The Complex Surgical Abdomen: What the Nonsurgeon Intensivist Needs to Know

Intensivists are often called upon to help care for patients who develop severe sepsis syndrome and septic shock where the primary source is an enterocutaneous fistula (ECF). The purpose of this article is to describe to the nonsurgeon intensivist how these complex surgical situations arise in the first place and provide the reader with a detailed understanding of the potentially devastating complications of ECF. In addition, we will describe a structured algorithm regarding the management of this often highly challenging surgical situation.

Nonoperative management of spontaneous splenic rupture in infectious mononucleosis: the role for emerging diagnostic and treatment modalities

Infectious mononucleosis (IM) is a self-limiting lymphoproliferative disorder affecting teenagers and young adults. Splenomegaly is a common manifestation of IM and results in a compromised organ that may rarely rupture spontaneously, with significant morbidity and mortality. The IM spleen should be protected from even minor trauma. Although traditional management of spontaneous splenic rupture in IM has been splenectomy, the role of nonoperative management is evolving. The advent of endovascular interventional modalities has augmented the physician's armamentarium in managing these patients nonoperatively. We report a case of spontaneous splenic rupture in a patient with IM managed conservatively with the aid of splenic angiography. The option of arteriography, with or without embolization, should be considered in the management of all patients with spontaneous splenic rupture in the setting of IM.

Association of Super-Super-Obesity and Male Gender with Elevated Mortality in Patients Undergoing the Duodenal Switch Procedure

BACKGROUND

Previous studies have reported that risk factors for elevated mortality after Roux-en-Y gastric bypass include male gender, as well as a very elevated BMI. The present study was aimed at determining whether these same risk factors applied to patients undergoing the duodenal switch (DS) operation.

MATERIALS AND METHODS

A retrospective chart review was performed of a cohort of 385 patients who underwent DS. The 30-day mortality of super-superobese (SSO) patients [BMI > or =60 kg/m2 (n=102)] was compared with the mortality of the super- and morbidly obese (SMO) patients [35<BMI<60 kg/m2 (n=283)].

RESULTS

Overall mortality in SSO patients was 7.8% (8/102), compared with 0% (0/283) in SMO patients undergoing the same procedure (P<0.001). When a gender-based subgroup analysis was performed in the SSO patients, men had a 16.7% mortality (7/42) while women had only a 1.7% (1/60) mortality.

CONCLUSIONS

In this study of patients undergoing DS, being SSO -- specifically SSO men -- was associated with increased mortality. Further studies will be needed to better determine the precise mechanism of these risk factors leading to such an elevation in mortality. Until then, caution should be exercised before performing DS in male patients with BMI > or =60 kg/m2.

The effects of nitric oxide inhibition on regional hemodynamics during hyperdynamic endotoxemia

OBJECTIVE

To determine the effect of the inhibition of nitric oxide (NO) on selective organ blood flow in endotoxin-induced sepsis.

DESIGN

Nonrandomized, controlled experiment.

SETTING

Animal research facility in Brooklyn, NY.

PARTICIPANTS

Eleven mongrel dogs.

INTERVENTION

Eleven dogs were divided into one of two groups: a control group (n = 5) and an endotoxin-treated group (n = 6). The animals were anesthetized, and electromagnetic and ultrasonic flow probes were placed on the distal aorta, right internal carotid artery, superior mesenteric artery, and left renal artery. Sepsis was induced with a 60-mg/kg intravenous injection of Escherichia coli endotoxin. When the arterial blood pressure decreased to less than 60 mm Hg despite adequate fluid resuscitation, NO synthesis was inhibited with a 25-mg/kg intravenous administration of NG-monomethyl-L-arginine. After 15 minutes of inhibition, a 400-mg/kg intravenous administration of L-arginine, the substrate of NO synthase enzyme, was given. Physiologic measurements were continued for 15 minutes thereafter.

MAIN OUTCOME MEASURES

Heart rate, blood pressure, central venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, hematocrit, arterial and venous blood gas values, and blood flow measurements of right internal carotid artery, superior mesenteric artery, left renal artery, and distal aorta.

RESULTS

Control animals did not demonstrate a significant (P > .05) decrease in blood flow in the internal carotid artery, superior mesenteric artery, and distal aorta after the administration of NG-monomethyl-L-arginine. The endotoxin-treated group showed a significant (P < .05) decrease in organ perfusion when treated with the NO synthase inhibitor, NG-monomethyl-L-arginine.

CONCLUSIONS

Inhibition of NO production in the treatment of sepsis caused a significant decrease in blood flow to all vascular beds in vivo. The role, if any, of the inhibition of NO in the treatment of sepsis is questioned.

Nitric oxide inhibition in the treatment of the sepsis syndrome is detrimental to tissue oxygenation

The manifestations of the septic syndrome are thought to be mediated by cytokines through their role in the production of nitric oxide (NO). It is hypothesized that the inhibition of NO production with an inhibitor such as NG-monomethyl-L-arginine (L-NMMA) may be beneficial in the treatment of septic shock. Sepsis was induced by the intravenous administration of Escherichia coli endotoxin (60 micrograms/kg) in six conditioned mongrel dogs (20-24 kg). Mean arterial pressure (MAP), heart rate (HR), central venous pressure (CVP), and pulmonary artery pressure (PAP) were continuously monitored. Cardiac output (CO), pulmonary capillary wedge pressure (PCWP), and arterial and mixed venous blood gases were obtained every 10 min. When the MAP decreased below 60 mm Hg, NO inhibitor L-NMMA was given by intravenous injection (25 mg/kg). Physiologic parameters were then measured at 2 and 5 min after L-NMMA injection. Subsequently, L-arginine (400 mg/kg), the substrate for the NO synthase enzyme, was administered and measurements were repeated at similar intervals. L-NMMA in septic canines produced a significant increase in MAP and SVR with a significant decrease in CO and tissue oxygenation (DO2 and VO2). These changes were reversed with the administration of L-arginine. There were no significant differences in the PCWP, CVP, PAP, or HR throughout the entire study. These results suggest that the inhibition of NO production by L-NMMA in a septic model produces elevated MAP and SVR at the expense of tissue oxygenation. Thus, its use, as a principal means of therapy for the septic syndrome, may not be appropriate because of detrimental effects on tissue oxygenation.

Aortoesophageal fistula: case report and literature review

Fistulous communication between the aorta and esophagus is a rare but usually fatal disorder. Esophageal foreign bodies have been reported to cause aortoesophageal fistula rarely. Spontaneous aortoesophageal fistula as a result of atherosclerotic disease of the aorta has not been reported. This article describes a case of aortoesophageal fistula caused by an ulcerated atherosclerotic plaque, which we believe is the first case report implicating such an etiologic factor.

Coping patterns of mothers of poor boys

Using the same 201 impoverished, urban dwelling black and Cuban refugee mothers from their previous study ""Psychopathology & Fatherlessness in Poor Boys,'' Adams and Horovitz examine the coping sytles of these women. The differing groups of mothers were classified according to their firstborn son's ages, their ethnicity and the presence or absence of a father in their household. Scored according to scales L, F, K, 1--4, and 6--9 of the MMPI, the women were profiled and a descriptive comparison employed. In most instances the null hypothesis was confirmed: mothers of fathered boys did not differ in their coping strategies from mothers of fatherless boys regardless of the family's ethnicity and the boy's psychopathology or age. Of note was the high scores in the ""paranoia'' scale of MMPI, indicating that it may be functional and adaptive to use projection in an urban slum.

Psychopathology and fatherlessness in poor boys

The study reported represents an effort to expand an earlier investigation of how psychopathology is related to fatherlessness. The sample (N=201), composed of U.S. blacks and Cuban refugees of white derivation, was controlled for the family's economic class position, ethnicity, place of residence, and for the children's age, gender, and ordinal position and matched with a control group of ""fathered'' children. Instruments used were a mini MMPI (76 items) and the Louisville Aggression Survey Schedule-1. All of the data obtained in the study were supplied by the mothers--both about themselves and their firstborn male child. No positive association between the boys' psychopathology and their fatherlessness was found. Moreover, the data seemingly indicate that poverty exerts a leveling influence that overrides the differentiating characteristics of ethnic and age grouping, family structure, father presence or absence, and liguistic and cultural heritages.

Pulmonary complications in the burn patient

Pulmonary complications--carbon monoxide poisoning, upper airways obstruction, and acute pulmonary insufficiency--occur frequently in patients hospitalized because of burns and/or smoke inhalation. The morbidity and mortality of these complications are quite high; therefore, early diagnosis and early institution of therapy are mandatory.

Withdrawal from positive end-expiratory pressure

A retrospective review was carried out involving 82 patients who required positive end-expiratory pressure (PEEP) therapy for acute respiratory insufficiency. One third of the attempts at reducing the level of PEEP were unsuccessful and led to reinstitution of the original or an increased level of PEEP. Premature lowering of PEEP resulted in significant deterioration in oxygenation which persisted for more than 24 hours after reinstitution of PEEP in a significant number of patients. In addition, one half of these patients required increased levels of PEEP (above prelowering levels) to achieve adequate oxygenation. PEEP lowering attempts were categorized as either successes or failures. A comparison was made between the prelowering respiratory measurements of these two groups. The discriminant criteria produced were (1) an improving oxygenation index (rising (PaO2/FIO2) and (2) a stable or improving effective compliance. Using these prelowering criteria, it was possible to distinguish between the successes and failures in 95% of cases. Based on the data collected, proposed guidelines for PEEP lowering are presented.

Postoperative monitoring following critical trauma

This review has focused on several aspects of monitoring post-injury patients. A few of the more commonly used monitoring devices have been discussed to emphasize that their use carries some risk and, as such, proper indications, based on the benefit to be achieved, must be available before they are used. Guidelines for the safe use of these devices have been outlined. The postoperative injury patient is at risk for developing certain complications as a result of the magnitude of injury. This review has dealt with respiratory insufficiency, renal insufficiency, and stress ulceration. Guidelines have been presented to aid in the prevention, early diagnosis, and management of these problems.