Intra-abdominal pressure development after different temporary abdominal closure techniques in a porcine model

BACKGROUND: Decompressive laparotomy followed by temporary abdominal closure (TAC) is an established prophylaxis and treatment for abdominal compartment syndrome. The herein presented study aimed at the comparison of volume reserve capacity and development of intra-abdominal hypertension after forced primary abdominal closure and different TAC techniques in a porcine model. METHODS: Eight anesthesized and mechanically ventilated domestic pigs underwent a standardized midline laparotomy. A bag was placed into the abdominal cavity. Before abdominal closure, the bag was prefilled with 3,000 mL water to simulate increased intra-abdominal volume. The intra-abdominal pressure (IAP) was then increased in 2 mm Hg steps up to 30 mm Hg by adding volume (volume reserve capacity) to the intra-abdominal bag. Volume reserve capacity with the corresponding IAP were analyzed and compared for primary abdominal closure, bag silo closure, a zipper system, and vacuum-assisted closure (VAC) with different negative pressures (-50, -100, and -150 mm Hg). Hemodynamic and pulmonary parameters were monitored throughout the experiment. RESULTS: Volume reserve capacity was the highest for bag silo closure followed by the zipper system and VAC with primary abdominal closure providing the least volume reserve capacity in the whole IAP range. Of interest, VAC -50 mm Hg resulted in a lower volume reserve capacity when compared with VAC -100 and -150 mm Hg. Pulmonary and hemodynamic parameters demonstrated no significant differences between primary abdominal closure and the evaluated TAC techniques at all IAP levels. CONCLUSIONS: The present experimental in vivo study indicates that bag silo closure and zipper systems may be favorable TAC techniques after decompressive laparotomy. In contrast, the VAC techniques resulted in lower volume reserve capacity and therefore may bear an increased risk for recurrent intra-abdominal hypertension in the initial phase after decompressive laparotomy.

Clinical and functional outcomes of acute lower extremity compartment syndrome at a Major Trauma Hospital

Background: Acute lower extremity compartment syndrome (CS) is a condition that untreated causes irreversible nerve and muscle ischemia. Treatment by decompression fasciotomy without delay prevents permanent disability. The use of intracompartmental pressure (iCP) measurement in uncertain situations aids in diagnosis of severe leg pain. As an infrequent complication of lower extremity trauma, consequences of CS include chronic pain, nerve injury, and contractures. The purpose of this study was to observe the clinical and functional outcomes for patients with lower extremity CS after fasciotomy. Methods: Retrospective chart analysis for patients with a discharge diagnosis of CS was performed. Physical demographics, employment status, activity at time of injury, injury severity score, fracture types, pain scores, hours to fasciotomy, iCP, serum creatine kinase levels, wound treatment regimen, length of hospital stay, and discharge facility were collected. Lower extremity neurologic examination, pain scores, orthopedic complications, and employment status at 30 days and 12 months after discharge were noted. Results: One hundred twenty‑four patients were enrolled in this study. One hundred and eight patients were assessed at 12 months. Eighty‑one percent were male. Motorized vehicles caused 51% of injuries in males. Forty‑one percent of injuries were tibia fractures. Acute kidney injury occurred in 2.4%. Mean peak serum creatine kinase levels were 58,600 units/ml. Gauze dressing was used in 78.9% of nonfracture patients and negative pressure wound vacuum therapy in 78.2% of fracture patients. About 21.6% of patients with CS had prior surgery. Nearly 12.9% of patients required leg amputation. Around 81.8% of amputees were male. Sixty‑seven percent of amputees had associated vascular injuries. Foot numbness occurred in 20.5% of patients and drop foot palsy in 18.2%. Osteomyelitis developed in 10.2% of patients and fracture nonunion in 6.8%. About 14.7% of patients underwent further orthopedic surgery. At long‑term follow‑up, 10.2% of patients reported moderate lower extremity pain and 69.2% had returned to work. Conclusion: Escalation in leg pain and changes in sensation are the cardinal signs for CS rather than reliance on assessing for firm compartments and pressures. The severity of nerve injury worsens with the delay in performing fasciotomy. Standardized diagnostic protocols and wound treatment strategies will result in improved outcomes from this complication.

Chirurgie [Surgery].

The evolution of visceral surgery is characterized by defining with ever increasing precision the real role of new techniques. Hernia repair, abdominal compartment syndrome, pancreatic and colorectal cancers, as well as haemorrhoids, confirm this reality. Although laparoscopy has clear indications in hernia repairs, many still prefer open approach. The abdominal compartment syndrome, now better understood thanks to laparoscopy, is increasingly important in intensive care. The role of laparoscopy for pancreatic and colorectal cancers is still limited. The development of minimally invasive techniques has led to a reduced morbidity of surgery for haemorrhoids and better results. The economic impact of new technologies must remain a primary concern.

Überinfusion von Verbrennungsopfern: häufig und schädlich [Over infusion in burn victims: frequent and injurious]

Major burns are characterized by an initial capillary leak, which requires fluid resuscitation for hemodynamic stabilization. While under resuscitation was the major cause of death until the 1980s, over resuscitation has become an important source of complications, including abdominal compartment syndrome, escharosis, impaired gas exchange with prolonged mechanical ventilation and hospital stay. Fluid over infusion started in the 1990s with an increasing proportion of the fluid delivered within the first 24 h being well above the 4 ml/kg/% burn surface area (BSA) according to the Parkland formula. The first alerts were published in the form of case reports of increased mortality due to abdominal compartment syndrome and respiratory failure. This paper analyses the causes of this fluid over infusion and the ways to prevent it, which include rationing prehospital fluid delivery, avoiding early administration of colloids and prevention by permissive hypovolemia.

Surréanimation liquidienne pré et intrahospitatière des patients brûlés: fréquente et néfaste [Pre- and intra-hospital over-resuscitation in burns: frequent and deleterious].

Major burns are characterized by an initial capillary leak which requires fluid resuscitation for hemodynamic stabilisation. While under-resuscitation was the major cause of death until the 80ies, over-resuscitation has become an important source of complications: abdominal compartment syndrome, escharotomies, impaired gas exchange and prolonged mechanical ventilation and hospital stay. The fluid creep started in the 90ies with an increasing proportion of the first 24 hours' fluid delivery above the 4 ml/kg/% BSA Parkland prediction. The first alerts were published under the form of case reports of increased mortality due to abdominal compartment syndrome and respiratory failure. The paper analyses the causes of this fluid creep, and the ways to prevent it, which includes rationing prehospital fluid delivery, avoiding early colloids and permissive hypovolemia.

Effects of different tidal volumes in pulmonary and extrapulmonary lung injury with or without intraabdominal hypertension

We hypothesized that: (1) intraabdominal hypertension increases pulmonary inflammatory and fibrogenic responses in acute lung injury (ALI); (2) in the presence of intraabdominal hypertension, higher tidal volume reduces lung damage in extrapulmonary ALI, but not in pulmonary ALI. Wistar rats were randomly allocated to receive Escherichia coli lipopolysaccharide intratracheally (pulmonary ALI) or intraperitoneally (extrapulmonary ALI). After 24 h, animals were randomized into subgroups without or with intraabdominal hypertension (15 mmHg) and ventilated with positive end expiratory pressure = 5 cmH(2)O and tidal volume of 6 or 10 ml/kg during 1 h. Lung and chest wall mechanics, arterial blood gases, lung and distal organ histology, and interleukin (IL)-1 beta, IL-6, caspase-3 and type III procollagen (PCIII) mRNA expressions in lung tissue were analyzed. With intraabdominal hypertension, (1) chest-wall static elastance increased, and PCIII, IL-1 beta, IL-6, and caspase-3 expressions were more pronounced than in animals with normal intraabdominal pressure in both ALI groups; (2) in extrapulmonary ALI, higher tidal volume was associated with decreased atelectasis, and lower IL-6 and caspase-3 expressions; (3) in pulmonary ALI, higher tidal volume led to higher IL-6 expression; and (4) in pulmonary ALI, liver, kidney, and villi cell apoptosis was increased, but not affected by tidal volume. Intraabdominal hypertension increased inflammation and fibrogenesis in the lung independent of ALI etiology. In extrapulmonary ALI associated with intraabdominal hypertension, higher tidal volume improved lung morphometry with lower inflammation in lung tissue. Conversely, in pulmonary ALI associated with intraabdominal hypertension, higher tidal volume increased IL-6 expression.

Anestesia regional y periférica guiada por ultrasonido en el paciente critico

El presente trabajo es un capítulo de libro titulado “Anestesia Regional y Periférica Guiada por Ultrasonido en el Paciente Crítico” que será incluido en la última edición del libro “Manual de Ultrasonido en Terapia Intensiva y Emergencias” cuyo editor es el Doctor José de Jesús Rincón Salas y que será publicado por la Editorial Prado de México para distribución latinoamericana desde dicho país. Por solicitud del editor y teniendo en cuenta el enfoque del libro, el presente trabajo está dirigido a estudiantes de formación, médicos graduados y especialistas en las áreas de cuidado intensivo, anestesiología, dolor, medicina interna y medicina de urgencias. Tiene como propósito empapar de conocimientos necesarios y prácticos en anestesia regional a personas que usualmente no han tenido contacto con la anestesia regional, pues desafortunadamente sólo en los últimos años ha sido posible que la anestesia regional haya comenzado a salir de las salas de cirugía, ámbito donde ha estado confinada tradicionalmente. El lenguaje utilizado es sencillo y el capítulo ha sido escrito para que sea fácil de leer y consultar, dejando así mensajes muy claros sobre la utilidad, viabilidad e implicaciones que tiene el uso de anestesia regional guiada por ultrasonido en cuidado intensivo. Los autores esperamos que de esta manera, el presente capítulo permita continuar superando los obstáculos que se interponen entre los invaluables beneficios de la anestesia regional y los pacientes de cuidado intensivo que necesitan de ella.

Laparoscopic repair of vesicovaginal fistula

Purpose: Vesicovaginal fistula (VVF) is one of the most devastating surgical complications that can occur in women. The primary cause remains an abdominal hysterectomy. Approach to this condition can be transvaginal or transabdominal. Laparoscopic repair of VVF may be an alternative approach to this treating rare condition. We present seven cases of VVF treated with transperitoneal laparoscopic technique and our results. Methods: We retrospectively reviewed the charts of 7 women ranging from 37 to 74 years in age (mean age 52.8 years) at our institution who underwent laparoscopic transperitoneal repair of VVF between February 2004 and March 2006. Etiology of the VVF, surgical technique, operative time, length of hospital stay, and complications were reviewed. Results: Six of the seven VVFs we repaired laparoscopically resulted from gynecologic procedures, and one patient presented with a VVF after a ureterolithotripsy. Mean operative time ranged from 130 to 420 minutes (mean 280 minutes), and mean hospital stay was 7 days. In one patient conversion to open surgery was necessary due to prolonged operative time. Two complications occurred a urinary tract infection in one patient and an inferior limb compartment syndrome in another. Conclusion: Transvaginal laparoscopic repair of VVF is feasible and safe and provides excellent results. It is a good alternative to the abdominal approach. However, advanced laparoscopic skills are mandatory. © 2008 Mary Ann Liebert, Inc.

Caracterização do padrão ventilatório em estudantes de canto

Objectivo: avaliar a influência da experiência de canto nas estratégias de padrão ventilatório durante tarefas vocais. Metodologia: a amostra foi constituída por oito estudantes de canto e treze indivíduos sem experiência na área. Foi monitorizada a variação dos perímetros torácico e abdominal em provas de canto e fala a diferentes intensidades. Resultados: Verificou-se um maior recrutamento torácico no grupo de cantores nas provas de contagem, nas três intensidades e canto, nas intensidades fraca e forte. Em termos de compartimento abdominal apenas se verificaram diferenças entre os grupos nas provas de canto de intensidade média e forte. Conclusão: as estratégias ventilatórias são variadas reflectindo a insustentabilidade de uma estratégia uniforme para diversas actividades vocais realizadas. Contudo, parece existir uma tendência para um maior recrutamento torácico nos estudantes de canto.

Snakebites by Bothrops spp in children in Campinas, São Paulo, Brazil

From January, 1984 to March, 1999, 73 children under 15 y old (ages 1-14 y, median 9 y) were admitted after being bitten by snakes of the genus Bothrops. Twenty-six percent of the children were classified as mild envenoming, 50.7% as moderate envenoming and 20.6% as severe envenoming. Two patients (2.7%) showed no signs of envenoming. Most of the patients presented local manifestations, mainly edema (94.5%), pain (94.5%) ecchymosis (73.9%) and blisters (11%). Local and/or systemic bleeding was observed in 28.8% of the patients. Before antivenom (AV) administration, blood coagulation disorders were observed in 60.7% (incoagulable blood in 39.3%) of the 56 children that received AV only in our hospital. AV early reactions, most of which were considered mild, were observed in 44.6% of these cases (in 15/30 patients not pretreated and in 10/26 patients pretreated with hydrocortisone and histamine H1 and H2 antagonists). The main clinical complications observed were local infection (15.1%), compartment syndrome (4.1%), gangrene (1.4%) and acute renal failure (1.4%). No deaths were recorded. There were no significant differences with regard to severity of envenoming versus the frequency of blood coagulation disorders among the three categories of envenoming (p = 0.75) or in the frequency of patients with AV early reactions between the groups that were and were not pretreated (p = 0.55). The frequency of local infection was significantly greater in severe cases (p < 0.001). Patients admitted more than 6 h after the bite had a higher risk of developing severe envenoming (p = 0.04).

Enclouage verrouillé du tibia [Interlocking nailing of the tibia]

Centromedullary nailing is a well-established method of treatment for diaphyseal long bone fractures. The indications have been broadened greatly since the introduction in 1974 of interlocking centromedullary nailing. The purpose of this paper is to review our first results with locked intramedullary nailing of the tibia. We report our experience with the first 19 cases of interlocking tibia nails (15 fractures, 1 delayed union, 2 pseudarthrosis, 1 osteotomy). On the extension table, the insertion of the nail and the placement of the interlocking screws did not cause any problem. In 3 cases, a proximal screw had to be removed within two weeks because of spontaneous displacement. Complications have been noticed in three patients (15.8%) (pulmonary embolism on day 1, and compartment syndrome two days later in one case, sciatic nerve neuroapraxia in the other two). The other patients have been mobilized 24 to 48 hours after surgery. 94% of the fractures were consolidated 4 months post-operatively, with no major deformation. Interlocking tibia nailing seems to be an attractive method in the treatment of certain fractures of the tibia. Early mobilisation and weight-bearing are provided. The indications, the technical aspects as well as the dangers of the method must be carefully respected in order to avoid complications and poor results.

Closed and open grade I and II tibial shaft fractures treated by reamed intramedullary nailing.

OBJECTIVE: To evaluate the results of closed and open grade I and II tibial shaft fractures treated by reamed nail and unreamed nailing. SUBJECTS AND METHODS: Between 1997 and 2000, 119 patients with tibial shaft fractures were treated with reamed tibial nails. Postoperatively 96 patients (70 closed and 26 grade I and II open fractures) were followed clinically and radiologically for up to 18 months. The nail was inserted either by patellar tendon splitting or by nonsplitting technique. The nail was inserted after overreaming by 1.5 mm. Postoperatively, patients with isolated tibial fracture were mobilized by permitting partial weight bearing on the injured leg for 6 weeks. Patients with associated ankle fractures were allowed to walk with a Sarmiento cast. RESULTS: Postoperatively, 6 (6.3%) patients developed a compartment syndrome after surgery. In 48 (50%) cases, dynamization of the nail was carried out after a mean period of 12 weeks for delayed union. Overall, a 90.6% union was obtained at a mean of 24 weeks without difference between closed or open fractures. Two (2.1%) patients with an open grade II fracture developed a deep infection requiring treatment. A 9.4% rate of malunion was observed. Eight (8.3%) patients developed screw failure without clinical consequences. At the last follow-up, 52% of patients with patellar tendon splitting had anterior knee pain, compared to those (14%) who did not have tendon splitting. CONCLUSION: Reamed intramedullary nail is a suitable implant in treating closed as well as grade I and II open tibial shaft fractures.

Breathing pattern and thoracoabdominal motion during exercise in chronic obstructive pulmonary disease

Subjects with chronic obstructive pulmonary disease (COPD) present breathing pattern and thoracoabdominal motion abnormalities that may contribute to exercise limitation. Twenty-two men with stable COPD (FEV1 = 42.6 ± 13.5% predicted; age 68 ± 8 years; mean ± SD) on usual medication and with at least 5 years of diagnosis were evaluated at rest and during an incremental cycle exercise test (10 watts/2 min). Changes in respiratory frequency, tidal volume, rib cage and abdominal motion contribution to tidal volume and the phase angle that measures the asynchrony were analyzed by inductive respiratory plethysmography at rest and during three levels of exercise (30-50, 70-80, and 100% maximal work load). Repeated measures ANOVA followed by pre-planned contrasts and Bonferroni corrections were used for analyses. As expected, the greater the exercise intensity the higher the tidal volume and respiratory frequency. Abdominal motion contributed to the tidal volume increase (rest: 49.82 ± 11.19% vs exercise: 64.15 ± 9.7%, 63.41 ± 10%, and 65.56 ± 10.2%, respectively, P < 0.001) as well as the asynchrony [phase angle: 11.95 ± 7.24° at rest vs 22.2 ± 15° (P = 0.002), 22.6 ± 9° (P < 0.001), and 22.7 ± 8° (P < 0.001), respectively, at the three levels of exercise]. In conclusion, the increase in ventilation during exercise in COPD patients was associated with the major motion of the abdominal compartment and with an increase in the asynchrony independent of exercise intensity. It suggests that cycling exercise is an effective way of enhancing ventilation in COPD patients.

Dynamics of chest wall volume regulation during constant work rate exercise in patients with chronic obstructive pulmonary disease

This study evaluated the dynamic behavior of total and compartmental chest wall volumes [(V CW) = rib cage (V RC) + abdomen (V AB)] as measured breath-by-breath by optoelectronic plethysmography during constant-load exercise in patients with stable chronic obstructive pulmonary disease. Thirty males (GOLD stages II-III) underwent a cardiopulmonary exercise test to the limit of tolerance (Tlim) at 75% of peak work rate on an electronically braked cycle ergometer. Exercise-induced dynamic hyperinflation was considered to be present when end-expiratory (EE) V CW increased in relation to resting values. There was a noticeable heterogeneity in the patterns of V CW regulation as EEV CW increased non-linearly in 17/30 "hyperinflators" and decreased in 13/30 "non-hyperinflators" (P < 0.05). EEV AB decreased slightly in 8 of the "hyperinflators", thereby reducing and slowing the rate of increase in end-inspiratory (EI) V CW (P < 0.05). In contrast, decreases in EEV CW in the "non-hyperinflators" were due to the combination of stable EEV RC with marked reductions in EEV AB. These patients showed lower EIV CW and end-exercise dyspnea scores but longer Tlim than their counterparts (P < 0.05). Dyspnea increased and Tlim decreased non-linearly with a faster rate of increase in EIV CW regardless of the presence or absence of dynamic hyperinflation (P < 0.001). However, no significant between-group differences were observed in metabolic, pulmonary gas exchange and cardiovascular responses to exercise. Chest wall volumes are continuously regulated during exercise in order to postpone (or even avoid) their migration to higher operating volumes in patients with COPD, a dynamic process that is strongly dependent on the behavior of the abdominal compartment.