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PubMed2003

Clinical outcomes following institution of the Canadian universal leukoreduction program for red blood cell transfusions.

CONTEXT: A number of countries have implemented a policy of universal leukoreduction of their blood supply, but the potential role of leukoreduction in decreasing postoperative mortality and infection is unclear. OBJECTIVE: To evaluate clinical outcomes following adoption of a national universal prestorage leukoreduction program for blood transfusions. DESIGN, SETTING, AND POPULATION: Retrospective before-and-after cohort study conducted from August 1998 to August 2000 in 23 academic and community hospitals throughout Canada, enrolling 14 786 patients who received red blood cell transfusions following cardiac surgery or repair of hip fracture, or who required intensive care following a surgical intervention or multiple trauma. INTERVENTION: Universal prestorage leukoreduction program introduced by 2 Canadian blood agencies. A total of 6982 patients were enrolled during the control period and 7804 patients were enrolled following prestorage leukoreduction. MAIN OUTCOME MEASURES: All-cause in-hospital mortality and serious nosocomial infections (pneumonia, bacteremia, septic shock, all surgical site infections) occurring after first transfusion and at least 2 days after index procedure or intensive care unit admission. Secondary outcomes included rates of posttransfusion fever and antibiotic use. RESULTS: Unadjusted in-hospital mortality rates were significantly lower following the introduction of leukoreduction compared with the control period (6.19% vs 7.03%, respectively; P =.04). Compared with the control period, the adjusted odds of death following leukoreduction were reduced (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.75-0.99), but serious nosocomial infections did not decrease (adjusted OR, 0.97; 95% CI, 0.87-1.09). The frequency of posttransfusion fevers decreased significantly following leukoreduction (adjusted OR, 0.86; 95% CI, 0.79-0.94), as did antibiotic use (adjusted OR, 0.90; 95% CI, 0.82-0.99). CONCLUSION: A national universal leukoreduction program is potentially associated with decreased mortality as well as decreased fever episodes and antibiotic use after red blood cell transfusion in high-risk patients.

Adult↗
PubMed1984

Vascular spasm and gangrene during heparin-dihydro-ergotamine prophylaxis.

A case is reported of a multiple trauma victim who developed severe vascular spasm whilst receiving heparin-dihydro-ergotamine thromboembolic prophylaxis which ultimately led to amputation of the right foot. Identification of high risk groups for this complication is attempted from a review of the literature. Treatment should be with intra-arterial or intravenous nitroprusside or nitrates. Little information is as yet available on the use of prostacyclin in this condition.

Adult↗
PubMed1992

Prospective study in adults of splenic preservation after traumatic rupture.

Seventy-five adults with splenic injury were evaluated prospectively over 45 months to examine the possibility of splenic preservation. Haemodynamically unstable patients underwent surgery with the intent of splenic preservation. Stable patients received non-operative treatment regardless of the grade of splenic injury determined by ultrasonography and computed tomography. Thirty-seven patients required splenectomy and in 38 the organ was preserved (20 operative preservation, 18 non-operative treatment). Of 22 patients initially receiving non-operative treatment, there were four secondary haemorrhages after 7, 7, 10 and 13 days making surgery necessary. Three of these patients underwent splenectomy and in one the spleen was preserved by partial resection. After splenectomy four patients required reoperation because of rebleeding or for evacuation of a haematoma. Patients who had undergone splenectomy had a significantly increased infection rate (P < 0.005) compared with those in whom the spleen was preserved, even when patients were matched with respect to multiple trauma using the Injury Severity Score (P < 0.01).

Adolescent↗
PubMed2003

Unique form of propriospinal myoclonus as a possible complication of an enteropathogenic toxin.

Propriospinal myoclonus is an uncommon form of spinal myoclonus propagated, presumably, by slowly conducting polysynaptic intraspinal pathways. Although most patients demonstrate no clear etiology, a variety of disorders have been linked to this abnormal movement, including trauma, multiple sclerosis, tumors, and infectious disorders such as herpes zoster, human immunodeficiency virus, and Lyme disease. We describe 2 young male patients from the same town in Northern Ontario, Canada, exposed to an outbreak of Escherichia coli O157:H7 from contaminated municipal water, who developed identical clinical and electrophysiological features suggestive of a rhythmic form of propriospinal myoclonus with activity alternating between abdominal and paraspinal muscles. A toxin-mediated microvascular thrombosis is proposed as a possible pathogenic mechanism underlying this novel association.

Adult↗
PubMed1993

High-frequency jet ventilation in children with the adult respiratory distress syndrome complicated by pulmonary barotrauma.

High-frequency jet ventilation (HFJV) was used in 29 children with severe ARDS complicated by pulmonary barotrauma (PBT). Treatment with HFJV was begun when PBT was progressing over a 24-h period while receiving conventional ventilation (CV). The mean (+/- SD) age was 0.95 +/- 1.21 years (range, 0.03-4 years). The most common diagnosis was viral pneumonia (n = 17); other diagnoses included aspiration pneumonitis (n = 4), bacterial pneumonia (n = 3), multiple trauma (n = 2), and near-drowning (n = 3). The Bunnell Life-Pulse ventilator was used at a rate of 240/min or 300/min, with inspiratory time of 0.02 sec. Twenty children survived (69%). Survivors and nonsurvivors had equal disease severity prior to HFJV as assessed by ventilator settings, alveolar-to-arterial oxygen tension gradient, oxygenation index, and blood gas values. Survivors had spent significantly less time on conventional ventilation prior to HFJV than nonsurvivors, with a mean (+/- SD) of 3.7 +/- 2.1 days vs 9.6 +/- 4.5 days, respectively (P < 0.05). Survivors underwent an average of 4.4 +/- 3.9 days of HFJV, which supported adequate gas exchange with lower airway pressures, and produced resolution or significant improvement in airleak on chest radiograph. In conclusion, we speculate that the application of HFJV early in the course of severe hypoxemic respiratory failure complicated by airleak, allows the reduction of airway pressures, thereby minimizing pulmonary barotrauma and allowing the lung to recover from the underlying insult. Further controlled evaluation of HFJV in this high risk group of patients is warranted.

Child, Preschool↗
PubMed2002

Health management technology for catastrophic medical conditions.

BACKGROUND: The excessive growth of health care expenditures in the United States is widely acknowledged. Costs are anticipated to double by the year 2006. The intractable issue which remains before health care leaders is how to appropriately restrain these costs while not sacrificing a desired level of care quality. A variety of management approaches have been developed in pursuit of more rational and cost-effective use of health resources. Current management approaches have proven inadequate in stemming health care cost inflation and have raised increasing concerns about their negative impact on the quality of health care. METHOD: One group has created and operated a data and structured, expert consensus-driven health management technology for the management of catastrophic medical conditions, including severe brain and spinal cord injury and severe multiple trauma and burns, since 1992 and has recently applied this same technology to high risk neonates and organ transplants. This integrated, severity risk adjusted, delivery system incorporates adequate clinical data capture and analysis, coupled with empirically derived management principles and consensus expert clinical judgment. INTERPRETATION: Preliminary data analysis indicates that patients treated under the ParadigmHealth model experienced an improvement in the health care process, improved quality in health care delivery and outcomes, and overall cost reduction.

Biomedical Technology↗
PubMed1988

Implanted pump systems for treatment of spasticity.

In about one third of patients with violent spasticity due to spinal trauma, multiple sclerosis, and diffuse brain injury adequate control with oral antispastic medication cannot be achieved and successful rehabilitation is severely handicapped. In the past these patients were subjected to destructive chemical procedures or extensive surgery. The authors present the results of management of uncontrollable spasticity by means of continuous intrathecal administration of baclofen with a totally implantable gas driven pump system (Infusaid). 30 patients were treated between June 1985 and January. 1987. The main indication was incapacitating spasticity resistant to oral treatment with baclofen and caused by spinal cord injury or lesion (11 patients), multiple sclerosis (11 patients), infantile cerebral palsy (3 patients) and cerebral injury, hypoxia or ischaemia (5 patients). Clinical assessment included spasticity scores, integrated electromyography (Iemg) and motography. Effective control for spasticity with mean reduction of Iemg by 55%, decrease of Ashworth's score from 3 to 0 and improvement of life quality was obtained in all patients with daily dose of 10-800 micrograms of Baclofen. Voluntary resting motoricity was not impaired and there were no untoward central side effects. The excellent effect of intrathecal baclofen in comparison with oral therapy is explained by local, spinal GABAergic inhibitory action of the drug which is delivered directly into spinal subarachnoid space. Dose finding and dose adjustment is performed prior to pump implantation by intermittent injections into a subcutaneous port. The complications of the procedure were minor (catheter displacement, disconnection) and easily correctable.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

A cytologic study of the sediments in pericardial fluid as it relates to a diagnosis of the mechanism of death.

We have studied the sediments obtained from the pericardial fluids of 70 cadavers subject to different causes of death. The fluids were taken in the course of corresponding legal autopsies. The samples were organized according to the cause of death and cellular predominance, in the following groups, respectively: hanging, multiple trauma, craniocerebral trauma, other violent deaths, myocardial infarction, pulmonary embolism, and other natural deaths. According to cell type followed these categories: Group 1 (isolated mesothelial cells), group 2 (isolated and plated mesothelial cells), group 3 (inflammatory cells and mesothelial cells, isolated and plated), and group 4 (inflammatory cells and mesothelial cells). The statistical analysis was attained through Pearson's coefficient. We have found a significant statistical relation (P less than or equal to 0.05) between the presence or lack of inflammatory cells and the mechanism of death. In those cases with a short survival period and without cardiac affectation, the presence of inflammatory cells was practically null. Furthermore, differences in the cross-sections of inflammatory cells reflected the duration of the death process, with elements characteristic of acute inflammation revealing acute cardiac process.

Cause of Death↗
PubMed1985

Epidural and intrathecal morphine in intensive care units.

Analgesia and sedation for patients in intensive care units (ICU) who require mechanical ventilation are most commonly provided by intermittent i.v. injections of opiates and benzodiazepines. However, the technique has a number of disadvantages. Also, in many cases these drugs are inadequate, even in large doses, and muscle relaxants may be necessary for patient respirator coordination. The analgesic effect of epidural and intrathecal morphine was studied in 24 ICU patients requiring controlled ventilation. In spite of large doses of phenoperidine, diazepam and a number of other analgesics and sedatives, all patients were restless, agitated and coordinated poorly with the respirator. Through an indwelling epidural catheter morphine (4 mg) was injected intermittently as required in 11 patients and as a continuous infusion (20-40 mg/day) in five patients. In eight patients morphine (2-4 mg) was injected intrathecally as a single injection. Both epidural and intrathecal morphine gave potent analgesia and good patient respirator coordination. The duration of analgesia was shortest after intermittent injections of epidural morphine and longest after intrathecal morphine. However, continuous infusion of morphine in the epidural catheter appears to be the most practical method. In patients with multiple trauma and in patients where frequent assessment of the level of consciousness is important this technique is superior to parenteral analgesic sedative combinations. Intrathecal morphine may be indicated in patients in a compromised position. The daily analgesic requirement can be reduced by about 10-100 times by the use of epidural and intrathecal morphine respectively.

Adult↗
PubMed1987

Cerebral oedema and the fat embolism syndrome.

A 19-year-old woman who sustained multiple trauma, but no head injury, developed the fat embolism syndrome. Her severe, fulminant and reversible neurological deterioration was associated with cerebral oedema. We suggest that cerebral oedema may contribute to the neurological deterioration in the fat embolism syndrome.

Adult↗
PubMed1984

Evaluation of I.V. labetalol for treatment of posttraumatic hyperdynamic state.

A hyperdynamic state, characterized by an elevated blood pressure and tachycardia is frequently seen during the first few days following severe multiple trauma. We examined the cardiovascular effects of the alpha and beta adrenoceptor blocking agent labetalol in patients presenting a hyperdynamic cardiovascular state some days after major trauma. Ten patients with a heart rate-systolic blood pressure product (RPP) of more than 2000 during 6 consecutive hours, despite normovolaemia, adequate ventilation, analgesia and sedation were investigated. After a mean dose of 2.1 +/- 1.2 mg X kg-1 (mean +/- SD) of labetalol injected intravenously over a 10-min period, heart rate decreased from 117 +/- 28 to 102 +/- 19 beats X min-1, systolic arterial pressure from 25 +/- 3.5 to 18.5 +/- 2.7 kPa, diastolic pressure from 11 +/- 1.7 to 9.5 +/- 1.7 kPa, mean arterial blood pressure from 15.5 +/- 2.1 to 12.4 +/- 2.1 kPa, and the RPP from 2880 +/- 867 to 1853 +/- 373. The beneficial effect of this dose lasted 24 h in 8 of 10 patients without additional administration. No important side effects such as cardiac arrhythmias, hypotension, or bronchospasm were noted. We conclude that labetalol used in fractional intravenous doses permits an adequate treatment of a "hypertension-tachycardia syndrome" in severely injured patients.

Adult↗
PubMed1976

[Specific probelms in the intensive care of patients with multiple injuries (author's transl)].

Respiratory problems such as throacic injuries, shock lung, fat embolism aspiration are predominant in a specialized intensive care unit for patients with multiple trauma. The most important pulmonary complications are tension pneumothorax (in which case an immediate diagnosis is essential), atelectasis, lesions of the trachea, and pulmonary infections (12 percent of the patients). With severe head injuries it is often difficult to decide whether intensive care is justified. Unfortunately, there are no clear criteria for an early assessment of the prognosis in many of these cases.

Adult↗
PubMed1978

[Retroperitoneal injuries: introduction (author's transl)].

Injuries of the retroperitoneal organs occur mainly in patients with multiple traumas. Spine and spinal muscle provide an effective protection against blunt trauma from behind. In the front the thin peritoneal layer is just a biological border. Therefore injuries of the abdominal and retroperitoneal organs frequently occur together. Direct clinical examinations are limited by the specific anatomical situation; further invasive diagnostic procedures deal mainly with indirect effects of retroperitoneal injuries. Massive hemorrhage with consequent retroperitoneal hematoma is the dominant pathophysiologic course; mortality is high.

Abdominal Injuries↗
PubMed1989

Monitoring in the intensive care unit is not always necessary.

Most patients receiving spinal narcotics can be monitored adequately by well-trained nurses on postoperative or postdelivery wards. Patients at high risk (e.g., those with preexisting lung disease or many elderly patients) do need monitoring in the intensive care unit. Also requiring special monitoring are patients for whom epidural narcotics alone will not cover their pain, such as young patients with multiple trauma. Patients without these restrictions, however, can be monitored successfully outside the intensive care unit, although the dose of epidural narcotic should be kept as low as possible.

Analgesics, Opioid↗
PubMed1992

Assessment of changes in body water by bioimpedance in acutely ill surgical patients.

OBJECTIVE: To evaluate the relationship between changes in body bioelectrical impedance (BI) at 0.5, 50 and kHz and the changes in body weight, as an index of total body water changes, in acutely ill surgical patients during the rapid infusion of isotonic saline solution. DESIGN: Prospective clinical study. SETTING: Multidisciplinary surgical ICU in a university hospital. PATIENTS: Twelve male patients treated for acute surgical illness (multiple trauma n = 5, major surgery n = 7). SELECTION CRITERIA: stable cardiovascular parameters, normal cardiac function, signs of hypovolemia (CVP < or = 5 mmHg, urine output < 1 ml/kg x h). INTERVENTIONS: After baseline measurements, a 60 min fluid challenge test was performed with normal saline solution, 0.25 ml/kg/min [corrected]. MEASUREMENTS AND RESULTS: Body weight (platform digital scale), total body impedance (four-surface electrode technique; measurements at 0.5, 50 and 100 kHz) and urine output. Fluid retention induced a progressive decrease in BI at 0.5, 50 and 100 kHz, but the changes were significant for BI 0.5 and BI 100 only, from 40 min after the beginning of the fluid therapy onwards. There was a significant negative correlation between changes in water retention and BI 0.5, with individual correlation coefficients ranging from -0.72 to 0.95 (p < 0.01-0.0001). The slopes of the regression lines indicated that for each kg of water change, there was a mean decrease in BI of 18 ohm, but a substantial inter-individual variability was noted. CONCLUSION: BI measured at low frequency can represent a valuable index of acute changes in body water in a group of surgical patients but not in a given individual.

Acute Disease↗
PubMed1985

[From prevention to health promotion].

There has been much talk about prevention in recent years in industrialized countries, especially in view of the problems care systems encounter. Often however, one refers particularly to secondary prevention, which is in fact the first step of a treatment process. It is essential to take into account the risk factors acting upstream, which medical professions have not done enough in the past. One has not considered enough either the inequalities which are still a frequent occurrence in our populations, and the multiples traumas of various sorts which present living environments inflict on individuals. Sometimes, excessive emphasis has been put on "negative" aspects (blame, social control) of prevention. These facts have lead to the elaboration of the concept of health promotion (and positive health), which implies an action on the environment, as well as the growth of everyone's ability to manage this environment and his own development. In this framework the creation of an adequate community oriented information system is very important; sharing of knowledge, skills and attitudes is indispensable. Health promotion, including the just mentioned sharing, includes certain risks. One may even wonder what a life fully focussed on health, where any transgression will be linked to guilt feelings, would really be. What would be its ideological underpinnings? These problems are by no means neutral, they reflect the consistencies as well as the contradictions of our society. This is one reason why research is much needed on these subjects in the future.

Adult↗
PubMed2002

Immunonutrition.

Nutrition and immunology are interrelated. Several nutrients like arginine, glutamine, omega-3-fatty acids and nucleotides enhance cellular immunity, modulate tumor cell metabolism and improve clinical outcome in stress situations. Glutamine supplementation has been shown to decrease incidence of sepsis and to reduce length of hospital stay in bone marrow transplant patients, low birth weight infants, surgical and multiple trauma patients. Studies with arginine have shown a reduction in infectious complications and lower mortality, however a better understanding of the biology of arginine is needed. Omega-3-fatty acid supplimentation as in fish oil stimulates the immune system. The beneficial effects of immunonutrition in surgical patients has been demonstrated in several studies. It significantly reduces infectious complications and length of hospital stay. In critically ill patients immunonutrition may decrease infectious complications but it is not associated with a mortality advantage. Pediatric experience is limited, but the future is promising.

Amino Acids↗