive, for a sensitivity of 72.5%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 96%. These data suggest that Doppler indices should be an integral part of the physical examination and can screen patients with proximal injuries for further studies such as duplex sonography or arteriography.

Adolescent↗
PubMed1996

A prospective randomized study of end points of resuscitation after major trauma: global oxygen transport indices versus organ-specific gastric mucosal pH.

BACKGROUND: Gastric tonometry, as a method of organ-specific monitoring of the status of the splanchnic circulation, has demonstrated prognostic and therapeutic implications in critically ill patients. The experience with this method in patients with trauma has been limited. STUDY DESIGN: Fifty-seven patients were prospectively randomized into two groups: group 1, n = 30, normalization and maintenance of gastric mucosal pH (pHi) at or above 7.3 and group 2, n = 27, maintenance of oxygen delivery index of 600 or an oxygen consumption index of greater than 150. The groups had statistically similar injury severity scores, lactate levels, and base deficits. RESULTS: Of the 44 patients with pHi greater than 7.3 at 24 hours, three (6.8 percent) died of multiple organ dysfunction syndrome as compared with seven (53.9 percent) of 13 in whom pHi was not optimized, p = 0.006. Optimization times for oxygen delivery index, oxygen consumption index, lactate levels, and base excess were similar between survivors and nonsurvivors. The time for pHi optimization was significantly longer in nonsurvivors. Multiple organ dysfunction syndrome points were significantly higher in patients who did not have pHi optimized within 24 hours (6.08 compared with 2.5, p = 0.03). Optimization time for pHi was predictive of mortality on multiple regression. Persistently low pHi was frequently associated with systemic or intra-abdominal complications. It was the first finding in all the nonsurvivors at least 48 to 72 hours before death. CONCLUSIONS: Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation. Monitoring of pHi may provide early warning for systemic complications in the postresuscitation period.

Adolescent↗
PubMed1995

Evaluation of subxiphoid pericardial window used in the detection of occult cardiac injury.

We critically evaluated several diagnostic modalities (clinical criteria, subxiphoid pericardial window (SPW) and laparoscopy) used in the detection of occult cardiac injury in haemodynamically stable patients at high risk of cardiac injury. Over 5 years, 122 patients were admitted to a Level I trauma centre with such an injury. They sustained 69 stab wounds, and 53 gunshot wounds. Sites of penetration were: precordial (81), right chest (25), lateral chest (13), thoracoabdominal (40) and abdominal (19). Vital signs in the emergency room were (mean +/- SD): systolic BP, 111 +/- 23.2 mmHg; HR, 106 +/- 18.7; GCS, 13.6 +/- 1.3; and CVP, 17 +/- 7.8 cmH2O. SPW was performed in all patients and was positive for haemopericardium in 26 patients, 24 (92 per cent) of whom had a cardiac injury at operation. Two patients had pericardial lacerations without cardiac injury. In addition, 14 patients with lower precordial and thoracoabdominal wounds underwent laparoscopy. At laparoscopy, the pericardium was evaluated by transdiaphragmatic inspection in 10 patients. The presence (two) or absence (eight) of blood within the pericardium was accurately predicted and verified by SPW. Univariate and multiple logistic regression analysis of clinical data failed to reveal any significant predictor of cardiac injury. SPW remains the standard means of diagnosing occult cardiac injury in high-risk patients. Since the incidence of occult cardiac injury in haemodynamically stable patients is 20 per cent, SPW should be used liberally. Laparoscopy may have a role in evaluating the pericardium in the subgroup of patients with lower chest wounds, and it facilitates inspection of intra-abdominal viscera and diaphragm at the same time.

Adolescent↗
PubMed1995

Current concepts in the use of cavitary endoscopy in the evaluation and treatment of blunt and penetrating truncal injuries.

The use of thoracoscopy in the patient with penetrating injury to the thorax is in its infancy. Although it is used mainly for diagnosis, evidence suggests that it will become a therapeutic tool during the initial management of the traumatized patient and in the postinjury period (early evacuation of retained hemothorax and the treatment of empyema). Although its role in injuries to the superior chest is clear, its role has not been established in the evaluation of the diaphragm. Both laparoscopy and thoracoscopy offer advantages in this area that must be considered when contemplating diagnosis and treatment. Further studies help define the place of these procedures for injuries in the thoracoabdominal area. The indications for cavitary endoscopy after truncal injury are summarized in Table 2. It must be remembered that experience in this field is rapidly increasing, and indications will change with new studies and new technology.

Abdominal Injuries↗
PubMed1995

Gastric mucosal pH and oxygen delivery and oxygen consumption indices in the assessment of adequacy of resuscitation after trauma: a prospective, randomized study.

OBJECTIVE: To compare gastric mucosal pH (pHi) and global oxygen variables [Oxygen Delivery Index (DO2I) and Oxygen Consumption Index (VO2I)] as indicators of adequacy of resuscitation after major trauma. METHODS: Twenty-seven patients were prospectively randomized into two groups: group 1 (n = 11), normalization and maintenance of pHi at or above 7.30; and group 2 (n = 16), maintaining a DO2I of 600 and a VO2I of > 150. The groups had statistically similar injury severity scores, lactate, and base deficit. RESULTS: The goals of therapy were achieved within 24 hours of admission in 10 of the 11 patients in group 1 and in 15 of the 16 patients in group 2. One patient (9.1%) in group 1 died. This patient had transient stabilization of pHi to 7.3 and subsequently had persistent mucosal acidosis. Of the 10 patients with pHi > 7.3 at 24 hours, 9 survived. In group 2, 5 (31.3%) died. Four of the 5 nonsurvivors had achieved DO2I and VO2I goals, but had pHi < 7.3 at 24 hours. A comparison of time taken for optimization of DO2I, VO2I, lactate, base excess, and pHi showed pHi and lactate as the variables different in survivors and nonsurvivors. Six of the 8 patients who developed multiple organ dysfunction syndrome had pHi < 7.3 at 24 hours. Persistently low pHi was the first sign of bacteremia (3 patients), small bowel gangrene or pregangrene (2 patients), intestinal anastomotic leak (2 patients), intra-abdominal hypertension (4 patients), and intra-abdominal abscess (5 patients). It was the first finding in all the nonsurvivors at least 72 hours before death. CONCLUSIONS: pHi may be an important marker to assess the adequacy of resuscitation. pHi monitoring may provide early warning for systemic complications in the postresuscitation period.

Adolescent↗
PubMed1994

Selective celiotomy for missile wounds of the abdomen based on laparoscopy.

The role of laparoscopy in the selective management of gunshot wounds (GSW) of the abdomen was prospectively investigated in 38 patients. All the patients were hemodynamically stable and had equivocal evidence of intraabdominal penetration. Laparoscopy was performed in the operating room under anesthesia. The site of penetration was in the thoracoabdominal area in 13, epigastrium in 7, and lower quadrants in 18. Twenty-three (60.5%) had nonpenetration on laparoscopy and a laparotomy was avoided. The remaining patients had injuries to the liver (4 patients), spleen (two patients), diaphragm (3 patients), hemoperitoneum or retroperitoneal hematoma (6 patients), and hollow viscus injuries (5 patients). Laparoscopy was also helpful in determining the need for laparotomy vs thoracotomy in lower chest wounds. The negative laparoscopy group (no penetration) had a significantly lower hospital stay compared to hemodynamically stable patients who had negative laparotomy without laparoscopy for nonpenetrating GSW. There were no complications related to laparoscopy. Laparoscopy is a useful modality in the evaluation of hemodynamically stable patients with abdominal missile wounds.

Abdominal Injuries↗